Claim Koppes, RonaldCLAIM 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: Ronald Koppes
2. Address: 12612 Brentwood Ct. Peosta, IA 52068
`
3. Telephone Number: (H) 563 590 1007; (W) 563 556 8392
4. Date of Incident: 8-31-04
5. Time of Incident: 2:45 P.M.
6. Location of Incident (Be specific): 15th & Central, Dubuque, IA
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.)
Mr. Koppoes was stopped at Stop Light on 15th & Central and was rearended by vehicle being driven by Timothy Miller.
8. What were weather conditions like? good
9. Give name and address of any witnesses: none
10. Did police investigate? (If so, give names of officers.) Yes, we are pending - receipt of report
Report # 04-39517 Dubuque PD
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, Mr. Koppes; Stiffness in shoulder, neck area.
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.)
Damage to vehicle $862.97;
Medical $710.00
Rental: $32.00
13. What other damages do you claim, if any? out of pocket $26.22 for rental expenses; Unknown
if Mr.Koppes will present bodily injury claim.
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.)
Insurance paid $812.97
Deduct $50 paid by me.
15. What amount do you claim from the City of Dubuque?
State Farm $812.97
16. Why do you claim the City of Dubuque is responsible?
Mr. Koppes was completed stopped at red light & hit from behind by cliamant.
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 4th day of February, 2005.
/s/ Jennifer Jessup on behalf of State Farm Insurance
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
OClLm ~ : S 32-qg - iY- !
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
.~,s
/s;-///
,/ / .I
, /
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:_~On ell cL I<. n p..pc, S
2. Address: 12lo I d- b '1-e (\ t LUOOc\ C t -"Fe u::~-b-- I A 52.00"0
3. Telephone Number:ltt }S'IM --sqo - 1007 CV,J) c;{o"2y-- 550 - 9"~ L
4. Date of Incident: 0'8 - '2, \ .. 0 tf
5. Time of Incident: ,;( 4-'2> P rn
6. Location of Incident (Be specific):
15th ... Un+((:L I
TJU..1l.\.LtJIJ..C
IA
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.) rv, _ . ,
.. . IIIf KOppes, ,NOS 5'+oW(1fJ.t c'~ht
Dn 1'O~.t (mtro../ fInd vJLts rf(Ufin~J b.1
VLht( IJL banj clflVlVl b"1l\m ()~lff
8. What were weather conditions like? qtJ7>cl
9. Give name and address of any witnesses: \ "\On Q
10. Did police investigate? (If so, give nlilmes of officers.) ~t t=l:
"'If;:" -- \,f\J(l. {La'/ (Y'nt1 ihj r:eoept ~ t"fP()Yt- OLJ-:?J:jSn
11. Was anyone injured? (If so, give nameJil, addresses, and extent of injuries).
~e.\- m( tow~S. S-\1t+h1,S<'
bUbUI~
PC
In ShDlA.lGlt( ,hOrk-- aXe..D--
I
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.)
D:llY\~-, -m Vthlt.lL g ~(Pl-.l1l
fY\Q(\Jdtl Jfllo. 00
Ym+-tL I 11 32 QP
13. What other damages do you claim, if any? 01 ~ ~ ot IX! CJee...t- ~ 21). ).;1 -bx
$l7ntl1L~peviX.s. Ilt,LrouJn It mr kD\~s Lu/ll.jlrf3:nt- &dJ l:J II~LUl.l
14. Have you been compensated for any part or all of your claim by any insu~ RJJY\,
company? (If so, give name and address of insurance company and amount paid.)
J nSUf <lnCL \)CllLL :] ~ \ )C) 1
LX cillO- $I q) eLlcL bvi I'YV--
15. What amount do you claim from the City of Dubuque?
5\R-k -rClr IY\ :$ 8 \ d- . q 1
16. Why do you claim the City of Dubuque is responsible?
tY)r ~es VVrb (Dmpll ~ s-rvppt:d 01 red tJq1}-
c'~11i1rlIJL~LYY1afl+
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
Vli'J
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 Dl:Ibtlo.juc., lewa this 4-
LWWln, tJS
daYOf~UflJ~ ' 20~
a~.e.) ~:~nw
Jxmd:ex Jtss ~
(Print Name)
(Rev. 1/00 & 7/01)
-;,.r;. --.-
:~n!=~~~!~~ /oH r
OWNER OF VEHICLE: [f-.:TE,hPP I SE Rnrr "-r~;~c.:~~~,~ Cn~.ir'Arl.;\' ". !'1 I' t'o!'1f.p*.~'.T
BRANCH ADDRESS: .l:}"",:.' P:~:SO;~F~TF~') ~:'AF'Y .:t'P ~ if"tt' S~::,:~'-3L __''>-8iY/:'
;"1 1;:"11 !(:':1 IF. h~; '-::;2(i~J~ r-"
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1 N tYPE 1 ~~:';:..~Eq.:? h ,;l..:~r,
r. 0 RENTER f:
AU l
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DRIVEN "1/ ~'lf~:"I"
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r IN ~"t~18 i:;;=;";";;:}'~'~7~~.,I; rr:'".
:~ iHlS CONTRACT O""retio~ln.,.yolhefS~.orCol.ollrYwjjI~tyol.lrll"bljjtY.rnl~lItldlll,th/II~(
~CH.AFRRGE", AFOCROLALNISIOANDDOITA'MOANGAEL ~'::::.<,;'~='=~.. :=~:::=~~"""" lIDiWl;
AGERESPOH_IUTY. sa;: fW;;l;: 2, I~COl.lJMNrORJGl1T,see OP'llCJNM.POOQ.
WAIVER TO COVER ALL OR PART ."""'''''' ,,,,,,",,,"'''',,,, ....,"ow ~ .--'-
gU~~~oRMf~~~t21L~~i1E2f. BOOE& .:'(;r-'~;Yt~ :~~:.,~''''"'''' ..' ;,:, l>'~'tJ }'r, ~'i'...D(.j
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OWN AUTOMOBILE JNSURANCE - -~'( '''r ~S.~T\H.' , "" ~"." ,
AFFORDS YOU COVERAGE FOR ~~~:'r;::':,LSOP~AI. ~~~~:"U::~M. BEtf[EB;
8t~~'lfo ~~J~t~5~{"6FV~~~ Wl1f.E;i).~,c'Pl' 'It? =~;g:':';;'~~C;~':'l~' ~ SU' ',.,;:/!yy
DEDUCTIBLE UNDER YOUR OWN ~- . . C' . . D_~':\!!.!!Y.t;iTtiJ!~E~Tj~;:'C?!l5;!'."'''!.'.!f"''''i''':'' -- '." ."iU""",,---
INSURANCE COVERAGE.' THE. ........ . . WH. ICH CONS.ISl:."S."OF,.'PAGES.. ~1,.;J"HRO!JGH'~'.iS:~....t,.:....,... r~~;'t r.:, "i)'~ii,LJJ)I';
FURCHASE OF THIS COlliSION """",:READ ANDAGREE,TO;THE",..,....;INp;CON.D'TJO'/$:O" '''';:SS;ITt<ROUGH '.OF,TH'~""REE'
'E>AMAGE WAIVER IS NOT MANDA. ;)E~r*p'~r~,My'fS!~~RE':BE1.OW.jITMt,'1He'~RE~~'u~R'nns A.G;~I;M~."BY~SIGNiNG 1 t:, E XC I E: ~. '):,)r:,.i >
"'ORY AND MAv BE ~ECLINED BE. lOW. "'. ""'. ,I\lJTH. ORlZlNG...<>WNER. iTtI.,p/lOCE. $S'CHI;AG.ES.D""~<;ReD1TCAI'lD{S) AN.DJOR.DElllT.
I ,T . GARQ(S) .F.OR'tADV~E;'OEf'CSlTSltINCR~TAL~AuTHOR1ZAT1ONSiDEPOSlTS:nANO~'CHARGfS
, ~~q'f~~:~gIAS.@~fflT~..BJ~F.UStO:B,Y;A\THlfW:PART.YMQ.~H<J:M.BILL~.wAS'9\RECT'i:;O~/.
~enterX /(/ K .~__<"'-'t..,....~~I"""""""'"1>_.~c--_____.__ ---'--,-
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\ DEPOSITS
1. \11\~I\\\~l~\I~I'I~~II~~ ' REFUN~~ I :
\.. _ _ l5-3~'~-7~1 R._.n _ j ~?'&L2Lll
Paid B c;asH' ..../ r-c:;heck Charge I
' ,~ ,- '" '" '" '" ,.. ESTIMATED TOTAL CHARGES FOR COLLISION DAMAGE " .......
WAIVER BASED ON INITIAL RETURN DATE. $ ,,-,'0 ReceopIOI Date I Amouo' IR"""''''''.y !
~ FE. \/9 114 318 '12 SIB 314 1/11 " I -- CashReh.n1 I
~ISanaltihateoIEnlerprlsaRent-A.CarCO>npafly,whiCt\ow!'\Sa~ngh\s\()Enterpru;enamesandrnark9 @ EnterP1ise' f3.~~;<"A-€ar Company - Midwest, 2004 ,
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ADDITIONAL INFQRlMi\QN
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Enterprise
r nt-a-car
Rental Agreement
0387894 - 6235
1605 ASSOCIATES PARK DR S 1048
DUBUQUE IA 52002
Bill To:
_.OdOll'_....F.U>>$llun
STATE FARM-ACC SERVICE FIRST
ATTN: Claim Rep-Team 2-
PO BOX 83106
LINCOLN NE 68501
RENTAL INFORMATION
Oat. Out
9/07/04
Renter
.RONALD KOPPES
Date In
9/08/04
Bll LING DETAil
escription Rate Amount
2 DAYS @ 25.99 51. 98
IA EXCIS 2.6
SALES TAX% 7.00 3.64
:-
\
Additional Driver
Name
NO OTHER DRIVER PERMITTED
RENTAL VEHICLES CLAIM INFORMATION
Color
STEElMIS
Model
05 CENT
license No. Claim #/Policy #/P.O. 11
102634 153248741
Unit II Insured
822353 KOPPES' RONALD'
Date of Loss Type of Loss
8/31/04 INSURED
Type of Car Repair Shop
CHEVSU8URB RICHARDSON B
15-3249-141 RB
'-
--- ../
OTAL CHARGES
ESS AMOUNT RECEIVEO
58.22
26.22
AMOUNT DUE. .. . . .. . . .. ... ~ 32.00
IMPORTANT INFORMATION
Billing Inquiries Call
563-583-8000
Billing Information
Fed Tax ID 1/
43-1614608
Thank You For Choosing Enterprise
REMEMBER 1~800.RENT-A.CAR FOR ALL YOUR
RENTAL NEEDS!
~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Please Return This.Portion with Remittance
Remit to:
ENTERPRISE RENT -A-CAR MIDWST**
ATTN: ACCTS RECEIVA8LE
P.O. BOX 1570
DAVENPORT . IA 52809-1570
09/09
AMOUNT DUE.. .. .. .. . .. ... ~
32.00
Paid by:
STATE FARM-ACC SERVICE FIRST
ATTN: Claim Rep-Team 2-
PO BOX 83106 .
LINCOLN NE 6850 1
Customer# Rental Agreement Amount GPBR
STF6292 0387894 32.00 6235
A
RBZ0003H
date: 02-04-05
page:
1
n~TI '..11I
IN$U....NCI
.
!i;i;iiii:;!!iJt;iii..iq~!i;~!\l~y...gi!?9l!1j!!,!!
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY
AUTO PAYMENTS
_1111IB~+8jz#,l;'tC
named insured
KOPPES, RONA.LD
policy number
:L798-:L45-:L5J
date of loss
08-3:L-04
C denotes consolidated payment
P denotes previous data
E denotes EFT payment
payment m.mber
106279237J
106960957J
106689494J
106685433K
106394057J
payee
DUBUQUE RADIOLOGY ASSOC
FINLEY HOSPITAL ON BEHAL
FINLEY HOSPITAL ON BEHAL
ENTERPRISE RENT A CAR-AT
RICHARDSON MOTORS ON BEH
total amount issued status
78.00 10-18-04 PAID
275.00 09-28-04 PAID
357.00 09-23-04 PAID
32.00 09-14-04 PAID
812.97 09-10-04 PAID
E
A
RBZ00032
date: 02-04-05
time: 05: 04 PM
UAn ......
INIUUNCt,
#t#tliii;i.....#i:?! .....ll!;;P~!:!Wiq9#~@~Y
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY
VEHICLE DAMAGE REPORT
P.....l......4.1. m....Itt.....iimbiiiiE
.......,.--...--...-......................----......
......................
;g!i+8i3...............I.~..... I4................~+8jz.#l....iJji.
.. .
date of loss
08-31-04
****************************************
* Estimate Vehicle Info *
* *
* Vehicle Owner: KOPPES, RONALD *
* Vehicle Description: 96 Chevrolet Suburban K1500 4D Ut 131" *
* *
****************************************
Damage Assessed By:
Supplemented By:
Type of Loss:
Date of Loss:
Deductible:
Claim Nunber:
Insured:
Address:
TeLephone:
Description:
Body Style:
VIN:
OEM/ALT:
Options:
JASON CHARLEY
JASON CHARLEY
Collision
8/31/2004
50.00
15-3248-74101
FED 10 #42-0813744
RICHAROSON MOTORS
1475 J.F.K. ROAO OUBUQUE, IA 52002
(563) 582-5411
Fax: (563) 582-4129
Oate: 9/8/2004 03:59 PM
Estimate 10: 15-3248-74101
Estimate Version: 2
SuppLement: 1(F) 9/8/2004 04:00:11 PM
FINAL
ProfiLe 10: Mitchell
RONALO KOPPES
1684 DREXEL ST OUBUQUE, IA 52001-5405
Work Phone: (563) 556-8392 Home Phone: (000) 556-4773
Mitchell Service: 911483
1996 Chevrolet Suburban K1500
40 Ut 131" WB
1GNFK16R9TJ343539
o
4WD or AWD, Alum/ALLoy WheeLs, Air Conditioning, Power
Automatic Transmission, AM-FM Stereo/CDPlayer(Single).
Line Entry Labor
Item Number Type Operation
1
2
s1 3
4
5
6
7
S1 8
S1 9
10
11
12
13
14
15
16
17
18
122160 REF
900500 BOY'
128505 BOY
122650 BOY
900500 BOY'
900500 BDS'
900500 BOY'
AUTO BOY
100046 BOY
AUTO REF
933005 BOY
933018 REF
AUTO
AUTO
BLENO
REMOVE/REPLACE
REPAIR
REMOVE/INSTALL
REMOVE/REPLACE
ADD'L LABOR OP
REMOVE/REPLACE
OVERHAUL
REMOVE/REPLACE
ADD'L OPR
ADD'L OPR
ADD'L OPR
ADD'L COST
ADD'L COST
Drive Train: 5.7L Inj 8 Cyl 4WD
Search Code: None
Windows, Power Door Locks, Cruise Control,
Line Item
Description
R QUARTER PANEL OUTSIOE
paint lower color only
HITCH PLUG BRACKET
mikes auto
R QUARTER OUTER PANEL
R REAR QUARTER AOHESIVE MOULOING
CLEAN ANO TAPE MLOS
PULL LOOSE RUNNING BOARO
FINAL REPAIR BILL
REAR BUMPER ASSY
REAR BUMPER FACE BAR
bumper kit
called n end had nothing 96 or newer
CLEAR COAT
RESTORE CORROSION PROTECTION
MASK FOR OVERSPRAY
PAINT/MATERIALS
HAZARDOUS WASTE DISPOSAL
ESTIMATE RECALL NUMBER: 9/7/2004 08:47:38
Mitchell Data Version:
UltraMate Version:
Part Type/
Part Number
Dollar
Amount
Labor
Units
C 1.4 *
Sublet
25.00 * 0.0 *
Existing
Existing
New
Existing
New
2.0 '#
0.2 *
5.00 * 0.5 *
0.3 *
0.0 *
1.5
422.52' INC
ORDER FROM DEALER
0.3
6.00 * 0.2 *
10.00 * 0.0 *
47.60 *
3.40 *
SEP_04_A
5.0.024
15-3248-74101
UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2002 Mitchell International
All Rights Reserved
Page 1 of 3
,
Judgement Item
Labor Note Applies
Included in Clear Coat Calc
#
C
ESTIMATE RECALL NUMBER: 9/7/2004 08:47:38
Mitchell Data Version:
UltraMate Version:
SEP_04_A
5.0.024
Date: 9/8/2004 03:59 PM
Estimate 10: 15-3248-74101
Estimate Version: 2
Supplement: 1(F) 9/8/2004 04:00:11 PM
FINAL
Profile 10: Mitchell
15-3248-74101
UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2002 Mitchell International
All Rights Reserved
Page 2 of 3
Add/l
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount
Body 4.4 45.00 6.00 0.00
Bdy-S 0.3 52.00 0.00 0.00
Refinish 1.7 45.00 10.00 0.00
Taxable Labor
Labor Tax @ 7.000%
Labor Summary
6.4
Ill. AdditionaL Costs
Taxable Costs
Sales Tax
@
7.000%
Non-Taxable Costs
Total Additional Costs
Body Shop: RIcHAROSON HONDA BUICK
Address: 1475 J.F.K RO
DUBUQUE, IA 52001
ESTIMATE RECAll NUMBER: 9/7/2004 08:47:38
Totals
204.00 T
15.60 T
86.50 T
306.10
21.43
327.53
Amount
3.40
0.24
47.60
51.24
Oate: 9/8/2004 03:59 PM
Estimate 10: 15-3248-74101
Estimate Version: 2
SuppLement: 1(F) 9/8/2004 04:00:11 PM
FINAL
Profile ID: Mitchell
11. Part Replacement Summary
Amount
Taxable Parts
Sales Tax
7.000%
452.52
31.68
@
Total Replacement Parts Amount
484.20
IV. Adjustments
Amount
Insurance Deductible
50.00-
Customer Responsibility
50.00-
I.
II.
II I.
Total labor:
Total Replacement Parts:
Total Additional Costs:
Gross Total:
327.53
484.20
51.24
862.97
IV.
Total Adjustments
Net Total:
less Original Net Total:
Net Supplement Amount:
50.00-
812.97
795.21
17.76
S1: JASON CHARLEY
17.76
Inspection Site: RICHARDSON MOTORS
Mitchell Data Version:
UltraMate Version:
SEP_04_A
5.0.024
15-3248-74101
UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2002 Mitchell International
All Rights Reserved
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