Claim Rokusek, Mark M.Clairfi Form .. , Page 1 of 3
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DLTBUQUE, IOWA
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Home Page: Departments: City Clerk: C a ms aflainst the City: Claim Form
City Clerk
First floor of City Hall, 50 W. 13th Street
Phone: (563) 589-4120
Fax: (563) 589-0890
Hours: 8 a.m. to 5 p.m. Monday through Friday
Emai[: jschneid @cityofdubuque.om
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the City of Dubuque, Iowa. You should comple
full and attach any additional information that supports your claim.
The claim must be filed with the City Clerk at City Hail, 50 West 13th St., Dubuque, IA 52001. It'
referred to the appropriate department for investigation and to the Legal Department. Once that
completed, a report and recommendation will be subrditted to the City Council. You will be provi
of that report and recommendation.
The final decision on all clams is made by the City CoUncil. No employee of the City of Dubuqu(
authority to make any representation to you as to whether your claim will or will not be paid.
1. Name of Claimant: Mark R. Rokusek
2. Address: 17847 Twin Springs Drive, Durango, IA 52039
3. Telephone Number: 588-2815
4. Date of incident: approx. 2000 Hours on March 5, 2003
5. Time of Incident: approx 2000 Hours
approx 2000 Hours on March 5, 2003
approx 2000 Hours
6. Locafionoflncident(Bespecific):Airport Terminal Parking Lot 2
parked between two cars dnder the streetli~ht
7. Describe the accident or occurrence that caused injury or damage. (Give full details upon whi
your claim, tfa City employee was 'nyc ved, g've the employee's name.)
Airport Maintenance ( Snow Removal) employee Robert Schiel
backed the Snowplow into the rear of my car. I was not there.
8. What were weather conditions like? BlJnding Snowstorm, heavv snow
9. Give name and address of any witnesses: No wi
Robert Schiel, Gord¥ ~etsch, and Daniel T. Klass ( attached
10. Did police investigate? (If so, give names of officers.)
Notified - City Parking Lot
http://www.cityofdubuque.org/index.cfm?pageid= 155 3/6/2003
Claim Form ,, Page 2 of 3
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No injuries
12. Wasanydamagedone m pmpedy?(Ifso, descdbeprope~yandthee~ent~ damages. Mt
damagesordescribebasis ~rascedaininge~entO damage.)
Entire rear end of car - Rear Bottom Panel, Trunk Lid, Trunk Light
sustained major damage.
13. What other damages do you claim, if any? Norm
14. Have you been compensated for any part or all of your ctaim by any insurance company? (11
and address of insurance company and amount paid.)
in any way,
f 5. What amount do you claim from the City of Dubuque? $ !, 902.65 Sea at tachad
repair quote / Ken Green @ ABRA RePair
16. Why do you claim the City of Dubuque is responsible? The car wa~ p~rko~ _~ xr~ry
carefully parked, and city employee caused the accident,
17. Have you made any claim against anyone else for damages as a result of this incident? (If y
and address.)
No
18. If the answer to Question 17 is yes, have you received any payment from that source, and if
amount?
Dated ~is ~ayof,~.rch ,20 03 -
(Signat~ 'e)
(Pdnt N~ ~0)
Home Paqe: Departments: City Clerk: Claims af]ainst the City.: Claim Form
http://www.cityofdubuque.org/index.cfm?pageid= 155 3/6/2003
iNGiDEN REPORT=
~,,~.~.~r~l.~.~i~ ~oi~Se n~incidents not nvblvin!~ aimmlt~ ~
Report #: I Date: Occurred March 05, 2003 Time:
03-05 I Report Written: March 05, 2003 Approximate y 2000 Hrs.
Type of Incident:
Damage to Vehicle Parked in Lot 2 dudng Snow Removal Operations.
Operations Notified Via:
Company Radio
Operations Notified By:
Robert (Bo) Schiel
Location of Incident:
Terminal Passenger Parking Lot 2
WeatheF.
Snow storm conditions with periods of heavy snow, visibilities ranged from % to I mile.
Agencies Notified:
Dubuque Dispatch for contact information.
Airport Personnel Involved Iff Incident
Name
Robert Schiel
Title
Airport Maintenance
Name
Registered to:
Mark or Lisa Rokusek
General Public Involved In Incident
Address
17815 Twin Springs
Durango, IA
Witness To Incident
Name Address
N/A
Other reports filed in conjunction ~ incident:
NIA
In your own words, give a complete descFipfion of the incident from start to finish
including any witness account of what occurred and attach.
On the night of March 4, 2003, I was notified by company radio that Bo had just hit a car in the
parking lot. I was involved with snow removal operations, so I asked him to stay there until I
could make it out to him. Upon ardval, Bo had moved the truck to another section of the parking
lot. I asked him where the vehicle was located so I could get a license number.
We proceeded to the vehicle and noticed a Green Dodge Intrepid, Iowa plate number 489 JAA.
The vehicle had noticeable damage to the rear trunk lid. Bo apologized to me for any
inconvenience he may have caused.
I copied the number down for report purposes later. Bo and I returned to winter storm procedures
after I asked him to keep his backing up to a minimum.
On March 5, 2003, I was still involved with snow removal operations SO I asked Gordy Vetsch to
obtain the necessary information for my reports. Gordy contacted the LEO on duty at the terminal
and obtained the name and contact information from above. Gordy also took a few digital
pictures which have been attached as #1.
I asked Bo during the lunch hour to give me a written statement, see attachment fK2.
An attempt will be made to contact the owners and hand deliver necessary claim forms, per
Peggy Dickson.
Operations Specialist: Daniel T. Klaee
Date: 3-5-03
03/25/2003 at 05:01 PM
24443
Job Number:
ABRA - DUBUQUE
Federal ID %:420782245
DBA: ANDERSON-WEBER INCi
3400 CENTER GROVE DR
DUBUQUE, IA 52003
(563)556-0696 Fax: (563)556-1899
PREL IM~NARY ESTIMATE
Written by: KEN GREEN #2444i3
Adjuster: ,
Insured:
Owner: MARK ROKUSEK
Address: 17815 TWIN SPRINGS
DURANGO, IA 52039
Business: (563)556-8884
Other: (563)588-2815
Claim #:
Policy ~,
Deductible:
Date of Loss:
Tlrpe of ~oss:
Point of Impact:
Inspect
Location:
Insurance
Company:
D~ys to Repair
1999 DODG INTREPID ES 6-3.2L-FI 4D SED GREEN Int:
VIN: 2B3HD56J8XH513153 Lic: 489 JA3~ IA Prod Date:
Air Conditioning
Cruise Control
Body Side Moldings
Clear Coat Paint
Power Windows
Power Mirrors
Passenger Air Bag
Bucket Seats
Rear Defogger
Intermittent Wipers
Dual Mirrors
Power Steering
Power Locks
Anti-Lock Brakes (4)
4 Wheel Disc Brakes
Aluminum/Alloy Wheels
08/1998 Odometer:
Tilt Wheel
Keyless Entry
Fog Lamps
Power Brakes
Power Driver Seat
Driver Air Bag
Cloth Seats
72167
NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT
1
2
4
5
6
7
8
9
10
11
12
13
14
15
REAR BUMPER
O/H rear bumper 0
Repl A/M CAPA Bumper cover 1
Add for Clear Coat 0
TRUNK LID
Repl Trunk lid 1
Add for Clear Coat 0
Add for Underside(Complete) 0
Repl Nameplate "INTREPID" chrome 1
REAR LAMPS
Repl High mount lamp 1
QUARTER PANEL
Blnd RT Quarter panel 0
Blnd LT Quarter panel 0
ELECTRICAL
0.00 2.0 0.0
267.00 Incl. 3.2
0.00 0.0 1.3
405.00 1.5 2.3
0.00 0.0 0.9
0.00 0.0 1.2
29.25 0.3 0.0
130.00 1.0 0.0
0.00 0.0 1.2
0.00 0.0 1.2
03/25/2003 at 05:01 PM Job Number:
24443
PRELII~INARY ESTIMATE
1999 DODG INTREPID ES 6-3.2L-FI 4D SED GREEN Int:
NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT
16' R&I Body 0 0.00 0.3 0.0
17# Subl HAZARDOUS WASTE DISPOSAL 1 4.00 T 0.0 0.0
18'* Repl A/M BAG / COVER CAR 1 4.00 0.2 0.0
Subtotals ==> 839.25 5.3 11.3
Parts 835.25
Body Labor 5.i3 hfs @ $ 45.00/hr 238.50
Paint Labor 11.i3 hfs @ $ 45.00/hr 508.50
Paint Supplies 11.13 hfs @ $ 28.00/hr 316.40
Sublet/Misc. 4.00
SUBTOTAL $ 1902.65
GRAND TOTAL $ 1902.65
ADJUSTMENTS:
Deductible 0.00
CUSTOMER PAY $ 0.00
INSURANCE PAY $ 1902.65
WARRANTY VALID ONLY WITH ORIGIONAL COPY OF YOUR RECEIPT PARTS SUBJECT TO
INVOICE NO GUARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF AFTERMARKET CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF iYOUR MOTOR VEHICLE. ANY
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE
MANUFACTURER OR DISTRIBUTOR OF THESE PARTS RATHER THAN THE MANUFACTURER OF YOUR
VEHICLE.
WARRANTY VALID ONLY WITH ORIGIONAL COPY OF RECEIPT. PARTS SUBJECT TO INVOICE.
NO GUARANTEES ON RUST. ALL PARTS NEW, UNLESS OTHERWISE SPECIFIED.
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwis~ noted all items are derived from
the Guide DR3PH98 Database Date 3/2003 and the parts selected are OEM-parts manufactured by the
vehicles Original Equipment Manufacturer. Asterisk (*) or Double Asterisk (**) indicates that the
parts and/or labor information provided by MOTOR may have been modified or may have come from an
alternate data source. Non-Original Equipment Manufacturer aftermarket parts are described as A~
or Qual Repl Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned
parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Prices
are provided from National Auto Glass Specifications, Inc. Pound sign (%) items indicate manual
entries.
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