Claim Keuter, Delbert C.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: Delbert C. Keuter
2. Address: 2540 N. Grandview Ave.
`
3. Telephone Number: 563 582 8398
4. Date of Incident: 10 30 03
5. Time of Incident: 10:15 A.M.
6. Location of Incident (Be specific):
28? Van Buren
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.)
I was driving west on Van Buren when a gust of wind sent a recycling bin into my door on the passenger side.
8. What were weather conditions like? Windy
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.)
Right front door was dented.
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?
$404.86
16. Why do you claim the City of Dubuque is responsible?
The landowner, city employee were not the owner or responsible for a recycling bin.
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 6th day of November, 2003.
/s/ Delbert C. Keuter .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUET/OWA
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.
1. Name of Claimant:
2. Address:
3. Telephone Number:
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.
4. Date of Incident:
5. Time of Incident: /~z/~__~ ~/~
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.) ~ ~-~:~-~ ~ ~ ~ ~j~_ /~_
{/ J
8. What were weather conditions like?
9. Give name and address of any witnesses: ~'~
10. Di~lice 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 damag'eS.
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?
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, in what amount?
Dated at Dubuque, Iowa this ~ day of
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Date: 11/06/2003 03:10 PM
Estimate ID: 8045
Estimate Version: 0
~relh~htary
ProfiJe ID: DUB-
MIKE FINNIN FORD
3800 DODGE STREET DUBUQUE, IA 62003
(563) 656-1010
Fax: (563) 690-1006
Tax ID: 14-1862673
Damage Assessed By: RICK STUMPF
Deductible: UNKNOWN
Telephone:
DEL KEUTER
2540 NORTH GRANVIEW DUBUQUE, IA 52001
Home Phone: (063) 582-8398
Mitchell Service: 917529
Descrydon: 2003 Chr~sJer SebrhtcJ LX
Body Style: 2D Cony Drive Train: 2.7L Inj 6 Cyl 4A FWD
VIN: IC3EL45T23N554269
Options: ALUM/ALLOY WHEELS, AtR CONDITIONING, pOWER STEEPJNG, POWER WINDOWS
POWER DOOR LOCKS, TILT STEERING WHEEL, CRLRSE CONTROl, ELECTRIC DEFOGGER
AUTOMATIC TRANSMISSION, AM-FM STEREO/CDPLAYER(SINGLE)
Line Enffy Labor Line Item pair Type/
item Number Type Operation Descrydon Par~ Number
Dolla~ Labor
mt Units
7O1554 BDY REPA~
AUTO REF REFINISH
AUTO REF ADD1. OPR
933006 BDY ADDI.. OPR
933018 REF ADD'L OPR
AUTO ADD'I- COST
AUTO ADD'L COST
R FRT DOOR SHELL
R FRT DOOR OUTSIDE
CLEAR COAT
RESTORE CORROSION PROTECTION
MASK FOR OVERSPRAY
pAINT/MATER]ALS
HAZARDOUS WASTE DISPOSAL
2.5*#
C 2.2
0.9
1.25' 5-1'
10.00' 0.2~
86.80 *
:3.00 *
* - Judgement item
# - Labor Note Applies
C - Included in Clear Coat Calc
Add'l
Labor Sublet
Labor Subtotals Units R'a~e Amoun~ Amount Totals
Body 2.6 48.00 1.25 0.00 126.00 T
R~efinish 3.3 4800 10.00 O.00 168,.40 T
Taxable Labor 294.45
Labor Tax ~ 7.000 % 20.61
Labor Story 5.9
IL Part Replacement Strmmary
Total Replacefl~nt Parts ~m]ount
ESTIUATE RECALL NUMBER: 11,~2003 10:07:t6 8045
UitzaMate is a Trademark of Mitchell InternaUonal
Mitchell Data Version: OCT_03_A Copyright (C) 1994- 2002 Mitchefi International
UltraMate Version: 4.8.012 All Rights Reserved
page I
Amount
0.00
of 2
Date: tl/0612003 03:10 PM
Estintate ID: 8045
Estimate V~: O
Prelbrdnary
Pl'ofile ID: DUB-A/M
III. /~lditional Cosis Amount
Non-Taxable Costs 89~80
Total Additional Coasts 89.80
iV. Adjustments
Cuslome; Real~sibil'~y
L Total [.abm:.
II. Total Replacement Pa~s:
III. Total A~lditisflat Costs:
Gross Total:
Total Adjustroents:
Net Total:
315.06
0.00
89.80
4O4,86
0.00
404.86
This is a preliminary estimate.
Additional chanqes to the estimate may be required for the actual repair.
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF AFTERMARKET C~ASH
PARTS SUPPLIED BY A SOURCE OTW~R T~AN THE MANu~'ACTURER OF YOUR MOTOR
VEHICLE. ANY ~a. RRANTIES APPLICABLE TO T~SE PARTS ARE PROVIDED BZ THE
MA~u~ACTuRER OR DISTRIBUTOR OF THESE PARTS RATHER THAN THE
MANUFACTURER OF ZOUR MOTOR VEHICLE.
WARNING: Accidental air bag deployment is poss~ole. Personal injmy may result. Avoid area n~ar steering wheel
and instrument panel even if air bags have deployed. Dual-stage air bag modules may be present that could
contain an undeployed stage. When dispostag of a deployed dual-stage air bag, always treat it as a "live" modu~e~
See appropriate MITCHELL® AIR BAG SERVICE & REPAIR MANUAL, or OEM informaUon.
ESTIMATE RECALL NUMBER: 11~6f2003 15:07:t6 8045
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: OCT_03_A Copyright (C) 1994 - 2002 Mitchell International
UltraMate Version: 4~8.012 All Rights Reserved
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