Claim Otterbeck, PeterCLAIM 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: Peter Otterbeck
2. Address: 719 Hill St., DBQ IA
`
3. Telephone Number: 563 556 1355
4. Date of Incident: 12-4-03
5. Time of Incident: 6:00 A.M. (Approximately)
6. Location of Incident (Be specific): In the driveway at 719 Hill 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.)
There was a new driver and a new truck and he didn't see my mini-van when he backed up the driveway.
8. What were weather conditions like?
Early morning - dark
9. Give name and address of any witnesses:
Paul Schultz came up to investigate - he told me to fill out claim.
10. Did police investigate? (If so, give names of officers.)
No, I talked with Paul Schultz
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.)
The back hatch of my 1995 Dodge Caravan sport was dented in and the corner of the hatch was curled a litt.e
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.)
No
15. What amount do you claim from the City of Dubuque?
$1857.48 or $1978.26
16. Why do you claim the City of Dubuque is responsible?
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
No
Dated at Dubuque, Iowa this 10th day of December, 2003.
/s/ Peter Otterbeck
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes'your claim against the City of Dubuque, Iowa.~Y0~oUld
complete this form in full and attach any additional information that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52001.
It will then be referred by the City Council to the appropriate department for investigation.
Once that investigation is completed, a report and recommendation will be submitted to the
City Council. You will be provided with a copy of that report and recommendation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE
OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO
YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant:
2. Address:
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
Location of Incident (Be specific):
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If a City employee was involved, give the
employee's name.) -7-~'/E~E ~-~$ /~ ~ ~P~V~ ~ ,~ ~,.~ ~;~/~-
8. What were weather conditions like?
9. Give name and address of any witnesses:
U?
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.)
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 ~)~.
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Date: 17J15/2003 12:39 PM
Estimate ID: 7
Estimate Version: 0
Prelb~tinery
Profile ID: DUB- A/M
MIKE FINNIN FORD
36~ DODGE STREET DUBUQUE, IA 52001
(663) 556-1010
Fax: (563) 690-1086
Tax ID: 14-1862673
Damage Assessed By: RICK STUMPF
Deductible: UNKNOWN
Insured: PETE OTTERBECK
Address: 719 HILL DUBUQUE, IA 52001
Telephone: Home Phone: (563) 556-1355
Mitchell Service: 914525
Description: 1995 Dodge Caravan SE
Body Style: Van 112" WB Drive Train: 3.0L Inj 6 Cyl 2WD
VIN: 2B4GH4530SR201551
Options: ALUMIALLOY WHEELS, AIR CONDITIONING, POWER WINDOWS, POWER DOOR LOCKS
CRUISE CONTROL, AUTOMATIC TRANSMISSION, AM-FM STEREO/CDPLAYER(SINGLE)
Line Entry Labor Une Item Part Type/
Item Number Type Operation Description Part Number
Dollar Labor
Amoun~ Units
UFTGATIE
I 438690 BDY REMOVE/REPLACE LIFTGATE SHELL 467H~.0 520.00
2 REF REFINISH LIFTGATE C 2.5
3 REF REFINISH LIFTGATE INSIDE C 1.0
4 439300 BDY REMOVE/REPLACE UFTGATE ADHESIVE EMBLEM ORDER FROM DEALER 13.35 0.1
5 439350 BDY REMOVE/REPLACE UFTGATE ADHESIVE NAMEPLATE EDgSKR4 25.20 0.1
6 439440 BDY REMOVE/I~PLACE UFTGATE ADHESIVE NAMEPt. ATE ED97KR4 d29.50 0.
7 439550 BDY REMOVE/REPLACE LIFTGATE ADHESIVE NAMEPLATE ED~4KR4 1075 0.1
8 439640 BDY REMOVE/REPLACE STRIPE TAPE DECAl- ORDER FROM DEALER 18.70 0.1 #
9 400379 BDY REMOVE/INSTAU. DOOR TRIM PANEL 0.3
10 439966 GLS REMOVE/INSTALL MFTGATEGLASS Sublet 24.95' 2.$*#
REAR BUMPER
11 445424 BDY I~"PAIR REAR BUMPER COVER Existing 2.5*
12 REF REFINISH REAR BUMPER COVER C 2.3
13 REF ADO'L OPR CLF_~ COAT 1.9
14 953018 REF ADO'LOPR MASK FOR OVERSPRAY 10.00' 0~2~
15 ADD'L COST PAINT/MATERIALS 215.60 *
16 ADD1. COST HAZARDOUS WASTE DISPOSAL 3,00 *
* - Judgement Item
# - Labor Note Applies
d - Discontinued by the Manufacturer
C - Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 12/15/2003 12:39:55 7
UltraMate is a Tradarerk of Mitchell Internalional
Mitchell Data Version: DEC_03_A Copyright (C) 1994 - 2003 Mitchsi] IntemaUona~
UltraMate Version: 5.O.01It Alt Rights Reserved
Page I of 2
YAGER MITSUBISHI
4488 DODGE STREET DUBUQUE, IA 52003
FEDERAL ID # 42-1131724
PHONE: 563-557-7376 FAX: 563-557-1709
CD LOG NO 2185-1 DATE:
SHOP CONTACT: GAYLE PURMAN INSP DATE:
OWNER: OTTEHBECK, PETE
ADDRESS: 719 HILL ST
CITY STATE: DUBUQUE, IA
ZIP: 52001-
INS CO:
CLAIM%:
POLICY%:
LOSS DATE:
START DATE:
PROMISE DATE:
VEH. DROP OFF DATE/TIME:
VEH. PICK UP DATE/TIME:
DRIVEABLE:
1995 DODGE CARAVAN
LIC#:
BODY COLOR: RED
SE 2DOOR PASSENGER VAN
HOME PHONE:
WORK PHONE:
FAX PHONE:
12/15/03
12/15/03
(563)556-1355
(800)622-0125
CONTACT:
PHONE:
CLAIM REP:
FILE HANDLER:
DEDUCTIBLE:
COMPLETION DATE:
RENTAL ASSISTED:
DAYS TO REPAIR:
0.00
ENGINE: 6CYL GASOLINE 3.0
VIN: 2B4GH4530SR201551
MILEAGE:
DAMAGE
LINE
1 SALVAGE PART
2 REFINISH
3 NEW PART
4 NEW PART
5 NEW PART
6 NEW PART
7 R&I ASSEMBLY
8 NEW PART
9 NEW PART
10 R&I ASSEMBLY
11 ECONOMY PART
12 ECONOMY PART
13 REFINISH
14 ADDNL LABOR
REPORT
REPAIR DESCRIPTION
TAILGATE ASSEMBLY
SHELL,TAILGATE
N/PLATE,TAILGATE
N/PLATE,TAILGATE
EMBLEM, TAILGATE
DECAL,TAILGATE
TAILGATE GLASS R & I
SEALANT KIT,T/GATE GLS
MLDG,TAILGATE GLASS
ARM, TAILGATE WIPER
TAILLAMP ASSEMBLY
COVER, REAR BUMPER
COVER, HEAR BUMPER
CLEAN UP USED TAILGATE
LT
ADJ% B%
PARTS$ LABORS
525.00* 54.60
226.80
44.70 8.40
29.20 8.40
10.35 8.40
23.75 12.60
23.75 117.60
27.25
4.20
45.00* 12.60
295.00* 46.20
100.80
42.00*
TOTALS
PARTS
PAINT MATERIAL
BODY LABOR-SM
MECH/ELEC LABOR-ME
1,024.00
195.00
315.00
0.00
PAGE 2
12/15/03
CD LOG NO 2185-1
FRAME-FR LABOR
REFINISH-RF LABOR
SUBLET
TOWING
STORAGE
TAX
ESTIMATE TOTAL
INSURANCE PAY
CUSTOMER PAY
0.00
327.60
0.00
0.00
0.00
116.66
1,978.26
1,978.26
0.00
(C) 1998 - 2003 ADP CLAIMS SOLUTIONS GROUP, INC.
R6.35
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF AFTERMARKET CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE
MANUFACTURER OR DISTRIBUTOR OF THESE PARTS RATHER THAN THE MANUFACTURER OF
YOUR VEHICLE.
Barry A. Lindahl, Esq.
Corporation Cormsel
Suite 330, Harbor View Place
300 Main Street
Dubuque, Iowa 520016944
(563) 583~t113 office
(563) 583-1040 fax
balesq@cityofdubuque.org
December 9, 2003
Peter Otterbeck
719 Hill Street
Dubuque, IA 52001
P.E: Claim Against The City Of Dubuque
Dear Mr. Otterbeck:
If you wish to file a claim against the City of Dubuque regarding alleged damage to your
vehicle when it was struck by a recycling truck, we would request that you fill out the
enclosed claim form and mail it to the City Clerk's O~ce at the following address:
Ms. Jeanne Schneider, City Clerk
City Hall - C. ity Clerk's O~ce
50 VVest 13~" Street
Dubuque, IA 52001
Once the claim has been stamped in by the City Clerk, it will be forwarded to the Legal
Department for investigation. Enclosed is an addressed envelope for your convenience.
Very sincerely,
Legal Department
Enclosure
cc: Jeanne Schneider, City Clerk
Service People Integrity Responsibility hmoval~on Teamwork