Claim, Slaats, LindaCLAIM 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: Linda Slaats
2. Address: 227 Moonstone Ln
`
3. Telephone Number: 815 747 6974
4. Date of Incident: 5 16 05
5. Time of Incident: 5:45 P.M.
6. Location of Incident (Be specific): Parking Lot W. 9th to Space #14
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.)
Was backing out of parking spot. Was a large rock under car. Hit with Tire - hit car under
rear door.
8. What were weather conditions like?
Dry
9. Give name and address of any witnesses:
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.)
Back side of car passenger side estimate enclosed.
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.)
301.70
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
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 20th day of May, 2005. , 20 .
/s/ Linda L.Slaats
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
- 4~4~
CLAIM AGAINST THE CITY OF DUBUQUE, I~
~..~
;jt /lJ
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 /IJ..J Aj 5/ AA /5"
2. Address:;;2.;l. 7 /VJ LJ b rJ 5' -f 0 IV '(/ L A J
.
3. Telephone Number: R / S .- ., S-, - ~ Lj /j y
-- ? .
4. Date of Incident: -5..,. /*-' t>6
5. Time of Incident: .5.~ ~ 6' P;v1.
6. Location of Incident (Be specific): p A/zJ:..~ tV 1 L 0 f LV 9 W
S-p/lGV #/9"
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.) .
Lti4d J~.4c:/<i (Vj cJ Lv -r cJ-f ;:>;4/2~;/\} S:P?I-T
fA) /1-6' A LAJl-r .R OG/o 4,"1Jt:J-<'-L-- CA~ J' J-J./-f 0uHL -:7:;- /Z--
J./ j.-1 C /.It )?/ U-N dL' ~ ;.2 (..4;e d /'~/) ~
8. What were weather conditions like? f)R.- /
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
J/U tJ
11. Was anyone injured? (If so, give name$, addresses, and extent of injuries).
/VCJ
,
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.)
E.L}LJe- 5);"';"(/ ()~ CA.rz, PCv5st'"~1~//-; ~'cJ~
r':' 5-!;/TI./Jit/ (',;V c. /~s-~ d
13. What other damages do you claim, if any?
IV 1) Il) '(/
.
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.)
/'JlJ
15. What amount do you claim from the City of Dubuque? 3 0 l 7 a
16. Why do you claim the City of Dubuque is responsible?
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
J1)o
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 d .0
day of ;l/I4 v
,/
, 2065 .
,'-; ")
~ 0,1 ., eX. y[jJ~./fl
(Signature)
t i dcJ~ L. ~LArq7f
(Print Name)
(Rev. 1/00 & 7/01)
,
Kieffer Body Shop
20100 US 20 WEST EAST DUBUQUE, IL 61025
(815) 747-3044
Fax: (815) 747-3044
Tax 10: 36-3028967
Damage Assessed By: Randy Beadle
Deductible: 0.00
Claim Number: NA
Owner LINDA SLAA TS
Address: 227 MOONSTONE EAST DUBUQUE, IL 61025
Telephone: Home Phone: (815) 747-6974
Mitchell Service: 916489
Date:
Estimate 10:
Estimate Version:
Preliminary
Profile 10:
Description: 1997 Buick LeSabre Custom
Body Style: 40 Sed Drive Train: 3.8 Inj 6 Cyl AO
VIN: 1G4HP52K2VtM81349
Options: ALUM/ALLOY WHEELS, AIR CONDITlONING, POWER STEERING, POWER WINDOWS
POWER DOOR LOCKS, TILT STEERING WHEEL, CRUISE CONTROL, ELECTRIC DEFOGGER
AUTOMATIC TRANSMISSION, AM-FM STEREOICDPLA YER(SINGLE)
Line Entry Labor
Item Number Type
1 600399 BOY
2 618870 BOY
3 AUTO REF
4 AUTO REF
5 933018 REF
6 AUTO
7 AUTO
Operation
REPAIR
REPAIR
REFINISH
ADD'L OPR
ADD'L OPR
ADD'L COST
ADD'L COST
Line Item
Description
R ROCKER REINF
R REAR DOOR SHELL
R REAR DOOR OUTSIlE
CLEAR COAT
MASK FOR OVERSPRAY
PAlNTIMATERlALS
HAZARDOUS WASTE DISPOSAL
* - Judgement Item
C - Included in Clear Coat Calc
I. Labor Subtotals
Body
Refinish
Labor Summary
Units Rate
1.8 45.00
2.9 45.00
Add,
Labor
Amount
0.00
5.00
Totals
81.00
135.50
H. Part Reptacement Summary
Sublet
Amount
0.00
0.00
Part Type!
Part Number
Existing
Existing
5/1812005 09:24 AM
2300
o
Mitchell
Dollar Labor
Amount Units
1.3*
0.5*
C 2.1
0.8"
5.00*
81.20 *
4.00*
Amount
Total RepIac:emeIlt Parts Amount
Non-Taxable Labor
216.50
4.7
216.50
ESTIMATE RECALL NUMBER: 5/1812005 09:24:43 2300
Ultra Mate is a Trademark of MitcheM International
Mitchell Data Version: APR_05_A Copyrigf1t (C) 1994 - 2003 MitcheM International
Ultra Mate Version: 5.0.205 All Rights Reserved
0.00
Page 1 of 2
#
Date:
Estimate 10:
Estimate Version:
Preliminary
Profile 10:
5/1812005 09:24 AM
2300
o
Mitchell
III. Additional Costs
Non-Taxable Costs
Amount IV. Adjustments Amount
85.20 Insurance Deductible 0.00
85.20 Customer Responsibility 0.00
I. Total Labor: 216.50
II. Total Replacement Parts: 0.00
II. Total Additional Costs: 85.20
Gross Total: 301.70
IV. Total Adjustments: 0.00
Net Total: 301.70
Total Additional Costs
This is a preliminary estimate.
Additional chanQes to the estimate may be required for the actual repair.
ESTIMATE RECALL NUMBER: 5/1812005 09:24:43 2300
Ultra Mate is a Trademark of MitdIeIIlntemationaI
Mitchell Data Version: APR_05_A Copyright (C) 1994 -2003 MiIcheIIlntemationaI
Ultra Mate Version: 5.0.205 An Rights Reserved
Page 2 of 2