Claim Green, JimCLAIM 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: Jim Green
2. Address: 1855 Atlantic St.
`
3. Telephone Number: 583 6557
4. Date of Incident: 12 10 03
5. Time of Incident: 8:05 A.M.
6. Location of Incident (Be specific):
1855 Atlantic Street
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.)
City recycling Refuse Truck was going down Atlantic St on his route. Street was icy and very slick - truck slid into right rear of my car.
8. What were weather conditions like? Rainy & Icy
9. Give name and address of any witnesses: City Employees on Refuse Truck
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, Right rear of my vehicle - a 2001 Chevrolet Malibu
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? $674.62 - as per estimate from Bird Chevrolet - Dubuque Iowa.
16. Why do you claim the City of Dubuque is responsible?
Damage was caused by City Refuse Truck - my Vehicle was parked in front of my residence.
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 10th day of December, 2003.
/s/ James S. Green
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA ·
You shod~
This written 'report constitutes' your claim against the City of Dubuque, Iowa.
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: ~--~'-~ ~'~'-~
4. Date of Incident:
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'sname')~--/-7-~, ~ ~-~.yC L/AJ~ ~ ~-~!J..~,~-~ '¥'P~ u c..,/~
8. What were weather conditions like? ~h~Y '~ /C X ,
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.)
,Ye:s-R/e.-tST /'?
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 --~'-~ ~--~ ~ ~ , 20 d .~.
(signature)
(Print Name)
(Rev, 1/00 & 7/01)
Date: t2/10/2003 10:26 AM
Estimate ID: 8946
Estimate Version: 0
prsIiminary
Profile ID: Mitchell
BIRD CHEVROLET
3255 UNIVERSITY AVE. P.O. BOX 57 DUBUQUE, IA 52001
(563) 583-9t21
Fax: (563) 556-4482
Tax ID: 42-0400210
Damage Assessed By: JOHN KLOTZ JR.
ueductibb: UNKNOWN
Owner JIM GREEN
Address: t855 ATLANTIC DUBUQUE, IA 52001
MitcheB Service: 911494-
Description: 2001 Chevrolet Malibu LS
Body Style: 4D Sed Drive Train: 3.1L Inj 6 Cyl 4A
VIN: IGINES2JOI6132192
Mileage: tl,445
Coloc MARRON
Options: ALUMIALLOY WHEELS, AIR CONDITIONING, POWER STEERING, POWER WINDOWS
POWER DOOR LOCKS, TILT STEERING WHEEL, CRUISE CONTROL, ELECTRIC DEFOGGER
AUTOMATIC TRANSMISSION, AM-FM STEREOICDPLAYER(SINGLE)
Li~e Ent~ Labor Line Item Part Type/
Item Number Type Operation Description Part Number
Dollar Labor
Amount Units
10126'l BOY REMOVE/REPLACE
AUTO REF REFINISH
AUTO REF ADD'L OPR
AUTO ADDq- COST
AUTO ADD'L COST
REAR BUMPER COVER
REAR BUMPER COVER COMPLETE
CLEAR COAT
pAINT/MATERIALS
HAZARDOUS WASTE DISPOSAL
1246~199 GM PART
303.75 1.5 #
C 2.6
1.0
100.80 *
3.24*
* - Judgement item
# - Labor Note Applies
C - Included in Clear Coat Calc
Add'l
Labor Sublet
L Labor Subtotals Uoits Rate Amount Amour~ Totals
Body 1.5 4S.00 0.00 0.00 67.50 T
Refinish 3.6 45.00 0.00 O.O0 162.00 T
Taxable Labor 229.50
Labor Tax ~ 7.000 % 16.07
Labor Summary 5.1 245.57
IL Part Replacement Summary
Taxable Parts
Sales Tax ~
Total Replecement Parts Amount
7.000%
Amount
303.75
21,26
325.0t
ESTIMATE RECALL NUMBER: 12/10/2003 10:26:44 8946
IJitraMate is a Trsdema~x of Mitchell International
Mitchell Data Version: DEC_03_A Copyright (C) t994 - 2003 Mitchell International
UltraMate Version: 5.0.018 All Rights Reserved
Page I
of 2
Additioflal Costs
Non-Taxable Costs
Amount
Date: t2/10/2B03 10:26 AM
Estimate ID:. 8946
E~timats Vera~on: O
Preliminary
Profile !D:
IV. Adjustments
Customer
L Total Labor:.
g. Tolal Replacement Parts:
Ill. Total Addi~ona! Costs:
IV. Total Adjustments:
This is a nreliminary estbnate.
Additional chan~.es~to the estimate mav be required for the actual repair.
24~.57
~ATE RECALL NUMBER: 12/10/2003 10'~.6:44 8946
UltraMa~e is a Trademark of Mitchell International
Mitchell Data Version: DEC_03 A Copyright (C) 1994 - 2003 Mitchell International
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