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Claim by Christine A. JensenTHE CITY OF DUB E MEMORANDUM Masterpiece on the Mississippi TRACEY STECKLEIN PARALEGAL -4-rD To: Mayor Roy D. Buol and Members of the City Council DATE: August 18, 2010 RE: Claim Against the City of Dubuque by Christine A. Jensen Claimant Date of Claim Date of Loss Nature of Claim Christine A. Jensen 08/13/10 08/05/10 Vehicle Damage This is a claim in which claimant that as she was backing out of a short -term parking spot at the Dubuque Regional Airport, a piece of rebar which was sticking out of the parking block caught and damaged the lower front body of claimant's vehicle. 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 Todd Dalsing, Airport Operations /Maintenance Supervisor Christine A. Jensen 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 Attorneys 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: CA it IS / /')) \ �Li,11 2. Address: �F I,3 C AT) ( rnC AL) 3. Telephone Number: CA 0 ) !3 - LA C(_ 4. Date of Incident: F 1 5. Time of Incident: r \) e ',1c.1 iYlc).\ Old . `,� Y 6. Location of Incident (Be specific): 1.1, 1.1rLt a 1 K >�� - - )1 C ( - T e C ) 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.) (1J( //1/C% (-) ; �)1(. 1 -f i% r,/ )( 1_0}L+Ch )cicirl(' nc i (.' 4-)k p)r)Co is I l)a- . 1 o 1;1 1)(\a_ royi►,i - \)/ (C) Li_ 1,1 i✓n))d,01)'1(_ 8. What were weather conditions like? nen 01 / ] ( / )1') Y1 L O 9. Give name and address of any witnesses: 2 I 4'.' / l ,l J \ )1Qgtrg �� \1i 1L bz1C`1 10. Did police investigate? (If so, give names of officers.) /Lk) 11. Was anyone injured? (If so, give names, addresses, and extent of injuries.) oc- 0\,ii1 I)? 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,) V )A—\ o,n■6 (10C'00 . �; 11 Inr,lkAA r\ (11,3a ) 9)(i.c 0_,\J- I - bac — [_>1 C. )1.0 \rG. A•\\ Cl L Q_CA ,C- 13. What other damages do you claim, if any? /Lk 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 res onsible? () .I f ( ) (1 >? / 11 . of ) ( qi) LI hr)(1 I(PC ntt �C()a1)�� C 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 this \ day of IA C' �,1 J� It'itc 1 _ikAc (Sipgnatur) // (Print Name) ,20 _n c) c • • 33 C ' GD m s? w m 5 CJ N m %.7"" Damage Assessed By: JERRY MOSHURE Deductible: Claim Number: Owner: Address: Telephone: Description: Body Style: VIN: OEM/ALT: Color: Options: 0.00 35895 Line Entry Labor Item Number Type Operation CLASSIC BODYWORKS, INC. JOE JENSEN 613 CRAGMOOR AVE., SAVANNA, IL 61074 (815) 273-2664 1 AUTO BDY OVERHAUL 2 102632 BDY REMOVE/REPLACE 3 AUTO REF REFINISH 4 102637 BDY REMOVE/REPLACE 5 102638 BDY REMOVE/REPLACE 6 100121 BDY REMOVE/REPLACE 7 AUTO REF ADD'L OPR 8 AUTO ADD'L COST 9 AUTO ADD'L COST * - Judgment Item # - Labor Note Applies C - Included in Clear Coat Calc 213 -17TH AVENUE NORTH, CLINTON, IA 52732 (563) 243 -2688 Fax: (563) 243 -5481 Mitchell Service: 911005 2010 Ford Focus SE Vehicle Production Date: 4D Sed Drive Train: 1 FAHP3FN4AW 120312 License: O Search Code: GRAY VEHICLE ANTI - THEFT, PASSENGER AIRBAG, DRIVER SIDE AIRBAG, POWER LOCK POWER WINDOW, POWER STEERING, REAR WINDOW DEFOGGER, MANUAL AIR CONDITION TILT STEERING COLUMN, ANTI -LOCK BRAKE SYS., ALUM /ALLOY WHEELS TIRE INFLATION/PRESSURE MONITOR, AUXILIARY INPUT, SATELLITE RADIO, CD PLAYER POWER ADJUSTABLE EXTERIOR MIRROR, AUTOMATIC TRANSMISSION, FRONT AIR DAM TINTED GLASS, FIRST ROW BUCKET SEAT, SECOND ROW SPLIT BENCH SEAT, KEYLESS ENTRY SECOND ROW FOLDING SEAT, REAR HEATING, VENTILATION & AIR CONDITIONING OUTSIDE TEMPERATURE GAUGE, CLOTH SEAT, TACHOMETER, SIDE AIRBAGS PASSENGER AIRBAG CUTOFF SWITCH/SENSOR, SIDE HEAD CURTAIN AIRBAGS REMOTE DECKLID OR TAILGATE RELEASE, MP3 PLAYER Line Item Description Frt Bumper Cover Assy Frt Bumper Cover Frt Bumper Cover R Frt Bumper Reinforcement L Frt Bumper Reinforcement Lwr Front Body Air Deflector Clear Coat Paint/Materials Hazardous Waste Disposal ESTIMATE RECALL NUMBER: 08/09/2010 16:42:44 35895 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: 8/ 9/2010 04:44 PM Estimate ID: 35895 Estimate Version: 0 Preliminary Profile ID: CLASSIC 8/09 2.0L Inj 4 Cyl 4A FWD RUNVS 13 IL None Part Type/ Part Number 8S4Z 17D957 APTM 8S4Z 17C947 A 8S4Z 17C947 B 8S4Z 8327 A Dollar Labor Amount Units 2.0 # 550.85 INC # C 2.8 14.43 0.2 # 14.43 0.2 # 68.85 INC 1.1 132.60 * 3.00 * Page 1 of 2 I. Labor Subtotals Body Refinish Labor Summary III. /{ddional Costs Taxable Costs Sales Tax Non - Taxable Costs Total Additional Costs Estimate Totals Add'I Labor Sublet Units Rate Amount Amount Totals II. Part Replacement Summary Amount 2.4 54.00 0.00 0.00 129.60 T Taxable Parts 648.56 3.9 54.00 0.00 0.00 210.60 T Sales Tax @ 7.000% 45.40 Taxable Labor 340.20 Labor Tax © 7.000 % 23.81 6.3 364.01 @ 7.000% Init Rate = 34.00 , Init Max Hours = 99.9, Addl Rate = 0.00 Amount IV. Adjustments 3.00 Insurance Deductible 0.21 132.60 135.81 This is a preliminary estimate. Additional changes to the estimate may be required for the actual repair. AUTHORIZED AND ACCEPTED: You are hereby authorized to make the above specified repairs. I understand that payment in full will be due upon release of vehicle including additional supplemental damage charges, and hearby grant you and /or your employees, permission to operate the vehicle herein described on streets, highways, or elsewhere for the purpose of testing and inspection. An express artisan's lein is hereby acknowledged on the above vehicle to secure the amount of repairs thereto. You will not be held responsible for loss or damage to the vehicle or articles left in vehicle in case of fire, theft, accident or any other cause beyond your control. OLD PARTS REMOVED FROM CAR WILL BE JUNKED UNLESS OTHERWISE INSTRUCTED. We guarantee our workmanship for a minimum of ONE year from the date of repairs, excluding rust. EIN #42- 1360864 ESTIMATE RECALL NUMBER: 08/09/2010 16:42:44 35895 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: 8/ 9/2010 04:44 PM Estimate ID: 35895 Estimate Version: 0 Preliminary Profile ID: CLASSIC Total Replacement Parts Amount 693.96 Amount 0.00 Customer Responsibility 0.00 I. Total Labor: 364.01 II. Total Replacement Parts: 693.96 III. Total Additional Costs: 135.81 Gross Total: 1,193.78 IV. Total Adjustments: 0.00 Net Total: 1,193.78 Page 2 of 2