Claim Barnhart, ChrisCLAIM 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: Chris Barnhart
2. Address: 2818 Jackson Dbq 52001
3. Telephone Number: 583 7417
4. Date of Incident: 7 7 03
5. Time of Incident: approx. 4:40 P.M.
6. Location of Incident (Be specific): In front of my home located at 2818 Jackson
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.)
The black base of an upright reflector was on the street up against the curb - the base was covered with mud. IAs I was parking my front wheel caught the corner of the of the unseen
8. What were weather conditions like? overcast, rainy
9. Give name and address of any witnesses: --
10. Did police investigate? (If so, give names of officers.)
No
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.)
Yes, passenger side of car... - behind front wheel -- was scraped and dented....see estimates enclosed
13. What other damages do you claim, if any?
None
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? see enclosed estimates
16. Why do you claim the City of Dubuque is responsible?
The upright reflectors were placed by employees doing construction on Jackson St.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
NA
Dated at Dubuque, Iowa this 10th day of July, 2003.
/s/ Chris A. Barnhart
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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.
L0cat,o. of,nc,dent (.e spec,f,c): %
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details up'on which you base your claim. If a City employee was involved, give the
employee~'s name.) ~ ~
8. What were weather conditions like? ~(,._.%~%~
9. Give name and address of any witnesses:~---~'~
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
13. What other damages do you claim, if
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.)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
'- \ x
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name an,d__ad~dress.)
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in wha~m?~t~
Dated at Dubuque, Iowa this
~ O'4~day of ~ ~. ~.~.~...~\ , 20 ~%.
{Signature)
{Print Name)
(Rev. 1/00 & 7/01)
Tilt Wheel
OOE~; 13F~3SBq dH NBLS:8000E 80 -119['
Date: 7/10/03 t0:08 AM
Estimate ID: 472t
Estimate Version: 0
Preliminary
Profile ID: Mitchell
LENNY VALENTINE & SONS, INC.
923 PERU RD DUBUQUE, IA 52001-8604
(563) 588-4659
Fax: (563) 588-4650
TWO CONTINENTAL FRAME MACHINES
GENESIS II COMPUTERISEDMEASURING S~STEM
PRICE IS EASY TO BEAT/QUALITY IS NOT
UNIBODY SPECIALISTS
Damage Assessed By: WAYNE VALENTINE
Deductible: UNKNOWN
Owner CHRIS BARNHART
Address: 2818 JACKSON DUBUQUE, IA 82001
Telephone: Work Phone: (583) 589-9370
Mitchell Service:
Description: 2000 Ford Taurus SES
Body Style: 4D Sed
VIN: 1FAFP552XYG193540
Home Phone: (563) 583-74t7
912626
Drive Train: 3.0L Inj 6 Cyl AO
Line EntJ7 Labor Line Item
Item Number Type Operation Description
1 200206 BDY REPAIR
2 AUTO REF REFINISH
3 200220 BDY REMOVE/REPLACE
4 200768 BDY REPAIR
5 AUTO REF REFINISH
6 200772 REF REFINISH
7 202616 BDY REMOVE/INSTALL
8 202618 BDY REMOVE/INSTALL
9 200776 BDY REMOVE/INSTALL
10 200818 REF REFINISH
tl 900500 BDY* ADD'L LABOR OP
t2 200679 BDY REMOVE/INSTALL
13 AUTO REF ADD'L OPR
14 933005 BDY ADD'L OPR
15 933018 BDY* ADD'L OPR
t6 AUTO ADD'L COST
17 AUTO ADD'L COST
18 AUTO ADD'L COST
Part Type/
Part Number
R FENDER PANEL Existing
R FENDER OUTSIDE
R FENDER ADHESIVE NAMEPLATE F3DZ 5420948 A
R FRT DOOR SHELL Existing
R FRT DOOR OUTSIDE
R FRT DOOR MOULDING
R FRT UPR DOOR MOULDING
R FRT OTR BELT MLDG
R FRT DOOR MIRROR
R FRT HANDLE
MASK JAMS Existing
R FRT ROCKER MOULDINGS COMPLETE
CLEAR COAT
RESTORE CORROSION PROTECTION
MASK FOR OVERSPRAY
PAINT/MATERIALS
SHOP MATERIALS
HAZARDOUS WASTE DISPOSAL
Dollar Labor
Amount Unite
1.5'#
C 2.0
16.42 0.2
3.5*#
C 1.9
C 0,4
1.1 #
0.2 #
INC #
C 0.5
0.5*
0.3 #
1.4
10.00' 0.3*
5.00'
179.80'
12.50 *
4.65 *
ESTIMATE RECALL NUMBER: 7110/03 10:04:03 4721
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: JUL_03_A Copyright (C) 1994 - 2002 Mitchell International
UltrsMate Version: 4.8.012 All Rights Reserved
Page I of 2
Date: 7/10103 10:08AM
Estimate ID: 4721
Estimate Version: 0
Preliminary
Profile ID: Mitchell
* - Judgement Item
# ~ Labor Note Applies
C - Included in Clear Coat Calc
L Labor Subtotals
Body
Refinish
Add'l
Labor Sublet
Units Rate Amount Amount Totals II. Part Replacement Summary
7.6 45.00 15.00 0.00 357.00 T Taxable Parts
6.2 45.00 0.00 0.00 279,00 T Sales Tax
Taxable Labor 636.00
Labor Tax ~ 7.000 % 44.52
Labor Summary 13.8
IlL
Additional Costs
Taxable Costs
Sales Tax
7.000%
Non-Taxable Costa
Total Additional Costa
680.52
Amount
4.65
0.33
192.30
197.28
Total Replacement Parts Amount
IV. Adjustments
Customer Responsibility
I. Total Labor:
I1. Total Replacement Parts:
IlL Total Additional Costs:
Gross Total:
7.000%
Amount
15.42
1.08
16.50
Amount
0.00
680.52
16.50
197.28
894.30
IV. Total Adjustments:
Net Total:
0,00
894.30
This is a preliminary estimate.
Additional chanqes to the eStimate may be required for the actual repair.
WARNING: Accidental air bag deployment is possible. Personal injury may result. Avoid area near steering wheel
and instrument panel even if air bags have deployed. Dual-stage air bag modules may be present that could
contain an 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: 7110103 t0:04:03 472t
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: JUL 03 A Copyright (C) 1994 - 2002 Mitchell International
UltraMate Version: 4.8.012 All Rights Reserved
Page 2
of 2