Claim Houselog, RachelCLAIM 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: Rachael Houselog
2 Address: 2590 Rosewood Dr.
`
3. Telephone Number: 563 556 9027
4. Date of Incident: 9 13 03
5. Time of Incident: 4:30 - 5:00 P.M.
6. Location of Incident (Be specific):
Exited Mall left on University...hit while making left turn
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.)
While turning a City bus driven by Pat Healey cross the center line and hit my right front
8. What were weather conditions like?
cloudy, rainy, bus had very foggy windows
9. Give name and address of any witnesses:
Chad Schroeder, 2555 Central Apt. 2
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.)
The right front fender was scraped.
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?
$349.60
16. Why do you claim the City of Dubuque is responsible?
Because it was a city driven vehicle that hit me. The vehicle failed to stay in its appropriate lane.
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?
No
Dated at Dubuque, Iowa this 16 day of September, 2003.
/s/ Rachael Houselog
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF OUBUQUE~qOWA
This written report constitutes your claim against the City of Dubuque, Io~Na. 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:
2. Address: ~C~.(~.
3. Telephone Number: ~_~)~.~- ,~L~- CIC~ ~'~
4. Date of Incident:
5. Time of Incident: ¼"~ - ~--: ~ ~.
6. Location of Incident (Be specific):
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? C~0~6~ (~j) _)
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 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?
16. Why do you claim the City of Dubuque is responsible? "~_~_~_ ~i~ ~cj% 0._
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, inwhat amount?
Dated at Dubuque, Iowa this [~ day of ~57~C~,.~~
, 20 0~.
(Signature) ~.~
(Print Name)
(Rev. 1/00 & 7/01)
Date: 9117/2003 03:3t PM
Estimate ID: 8643
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 RACHAEL HOUSELOG
Address: 2590 ROSEWOOD DR DUBUQUE, IA 52001
Telephone: Home Phone: (563) 556-9027
Mitchell Service: 914493
Body Style:
VIN:
Options:
2000 Chevrolet CavaUer
2DOpe Drtve T~ain: 2-2L tej 4 Cyl3A FWD
'lGl JCt244Y7185263
ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER STEERING, POWER WINDOWS
POWER DOOR LOCKS, TILT STEERING WHEEL, CRUISE CONTROL, ELECTRIC DEFOGGER
AUTOMATIC TRANSMISSION, AM-FM STEREOICDPLAYER(SINGLE)
Line Entry Labor Une Item Part Type/
Item Number Type Operefion Description Part Number
Dogar Labor
Amount Units
402652 BDY REMOVEItNSTALL
402654 BDY REPAIR
AUTO REF REFINISH
AUTO REF ADD'L OPR
AUTO ADD'L COST
AUTO ADD'L COST
FRT BUMPER ASSY
FRT BUMPER COVER
FRT BUMPER COVER
CLEAR COAT
PAINT/MATERIALS
HAZARDOUS WASTE DISPOSAL
Existing
1.3 #
1.0'#
C 2-2
0.9
86-80 *
2.79 *
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
Add'l
Labor Subk~t
Labor Subtotals Units Rate Amount Amount Totals
Body 2.3 45.00 0.00 0.0~ 103.50 T
Refinish 3.1 45.00 0.00 0.00 139.50 T
Taxable Labor 243.00
Labor Tax ~ 7.000 % 17.01
Labor Sunmmry &4 260.0t
Part Replacement Summary
Totel Replacement Pa~ts Amount
0.00
ESTIMATE RECALL NUMBER: 9117/2003 15:3t:22 8643
UitraMate ~s a Tredema;k of Mitchell International
Mitchell Data Version: SEP_03_A Copyright (C) 1994 - 2003 Mitchell International
UIb'-aM ate Version: 5.0.015 All Rights Reserved
Page I
of 2
.a · ~ Data: 911712003 03:3t PM
Est/mata ID: 8643
Estimate Version: 9
preliminary
~t Profile ID: li~heil
III. Additional Costs Amount
Non-Taxabte Costs 89.59
Total Additional Costs 89.59
IV. Adjustments
Customer Responsibility
I. Total Labor.
IL Total ITe~lacement Parts:
III. Totst~l~ttonal Costs:
Gross ~)tal:
260.01
0.00
89.59
349.60
IV. Total Adjustments:
Net Total:
This is a preliminary estimate.
Additional changes to the estimate may be required for the actual repair.
PARTS PRICES ARE SUBJECT TO CHANGE
ESTIMATE RECALL NUMBER: 9117/2003 t5:31:22 8643
UlkaMate is a Trademark of Mitchell Intamational
Mitchell Data Version: SEP 03~ A~* Copyright (C) 1994 - 2003 Mitchell International
Ultrablate Version: 5.0.015 Alt ~ Reserved
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