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Claim Schaver, AmandaCLAIM 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: Amanda Schaver 2. Address: 750 South Grandview - Dubuque, IA 520033 ` 3. Telephone Number: (563) 588 8604 4. Date of Incident: June 18, 2004 5. Time of Incident: 8:40 a.m. 6. Location of Incident (Be specific): 750 South 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.) I had just entered my parked vehicle. Before I could put my seat belt on or start my vehicle, I felt a vehicle hit me from behind. I exited my vehicle and saw the recycling truck had hit my vehicle. Paul Schult has copy of incident report and employee name. 8. What were weather conditions like? good 9. Give name and address of any witnesses: n/a 10. Did police investigate? (If so, give names of officers.) No, Paul Schultz (Solid Waste Mgmt. Supervisor) assisted with report. 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.) Tire cover ripped. Spare wheel dented. Rear bumper damages, rear door damaged at point where tire attached to back door. See attached ABRA estimate for details. 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? Total cost of repairs (Est. at $2194.92) 16. Why do you claim the City of Dubuque is responsible? The City Vehicle sturck my vehicle. The driver stated brake not applied in time. 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 21st day of June , 2004. /s/ Amanda Schaver (Signature) (Print Name) (Rev. 1/00 & 7/01) . cd~, /1;'//7, ~/ 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: A\tncnclO\ CChctver 2. Address: 7é:O ôoi.M-'vl 6rrA'ìdvrew - DLAbutfUe í I A 52003 3. Telephone Number: (:5ri3Jo8K-ß(o{)4 4. Date of Incident: "Jü he ß) 200 '-/ 5. Time of Incident: ~ 8: L 0 AWl. 6. Location of Incident (Be specific): 7t5() &u.+h Grand VIew 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.) T htÃd jUst en-wecl ¥Y'\j pGv"Kea' Velrlrcle. BeØre . I COlAlci pAt- . In} .sea+ belt Of) or àvN- VY\' \Jenlac :I .(è¡+ ()¡ veh de hit ~ ~h . T e Ide d i+-vrl" Veh¡de. PoA~hL,ltz ~ ()i~H~ícMt report-co empl 8. What were weather conditions like? )OU 9. Give name and address of any witnesses: N / A 10. Did police investigate? (If &0, $live names of officers.) .. . Ala j Paul S\hult2 ~hd Waslt: JVlðmt- Supr¡Á&Y \ a35i6iecl G report 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). !Va 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.) ~(e. (\()\W' r:pfXd. ~ \~Àt1eeltt dFmed I (Per. f bumptr'demúl{fC1, r f'ev- c~ lÂVYnjfd tic 1 poih-t \N here -hh' 0. m c.ir1ed ,-fu ha c k.. ßúOr, See {Ã~ed AßI<A e~-Ie-f7)1" defõtd.s /Vone 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 ID-/a Ie 15. What amount do you claim from the City of Dubuque? 06t of (EstmaJ-ed ctf $2/q4 QZ) wpalV"S 16. Why do you claim the City of Dubuque is responSible?~ S1wtcK Im\J \/evnc:le. Ire dvNfr ek\hi . ~~ I'V) ~me ~¡-hl Veh~c/e.. I bAKe ht'á 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) !\J 0 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? 2 '{jr ~ . Dated at Dubuque, Iowa this 1E day of \....,j LAhe , 20 ()L/ . ~2~ (Signature) ~rmm . ~/r¡() ver (Print Name) (',1 ('.J ~ c.) .~ c'.j C:J (Rev. 1/00 & 7/01) --~ , -- ~-_.c 06/21/2004 at 09:32 AM 24443 Job Number: ABRA - DUBUQUE Federal 10 #:420782245 DBA: ANDERSON-WEBER INC 3400 CENTER GROVE DR DUBUQUE, IA 52003 (563)556-0696 Fax: (563)556-1899 PRELIMINARY ESTIMATE Written By: DAVE BIGELOW Adjuster: Insured: Owner: Address: AMANDA SCHAVER 750 S GRANDVIEW DUBUQUE, IA 52003 (563)588-8604 (563)589-9030 Claim # Policy # Deductible: Date of Loss: Type of Loss: Point of Impact: 6. Rear Evening: Business: Inspect Location: Insurance CITY OF DUBUQUE Company: Days to Repair 2004 JEEP LIBERTY 4X4 SPORT 6-3.7L-FI 40 UTV SILVER Int: VIN: 1J4GL48K84W158599 Lie: Prod Date: Air Conditioning Rear Defogger Intermittent Wipers Rear Wiper Dual Mirrors Clear Coat Paint Power Brakes Driver Air Bag 4 Wheel Disc Brakes Cloth Seats Styled Steel Wheels Odometer: Tilt Wheel Body Side Moldings Power Steering Passenger Air Bag Bucket Seats 7629 ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER 2 Repl Bumper cover silverstone 1 322.00 2.3 0.0 3 Repl RT Step pad 1 86.60 Incl. 0.0 4 Repl LT Step pad 1 86.60 Incl. 0.0 5 Repl RT Absorber 1 19.00 0.1 0.0 6 Repl LT Absorber 1 19.00 0.1 0.0 7 TAIL GATE 8 Repl Tail gate 1 400.00 3.6 2.1 9 Add for Clear Coat 0 0.00 0.0 0.8 10 Add for Underside (Complete) 0 0.00 0.0 1.2 11 Add for Clear Coat 0 0.00 0.0 0.2 12 Repl Nameplate "Jeep" 1 20.70 0.2 0.0 13 Repl Nameplate "3.7L" 1 11.85 0.2 0.0 14 Rep1 Nameplate "4x4" 1 14.35 0.2 0.0 15 SPARE TIRE CARRIER 16 Rep1 Spare bracket 1 62.70 0.2 0.0 1 06/21/2004 at 09:32 AM 24443 Job Number: PRELIMINARY ESTIMATE 2004 JEEP LIBERTY 4X4 SPORT 6-3.7L-FI 40 UTV SILVER Int: ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 17 Repl Spare Spare cover accessory 1 46.00 0.0 0.0 black cloth w/logo 18 WHEELS 19 Repl Spare Wheel, alloy code WN5, 1 262.00 ill 0.3 0.0 WD5 20# Subl TIRE MOUNT & BALANCE 1 12.00 T 0.0 0.0 21# Repl BAG / COVER CAR 1 4.00 0.2 0.0 22# Subl HAZARDOUS WASTE DISPOSAL 1 4.00 T 0.0 0.0 23# Repl CORRISON PROTECTION 1 4.00 T 0.3 0.0 ------------------------------------------------------------------------------- Subtotals ==> 1374.80 7.7 4.3 Parts Body Labor Paint Labor Paint Supplies Sublet/Misc. 7.7 hrs @ $ 47.00/hr 4.3 hrs @ $ 47.00/hr 4.3 hrs @ $ 28.00/hr 1354.80 361.90 202.10 120.40 20.00 ---------------------------------------------------- SUBTOTAL Sales Tax $ 1938.80 @ $ 2059.20 7.0000% 135.72 ---------------------------------------------------- GRAND TOTAL $ 2194.92 ADJUSTMENTS: Deductible 0.00 ---------------------------------------------------- CUSTOMER PAY INSURANCE PAY $ 0.00 $ 2194.92 WARRANTY VALID ONLY WITH ORIGIONAL COpy OF YOUR RECEIPT PARTS SUBJECT TO INVOICE NO GUARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED Estimaee based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noteei all Hems are derived from the Guide DR3WD02 Database Date 06/2004, CCC Data Date 06/2004, and the parLs selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. Asterisk (* I or Doûble Asterisk (HI indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign i-) items ineiicate MOTOR Not-Inoluded Labor operations. Kon-Orig:'nal Equipment Manufacturer aftermarket parts are described as AM, Qual '(epl Parts or Camp Repl Pares 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. NAGS Part Numbers anei Prices are provided by National Auto Glass Specifications, enc. Pound sign (#) items iDdicate manual em:ries. CCC Pathways - A prod'Jct of CCC Information Services Inc. 2