Claim Neis, Sarah J.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 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: Sarah J. Neis
2. Address: 3642 Pine St. P.O. Box 223, Kieler, WI 53812
`
3. Telephone Number: 608 568 3451, 608 778 3972
4. Date of Incident: 2/9/04
5. Time of Incident: unsure
6. Location of Incident (Be specific):
Corner of Althauser & STafford 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.)
See Attached letter... (none attached)
8. What were weather conditions like? Icey from the rain/snow the night before.
9. Give name and address of any witnesses:
I found the note on my car when I came home from work.
10. Did police investigate? (If so, give names of officers.)
No (See attached letter)
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.)
Left tail light broken
13. What other damages do you claim, if any?
None, I just want my car fixed to its original condition
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?
Estimate from Len's Paint and Place $765.00
16. Why do you claim the City of Dubuque is responsible?
See attached letter....
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
Dated at Dubuque, Iowa this 02 day of March, 2004.
/s/ Sarah J. Neis
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST TIlE CITY OF OUBUQUE, I~:$~
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: b4llMf:J ¡J?:ts
2. Address: jlPl/:Â ~¡¡Jf:. Sr It> 60'£ »'3 Xldif ¿J¡ 5~f¡2.-
3. Telephone Number: (¿Of- $/." '(- 5J.£)¡ { hÓð'-'77f- 3Q7,l,..-
I
4. Date of Incident: ,.z / ()q /0 t!-
Un UN-
5. Time of Incident:
6. Location of Incident (Be specific): & Î/ltr ¿do. 4/ fÍlaus.el' 114-/ ~é}f'd .sl-
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.) Á ¿Lilacl ./." '£/¡..'
- :i d L~ 'U"'
8. What were weather conditions like? ~ -f!rol/¡l flu. ~¡)Jfl/9!/JZI) fit.¿ f/)tfi J- œ4J~
9. Give name and addre:s of any witnesses: _f h./JI j +l.t ft¡¡f,¿ OIL I/if¡ ¡1ð/
{lJ~ 1-. MÆi.t á.nw, /rOM !l)OfÍ¿ ,
10. Did police inNotiga~e? (If s,/:}ve names çf officers.)
C~.f () 'f'iuL (file r )
...
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
¡Vb
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.)
¿ell- 12ül (!flU- ¡)/7Jtf.uu
13. What other damages do you claim, if any?
f-r'allL fD tl- IS
/I!o¡¿¿ j .£ ¡' Llf¿ f-- ! J)j)¡ 1- f1A jJ ear
v I
Otfqfl1td ~ .lwliHó;(J
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.)
Nl9
15. What amount do you claim from the City of Dubuque?
~óJ flf IlL.lI{v», 1 (j), 1-£
16. Why do you claim the City of Dubuque is responsible? J-f.l ~ it'dt'/"
i 5h t1Mlk /n; M
[tj;1 {<;
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) ÆJ ó
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 ~t.Á , 20 oLi.
kÆ/lj/ ~.ì1I{~
(Sign ture)
,i4-Ww f ¡VEf5
(Print Name)
co
LtC)
Sì2
33
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~
Ln
,
ð
(Rev. 1/00 & 7/01)
ons and Maintena.'1ce Department
per Boulevard
te, Iowa 52001-2338
9-4250 office
9-4252 fax
94193 TDD
tint@cityofdubuque,org
THEo;YOF ~
DUB ùt2UE
~cÆ~
ear Sir/Ms:
he City of Dubuque Operations & Maintenance Department
:knowledges th~.t we have damaged your property, building and/or
9hicle. Since the emplòyee's supervisor has determined that the
5timated cost to repair the dà*mage does not exceed $1,000.00, the
olice Department was notrequired to assist with paperwork,
Ivestigation, etc..
lease contact the City Clerk at 589-4120 to ,obtain a damage claim
. ...-rrt-.
Ie apologize for the damage we have caused and the
Iconveniences that have resulted for you. .
incerely,
~
LENS PAINT N PLACE
COLLISION REPAIR CENTER
3530 COUNTY HHH
KIELER, WI 53812
PHONE: 608-568-3366
CD LOG NO 1664-1
DATE 02/19/04
CITY STATE:
ZIP:
LENS PAINT N
BOX 104
3530 COUNTY
KIELER, WI
53812-
PLACE
INSP DATE:
CONTACT:
PHONE 1:
FAX:
02/19/04
RYAN KIELER
(608)568-3366
(608)568-3887
SHOP:
ADDRESS:
HHH
OWNER: NEIS, SARAH
ADDRESS: BOX 223
CITY STATE: KIELER, WI
POINT OF IMPACT: 8
LIC#: 982-ESJ
BODY COLOR: BROWN
CONDITION: GOOD
STATE: WI
VIN:
MILEAGE:
ACCTNG CTL#:
2G1WF52E929190560
19,000
*=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
2002 CHEVROLET IMPALA STD 4DOOR SEDAN
CODE: U4163A/C OPTNS E/24
6CYL GASOLINE 3.4
OPTIONS:
TWO-STAGE - EXTERIOR SURFACES
TWO-STAGE - INTERIOR SURFACES
OP GDE MC DESCRIPTION MFG.PART NO. PRICE AJ% B% HOURS R
-- ----------- ------------ ----- -
I 0376 PANEL, QUARTER LT REPAIR 0.5*1
L 0376 # PANEL, QUARTER LT REFINISH 3.2*4
# = 13, 10
E 0533 TAILLAMP ASSEMBLY LT 10335607 GM PART 138.00 0.3 1
I 0566 COVER,REAR BUMPER REPAIR 1. 0*1
L 0566 10 COVER,REAR BUMPER REFINISH 2.0*4
E 0585 STRIP,REAR IMPACT 10341349 GM PART 107.20 0.3 1
6 ITEMS
MC MESSAGE(S)
10 INCLUDES ADP TIME TO CLEAR ENTIRE PANEL
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
PAGE
.2002 "eHEVROLET IMPALA
'CD LðG NO 1664-1
STD 4DOOR SEDAN
FINAL CALCULATIONS & ENTRIES
GROSS PARTS
PAINT MATERIAL
PARTS & MATERIAL TOTAL
TAX ON PARTS & MATERIAL @
5.500%
245.20
140.40
385.60
21.21
LABOR
1-SHEET METAL
2-MECH/ELEC
3-FRAME
4-REFINISH
5-PAINT MATERIAL
LABOR TOTAL
TAX ON LABOR
SUBLET REPAIRS
TOWING
STORAGE
RATE
46.50
55.00
55.00
46.50
27 .00
REPLACE HRS
0.6
REPAIR HRS
1.5
97.65
5.2
241. 80
@
5.500%
339.45
18.67
GROSS TOTAL
764.93
NET TOTAL
764.93
ADP SHOPLINK U2241 ES CD LOG 1664-1 DATE 02/19/04 01:09:50PM R6.35
HOST LOG
(C) 1998 - 2003 ADP CLAIMS SOLUTIONS GROUP, INC.
CD 01/04
1.8 HRS WERE ADDED TO THIS EST. BASED ON ADP TWO-STAGE REFINISH FORMULA.
--------------------------------------------------
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE REPLACEMENT
PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE
MANUFACTURER OR DISTRIBUTOR OF THE REPLACEMENT PARTS RATHER THAN BY THE
MANUFACTURER OF YOUR MOTOR VEHICLE.
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