Claim Schmitt, EricCLAIM 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: Eric Schmitt
2.Address: 2316 Harvest View Drive
`
3. Telephone Number: 599 7049
4. Date of Incident: 1/17/04
5. Time of Incident: 5:30 AM
6. Location of Incident (Be specific):
On the street in front of 2316/2320 Harvest View Drive.
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.)
Francis Marshal hit my parked vehicle driving a city plow truck.
8. What were weather conditions like?
Icey rain
9. Give name and address of any witnesses:
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, dmaage to the rear of my vehicle $211.77 (see estimate)
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? $211.77
16. Why do you claim the City of Dubuque is responsible?
Francis Marshall knocked on the door at 5:30 AM and told me he hit my parked vehicle with the City
snowplow.
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 21st day of January, 2004.
/s/l Eric Schmitt
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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~h 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: ~'F/d ~'~/~,n,~7L
2. Address: <:~_~ J ~ · ~L'~fl~'W~ 5-1L ~,'~ ~ ~,~-
3. TelephoneNum~r: ~- ~?
4. Date of Incident: {/I 7 / 0
5, Time of Incident: ~,' 3~ ~, ~.
7. D~soRIB5 AoOIDSNT OR O00UBREN05 THAT OAUSSD INdU~Y OR DAMAGe. (Give
~ull details upon ~hioh ~ou b~se ~ou~ olsim. I~ ~ Oity employee Was involved, ~ive the
emDlo~'s name.)
8. What were w~ther conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)'
/[/0 .
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.) fb/~
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
(Rev. 1/00 & 7/01)
FED ID #42-0813744
Date: 1/22/2004 01:58 PM
Estknnate ID: 9046
Estimate Version: 0
Preliminary
Profile ID: CUSTOMIZED
RICHARDSON MOTORS
1475 J.F.K. ROAD DUBUQUE, IA 52002
(563) 582-5411
Fax: (563) 582-4129
Dedneb~de: UNKNOWN
Owner ERIC SCHMITT
Address: 2316 HARVEST VLr~N DUB, IA 52002
Telephone: Home Phone: (563) 588-1611
Mitchell Service: 916482
Description: 1999 Chevrolet Tahoe LS
Bo~lyStyle: 4DGtllT'WB DriveTrsi~: 5.TLInjSCyI4WD
VIN: 1GNEKlSRgXJ547540
Options: ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER WINDOWS, POWER DOOR LOCKS
CRUISE CONTROL, AUTOMATIC TRANSMISSION, AM-FM STEREO/CDPLAVER(S INGLE)
Line Entry Labor Une Item Part Typet Dollar Labor
Item Number Type Ofleralion Description Part Number A~nount Units
1 601707 BDy REMOVE/R~PLACE L REAR UPR QUARTER APPUQUE 15154325 GM PART 41.58 0.$
2 620140 BDY REMOVE/REPLACE L COMBINATION LAMp ASSEMBLY 597786'/' GM PART 120.34 0.3
I. Labor Sub~otals Units Rate
Body 0.8 4~.00
Taxable labor
Labo~ Tax
Labm- Sr~ 0.8
Add'l
Labor Sublet
Rmount Amount Totals
0.00 0.00 36.80 T
36.80
7.000 % 2.58
III. Additional Costs Amount
Total Additional Costs 0.00
IL Part Replacement Summary
Taxable Pa~(s
Sales Tax ~
Totel Replacement Parts Amount
Custom~r Responelb~ty
7.000%
Arneunt
161.92
11.33
173.25
Amount
6-00
ESTIMATE RECALL NUMBER: 1~ 13.58:50 9046
UltraMnte is a Trademark of Mib~hell International
Mitchell Data Version: JAN_64_A Copyright (C) 1994 - 2003 Mitchell International
UlttaMate Version: 5.0.021 All Rigltts Resented
Page I of 2
Date: 1;22/2004 01:58 PM
Esthnate ID: 9046
F_sthn~e Version: 0
Proltle ID: CUSTOMIZED
I. Total Labor:
II. Total Replace,merit Parts:
III. Total Additional Costs:
Gross Total:
39.38
173.26
212.63
IV. Total Adjuslments:
Ne~ Total:
0.00
212.63
This is a preliminary estimate.
Additional cbenqes to the estimate may be r~n,,_,_i_red for the actual repair.
ESTIMATE RECALL NUMBER: 1,'22/20~4 13:58:$0 9046
UltraMate is a Trademark of Mitch~l International
Mitchell Data Version: JAN_04_A Copyright (C) 1994- 2003 Mitchell International
UltraMate Version: $.0.o21 All Rights Reserved
Page 2 of 2
Jason Charley
Body Shop Manager
Business (563) 582-5411
1475 .John R Kennedy Rd. Fax (*563) 582-4~29
Dubuque, Iowa 52002
Tol! Free: 888-806-5411
JOHN KLOTZ JR.
3255 University Avenue Dubuque, Iow~ 5200 I
Phone 563-583-9121 · Toll Free 800-747-4042 · F~x 563-556-~J-482
www. birdchevrole~com
Data: 1/22/2004 01:51 PM
Esfimata ID: 9114
Estimate Version: 0
Preliminary
Profile ID: Mitchell
BIRD CHEVROLET
3255 UNIVERSITY AVE. P,O. BOX 57 DUBUQUE, IA 52001
(563) 583-9121
Fax: (563) 556-4482
Tax ID: 42-0400210
Damage Assessed By: JOHN KLOTZ JR.
Deductibls: UNKNOWN
Owner ERIC SCHMITT
Address: 2316 HARVEST V~EW DR DUBUQUE, IA 52002
Telephone: HomePhone: (563)588-1611
Mitchell Service: 916482
Description: 1999 Chevrolet Tahoe LT
BodyStyle: 4DUtI17"WB Drive Train: 5.TLInjSCyl4WD
VIN: 1GNEKI3R9XJ547540
Options: ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER WINDOWS, POWER DOOR LOCKS
CRUISE CONTROL, AUTOMATIC TRANSMISSION, AM-FM STEREOICDPLAYER{SINGLE)
Line Entry Labor Line Itam Part Type/
Item Number Type Operation Description Part Number
1 601707 BDY REMOVE/REPLACE L REAR UPR QUARTER APPLIQUE
2 620140 BDY REMOVE/REPLACE L COMBINATION LAMp ASSEMBLY
Dollar Labor
Amount Units
15154325 GM PART 41.58 0.5
5977867 GM PART 120.34 0.3
Add'l
Labor Sublet
L Labor Subtotals Units Rata Amount Amount Totals
Body 0.8 45.00 0.00 0.00 36.00 T
Taxabls Labor 36.00
Labor Tax ~ 7.000 % 2.52
Labor Summary 0.8 38.52
IL Part Replacement Summary
Taxable Parts
Sales Tax ~
Total Replacement Parts Amount
Amount
16t.92
7.000% 11.33
173.25
I. Total Labor. 38.52
0. Total Replacement Parts: 173.25
IlL Total Additional Costa: 0.00
Gross Total: 211.77
ESTIMATE RECALL NUMBER: 1/22/2004 13:51:34 9t14
UtiraMata is a Trademark of Mitchell Intarnetional
Mitcheil Data Version: JAN 04 A Copyright (C) 1994 - 2003 Mitchell tatamational Page I of 2
UtiraMate Version: 5.0.0~1 - AIl Rights Reserved
III. Additional Costs Amount IV. Adjustments Amount
Total Additional Costs 0.00 Customer Responsibility 0.00
Data: 1122/2004 01:51 PM
Estirn~e ID: 9114
Estimate Version: 0
Preliminary
Profile ID: Mitchell
IV. Total Adjustments:
Net Total:
0.00
211,77
This is a preliminary estimate.
Additional chan;les to the estimate may be required for the actual repair.
PARTS PRICES ARE SUBJECT TO CHANGE
ESTIMATE RECALL NUMBER: 1122/2004 13:51:34 9114
UitraMate is a Trademark of Mitchell International
Mitchell Data Version: JAN_04_A Copyright (C) 1994 - 2003 Mitchell International
UltraMata Version: 5.0.021 All Rights Reserved
Page 2 of 2