Claim McDonell, JodiCLAIM 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: Jodi McDonell
2. Address: 2745 Broadway
`
3. Telephone Number: 582 0188
4. Date of Incident: May 14, 04
5. Time of Incident: 12:29 P.M.
6. Location of Incident (Be specific):
Across street from place of employment @ 300 N.Grandview
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.)
Ronald McKiernan - he was backing out of a driveway and hit my car.
8. What were weather conditions like?
Sunny - nice
9. Give name and address of any witnesses:
Tabitha Ashley, 2289 Southway
10. Did police investigate? (If so, give names of officers.)
Yes, Thomas Schmeichel, Sr.
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, left front - chrome, fender, wheel molding, and above wheel molding, scraped and scratched.
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?
$1232.87
16. Why do you claim the City of Dubuque is responsible?
City employee said he did it - told officer accident report filed.
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 24th day of May, 2004.
/s/ Jodi McDonell , 20 .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
œ : ft1 II fI1 '
.. "', CLAIM AGAINST THE CITY OF DUBUOUE,IOWA ~~'dJ5DtII
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: -.JOcÁ.l t'(\ t'.-t?ruJ \
2. Address: ¿ZÎ Y 5 ßrvcuiwlUj
3. Telephone Number: 6ßé7> 0 ¡ ~
m~ ILl -oL/
/a.:dAOt pm
4. Date of Incident:
5. Time of Incident:
6. Locationoflncident(Bespecific): Was') 'i;;~+- ~rY\- plCA.C..L,òb ~to~~
@, 3JjJ N -~vleJ -
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 n~mone')cn(J. rne-K 1~¡fV)CV\
f"\ hi Lðú.) hlM'A'4r(fVJ- ~ ú
cL/2,t-iH.úfrv-¡ ~ hl;¡'- ~ UiÁ-
8. What were weather conditions like? SUY\()<-j- VI L èß
9. Give name and address of any witnesses: ~6t't¡'/L ASh~ - d.;<J<z ~l.AJw.-¡,
10. Did police investigate? (If so, give names of officers.)
lÀ,e...<; - -Ch:Jmo <; SchmlL~ ,S(L
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
rO
12. Was any damage done to property? (If so, describe property and the extent of ddtnagts.
Attach estimates of damages or describe basis for ascertaining extent of damage.)
\.ftZS /'. ~ Jaøf\:J-,~ ~hl2oN J ~ I 1I )~t mcl~ ,(JJìN'ß.
Q \)ju{ U}UQ ((Y\C!L~ - ~lfiA.-P-Ld.. 'I- Sc.Y7L~-
13. What other damages do you claim, if any? fvlJN
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.)
lIó
15. What amount do you claim from the City of Dubuque? ~ I~ 3d..., 'is'7
16. Why do you claim the City of Dubuque is responsible? r 1 xN ...p O'Y\ JI] ().)..~ 'sct..tê1
" CJ
\\t ale! Ck - 1ttd oW lQJl- - (lCC~* ~óYU- ~~d '.< '
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
ro
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
. '11t
~
~ch.~
I (Signature)
Jdd¡" mQ/Jone.l(
(Print Name)
,20d.
SC:O1W'il SZ}..,~\,!~O
03/\i:::\J3d
(Rev.HOO & 7/01)
05/18/2004 at 12:48 PM
24443
Job Number:
ABRA - DUBUQUE
Federal ID #:420782245
DBA: ANDERSON-WEBER INC
3400 CENTER GROVE DR
DUBUQUE, IA 52003
(563) 556-0696 Fax: (563) 556-1899
PRELIMINARY ESTIMATE
Written By: BILL PFAB #24443
Adjuster:
Insured:
Owner:
Address:
JODI MCDONELL
JODI MCDONELL
2745 BROADWAY
DUBUQUE, IA 52001
(563)582-0188
Claim #
Policy #
Deductible:
Date of Loss:
Type of Loss:
Point of Impact: 11.
Left Front
Day:
Inspect ABRA - DUBUQUE
Location: 3400 CENTER GROVE DR
DUBUQUE, IA 52003
Business:
(563)556-0696
Insurance
Company:
Days to Repair
1998 FORD EXPEDITION 4X4 EDDIE BAUER 8-5.4L-FI 4D UTV
VIN: 1FMPU18LXWLA19708 Lic; 859 AXS IA Prod Date:
Air Conditioning Rear Defogger
Cruise Control Intermittent Wipers
Rear Wiper Body Side Moldings
Privacy Glass Luggage/Roof Rack
Clear Coat Paint Two Tone Paint
Power Brakes Power Windows
Power Driver Seat Power Mirrors
Driver Air Bag Passenger Air Bag
Leather Seats Bucket Seats
Aluminum/Alloy Wheels
BLUE/TAN
09/1997 Odometer: 90924
Tilt ~¡heel
Keyless Entry
Dual Mirrors
Fog Lamps
Power Steering
Power Locks
Anti-Lock Brakes (4)
4 Wheel Disc Brakes
Rear Step Bumper
-------------------------------------------------------------------------------
NO.
OP.
DESCRIPTION
QTY EXT. PRICE LABOR
PAINT
-------------------------------------------------------------------------------
1 FENDER
2 R&I LT Wheel opng mldg Eddie 0 0.00 0.3 0.0
Bauer prairie tan
3 Refn LT Wheel opng mldg Eddie 0 0.00 0.0 0.8
Bauer prairie tan
4* R&I LT Nameplate "EXPEDITION 0 0.00 0.2 0.0
EDDIE BAUER"
5 Refn LT Fender w/wheel lip 0 0.00 0.0 2.2
6 Add for Clear Coat 0 0.00 0.0 0.9
7 Add for Two Tone 0 0.00 0.0 0.9
8 GRILLE
9 R&I R&I grille assy 0 0.00 0.6 0.0
1
05/18/2004 at 12:48 PM
24443
Job Number:
PRELIMINARY ESTIMATE
1998 FORD EXPEDITION 4X4 EDDIE BAUER 8-5.4L-FI 4D UTV BLUE/TAN
-------------------------------------------------------------------------------
NO.
OP.
DESCRIPTION
QTY EXT. PRICE LABOR
PAINT
-------------------------------------------------------------------------------
10 Refn Grille Eddie Bauer Toreador 0 0.00 0.0 1.5
11 FRONT BUMPER
12 O/H front bumper 0 0.00 1.5 0.0
13 R&I Pad assy royal blue 0 0.00 Incl. 0.0
14* Rpr Pad assy royal blue 0 0.00 1.0 1.5
15 Repl Bumper chrome 1 266.92 Incl. 0.0
16 Add for fog lamps 0 0.00 0.3 0.0
17 STRIPE TAPE
18 Repl LT Stripe tape Prairie Tan 1 66.88 1.0 0.0
19# Subl HAZARDOUS WASTE DISPOSAL 1 4.00 T 0.0 0.0
20# Rep1 BAG / COVER CAR 1 4.00 0.2 0.0
-------------------------------------------------------------------------------
Subtotals ==>
341.80
5.1
7.8
Parts
Body Labor
Paint Labor
Paint Supplies
Sublet/Misc.
5.1 hrs @ $ 47.00/hr
7.8 hrs @ $ 47.00/hr
7.8 hrs @ $ 28.00/hr
337.80
239.70
366.60
218.40
4.00
----------------------------------------------------
SUBTOTAL
Sales Tax
$
948.10 @
$ 1166.50
7.0000% 66.37
----------------------------------------------------
GRAND TOTAL
$ 1232.87
ADJUSTMENTS:
Deductible
0.00
----------------------------------------------------
CUSTOMER PAY
INSURANCE PAY
$ 0.00
$ 1232.87
WARRANTY VALID ONLY WITH ORIGIONAL COpy OF YOUR RECEIPT PARTS SUBJECT TO
INVOICE NO GUARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED
Estimate based on MOTOR CRASH ESTIMATING GUIDE, Unless otherwise noted all items are derived from
the Guide DR2!1C97 Database Date 4/2004 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 AM,
Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are
described as LKQ, Qual Recy Parts, RCY, or USED, Reconditioned parts are described as Recon,
Recored parts are described as Recore. NÞ,GS Part Nmnbers and Prices are provided from National
Auto Glass Specifications, Inc, Pound sign (#) items indicate manual entries.
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