Claim Johns, Barbara
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: Barbara Johns
2. Address: 1124 Tressa, Dubuque IA 52003
`
3. Telephone Number: 563 582 4410
4. Date of Incident: 9 11 05
5. Time of Incident: 1:30 P.M.
6. Location of Incident (Be specific): 2491 Kerper Blvd.
On street in front of Hurst Logistics
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.)
Snow pole attached to Fire Hydrant was bent down into street. Hit pole.
8. What were weather conditions like? Good, dark.
9. Give name and address of any witnesses: Larry Johns, 1124 Tressa, Dubuque IA 52003
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.)
Yes, Car Right front & right side.
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? All - $1,941.00
16. Why do you claim the City of Dubuque is responsible? Snow Poles should be
checked on a regular basis.
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 15 day of September, 2005.
/s/ Barbara Johns
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
IIIDIO~ .
cc:
CLAIM AGAINST THE CITY OF DUBvaUE,~'IOWA '
a6lo/2.e4 ~ --
This written report constitutes your claim against the City of Dubuque, Iowa. You ShOUldH
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:---54"Da. ru.. ::]1) h vt'S
2. Address:---.J \ ~ ~ J f'('.."SS A . )) u. b ~ (& -e I '1-~ s-.;)()o ~
3. Telephone Number: S (0 3 ~ ~ d ~ 44 / 0
4. Date of Incident: 9'" /1 - 0 S-
5. Time of Incident: ) ',30 A-M
6. Location of Incident (Be specific): ;; L/ ~ t' f"-'P(?r IS J u d
o Y\ .s:b-e -e} '\ f\ ~ -\- 0+ r+ L<-1f'-;5::t L ("j 'd- i;, -t-i cS
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.)S ~ \ U. "'\ 1- \' W-i I \ ~,
C\.cJv.) po e Q 1lO-C I yea ~ TI f"-e. . ~I (\ll'o. ~\
lD~) YJeV\-t o\cwon ~\(\-6 ~e+ t r\;t_t~Q.Je~
8. What were weather conditions like? 'a 00 did ~ r \(
9. Give name and address of any witnesses: l~ {' r l.J ::J1Jh Yt s
I\~~ tr--cB"'iiA Du.b~~u..eJ ~ S-d-063
10. Did police investigate? (If so, give names of officers.)
1\.0
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
l\'D
.J
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.)
.~ .~_S 1 OrA ('
'R.\~h--\- ~I'CM\- ~.6 f'1l\h,\- Skill
13. What other damages do you claim, if any? 1\ on.e...
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? .-ft-lL -
/, q V/,O ()
.
16. Why do you claim the City of Dubuque is responsible? 6> ^("5"'VJ pd e:)
~()v..'\ A '0 -e clie2i 'E' A rJY\ D.. ~L~ u.b..v-- '0 c...S'1 S.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
1\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 15
day of 5ejl-fC/1l-J;e,
, 20 t) re:;:-
L'.-
(~-
I'
l--~'
r..~ .
~
-Q
<~~
I' .
(Signature)
-.t'a ,rb<< Y'~ JO )J/tj
(Print Name)
('..J
-~
L~;
U'. l.
." 1
-~,~
.,
-,,1
Q)
(..."J
::.'::. <(
,..-....."'), ---
C"..,J
~
tJ?
0._
L;..J
(/'"')
Lr:~
r..:J
z..C=:
G
(Rev. 1/00 & 7/01)
...
.'" I
.
" ,
;!
,1t ,-
\ I
,j i
\
\ 1
~ r
" :\
1
J' '\
\ "J
\
L "
f...... ~
\
l
I
r
tl
Damage Asset.eeI By: john IdoIz
BIRD CHEVROLET
3255 UNIVERSITY AYE DUBUQUE, IA 52001
(513) 583-1121
Fax: (513) SS8-4482
Deductible: UNKNOWN
Insul8d: BARB.u.
Add....: 1124 TRESSA DUBUQUE.IA 52003
IIItcbeII Service: 912489
Description: 1994 PonIIac Bonnev" SE
Body Style: 4D Sed
VIN: 1G2HX52L1R4251171
Line Entry Labor
Item Number Type
1 201090 BOY
2 201150 BOY
3 AUTO REF
4 202A52 BOY
5 AUTO BOY
6 2OI4OO.-w
7 AUTO REF
8 AUTO REF
9 218920 BOY
10 219082 BOY
11 AUTO REF
12 ~ BOY
13 AUTO REF
14 221090 BOY
15 AUTO REF
16 AUTO
17 AUTO
Operation
REIIOYEIINSTALL
REPAIR
REFlllSH
REIIOVElREPLACE
CHECKlADJUST
REIIOVEIREPlACE
REFIIII8H
REFINISH
REIIOVEIINSTALL
REPAIR
REFINISH
REPAIR
REFIMSH
REIIOVEIINSTALL
ADD'L OPR
ADD'L COST
ADD'L COST
Dale: 91141200510-.46 All
E1.6...1D: 147&
Estimat8 V....Ion: 0
PntIimInaIy
Profile ID: Mitchell
DrIve Train: 3.8L InJ 8 Cyl AO FWD
Line Item
DescripIiOn
FRT BUllPER ASSY
FRT BUllPER COVER
FRT BUllPER COVER
R COMBINATION LAMP ASSY
HEADI AIIPS
R FENDER PAIEl
R FENDER OUTSIDE
R FENDER EDGE
R FRT LWR DOOR 1l0ULDING
R FRT LWR DOOR 1l0ULDING
R FRT LWR DOOR 1l0ULDING
R REAR DOOR SHELL
R REAR DOOR OUTSIDE
R REAR DOOR 1l0ULDING
ClEAR COAT
PAlNTIllATERIALS
HAZARDOUS WASTE DISPOSAL
.. . Judgement 18m
# . Labor Note Applies
C . Included in Clear Coat Calc
ESTIIIATE RECALL NUllBER: 9I141ZOOS 10:41:44 1476
UIInIIaee is . T........... of lIiIdIeIIlnt8maIIonaI
IIItcheII DaIlI Version: AUG_OI_A Copyright (C) 1114 - 2003 lIiIdIeII Inlamallonal
UltrallatB Version: 5.0.211 AI RIghts Reserved
Part Typel
Part Number
ExIstIng
18519272 GII PART
2511557& GII PART
ExIsting
ExiIIIIng
Dollar Labor
Amount Units
1.3
O.S-.
C2.3
221.78 0.1
0.4
358.10 2.5.
C2.7
C 0.1
0.3
0..1*
C 0.4
21
C 2.1
0.3
2.1
313.10 ..
6.00"
Page 1 of 2
Date: 91141200510:48 All
EstimateID: 1476
&6waaIit Version: 0
PrelImInary
Profile 10: IIItcheII
I. Labor Subtotals
Body
RefInish
Add'I
Labor Sublet
UnIIs RaIe Amount Amount
7.9 52.GO 0.00 0.00
10.1 52.00 0.00 0.00
Totals
410.80 T
125.20 T
II. Part RepIKement SUIIIIIIlIIJ
Taxable Parts
..... Tax .
Total Replacement Parts AInounl
7..000%
Amount
579.88
40.59
820.47
Labor SUIIIIII8IJ
Taxable Labor
Labor Tax . 7.000 %
18.0
93UO
85.12
1.001.52
ill Additional Costs
Non-TaxabIe Costs
Total Additional Costs
Amount IV. AdjustmeDIs
319.10 Customer R8sponSIbay
319.10
Amount
0.00
L
II.
ill
TObII Labor:
Total RepIKement ParIs:
Total AddIIionaI Costs:
Gross Total:
1....52
82D.47
319.10
1,941.09
IV.
To4aI AcIJu8tInentS:
Net Total:
0.00
1,941.09
This is a D~", .......
Additional chanG88 to the estimate maw be raauired for the actuall'8D8ir.
ESTIMATE RECALL NUllBER: 9I141ZOOS 10:48:44 1476
UltrallaIe is a Trademark of IIltdIeIIlnternationaI
IIltchel D8Ia Version: AUG_05_A Copyright (C) 1114 - 2OO3111tct1e11nterna11ona1
Ullrallate Version: 5.0.211 AI RIghts Reserved
Page 2 of 2
RICHARDSON MOTOR:;
1475 J.F.K. ROAD
DUBUQUE, IA 5200;~
PHONE: (563) 582-5411 FAX: ;563) 582-4129
f~U.r..;AAL ID: 42-0813744
CD LOG NO 968-1
DA'l'E 09/1 :,/U5
SHOP:
ADDRESS:
CITY STATE:
ZIP:
RICHARDSON MO~ORS
) 4" 5 JOHN F. KENNEDY RD
DUBUQUE, IA
52002
INSP DA'fE;
PBON]~ 1.:
FAX:
OWNER:
JOHNS, BAR.B
POINT OF IMPACT: 2
l.,rc# :
BODY COLOR:
CONDITION:
'*'=-USER-ENTERED VAT.TTF.
EC=REPLACE ECONOMY
UM=REMAN/REBUILT PRT
Or:::""REPI,ACE PXN 01:': SRPLS
TE~PARTL REPL PRICE
I =RF.PAl R
TT=TWO-TONE
N=ADDITIONAI. LABOR
AA=APPEAR ALLOWANCE
09/15/05
(563)502-541J.
(563)S82-4129
STATE:
V1N: 1G2HXS2L1R4251171
Ml LE:A.GE:
ACCTNG CTL1t:
E-=REPLACE OEM
UE=REPLACE OE SURPLUS
EU=REPLACE SALVAG~:
PC=PXN Rfo:CONDITI0N'Rf":o
ET=PAR'l'L REE'L LABOR
L=REFINISH
CG'--CHIPGU1\RI.>
Rl""R&I ASSEMBLY
RP=RELA'1'8D PRIOR
NG=REPLACE NAGS
UC=RECONDITIONED PR'f
EP=REPLACE PXN
PM=PXN REMAN/REBUI~T
IT=PARTIAL REPAIR
BR=BLEND REFINISH
SB>::StroLET
P=-=CHECK
UP=UNRELATED PRIOR
1994 PONTIAC BONNEVILLB SE 4DOOR SED1\N 6CY~:' GASOLINE 3.8
CODE: W4313A/C OPTNS D/24FQ
OPTIONS:
TwO-s'rAGR - F.X1'ERIOR SURFACES TWO-ST.f\GE - INTERIOR SURfACES
ANTI-LOCK BRAKE SYSTEM PASSI-;NGER SIDE. AIRBAG
or GDE Me DESCRIPTION MFG_PAR1' Ni)_ PRICE AJ% B\li
----------- ------------ ----- --- --
N 0009 FRT BUMPER CVR OVERHAU ADDNl; [.ABO R :)PERJ>.
I 0006 COVER, FRONT BUMPER ll.EPA!R
L 0006 13 COVER, FRONT Blf'MPER REFINISH
E 0042 HEADLAMP ASSY,HALOG RT 16519272 Gr4 PART 221. 78
N 0973 HEADLAMPS AIM AnDN!; !.ABOR OPERA
E 0104 FENDf.;R, FRONT RT 256155016 GM PART 358.10
L 0104 FENDER, FRONT RT REFINISH
I 0269 MLDG, FRON'r DOOR LOW RT REPAIR
RI 0269 MLDG,fRONT DOOR LOW RT R&I ASSEMBLY
L 0269 MLDG. FRONT DOOR LOW RT REFINISH
I 0288 DOOR SHELL, REAR RT REPAIR
L 0288 DOOR SHELL/REAR B'l' REFINISH
;:>.1 0331\ MLDG,REAR DOOR LOW~ ~T n~T ASSEMBLY
RI 0306 01 I~DLE,RR DOOR OUTE RT R&I ASSEMBL Y
H01JRS R
3.0 1
0.5*1
3.6 4
INC 1
0.4 1
1. 7 1.
3.6 <1
0.5"'1
0.7 1
0.5 4
2.0*1
2.5 4
0.7 1
0.6 1
Pi\GE 1
. .
1994 PONTIAC BONNEVILLE SE 4DOOR SEDAN
cn lJOG NO 9(jO-l
N M14
Ny .Ml T
SB M60
CORROSION PROTECTION
COVJ:.;J:{ CM J:.;2<:fJ:.;J:{lUl'<.
HAZARD. WSTE. REM.
ADDNt. LABOR OPERA
J\VDNL LABOR OPERA
SUBLET REPAIR
6.00'"
6.00.
6.00*
0.2*41-
0.2*4*
1 ~.
17 ITEMS
MC MESSAGE IS)
01 CALL DEALER fOR EXACT P~T tmMBER / PRICE
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
FtNA,L CALCUIJA1'IONS & ENTRIES
GROSS PARTS
OTHER PARTS
PAINT MATER IAL
Pk~TS & MATERIAL TOTAL
T1U<. UN }:' AK.T::; @
7.000%
5)9.88
12.00
302.10
893.98
41 .43
LABOR
I-SHEET METAL
2-MECH/ELEC
3 - FRA.?1E
4-REflNISH
5-PAINT MATERIAL
LABOR TOTAL
TAX ON LABOR
SUBLET REPAIRS
TAX ON ~UJ)J..IE'f
TOWING
STORAGE
RATE
47.00
54.00
54.00
4"J .00
28.50
RF~Pl,A.CE HI-l.S
3.7
REPAIR HRS
6.4
474.70
10.2
0.4
498.20
@
7.000~
qT) . qn
68.10
6.00
0.42
(~
7.000\\
GROSS TOTAL 1,982.83
NET TOTAL 1,982.83
ADP SHOPLINK UN189 ES CD LOG 968-1 DATE 09/15/C5 02:37:42PM R6.37 CD 08/05
PXN: Y/OO/OO/OO/OO/OO CUM 00/00/00/00/00 GEOCON: 52002
EDU: 0908 HOST LOG
(el 1998 - 2005 ADi? CLAIMS SOLUTIONS GROUP, 1/'J'C.
2.2 HRS WERB ADDED TO THIS EST. BASED ON ADP Tli'O-STAGE REFINISH FORMULA.
-----------------------------------------------.---