Claim by Darlene Ryan4 7/ /lam
CLAIM AGAINST THE CITY OF DUBUQUE, IOW
2
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. 13 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: Di'kiie_
fib 11
2. Address: / � ] (p) Pp iSi-D 1 0 r
3. Telephone Number: 5 ' c Lea(/*
4. Date of Incident: 9 / 2 � /
5. Time of Incident: a:/ D PIY1
6. Location of Incident (Be specific): On 30th i par ked h" TI1�1�
O I-to I 6hbs1 ,S ihn 1 Eifi'a cc- -
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.)
vas park 3o a i n - &ron+ of Holy GMs frwc--
tad- - then k I 1oe, 7 tnsi 1- nit �1i [u 5 artirq- Rona( i)'t�Kc a
'teg� Pf-cel -to pa , , n { rcx+- 4F , u m, s ude d 4& d r anCR.
8. W hat were weather conditions like? ci IA f 1+1, . #r a,n•1 - A r1 ex 5 CCr
6 ��� 1 C, rill its hk.. put 1 r n
9. Give name and address of any witnesses: T (a& y to Rf. ' L Sot 550 71
Er n'Iy Oe14 Row 6n,insu)ick SA
10. Did police investigate? (If so, give names of office
e„ Uffic AI i 611014 Jobc &coke. Cam
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
0 J but
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.)
11Ii Je ma fo - Frnf C vrne,r panel - b- m pe, , door
`Ni
he a 1 1, -ti 1 . 15 coopy c `eshmak. ,r mat 1 .
13. What other damages do you claim, if any? + O A ' a . da mays aS I . 39
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. W at amount do you clam fro the City of Dubuque?
as-11,z - -�� x-td fc m a i s cti on Wa Vt f hla� -r
u ril 4 fv orilina ( c&d f i O
16. Why do you claim the City of Dubuque is responsible?
� a n fiic Risen- do 1nsrt S he GOhcn ri rg tn9 -1-o pa
bus ‘1,0 ', b i c 1-(1 - Le-
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) �)
o
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 1 la day of 06-obe-r , 20 10.
(Rev. 1/00 & 7101)
N
(Signature)
I} 4 you u (Print Name)
0
rn
0
Damage Assessed By: john klotz
Deductible:
Claim Number:
Insured:
Address:
Telephone:
Description:
Body Style:
VIN:
OEM /ALT:
Options:
0.00
8819
darleen ryan
1765 bristal, dubuque, IA 52001
Home Phone: (563) 582-3434
2007 Chevrolet TrailBlazer LS Drive Train: 4.2L Inj 6 Cyl 4WD
4D Ut
1GNDT13S2721
0 Search Code: None
VEHICLE ANTI- THEFT. PASSENGER AIRBAG, DRIVER SIDE AIRBAG, POWER LOCK
POWER WINDOW, POWER STEERING, MANUAL AIR CONDITION, CRUISE CONTROL
TILT STEERING COLUMN, ANTI-LOCK BRAKE SYS., ALUM/ALLOY WHEELS
TIRE INFLATION/PRESSURE MONITOR, SATELLITE RADIO, CD PLAYER, TOW HITCH RECEIVER
4WD OR AWD, FRONT AIR DAM, TINTED GLASS, FIRST ROW BUCKET SEAT
SECOND ROW SPLIT BENCH SEAT, SECOND ROW FOLDING SEAT
REAR HEATING, VENTILATION & AIR CONDITIONING, CLOTH SEAT, EXTERIOR RAILS
TACHOMETER, AUTOMATIC HEADLIGHTS, VEHICLE THEFT TRACKING/NOTIFICATION, STAR DDAYTT RUNNING LIGHTS
ne Entry Labor
em Number Type Operation
i AUTO BDY OVERHAUL
000015 BDY REMOVE/REPLACE
AUTO REF REFINISH
007510 BDY REMOVE/REPLACE
i AUTO BDY CHECK/ADJUST
000309 BDY REMOVE/REPLACE
i AUTO REF REFINISH
AUTO REF REFINISH
000894 REF BLEND
10 006800 BDY REMOVE/INSTALL
t 1 002033 BDY REMOVE/INSTALL
t2 006930 BDY REMOVE/REPLACE
[3 001046 BDY REMOVE/INSTALL
14 AUTO REF ADD'L OPR
t5 933005 BDY ADD'L OPR
16 933018 REF ADD'L OPR
17 AUTO ADD'L COST
18 AUTO ADD'L COST
BIRD CHEVROLET
3255 UNIVERSITY ) AVE, DUBUQUE, IA 52001
Fax: (563) 690-1423
Email: johnklotz @birdchevrolet.com
Tax ID: 42.0400210
Mitchell Service: 910501
Part Type/
D ine Item part Number
Description
Frt Bumper Cover Assy
Frt Bumper Cover
Frt Bumper Cover
L Frt Combination Lamp Assembly
Headlamps
L Fender Panel
L Fender Outside
L Add To Edge Fender
L Frt Door Outside
L Frt Otr Belt Moulding
L Frt Door Adhesive Moulding
L Frt Door Rear View Mirror
L Frt Door Handle
Clear Coat
Restore Corrosion Protection
Mask For Overspray
Paint/Materials
Hazardous Waste Disposal
ESTIMATE RECALL NUMBER: 09 /20/2010 16:52:40 8819
Mitchell Data Version: OEM: AUG_10_V Ulc pMag Mitchell
(C) 1994 2010 A hell International International
UltraMate Version: 7.0.022 All Rights Reserved
Preliminary
Profile ID: Mitchell
88937008 GM PART
25970915 GM PART
12477993 GM PART
Dollar Labor
Amount Units
1.4 #
419.51 INC #
C 2.5
313.38 0.3 #
0.4
255.72 1.6 #
C 2.2
C 1.0
C 1.0
0.3
Existing 0.4 r
ORDER FROM DEALER 318.90 0.3 #
0.6 #
1.8
4.00 * 0.2*
10.00 *
297.50 *
6.00 *
Page 1 of 2
Add'I
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
Body 5.5 57.00 4.00 0.00 317.50 T Taxable Parts 1,307.51
Refinish 8.5 57.00 10.00 0.00 494.50 T Sales Tax @ 7.000% 91.53
Labor Summary
L Additional Costs
* - Judgment Item
# - Labor Note Applies
C - Included in Clear Coat Calc
r - CEG R &R Time Used For This Labor Operation
Estimate Totals
Estimate ID: 8819
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Taxable Labor 812.00 Total Replacement Parts Amount
Labor Tax @ 7.000 % 56.84
14.0 868.84
Paint Material Method: Rates
Init Rate = 35.00 , Init Max Hours = 99.9, Addl Rate = 0.00
Amount IV. Adjustments Amount
Non-Taxable Costs 303.50 Insurance Deductible 0.00
Total Additional Costs 303.50 Customer Responsibility 0.00
I. Total Labor= 868.84
II. Total Replacement Parts. 1,399.04
III. Total Additional Costs= 303.50
Gross Total: 2,571.38
IV. Total Adjustments: 0.00
Net Total: 2,571.38
This is a preliminary estimate.
Additional changes to the estimate may be required for the actual repair.
ESTIMATE RECALL NUMBER: 09 /20/2010 16.5240 8819
Mitchell Data Version: OEM: AUG_10_V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2010 Mitchell International
UltraMate Version: 7.0.022 All Rights Reserved
1,399.04
Page 2 of 2
u
N
- I r
001
Driver's Name - Last
MCKIERNAN -
First I Middle
RONALD I JOSEPH
Suffix
Address City - 1
13036 CIRCLE RIDGE ROAD j SHERRILL
State
IA
Z'p
52073 - 0000
Home /Cell Phone
(563) 552 - 2007 x
Gender •
Male
1
Class T State
C,M LIA State
Endorsements
Restrictions
L
Insurance Co. Name Insurance Co. Phone #
ICAP
Insurance Policy #
Owner Company Name
CITY OF DUBUQUE
Owner's Name - Last
First
Middle
Suffix
Address
50 W. 13TH
City
DUBUQUE
State
IA
Zip
52001 -
VIN No
1FDXE40S3WHA64144
Year Make
1998 FORD
Model
E - SUPER DUTY
Style
MINI BUS
Vehicle Configuration
19
License Plate #
111985
State
IA
Year
Most Damaged Area
02 - Right Front
Approximate Cost to Repair or Replace
$100.00
Driver's Name - Last
u RYAN
First
DARLENE
Middle
MAE
Suffix
N Address
1765 BRISTOL DR
City
DUBUQUE
State
1 IA
Z'p
52001 - 0000
Home /Cell Phone
(563) 582 - 3434 x
I
T Gender
Female
Class
C
State
IA
Endorsement
NONE
Restrictions
LB
Insurance Co. Name Insurance Co. Phone #
WESTFIELD (563) 556 - 0272 x
002 Owner Company Name
Insurance Policy #
WNP7049664
Owner's Name - Last I First
RYAN 1 DARLENE J
Middle 1
MAE
Suffix
Address
1765 BRISTOL DR
City .. I State
DUBUQUE I IA
Zip
52001 - 0000
VIN No.
1GNDT13S272160415
Year
2007
Make
CHEV
Model
TBZ
Style
SW
Vehicle Configuration
04
License Plate #
039AVU __
State
I IA
Year
2007
I Most Damaged Area
08 - Left Front _ _ __
Approximate Cost to Repair or Replace
$1,000.00 __ ___ —
_
County T Accident
Dubuque - 31
occurred within corporate limits of (city)
I Dubuque - 2100
Literal Description
W 30TH ST
X Coordinate IT
00690441 4710686
If accident occurred outside of city
limits show general vacinity: "N /A"
Direction
"N /A" of
Nearest City
"N /A"
Route (Cardinal)
Travel Direction "N /A"
On Road, Street, or Highway:
W.30TH
At Intersection with:
"N /A"
Distance
50 Ft
Direction
13 - and
Distance
"N /A"
Direction
"N /A' of
Milepost Number
"N /A" Or
Definable intersection, bridge, or railroad crossing
LEMON ST
Officer
JOBGEN, NICHOLAS B
Badge No
77
Law Enforcement Case Number
01
Date of Accident I Time of Accident
09/20/2010 1 14:10 Hrs.
. Printed At: Dubuque Police Department 09/20/2010 03:56 PM
Page 1 Form #: 01- 10-45896
Driver Information Exchange Report
Dubuque Police Department