Claim by Kayla McLaughlin, Nicole Huseman11/1 ! / n -
: : )K4/ t` q'Lx
CLAIM AGAINST THE CITY OF DUBUQUE, IO A fLL^'wl
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 West 13 St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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: (,k.\\■,'■ I \ vkAk.\1111■YA
\\Y \ MON)
TA) - Z J1
2. Address:
3. Telephone Number 510''S �l2 9 zl 0 L
4. Date of Incident: \7. I I ) ( b
5. Time of Incident: k
10. Did olice investigate? (If so, give names of officers.)
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6. Locati n of J ent (Be specific
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7. Describe the 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.)
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8. What were weather conditions Fke?
9. Give name and address of any witnesses:
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11.1 r) W as anyone injured? (If so, give names, addresses, and extent of injuries).
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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.)
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13. What other damages do you claim, if any?
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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?
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16. Why do you claim the City of Dubuque is responsible?
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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
sou c and if so, in what amount?
Dated this day of ekcl 0),VY1 , 20 U .
(Signature
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Damage Assessed By: Rick Stumpf
Deductible: 0.00
Claim Number: 9595
Insured:
Address:
Telephone:
Description:
Body Style:
VIN:
OEM /ALT:
Color:
Options:
Line Entry Labor
Item Number Type
1 003109 BDY
2 003111 BDY
3 AUTO REF
4 003119 BDY
5 000034 BDY
6 AUTO BDY
7 000138 BDY
8 AUTO REF
9 000146 BDY
10 936014
11 AUTO REF
12 933005 BDY
13 933018 REF
14 AUTO
15 AUTO
Mike Finnin Ford
KAYLA MCLAUGHLIN
2512 STAFFORD, DUBUQUE, IA 52001
Home Phone: (563) 557 -9172
2008 Pontiac G6 GT
4D Sed Drive Train: 3.5L Inj 6 Cyl 4A FWD
1G2ZH57N784115721
0 Search Code: None
SILVER
VEHICLE ANTI - THEFT, PASSENGER AIRBAG, DRIVER SIDE AIRBAG, POWER DRIVER SEAT
POWER LOCK, POWER WINDOW, POWER STEERING, REAR WINDOW DEFOGGER
MANUAL AIR CONDITION, CRUISE CONTROL, TILT STEERING COLUMN, ANTI -LOCK BRAKE SYS.
TRACTION CONTROL, FOG LIGHTS, AUXILIARY INPUT, LEATHER STEERING WHEEL
SATELLITE RADIO, CHROME WHEELS, POWER ADJUSTABLE EXTERIOR MIRROR, TINTED GLASS
FIRST ROW BUCKET SEAT, KEYLESS ENTRY, CLOTH SEAT, INTERACTIVE TRANSMISSION
TACHOMETER, SIDE AIRBAGS, AUTOMATIC HEADLIGHTS
PASSENGER AIRBAG CUTOFF SWITCH /SENSOR, REMOTE DECKLID OR TAILGATE RELEASE
VEHICLE THEFT TRACKING /NOTIFICATION, ONSTAR, DAYTIME RUNNING LIGHTS
Operation
OVERHAUL
REPAIR
REFINISH
REMOVE /REPLACE
REMOVE /REPLACE
CHECK/ADJUST
REPAIR
REFINISH
REMOVE /REPLACE
ADD'L COST
ADD'L OPR
ADD'L OPR
ADD'L OPR
ADD'L COST
ADD'L COST
3600 Dodge Street, Dubuque, IA 52003
(563) 556 -1010
Fax: (563) 690-1086
Email: bodyshop@finninautos.com
Tax ID: 14- 1862673
Mitchell Service: 910410
Line Item
Description
Frt Bumper Cover Assy
Frt Bumper Cover
Frt Bumper Cover
L Frt Bumper Bracket
L Front Combination Lamp Assembly
Headlamps
L Fender Panel
L Fender Outside
L Fender Liner
Flex Additive
Clear Coat
Restore Corrosion Protection
Mask For Overspray
Paint/Materials
Hazardous Waste Disposal
ESTIMATE RECALL NUMBER: 12/15/2010 10:46:54 9595
Mitchell Data Version: OEM: NOV_10_V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2010 Mitchell International
UltraMate Version: 7.0.224 All Rights Reserved
-I
Date: 12/15/2010 10:46 AM
Estimate ID: 9595
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Part Type/
Part Number
Existing
20819715 GM PART
20821143 GM PART
Existing
25956106 GM PART
Dollar Labor
Amount Units
3.2 #
3.0*#
C 2.6
22.83 INC #
257.18 INC
0.4
3.0*#
C 1.9
44.72 0.4
8.00 *
1.4*
10.00 * 0.2*
10.00 * 0.2*
212.40 *
5.00 *
Page 1 of 2
u
N
I
T
001
Driver's Name - Last
LUCAS
First 1 Middle I Suffix
JOYCE i ANN
Date of Birth
09/06/1947
Address
2754 WASHINGTON ST
City '
DUBUQUE
State
IA
Zip
52001 - 0000
Home /Cell Phone
Gender
Female
Driver License Number 1
773YY7031
Class State
I B I IA
Endorsements
P
Restric' ions
B
Insurance Co. Name Insurance Co. Phone # i
SELF - CITY OF DUBUQUE (563) 589 - 4130 x
Insurance Policy #
Owner Company Name
CITY OF DUBUQUE
Owner's Name - Last
First 1 Middle 'i Suffix
Address
50 W. 13TH
City 1
DUBUQUE
State
1 IA
Zip
52001 -
, i
VIN No
4RKJNTFA22R835550
Year
2002
Make
RTS
Model
62VN
Style
BUS
Vehicle Configuration
License Plate #
85985
State
IA
Year 1
2010
Most Damaged Area
Approximate Cost to Repair or Repia,=.
N
T
002
Driver's Name - Last
PARKED
First 1 Middle j Suffix Date of Birth
I
Address
City
State
Zip
Home,'Cell Phone
Gender
Driver's License Number
Class ' State Endorsements
NONE
1-
Restrictions
NONE
Insurance Co. Name Insurance Co. Phone #
AMERICAN FAMILY MUTUAL
Insurance Policy #
Ownar Company Name
Ovine s Name - Last
HUSEMAN
First iddle Suffix
1 NICOLE 1 1 MARY
Address
2 685 QUEEN
City
DUBUQUE
I State
IA
Zip I
52001 -
VIN No.
1G2ZH57N784115721
I i
Year Make
2008 PONT I
Model 1
G6
Style
Y
Vehicle Configuration
License Plate #
APPLFOR
State
IA
Year I Most Damaged Area
I _
Approximate Cost to Repair or Replace
-
County
Dubuque - 31
Literal De°._rioticn
"N /A"
X Coordinate
'N /A"
If accident occurred outside of city
limits show general vacinity "N /A"
Dri Road, Street, or Highway
MERZ
Definable intersection, brid;;e, or railroad crossing
STAFFORD / MERZ
Officer
FLANNERY. ROBERT
Driver Information Exchange Report
Accident occurred within corporate limits of (city
Dubuque - 2100
Cirection
"N /A" of
Dubuque Police Department
563- 589 -4410
Nearest City
"N /A"
Distance Direction I Distance Direction
25 Ft 3 - E and "N /A" 1"N/A'
Y Coordinate
"N /A"
At Intersection vdith.
"N /A"
of
Printed At: Dubuque Police Department 12;15/2010 08:34 AM P,e 1
Milepost Number
"N /A" Or
Route (Cardinal)
Travel Direction "N /A"
Badge No. I Law Enforcement Case Number Date of Accident I Time cf Accident
15A I01 - 10 - 61170 12/15/2010 07:36 Hrs.
Form #: 01-10-81170
Y
* - Judgment Item
# - Labor Note Applies
C - Included in Clear Coat Calc
Estimate Totals
Date: 12/15/2010 10:46 AM
Estimate ID: 9595
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Add9
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
Body 10.2 56.00 10.00 0.00 581.20 T Taxable Parts 324.73
Refinish 6.1 56.00 10.00 0.00 351.60 T Sales Tax @ 7.000% 22.73
Taxable Labor 932.80 Total Replacement Parts Amount 347.46
Labor Tax @ 7.000 % 65.30
Labor Summary 16.3 998.10
III. Additional Costs Amount IV. Adjustments Amount
Taxable Costs 8.00 Insurance Deductible 0.00
Sales Tax @ 7.000% 0.56
Customer Responsibility 0.00
Non - Taxable Costs 217.40
Total Additional Costs 225.96
Paint Material Method: Rates
Init Rate = 36.00 , Init Max Hours = 99.9, Addl Rate = 0.00
ESTIMATE RECALL NUMBER: 12/15/2010 10:46:54 9595
Mitchell Data Version: OEM: NOV_10_V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2010 Mitchell International
UltraMate Version: 7.0.224 All Rights Reserved
I. Total Labor: 998.10
II. Total Replacement Parts: 347.46
III. Total Additional Costs: 225.96
Gross Total: 1,571.52
IV. Total Adjustments: 0.00
Net Total: 1,571.52
This is a preliminary estimate.
Additional changes to the estimate may be required for the actual repair.
Page 2 of 2