Claim Felderman, LauraCLAIM 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: Laura Felderman
2. Address: 978 S. Rocky Hill (Galena??)
`
3. Telephone Number: 815 777 4027
4. Date of Incident: Tuesay,April 19th
5. Time of Incident: 4:15 P.M.
6. Location of Incident (Be specific): To the far right of Dubuque Mining Co.
Entrance beyond end of building.
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 went to the Kennedy Mall entrance to pick up my 5 yr.old from a friend. I got out for
2 minutes to get her book bag, the car was running and I was about to get back in and I saw the bus sideswiped
8. What were weather conditions like? nice weather
9. Give name and address of any witnesses: Joyce Bocklemann 815 777 3726
G.W. Baypath, Galena, IL 61036; Lori Ritche 815 492 2491, Apple River, IL
10. Did police investigate? (If so, give names of officers.)
We called Police - couldn't come because of private property & no physical injury
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No - Driver also claimed he was at fault. He said he was trying to get close to the curb because he had to get a wheel chair out.
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.)
Only to vehicle - right rear end of vehicle scraped and chipped paint on door & quarter
panels.
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?
$572.85
16. Why do you claim the City of Dubuque is responsible?
Because the driver works for the City of Dubuque Bus Service
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 10th day of May, 2005. , 20 .
/s/ Laura Feldermann
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
-
/l;p/jplty( f~
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 _ AI J R A Fe L()t;.K mA N tJ
2. Address: q 7 f3 5 .K O(~ t.L4 h; J I
3. Telephone Number: B 15 - fll] I d 'i () d- 'I
4. Dale of InCidenl:_IL4."fS ~ A pciJ . I Cf tb
5. Time of Incident: 4 4 I Sf]. rn . M "
, r
6. Location of Incident (Be specific):
W
t'...
7. DESCRIBE CCIDENT 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.)
r (.df'l\..J fD --Me tfnlled J fYl,,-ll 61fi,'v'lce -fo Pi; I( ~() j}'j ~()/d.
trt1;Vl IA.-tnf;,rj. Jjil1--UH,1 -fur () 11'1I1/~kJ -In Jef hff h'd/C be--;; -Jt.-r.-
, lA~ ~ J
C.... W 1\<; C WlIl, I'j <>I- .r wA s: M 0 vL/ 1/) 1:,{'1- &/c.I ( 1'lJ 5f-fAe hw s,k) "'If x .
tlll':'1 u t: It Ide.. w e. Iv IV' cf CI,.; {r iA/I. c.J... 4.[ A.e W Ir1 tel> t' ",(:~
8. What were weather condiUons like? n, U vJ ett-tA(f' (/'
9. Give name and address of any witnesses: J01[e {SlJ cje It' ~ /1/} - ~. 8J5-777512fc:.
!t/iJlf/1,1:47J1 I IlO 7C i-kite -'1(') - '1 q ).... - 2'-/ ':(1 -
ftVi '.If L.- {p7(~3~ f1'AO/<' 'R/vf/L XL . .
10. Did poride investigate? (If so, giv~ names of officers.) ~ '. I
, 't- C {0 ; ~ C. f IJAf'C.... ro. i- r
/VO p .,rl I ~fvYvf.
11. Was anyone injured? (If so, give names, addre~se~, a d ext~nt h mjul'fes).
tvD -- Orjl!(r &vIsa eta; Mea L (A)~' Iff
EiM.g - +J.( ~ t41 LJ H-r~ /~ J{t)/ l;Jc . 10
6 i?;;.. S:f!lJ ~... ~ llf f 00 ftJ,puk !tct-WJ
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.)
VC:hJ'0{~ - . ( . ( .
S;('t/i cd
fX4l ds..... - . .
13. What other damages do you claim, if any?-DOflL..1
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.)
~D
15. What amount do you claim from the City of Dubuque?
.S7J, ~S
16. Why do you claim the City of Dubuque is responsible? bCC{)..lj fG
1)( rA" *3 J+ O~WJv-e.
-fh(
:&Ai
dr',Jfr vuort s
~(U~CP
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) tV 0
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
10 !Iv
day Of, r;rJ , 20~.
e#tlllLf.J ~~ /7l7t24uU.
(Signature) .
JILl j (0 J ~('t19Q()()
(Print Name)
pol It { ~'" -c'Lj- u#
C{jJJ~ C~ ~~ v1II~
cMcJ4 o~. f/~u . .
6h LJ fVl7 r'7, MJ)
(Rev. 1/00 & 7~1)~ l'\~~
f pf [' I
c-!
_J =1/ ~
:J
"
Date:
Estimate 10:
Estimate Version:
Preliminary
Profile 10:
5/121200510:18 AM
1000
o
Mitchell
BIRD CHEVROLET
3255 UNIVERSITY AVE DUBUQUE,IA 52001
(563) 583-9121
Fax: (563)556~2
Damage Assessed By: john klotz
Deductible: UNKNOWN
Insured: L~~~ELDERMAN
Mitchell Service: 912493
Description: 1997 GMC Jimmy SLE
Body Style: 40 Ut 10r WB Drive Train: 4.3 Inj 6 Cyl 4WD
VIN: 1GKDT13W8V2574439
Options: ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER WINDOWS, POWER DOOR LOCKS
CRUISE CONTROL, AUTOMATIC TRANSMISSION, AM-FM STEREO/CDPLAYER(SINGLE)
12383118 GM PART
Dollar Labor
Amount Units
2.0*'
C 2.1
0.3
0.9
66.70 0.3'
C 0.5
0.9
Line Entry Labor
Item Number Type
1 202529 BOY
2 AUTO REF
3 202011 BOY
4 201713 BOY
5 201725 BOY
6 AUTO REF
7 AUTO REF
8 AUTO
9 AUTO
Operation
REPAIR
REFINISH
REMOVEnNST ALL
OVERHAUL
REMOVElREPlACE
REFINISH
ADD'L OPR
ADD'L COST
ADD'L COST
Line Item
Description
R QUARTER OUTER PANEL
R QUARTER PANEL OUTSIDE
R REAR COMBINATION LAMP
REAR BUMPER ASSY
R REAR BUMPER EXTENSION
R REAR BUMPER EXTENSION
CLEAR COAT
PAINTIMATERIALS
HAZARDOUS WASTE DISPOSAL
Part Type!
Part Number
Existing
108.50 *
3.50 *
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
Add'l
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
- -
Body 3.5 52.00 0.00 0.00 182.00 T Taxable Parts 66.70
Refinish 3.5 52.00 0.00 0.00 182.00 T Sales Tax @ 7.000% 4.67
Taxable Labor 364.00 Total Replacement Parts Amount 71.37
Labor Tax @ 7.000 Ok 25.48
Labor Summary 7.0 389.48
ESTIMATE RECAlL NUMBER: 5/12/200510:17:55 1000
UltraMate is a Trademark of Mitchelllnternatlonal
Mitchell Data Version: APR_05_A Copyright (C) 1994 - 2003 Mitchell International
UltraMate Version: 5.0.205 All Rights Reserved
Page 1 of 2
1
Date:
Estimate 10:
Estimate Version:
Preliminary
Profile 10:
51121200510:18 AM
1000
o
Mitchell
III. Additional Costs
Non-Taxable Costs
Amount
112.00
IV. Adjustments
Customer Responsibility
Amount
0.00
Total Additional Costs
112.00
I.
II.
III.
Total Labor:
Total Replacement Parts:
Total Additional Costs:
Gross Total:
389.48
71.37
112.00
572.85
IV.
Total Adjustments:
Net Total:
0.00
572.85
This is a Dreliminarv estimate.
Additional changes to the estimate may be reauired for the actual reDair.
ESTIMATE RECALL NUMBER: 51121200510:17:55 1000
UItraMate Is a Trademark of Mitchell International
Mitchell Data Version: APR_05_A Copyright (C) 1994 - 2003 Mitchell International
UltraMate Version: 5.0.205 All Rights Reserved
Page 2 of 2