Claim Steinlicht, JasonCLAIM 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: Jason Steinlicht
2. Address: 1120 Main St Dubuque IA 52001
`
3. Telephone Number: 563 587 0031 cell 641 430 3040
4. Date of Incident: 2 10 04
5. Time of Incident: 0900 Hrs.
6. Location of Incident (Be specific): In front of 1806 Delhi
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.)
Bus Driver City Employee Wm. J. Gibson was driving a City bus and side swiped the back rearside of my Pontiac Grand Prix which was parked
along the Street.
8. What were weather conditions like? Clear & Sunny
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.) Officer Flanner Badge #15A
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.)
No
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?
$3083.55
16. Why do you claim the City of Dubuque is responsible?
May car was parked on the side of the road and was hit by a City bus.
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 17th day of February, 2004.
/s/ Jason Steinlicht
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
æ IT/V' I
CLAIM AGAINST THE CITY OF DUBUQUE.-IOWA ~~
This written report constitutes your claim against the City of Dubuque, Iowa. You should
complete thi.s 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
Y.OU AS TO WHETHER Y. OUR CLAIM WILL O~ WILL NOT BE PAID.
1. Name of Claimant: :Jði¿""", Sf€'-,' ",I, ¿)'d .
It) ¡; ;fIb!:^. 4-+, OJ),¡/v~ f <)}--oOf
~,~ 5ß7-QO3 ¿ell ~1f1"-Jf3D.30'ft?
'd-- /O~u+
2. Address:
3. Telephone Number:
4. . Date of Incident:
5. Time of Incident: Ô '1 DO ¡-{r""
6. Location of Incident (Be specific): 1" +(~M i
)80& Delhi
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
emto r~~~s n~me1 '» . ..., w:I/;"", -:s.ç:~!70!1 1M dr"r:n ú\ ¿if
-Äe ha.¿~Je"r.¿Je j v>y ¡?OY'-f:c<t: 5',c<')priX~thh-¡,çpMkel
t]freef.
8. What were weather conditions like? . aM J.. ~/i1"'7
9. Give name and address of any witnesses:
10. DidpoJige inv¿¡stigate? (If so, give n~~s °lOff/sicers.)
()H'ur \ O'J>nPfj IP"¿yt'" ð:.
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 damag~s.
Attach estimates of damages or describe basis for ascertaining extent of damage.)
/(0
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? . 11 3 ¡ôr¡,,3. 55
16. Why do you claim the City of Dubuque is responsible? ¡11y /:"', IN"-;
ó{// fÄl' 07;1 ",-{- +k, «?J 411 J vaJd by 0\ &:ftb~~,
¡/Je ~
I
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
tf.
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
It'
day of
Fe~r ¡Jl{((
~ ~/~Jt&
/' (Signature)
::5a So 'ì t(;fe;~ lc~f
(Print Name)
,20~.
CO
uJ
w-
(.'
~
,-
IS
(Rev. 1/00 & 7/01)
, -.,,--_.-~..,-~.
PHONE:
WILSON BROS. DODGE
90 JFK
DUBUQUE, IA 52002
(563) 583-5781 FAX: (563) 556-6928
FED TAX ID: 420779647
~.
, .<
CD LOG NO 3009-1
DATE 02/16/04
OWNER: OBRECHT, SUE
ADDRESS: 1008 WINSOR PLACE
CITY STATE: BELMONT, IA
ZIP: 50421-
HOME PHONE:
02/13/04
JIM BODISH
(563)583-5781 EXT 230
(563)556-6928
(641) 444-4728
SHOP: WILSON BROS AUTO BODY
ADDRESS: 90 JFK
CITY STATE: DUBUQUE, IA
ZIP: 52002-
INSP DATE:
CONTACT:
PHONE 2:
FAX:
POINT OF IMPACT: 7
LIC#:
BODY COLOR: RED
CONDITION: EXCL
STATE:
VIN:
MILEAGE:
ACCTNG CTL#:
1G2WP52K8XF200220
DRIVEABLE:
YES
VEH. INSP#:
*=USER-ENTERED VALUE
EC=REPLACE ECONOMY
EU=REPLACE SALVAGE
PM=PXN REMAN/REBUILT
IT=PARTIAL REPAIR
BR=BLEND REFINISH
SB=SUBLET
P=CHECK
UP=UNRELATED PRIOR
E=REPLACE OEM
UC=RECONDITIONED PRT
EP=REPLACE PXN
TE=PARTL REPL PRICE
I=REPAIR
TT=TWO-TONE
N=ADDITIONAL LABOR
AA=APPEAR ALLOWANCE
NG=REPLACE NAGS
UM=REMAN/REBUILT PRT
PC=PXN RECONDITIONED
ET=PARTL REPL LABOR
L=REFINISH
CG=CHIPGUARD
RI=R&I ASSEMBLY
RP=RELATED PRIOR
1999 PONTIAC GRAND PRIX GT 4DOOR SEDAN
CODE: W3263B/C OPTNS K/24FJR
6CYL GASOLINE 3.8
OPTIONS:
TWO-STAGE - EXTERIOR SURFACES
REAR SPOILER
TRACTION CONTROL SYSTEM
TWO-STAGE - INTERIOR SURFACES
CRUISE CONTROL
OP GDE MC DESCRIPTION MFG.PART NO. PRICE AJ% B% HOURS R
-- ----------- ------------ ----- -
I 0933 SUSP ALIGN,4 WHEEL REPAIR 2
N 0933 SUSP ALIGN, 4 WHEEL ADDNL LABOR OPERA 2.0 2
BR 0287 13 DOOR SHELL,REAR LT BLEND REFINISH 2.1 4
RI 0473 MLDG,REAR DOOR BELT LT R&I ASSEMBLY 0.2 1
RI 0305 HANDLE,RR DOOR OUTE LT R&I ASSEMBLY 0.6 1
RI 0398 MLDG ASSY,BACK GLASS R&I ASSEMBLY INC 1
E 0389 PANEL,QUARTER LT 88950746 GM PART 655.02 16.2 1
L 0389 PANEL,QUARTER LT REFINISH 3.7 4
E 0397 DOOR,FUEL FILLER LT 10294265 GM PART 32.41 INC 1
PAGE 1
. ,
1999 PONTIAC GRAND PRIX
CD LOG NO 3009-1
GT 4DOOR SEDAN
. .
t 0397 DOOR,FUEL FILLER LT REFINISH
RI 0472 SPOILER,DECK LID R&I ASSEMBLY
E 0533 TAILLAMP ASSEMBLY LT 5978571 GM PART
I 0517 COVER,REAR BUMPER REPAIR
L 0517 COVER,REARBUMPER REFINISH
N 0010 SUSPENSION ALIGN REAR ADDNL LABOR OPERA
N M03 FLEX ADDITIVE ADDNL LABOR OPERA
E M04 UNDERCOATING NEW PART
N M14 CORROSION PROTECTION ADDNL LABOR OPERA
P M60 HAZARD. WSTE. REM. CHECK
E M66 COLOR, SAND & BUFF NEW PART
EC SHOP SUPPLIES ECONOMY. PART
E SEAM SEALER NEW PART
22 ITEMS
248.12
0.4 4
0.5 1
INC 1
*1
3.0 4
1. 0 2
*4*
0.3*1*
0.2*4*
*1*
2.0*4
*1*
0.2*1*
5.00*
12.00*
8.00*
5.00*
45.00*
3.50*
15.00*
MC MESSAGE(S)
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
FINAL CALCULATIONS & ENTRIES
GROSS PARTS
OTHER PARTS
PAINT MATERIAL
PARTS & MATERIAL TOTAL
TAX ON PARTS @
LABOR
1-SHEET METAL
2-MECH/ELEC
3-FRAME
4-REFINISH
5-PAINT MATERIAL
LABOR TOTAL
TAX ON LABOR
SUBLET REPAIRS
TOWING
STORAGE
RATE
47.00
54.00
54.00
47.00
29.00
REPLACE HRS
18.0
11.2
@
GROSS TOTAL
NET TOTAL
7.000%
1,007.55
21. 50
330.60
1,359.65
72.03
REPAIR HRS
846.00
3.0 162.00
0.2 535.80
1,543.80
7.000% 108.07
3,083.55
3,083.55
CD 01/04
ADP SHOPLINK UB303 ES CD LOG 3009-1 DATE 02/16/04 04:39:16PM R6.35
HOST LOG
(C) 1998 - 2003 ADP CLAIMS SOLUTIONS GROUP, INC.
2.3 HRS WERE ADDED TO THIS EST. BASED ON ADP TWO-STAGE REFINISH FORMULA.
--------------------------------------------------
LIFETIME WARRANTY ON PAINT ONE YEAR ON WORKMANSHIP NO WARRANTY ON RUSTWORK
PAGE 2
y-\"
RUNDE CHEVROLET INC.
780 RT. # 35 NORTH EAST DUBUQUE, IL 61025
(815) 747-3011
Fax: (815) 747-7721
Tax 10: 36-4320504
Damage Assessed By: MIKE RUNDE
Accident Date: 2111/2004
Deductible: UNKNOWN
Insured: SUE OBRECHT
Address: 1008 WINSOR PLACE BELMONT, IA 50421
Telephone: Home Phone: (641) 444-4728
Mitchell Service: 915493
Description:
Body Style:
VIN:
Options:
Date: 2111/200412:46 PM
Estimate 10: 1010
Estimate Version: 0
Preliminary
Profile 10: Mitchell
1999 Pontiac Grand Prix GT
40 Sed
1G2WP52K8XF200220
ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER STEERING, POWER WINDOWS
POWER DOOR LOCKS, TILT STEERING WHEEL, CRUISE CONTROL, ELECTRIC DEFOGGER
AUTOMATIC TRANSMISSION, AM-FM STEREO/CDPLAYER(SINGLE)
Drive Train: 3.8L Inj 6 Cyl AO
Line Entry Labor Line Item
Item Number Type Operation Description
1 500290 MCH ALIGN FOUR WHEEL
2 500693 BOY REMOVEIINSTALL L ROCKER MOULDING
3 500936 REF REFINISH L REAR DOOR OUTSIDE
4 500952 BOY REMOVE/INSTALL L REAR BELT MOULDING
5 500954 BOY REMOVE/INSTALL L REAR LWR DOOR MOULDING
6 500964 BOY REMOVEIINSTALL LREARDOORADHESNEMOULDING
7 500986 BOY REMOVEIINSTALL L REAR OTR DOOR HANDLE
8 900500 BOY' REMOVE/REPLACE STRIPES
9 900500 REF' REFINISH/REPAIR EPOXY PRIME WELDS
10 900500 BOY' REMOVE/REPLACE PANEL ADHESIVE
11 900500 BOY' REMOVEIREPLACE SEALING FOAM
12 900500 BOY' REMOVEIREPLACE CAR COVER
13 900500 BOY' REPAIR UNDERCOATING
14 900500 BOY' REPAIR TINT COLOR
15 502437 BOY REMOVE/INSTALL L REAR DOOR VENT GLASS ASSEMBLY
16 501033 BOY REMOVE/REPLACE L ROOF JOINT MLDG
17 900500 REF' REFINISH/REPAIR L ROOF JOINT MLDG
18 900500 BOY' REPAIR MASK FRT GLASS
19 900500 REF' REFINISH/REPAIR ROOF L SIDE
20- 900500 BOY' REPAIR CLEAN & DETAIL
21 502196 BOY REMOVE/REPLACE BACK WINDOW REVEAL MLDG
22 900500 BOY' REPAIR STRAIGHTEN INNER PNLS
23 501130 BOY REMOVEIREPLACE LQUARTER OUTER PANEL
24 AUTO REF REFINISH L QUARTER PANEL OUTSIDE
25 AUTO REF REFINISH L LOCK PILLAR
26 AUTO REF REFINISH L QUARTER PANEL EDGE
27 501134 BOY REPAIR LQUARTER FUEL DOOR FILLER
28 501175 BOY REMOVE/INSTALL LUGGAGE LID ASSY
ESTIMATE RECALL NUMBER: 2111/200412:46:25 1010
UltraMate is a Trademark of Mitchellintemational
Copyright (C) 1994 - 2003 Mitchell International
All Rights Reserved
-M
Mitchell Data Version:
UltraMate Version:
JAN_04_A
5.0.021
Part Type/
Part Number
Existing
üQual Repl Part
Existing
New
New
New
Existing
Existing
Existing
88987585 GM PART
Existing
Existing
Existing
Existing
10433053 GM PART
Existing
88950746 GM PART
Existing
Dollar
Amount
Labor
Units
--
1.9
0.7
C 2.2
0.3
0.3
0.2'
0.7 #
25.00' 0.5'
0.7'
0.0'
0.5'
0.3'
0.4'
0.7'
1.4'#
34.70 0.3
0.5'
0.4'
1.8'
0.7'
39.95 INC #
1.0'
655.02 -13.5 #
C 2.0
C 0.5
C 0.5
0.2'#
0.5
35.00 '
25.00'
5.00'
Page 1 of 2
~
29
30
31
32
33
34
35
36
37
501255 REF
501294 BDY~
900500 GLS'
501314 BDY
501316 BDY
AUTO REF
AUTO REF
AUTO
AUTO
REFINISH
REMOVE/REPLACE
REMOVE/INSTALL
REMOVE/INSTALL
REPAIR
REFINISH
ADD'L OPR
ADD'L COST
ADD'L COST
REAR BODY PANEL
L COMBINATION LAMP ASSEMBLY
BACK GLASS
REAR BUMPER ASSY
REAR BUMPER COVER
REAR BUMPER COVER
CLEAR COAT
PAINT/MATERIALS
HAZARDOUS WASTE DISPOSAL
. - Judgement Item
# - Labor Note Applies
C -Included in Clear Coat Calc
I. Labor Subtotals
Body
Refinish
Glass
Mechanical
Labor Summary
Add'i
Labor Sublet
Units Rate Amount Amount Totals
24.1 45.00 0.00 0.00 1,084.50
14.0 45.00 0.00 0.00 630.00
0.0 45.00 0.00 125.00 125.00
1.9 69.00 0.00 0.00 131.10
Non-Taxable Labor 1,970.60
40.0 1,970.60
III. Additional Costs
Taxable Costs
Sales Tax
Non-Taxable Costs
Total Additional Costs
@
6.250%
Amount
378.00
23.63
Date: 2/11/200412:46 PM
Estimate ID: 1010
Estimate Version: 0
Preliminary
Profile ID: Mitchell
5978571
Sublet
GM PART
7.00
408.63
Existing
II. Part Replacement Summary
Taxable Parts
Sales Tax @
Total Replacement Parts Amount
IV. Adjustments
Customer Responsibility
I.
II.
III.
Total Labor.
Total Replacement Parts:
Total Add~ional Costs:
Gross Total:
IV.
Total Adjustments:
NetTotal:
This is a preliminary estimate.
Additional chanqes to the estimate mav be required for the actual repair.
ESTIMATE RECALL NUMBER: 2/11/200412:46:25 1010
UltraMate is a Trademark of Mitchellintemational
Mitchell Data Version: JAN_04_A Copyright (C) 1994.2003 Mitchell International
UltraMate Version: 5.0.021 All Rights Reserved
C 1.1
248.12 INC
125.00' 0.0'
INC
1.5'#
C 2.5
2.2'
378.00 '
7.00'
6.250%
Amount
1,067:79
66.74
1,134.53
Amount
0.00
1,970.60
1,134.53
408.63
3,513.76
0.00
3,513.76
Page 2 of 2