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Claim Hoskins, Mike & JodiCLAIM AGAINST THE CITY OF DUBUQUE, IOWA This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this form in full and attach any additional information that supports your claim. The Claim must be filed with the City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52001. It will then be referred by the City Council to the appropriate department for investigation. Once that investigation is completed, a report and recommendation will be submitted to the City Council. You will be provided with a copy of that report and recommendation. THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. 1. Name of Claimant: Mike and Jodi Hoskins 2. Address: 500 Hill Street Dubuque IA 52001 3. Telephone Number: 563 583 5528 4. Date of Incident: 6/12/03 5. Time of Incident: approx. 8 am. 6. Location of Incident (Be specific): In front of 462 Birch St. - Burch St. 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give full details upon which you base your claim. If a City employee was involved, give the employee's name.) City garbage truck hit our vehicle while parked on Burch St. 8. What were weather conditions like? Clear and dry 9. Give name and address of any witnesses: None 10. Did police investigate? (If so, give names of officers.) No - as per Paul Schultz, city Solid Waste Manager 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). No 12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.) Damage to left rear quarter panel and back bumper 13. What other damages do you claim, if any? 1 days wages for vacation day to obtain estimates for Mr. Hoskins and complete paper work 14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name and address of insurance company and amount paid.) No 15. What amount do you claim from the City of Dubuque? $1,888.00 Low damage estimate + 157.69 = $2045.69 (Based on $41,000 annual salary divided by 260 working days) 16. Why do you claim the City of Dubuque is responsible? City driver hit my vehicle 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? Dated at Dubuque, Iowa this 16th day of June, 2003. /s/ Michael E. Hoskins/ Jodi Hoskins (Signature) (Print Name) (Rev. 1/00 & 7/01) This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this form in full and attach any additional information that supports your claim. · The Claim must be filed with the City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52001. It will then be referred by the City Council to the appropriate department for investigation. Once that investigation is completed, a report and recommendation will be submitted to the City Council. You will be provided with a copy of that report and recommendation. THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. 1. Name of Claimant: ~,~--~ / 3. Telephone Number: 4. Date of Incident: 5. Time of Incident: 0--P,,O~,~-~zt . o° 6. Location of Incident (Be specific): ~, 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. full details upon which you base your claim. employee's name.) , ,::3.3 ,.-J . (Give If a City employee was involved, give the 8. What were weather conditions like? (~.. 1 ~ 0-- Y" 0./'¢',-C) t} .~ 9. Give name and address of any witnesses: .~J ~ 10. Did police investigate? (If.so, give names of o.fficers.)., ~- 'c..;, © o 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). 1,2. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.) I 13. What other damages do you claim, if any? ave yo~pensa ed for any part or all of your claim by any insurance company? (If so, give name and address of insurance company and amount paid.) 15. What amount do you claim from the City of Dubuque? 16. Why do you Claim the City of Dubuque is responsible? 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? Dated at Dubuque, Iowa this ¥! 'enbnqnQ O ASO H (Signature) (Print Name 7 (Rev. 1/00 & 7/01) Operations and Maintenance Depazt:ment 925 Kerper Boulevard Dubuque, Iowa 52001-2538 (563) 5894250 office (563) 58%4252 fax (563) 5894193 TDD ops&maint@cityo fdubrtque.org Dear SidMs: The City of Dubuque Operations & Maintenance Department acknowledges that we have damaged your property, building and/or vehicle. Since the employee's supervisor has determined that the estimated cost to repair the damage does not exceed $1,000.00, the Police Department was not required to assist with paperwork, investigation, etc.. Please contact the City Clerk at 589-4120 to obtain a damage claim We apologize for the damage we have caused and the inconveniences that have resulted for you. Sincerely, Opera i~ns & Maintenance Manager Sewice People Integrity R~ponsib£1ity YAGER MITSUBISHI 4488 DODGE STREET DUBUQUE, IA 52003 FEDERAL ID ~ 42-1131724 PHONE: 563-557-7376 FAX: 563-557-1709 CD LOG NO 1667-1 DATE: SHOP CONTACT: GAYLE PURMAN INSP DATE: OWNER: HASKINS, MIKE ADDRESS: 580 HILL CITY STATE: DUBUQUE, IA ZIP: 52001- INS CO: CLAIM#: POLICY%: LOSS DATE: START DATE: PROMISE DATE: VEH. DROP OFF DATE/TIME: VEH. PICK UP DATE/TIME: DRIVEABLE: 1993 OLDSMOBILE CUTLASS SUPREME LIC%: BODY COLOR: GOLD HOME PHONE: WORK PHONE: FAX PHONE: 06/16/03 06/16/03 (563)583-5528 (815)394-3728 CONTACT: PHONE: CLAIM REP: FILE HANDLER: DEDUCTIBLE: COMPLETION DATE: RENTAL ASSISTED: DAYS TO REPAIR: 0.00 S 4DOOR SEDAN ENGINE: 6CYL GASOLINE 3.1 VIN: 1G3WH54TgPD348807 MILEAGE: DAMAGE LINE REPORT REPAIR DESCRIPTION 1 R&I ASSEMBLY 2 REFINISH 3 R&I ASSEMBLY 4 R&I ASSEMBLY 5 R&I ASSEMBLY 6 REPAIR 7 REFINISH 8 BLEND REFINI 9 NEW PART 10 REFINISH 11 NEW PART 12 REFINISH 13 REFINISH 14 SALVAGE PART 15 NEW PART 16 REFINISH 17 NEW PART 18 NEW PART 19 ADDNL LABOR 20 ADDNL LABOR ADJ% DEFLECTOR, ROCKER PANEL LT PNL,REAR DOOR OUTER LT MLDG,REAR DOOR BELT LT HANDLE,RR DOOR OUTER LT DEFLECTOR, REAR DOOR LT PANEL,QUARTER LT PANEL,QUARTER LT PANEL,QUARTER RT DOOR, FUEL FILLER LT DOOR, FUEL FILLER LT MLDG,QTR WHL OPENING LT MLDG,QTR WHL OPENING LT LID,REAR DECK TAILLAMP ASSEMBLY LT COVER, REAR BUMPER COVER, REAR BUMPER MLDG,REAR BUMPER COVER LT MLDG,REAR BUMPER COVER RT COVER CAR EXTERIOR HAZARD. WSTE. REM. B% PARTS$ LABORS 58.80 92.40 16.80 8.40 33.60 273.00~ 88.20 46.20 56.83 8.40 12.60 41.67 8.40 8.40 63.00 75.00* 12.60 351.66 92.40 105.00 36.58 36.58 - 5.00* 3.00* 8.40* CD LOG NO TOTALS 1667-1 PARTS 606.32 PAINT MATERIAL 252.50 BODY LABOR-SM 512.40 MECH/ELEC LABOR-ME 0.00 FRAME-FR LABOR 0.00 REFINISH-RF LABOR 424.20 SUBLET 0.00 TOWING 0.00 STORAGE 0.00 TAX 92.58 ESTIMATE TOTAL 1,888.00 INSURANCE PAY 1,888.00 CUSTOMER PAY 0~00 PAGE 2 06/16/03 (C) 1998 - 2002 ADP CLAIMS SOLUTIONS GROUP, INC. R 6.3 THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF AFTERMARKET CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR 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. Date: 6/16/2003 09:45 AM Estimate ID: 82t3 Estimate Version: 0 Preliminary Profile ID: Mitchell BIRD CHEVROLET 3255 UNIVERSITY AVE. P.O. BOX 57 DUBUQUE, IA 52001 (563) 583-9121 Fax: (563) 556-4482 Tax ID: 42-0400210 Damage Assessed By: JOHN KLOTZ JR. Deductible: UNKNOWN Owner MIKE HOSKINS Address: 500 HILL ST DUBUQUE, IA 52001 Telephone: Home Phone: (563) 583-5528 Mitchell Service: 911484 Description: 1993 OMsmobile Cutlass Supreme S Body Style: 4D Sed VIN: 1G3WH54T9PD348807 Drive Train: 3.1L Inj 6 Cyl A Line Ent.-y Labor Line Item Part Type/ Item Number Type Operation Description Part Number Dollar Labor Amount Unite I 122550 REF BLEND 2 122954 BDY REMOVE/INSTALL 3 122964 BDY REMOVE/INSTALL 4 101522 BOY REPAIR 5 AUTO REF REFINISH 6 126640 BDY REMOVE/REPLACE 7 126900 BDY REMOVE/REPLACE 8 AUTO REF REFINISH 9 126950 BDY REMOVE/REPLACE 10 AUTO REF REFINISH 11 130370 BDY REMOVE/REPLACE 12 131070 BDY REMOVE/REPLACE 13 AUTO REF REFINISH t4 AUTO REF ADD'L OPR 15 AUTO ADD'L COST 16 AUTO ADD'L COST L REAR DOOR OUTSIDE L REAR BELT MLDG L REAR LWR FINISH PANEL L QUARTER OUTER PANEL L QUARTER PANEL OUTSIDE L QUARTER FUEL DOOR L QUARTER MOULDING L QUARTER MOULDING L QUARTER WHEEL OPENING MLDO L QUARTER WHEEL OPENING MLDG L COMBINATION LAMP ASSEMBLY REAR BUMPER COVER REAR BUMPER COVER CLEAR COAT PAINT/MATERIALS HAZARDOUS WASTE DISPOSAL * - Judgement Item # - Labor Note Applies C - Included in Clear Coat Calc Exi~ing 10236260 12009621 10151785 5977167 12530410 GM PART GM PART GM PART GM PART GM PART C 0.9 0.3 0.4 8.0* C 2.4 56.83 0-3 102.06 0:3 C 0.3 41.67 0.3 C 0.3 172.65 0.3 351.66 2.0 C 2;5 t.8 229.60 * 6.00 * ESTIMATE RECALL NUMBER: 6116/2003 09:41:56 8213 UitraMate is a Trademark of Mitchell International Mitchell Data Version: JUN_03_A Copyright (C) t994 - 2002 Mitchell International UltrsMate Version: 4.8.0t2 All Rights Reserved Page I of 2 Data: 61t612003 09:45 AM Estimata ID: 82t3 Estimate Version: 0 Preliminary Profile ID: Mitchell L Labor Subtotals Units Body 11.9 45.00 Refinish 8.2 45.00 Add'l Labor Sublet Ra~e Amount Amount Totals 0.00 0.00 535.50 T 0.00 0.00 369.00 T Taxable Labor Labor Tax ~ 6.000 % Labor Summary 20.f 904.50 54.27 Ill. Additional Costs Non-Taxable Costs Total Additional Costs II. Part Replacement Summary Taxable Parta Sales Tax ~ Total Replacement Parts Amount Amount IV. Adjustments 235.60 Customer Responsibility 235.60 6.000% 724,~ 76~36 Amount 0.00 I. Total Labor: II. Total Replacement Paris: IlL Total Additional Costs: Gross Total: IV. Total Adjustments: Net Total: 958.77 768.36 235.60 1,962.73 0.00 1,962.73 This is a preliminary estimate. Additional chan~qes to the estimate may be required for the actual repair. PARTS PRICES A~E SUBJECT TO CHANGE WARNING: Accidental air bag deployment is possible. Personal injury may rosulL Avoid area near steeling wheel and instrument panel even if air bags have deployed. Dual-stage air bag modules may be present that could contain au undeployed stage. When disposing of a deployed dual-stage air bag, always treat it as a 'live" module. See appropriate MITCHELL® AIR BAG SERVICE & REPAIR MANUAL, or OEM information. ESTIMATE RECALL NUMBER: 6/1612003 09:41:56 8213 UltraMate is a Trademark of Mitchell International M [taheti D'~V~sion: JUN_03_A Copyright (C) 1994 - 2002 Mitchell International UlfwaMa~Vemion: 4.8.012 All Rights Reserved Page 2 of 2