Claim Ernst, Paul A.
.4u~ 9. 20í~L ":26AM
CITY or DBa LEGAL DEn
No. 0648d 2/~
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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 addltlonellnformation that supports your claim.
The Clelm must be flied 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:
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2. Address:
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«;/-» 7y~ .210';-
7 - ð' , 0 <¡
.4/"P/.e if/vI',,", IL. (,'/e Of
3. Telephone Number:
4. Date Of Incident:
5. Time of Incident:
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8. Location of Incident (Be specific):
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7. DESCRIBE ACCIDa:NT 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?
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9. Give name and address of any witnesses:
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10. Did police Inves!i ilate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give name" addresses, and extent of Injuries).
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CITY OF DBa LEGAL DEPT
No. (1648
P, 3/3
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? (" 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?
J¡ /92.30
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 end address.) .:þ
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18. If the answer to Question 17 Is yes, have you received any payment from that source,
and If so, In what amount? If
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Dated at Dubuque, Iowa this q +.!: day of Ii "5" <-f
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(Signature)
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(Print Name)
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(Rev. 1/00 & 7/01)
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fi1>!": I<Π611}.420-52Q5 To: ]()9!;~11682
Daœ: 7Jul0't Jim.: 2:'18:211 PM
"-'3ot5
ACE REVIEW FOR FARMERS UNION CO-OP INSURANCE
P.O, BOX 541090
OMAHA, NE 68154
(888) 816 - 2436
ESTIMATE AUDIT
Insured
Claimant
InsCo
A5Si¡¡ned By
Repair Fac
PhoneJFa.
Fedentl 10
Vehicle
PAUL ERNST
PAUL ERNST
ACE: REVIEW FOR FARMERS UNION
DAVE BENSON
KAISER'S AUTO BODY
215 RAILROAD ST
WARREN, IL 61087
(815) T45-3392 í (815ì 745-3392
353581189
1998 Chrysler Concord<:: LXI
1'H/$ DOCUMENT IS NOT AN APPRAISAL
File Number
Policy Number
a..im Number
Date of !...au
D~te Inspected
Auditor
717939 fC36
APILOOO247
0110400882
07/08104
07/13104
RJA
# Operation
Labor PaW:
Description
Part TypeIPart Number
Price
1 REMOVEIREPLAC REPLACE LUGGAG" LID
2 REFINISH ,-UGGAGE LID
-j----REFI-NISH-- --:"-fjti-FëYRUÑDËRSlfjE------"----"'---"----'..----..m'_~_-_m___,__,,---
4 ----[5ö';'s Aute r773¡ 721 -2800
5-.-,_m---,-- - LINE MARKÜP-%"2S'ÖÖ---'--_oo,___m'--oo--"",oo.,_,_,m_----,-,----------"-______m--_""_---"-'--~:75-'------
-¡¡_m-'REMOii8REPLAC "REÄR-R-EPLACË-¡¡UMPEf¡-_OO- --'."-----'ÖüäïR"iiëýëïiiii-Pärt---- ---"'--"25õïi:ï--ìÑc'------_.
7 REFINISH REAR BUMPER -- -- --, 1,8
8 - - --"'Öön;sAiiió-(773ji2i~2600m-,-- '--nom ..m----'---m___m -- - - - -"__m_____'-----'--m__,___-
'ë--""-------------' '-CliiEMÄRKÛf"Îb2¡¡-ÖO--- _m----____-,-___,..m_____m__,_--_--,_m___.""..---6i¡¡a--'-----
_10_,~EMOVEIREPLAC . R_R~f'LA~~T~J~ U\MP~~:-:::- Qual Reç~,ed~~ ._,_...~~~~~---,O,3----___-
11 Neal's auto: (309J 673-7404 00 -
'1:1"---- --CINEMA-RKU-¡'%2500oo_n ----.-------'."--'-- 25.00
'1"3--n--- - END OF ATG SectiON n.- ,---,----------,---
1¡"'f~EPÁIR n¡fÖ-UAiÙËR Ö'UP-=R-PÄNECoo"..__,oo_,...__n-êj;j,¡¡¡r.-ïi,--m_- ------m_n -m___'------------.1.Õ'-~--
15 REFINISH R QUARTER PANEL OUTSIDE "2:0
ïïf--'REPÄiR-----,---,_oo_-_n-CaÜÄRTEROUTER.PÁNËC -. ----8d8tiñiï"'--'_____m___--_._---.'_.".--"""--"io----
17 REFINISH L QUARTER PANEL OUTSIDE'- 2.0
18 REMOVElRe;PLAC ~UGGAGE-~iD ADHESIVí: NAMEPLATE 4805308AA 47.75 0,2
'19'---REMOŸËiRËPï:Ac---ŒGGÄGEÜÖ-WEA'ffiERsrnîpm_,--_mm_,.....,_..."'457522m,---_m__----_,.,-------- - ----74:75---0:2---------
20 REMOVElREPlÄCOO_-REAReÓDYPANEL n- - -m----- 45752O8AF--'" - 7~45 7,5
21---1fé'FiÑišR--.--_...--,-_mREAffBODYP/¡:NEL-m_-_m,_m__- '--'-------_"""',OO_'_------nm_--__----_m___---'----_OO--hn,_----- '_____OO'-'--'õ.é'
':i2"--RËFïNiSl:j-----_m_'._--RËÄR-OOD'{EDGË -- m_OO__'___-",.,.,---",,-----nm__m----,m--_----..........-.----,-,- n_-0.8
23 REPAIR R REAR BODv FLOOR PAN REINF Existing '1,0
2400 R:EPAIR ~ RI;AR BoDY FL.oOR PAN-REiNFm -m_'---EXiSting." "_n m--'i.o--m_----
-2!j----R"Ëii.ïOVEiiNSTÄlC- -fiËÄRBUMPERASSy----____n'_____---,,_._-----m.,---_m_nnn_- - --------.--__m______----_,_--_m'-ïÑë----""--
Qual Recycled Part
'17500
1,1
2,0
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J~13, 2004 01:09 PM
u- Is a T- of _hoII-
""""".Dot.v","""" JUL_O4_A C_(CJ1""-zuœ__-
All R;! hts R.....--d
f'ro!n: o\Π611H29-5205 To: JC98211682
Dote: 7/13/0'11i...: 2:11:31'1'1
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ACE REVtEW FOR FARMERS UNION Co-op INSURANCE
p,o, BOX 541090
OMAHA, NE 68154
(888) 816 - 2436
ESTIMATE AUDIT
Insured PAUL ERNST
Claimant PAUl.. ERNST
Ins Co ACE REVIEW FOR FARMERS UNION
Assigned By: DAVE BENSON
Repair Fac KAISER'S AurO BODY
215 RAILROAD 51
WARREN, IL 61087
(815) 745-3392/ (815) 745-3392
353581189
1998 Chrysler Conoorde LXi
THIS DOCUMIiNT IS NOT AN APPRAISAL
File Number
Policy Number
Claim Number
Date of LOH
Date Inspected
Auditor
, 717939/C36
: APILOOO247
: 011 04CI0I82
: 07lOaJ04
: 07f'!3104
: RJA
PhoneJFax
FederailD
VehICle
# Operation Description
28 ADQ'L CPR CLEAR COAT
ZT ADD'L OF'!'! TINT COLOR
28 AOO'L CPR LKQ PART CLEANJP -
-29-"'-ÃB5'[CöSi'~~'-'" '. "S-";iÑf';;'¡ ÃTËR iAcs".....n..n -, "...... -'---,-'_n- m
Part TypelPsrt Number
Price
Labar PIIttt
2.6
"0,5
*1,5
-'--------"-""--'----""---"'--'--""-'-353-80 ------
-"-------~"--,-,--,-------,----
. . Judgement Item
# . Labor Nate AppIi8S
C - Included In Clear COM Calc
I/tnMate Is" T_ør_holl-
IIIItdJol DalaV..8œr. JUL_Ð4..A Copyr\ ¡ -tIC)1!iM.2IIO3_1_lonoi
All Rlghls R--..cI
",,'3,20040'<111""
Fn¡m; IŒ 51[1.429-§205 To: 3O9B211682
DatJo: 7/13/04 Time: 1:48:21 PM
I'11III5",5
ACE REVIEW FOR FARMERS UNION CO-OP INSURANCE
P,O. BOX 541090
OMAHA. NE 68154
(888) 818 - 2438
ESl1MATE AUDIT
Insured
PAUL ERNST
File Number
. 717939/C36
Parts
Labor
Tæoobl.. p-
"'.rIs Adjustm-
SaIe5 Tax
720.95
13125
53.26
Body
ReIi~i'"
Add!. Labor Additional Colts
1580 @ 4400 0,00 = 9I5,2IJ AdcIIIion8I CII8IB
13.60 @ 4400 0,00 = 5118,40 T ox on Add, Costa
SUo
22.10
Subtotals
5105.48
29.40
1,2\13,60
375. 7D
Taral Labar:
T_I Rep18C81118nt Pe-
T- AdcIItI- ~
GrQ88 TOI8I:
1o18t Ad,juIllmMtl:
NatTCIIIII:
1,293.110
905,411
!75,7D
2,574.78
O.CO
2,574,78
REMARKS:
This is NOT an AuthorIuIion to Repair. No Supplements without prior appl'OV8l.
AGREED PRICE HAS BEEN REACHED WIn-! WAYNE KAISER ON 7/13J04,
Arrt person who ~n;Iy and wIIh IIIt8nt 10 derraUd IIIIV' IrISlII'enee compellw ,.. ....... ...- fiI8s an appIic:8IIcIn f8r ~..
Bt8I8ment fit chIlm containing any matvriatly fill.. InronnatiOn or conc:aals lOr the II/qICII8 fit mis_lng, InftInn8IIaII c:o-.unø
any fact _81_"" """,m"'" a fraudulent insunmc:e act, which is a crime and aull ects IlUCII pe.-1o crII8ll1111 and c:I1IIl
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Enterprise
rent-a-car
427 WEST SOUTH STREET
FREEPORT IL 61032-4113
I) At-)r~~ ,";,'.~: ,j
Bill To:
_._._,-,.,.~,-,.
fARMERS UNION-OMAHA
ATTN: BENSON(309-821-1682)*0
407 NORTH 117TH STREET
OMAHA NE 68154
oat. Out
7/13/04
I18nto,
PAUL! JOAN ERNST
Dato In
7/29/04
Color
RADIUM K
MDdol
04 SENT
liconso ND, Claim I/IPDlicy I/IP,O, 1/
T449521 0110400662
Unit 1/ Ins.rod
BT4944 ERNST' PAULI JOAN'
Oat. of Loss Type of LDSS
INSURED
Repair Shop
KAISER AUTO
Type Df Car
CHRYSLER 3
.
.
.
Please Return This Portion with Remittance
.
.
.
.
.
Remit to:
ENTERPRISE RENT -A-CAR MIOWST**
ATTN: ACCTS RECEIVABLE
P,D, BOX 1570
DAVENPORT IA 52809-1570
07/30
.
.
Additional Driver
Namo
NO OTHER DRIVER PERMITTED
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Rental Agreement
0431442 - 6241
Description
Rate
Amount
17 DAYS @
SALES TAX,,"
407,83
24,47
23,99
6.00
AUG ..
-:J 2ÐO4
OTAl CHARGES
ESS AMOUNT RECE IVEO
432.30
92,3C
AMOUNT DUE. . . . .. .. . .. ... ~
340.00
¡
iIIing Inquiries Call
815-235-7606
illing Infannation
$20,OO/OAY NO
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Fed Tax 10 "
43-1614608
SALES TAX
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AMOUNT DUE............., ~
:uo.oo
Paid by:
fARMERS UNION-OMAHA
ATTN: BENSON(309-82,.,682¡*D
407 NORTH 117TH STREET
OMAHA NE 68154
Custom.r# Rontal Agreemont Amount
FUN6219 0431442 340.00
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