Claim, Brown, Richard
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CLAIM AGAINST THE CITY OF DUBUQUE, IOW~-u-- dM-<J
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: l7, i.- L'-4. - (I 7--) lit'- <. , ,~
2. Address: (,.., . 7 L l ~'-..' , ( <"'<-" , ~
3. Telephone Number: L) '-6 2- CY<" I '7
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4. Date of Incident: . Z <.."'\ (.> . L ' '>
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5. Time of Incident: I. C. If \ Gc1
6. Location of Incident (Be specific): t'" b vc<~ ,{) "15 7 D l ~ , 1 '., () c......
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,n_~me.) I l' , . -+
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8. What were weather conditions like?
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9. Give name and address of any witnesses:
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10. Did police~~"estigat~? (If,so, give nam. es of offi.cers.) r C
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)
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 as<;ertaining extent of damage.)
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13. What other damages do you claim, if any?
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.)
L------'J
15.
What amount do you claim from the City of DUbUquel ? 7 (', q (f
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Why do you claim th~ City of Dubuque is res~onSible? - ;.~-l.. ~'Lc ( (a _
16.
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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.)
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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 Dubuque, Iowa this
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day of
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((;?~l~
~.ii~gnature)
\Z .\ ~voc 0 '-----'
(Print Name)
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, 20 () '"
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(Rev. 1/00 & 7/01)
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Dale: 10/311200511:42 AM
Eslimale 10: 11180
o
Preliminary
Profile 10: Mitchell
Hanley Auto Body Inc.
1030 century Circle Dubuque, IA 52002
(1183) 1183-7220
Fax: (1183) 1183-8355
Damage As....sed By: Robert Hanley
Deducllble: 0.00
Claim Number: 1
Owner Rick Brown
Address: 874 Wilson St Dubuque, IA 52001
Telephone: Horne Phone: (553) 582-4377
MKchetl Service: 915130
DescrIption: 1995 Honda CIYIc CX
Body Style: 20 HB
Drive Train: 1.5L InJ 4 Cyl6M
Line Entry Labor
IIem Number Type
1 501966 REF
2 800800 BOY'
3 AUTO REF
4 AUTO
6 AUTO
Operation
REFINISH
REPAIR
ADD'L OPR
ADD'L COST
ADO'L COST
Line Item
DescrIption
R QUARTER PANEL OUTSIDE
BUFF REAR BUMPER SCRATCH
CLEAR COAT
PAlNTIMATERlALS
HAZARDOUS WASTE DISPOSAL
Pari Type!
Part Numbe<
Dollar Labor
Amount Units
C 2.1
0.0"
0.8
Existing
78.30-
5.00'
. - Judgement Item
C -Included in Clear Coat Calc
Add'I
Labor Su_
I. Labor Subtotal. Units Rate Amount Amount ToIal. II. Pari Replacement Summary Amount
Refinish 2.9 46.00 0.00 0.00 130.60 T
Total Replacement Paris Amount 0.00
Taxable Labor 130.80
Labor Tax @ 7.000 % 9.14
Labor sumnary 2.9 139.84
III. Additional Costs Amount IV. AdJu-. Amount
Non-Taxable Costs 83.30 In.urance Deducllble 0.00
ToIal AddIUonaI Costs 83.30 Customer Responsibility 0.00
ESTIMATE RECALL NUMBER: 10/311200511:42:06 11160
UllraMaIe i. a Trademark of MIIl:heIIIn1emallonal
MIIc:helI Data Version: OCT 06 A Copyright IC) 1984 - 2003 Mltchelllnlemallonal
e.o.212 - All Rights Reserved
P_lof2
Date: 101311200511:42 AM
Estimate 10: 11150
o
Preliminary
Profile 10: Mllchell
I,
II.
III.
Total Labor:
Total Replacement Parts:
Total Additional Costs:
Gross Total:
IV.
Total Adjuslments:
Net Total:
This is a Dreliminarv estimate.
Additional chanQes to the estimate mav be required for the actual reDair.
ESTIMATE RECALL NUMBER: 1013112005 11:42:06 11160
UltraMale Is a Trademark 01 MiIcheIl International
MIIcheII Data Version: OCT_06_A Copyright (CI1_ - 2003 MltchelllnternaIIonaI
5.0.212 All Rights Reserved
Page 2 01 2
139.64
0.00
83.30
222.94
0.00
222.94