Claim Krawczuk, Ferdinand WalteCLAIM 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: Ferdinand Walter Krawczuk
2. Address: 965 Shady Lane
`
3. Telephone Number: 563 588 1372
4. Date of Incident: 7 Sept. 04
5. Time of Incident: 0926 hours
6. Location of Incident (Be specific): Corner of Northridge & Shady Lane - 965 Shady Lane
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.)
See Accident report Case # 04-40628
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
Yes
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
Yes, enclosed 2 estimates
13. What other damages do you claim, if any?
Please fix truck
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?
$4,314.60
16. Why do you claim the City of Dubuque is responsible?
Pictures were taken. City officials spoke to me. Police were there.
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 9 day of Sept. , 2004.
/s/ Ferdinand W. Krawczuk
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
r/l~¿¡ é{~r3~
;1fJlfrj
~-f/-
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.
CLAIM AGAINST THE CITY OF DUBUQUE,IOWA
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: FrJ,"iV-..MJ CAJc. l4."ì M'rUf>.)C7-({/¿
q(~ r ,\/,.cf'1 J. /'}-A(r-
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I
() c¿.2G:, 'rS.
2. Address:
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific): Cf') r--.....:?I' cr! ^(ð~ /'. \~.R
1
S; h~1 L~ >1è . CfGr S~l.._c..Jj )~A.. ",\?
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.) A ('r:J f kß Î<.t<-a,c-l
I
*-
1
G
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
r~ ß ~ D J :2 ,Bj~ 7 =-f:;;; ~
13. What other damages do you claim, if any?
P l~{Ã5 ~
of ~
-Ire< ~ IG
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.)
I"Ù.
15. What amount do you claim from the City of Dubuque?
S:I=F Þ:s.¡;,~~~
~ ¿( J/f(.. Gn
16. Why do you claim the City of Dubuque is responsible?
PI' ct f'..E:.5 w.:?I", ~ )c-..-.... r/h./
I ' I
Jf" 1 (--!' rTD l~--::' /)ð! I~ ~,,~ //..?I'<-
I
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) f-/ ù '
.P I}/ ~t'~
.
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 S'<,,!) ¡ . , 20~.
~~, .Q.A{y~~ ¿
(Signature) ()
Fe rcP, I "'~ r-cJ (Ù, h1q We ZtI )~
(Print Name)
L';
(1)
."
Le-
i." '
c,)
(Rev. 1/00 & 7/01)
PLEASE TYPE OR PRINT
~~~~;.:.~r;:'~:~T".",POrtal;OO tß,t;.lowa Department of Transportation
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Officer's Name
Badge No.-
FED ID #42-0813744
RICHARDSON MOTORS
1475 J.F .K. ROAD DUBUQUE, IA 52002
(5631582-6411
Fax: (5631582-4129
Damage Assessed By: JASON CHARLEY
Deductible: UNKNOWN
OWner walter krawczuk
Address: 966 shady lane dubuque,lA 52001
Telephone: W- Phone: (583158808342
Home Phone: (5831 588-1372
Mitchell Service: 916495
Description: 2002 GMC Pickup Sierra K1500 SL T
Body Style: 4D PkupXCb 6' Bed 143- we
VIN: 2GTEK19T721189632
Options: 4WD OR AWD
Line Entry Labor
Item Number Type
1 AUTO BOY
2 501717 BOY
3 503495 BOY
4 503496 BDY
5 501740 BOY
6 500297 BDY
7 AUTO REF
8 AUTO REF
9 600421 BOY
10 500608 MCH
11 602974 BOY
12 AUTO REF
13 AUTO REF
14 604927 BOY
15 501285 BOY
16 501363 BOY
17 AUTO REF
18 501364 BOY
19 AUTO REF
20 603103 REF
21 604135 GLS
22 900500 BOY .
23 900500 REF.
24 900500 BOY .
25 900500 BOY .
26 900600 BOY .
27 AUTO REF
Operation
OVERHAUL
REMOVEIREPLACE
REMOVEIREPLACE
REMOVElREPLACE
REMOVEIREPLACE
REMOVElREPLACE
REFINISH
REFINISH
REMOVEIREPLACE
ALIGN
REMOVEIREPLACE
REFINISH
REFINISH
REMOVElREPLACE
REMOVEIREPLACE
REMOVElREPLACE
REFINISH
REMOVEIREPLACE
REFINISH
BLEND
REMOVEnNSTALL
REMOVEnNSTALL
REFINISHIREPAIR
REMOVElREPLACE
REPAIR
REMOVEIREPLACE
ADD'L OPR
Date: 9/812004 04:20 PM
Estimate ID: 9766
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Drive Train: 5.3L Inj 8 Cyl4WD
Line Item
Description
FRT COVER ASSY
FRT BUMPER FACE BAR
R FRT OTR BUMPER BRACE
L FRT OTR BUMPER BRACE
R FRT BUMPER FILLER
R FENDER PANEL
R FENDER OUTSIDE
R FENDER EDGE
WHEEL
FRONT SUSPENSION
R FRT DOOR SHELL
R FRT ADO FOR JAMBS & INSIDE
R FRT DOOR OUTSIDE
R FRT DOOR REAR VIEW MIRROR
R FRT DOOR ADHESIVE MOULDING
R FRT UPR DOOR SIDE HINGE
R FRT UPR DOOR HINGE DOOR SIDE
L FRT UPR DOOR SIDE HINGE
L FRT UPR DOOR HINGE DOOR SIDE
R REAR DOOR OUTSIDE
R REAR DOOR MOVEABLE GLASS
RUNNING BOARD
BLEND ROCKER PANEL
TIRE FIRESTONE WlLERNESS AT P2651751R15
SRAIGHTEN FRAME BRACKETS
CLEAN AND TAPE MLDS
CLEAR COAT
-M
ESTIMATE RECALL NUMBER: 9/81200416:15:15 9756
UltraMate is a Trademark 01 Mitchellintemational
Mitchell Data Version: SEP 04 A Copyright (C) 1994 - 2003 Mitchellintemational
UItraMate Version: 5.0.024 - All Rights Reserved
Part Type!
Part Number
ORDER FROM DEALER
15705678 GM PART
16705677 GM PART
15102067 GM PART
89944418 GM PART
12368953 GM PART
15017224 GM PART
ORDER FROM DEALER
ORDER FROM DEALER
12472844 GM PART
12472843
GM PART
Sublet
Existing
Existing
New
Existing
New
Dollar Labor
Amount Units
--
1.6 #
381.63 INC #
28.07 0.2 #
28.07 0.2 #
15.67 INC
224.05 1.4 #
C 2,0
C 1,2
499.69 0.3
2.1
488.40 4.7 #
C 1.0
C 2.2
166.20 INC
61.&0 0.1
130,60 INC #
C 0.2
130.&0 1.& #
C 0.2
C 1.0
100.00. 0.0.#
0.8.
1.0.
115.00. 2.0.
2.0.
5.00. 0.5.
2.3
Page 1 01 2
Date: 9/812004 04:20 PM
Estimate ID: 9756
Estimate Version: 0
Preliminary
Profile ID: Mitchell
28
29
30
31
933005 BDY
933018 REF
AUTO
AUTO
ADD'L OPR
ADD'L OPR
ADD'L COST
ADD'L COST
RESTORE CORROSION PROTECTION
MASK FOR OVERSPRA Y
PAINT/MATERIALS
HAZARDOUS WASTE DISPOSAL
6.00" 0,2"
6.00 " 0.2"
316.35 "
6.00 "
. -Judgement Item
# - Labor Note Applies
C -Included in Clear Coat Calc
Add1
Labor Sublet
I, Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
Body 15.5 46.00 6.00 0.00 719.00 T Taxable Parts 2,274.58
Refinish 11.3 46.00 6.00 0.00 525.80 T Sales Ta. @ 7.000% 159.22
Glass 0.0 46.00 0.00 100.00 100.00 T
Mechanical 2,1 53.00 0.00 0.00 111.30 T Total Replacement Parts Amount 2,433.80
Taxable Labor
Labor Tax
@
7.000 %
1,456.10
101.93
Labor Summary
28.9
1,558.03
III. Additional Costs
Taxable Costs
Sales Tax
@
7.000%
Amount
6.00
0.42
IV. Adjustments
Customer Responsibility
Amount
0.00
Non-Taxable Costs
315.35
Total Additional Costs
322.77
I.
II.
III.
Total Labor:
Total Replacement Parts:
Total Additional Costs:
Gross Total:
1,558.03
2,433.80
322.77
4,314.60
IV.
Total Adjustments:
Net Total:
0.00
4,314.60
This is a preliminary estimate,
Additional chanGes to the estimate may be reQuired for the actual repair.
ESTIMATE RECALL NUMBER: 9/812004 16:15:15 9766
UitraMate is a Trademark of Mitchett International
Mitchell Data Version: SEP 04 A Copyright (C) 1984 - 2003 MitcheH International
UitraMate Version: 5,0.024 - All Rights Reserved
Page 2 of 2
09/08/2004 14: 51
1-608-854:~_"
JOHNS BODY SHOP
JOHNS BODY SHOP
3520 PERCIVAL STREET
HAZEL GREEN, WI 53811
PHONE: (606) 854-2341
FAX: (608) 854-2342
CD LOG NO 1195-1
DATE 09/08/04
SHOP: JOHNS BODY SHOP
ADDRESS: PO BOX 85 3520 PERCIVAL ST.
CITY STATE: HAZEL GREEN, WI
ZIP: 53811-
INSP DATE:
PHONE 1:
FAX:
OWNER: WALTER, KRAWCZUK
ADDRESS: 965 SHADY LJ\NE
CITY STATE: DUBUQUE, IA
ZIP: 52001-
HOME PHONE:
POINT OF IMPACT: 1
LIC#:
BODY COLOR:
CONDITION:
STATE:
VIN:
MILEAGE:
ACCTNG CTL#:
*=USER-ENTERED VALUE
EC=REPLACE ECONOMY
EU=REPLACE SALVAGE
PM=PXN REMAN/REBUILT
IT-PARTIAL REPAIR
BR~BLEND REFINISH
SB~SUBLET
P=CHECK
UP=UNRELATED PRIOR
E=REPLACE O£M
UC=RECONDITIONED PRT
EP=REPLACE PXN
TE=PARTL REPL PRICE
I=REPAIR
TT~TWO-TONE
N=ADDITIONAL LABOR
M=APPEAR ALLOWANCE
PAGE 01
09/08/04
(608)654-2341
(608)854-2342
(563) 588-1372
2GTEK19T721189532
NG=REPLACE NAGS
UM=REMAN/RtBUILT PRT
PC=PXN RECONDITIONED
ET=PARTL REPL LABOR
L=REFINISH
CG=CHIPGUARD
RI=R&I ASSEMBLY
RP=RELATED PRIOR
2002 GMC SIERRA K1500 SL 4DOOR EXT CAB
CODE: U8043C/D OPTNS T/24XWTU
aCYL GASOLINE 5.3
OPTIONS:
TWO-STAGE - EXTERIOR SURFACES
4-WHEEL DRIVE
AIR CONDITIONING
TWO-STAGE - INTERIOR SURFACES
REAR ACCESS DOOR,LEFT
AUTOMATIC TRANS
OP GDE MC DESCRIPTION
MFG. PART NO.
-- -----------
------------
PRICE
AJ% B%
HOURS R
E 0005 BUMPER,FRONT 15758072 GM PART 381.63 2.2 1
E 0022 FILLER,FRONT BUMPER RT 15102067 GM PART 15.67 INC 1
E 0155 BRACE,FRONT BUMPER LT 15705657 GM PART 27.74 0.2 1
E 0156 BRACE,FRONT BUMPER RT 15705658 GM PART 27.74 0.2 1
E 0104 FENDER,FRONT RT 88944418 GM PART 224.05 2.9 1
L 0104 13 FENDER,FRONT RT REFINISH 5.0 4
E 0811 WHEEL,FRONT RT 88892482 GM PART 548.01 0.3 1
N 0974 SUSPENSION ALIGN,FRT ADDNL LABOR OPERA 2.0 2
E 0208 DOOR SHELL,FRONT RT 15017224 GM PART 4B8.40 4.7 1
L 0208 DOOR SHELL,FRONT RT REFINISH 4,1 4
E 0246 MIRROR,OUTER STANDA RT 15172059 GM PART 186.70 INC 1
P1\,GE
09/08/2004 14:51
1-508-8~~=-~3~_____..~Œ!N..?J!QI?V SHOP
PAGE 02
2002 GMC SIERRA K1500
CD LOG NO 1195-1
SL 4DooR EXT CAB
E 0070 HINGE,DOOR SIDE UPP RT 12412844 GM PART 130.60 INC 1
L 0070 HINGE,DOOR SIDE UPP RT REFINISH 0.2 4
E 0214 HINGE/DOOR SIDE LOW RT 12472844 GM PART 130.60 INC 1
L 0214 HINGE,DooR SIDE LOW RT REFINISH 0.2 4
BR 0288 DOOR SHELL,REAR RT BLEND REFINISH 2.4 4
RI0501 GLAss,REAR VENT T RT RliI ASSEMBLY 1.4 1
EC M14 CORROSION PROTECTION ECONOMY PART 12.00* 4
L M17 COVER CAR EXTERIOR REFINISH 7.00" 4
RI RUNNING BOARD RU ASSEMBLY 1.0*1*
Ee TIRE ECONOMY PART 115.00" 2.0*1*
I STRAIGHTEN FRAME BRACK REPAIR 2.0*1*
22 ITEMS
MC MESSAGE (S)
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
FINAL CALCULATIONS Ii ENTRIES
GROSS PARTS
OTHER PARTS
PAINT MATERIAL
PARTS Ii MATERIAL TOTAL
TAX ON PARTS Ii MATERIAL @
5.500%
2,161,14
134.00
333.20
2,628,34
144,56
LABOR
I-SHEET METAL
2-MECH/ELEC
3-FRAME
4-REFINISH
5-PAINT MATERIAL
LABOR TOTAL
TAX ON LABOR
SUBLET REPAIRS
TOWING
STORAGE
RATE
48.00
52.00
52.00
48.00
28,00
REPLACE HRS
14.9
REPAIR HRS
2.0
2.0
811.20
104.00
11.9
571. 20
@
5.500%
1,486.40
81. 75
GROSS TOTAL
4,341.05
NET TOTAL
4,341.05
ADP SHOPLINK UC253 ES CD LOG 1195-1 DATE 09/08/04 03:11:12PM R6.35
PXN: NO GEOeODE
HOST LOG
(C) 1998 - 2004 ADP CLAIMS SOLUTIONS GROUP, INC.
2.8 HRS WERE ADDED TO THIS EST. BASED ON ADP TWO-STAGE REFINISH FORMULA.
CD 08/04
--------------------------------------------------
PAID IN FULL
AMOUNT PAID
CHECK .,.
CASH
PAGE 2