Claim by Katie Schaefer) Q, \\Kk f\kk ))YI S '-1 n
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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. 13 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: t' 1 Q k
2. Address: m l t" t u- l /)./ -),)
3. Telephone Number 'LD n ` J 0) R
4. Date of Incident: I c pot 0
5. Time of Incident: Lo . L 4 C NA
6. Location of Incident (Be specific): i O \D C UtO -\ 0-n d prot
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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.) ukuLe
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9. Give name and address of an y witnesse 4e_
10. Did police investigate? (If so, give names of officers.)
10 - k LM A) ' Sh - ;(16 r rn--CC mVci n (u
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1 a s anyone lure I f 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.)
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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?
4 7// (a . (OLD
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 in�rhat amount?
Dated at Dubuque, Iowa this / day of
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(Rev. 1/00 & 7/01)
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(Signature)
(Print Name)
Damage Assessed By: BILL TRILL
Deductible:
Claim Number:
Insured:
Address:
Telephone:
Description:
Body Style:
VIN:
OEM /ALT:
Options:
0.00
NA
Line Entry Labor
Item Number Type Operation
KRUSE - WARTHAN Nissan, Pontiac, BMW
KATIE SCHAEFER
1515 N GRANDVIEW, DUBUQUE, IA 52001
Home Phone: (563) 543 -5768
2009 Nissan Rogue S
4D Ut Drive Train: 2.5L Inj 4 Cyl AWD
JN8AS58V19W171608
0 Search Code: None
VEHICLE ANTI - THEFT, PASSENGER AIRBAG, DRIVER SIDE AIRBAG, POWER LOCK
POWER WINDOW, REAR WINDOW DEFOGGER, MANUAL AIR CONDITION, CRUISE CONTROL
TILT STEERING COLUMN, ANTI -LOCK BRAKE SYS., TRACTION CONTROL
TIRE INFLATION /PRESSURE MONITOR, AUXILIARY INPUT, REMOTE FUELDOOR RELEASE
CD PLAYER, POWER ADJUSTABLE EXTERIOR MIRROR, 4WD OR AWD, FRONT AIR DAM
TINTED GLASS, FIRST ROW BUCKET SEAT, SECOND ROW BENCH SEAT, KEYLESS ENTRY
SECOND ROW FOLDING SEAT, THEATER STYLE SEATING, CLOTH SEAT
VARIABLE ASSISTED STEERING, ADAPTIVE AUTOMATIC TRANSMISSION, TACHOMETER
SIDE AIRBAGS, PASSENGER AIRBAG CUTOFF SWITCH /SENSOR, SIDE HEAD CURTAIN AIRBAGS
1 100905 BDY REMOVE /REPLACE
2 AUTO REF REFINISH
3 100908 BDY REMOVE /REPLACE
4 AUTO REF REFINISH
5 AUTO REF ADD'L OPR
6 AUTO ADD'L COST
7 AUTO ADD'L COST
* - Judgment Item
# - Labor Note Applies
C - Included in Clear Coat Calc
600 Century Drive, Dubuque, IA 52002
Email: bthill @dubuqueautoplaza.com
Tax ID: 420655341
Mitchell Service: 911003
Line Item
Description
L Frt Door Rear View Mirror
L Frt Door Mirror
L Frt Door Mirror Cover
L Frt Mirror Cover
Clear Coat
Paint/Materials
Hazardous Waste Disposal
ESTIMATE RECALL NUMBER: 01/03/2011 13:22:24 E10847
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
Date: 1/ 3/2011 01:22 PM
Estimate ID: E10847
Estimate Version: 0
Preliminary
Profile ID: * Mitchell
Part Type/
Part Number
96302 -JM200
96374 -JMOOA
Dollar Labor
Amount Units
209.53 * 0.3 #
C 0.7 #
79.68 * 0.2
INC
0.1 *
27.20 *
3.50 *
Page 1 of 2
Add'I
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals U. Part Replacement Summary Amount
Body 0.5 55.00 0.00 0.00 27.50 T Taxable Parts 289.21
Refinish 0.8 55.00 0.00 0.00 44.00 T Sales Tax @ 7.000% 20.24
Taxable Labor 71.50 Total Replacement Parts Amount 309.45
Labor Tax @ 7.000 % 5.01
Labor Summary 1.3 76.51
III. Additional Costs Amount IV. Adjustments Amount
Non - Taxable Costs 30.70 Insurance Deductible 0.00
Total Additional Costs 30.70 Customer Responsibility 0.00
Paint Material Method: Rates
Init Rate = 34.00 , Init Max Hours = 99.9, Addl Rate = 34.00
Estimate Totals
I. Total Labor: 76.51
II. Total Replacement Parts: 309.45
III. Total Additional Costs: 30.70
Gross Total: 416.66
IV. Total Adjustments: 0.00
Net Total: 416.66
This is a preliminary estimate.
Additional changes to the estimate may be required for the actual repair.
Date: 11312011 01:22 PM
Estimate ID: E10847
Estimate Version: 0
Preliminary
Profile ID: * Mitchell
THIS DAMAGE REPORT IS BASED ON OUR INSPECTION AND DOES NOT
COVER ANY ADDIONAL PARTS OR LABOR WHICH MAY BE REQUIRED AFTER
THE WORK HAS BEEN OPENED UP. THE INSURANCE COMPANY WILL BE NOTIFIED.
WE GUARANTEE OUR COLLISION REPAIR WORKMANSHIP FOR AS LONG AS YOU OWN
YOUR VEHICLE.
ACCIDENTS ARE A PAIN BUT WE MAKE THE REPAIR A PLEASURE!!!
ESTIMATE RECALL NUMBER: 01/03/2011 13:22:24 E10847
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
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