Claim Huseman, JenniferCLAIM 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: Jennifer Huseman
2. Address: 805 Southern Ave.
`
3. Telephone Number: 582 9924
4. Date of Incident: January 6, 2005
5. Time of Incident: I don't know - I was working
6. Location of Incident (Be specific):
1745 Eden 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.)
City snowplow hit my parked vehicle.
8. What were weather conditions like? Snow covered roads
9. Give name and address of any witnesses: none
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
Both passenger doors were damaged by snow plow
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?
$1,469.91 or $1,353.43
16. Why do you claim the City of Dubuque is responsible?
City of Dubuque snowplow hit my parked vehicle.
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 19th day of January, 2005. , 20 .
/s/ Jennifer Huseman
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
('r. /.~!/,~~
.___~. 'I
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA SJ1~~'~tklt'l<-d-;(/
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: ~en 1"\ '~ H Lt Svn q Jr)
2. Address: 90S- sCX-\.1\\'I-vY\ \\V-e....-
3. Telephone Number: S-8 ;;( - r~ J if
4. Date of Incident: C)o.YIW~ (~, ~,oo~5
5. Time of Incident:.::I & ~ ~a.U ( J \AJctS lVOV):;, ~ J
6. Location of Incident (Be specific): \ 1 ~ S- t;Q-€.Vl~ 0
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.) C 'dy S'r\O~OLU hi:t=::..-m)/ ~>>
\Ip~\de_ .
v \
8. What were weather conditions like? ShtH.l / CoU.oGY,JI vrodls
9. Give name and address of any witnesses: hfll"\>9 -
10. Did police investigate? (If so, give names of officers.)
'n/)
11. Was anyone injured? (If so, give name~, addresses, and extent of injuries).
YJO
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.)
Px,~ ~s<;e~eV J/coVS vJ--eY-e..- rila..W'O--~eD ~ y Sno<.vF)<X.L).
13. What other damages do you claim, if any? f\()Y)P_
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.)
_'__~' __...JjD ____
15. What amount do you claim from the City of Dubuque? / J Y ~ 7- 9/ or 03S>:? i5
16. Why do you claim the City of Dubuque is responsible? r" \ f;/ cf( Dub(./~u.. ~
'SVVJwp)OV-l \r1;+ VYJ)/ fcwkJJ \J~lJ e. ·
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) b f)
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
1/
day of
~D..VlLla..VI ' 20D5'"".
H-~,
( ignature)
G-'<Y1h ,;~V' Hu.~emq~,
(Print Name)
,-:
';:J
J ! ~
\ ,_~ ,,!:~ I' I
. ,
'i~_.J '~:Cl
(Rev. 1/00 & 7/01)
.
01/19/2005 at 04:13 PM
30799
Job Number:
BRlMEYER AUTO BODY
License #:30799 Federal 10 #:421438480
10709 COLLISION DR.
DUBUQUE, IA 52001
\5631581~4456 Fax: (563J583~1838
PRELIMINARY ESTIMATE
Written By: KEVIN SMITH
Adjuster:
Insured: JENNIFER HUSEMAN
Owner: JENNIFER HUSEMAN
Address: 805 SOUTHERN AVE
DUBUQUE, IA 52003
Claim #
Policy #
Deductible:
Date of Loss:
Type of Loss:
Point of Impact:
Day:
Evening:
Inspect
Location:
Insurance
Company:
Days to Repair
1y91 TOYO COROLLA DELUXE 4-1.6L-FI 40 SED GRAY Int:
VIN: JT2AE94A9M3415067 Lic: 108 AWG IA Prod Date:
Rear Defogger Intermittent Wipers
Body Side Moldings Dual Mirrors
Power Brakes Cloth Seats
Rec~ine/Lounge Seats
NO.
OP.
DESCRIPTION
1 FRONT DOOR
2' Repl LKQ RT door assy +25%
3 Add for Clear Coat
4 R&I RT Belt w'strip outer
5 R&1 RT Handle, outside
6 R&I RT Mirror w/o remote mlrror
7' R&1 RT Body side mldg sedan OX
8 REAR DOOR
9' Repl LKQ RT door assy +25%
10 Overlap Major Adj. Panel
11 Add for Clear Coat
12 R&1 RT Belt w'strip outer belt,
sedan OX
13 R&1 RT Body side mldg 2WD, Japan
built OX
14 R&1 RT Handle, outside DX
15 FENDER
16 BInd RT Fender 2WO
17 QUARTER PANEL
18 Blnd RT Quarter panel w/DX & LE
:CJ# Repl CLEAN UP LKQ DOORS
.20# Repl MASf FOR OVERSPBAY
21 OTHER CHARGES
22# E.P.C.
Subtotals =->
Parts
Body Labor
Paint Labor
Paint Supplies
Other Charges
SUBTOTAL
Sales Tax
GRAND TOTAL
ADJUSTMENTS:
Deductible
CUSTOMER PAY
INSURANCE PAY
1
Odometer
Tinted Glass
Clear Coat Paint
Bucket Seats
107124
QTY EXT. PRICE LABOR
PAINT
1
3.0
1.2
156.25
1.5
0.3
0.3
U.J
0.3
1
125.00
1.3
3.0
-U.4
0.5
0.3
0.3
0.6
1.2
l.O
1
1
3.0
8.0U
4.00
293.25
8.2
Q.5
2l:l9.25
8.2 hrs @ $ 47.00/hr 3e5.4rJ
9.5 hrs @ $ 47.00/hr 446.5CI
9.5 hrs @ $ 28.00/hr 266.0n
4.0n
$ 1391. IS
$ 1125.15 @ 7.0000~ 78.76
$ 1469.91
o . iJ ~I
$ 0.00
$ 1469.Yl
.
,
01/19/2005 at 04:13 PM
30799
Job Number:
PRELIMINARY ESTIMATE
1991 TOYO COROLLA DELUXE 4-1.6L-FI 40 SED GRAY lnt:
:~5:tiHldte based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted dll ltems a.le; dpliverl fr~n
tne Guide AEM8407 Database Date 01/2005, CCC Data Date 01;2005, Clod t:he par'::5 sele,~tf:'d oil>"
JEM parts manufactured by the vehicles Original Equipment Mdnufacturer. OEM parts are d\Tallabl~ d:
G:::,'Vehi::le ,iealerships. Astelisk (*) or Double Asterisk I**i indicdtes ::hat the part.", and,'or IdboL
ir.::LrnlatiolJ provirled by MOTOR may have beell modified or may have come from all dlternate data
5011rce. Tilde 31g0 (-I ltems indicate MOTOR Not-Included Labor operations. Non-Origindl Equipment
Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Camp Repl Parts which stand~
tor ':ompetitive Replacement Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED.
Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Part
Nnmbers and Prices are provided by National Auto Glass Specifications, Inc. Pound sign (#) items
indi:::ate manual entries. Some parts that are described as Recan. may be OE Surplus part'" or other.
OE parts offered at a special pricing discount. For further clariflcatlon please revi~w th~
Snppliers List attached to this estimate, or consult the appraiser or. estulIatol.
CCC Pathways
A product of CCC Informatlon Services Inc.
Date: 1/19/200504:16 PM
Estimate 10: 5784
Estimate Version: 0
Preliminary
Profile 10: Mitchell
Lenny Valentine & Sons, Inc.
923 Peru Rd. Dubuque, IA 52001
(563) 588-4659
Fax: (563) 588-4650
TWO CONTINENTAL FRAME MACHINES
GENESIS II COMPUTERISED MEASURING SYSTEM
PRICE IS EASY TO BEAT/QUALITY IS NOT
UNIBODY SPECIALISTS
Damage Assessed By: DICK VALENTINE
Deductible: UNKNOWN
Owner JENNIFER HUSEMAN
Address: 805 SOUTHERN DUBUQUE, IA 52001
Telephone: Home Phone: (563) 582.9924
Mitchell Service: 910750
Description: 1991 Toyota Corolla OX
Body Style: 40 Sed
VIN: JT2AE94A9M3415067
Drive Train: 1.6L loj 4 Cyl 3A
Line Entry Labor
Item Number Type
---
1 022180 BOY
2 AUTO REF
3 022690 BOY
4 025420 BOY
5 AUTO REF
6 025760 BOY
7 AUTO REF
8 AUTO
9 AUTO
10 AUTO
Operation
REPAIR
REFINISH
REMOVE/REPLACE
REPAIR
REFINISH
REMOVE/REPLACE
ADO'L OPR
ADD'L COST
ADD'L COST
ADD'L COST
Line Item
Description
R FRT DOOR SHELL
R FRT DOOR OUTSIDE
R FRT DOOR ADHESIVE MOULDING
R REAR DOOR SHELL
R REAR DOOR OUTSIDE
R REAR DOOR ADHESIVE MOULDING
CLEAR COAT
PAINT/MATERIALS
SHOP MATERIALS
HAZARDOUS WASTE DISPOSAL
Part Type/
Part Number
Existing
Dollar Labor
Amount Units
7.0*
C 2.1
60.62 0.2
8.0*
C 1.7
42.04 0.2
1.2*
75731-02030
Existing
75741.02010
150.00 .
20.00'
3.75 *
. . Judgement Item
C - Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 1/19/200516:16:57 5784
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: OEC_04_A Copyright (C) 1994 ~ 2003 Mitchell International
UltraMate Version: 5.0.027 All Rights Reserved
Page 1 of 2
.
Date:
Estimate 10:
Estimate Version:
Preliminary
ProfilelD:
1/19/200504:16 PM
5784
o
Mitchell
Add'l
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount
- -
Body 15.4 49.00 0.00 0.00
Refinish 5.0 49.00 0.00 0.00
Taxable Labor
Labor Tax @ 7.000 %
labor Summary 20.4
Totals
754.60 T
245.00 T
II. Part Replacement Summary
Taxable Parts
Sales Tax @
7.000%
Amount
102.66
7.19
999.60
69.97
Total Replacement Parts Amount
109.85
1,069.57
III. Additional Costs
Taxable Costs
Sales Tax
@
7.000%
Amount
3.75
0.26
IV. Adjustments
Customer Responsibility
Amount
0.00
Non-Taxable Costs
170.00
Total Additional Costs
174.01
I.
II.
III.
Total Labor:
Total Replacement Parts:
Total Additional Costs:
Gross Total:
1,069.57
109.85
174.01
1,353.43
IV.
Total Adjustments:
Net Total:
0.00
1,353.43
This is a preliminarv estimate.
Additional chanaes to the estimate may be reauired for the actual repair,
ESTIMATE RECALL NUMBER: 1/19/200516:16:57 5784
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: DEC_04_A Copyright (C) 1994 - 20C3 Mitchell International
U1traMate Version: 5.0.027 All Rights Reserved
Page 2 of 2