Claim Pollard, Nicole R.CLAIM 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: Nicole R. Pollard
2. Address: 112 Peterson Dr.
`
3. Telephone Number: (563) 495 6780
4. Date of Incident: 12 17 04
5. Time of Incident: 1:10
6. Location of Incident (Be specific): K-Mart on Dodge
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.)
Bus 2565 hit left side of car while loading car up in the red zone and helping an elderly lady.
8. What were weather conditions like?
sunny, nice
9. Give name and address of any witnesses:
Julie Manternach; Marc Colby (563) 495 6780 (918) 747 7424
10. Did police investigate? (If so, give names of officers.)
No, went directly to bus terminal
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Luckily no
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, drivers side rearview mirror torn off and side of car scraped and dented;
13. What other damages do you claim, if any?
None
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?
16. Why do you claim the City of Dubuque is responsible?
Witnesses in and out of car
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 17th day of December, 2004.
/s/ Nicole R. Pollard
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
,,7/ //,-
/ ,/
CLAIM 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: I'-J\COI ó 'I<. - Tbt l A-12D
2. Address: I )/J P£ì<r:.e Sm.) OJ¿
3. Telephone Number:t?l(~) c¡qS-" ¿'7Sn
4. Date of Incident: }J.-I1¡. - 0'-/
5. Time of Incident: I ~ I ()
6. Location of Incident (Be specific): 11.- m~IèT
aD T::f)T>(l'é.
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.)Y:,\ )~ ~ ,;(5(¡ ~ hi. .- Jd-+ s;('I~ {ýr- Crlr
~jl{. /00[/1(14 rCU'" up jfL --vlv- rui ~OA~ ~ t~t2i/"-'1
,-ù'\ .i Id-lv l\{ I~
8. What were weather conditions like? 51 .LV\..¥\ A A N c.L
~
9. Give name and address of any witnesses: \u.l i t: I'nCVì+-e .nO\. cL
;~~It~~~~1D (Q/8)7Y1--Î4JY
10. Did police investigate? (If. so, give nam s of officers.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
I lACtJ \(
hi)
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.)
J4{ 5 - dr,vD) Q,)c\~ +Om bU ~ ~ìc\ t oÇ.
LO- ¡r ~(I.r 0. \'If d
n Of\[ í t uJM.i ( rOr
11Y\c\ A-t> n+.fd
13. What other damages do you claim, if any? hC'iYì-L
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.)
() L)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible? ---LJ.d1)( 5 <;.t <)
\f\ D.rî d
ow.-
or-
(' (\y
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?
L..
1ftI' day of
I '7
7i~ldf:!:J
(Signature)
A}ltoLÇ: ~, fJOLL-A:R-D
(Print Name)
Dated at [)ubUl~~e, Iowa this
, "
r.
'-'
(Rev. 1/00 & 7/01)
Dale: 12/17/2004 02:12 PM
E_ID: 6799
0
Preliminary
Profile ID: Mitchell
Hanley Auto Body Inc,
1030 Century Circle Dubuque. IA 52002
(563) 563.7220
Fax: (563) 583-8355
~ Assessed By: Robert Hanley
Deductible: UNKNOWN
Owner Nicole Pollard
Address: 172 Peterson Drive Peosta. IA 52068
Telephone: Home Phone: (583) 495-6880
Description:
Body Style:
VIN:
0pIi0ns:
Une Entry Labor
Item_Type
1 100643 REF
2 101527 BOY
3 AUTO REF
4 100788 BOY
5 AUTO REF
6 AUTO REF
7 AUTO
8 AUTO
Mik:heI Service: 911623
1997 FOI'd T- GL
4D Sed
1FALP52U9VG244835
ALUM/ALLOY WHEELS, AIR CONDITIONING. POWER STEERING, POWER WINDOWS
POWER DOOR LOCKS, TILT STEERING WHEEL. CRUISE CONTROL. ELECTRIC DEFOGGER
AUTOMATIC TRANSMISSION, AM-FM STEREOICDPLAYER(SINGLE)
Drive Train: 3.0L Inj 6 Cyl AO
Dper-
REFINISH
REPAIR
REFINISH
REPAIR
REFINISH
ADD"\. OPR
ADD'L COST
ADD"\. COST
Une Item
Description
L FRT DOOR OUTSIDE
L FRT DOOR REAR YEW MIRROR
L FRT DOOR MIRROR
L REAR DOOR SHELL
L REAR DOOR OUTSIDE
CLEARCDAT
PAINT/MATERIALS
HAZARDOUS WASTE DISPOSAL
Part Type!
Part-
Existing
Existing
. - Judgement Item
# - Labor Note Applies
C -Included in Clear Coat Calc
I. Labor Subtotals
Body
Refinish
Labor Summary
Add'
Labor ~
Units Rate Amount Amount Totals II. Part Replacement Summary
2.6 ".00 0.00 0.00 112.50 T
6.3 ".00 0.00 0.00 283.50 T T- Replacement Parts Amount
Taxable Labor
Labor Tax
7.000%
396,00
27.72
@
8.8
423.72
ESTIMATE RECALL NUMBER: 12/17/200414:12:37 6799
UllraMale is a Trademarlt of Mik:hellntemaoonaJ
Milchell Data Version: NO\( 04 B Copyright (C) 1994 - 2003 MiIcheIIlnIemational
5.0.027 - An Rights Reserved
Dollar Labor
Amount Units
--
C 2,3
0.5'/1
C 0.8
2.0'
C1.B
1.4
170.10'
5.00'
Amount
0.00
Page 1 of 2
Date: 12117/2004 02:12 PM
Estimate ID: 6799
0
Preliminary
Profile 10: Mitchel
III. Additional Costs
Non-Taxable COSts
Amount
175.10
IV. Adjustments
Customer Responsibility
Amount
0.00
Total Additional Costs
175.10
L
II.
HI.
Total Labor:
Total Replacement Parts:
Total Additional COSts:
Gross Total:
423.72
0.00
175.10
598.82
IV.
Total Adjustments:
Net Total:
0.00
598.82
This is a preliminary estimate.
Additional chanQes to the estimate mav be required for the actual repair.
ESTIMATE RECALL NUMBER: 12117/2004 14:12:37 6799
UltraMate is a Trademark of Mitchellinternationat
Mitchell Data Version: NOV 04 B Copyright (C) 1994 - 2003 MitcheU International
5.0,027 - All Rights Reserved
Page 2 of 2