Claim Hoyne, Jeff
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,. CLAIM AGAINST THE CITY OF DUBUaUe,"IOWAv' ifJ¡li[.i I 'Y>.,' (,.
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This written report constitutes your claim against the City of Dubuque, Iowa. You s~ould
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: 'eft' Ho'fWE
IOij~o NeW ¡¿lIj~p e..j
3. Telephone Number: 5ið,{ SKJ. fOOq
9 A/o y
2. Address:
IX?4 1:4 c.x.Þ I
4. Date of Incident:
5. Time of Incident:
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6. Location of Incident (Be specific):
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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.) ,
(I~ PMplv'1u D'lIIl Jôytt" ¿ /¡".< (fu tI J_) 7;;) ¡(¿'ill Y)f 11"l~J ¡-J:
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fu~ I/f,,";~ ( ""{~- pu.;{tl'd AT ~ fI/t",{{lv c/Ce1'A1' lor,
8. What were weather conditions like? &,' / c It",
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9. Give name and address of any witnesses: f.tl';(¿ -c;l- /YJe.-,^p-K.t fMilEtler
,
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10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
NiP
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? ¡Jb ~
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.)
~b
15. What amount do you claim from the City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible? ,It ~({J' { {J't> .{JM/!tye!
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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 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 a~pubttque, Iowa this
/j
day of
, JJP+fMb-t,
()ßs; r/!. r:!:.)
( t ff !/oft L-
(Print Name)
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(Rev. 1/00 & 7/01)
09113/2004 at 03:07 PM
30799
Job Number:
BRIMEYER AUTO BODY
License #:30799 Federal 10 #:421438480
10709 COLLISION DR.
DUBUQUE, IA 52001
(563)583-4456 Fax: (563)583-1838
PRELIMINARY ESTIMATE
written By: BRIAN HOCHBERGER
Adjuster:
Insured: JEFF HOYNE
Owner: JEFF HOYNE
Address: 10400 NEW RIDGE RD,
DUBUQUE, IA 52001
Other: (563)582-1009
Claim #
policy #
Deductible:
Date of Loss:
Type of Loss:
Point of Impact:
Inspect
Location:
Insurance
Company:
Days to RepaH
1988 CHEV KI0 4X4 FLEETS IDE 8-5,7L-FI 20 LONG Int:
VIN: IGCDK14K2JZ247711 Lic: Prod Date: Odometer: 121000
Dual Mirrors Two Tone Paint Power Steering
Power Brakes
NO,
Op,
DESCRIPTION
QTY EXT, PRICE LABOR
- - - - - - - - - - - - - - - - - - u - - - - - - - - - - - - - - - - -- - - - - - - u - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - --
PAINT
- - - - - - - - - - - - - - - - -- - - - - - u - u - u - - - _c- - - - u C u - - - - - - - - u - - - - - - - - - - - - - - -- - - - - -- --
1 PICK UP BOX
2' Rpr LT Side panel wlo dual wheel 4,0 i2
3' Add for Two Tone ~
4' R&I LT Body side mldg front wlo Q.2
Sport package black
5' R&I LT Body side mldg rear wID 0,3
Sports package black
Repl LT Decal 4X4 wlo bow tie 24,08 0,3
argent & red
7' R&I LT Protector wheel opening 0,2
8' Repl Stripe tape 35,00 !L2
9 REAR LAMPS
10 R&I LT Combo lamp assy Fleetside 0,5
11 REAR BUMPER
12 Repl LT Impact strip wlo white 4,60 0,3
bumper
13 Repl Step pad chrome bumper black 50,71 0,4
molding
Subtotals ~~>
114.39
6,8
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - -- - - - u - -- - - - - - - -- - u - - - - - - - - - - - - - - - - --
4,3
Parts
Body Labor
Paint Labor
Paint Supplies
6,8 hrs @ $ 46,00/hr
4,3 hrs @ $ 46,00/hr
4.3 hrs @ $ 28,00/hr
114,39
312,80
197,80
120,40
SUBTOTAL
Sales Tax
$
7,0000%
- u - -- - - - - - - - - - - - - - - c - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --
745,39
43,75
624,99 @
- ------ --- -------- ----- --- ------ -- - --- --- - -- - --- ----
GRAND TOTAL
ADJUSTMENTS:
Deductible
789,14
0,00
CUSTOMER PAY
INSURANCE PAY
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --
0,00
789,14
JEf?~ !/oY/VE'
HABERKORN AUTO CENTER
3801)
ð - J/J C;/- 602PERUROAD' DUBUQUE,IOWA52001 . PHONE (319)556-8872
OWNER ,{M '/"'" r ~ - ADDRESS
rŒ~ T '~~ T"°t;:)(t¡~ rWjj)f"""CAm""O IM"'AGE
FRONT OF CAR
BUMPER
BUMPER BRKT
BUMPER GUARD
'" "" ~~:~~¡At
LEFT SIDE
HEADLIGHT
COMPOSITE
PARTS
GRILL
GRILL
GRILL MLDG,
PARKING, LIGHT
FENDER, FRONT
FENDER, APRON
FENDER MLDG,
FENDER MLDG,
FENDER MLDG,
FENDER MLDG,
DOOR, FRONT
DOOR, MLDG,
DOOR GLASS
VENT GLASS
GRAVEL SHIELD
WINDSHIELD
HEADER PANEL
COWL
RAD, SUPPORT
RAD, CORE
ANTIFREEZE
FAN BLADE
FAN SHROUD
CENTER POST
DOOR, REAR
DOOR, MLDG,
DOOR GLASS
HOOD
HOOD HINGES
HOOD MLDG,
ROCKER PANEL
ROCKER MLDG
FLOOR
1/4 PANEL I?...w
1/4 PANEL
1/4 PANEL
WHEEL HOUSE
1/4 MLDG,
ORNAMENT
NAME PLATE
LOCK PLATE, LR,
LOCK SUPT
REAR OF CAR
L¡. -;.:4
~
,
TAILLIGHT
Yf} 'II TAILLIGHT
'I- 160 TAILLIGHT
TAILLIGHT
BACK-UP LIGHT
BACK-UP LIGHT
BUMPER
BUMPER BRKT,
BUMPER GUARD
PaA' Ju?
tf'",..,/£~~
IV,5
N ('j
GRAVEL SHIELD
LOWER PANEL
FLOOR
TRUNK LID
TRUNK HINGE
TRUNK MLDG,
LICENSE LIGHT
TOP
FRAME
TIRES
HUBS CAPS
WHEEL DISC,
DATECf-1 ?-'90Ç<
\"C~E;9' '#II~ \
'" "" ~~:~~¡At
RIGHT SIDE
HEADLIGHT
COMPOSITE
'" "" ~~:~~¡At
PARTS
PARTS
PARKING, LIGHT
FENDER, FRONT
FENDER, APRON
FENDER MLDG,
FENDER MLDG,
FENDER MLDG,
FENDER MLDG,
DOOR, FRONT
DOOR, MLDG,
DOOR GLASS
VENT GLASS
CENTER POST
DOOR, REAR
DOOR MLDG,
DOOR GLASS
Il l../J If./J
ROCKER PANEL
ROCKER MLDG,
FLOOR
1/4 PANEL
1/4 PANEL
1/4 PANEL
WHEEL HOUSE
1/4 MLDG,
,S'
7vS
N .S
IN"
1'5'00
t::ç-
ð Ii TAILLIGHT
TAILLIGHT
TAILLIGHT
TAILLIGHT
BACK-UP LIGHT
BACK-UP LIGHT
CLEAR COAT
CLEAN-UP
LABOR
:A. :J k I!)O
I ^ ID/
1':'-7... eo
p
.f)
MISC, ITEMS
HRS, @
PARTS
PAINTING
TOWING
MATERIAL
N NEW ""A,"ooe
R REPAIR WAm
OH OVERHAUL
A ALIGN
P PAINT TAX
S SUBLET
1; 55"" () ð
IDENTIFICATION
KEV
ClO
I!IO
;¿ I 0
It)
TOTAL
WO", A",Hoe"" "
ESTIMATE