Claim Keuter, KristinaCLAIM 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: Kristina Keuter
2. Address: 2855 Timberline
`
3. Telephone Number: House 557 1520 work 582 1841
4. Date of Incident: 9 25 03
5. Time of Incident: Between 7:45 A.M. - 5:15 P.M.
6. Location of Incident (Be specific):
9th and Iowa Parking Lot #1
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 painting of the parking meter with car parked next to it, end result was paint on front end of car, meter wasn't painted at 7:45 but was at 5:15 along with the car.
8. What were weather conditions like? Partly cloudy
9. Give name and address of any witnesses: None
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, paint on front end of car
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.)
No
15. What amount do you claim from the City of Dubuque?
The amount money of the lowest estimate of repair
16. Why do you claim the City of Dubuque is responsible?
Because the City of Dubuuqe employee painted the parking meter.
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 1st day of October, 2003.
/s/ Kristina Keuter
(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:
2. Address:
3. Telephone Number:J{,¢ S'5 7 -/~-=~0
4. Date of Incident: ~*~'- 03
5. Time of Incident:
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? ?~r?'~ ~]~.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?
J
(If yes, give name and address.)~ d.~
18.
and if so, in what amount?
Dated at Dubuque, Iowa this
If the answer to Question 17 is yes, have you received any payment from that source,
(Print Name)
(Rev. 1/00 & 7/01)
WILLIS AUTO BODY
1982 ROCKDALE RD
DUBUQUE, IA 52003
PHONE: 563-583-9329
CD LOG NO 243-1 DATE 09/30/03
SHOP:
ADDRESS:
CITY STATE:
ZIP:
WILLIS AIKfO BODY
1982 ROCKDALE RD.
DUBUQUE, IA
52003-
INSP DATE:
CONTACT:
PHONE 1:
FAX:
09/29/03
MARK WILLIS
(563)583-9329
(563)583-9329
OWNER:
ADDRESS:
CITY STATE:
ZIP:
KEUTER, KEVIN
2855 TIMBER LINE DE.
DUBUQUE, IA
52001-
HOME PHONE:
(563)557-1520
POINT OF IMPACT: 3
TYPE OF LOSS: /DRV
LIC%:
BODY COLOR:
CONDITION:
DARK GREEN
STATE:
VIN:
MILEAGE:
ACCTNG CTL%:
1G1JC5248T7223397
DRIVEABLE: YES
VEH. INSP%:
*=USER-ENTERED VALUE
EC=REPLACE ECONOMY
EU=REPLACE SALVAGE
PM=PXN REMAN/REBUILT
IT=PARTIAL REPAIR
BR=BLEND REFINISH
SB=SUBLET
P=CHECK
UP=UNRELATED PRIOR
E=REPLACE OEM
UC=RECONDITIONED PRT
Ep=REPLACE PXN
TE=PARTL REPL PRICE
I=REPAIR
TT=TWO-TONE
N=ADDITIONAL LABOR
AA=APPEAR ALLOWANCE
NG=REPLACE NAGS
UM=REMAN/REBUILT PRT
PC=PXN RECONDITIONED
ET=PARTL REPL LABOR
L=REFINISH
CG=CHIPGUARD
RI=R&I /LSSFaMBLY
RP=RELATED PRIOR
1996 CHEVROLET CAVALIER STD 4DOOR SEDAN
CODE: U2344A/B OPTNS D/24V
4CYL GASOLINE 2.2
OPTIONS:
TWO-STAGE - EXTERIOR SURFACES
ANTI-LOCK BRAKE SYSTEM
TWO-STAGE - INTERIOR SURFACES
OP GDE MC DESCRIPTION
EC Materials
N clean,buff & wax frt
MFG.PART NO.
ECONOMY PART
ADDNL LABOR OPERA
PRICE AJ% B% HOURS R
20.00* 1'
2.5'1'
2 ITEMS
FINAL CALCULATIONS &
ENTRIES
PAGE 1
19~6 CHEVROLET CAVALIER
CD,,LOG NO 243-1
OTHER PARTS
PARTS TOTAL
TAxX ON PARTS @
STD 4DOOR SEDAN
LABOR
i-SHEET METAL
2-MECH/ELEC
3-FRAME
4-REFINISH
5-PAINT MATERIAL
LABOR T OTA~L
TAX ON LABOR
SUBLET REPAIRS
TOWING
STORAGE
RATE
45.00
50.00
50.00
45.00
26.00
REPLACE HRS
GROSS TOTAL
NET TOTAL
ADP SHOPLINK U9956 ES CD LOG 243-1 DATE 09/30/03
HOST LOG
(C) 1998 - 2003 ADP CLAIMS SOLUTIONS GROUP, INC.
7.000%
REPAIR HRS
2.5
20.00
20.00
1.40
t12.50
112.50
7.000% 7.88
141.78
141.78
09:16:39AM R6.3 CD 09/03
PAGE 2
HART AUTO BODY & PAINT
800 CEDAR CROSS ROAD DUBUQUE, IOWA 52003
PHONE: (563) 556-8323 FAX: (563) 556-8324
DAMAGE REPORT
PRICES SUBJECT TO CHANGE
Items CIRCLED are not in the total in
our opinion, are not part of this c~m.
C LDR
Or Pai.t Or Ho..i P~r~ Syn. LEFT RIGHT
H~d Hinge R~R MISC.
SERVICES ~, 6HRS, ~
Windshield Gas Tank SUBLET OR PAINTING
Frame SUB TOTAL
w.~ T~
Hub & Drum PAINT-MATRL-HDW.