Claim Freund, John W III
" .
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U.
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
Mvt1
t:1 ~r IN
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: ..:r;,kV\ hI r.eLl""ct
2. Address: 2677 1-/", (~? /-'fill PI
rrr
/I\jlc,<'"'\ I A
f ) I
SZCl02
3. Telephone Number: :5t3- 5fO-- 5l/5'7
4. Date of Incident: II /q /01
5. Time of Incident:
/6 '2.3
A. t-<.
6. Location of Incident (Be specific): C~,^-'wcJ) A()~
(AH<>':>S Q"""
\JDG ')
,
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.)
T (Jot, IYN~) w"-5 a~k"J ~ -"CN ~7 Cd? 50 nr. 1::.1(<1 a..(/ (}C,-6S It.. $CwLr
{(, ...
0<11
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~ffd ,;,.~ Ik sir..+ ~~..R sl. ,,I
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r-'!ar b.._ Ir
8. What were weather conditions like? -
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
r~o",,) S-b", - ~JU t)<',L.~St tZeJl">r..(. AH..t./ ~I to-S<. JJ~_bLr,
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.)
fee" e,"^~per (o-f\d-<Ij ~O----Q<J-<~' gy l-\~ I\(C"'C\..
13. What other damages do you claim, if any?
14. Have you been compensated for any part or all of your claim by any insurance
company? (If so, give name and address of insurance company and amount paid.)
W()
15. What amount do you claim from the City of Dubuque?
~(rb~
16. Why do you claim the City of Dubuque is responsible? T V-JG.3 C\.,' Ie"..) ~ ---"'-'~
""'j 0QLde GJ\J- c..<: r v-X-s 'v-"G,:+;~');'" -\.(,"4+;( "--~ ~ (2..QJ. \"% l-l.) fAr i?-~
\,\0(",,0 -k _ov~ h;<; \)ii.~C Ie, I/9ii..OO ')',J~ 5'-'-"1"') ""-J C,,-, Ci.Y\Q~ (\1"1'" cfr {l.
{'"",r b",-,\",j_
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yelJ ~ive name and address.)
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 Z 'i3
day of _}-J~V~
(Signature)
:Jb"'~ w 'f=r' 4.--J ..rrr:
(Print Name)
, 20<JS.
'j i~~l
(Rev. 1/00 & 7/01)
1'l\!IA
.
'RYAN,'STAN
1::--,--=~".,=:c.,-=,--
,,~~~~~L~ iO~1'-ll~~SG08B
1--'-----.------'
: 11104/2006
12:03
Hrs. n,l
Printed At: Dubuque Pollce Department
Page 1
Form #: 01-06-50088
e
Driver Information Exchange Report
Dubuque Police Department
563-589-4410
I
I~
I ~
1001
I Driver's Name. Last
, KELLY
i Address
2630 ROOSEVELT STREET
Middle
JOHN
lSUffiX 1 Date of Birth
. 06/28/1866
Sta~ Zip
IA 62001
Insurance Co. Name
IOWA COMM. INS. POOL
Phone
Driver's License Number
864ZZ9884
Owner Company Name
Class
A
City
I DUBUQUE
[I State i Endorsements I Reslrj~tions
IA . N NONE
Insurance Co_ Phone #
Insurance Policy #
ICAP 0300
I
I
~
License Plate #
I 64606
\ Driver's Name. Last
FREUND
I Address
2080 KEY LARGO ST #2
First Middle Suffix
.,-1~--1 ~~BUQ~;" "---'~I;-I i~OOl- 'I
Make-~-TM(;d;I - ~- IvehlcleCOnflQuratlOn II'
INTL [ TK __
Year I Most Damaged Area I ~pproxlmate Cost to RepaIr or Replace I
2020 ,.L. __, ~60.00 ~
-- ~ lMTddle - I SuffIX I Date of Birth 1
~, ~,W1LLlA, M ~' 07/2, 4/1881 I
! City Sta~ l Phone I
c--T-'-~ 1 DUBUQUE __ __~' _ IA ~02 I ----1
Class I StCl:e I Ef\dorsements~eslridions I Insllrance Co, Name Insurance Co. Phone #
C ' IA _1. NONE I B ' STATE FARM MUTUAL (663) 683-8301 X
Owner's Name - Lasl
CITY OF DUBUQUE
Address
60W lSTST
VINNo,
I lHTZZAARX6JOl1561
U
N
I
I T Gender Driver's License Number
I Male 766YY8246 '
i 0021 Owner Company Name
Oimer's Name ~ Last
i FREUND
f-
I Address
, 2080 KEY LARGO ST #2
,
I \fIN No.
, " lHGCD6662RA002667
: ; License Plate #
W 744JEA ,
1 County -
~ Dubuque a 31
~Uleral Description -------.--
: "N/A"
Insuranoe Policy #
378690F2215
I First --lMlddle . ! SuffIX
,~_,__L0t:I!J ____rc.Y_~'-.IAM ---,-d-~- Zip-------. 1
i DUBUQUE ~.~ 52002- j
'I Make .. j Model - -rStYi8 . 1 V,_ehicle C,onfiguration '[
1994 i HON[~ -----.. At.."C- - -~~~ - i .
t S1ate Most ~ed A~e--"'-----_.l : Approximate Co~t to Repair Or RePlace!
J IA 1 $700.00 , ~
: Accident occurred Nithin corrorate limits of icity) -I
: Dubuque. 2100
, --~-_.__._-,-----~-
-1
-l
I
I
'1
I
IX-Coordinate -- .- ---------~----TY:.coordinate ---. ""------- --
I "N/A" 1 "N/A"
If accident occurred owtside of city --lOirection ll'.;earesl Cill'- ... Jl Route (Catdinal)
I limits show general vacinity: "N/A~ "N/A" of ! "N/A" Travel Direction "N/A"
I ~~~~~t;:'~~~ Highway ---~-~-'-r~~;:,,;;Oci;On'7';';;:-----~-'---'
:-Distance ~6'-S're(ction- - - - --TDiStance- - '-'---lDirect~n'-----]-MifeposiNumber _ _._"_t______~
! 100 Ft ~ and I"NIA"___ ,"N/A':, of , "NIA" Or i
DEofinable intersection bridge, or railroad crossing !
KAUFMANN AVE.
Officer
RYAN, STAN
---....-.T-.- ---
I ~dge No.
l!8E
--- .
--------..-------- -- ---1--
'I La'li Enforcement Case Number Dale or Accident
, 01..~6-60788 , ! 11/09/2006
Time of Accident
10:23
HfS')/
.
^~.
1475 J.F.K. ROAD
DUBUQUE, IA 52002
PHONE: (563) 582-5411 FAX: (563) 582-4129
FEDERAL ID: 42-0813744
"0
SHOP:
ADDRESS:
CITY STATE:
ZIP:
CD LOG NO 1168-1
DATE 11/09/05
RICHARDSON MOTORS
1475 JOHN F. KENNEDY RD
DUBUQUE, IA
52002-
INSP DATE:
CONTACT:
PHONE 1:
FAX:
OWNER:
ADDRESS:
CITY STATE:
ZIP:
FREUND, JOHN
2677 HALES MILL RD
DUB, IA
52002
POINT OF IMPACT: 9
LIC#:
BODY COLOR: BLACK
CONDITION:
*=USER-ENTERED VALUE
EC=REPLACE ECONOMY
UM=REMAN/REBUILT PRT
OE=REPLACE PXN OEo SRPLS
TE=F~TL-REPL-PRICE
I=REPAIR
TT=TWO-TONE
N=ADDITIONAL LABOR
AA=APPEAR ALLOWANCE
HOME PHONE:
11/09/05
JASON CHARLEY
(563) 582-5411
(563)582-4129
(563)590-5457
VIN: 1HGCD5662RA002657
MILEAGE:
ACCTNG CTL#:
STATE:
E=REPLACE OEM
UE=REPLACE OE SURPLUS
EU=REPLACE SALVAGE
PC=PXNRECONDITIONED
ET=PARTL REPL LABOR
L=REFINISH
CG=CHIPGUARD
RI=R&I ASSEMBLY
RP=RELATED PRIOR
NG=REPLACE NAGS
UC=RECONDITIONED PRT
EP=REPLACE PXN
PM=Fm~!REBUILT
IT=PARTIAL REPAIR
BR=BLEND REFINISH
SB=SUBLET
P=CHECK
UP=UNRELATED PRIOR
1994 HONDA ACCORD EX 4DOOR SEDAN 4CYL GASOLINE 2.2 VTEC
CODE: H1243C/A OPTNS B/24MBJCEFRH
OPTIONS:
TWO-STAGE - EXTERIOR SURFACES
ELEC REMOTE CONTROL MIRRORS
POWER WINDOWS
ANTI-LOCK BRAKE SYSTEM
HEATED BACK GLASS WITH ANTENNA
OP GDE MC DESCRIPTION
E 0566
L 0566 13
SB M60
TWO-STAGE - INTERIOR SURFACES
POWER DOOR LOCKS
MOONROOF
AIR CONDITIONING
CRUISE CONTROL
MFG. PART NO. PRICE AJ% B% HOURS R
------------ ----- ----- -
04715SV4AOOZZ 255.19 2.0 1
REFINISH 3.0 4
SUBLET REPAIR 6.00* 1*
COVER,REAR BUMPER
COVER,REAR BUMPER
HAZARD. WSTE. REM.
3 ITEMS
MC MESSAGE (S)
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
PAGE 1
1994 ,HONDA ACCORD EX 4DOOR SEDAN
CD LOG NO 1168-1
FINAL CALCULATIONS & ENTRIES
GROSS PARTS
PAINT MATERIAL
PARTS & MATERIAL TOTAL
TAX ON PARTS @
7.000%
255.19
85.50
340.69
17 .86
LABOR
1-SHEET METAL
2-MECH/ELEC
3- FRAME
4-REFINISH
5-PAINT MATERIAL
LABOR TOTAL
TAX ON LABOR
SUBLET REPAIRS
TAX ON SUBLET
TOWING
STORAGE
RATE
47.00
54.00
54.00
47.00
28.50
REPLACE HRS
2.0
REPAIR HRS
94.00
3.0
141. 00
@
@
7.000%
235.00
16.45
6.00
0.42
7.000%
GROSS TOTAL
616.42
NET TOTAL
616.42
ADP SHOPLINK UN189 ES CD LOG 1168-1 DATE 11/09/05 04:11:08PM R6.37 CD 10/05
PXN: Y/OO/OO/OO/OO/OO CUM 00/00/00/00/00 GEOCODE 52002
EDU: 1101 HOST LOG
(C) 1998 - 2005 ADP CLAIMS SOLUTIONS GROUP, INC.
1.0 HRS WERE ADDED TO THIS EST. BASED ON ADP TWO-STAGE REFINISH FORMULA.
PAGE 2
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L LaborI~Lt ~18 Unlbl - - - T_ a. Part RepllCIJ7UInt Summary -
...., 1-1 47-10 0.00 .... 7UD T TuablltPorts 307.
_Ioh 2.8 47.00 0.00 0.00 '31.10 T _T_ et 7.l1OO% 21.54
7_LlIbar 201.10 T..... Re........nt...... AmoURI nt.1.
..-r_ II 7.000 'lIo 14.41
~-" 4.4 221..
IL ad ~ll 'All C08II - IV. A4-A.....* _unt
Non-T_eoe.. 47J11l n&lnlllCe o.dI...... 0.00
7_-__1~ 47.10 -ReIponaIbllllr 0.00
.-n; RIIQIU...
_OtolIV_:
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_11~10:1T:01 81M
U............ T......... oIl111tche11.6.4~.....-.' D ...
OCT_otI-" CoprrIgM ICl 1184._ _ __....
11.0.212 AlI~_
Page 1 of 2
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