Claim Walgren, James C DDSCLAIM 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: James C. Walgren DDS
2. Address: 68 Ford Dr. East Dubuque, IL 61025
3. Telephone Number: 815 747 2846
4. Date of Incident: Oct 1, 2003
5. Time of Incident: 12:35 PM
6. Location of Incident (Be specific): Grandview Ave. Southbound Lane North of Light at Dodge St.
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 stopped for light I was hit from behind by a City truck. John Klosterman was called to the scene to speak for the driver.
I do not know the driver's name.
8. What were weather conditions like?
Clear, sunny
9. Give name and address of any witnesses:
Dr, Donald Allord, 122 Rockdale Rd (Wednesdays). REsidence in Bettendorf, IA
10. Did police [nvestigete? If so,,given~mes of officers.)
Officer stopped but didn't investigate. Name unknown by me.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
I have a sore neck resulting from accident
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.)
My car was damaged
13. What other damages do you claim, ifany? None at this time.
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 doyou claim from the City of Dubuque? ~ $1,150.48
16. Why do ~(ou claim the City of Dubuque is responsible?
John Klostermann told me the City would pay the damages.
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?
Dated at Dubuque, Iowa this 7th day of October, 2003.
/s/ James C. Walgren DDS
day of
(Print Name)
(Rev. 1/00 & 7/01)
~ ~ Date: t 011/2003 0t:37 PM
Estimate ID: 613
· Estimate Version: 0
Preliminary
Profile ID: Mitchell
Dan Kruse PontiaC, Nissan, BMW
600 Century Dubuque, IA 52002
{563) 583-7345
Fax: (563) 588-3874
Damage AsseSsed By: Dave DeMoss
Deductible: UNKNOWN
Insured: JAMES WALGREN
Address: 68 FORD DR EAST DUBUQUE, IL 61025
Telephone: Work Phone: (563) 556-2650
Home Phone: (815) 747-2846
Mitchell Service: 913225
Description: 2000 BNJW MS
Body Style: 4D Seal Dr'we Train: 5.0L Inj 8 Cyl 6M
VIN: WBSDE9341YBZ97086
Options: ANTI-LOCK BRAKE SYS. (ABS), ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER STEERING
POWER WINDOWS, POWER DOOR LOCKS, POWER PASSENGER SEAT, TILT STEERING WHEEL
CRUISE CONTROL, ELECTRIC DEFOGGER, LEATHER SEATS, TRACTION CONTROUELECTRONIC
PREMIUM SOUND SYS., POWER DRIVER SEAT, AM-FM STEREO/CDPLAYER(SINGLE)
Line Entry Labor Line Item Part Type/
Item Number Type Operation Description Part Number
Dollar Labor
Amount Units
t
2
3
4
5
6
7
8
9
AUT~O - BDY OVERHAUL REAR COVER ASSY
304925 BDY REMOVE/REPLACE REAR BUMPER COVER 51 12 2 498 489
AUTO REF REFINISH REAR BUMPER COVER
AUTO BDY REMOVE/REPLACE REAR ADD W/SENSOR
304942 BDY REMOVE/REPLACE REAR BUMPER REINFORCEMENT 5t 12 8 193 200
AUTO REF ADD'L OPR CLEAR COAT
933003 REF ADD'L OPR TINT COLOR
AUTO .... ADD'L COST PAINT~/IATERIALS
AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
2.0
499.50 INC
C 2~5#
0.3
189.00 INC ·
0.5'
108.00 *
3.50 *
Add'l
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Tots~s IL Part Replacement Summary
Body 2.3 45.00 0.00 0.00 103.50 T Taxable Parts
Refinish 4.0 45.00 0.00 0.00 t80.00 T Sales Tax
Taxable Labor 283.50 Total Replacement Parts Amount
Labor Tax ~ 7.000 % t9.85 .
303.35
Labor Summary 6.3
ESTIMATE RECALL NUMBER: 101 t/2003 13:32:02 613
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: OCT_03_A Copyright (C) 1994 - 2002 Mitchell international
UltrsMate Version: 4.8.0t2 All Rights Reserved
7.000%
Page I
Amount
687.50
48.t3
735.63
of 2
Date: I01112003 01:37 PM
Esfimata ID: 613
Estimate Version: 0
' Preliminary
Profile ID: Mitchell
Ill. Additional Costs Amount iV. Adjustments
Non-Taxable Costs t t t.50 Customer Responsibility
Total Add~onaI Costs 111.50
Amount
0.00
I. Total Labor:
II. Total Replacement Parts:
IlL Total Additional Costs:
Gross Total:
303.35
735.63
tlt.50
1,150.48
IV. Total Adjustments:
Net Total:
0.00
1,150.48
This is a preliminary estimate,
Additional chan.qes to the estimate may be required for the actual repair.
THIS DAMagE REPORT IS BASED ON OUR INSPECTION AND DOES NOT
COVER AN~ADDION]tL PARTS OR L~BORWHICHM~Z BE P~QUIREDAFTER
THE WORK HA~ BEEN OPENED UP THE INS,WILL BE NOTIFIED.
WE FEATURE A THREE I'EARWORKM~NSHIP LIMITED ~T- SEE OUR WRITTEN
~ FOR COMPLETE DETAILS.(EFECTIVE 10-01-01)
WARNING: Accidental air bag deployment is possible. Personal injury may result. Avoid area near steering wheel
and instrument panel even if air bags have deployed. Dual-stags air bag modules may be present that could
contain an undeployed stags. When disposing of a deployed dual*stage air bag, always treat it as a 'live" module.
See appropriate MITCHELL® AIR BAG SERVICE & REPAIR MANUAL, or GEM information.
ESTIMATE RECALL NUMBER: t0/112003 13:32:02 6t3
UltraMate is a Trademark of Mitchell international
Mitchell Data Version: OCT_03_A Copyright (C) 1994 - 2002 Mitchell Intarsational
UitraMate Version: 4,8.0t2 Ali Rights Reserved
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