Claim Sullivan, Patrick
Nov. 1. 2005 1201PM CITY OF DBQ LEGAL DEFT ~o. 5533 P. 3/J
11~SCC f1fJf1
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA ~
This written report constitutes your claim against the City of Dubuque, Iowa. You ShOUI~1
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: :::p;,. T,-....,' <: k Si'l' /- L /' / A ,v
2. Address: Jf~ q ~/hA- 11/1 f;'Vk Y.1'2-
3. Telephone Number: S-so '3. ~3R' /
4. Date of Incident: I If - :J / - c.s-
5. Time of Incident; / '3 ~.::L
6. Location of Incident (Be specific):
~ ,e. a'
l3e/.-L
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon, which you base your claim, If 8 City emp.loyee was involved, give the
employee's name.)_ . / )
-/-.--' Th e. k, ~ loT b y,'/!-h7(),dd "tie: J",./ 15'<>//
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8. What were weather conditions like? 6- a <' d'
I"..-T" /?'tV e/l~ +-.rI
/
AI~ w/t.$ h./lOK,/..;7 t') <17:
9. Give name and address of any witnesses:
#0;</ e
r--- r
1 D. Did police investigate? (If 60, give names of officers.) ,
yes
.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries)..
tJ()
(L"
~ov. 1. 2005 1201PM
CITY OF DBO LEGAL DEPT
~o. 5534 P. III
12. Wa,s 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?
pi (J ;v' e..
14. Have you been compensated for any part oral! of your claim by any insurance
company? (If so, give name and address of insurance company and amount paid.)
Ith
.
15. What amount do you claim from the City of Dubuque?
4/(" 7P: ~7
16. Why do you claim the City of Dubuque Is responsible?
.bile k /uT" /71/ t!/lI!-.
/
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
,Vo
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 /1-/- oS-
day of ;I/o vem)e,t!.. ,20oS-:
9~~~-
(Signature)
~7/v'ck s:/ .J-"C//1/'-""
(Print Name)
':::'
(Rev. 1100 III 7/01)
Form 433003 MAIL REPORTS TO: ~~Iowa Department of Transportation Sheet of
01-01 Iowa Department of Transportation Law Enforcement Case Numbers
Office of Driver Services
Park Fair Mall, 100 Euclid Avenue ~ INVESTIGATING OFFICER'S REPORT , , " "
P.O, Box 9204 OF MOTOR VEHICLE ACCIDENT "
PLEASE TYPE OR PRINT Des Moines, Iowa 50306-9204 Legal Private
Intervention? D Property? D
, Date of Accident I Time of Accident -1 County / I Accident occurred within
" /. //.,,- . Hrs corporate limits of (city)
IfacClde'ntoccurred outside of N NE E SE S SW W NW County:_Route:_
city limits show general vicinity miles 00000 0 0 0 of nearest city X-Coordinate
:Ai On Road, Street, 1 At Intersection
or Highway: . with: Y-Coordinate
Note: Unless accident occurredat an intersection which is 'compietely described above, use the space below to give the exact location from a milepost
or definable intersection, bridge, or railroad crossing, using tw'o distances and directions if necessary.
Feet Miles N NE E SE S SW W NW Feet Miles N NE E SE S SW W NW If Divided Highway, Provide Route
" 0 0 0 0 0 0 0 0 ,cd " 0 0 0 0 0 0 0 0 of (Cardinal) Travel Direction
NB SB EB WB
Milepost o Definable intersection, 0 0 0 0
Number rbridge,orrailroadcrossing
'L Driver's Name (Last, First, Middle). I Address City State Zip
" /
i!:, Date of Birth Dfiver'sLicense N~inber- , '. .. . ,
Citation
:;; Charge 1 3
;;; " ,. " " , ,
ijf -- State I Class l'Endorsementsl Restrictions 2 4
Male Female 1 ~rug
0 0 Alcohol 1 None 3. Urine 5, Vitreous Test Results 1 None 3, Urine Pos. Neg
',' ,'.. " Test Given? U 2, Blood 4. Breath 9. Refused TestGiven?U 2 Blood 9. Refused 0 0
I:;; Owner's Name (Last, First, Middle} I ~d_~ress City State Zip
. , ,', ,
Insurance Co. Insurance , "'1 stat~ '1 Year_' ,
I License
Name Policy # Plate #
Ui VIN# /,', . '" .. ..' Year Make , I Model < 'j'StYle Tow # Approximate Cost to
i Repair or Replace
II" '11: ii' ' Most Damaged W I Extent of Private?
Initial Travel Vehicle Speed Point of LLJ II Underride/ D $
Direction U Action L..LJ Limit L..LJ Initial Impact Area Damage UOverrldeU
Total Traffic II Vehicle L..LJ I~argo BOdYLLJ Vehicle j I ~river J 1 ~ision Contributing Circumstances, LLJ
Occupants L..LJ Controls LLJ Config Type Defect LLJ Condition U Ouscured LLJ Dnver (upto tw'o) LLJ
Commercial Trailer Attached to State Year Attached to State Year Emergency Emergency
License Plate # Power Unit: TrailerUnil: Vehicle TypeU Status U
Carrier I Address City State Zip
Name
US DOT# or Me. I I I I I I I IT Number I Gross Vehicle I Placard # I I U l~azardousMaterialsU
0 0 I of Axles Weight Rating I I I Released?
Driver's Name {t.ast, First. Middle} I Address City State Zip
, ' , .' ,
Date of Birth Driver's License Number Citation
Charge 1 3
, ^
Mal~ State J Class I Endorsementsl Restrict:,o~s 2 4,
Female
0 0 Alcohol 1 None 3, Urine 5. Vitreous Test Results .1 Drug 1 None 3. Urine Pos. Neg
, ,'.. , TestG,ven?U 2 Blood 4, Breath 9 Refused TestGiven?U 2 Blood 9. Re/used 0 0
Owner's,l'<taine (Last, First, Middle) 1 Address City State Zip
U , ,:
N 1 State" ) I Year,
I Insurance Co Insurance ..1ILicense , .. ~ - "
Name .' " ,: Policy # . " ; ~~ Plate # ~ ,"".
T / -, ,
, ] Model I Style ApprO)(imateCosti~
VIN# Year: Make Tow #
. ' ~. ' I , . . I , . , :,' , '" Repair or Replace
2 Private?
Initial Travel 11 Vehicle II Speed 1 I Point ol Most Damaged LLJ I Extent of JllUnderride!
Direction U Action L..1..J Limit LLJ Initial Impact LLJ Area Damage UOverrldeU D S
Total Traffic J 1 Vehicle LLJ 1cargo Body L..1..J Vehicle II ~river II Vision Contributing Circumstances.LU
occupantsLU Controls LU Config Type Defect LLJ Condition U Obscured LLJ Dnver(uptotw'o) LLJ
Commercial Trailer Attached to State Year Attached to State Year Emergency Emergency
License Plate # Power Unit Trailer Unit Vehicle TypeU Status U
Carrier I Address City State Zip
Name
US DOT# or MC# I I I I I I I J I ~Umber I Gross Vehicle 'I Placard # I U l~azarclousMaterialsU
0 0 I of Axles Weight Rating I I I I Released?
liP roperty other than nlObject I ~stimateof Unit 1 Unit 2 SEQUENCE OFEVENT~
"h iclesdamagedexplain Damaged Damage $
Owner's Full Name I Was owner or 1 "Yes 9-Unknown LLJ LLJ
{Last, First. Middle} tenant notified? U 2 - No First Event
Street or I (ity, State, LLJ LLJ Second Event
RFD &ZipCode
ACCIDENT ENVIRONMENT ROADWAY CHARACTERISTICS WORK ZONE RELATED? LLJ LLJ Third Event
Major Contributing Circumstances o Yes 0 No LLJ LLJ
LocationofFirstHarmfulEventU Weather Conditions LLJ Fourth Event
{up to two) Environment U U Location -----------~------------
Manner of CrashlCollision U LLJ LLJ LLJ Most Harmlul Event
Roadway LLJ U Type (by vehicle}
Light Conditions U Surface Conditions U Type of Roadway Junction/Feature LLJ U Workers Present? LLJ First Harmlul Event of Crash
(use codes 11-42 only)
Officer's Name
10/31/2005 at 02:53 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:
Owner:
Address:
Evening:
PATRICK SULLIVAN
PATRICK SULLIVAN
1449 TOMAHAWK DR.
DUBUQUE, IA 52003
(563)583-4381
Claim #
Policy #
Deductible:
Date of Loss:
Type of Loss:
Point of Impact:
Inspect ABRA - DUBUQUE
Location: 3400 CENTER GROVE DR
DUBUQUE, IA 52003
Business: (563) 556-0696
Insurance
Company:
Days to Repair
1995 BUIC LESABRE LIMITED 6-3.8L-FI 40 SED SILVER Int:
VIN: 1G4HR52L4SH556342 Lie: Prod Date:
Air Conditioning Rear Defogger
Cruise Control Intermittent Wipers
Theft Deterrent/Alarm Tinted Glass
Bumper Guards Dual Mirrors
Clear Coat Paint Power Steering
Power Windows Power Locks
Power Antenna Power Mirrors
AM Radio FM Radio
Cassette Search/Seek
Driver Air Bag Passenger Air Bag
Split Bench Seats Recline/Lounge Seats
Overdrive Aluminum/Alloy Wheels
Odometer: 133708
Tilt Wheel
Keyless Entry
Body Side Moldings
Custom Interior
Power Brakes
Power Driver Seat
Power Trunk/Tailgate
Stereo
Anti-Lock Brakes (4)
Cloth Seats
Automatic TransmissioTl
-------------------------------------------------------------------------------
NO.
OP.
DESCRIPTION
QTY EXT. PRICE LABOR
PIUKT
-------------------------------------------------------------------------------
1 QUARTER PANEL
2* Rpr RT Quarter panel 0 0.00 1.0 '.3
3 Add for Clear Coat 0 0.00 0.0 ).9
4# Refn DEDUCT FOR BLEND WITHIN 0 0.00 0.0 .8
5 Repl RT Nameplate "LE SABRE 1 15.94 0.3 'J.O
LIMITED"
6 Repl RT Wheel opng m1dg 1 67.80 0.3 0.0
7 REAR BUMPER
8 R&I R&I bumper assy 0 0.00 1.2 0.0
9* Rpr Bumper cover 0 0.00 0.5 2.5
1
10/31/2005 at 02:53 PM
24443
Job Number:
PRELIMINARY ESTIMATE
1995 BUIC LESABRE LIMITED 6-3.8L-FI 40 SED SILVER Int:
NO.
OP.
DESCRIPTION
QTY EXT. PRICE LABOR
PAINT
10 Add for Clear Coat 0 0.00 0.0 1.0
11# Refn DEDUCT FOR BLEND WITHIN 0 0.00 0.0 -1.0
12 Rep1 RT Molding side 1 86.20 0.3 J.O
13 REAR SUSPENSION
14 Rep1 RT Knuckle 1 120.02 m 1.8 M C.O
15** Rep1 Qual Repl Parts RT Hub & 1 290.05 m Incl. 0.0
bearing w/ABS
16*' Rep1 Qual Rep1 Parts RT Strut 1 138.00 m 0.9 M 'c;.O
--...----
standard
17 Deduct for Overlap 0 0.00 -0.4 M G.O
18# Sub1 4 WHEEL ALIGNMENT 1 69.95 T 0.0 C.O
19# Repl BAG / COVER CAR 1 10.00 0.0 0.0
20# Subl HAZARDOUS WASTE DISPOSAL 1 4.00 T 0.0 0.0
-----------------~-----------------------------------------------------~-------
Subtotals ==> 801.96 5.9 4.9
Parts 728,01
Body Labor 3.6 hrs @ $ 47.00/hr 169.20
Paint Labor 4.9 hr.s @ , 47.00/hr 230.30
~
Mechanical Labor 2.3 hrs @ $ 62.00/hr 142.60
Paint Supplies 4.9 hrs @ c 28.00/hr 137.20
~
Sublet/Misc. 73.95
----------------------------------------------------
SUBTOTAL
Sales Tax
$ ]481.26
$ 1344.06 @ 7.0000% 94.08
----------------------------------------------------
GRAND TOTAL
$ ~575.34
ADJUSTMENTS:
Deductible
0.00
----------------------------------------------------
CUSTOMER PAY
INSURANCE PAY
$ 0.00
S :,75.34
WARRANTY VALID ONLY WITH ORIGIONAL COPY OF YOUR RECEIPT PARTS SJRJECT TO
INVOICE NO GUARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF AFTERMARKET CRASH PA"TS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE
MANUFACTURER OR DISTRIBUTOR OF THESE PARTS RATHER THAN THE MANUFACTURER OF YOUR
VEHICLE.
WARRANTY VALID ONLY WITH ORIGIONAL COPY OF RECEIPT. PARTS SUBJECT TO JJVOICE.
NO GUARANTEES ON RUST. ALL PARTS NEW, UNLESS OTHERWISE SPECIFIED.
2
10/31/2005 at 02:53 PM
24443
Job Number:
PRELIMINARY ESTIMATE
1995 BUle LESABRE LIMITED 6-3.8L-FI 4D SED SILVER Int:
31~_:na te based un rl0~OR ~:R;\SH ~.s,=,=]\1Ji.T ING GC:::0E.
Unless otr.en^li,:,>::> ~I( . n'j aJ 1 i Lerrs an:
i \'!::',d =rc:lT:1
Ll'h-'l C;l-,icie U~~Tl..i:\..:~2 ~)3tabdSE =:late -10/2005, CCC Data Date 10/2()C: rid the oa:::-:::s select> '11'0
()Ev;-pa::-:-_s :n2Eu::acttlre:J bj' Lhe ve~,~c.1cs Origina" Equipment Manl,f2.( (jf,1vl part3 3rc' la)Je a
c)r/\'e~ic:le dcalcr.sr-:ip,". OP'":' OEJ'vl ':Optional OEM) parts are O~H [",.- rlCl-C no,,/ be pn i::](
tJ:cJugh al ternaLc-) -'Ocmrces ;:)tl:er ':::'13n the OE/Ve~icle dealershi.p:=:. O?'-: :JE2Vl parLs na:':,' rc' .SCll_,C-,
specific, spccidl, 0-:- unique prici::1g 0:::- discount. Asterisk (") I):;uble Ji.s~cris:": :'+"1') Cd-:-_P~-;
that :::-18 pC:lrls 2nd/or laborinforrr.a-r.ion provided by :vIOTOR IT_ay Lave 1:> (_~r: rr_ocU ficd or :11a'/ l; 'J(; c::Jne
from a~ al~ernat0 data source. Tilde sign (~) items indica~e MOTC)R NoL-I~cluQed Labor opE~atLo[!s.
NC:l-Cr-=-gj nal Equipnen [vjan:Jfdcturer aftermarket parts are describeci ao }',r1, Qual Repl Lirt C~'.L' C:CJT1P
Repl Parts \\lr.ich sLauis faT CC:JTnpeLit-=-ve Replacement Parts. Used relLts are desc.::::ibeci 23 U<:), Qual
Re<::y ~arts, kef, ,;.r USED. Recl::1ditioned parts 2re described as EeCOL. EeC:J~H:i parl.=: ,'!rr' i:scrib:'cl
as Rec,)re. NJI.C;::-; :='art NU:LLbers and FLi~;es are provided by National h-,.1f,-) (-;las.:-3 Specif.:.. T~r::.
PC)u:ld :=0'1:-1 '::#:1 iteTIS iLdicate n~arudl entries. Some 2:]06 venicl~ .,):;t>_,_n l.Il"Clr ~:j--:.~r:(-1'-"- l-rr-n, -:'1''''
prc\lic;c.1s YC31:-. ~\ ],cse \'ehjclcs, prior to receiving upda"::'_ed 0.:.1-;-:;': I"(:n the ,]chicle rT:'i.
aLar ~~d parts ~a- fro~ the previous year rray be used. The r~-:'ways est~~alor t~s a
L::_st of appll'~:>:1b_e ve_'1:cles. P2::::-::S numbers and prices sl-:.culd hE'::::c:lfirmed 'i.lith In(
deale::::-ship.
!,:tcJ :e~
(:0 ('I
'd L
CCC Pat~l~.\)ays - i\. product of CCC Informa::jcm :>:::rvi:::es I;,c.
3
11/01/2005 at 11:32 AM
30799
Job Number;
,.
BRIMEYER AUTO BODY
License #;30799 Federal 10 #:421438480
10709 COLLISION DR.
DUBUQUE, IA 52001
(563)583-4456 Fax: (563)583-1838
PRELIMINARY ESTIMATE
Written By: Kevin Smith
Adjuster:
Insured: PAT SULLIVAN
OWner: PAT SULLIVAN
Address: 1449 TOMAHAWK DR
DUBUQUE, IA 52003
Day: (563) 583-4381
Claim #
Policy #
Deductible:
Date of Loss:
Type of Loss:
Point of Impact:
Inspect
Location:
Insurance
Company:
Days to Repair
1995 BUIC LESABRE LIMITED 6-3.8L-FI 40 SED SILVER Int:
VIN: 1G4HR52L4SH556342 Lie: Prod Date:
Air Conditioning Rear Defogger
Cruise Control Intermittent Wipers
Theft Deterrent/Alarm Tinted Glass
Bumper Guards Dual Mirrors
Clear Coat Paint Power Steering
Power Windows Power Locks
Power Antenna Power Mirrors
AM Radio FM Radio
Cassette Search/Seek
Driver Air Bag Passenger Air Bag
Split Bench Seats Recline/Lounge Seats
Overdrive Aluminum/Alloy Wheels
Odometer:
Tilt Wheel
Keyless Entry
Body Side Moldings
Custom Interior
Power Brakes
Power Driver Seat
Power Trunk/Tailgate
Stereo
Anti-Lock Brakes (4)
Cloth Seats
Automatic Transmission
NO.
OP.
DESCRIPTION
QTY EXT. PRICE LABOR
PAINT
1 REAR BUMPER
2 R&I R&I bumper assy 1.2
3* Rpr Bumper cover 2.0 2.5
4 Add for Clear Coat 1.0
5 Repl RT Molding side 1 86.20 0.3
6 REAR LAMPS
7 R&I RT Tail lamp assy 0.5
8 REAR SUSPENSION
9" Repl AIM RT Hub & bearing w/ABS 1 224.00 m 0.8 M
10** Repl AIM RT Strut standard 1 95.99 m 0.9 M
11 Align four wheels m 2.7 M
12** Repl AIM RT Stabilizer link 1 11. 54
bushing kit
13 QUARTER PANEL
14* Rpr RT Quarter panel 2,0 2.3
15 Add for Clear Coat 0.9
16 Rep1 RT Wheel opng mldg 1 67.80 0.3
17 ELECTRICAL
18 R&I Antenna assy 1.0
19# Rep1 TAPE STRI PE 1 12.00 0.2
-------------------------------------------------------------------------------
Subtotals ==>
497.53
11.9
6.7
Parts
Body Labor
Paint Labor
Mechanical Labor
Paint Supplies
7.5 hrs @ $ 47.00/hr
6.7 hrs @ $ 47.00/hr
4.4 hrs @ $ 52.00/hr
6.7 hrs @ $ 28.00/hr
497.53
352.50
314.90
228.80
187.60
SUBTOTAL
Sales Tax
$ 1581.33
$ 1393.73 @ 7.0000~ 97.56
GRAND TOTAL
$ 1678,89
ADJUSTMENTS:
Deductible
0.00
1
11/01/2005 at 11:32 AM
30799
Job Number:
,- .
PRELIMINARY ESTIMATE
1995 Bure LESABRE LIMITED 6-3.8L-FI 40 SED SILVER Tnt:
CUSTOMER PAY
INSURANCE PAY
$ 0.00
$ 1678.89
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from
the Guide DE1AA92 Database Date 10/2005, CCC Data Date 10/2005, and the parts selected are
OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at
OE/Vehicle dealerships. OPT OEM (Optional OEM) parts are OEM parts that may be 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 Camp
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. Some 2006 vehicles contain minor changes from the
prev~ous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer.
labor and parts data from the previous year may be used. The Pathways estimator has a complete
list of applicable vehicles. Parts numbers and prices should be confirmed with the local
dealership.
CCC Pathways - A product of CCC Information Services Inc.
2