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Claim Kohnen, ShawnCLAIM 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: Shawn Kohnen 2. Address: 511 1/2 Rhomberg ` 3. Telephone Number: message #588 1424 Home # 583 4361 4. Date of Incident: 9 3 03 5. Time of Incident: 10:00 A.M. 6. Location of Incident (Be specific): The car (97 Chevy malibue) was parked on the street of Rhomberg outside of claimant address. 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.) Dennis Corkery attempted to park his keyline bus between the car described and our van as he pulled in between he strucked the car described above and scrapped the front driver side bumper 8. What were weather conditions like? clear and sunny 9. Give name and address of any witnesses: 513 Rhomberg (Trene Snyder) 511 Rhomberg (Sharron Sargent) 511 1/2 Rhomberg (Tom Kohnen) 2409 Central (Dennis Corkery) 10. Did police investigate? (If so, give names of officers.) No Police did not come because Dennis had already left the scene. 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). No one that I am aware of. 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.) 1997 Chevy Malibue was scaped on the front bumper of driver's side. 13. What other damages do you claim, if any? N/A 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 - None at all 15. What amount do you claim from the City of Dubuque? $417.92 16. Why do you claim the City of Dubuque is responsible? Because the car described was hit by one of your keyline busess with the driver named Dennis Corkery employed by the City of Dubuque. 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) No - no one else is responsible 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 3rd day of September , 2003. /s/ Shawn M. Kohnen (Signature) (Print Name) (Rev. 1/00 & 7/01) 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 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: ,~ ~£x (~k~ ~'~ 2. Address: ~[~ ~ 3. Telephone Number: ~C~ ~ ~-~ ~~J ~/~ 4. Date of lncident: ~-- ~--~ 5. Time of Incident: [ ~ '. ~ ~ 6. Location oflncident (Be specific): ~ ~ ~ C~ ~'~ 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.) 8. What were weather conditions like? ,. ]u. uio police inyestigate.. (If so: give names ~ 1. Was anyone injure~7 (If so, si~e names, a~resses, an~ 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 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.) 15. What amount do you claim from the City of Dubuque? S ~ Il, 9C'~ 16. Why do you claim the City of Dubuque is responsible? 17. ~ave you made any claim against a~one 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 (Signature) (Print Name) (Rev. 1/00 & 7/01) 09/03/2003 at 10:35 AM 30799 Job Number: BRIMEYER AUTO BODY License ~:30799 Federal ID %:421438480 10727 JOHN F. KENNEDY RD DUBUQUE, IA 52001 (563)583-4456 Fax: (563)583-1838 Written by: BRIAN HOCHBERGER Adjuster: Insured: KOHNEN SHAWN Owner: KOHNEN SHAWN Address: 511 1/2 RHOMBERG AVE. Other: (563)583-4361 Inspect Location: Claim % Policy # Deductible: Date of Loss: Type of LOSS: Point of Impact: 1997 CHEV MALIBU 4-2.4L-FI 4D SED Iht: VIN: 1G1HD52T5V6128472 Lic: Air Conditioning Tilt Wheel Body Side Moldings Dual Mirrors Power SteerlnS Power Brakes Anti-Lock Brakes (4) Driver Air BaS Cloth Seats Bucket Seats Days to Repair Prod Date: Odometer: Intermittent Wipers Clear Coat Paint Power Trunk/Tailgate Passenger Air Ba9 NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT 1 FRONT BUMPER 2 H&I N&I bumper cover 1.2 3* Rpr Bumper cover %.O 3.0 4 Add for Clear Coat 1.2 5 OTHER CHARGES 6~ E.P.C. 1 3.00 Subtotals ==> 3.00 2.2 4.2 Parts 0.00 Rody Labor 2.2 hrs @ $ 44.00/hr 96.80 Paint Labor 4.2 hrs @ $ 44.00/hr 184.80 Paint Supplies 4.2 hrs @ $ 27.00/hr 113.40 Other Charses 3.00 SUBTOTAL $ 358.00 Sales Tax $ 284.60 @ 7.0000% 19.92 GRAHD TOTAL $ 417.92 ADJUSTMEHTS: Deductible 0.00 CUSTOMER PAY $ 0.00 INSURANCE PAY $ 417.92 Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DRlCP97 Database Date 7/2003 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. Tilde sign {-) items indicate MOTOR Not Included Labor operations. Non Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement 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 Pare Numbers and Prices are provided from National Auto Glass Specifications, Inc. Pound sign (~) items indicate manual entries. Pathways - A product of CCC Information Services Inc.