Claim Caley, Juanita KayCLAIM 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: Juanita Kay Caley
2. Address: 656 North Adams, Lancaster, WI 53813
`
3. Telephone Number: 608 723 7345
4. Date of Incident: December 13, 2005
5. Time of Incident: 7:45 A.M. - 8:10 A.M.
6. Location of Incident (Be specific): Driveway of 2429 Hacienda (ARC Home)
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.)
RTA bus came to home to pick up individuals. When I went out to my car I noticed it had been hit.
(RTA was only vehicle to come into driveway after me).
8. What were weather conditions like? A bit snowy (flurries)
9. Give name and address of any witnesses:
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.)
Mirror on car was broken off - see enclosed estimates $457.14.
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.)
15. What amount do you claim from the City of Dubuque? $457.14
16. Why do you claim the City of Dubuque is responsible? RTA only vehicle to enter driveway.
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 22nd day of December, 2005. , 20 .
/s/ Juanita Kay Caley
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
17/Y, fl1 //;:11
lA, &
CLAIM AGAINST THE CITY OF DUBUQUEj'IOWA ;4~
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.
.K~,
1. Name of Claimant: -::r IAG.!\ 11 Q,
2. Address: ~51.o ;UoY"1'h
3. Telephone Number: ( (" () i:, ')
4. Date of Incident:_n-e(1((Y\ bw
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5. Time of Incident: (r '-i5A - ~ 10 A
6. Location of Incident (Be specific): Or;u{'w~ o\- 'J'1~ era H O\,~; ~d f'.
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(' Ar<- c- ~O(he)
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
m I yee's name.)
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8. What were weather conditions like? 0- b:t jY\Ol,Jc1 (~k"J"-f/)
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9. Give name and address of any witnesses:
1 O. Did police investigate? <If so, give names of officers.)
1'\0
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
1'\..0
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? Y\ 0 1\€-
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.)
Y\D
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15. What amount do you claim from the City of Dubuque? -i)
16. Why do you claim the City of Dubuque is responsible? Rift 0(\'1 {)-f~.d~ Co
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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.) 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 dJ,,,J day of 0""-%\:'-1/
, 20....Q1..
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(Signature)
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(Print Na e)
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(Rev. 1/00 & 7/01)
BRYHAN'S BODY & PAINT SPECIALISTS INC.
1175 US HWY 61 NORTH, PO BOX 86
LANCASTER, WI. 53813
608-723-6800 FAX: 608-723-7392
"YOU'LL LIKE OUR GUARANTEE"
CD LOG NO 6019-1
DATE 12/13/05
SHOP: BRYHAN'S BODY & PAINT SPECIA
ADDRESS: 1175 HWY 61 N
P.O. BOX 86
CITY STATE: LANCASTER, WI
ZIP: 53813-
INSP DATE:
CONTACT:
PHONE 1:
FAX:
OWNER:
CITY STATE:
ZIP:
CALEY, BOB & JUANITA
LANCASTER, WI
53813
POINT OF IMPACT: 5
LIC#:
BODY COLOR:
CONDITION:
366-EZM
BLACK
GOOD
*=USER-ENTERED VALUE
EC=REPLACE ECONOMY
UM=REMAN/REBUILT PRT
OE=REPLACE PXN OE SRPLS
TE=PARTL REPL PRICE
I=REPAIR
TT=TWO-TONE
N=ADDITIONAL LABOR
AA=APPEAR ALLOWANCE
STATE: WI
12/13/05
JIM BRYHAN
(608) 723-6800
(608) 723-7392
2C3AC56G71H521828
VIN:
MILEAGE:
ACCTNG CTL#:
E=REPLACE OEM
UE=REPLACE OE SURPLUS
EU=REPLACE SALVAGE
PC=PXN RECONDITIONED
ET=PARTL REPL LABOR
L=REFINISH
CG=CHIPGUARD
RI=R&I ASSEMBLY
RP=RELATED PRIOR
2001 CHRYSLER LHS STD 4DOOR SEDAN
CODE: M4283A/C OPTNS A/24
NG=REPLACE NAGS
UC=RECONDITIONED PRT
EP=REPLACE PXN
PM=PXN REMAN/REBUILT
IT=PARTIAL REPAIR
BR=BLEND REFINISH
SB=SUBLET
P=CHECK
UP=UNRELATED PRIOR
6CYL GASOLINE 3.5
OPTIONS:
TWO-STAGE - EXTERIOR SURFACES
OP GDE MC DESCRIPTION
E 0283 01 MIRROR,OUTER R/C
1 ITEMS
TWO-STAGE - INTERIOR SURFACES
MFG. PART NO.
LT 4805647AB
PRICE AJ% B% HOURS R
399.00*
0.7 1
MC MESSAGE(S)
01 CALL DEALER FOR EXACT PART NUMBER / PRICE
FINAL CALCULATIONS & ENTRIES
GROSS PARTS
PARTS & MATERIAL TOTAL
TAX ON PARTS & MATERIAL @
5.500%
399.00
399.00
21.95
PAGE 1
12/13/05
2,001 I;:IjRYSLER LHS
CJ;) LOG'NO 6019-1
STD 4DOOR SEDAN
LABOR
I-SHEET METAL
2-MECH/ELEC
3-FRAME
4-REFINISH
5-PAINT MATERIAL
LABOR TOTAL
TAX ON LABOR
SUBLET REPAIRS
TOWING
STORAGE
RATE REPLACE HRS
49.00 0.7
65.00
55.00
49.00
28.50
@
REPAIR HRS
34.30
5.500%
34.30
1. 89
GROSS TOTAL 457.14
NET TOTAL 457.14
ADP SHOPLINK U8349 ES CD LOG 6019-1 DATE 12/13/05 10:03:38AM R6.37 CD 11/05
PXN: Y/OO/OO/OO/OO/OO CUM 00/00/00/00/00 GEOCODE 53813
HOST LOG
(C) 1998 - 2005 ADP CLAIMS SOLUTIONS GROUP, INC.
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE REPLACEMENT
PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE
MANUFACTURER OR DISTRIBUTOR OF THE REPLACEMENT PARTS RATHER THAN BY THE
MANUFACTURER OF YOUR MOTOR VEHICLE.
"MOTOR VEHICLE REPAIR PRACTICES ARE REGULATED BY CHAPTER ATCP 132, WIS. ADM
O. CODE, ADMINISTERED BY THE BUREAU OF CONSUMER PROTECTION, WISCONSIN DEPT. OF
AGRICULTURE, TRADE AND CONSUMER PROTECTION, P.O. BOX 8911, MADISON, WISCONSIN
53708-8911. "
PAINT & WORKMANSHIP GUARANTEED AS LONG AS YOU OWN VECHICLE
(RUST IS NOT INCLUDED)
YOU'LL LIKE ARE GUARANTEE
WHERE EXCELLENT COLLISION REPAIR IS NO ACCIDENT.
PERMISSION TO START REPAIRS: DATE:
PAGE 2
12/13/05
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CITY ;3':'F..TE:
ZIP:
L.?~\rCAS':'E;:<. AUT=: 3CC-:{ LLC
:22>r SOUTH ~.1.'WISON ST.
LA.'-lCASTER, WI
53813-
INSP DATE:
:::::::NT.I\.CT:
?iiONE 1:
FAX:
OWNER:
ADDRESS:
':1TY S':'F.TE:
2I?:
CALEY, JUANITA
656 N. ADAMS STREET
LAi'KASTER, WI
538:1..3
HOME PHONE:
?OI~T OF IM?ACT: 6
LIC#: 366-EZM
3CLY r:JLCR: B~4~'c.:=<
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S~..n..TS: WI
VIN:
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P.Il.IN~ CODE:
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~C=REPLACE ECONOMY
L~=REMAi~/REB~ILT ?RT
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~E=PAP.TL R~?~ ?R=C~
E=REPLACE OEM
UE=REPLACE OE SURPLUS
EU=REPLACE SALVAGE
PC=PXN RECONDITIONED
ET=PARTL RERL Lp~OR
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12/13/05
DAVID THOLE
(608) 723-H32
(608) 723-H33
(608)723-7345
2C3AC56G-:H52:,~:3
52,836
NG=REPLACE ::."'.G3
UC=RECONDITIONED ~~.
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PN=PXN REMlL\i/?:::3C-IIT
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69.00
59.01:'
49.00
29.00
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