Claim Brissey, Lisa
/,' ,-'.
" \ u~ J V" /
, CLAIM AGAINST THE CITY OF DUBUQUEj'IOWA " !31L. " G
, /)1 &/L/( -¡~':I(Jd'-
This written report constitutes your claim against the City of Dubuque, Iowa. You sh9~
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:_L \ S cl Ú"\¡;-:, s.s~'I
2. Address: \3~E; \<'\\'Y'\;::¡I---;w k. (Jr. J f)I.Al""V~
3. Telephone Number: SF; 3 - .5'?;). - CIS; '?
4. Date of Incident: \u.~sJ~, A(.,~¡^çt Ç),'--/¡ ;l(X)t.-¡
5. Time of Incident: °pr/ox, 5:00 ~(Ì"\
S.:).on:1
6. Location of Incident(Be specific): 'Ç."(,Oi'\-t 0+ k.~ìr,e.cly fìì ¿ l\ JII'\ ,\:'"",,-t 0+
-\~Q..-
~ð\" Ç> M'-\- n~f'lc." ..
10. Did police investigate? (if so, give names of officers.)
~CI\\C" ;o,-.'-;v-o.:\ c~ +",l. ¡r,J'oc-..",t,'-f\ (SI, b"+l, Jr-,VV'~ b;::r -(J..... ¡nail ; <; pfõ'v,;<'h rpr'f"r-/.IJ
'So k CAv-.\J Y'o4t p\'.}<:R, b\~ c('- "'r.1-~ +íd:....f. ' ü
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
f'\o
\t'\~~;'è.S, .
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.)
9?,~' ~,/-:~L-
/'5 ?'7- 2-9-
,
13. What other damages do you ciaim, if any? ~ ~ 3 ~ .
((:f()- J:--~ /' ~ÓJ-
( r
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.)
1)0.
15. What amount do you claim from the City of Dubuque? /S-71,27 f Í'ð {'-
16. Why do you claim the City of Dubuque is responsible? \)'\\ \:.., w-;>s rlr\'v; J ;:\
C\\~ ~ '~l.Alov'^" k.~'t\\;,~ \n,..,.,~t bIAs wk II.» ~ ;,,4., '\.oq .. ì\~ Io,^~
\.0 ";"..v.~ Io~ -\-h.. Crtv ¿: QLV c,c c.<>rd¡"'ð .-t" -+~ ~:c..;s f)J<ri '
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
\'ID,
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
Î\ (A
2--- day of ,~' , 20~.
.. ,,^_~_,_T' C'~~ ~J/~O~ '
C? ~ I'\,ù-k ; \\~ If\v~'t'~ <YJ " (Signature) 0 -
1;6l.~" p~ ~ "tF:h Õ ~ ~lSd ~í\S~~: u~,
1J 7 /J.. Y /0:1 ~~ () '6/)" Y /0 y , (Print Nam ... ..-
-r, ' - . ,,~,~ ~"\ <--<>I~"'--+"'¿ ~
, ",,- I',>\,~~V~
\~ ~CI.""- eft -tlt-o- ~~r ';;~ A"c.""
\~ C1)rf~~. ~ h~..... \I"'--\v.d-';:; c, c.-ol)(j
(Rev. 1/00 & 7/01) -"¡; -'<h" c."'r~-\'-J "'flfrl
tn", -I:\~ r,,-c,>: ~--' ¥' v~'
-'<k 1'-";,,,,- ~".d ;O"-
Dated at Dubuque, Iowa this
-
I ¡
;'
eel
.. ,
,',
BIRD CHEVROLET
3255 UNIVERSITY AVE, P,O. BOX 57 DUBUQUE,IA 52001
(563) 563,9121
Fax: {5631556-4482
TaxlD: 42-0400210
Damage Asaessed By: JOHN KLOTZ JR.
Deductible: UNKNOWN
Owner LISA BRISSEY
Address: 1325 TOMAHAWK DR, DUBUQUE, IA 52003
Telephone: Home Phone: (5631562-9578
Mitchell Service: 912492
Date: 9/212004 09:37 AM
Estimate ID: 9977
Estlmale Veralon: 0
Preliminary
Profile ID: Mitchell
Description: 1996 Chevrolet Lumina APV
Body Style: VanP_IO9" WB Drive Train: 3,4L Inj 6 Cyl2WD
VlN: 1GNDU06E5TT132237
Options: ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER WINDOWS, POWER DOOR LOCKS
CRUISE CONTROL, AUTOMATIC TRANSMISSION, AM,FM STEREOfCDPLAYER(SINGLE)
LIne Entry Labor
Item Number Type
1 201141 BOY
2 AUTO REF
3 200451 BDY
4 200453 BDY
5 2O04S5 BOY
6 200457 BOY
7 200888 BOY
8 226530 BDY
9 227700 BDY
10 AUTO REF
11 200892 BDY
12 228310 BDY
13 230040 REF
14 230450 BDY
15 AUTO REF
16 200693 BDY
17 AUTO REF
18 933018 REF
19 933019 BDY
20 AUTO
21 AUTO
Operation
REPAIR
REFINISH
REMOVEIINST ALL
REMOVEIINSTALL
REMO\IEIINSTALL
REMOVEIINSTALL
REMOVEIINST ALL
REMO\IEIINSTALL
REPAIR
REFINISH
REMOVEIINST ALL
REMOVEIINST ALL
REFINISH
REPAIR
REFINISH
REMO\IEIINSTALL
ADO'L OPR
ADD'L OPR
ADO'L OPR
ADD'L COST
ADD'L COST
Line Item
Description
R FRT DOOR SHELL
R FRT DOOR OUTSIDE
R FRT REAR VIEW MIRROR
R FRT DOOR FRT WINDOW FRAME MLOG
R FRT DOOR FRAME MLOG
R FRT OTR BELT MOULDING
R FRT DOOR HANDLE
R FRT DOOR CYLINDER KIT
R SIDE DOOR SHELL
R SIDE DOOR OUTSIDE
R DOOR HANDLE
R SIDE DOOR UNCODED LOCK CYLINDER
HINGE COVER
R QUARTER VAN SIDE PANEL
R VAN SIDE PANEL OUTSIDE
REAR BUMPER ASSY
CLEAR COAT
MASK FOR OVERSPRA Y
TAPED STRIPE
PAlNTIMATERIALS
HAZARDOUS WASTE DISPOSAL
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 9/212004 09:37:17 9977
UltraMate is a Trademark of Mitchell International
Mitchell Da1a Veralen: SEP 04 A Copyright (C) 1994 ,2003 Mitchellinlernalional
UItraMate Veralon: 5.0.024 - All Righle Reeerved
Dollar Labor
Amount Units
--
2.0"
C 2.7
0.4
0.2
0.3
0.5
0,7 ,
0,3"
4.0'
C 2.8
0,7 ,
0.2'"
C 0.6
4.0"'
C 2.2
1.0
2.2
0,3"
0,5*
Part Typel
Part Number
Existing
Existing
Existing
Existing
Existing
8,00"
10.00"
294,00 .
6,00'
Page 1 of 2
Foem 433!03
01-01
Cooo'y_Roo"-
X-Coo,di,,'..
Y-Cooedic""
If Di.id,d Hi,hw,y, Pm.id, R""
(C,,"co') T"." Di"olioc
NB SB EB WB
000 0
St", Zip
.'~, -"lÄ: ~
Po, N"
0 0
Zip
p" N"
0 0
Zip
U
N
I ~::::c'" Co
T
Y",-
'C-.:>
C,cci"
Nam,
VS DOT# oe MC#
0 0
If P'op,rty "hoc 'hoo Obi'"
.,h"'"d,m,,"d"'p',ic O,m",d
Owoe" Foil N,m,
(L"I. ""I. Middl"
Vcit ,
Vmt2
SEQUENCE OFEVENT
Ec.""m,"'
U U Looe"oc
LLJ U Typ,
:~~' 9-Vckcowc LLJ LLJ ",,'E.,"'
LLJ LLJ S"oed E.,"'
LLJ LLJ Th',d E.,ot
LLJ LLJ Foorth E.,",
0 No
S',",'oe
RFO
AWOENT ENV'RONMENT
ROADWAY CHARACTER'ST'CS
WORK ZONE RELATED'
Looeli" of F"" H"m'o' E."I U W",'h" Cocdit"" LLJ
(op '0 two)
M'Ioe C"",botlc, CI"om","",
0 Ye,
------------------------
Moococ of C",hlCo"','oc U LLJ
",hICond"io", U So"""Cocditio", U
Officer's Name j{{[}l(
Ro,dw,y
LLJ LLJ ~:';,~::;o' E.,n'
LLJ ~:~;:;~:o,',~;c;~:~"'h
Type of Ro,dw,y JocotloclF",o" LLJ U Wo,k", p","c\?
BadQe No,2(.,o,A-
w
NON-MOTORIST
Type LJ LooeOoo LJ
AaOoo LJ CoodlOoo LJ
S,f"y Eq"'pm,"1 LJ
Mo,o"yale 5,,00' Po,illon SEATING POSITION
01-Molo"yale D,'",
D4-Molo"ya'eP""n",
88 ~ Dth" ,"pl,'n In ",""""
10,51""",5,,000
11 ~ 'oolo"d C"90 A".
12 - U",nolo"d C"90 A",
13-T",illn,Unii
14-"",101
15- P,d,,"'"
16-Ped"cya""
17-Ped"cyali",p""o",
88-0Ih"",p"ln In ","""" ~
99 - Uo'",wn '"
Cool,ib"',", CI"om"",oe,LLj
-
01 02 03
04 05 06
07 08 09
Uoil No. of Vehlale Sink,",
LJ
D
R
I
V
E
R
5
Pho",
DRIVER OF UNIT 1
Pho",
DRIVER OF UNIT 2
T",",portedlo
N,me
p 1
E Add""
R
5 Name
a 2
N Add""
5
I N,me
N 3
J Add""
U
R Name
E 4
D Add""
D"eofBlrth
T"'",port,d~,
D'te 01 Birth
T"",ported~
D'te of Birth
T"",ported~,
D"eofBlrth
T,,",port" 10'
DIAGRAM WHAT HAPPENED
1ú.ftc..¡t.é<1-
1
1"lmOOon
Nomb",",h,ehlole"d.howdl"aOonofl",el by",ow
D
I
A
G
R
A
M
-c:=J><C:J--
U" ,olid Ii", 10 ,how p"h before ",aid,"L
-c=Þ
D::'d Ii::::E=j;:œide",
->~
Showpede"""'by,--o
Show ",,¡¡o,d by -tttttt-
Show otilily pole, by , <þ
Show molo"yale by -e-e-
Show,"lm,lby, R
h~~9-t ~\..L-
De""be wh,1 h'ppe",d ,tef" 10 "hlal" by comb,,}
N
A
R
R
A
T
I
V
E
~
~
c
°
~
m
]
c
0
~
£
~
c
~
~
~
~
.
¡ g
¡¡¡ w
~
~
m
~
,
~
~
~
~
~
!
~
,
8
( I
T""ported by'
f
INDICATE 0
NORTH 0
"-'~'----
Q\~'?
W N,me ""I, F,~I)
I
T
I N
I ~ I
I 5
SI,,"o,RFD
Cily
S"te
PM",
Z'p
H~I
Date: 91212004 09:37 AM
Estimate iD: 9977
Estimate Version: o
Preliminary
ProfilelD: Mitchell
I. Labor Subtotals
Body
Refinish
Units
14.8
10,8
Add'i
Labor
Rate Amount
46,00 10.00
46.00 8.00
Sublet
Amount Totals
0.00 690.80 T
0_00 504.80 T
II. Part Replacement Summary
Amount
Total Replacement Parts Amount
0.00
Taxabie Labor
Labor Tax
@
7.000 %
1,195.60
83.69
Labor Summary
25.6
1,279.29
ill. Additional Costs
Non-Taxable Costs
Amount
300.00
IV. Adjustments
Customer Responsibility
Amount
0,00
Total Additional Costs
300,00
I.
II,
ill.
Total Labor:
Total Replacement Parts:
Total Additional Costs:
Gross Total:
1,279.29
0.00
300.00
1,579.29
IV,
Total Adjustments:
Net Total:
0.00
1,579,29
This is a Dreliminarv estimate.
Additional chanQes to the estimate may be required for the actual reDair.
PARTS PRICES ARE SUBJECT TO CHANGE