Claim Roy, Randel J.
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA &4/ - ;~r
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.
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1. Name of Claimant:
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2. Address:
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3. Telephone Number:
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4. Date of Incident:
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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.)
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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 pol~c~in~es~!f!,ate} (,If so',~ive nt'me~ oJ ~fficers.)
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11. Was anyone injured? (If so, give name$, addresses, and extent of injuries).
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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?
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16. Why do you claim the City of Dubuque is responsible? T~2 6,:) r-,ð}/:; i~~ ,:;¡J/,-,
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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.)
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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?
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Dated at Dubuque, Iowa this
day of
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(Print Nam~)
(Rev. 1/00 & 7/01)
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12108/2004 at 12: 51 PM
30799
Job Number,
BRIMEYER AUTO BODY
License #:30799 Federal ID #:421438480
10109 COLLISION DR,
DUEUQUE, IA 52001
(563) 583,4456 Fax: (563) 583-1838
PRELIMINARY ESTIMATE
Written Ey: ERIAN HOCHEERGER
Adjuster:
Insured: RANDY ROY
Owner: RANDY ROY
Address: 3625 KEYSTONE
DUBUQUE, IA 52001
Other: (563) 588-3582
Claim *
Policy *
Deductible:
Date of Loss:
Type of Loss:
Point of Impact:
Inspect
Location:
Insursnce
Company:
Days to RepaH
2004 FORD El50 4X4 SUPERCAB 8'4, 6L-FI
VIN: lFTRX14W54NB63l62 Lie:
AH Conditionwg Tilt Wheel
Dual Mirrors Clear Coat Pawt
Power Brakes Dnver AH Eag
4 Wheel Disc Brakes Cloth Seats
Styled Steel Wheels
40 SHORT Int:
Prod Date: Odomete"
Intermittent Wipers
Power Steering
Passenger AH Eag
Rear Step Bumper
-, -" - -" - -, - - -- - -", -, - -, - -, - u -, - -, - -, -, - -, -, - -, -, -" -, - -, - - - -" - -" -" -"""
NO,
OP,
DESCRIPTION
QTY EXT, PRICE LAEOR
PAINT
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1
2'
3
4*
5'
6#
PICK UP EOX
Rpr Tail gate 5,5 foot bed
Add for Clear Coat
R&I Emblem
R&I Nameplate "F150"
CLAEN UP AND REPLACE TWOFACE
TAPE
2,0
1.9
o:s
3,00 X
0,2
0:2
0:3
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Subtotals ::> 3,00 2,7 2,7
Parts 0,00
Eody Labor 2,7 hrs @ $ 46,00/hr 124,20
Paint Labor 2,1 hrs @ $ 46,00/hr 124,20
Paint Supphes 2.7 hrs @ $ 28,00/hr 15,60
Sublet/Mise, 3,00
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SUE TOTAL
Sales Tax
248,40 @
$
7,0000%
327,00
17,39
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GRAND TOTAL
344,39
ADJUSTMENTS:
Deductible
0,00
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CUSTOMER PAY
INSURANCE PAY
0,00
344,39
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Estimate based on MOTOR CRASH ESTIMATING GUIDE, Unless otherwise noted all items
the Guide DR2MA04 Database Date 11/2004, cee Data Date 11/2004, and the parts
manufactured by the vehicles Original Equipment Manufacturer. OEM
dealerships, Asterisk (,) or Double Asterisk (H) indicates that
information provided by MOTOR may have been modified or may have come from an
source, Tilde sign (-) items indicate MOTOR Not-Included Labor operations,
Manufacturer aftermarket parts are described as AM, Qual Repl Parts or
for Replacement Parts, Used parts are described as LKQ, Qual RCY, or USED,
parts are described as Recon, Recored parts are described as NAGS Part
Numbers and Prices are provided by National Auto Glass Specifications, Inc, Pound sign (#) items
indicate manual entries, Some parts that are described as Recon, may be OE Surplus parts or other
DE parts offered at a special pricing discount. For further clarification please review the
Suppliers List attached to this estimate, or consult the appraiser or estimator.
eee Pathways, A product of cee Information Services Inc.