Claim Benn, DanElCLAIM 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: DanEl' Benn
2. Address: 1921 N. Grandview
`
3. Telephone Number: (563) 556 5853 Tues/Thurs) M-We-Fr (563 582 8832 work)
4. Date of Incident: 2 11 04
5. Time of Incident: Some time in the afternoon vehicle was parked
6. Location of Incident (Be specific): In municipal lot right behind 9th St. Fire Station - Parking Spot
#10 I think.
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.)
No injury to me only vehicle. John A. Hutchcroft was Assistant Fire Chief who left business card on my windshield explaining incident.
8. What were weather conditions like?
Snow but clear
9. Give name and address of any witnesses:
None that I'm aware other than Personnel of 9th Street Fire Dept.
10. Did police investigate? (If so, give names of officers.)
Not that I'm aware
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No that I'm aware
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, rear drivers side bumper and tail light. I have attached estimate.
13. What other damages do you claim, if any?
None just the repair of my vehicle in full.
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?
$269.04 at present unless Abra would find more under plastic bumper
16. Why do you claim the City of Dubuque is responsible?
Because John A. Hutchcrof of the 9th Street fire dept. told me so.
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 12th day of February, 2004.
/s/ DanEl' D. Benn
(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. 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 TH E 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: '~(~.w__~.li ~-~,~.F-~
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.
full details upon which you base your claim.
employee's~e.)~_~---- ~ ~ ~_
_/
8. What were weather conditions like?
(Give
If a City employee was involved, give the
,,
9. Give name and address of any witnesses:
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 prope ~r~y and the extent of damages.
Attach estimates of damages or describe basis.for ascertaining extent of damage.)
13. What other damages do you claim, ifany? ,~-~-e ~D~q.~L .?L/~_e £~o,'~
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
~ / , 20 a/q/.
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
02/12/2004 at 08:45 AH
24443
Jeb Number:
A~RA - DDI~UQUE
Federal ID %:420782245
DBA: ANDERSON-WEBER INC
3400 CENTER GROVE DR
DUBUQUE, IA 52003
(563)556-0696 Fax: {563)556-1899
PP. ELIMINA~Y ESTI~TE
Written By: DAVE BIGELOW
Adjuster:
Insured: DANEL BENN
Owner: DANEL BENN
Address: 1921 N GRANDVIEW
DUBUQUE, IA 52001
Evening: (563)556-5853
Claim #CITY OF DUBUQUE
Policy #
Deductible:
Date of Loss:
Type of Loss:
Point of Impact: 6. Rear
Inspect
Location:
Insurance
Company:
Days to Repair
2000 FORD WINDSTAR 4X2 LX 6-3.SL-FI 3D VAN MAROON
VIN: 2FMZA5146YBB73661
Air Conditioning
Cruise Control
Dual Mirrors
Power Brakes
Power Hirrors
Passenger Air Bag
Lic: 079AXV IA
Rear Defogger
Keyless Entry
Clear Coat Paint
Power Windows
Anti-Lock Brakes
Cloth Seats
Prod Date: 02/2000
(4)
Odometer:
Tilt Wheel
Body Side Moldings
Power Steering
Power Locks
Driver Air Bag
Bucket Seats
42485
NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT
1 REAR BUMPER
2* Repl Bumper cover neutral gray 1 126.64 1.0 0.0
3 REAR LAMPS
4** Repl A/M LT Tail lamp assy 1 59.00 0.4 0.0
Subtotals ==> 185.64 1.4 0.0
Parts 185.64
Body Labor 1.4 hrs @ $ 47.00/hr 65.80
SUBTOTAL $ 251.44
Sales Tax $ 251.44 @ 7.0000% 17.60
GRAND TOTAL $ 269.04
ADJUSTMENTS:
Deductible
1
0.00
02/12/2004 at 08:45 AM Job Number:
24443
PRELIMINARY ESTIMATE
2000 FORD WINDSTAR 4X2 LX 6-3.8L-FI 3D VAN MAROON
CUSTOHER PAY $ 0.00
INSURANCE PAY $ 269.04
WARRANTY VALID ONLY WITH ORIGIONAL COPY OF YOUR RECEIPT PARTS SUBJECT TO
INVOICE NO GUARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED
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.
WARRANTY VALID ONLY WITH ORIGIONAL COPY OF RECEIPT. PARTS SUBJECT TO INVOICE.
NO GUARANTEES ON RUST. ALL PARTS NEW, UNLESS OTHERWISE SPECIFIED.
Estimate based on HOTOR CRASH ESTIMATING GUIDE. Unless otherwise notes all items are derived from
the Guioe DR2HT99 Database Date 1/2004 and the parts selected are OEM-parts manufactured by the
vehicles Original Equipment Manufacturer. Asterisk (*) or Double Asterisk {**) indicates that the
parts and/or labor information provided by MOTOR may have been modified or may have come from an
alternate data source. Non-Original Equipment Manufacturer aftermarket parts are described as ANi,
Qual Rep! Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are
described as LKQ, Gual Recy Parts, RCY, or USED. Reconditioned parts are described as Recon.
Recored parts are described as Recore. NAGS Part Numbers and Prices are provided from National
Auto Glass Specifications, Inc. Pound sign (%) items indicate manual entries.
Pathways - A product of CCC information Services Inc.
02/12/2004
24443
at 08:45 AH Job Number:
PRELIMINARY ESTIMATE
2000 FORD WINDSTAR 4X2 LX 6-3.SL-FI 3D VAN MAROON
ALTERNATE PARTS SUPPLIERS
4 A/H LT Tail lamp assy Part No. F02800127 Price $59.00
Keystone Auto
2400 KERPER BLVD.
DUBUQUE, IA 52001
(800)747-2500
(319)556-5030
Keystone Auto
1825 JEFFERSON STREET
WATERLOO, lA 50702
(800)373-6215
(319)234-7748
Keystone Auto
1040 WEST 4TH STREET
DAVENPORT, lA 52802
(800)233-0518
(319)323-3697
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