Claim Phillips, Keith
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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.
. . .
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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:Je:nH PH ILL I P5
2. Address: Ie2$"3 L...Pr{:..ç ~k::ft-~ù¡¿R-ò Du$'
3. Telephone Number: S3- 7 -/939
4. Date of Incident: --; - 2.-L1- C {-
tj' ~ 30 1t 11.
6. Location of Incident (Be specific): fey uJ ¡;s:y í/è J G ¿! i4:-L¡) ç !-I-/tt:.[;MJJ4IJ=-
WT
IA
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
employee's name.)
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8. What were weather conditions like? f'?~/!... Ft::--c..¡
9. Give name and address of any witnesses: ~.. .
pit ~ ê t+L.-L A- li'1i- f-) ;f- II e:: m+ Ai- I LL I B;:
10. Did police Investigate? (If so, give names of officers.)
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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.)
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13. What other damages do you claim, if any?
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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.)
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15. What amount do you claim from the City of DUbUqUe?:If !?z... 7. í5 S-
16. Why do you claim the City of Dubuque is responsible? crry ¿(Iv¡ fìÐy£t; !!ik1:.S
en)! V~HICLE /~fO PF+RK6Þ Tf!.lJcJ::.. / N iJJE:LL M ~£D
(JNz K , tJ G L-bT I t-J Pè: ¡¿ ~I t,J elfTl+G,e .
17. Have you made any claim against anyone else for damages as a result of this Incident?
(If yes, give name and address.) N '0
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 .3 (:,'D day of
A-v 6 US)
, 200Lf.
,-
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(Signature)
/FIT7/- /VI. PH/LLI ß:
(Print Name)
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(Rev. 1/00 & 7/01)
Date: 8/ 312004 08:28 AM
Estimate ID: 9874
Estimate Version: 0
Preliminary
Profile ID: MRchell
BIRD CHEVROLET
3255 UNIVERSITY AVE. P.O. BOX 57 DUBUQUE, IA 52001
(563) 583-9121
Fax: (5631 556-4482
Tax ID: 42.Q400210
Damage Assessed By: JOHN KLOTZ JR.
Deductible: UNKNOWN
Owner KEITH PHILLIPS
Address: 10283 LAKE ELENOR RD DUBUQUE, IA 52003
Telephone: Home Phone: (563) 557-1939
MRchell Service: 9t5495
Description:
Body Style:
VIN:
Mileage:
Color:
Options:
2004 Chevrolet Pickup Silverado K15OO
2D Pkup 6' Bed 119" WB
1GCEKt4T94Z258018
1,812
PEWTER
4WD OR AWD, ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER WINDOWS, POWER DOOR LOCKS
CRUISE CONTROL, AUTOMATIC TRANSMISSION, AM-FM STEREO/CDPLAYER(SINGLE)
Line Entry Labor
Item Number Type
1 AUTO BDY
2 501885 BDY
3 900500 BDY .
4 900500 BDY'
5 900500 REF'
6 AUTO
7 AUTO
Operation
OVERHAUL
REMOVEIREPLACE
REMOVEnNSTALL
REPAIR
REFINISH/REPAIR
ADD'L COST
ADD'L COST
Line Item
Description
REAR BUMPER ASSY
REAR BUMPER FACE BAR
LR RUNNING BOARD
REPAIR FIBERGLASS
REFINISH BOARD
PAINTIMATERIALS
HAZARDOUS WASTE DISPOSAL
. - Judgement Item
Add'i
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totels
Body 3.2 46.00 0.00 0.00 147.20 T
Refinish 1.5 46.00 0.00 0.00 69.00 T
Taxable Labor
Labor Tax
7.000 %
216.20
15.13
@
Labor Summary
4.7
231.33
Drive Train: 5.3L Inj 8 Cyl4WD
License: 799AW
Part Typa/
Part Number
ORDER FROM DEALER
Existing
Existing
Existing
II. Part Replacement Summary
Taxable Parts
Sales Tax @
Totel Replacement Parts Amount
ESTIMATE RECALL NUMBER: 8/31200408:27:599874
U~raMate is a Trademark of MRchelllntematlonal
MRchell Date Version: AUG 04 A Copyright (CI1994 . 2003 MRchelllntematlonal
U~raMate Version: 5.0.024 - All Rights Reserved
Dollar Labor
Amount Unns
~~
1.2
516.95 INC
1.0'
1.0'
1.5'
42.00'
1.38'
7.000%
Amount
516.95
36.19
553.14
Page 1 of 2
Date: 8/ 3/2004 08:28 AM
Estimate ID: 9874
Estimate Version: 0
Preliminary
Profile ID: MRchell
III. Additional Costs
Non-Taxable Costs
Amount
43.38
IV. Adjustments
Customer Responsibility
Total AddRional Costs
43.38
I.
II.
III.
Total Labor:
Total Replacement Parts:
Total AddRional Costs:
Gross Total:
IV.
Total Adjustments:
Net Total:
This is a Dreliminarv estimate.
Additional changes to the estimate mav be reQuired for the actual reDair.
PARTS PRICES ARE SUBJECT TO CHANGE
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~ , ~ CarnmIIIIan Ibnb8r 7II7D4
. My CarnmIIIIan
,. J8nu8ry 18, ~
¿b
'f; -:3 --04
ESTIMATE RECALL NUMBER: 8/312004 08:27:59 9874
UItraMate ¡a a Trademark of MRchelllntemational
MRchel1 Data Version: AUG 04 A Copyright (C) 1994 - 2003 Mhchellintemational
UhraMate Version: 5.0.024 - All Rights Reserved
Page 2 of 2
Amount
0.00
231.33
553.14
43.38
827.85
0.00
827.85
FED ID #42-0813744
Date: 8/312004 08:33 AM
Estimate 10: 8667
Estimate Version: 0
Preliminary
Profile ID: MRcheil
RICHARDSON MOTORS
1475 J.F.K. ROAD DUBUQUE,IA 62002
(&831 682-6411
Fax: (&831682-'129
Damage Assessed By: JASON CHARLEY
Deductible: UNKNOWN
OWner keRh phillups
Telephone: Home Phone: (5631 &&7.1839
MRchell Service: 91&48&
Description: 2004 Chev- PIckup SiIverado K1&oO
Body Style: 2DPkup6'Bed11S"WB DrIveTrain: 6.3Llnj8CyI4WD
VlN: 1GCEK14T94Z2&&O18
Options: 4WD OR AWD, ALUM/ALLOY WHEELS. AIR CONDITIONING, POWER WINDOWS, POWER DOOR LOCKS
CRUISE CONTROL, AUTOMATIC TRANSMISSION, AM.f'M STEREOICDPlAYER(SINGLE)
Line Entry Labor
Item Number Type
1 AUTO BOY
2 601885 BOY
3 900600 BOY .
4 900&00 BOY .
6 900&00 REF'
6 AUTO
7 AUTO
Operation
OVERHAUL
REMOVEIREPlACE
REMOVEIINSTALL
REPAIR
REFINISHIREPAIR
ADO'!.. COST
ADD'!.. COST
Line Item
Descñption
REAR BUMPER ASSY
REAR BUMPER FACE BAR
RUNNING BOARD
RUNNING BOARD
RUNNING BOARD
PAlNTIMATERIALS
HAZARDOuS WASTE DISPOSAL
. - Judgement Item
Add,
Labor SUblet
I. Labor Subtotals Units Rate - - Totals
Body 3.4 48.00 0.00 0.00 16&.40 T
Refinish 1.6 48.00 0.00 0.00 69.00 T
Labor SOOIfI1ary
T- Labor
Labor Tax
7.000 %
22&.AO
16.78
Part Type!
PartNIRIIber
ORDER FROM DEALER
Existing
Existing
Existing
II. Part Replacement St8nmary
Taxable Parts
Sales Tax @!
Total Replacement Parts-
ESTIMATE RECALL NUMBER: 8/312004 08:33:61 96&7
Ultra Mate is e Tredemerk of MRchelllntemelionel
Mitchell Data Version: AUG 04 A Copyright IC) 1994 - 2003 Mitchelllnlemational
UltraMate Version: 6.0.024 - All Rights Reserved
@!
4.9
241.18
Dollar Labor
Amount UnRs
--
1.2
616.86 INC
1.2"
1.0'
1.6'
42.76'
3.00'
7.000%
Amount
616.96
38.19
&&3.14
Page 1 of 2
III. Additional Costs
Taxable Costs
Sales Tax
7.000%
Amount
3.00
0.21
@
Non-Taxable Costs
42.7&
Total Additional Costs
45.9&
Dale: 8/312004 08:33 AM
EstImate ID: 96&7
Estimate Ve<sion: 0
Preliminary
Profile ID: MRcheU
IV. Adjustments
Customer Respon_1ity
I.
".
III.
Total Labor:
Total Replacement Parts:
TotaI- Costs:
Gross Total:
IV.
Total Adjustments:
Net Total:
This is a Dreliminarv estimate.
Additional changes to the estimate mav be required for the actual repair.
~
idL~'
~~ UNDAA.DU~CINI
, f. CDmmII8Ian NumÞer 707834
. , ' My CommIIIIon Expne
°: JInuery 18. 2007
ESTIMATE RECALL NUMBER: 8/312004 08:33:51 9667
UItraMate Is a Trademarl< of Mitchellintemationel
Mitchell Data Ve<sion: AUG 04 A CopyrlghllCl1- - 2003 MiIcheIllnWnatlonal
UUraMate Version: 5.0.024 - All Rights Reserved
Page 2 of 2
Amount
0.00
241.18
&&3.14
45.96
840.28
0.00
840.28