Claim by Michelle GrobstickMasterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
MEMORANDUM
ist,D.
To: Mayor Roy D. Buol and
Members of the City Council
DATE: August 6, 2010
RE: Claim Against the City of Dubuque by Michelle Grobstick
Claimant Date of Claim Date of Loss Nature of Claim
Michelle Grobstick 08/05/10 07/24/10 Vehicle Damage
This is a claim in which claimant alleges that her vehicle was damaged after she drove
over a manhole on Gateway Drive which didn't have a cover on it.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager
John Klostermann, Street & Sewer Maintenance Supervisor
Michelle Grobstick
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001 -6944
TELEPHONE (563) 583 -4113 / FAx (563) 583 -1040 / EMAIL tsteckle @cityofdubuque.org
CLAIM 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 West 13 St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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:
2. Address: 1\ . Ca2, CC\ac_FTAAI
3. Telephone Number
4. Date of Incident:
5. Time of Incident:
O.( , r5 C\ \ Pty
6. Location of Incident (Be specific):
Ck, (,�. ��a. �c . `T Y0 \\(1.c c,,Q)cri\
7. Describe the 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.)
.ft
..
0„4c- 'ppt \ •o t,n.. C x { - e•Ai
8. What were weather conditions like?
9. Giue name and address of any witnesses:
10. Did police investigate? (If so, • ive names of officers.)
(N f o
co 3 ( O n 'r-k �y C�, L�� i nip 'A,
/"'
11 \jas 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.)
— •rte \gyp Cc) (Nr\
13. What other damages do you claim, if any?
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.)
\\) rte,
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
Dated this day of ;; T1
(Sigtdature)
6),� \ \O
( Name)
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?
, 2010
Damage Assessed By: john klotz
Deductible: 0.00
Claim Number: 8712
Insured BARNEY GROBSTICK
Address: 7251 OLDE MASSEY RD, DUBUQUE, IA 52003
Telephone: Home Phone: (563) 590-4056
Description:
Body Style:
VIN:
Mileage:
OEM /ALT:
Color:
Options:
Line Entry Labor
Item Number Type
1 004390 BDY
2 003880 BDY
3 AUTO REF
4 000310 BDY
5 AUTO REF
6 AUTO REF
7 003961 BDY
8 003974 BDY
9 000893 REF
10 006810 BDY
11 006812 BDY
12 008451 BDY
13 001045 BDY
14 900500 BDY*
15 AUTO REF
16 900500 MCI]*
17 933018 REF
18 AUTO
Operation
OVERHAUL
REPAIR
REFINISH
REMOVE/REPLACE
REFINISH
REFINISH
REMOVE /REPLACE
REMOVE/REPLACE
BLEND
REMOVE/INSTALL
REMOVE/INSTALL
REMOVE /INSTALL
REMOVE/INSTALL
REPAIR
ADD'L OPR
ALIGN
ADD'L OPR
ADD'L COST
BIRD CHEVROLET
3255 UNIVERSITY AVE, DUBUQUE, IA 52001
(563) 583-9121
Fax: (563) 690-1423
Email johnklotze4birdchevrolet.com
Tax ID: 42
Mitchell Service: 910501
2005 GMC Envoy XL SLE
4D Ut Drive Train: 4.2L Inj 6 Cyl 4WD
IGKET16SX56172881 License: 340PZJ
57,151
O Search Code: None
WHITE
VEHICLE ANTI-THEFT, PASSENGER AIRBAG, DRIVER SIDE AIRBAG, POWER LOCK
POWER WINDOW, POWER STEERING, REAR WINDOW DEFOGGER, MANUAL AIR CONDITION
TILT STEERING COLUMN, HEATED EXTERIOR MIRROR, ANTI-LOCK BRAKE SYS., FOG LIGHTS
ALUM /ALLOY WHEELS, LEATHER STEERING WHEEL CD PLAYER, TOW HITCH RECEIVER
POWER ADJUSTABLE EXTERIOR MIRROR, 4WD OR AWD, PRIVACY GLASS
FIRST ROW BUCKET SEAT, SECOND ROW SPLIT BENCH SEAT, KEYLESS ENTRY
REAR SEAT HVAC CONTROLS, SECOND ROW FOLDING SEAT, THEATER STYLE SEATING
THIRD ROW SEAT, REAR HEATING, VENTILATION & AIR CONDITIONING, CLOTH SEAT
EXTERIOR RAILS, TACHOMETER, AUTOMATIC HEADLIGHTS
PASSENGER AIRBAG CUTOFF SWITCH /SENSOR, REMOTE DECKLID OR TAILGATE RELEASE
ONSTAR, DAYTIME RUNNING LIGHTS
Line Item
Description
Frt Bumper Cover Assy
Frt Bumper Cover Existing
Frt Bumper Cover
R Fender Panel
R Fender Outside
R Add To Edge Fender
Alloy Wheel Recored
Wheel Valve Stem 274288 GM PART
R Frt Door Outside
R Frt Rear View Mirror
R Frt Otr Belt Moulding
R Frt Door Adhesive Moulding Existing
R Frt Door handle
RETAPE MOLDING Existing
Clear Coat
ALIGN FT END Sublet
Mask For Overspray
Paint/Materials
ESTIMATE RECALL NUMBER: 07/30/2010 13 :18 :38 8712
Mitchell Data Version: OEM: ,ILUL_10_V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2010 Mitchell International
UltraMate Version: 7.0.022 All Rights Reserved
Date: 7/30/2010 0118 PM
Estimate ID: 8712
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Part Type/
Part Number
12477996 GM PART
Dollar Labor
Amount Units
1.8 #
2.0 *#
C 2
283.50 1.6 #
C 2.2
C 1.0
179.00 * 0.3
2.02
C 1.0
0.3 #
0.3
0.4 r
0.6 #
0.3*
1.7
69.95 * 0.0*
10.00 *
283.50 *
Page 1 of 2
19 AUTO • ADD'L COST Hazardous Waste Disposal
* - Judgment Item
# - Labor Note Applies
C - Included in Clear Coat Cale
r - CEG R &R Time Used For This Labor Operation
Add'I
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary
Body 7.6 57.00 0.00 0.00 433.20 T Taxable Parts
Refinish 8.1 57.00 10.00 0.00 471.70 T Sales Tax « 7.000%
Mechanical 0.0 62.00 0.00 69.95 69.95 T
Taxable Labor
Labor Tax
Labor Summary 15.7
III. Additional Costs
Non -Taxable Costs
r 7.000 %
Paint Material Method: Rates
Init Rate = 35.00 , Init Max Hours = 99.9, Addl Rate = 0.00
Estimate Totals
974.85
68.24
1,043.09
Amount IV. Adjustments Amount
289.50 Insurance Deductible 0.00
Total Additional Costs 289.50 Customer Responsibility 0.00
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.
E. Total Labor: 1,043.09
II. Total Replacement Parts: 497.04
III. Total Additional Costs= 289.50
Gross Total: 1,829.63
IV. Total Adjustments: 0.00
Net Total 1,829.63
This is a preliminary estimate.
Additional changes to the estimate may be required for the actual repair.
ESTIMATE RECALL NUMBER: 07/30/2010 13:18:38 8712
Mitchell Data Version: OEM: JUL_10_V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2010 Mitchell International
UltraMate Version: 7.0.022 All Rights Reserved
Date: 7/30/2010 01:18 PM
Estimate ID: 8712
Estimate Version: 0
Preliminary
Profile ID: Mitchell
6.00 *
Amount
Page 2 of 2
464.52
32.52
Total Replacement Parts Amount. 497.04
THE CITY OF
DUB
Dubuque
AFB
2007
5 sY
Masterpiece on the Mississippi
Police Department
Dubuque Law Enforcement
E" Center
770 Iowa Street
PO Box 875
Dubuque, Iowa 52004 -0875
(563) 589 -4410 Office
(563) 589 -4497 Fax
(563) 589 -4415 Dispatch
911 Emergency
TTY (563) 583 -1711
Officer J. Brokens
Patrol Officer - 46