Claim Weidenbacher, Molly
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CLAIM AGAINST THE CITY OF DUBUQUE,~'IOWA . f:j;/vtJ
This written report constitutes your claim against the City of DUbUqUe.lowa.h~s~
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 Cl~IM WII,.~ OR rill NOT BE PAID.
1. NameofClalmant:~ Wu ckil0C1LhLr
2. Address: IQ'7 <) nO', ~ Gr6J1duJu~
3. Telephone Number: 5'&3 ,5 ?fd - ~S ~
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4. Date of Incident:
6.
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7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give ~
full details upon whic If a City employee was involved, give the
employee's name.) ~
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5. Time of Incident:
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8. What were weather conditions fJ. I Cl {ja 1
9. Give name and address of any witnesses: n () n f2
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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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.)
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13. What other damages do you claim, if any?
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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.)
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15. What amount do you claim from the City of Dubuque?
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Why do you claim the City of Dubuque is responsible?
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17. Ha you made any claim against anyone else for dama s as a result of this incidenti-T1-e.9{
(If yes, give name and address.)
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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 Dypuque, Iowa this /0
r"r;
day of
( ignature) .
YJIlol~~R,,'-Jc j'l bH Lv
I (Print Name)
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(Rev. 1/00 & 7/01)
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Form 433003
01-01
MAIL REPORTS TO:
Iowa Department of Transportation
Office of Driver Services
Park Fair Mall, 100 Euclid Avenue
P.O, Box 9204
Des Moines, Iowa 50306-9204
~~ Iowa Department of Transportation
~ INVESTIGATING OFFICER'S REPORT
OF MOTOR VEHICLE ACCIDENT
Sheet
of
Law Enforcement Case Numbers.
Legal
Intervention?
D
Accident occurred within
corporate limits of (city)
If accident occurred outside of
city limits show general vicinity
N NE E SE S SW W N.W
miles 0 0 0 0 0 0 0 0 of nearest city
County:_Route: _
X-Coordinate:
On Road, Street, At Intersection
or Highway: with:
Note: Unless accident occurred at an intersection which is completely described above, use the space below to give. the exact location from a milepost
or definable intersection, bridge, or railroad crossing, using two distances and directions if necessary.
Y-Coordinate:
Feet
Miles
N NE E SE S SW W NW Feet
o 0 0 0 0 0 0 0 and
Miles
N NE E SE S SW W NW
00000000 of
If Divided Highway, Provide Route
(Cardinal) Travel Direction
NB SB EB WB
000 0
or
or
o Definable intersection,
r bridge, or railroad crossing
City
State
Zip
Driver's Name (Last, First, Middle)
Date of Birth
Driver's License Number
Citation
Charge
1.
3,
2,
4,
Female State
e.>
1. None 3, Urine 5, Vitreous Test Results: Drug 1, None 3. Urine
2. Blood 4, Breath 9, Refused Test Given? LJ 2. Blood 9. Refused
Pas, Neg,
o 0
Owner's Name (Last, First, Middle)
City
State
Zip
Year
Tow #
Approximate Cost to
Repair or Replace
Private?
D
Attached to
Power Unit:
State
Year
Carrier
Name
City
State
Emergency
Status U
Zip
US DOT# or MC#
o 0
Placard # I
City
I -U ~:~a~~~~; Materials U
Driver's Name (Last, First, Middle)
State
Zip
/i
Date of Birth
Driver's License Number
Citation
Charge
1,
3,
2
2.
4.
Male
o
Restrictions
Alcohol 1, None 3. Urine 5, Vitreous Test Results:
Test Given? U 2, Blood 4. Breath 9. Refused
Drug .' 1, None 3. Urine
Test Given? U 2. Blood 9, Refused
Pas, Neg.
o 0
Owner's Name (Last, First, Middle)
City
State
Zip
U
N
I
T
Insurance Co.
Name .
Ye,.r "..
( ;-~
VIN#
Initial Travel
Direction
LLJ
Commercial Trailer Attached to
License Plate # Power Unit:
Carrier
Name
State Year
Attached to
Trailer Unit:
State
If Property other than
vehicles damaged explain
Owner's Full Name
(Last, First, Middle)
Street or
RFD
ACCIDENT ENVIRONMENT
Object
Damaged
City
State
Emergency
Status U
Zip
US DOT# or MC#
o 0
Placard #
I-U ~:~~~~~; Materials U
Unit 1
Unit2
SEQUENCE OFEVENT
U
1 - Yes 9 - Unknown
2 - No
LLJ LLJ First Event
LLJ LLJ Second Event
LLJ LLJ Third Event
LLJ LLJ Fourth Event
------------------------
LLJ LLJ Most Harmful Event
(by vehicle)
LLJ First Harmful Event of Crash
(use codes 11-42 only)
City, State,
& Zip Code
ROADWAY CHARACTERISTICS
WORK ZONE RELATED?
o Yes 0 No
Location of First Harmful Event U
Major Contributing Circumstances:
Weather Conditions
(up to two)
LLJ
LLJ
U
Roadway
Environment
U
LLJ
U Location
U Type
U Workers Present?
Manner of Crash/Collision U
Light Conditions U
Surface Conditions
Type of Roadway Junction/Feature LLJ
Officer's Name
Badge No,
07/14/2005 at 02:50 PM
24443
Job Number:
ABRA - DUBUQUE
Federal 10 #:420782245
DBA: ANDERSON-WEBER INC
3400 CENTER GROVE DR
DUBUQUE, IA 52003
(563)556-0696 Fax: (563)556-1899
PRELIMINARY ESTIMATE
Written By: DAVE BIGELOW
Adjuster:
Insured: MOLLY WEIDENBACHER
Owner: MOLLY WEIDENBACHER
Address: 4318 RIVER LANE
POTOSI, WI 53820
Evening: (608)568-3739
Business: (563) 582-0552
Claim #
Policy #
Deductible:
Date of Loss:
Type of Loss:
Point of Impact:
Inspect
Location:
Insurance
Company:
Days to Repair
1999 FORD CONTOUR SE 6-2.5L-FI 40 SED GREEN Int:
VIN: IFAFP66LOXKI09976 Lic: 819 HEE Prod Date:
Air Conditioning Rear Defogger
Intermittent Wipers Body Side Moldings
Clear Coat Paint Power Steering
Power Windows Power Locks
AM Radio FM Radio
Cassette Search/Seek
Passenger Air Bag Cloth Seats
5 Speed Transmission Overdrive
Odometer:
Tilt Wheel
Dual Mirrors
Power Brakes
Power Mirrors
Stereo
Driver Air Bag
Bucket Seats
99547
-------------------------------------------------------------------------------
NO.
OP.
DESCRIPTION
QTY EXT. PRICE LABOR
PAINT
-------------------------------------------------------------------------------
1 REAR BUMPER
2 R&I R&I bumper assy 0 0.00 0.7 0.0
3* Rpr Bumper cover 0 0.00 1.0 2.4
4 Add for Clear Coat 0 0.00 0.0 1.0
5# Subl HAZARDOUS WASTE DISPOSAL 1 4.00 T 0.0 0.0
-------------------------------------------------------------------------------
Subtotals ==>
4.00
1.7
3.4
1
07/14/2005 at 02:50 PM
24443
Job Number:
PRELIMINARY ESTIMATE
1999 FORD CONTOUR SE 6-2.5L-FI 40 SED GREEN Int:
Parts 0.00
Body Labor 1.7 hrs @ $ 47.00/hr 79.90
Paint Labor 3.4 hrs @ $ 47.00/hr 159.80
Paint Supplies 3.4 hrs @ $ 28.00/hr 95.20
Sublet/Misc. 4.00
----------------------------------------------------
SUBTOTAL
Sales Tax
$
243.70 @
$
7.0000%
338.90
17.06
----------------------------------------------------
GRAND TOTAL
$
355.96
ADJUSTMENTS:
Deductible
0.00
----------------------------------------------------
CUSTOMER PAY
INSURANCE PAY
$
$
0.00
355.96
WARRANTY VALID ONLY WITH ORIGIONAL COpy OF YOUR RECEIPT PARTS SUBJECT TO
INVOICE NO GUARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from
the Guide DR2JM95 Database Date 06/2005, CCC Data Date 06/2005, and the parts selected are
OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at
OE/Vehicle dealerships. OPT OEM parts are OEM parts that are provided by or through alternate
sources other than the OE/Vehicle dealerships. OPT OEM parts may reflect some specific, special,
or unique pricing or discount. Asterisk (*) or Double Asterisk (**) indicates that the parts
and/or labor information provided by MOTOR may have been modified or may have come from an
alternate data source. Tilde sign (-) items indicate MOTOR Not-Included Labor operations.
Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp
Repl Parts which stands for Competitive 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 Numbers and Prices are provided by National Auto Glass Specifications, Inc.
Pound sign (#) items indicate manual entries.
CCC Pathways - A product of CCC Information Services Inc.
2