Claim Mueller, Rick D.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: Rick D. Mueller D.L. 485 76 0092
2. Address: 4992 Asbury Cr. Dubuque IA 52002
`
3. Telephone Number: 563 556 2927 work 563 582 6489
4. Date of Incident: 6 7 04
5. Time of Incident: approx. 1:00 P.M.
6. Location of Incident (Be specific):
20th Central - Close to Intersection
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.)
I, Rick, Mueller, was traveling south on Central in right side lane when driver of City Truck #3418 decided change from left south bound lane to right hitting me in right rear door and real quarter. Driver said he
didn't see me. City Driver was Fred Clauer, 4255 Swan, Dubuque, IA 52001 Truck #3418
8. What were weather conditions like? Clear and dry
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No injury
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.)
Auto damage with Repair of $892.98 + 1 day loss of vehicle while repaired. Rental for day $55.00 - total claim $957.98
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?
Complete amount
16. Why do you claim the City of Dubuque is responsible?
City Driver crossed into my lane.
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 14th day of June, 2004. .
/s/ Rick Mueller
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
. cú:Øj'J/Ø; ~¿:/ ~r ')
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: r;f?è'/ dJ. /1Jlj6"'~.€r P~?'S::76 ¿J¿fP~
2. Address: q't?Çl.;( A ') /:;10' ?' æ,/ æ. .o?" ¿d?¿Jc: ..¡- A S-Z):7ð':;¡""--
3. Telephone Number: .:5'ïb..5 - ~ -;;[9 ð' "7 Û/.ø~ .s-~.:!' - ~~
4. Date of Incident': d- r'- ð?i'
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6. location of Incident (Be specific):
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5. Time of Incident:
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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
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8. What were weather conditions like? d/£A'L ,,6lVL/ ,L/,;¿-j:::;
,
9. Give name and address of any witnesses:
10. Did P, olice investigate? (If so, give names of officers.) 4'/..
. A'/~
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
t.
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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.)
#¿J
15. What amount do you claim from the City of Dubuque?
~ 4/" //e:;::;¿:- ,4 4b ¿/ U r
16. Why do you claim the City of Dubuque is responsible? ~ ~
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) A/' ¿J
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
/9" day of .7;; ),/£
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~2) ~-'/.&~
(Signature)
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(Print Name)
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(Rev. 1/00 & 7/01)
Damage Assessed By: Robert Hanley
Deductible: UNKNOWN
Date: 611012004 03:31 PM
Estimate ID: 6187
0
Preliminary
Profile ID: Mitchell
Hanley Auto Body Inc.
1030 Century Circle Dubuque, IA 52002
(563) 583-7220
Fax: (563) 583-8355
OWner Rick Mueller
Address: 4992 Asbury Circle Dubuque. IA 52002
Telephone: Home Phone: (563) 566~7
MiIcheII8ervice: 916489
Description: 1994 Buick LeSabre Custom
Body Style: 4D Sed
Line Entry Labor
Item Number Type
1 616450 REF
2 616870 BDY
3 600140 BDY
4 618880 BDY
5 AUTO REF
6 600162 BDY
7 600479 BDY
8 600168 BDY
9 621350 BDY
10 AUTO REF
11 621770 BDY
12 AUTO REF
13 933012 REF
14 AUTO
15 AUTO
Operation
BLEND
REMOVE1INSTALL
REMOVE1lNSTALL
REPAIR
REFINISH
REMOVEIINST ALL
REMOVE1INSTALL
REMOVEIINST ALL
REPAIR
REFINISH
REMOVEiREPLACE
ADD1- OPR
ADD'L OPR
ADD'L COST
ADD'L COST
Drive Train: 3.8L Inj 6 CyI AO
Line Item
DesciipIion
L FRT DOOR OUTSIDE
L FRT DOOR MOULDING
L FRT REAR VIEW MIRROR
L REAR DOOR SHELL
L REAR DOOR OUTSIDE
L REAR DOOR APPLIQUE
L REAR DOOR MOULDING
L REAR OTR DOOR HANDLE
L QUARTER OUTER PANEL
L QUARTER PANEL OUTSIDE
L QUARTER MlEEL OPENING MLDG
CLEAR COAT
STRIPE
PAINTIMATERIALS
HAZARDOUS WASTE DISPOSAL
PartTypei
PartNIm1ber
Dollar Labor
Amount Units
--
C 0.9
0.3
0.9 #
3.0"
C 2.1
0.3
0.2
0.8 #
1.0"#
C1.8
59.93 0.3
1.4
0.3"
Existing
Existing
88891491 GM PART
15.00'
167 AD'
5.00'
. - Judgement Item
# - Labor Note Applies
C -Included in Clear Coat Calc
Add,
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals
Body 6.8 46.00 0.00 0.00 306.00 T
Refinish 6.6 45.00 15.00 0.00 307.50 T
Taxable Labor
Labor Tax
@
613.50
42.95
II. Part Replacement Summary
Taxable Parts
Sales Tax @
Total Replacement Parts Amount
64.13
Amount
59.93
4.20
7.000%
7.000%
Labor Summary 13.3 656AS
ESTIMATE RECALL NUMBER: 61101200415:30;46 6187
UllraMate is a Trademark of MiIcheU International
Milehell Dala Version: JUN 04 A Copyright (C) 1994 - 2003 Milehellinternational
5.0.m - All Rights Reserved
Page1of2
Date: 611012004 03:31 PM
Estimate ID: 6187
0
Preliminary
Profile 10: Mitchell
UI. Additional Costs
Non-Taxable Costs
Amount
172.40
IV. Adjustments
Customer Responsibility
Amount
0.00
Total A_anal Costs
172.40
I.
II.
UI.
Total Labor:
Total Replacement Parts:
Total Additional Costs:
Gross Total:
656.45
64.13
172.40
892.98
IV.
Total Adjustments:
NetTotal:
0.00
892.98
This is a Dreliminarv estimate.
Additional chanQes to the estimate mav be required for the actual reDair.
ESTIMATE RECALL NUMBER: 6110/200415:30:46 6187
UllraMate is a Trademark of Mitcheliinlernaliçnal
Mitchell Data Version: JUN 04 A COpyright IC) 1994 - 2003 Mitchellinternalional
5.0.023 - All Rights Reserved
P_2of2