Claim Duster, StacyCLAIM 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: Stacey Duster
2. Address: 938 Arrowhead Drive, E. Dub. IL 61025
`
3. Telephone Number: 815 747 2376
4. Date of Incident: 11/25/2005
5. Time of Incident: 12:14
6. Location of Incident (Be specific): Stop Light by DDG gas heading out onto Hwy 20
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.)
City employee Larry Maule was driving the City bus and rear-ended
me while I was stopped at the red light. Enclosed are 2 estimates.
8. What were weather conditions like? Light snow
9. Give name and address of any witnesses: people on the bus
10. Did police investigate? (If so, give names of officers.)
Yes, Thomas Schmeichel, Badge #37
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, damage to bumper on van. Estimate attached.
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?
Amount needed to repair damages so I can sell my van.
16. Why do you claim the City of Dubuque is responsible?
The bus rear ended me while stopped at a red light.
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?
N/A
Dated at Dubuque, Iowa this 27th day of January, 2006.
/s/ Stacey Duster
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
I
I /),~ljc) 6 ~t:~? (! 1M
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA gaJt/V--!
This written report constitutes your claim against the City of Dubuque, Iowa. ~~~~
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: .:3st.r~
2. Add",,,, Q3Z ~ .tJ-v; v<:
c. f;fivb.
/L G/OdS
3. Telephone Number: 'is! S - / Lf / - d,) -; /,::;
4. Date of Incident: / / / d- ~ /d DOS
,
5. Time of Incident: /,;): /'-/
6. Location of Incident (Be specific):
s-Is-r (/r b;;
15])6 6aJ
kM7
~/'f.
Ok + i7Y'--h HW"J- S!O
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.) , '
CI1>;) a--1'Vlf{~ Larr(j ffl?lu/e vtt5 d.nv,^} --fL,
a'a r - ~,t:bd (h.f- IAJ 1--./ (( T woJ siP f~c:I t?l.f
E/lC /vyp/ c:Ave. c2 rZ :;A>v.. /{-f 5
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I,., V_ bu (
9. Give name and address of any witnesses: ~,NlI( ~ / l^.t! ~
I "-+
c-f>;;
-fl.-e
bv5 d-
,.,A
8. What were weather conditions like?
10. Did police investigate? (If sp, give names of officers.)
'-21" -- 00""" A 5 t;;?h l'Y'Ie j ci-.. -e / 0,0d tY' # "37
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
/70
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.)
~ -- j~Ar -f-o b v' Nt ~ (}Y-.. va vi - -e s-h/0 C? Ie)
a~ ~/I
13. What other damages do you claim, if any? /I rTY-\ -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.)
/10
a rn 0 U Y" -j- r-.tZR ~ cf
sel! ;r, y (/?i ^
-IN tVj rear
/'I. n>d /JgA-t
15. What amount do you claim from the City of Dubuque?
--I-n (a-r; r ~ fV\(ljf.) yv ~. c:.~
16. Why do you claim the City of Dubuque is responsible?
0yJ.RJ /h ~ hi {.... f !J. ,5 fo P pt' jl t?'t f
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
ht)
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount? N J fr
I
Dated at Dubuque, Iowa this d 7 day of
\
Ja"v~. , 20 61:
~~VS~
<Stac~ QVS+S-
(Print ame)
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(Rev. 1/00 & 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 ] I Private
I '._ ~ Ti~e ~f A~.~id~~~_ I co~nt: Intervention? D Property? 0
Dale of Accidenl I Accident occurred within
1<'1 , " c' '< corporate limits of (city) ,
1:1-:: If accident occurred oulside of N NE E 3E 3 3W W NW County:_Roule:_
:1:1: cily limils show general vicinity miles 00000 0 0 0 of neareslcily X-Coordinate
~l On Road, Street, I Al Intersection
, ,
. , or Highway With: V-Coordinate
.t' Note: Unless accident occurred at an intersection which is completely described above, use the space below to give the exact localion from a milepost
:1: or definable intersection, bridge, or railroad crossing, using two distances and directions if necessary
:11, Feet Miles N NE E 3E 3 3W W NW Feet Miles N NE E 3E 3 3W W NW If Divided Highway, Provide Route
'1'1' 0; 0 0 0 0 0 0 0 0 'cd 0; 0 0 0 0 0 0 0 0 of (Cardinal) Travel Direction
: f;; NB 3B EB WB
Milepost Or Definable intersection, 0 0 0 0
Number bridge, or railroad crossing
Wi Driver's Name (Last, First, Middle) I Addre.ss City State Zip
.. , " ,
Date of Birth Driver's License Number
:ig' Citation 1 3
.::: . , . , Charge ,
, , ,
:;; State ,I CI~~S I Endors:mentsl Restriction 2, 4,
Male Female I ?rug
0 0 Alcohol 1 None 3. Urine 5. Vitreous Test Results' 1 None 3. Urine Pos, Neg.
il: " " TestGiven?U 2 Blood 4, Breath 9 Refused TestGiven?U 2, Blood g. Refused 0 0
Owner's Name (Last, First, Middle) I Address City State Zip
.- , ' ,
, ,
Insurance Co Insurance IILicense I State I Year
Name " .- Policy # Plate #
;;;,<, VIN# ,I Year Make I Model I Style Tow # Approximate Cast to
;~.- , .., " ' " ", Repair or Replace
Initial Travel Vehicle II Speed j I Paint of LUI Most Damaged UJ I ~xtent of Jllunderridel Private?
Direction U Action UJ Limit UJ Initial Impact Area Damage UOverrideU 0 $
Total Traffic II ~ehicle UJI~argoBodYUJ Vehicle II Driver II Vision Contributing Circumslances,UJ UJ
occupantsUJ Controls UJ Config Type Defect UJ Condition U O.;scuredUJ Driver (up to two)
Commercial Trailer Attached to Stale Year Attached to State Year Emergency II Emergency
License Plate # Power Unit TrailerUnil: Vehicle TypeU Status U
Carrier I Address City State Zip
Name
US DOT# or MC# I I I I I I I II ~umber 1 ~rossVehiCle I Placard # I I I I I U l~azardoUsMatenalsU
0 0 I of Axles WeighlRatmg - Released?
Driver's Name (Last. First,Middle) I Addr~ss City State Zip
, " '. , ,
Date of Birth Driver's license Number Citation
Charge 1 3
'o' " ' ' 2
Sla.l:. I Class 1 Endorsementsl Restrictions 4
Male Female
0 0 Alcohol 1 None 3. Urine 5. Vitreous Test Results _I ~rug 1 None 3. Urine Pos, Neg
TestGiven?U 2 Blood 4. Breath g. Refused TestGiven?U 2 Blood 9. Refused o 0
Owner's Name (Last, First, Middle) I Address City State Zip
U
N I State I Ye~r
I Insurance Co. Insurance , ' I ~icense
Name " , , Policy # ' , Plate # ' ,
T ,
VIN# , I Ye~r Make I Model I Styie Tow # Approximate Cost to
Repair or Replace
2 LUI Private?
Initial Travel Vehicle 'I Speed II Point of Most Damaged UJ I ~xtent of II ~nderridel
Direction U Action UJ Limit UJ Initial Impact Area Damage UOverrideU 0 $
Total Traffic II iehicle UJ l;argOBOdYUJ Vehicle II ~river II :ision Contributing Circumstances, UJ
occupantsUJ ControlsUj Config Type Defect UJ Condition U ObscuredUJ Dnver lup to two) LU
Commercial Trailer Attached to State Year Altachedto State Year Emergency I Emergency
License Plate # Power Unit TrailerUnil: Vehicle TypeU Slatus U
Carrier I Address City State Zip
Name
US DOT# or Me# I I I 1 I I I II ~umber I ~rossvehicle I Placard # I I I I I U l~aZardOUsMaterialsU
0 0 I of Axles Weight Rating Released?
liP roperty olher than Object I ~stimateof Unit 1 Unit 2 SEQUENCE OFEVENT
"h iclesdamaged explain Damaged Damage $
Owner's Full Name I :as owner or 1- Yes 9- Unknown LULU
(Last, First, Middle) tenant notified? U 2 -No First Event
Street or I (ity, State, LULU Second Event
RFD &ZipCode
ACCIDENT ENVIRONMENT ROADWAY CHARACTERISTiCS WORK ZONE RELATED? LU LU Third Event
Location of First Harmful Event U Major Contributing Circumstances o Yes o No LU LU Fourth Evenl
Weather Conditions LU U
(up to two) Environment U Location ------------------------
Manner of Crash/Collision U LU LU LU Most Harmful Event
Roadway LU U Type (by vehicle)
Light Conditions U Surface Conditions U Type of Roadway Junction/Feature UJ U Workers Present? LU First Harmful Event of Crash
(use codes 11-420niy)
Officer's Name
Badge No.
'- ,-
.
Dale: 12/23/200510:14 AM
Estimate 10: 5751
Estimate Ve...ion: 0
Preliminary
Profile 10: CUSTOMIZED
MIKE FINNIN FORD
Damage Asoessed By: RICK STUMPF
Deducllble: 0.00
3600 DODGE STREET DUBUQUE, IA 52001
(563) 556-1010
Fax: (563) 690-1086
Tax 10: 14-1862673
Insured: STACY DUSTER
Address: 938 ARROWHEAD DR. EAST DUBUQUE,IL 61025
Telephone: Home Phone: (615) 747-2376
Mitchell Service: 913528
Description: 2000 Dodge GrandCaravan SE
Body Slyle: Van 119" WB Drive Train: 3.3L Inj 6 Cyl 2WD
VIN: 2B4GP44G2YR816496
Color: SILVER
Options: ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER WINDOWS, POWER DOOR LOCKS
CRUISE CONTROL, AUTOMATIC TRANSMISSION, AM-FM STEREO/CDPLAYER(SINGLE)
Line Ently Lebor
118m Number Type
1 301804 BOY
2 AUTO REF
3 304041 BOY
4 320217 BOY
5 302068 REF
6 302069 BOY
7 320237 BOY
8 AUTO REF
9 933005 BOY
10 933018 REF
11 AUTO
12 AUTO
Operation
REPAIR
REFINISH
REMOVElREPLACE
REMOVElREPLACE
REFINISH
REMOVE/INSTALL
REPAIR
ADD'L OPR
ADD'L OPR
ADD'L OPR
ADD'L COST
ADO'L COST
Line 118m
Description
LIFTGATE SHELL
LIFTGA TE OUTSIDE
R L1FTGATE ADHESIVE NAMEPLATE
L L1FTGA TE ADHESIVE NAMEPLATE
REAR BUMPER COVER
REAR BUMPER ASSY
REAR BUMPER COVER
CLEAR COAT
RESTORE CORROSION PROTECTION
MASK FOR OVERSPRAY
PAINTIMATERlALS
HAZARDOUS WASTE DISPOSAL
Part Type!
Part Number
Existing
Dollar Labor
Amount Units
2.0*
C 2.5
26.00 0.2
48.50 0.2
C 2.5
0.9
1.5*
1.5
2.00' 0.1'
12.00 <I 0.2*
182.00 '
3.25*
4857312AA
5303837 AA
Existing
. - Judgement Item
C - Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 12/23/200510:14:36 5757
UltraMate Is a Trademark 01 Mltchelllntemallonal
Mitchell Dale Version: DEC_05_A Copyright (C) 1994 - 2003 Mitchell International
11.......U....t...\I.......lftn. c n .,,,., .&11 Di...h+o Dowo............
Page 1 01 2
.
. .
.
I. Labor Su_1s
Body
Refinish
Add'l
Labor Sublet
Units Rate Amount Amount
~ ---
4.9 50.00 2.00 0.00
6.7 50.00 12.00 0.00
Taxable Labor
Labor Tax
@ 7.000%
Labor Summary 11.6
Totals
247.00 T
347.00 T
594.00
41.58
635.58
Date: 12/231200510:14 AM
Estimate 10: 5757
Estimate Version: 0
Preliminary
Profile 10: CUSTOMIZED
II. Part Raplacament Summary
Taxable Parts
Sales Tax @
7.000%
Amount
74.50
5.22
Total Replacement Parts Amount
79.72
III. Additional Costs Amount IV. Adjustments Amount
Non-Taxable Costs 185.25 Insurance Deductible 0.00
Total Additional Costs 185.25 Customer Responsibility 0.00
I. Total Labor: 635.58
II. Total Replacament Parts: 79.72
III. Total Additional Costs: 185.25
Gross Total: 900.55
IV. Total Adjustments: 0.00
Net Total: 900.55
This is a preliminarv estimate.
Additional chanaes to the estimate mav be reauired for the actual repair.
ESTIMATE RECALL NUMBER: 12/23/200510:14:36 5757
UltraMate is a Trademark of Milchelllntamationa'
Mitchell Date Version: DEC_05_A Copyright (C) 1994 - 2003 Milchalllnternstional
111.........__ \I..._i...... 1:" "14" All DI_~"" 10.._............
Page 2 of 2
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OLD PARTS WILL BE DISOARD~D UNLESS OTHERWISE INSTRUOTED
TOTALS .. (..~ $,0 I,~ 9715'0
TQ INVOt~ BODY (,.,~ h".., 4LJ~ ,J"J-. ll't::J
'BPAlNTS,Ohrs.OW- ;:;Z~olo:::
~ FRAME ~hr..., $'0 ~ '7 S 00
I hereby aUlhorlzelheabcVll work and IlCknowledge reaelpt of copy.
Signed X
Date
ME;CH _ nrs. 0
FtAFrTS Priess subj~t to ;llvtlk:8
SUBLET I MISO~LLANEOU5
~aln1 Suppllelil~hf'8..:J ,fJ!I
Body Bu~llaB_hl'&. 0
Towing I storag.
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DUEHR AUTO BODY REPAIR
You Bend 'em, We'll Mend 'em
19051 Balltown Road
Balltown, IA 52073
Phone (563) 552-2019
FAX # (563)552-223~7
Fed. ID /I 03-0495385 .,^ t\.. 0
WRITTEN BY
J",,, I DC
SUBTOTAL
TOTAL
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TAX ...L % on $ -"~),1!:l
EPA I Wall. OI8polal Charge
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IIOIeJA Inc" 1 Idea Way, Caldwell, 10 83&0!1 . CALL TOLL FR!!:! '.800-835-9281 . Ilsm No, FFl1 023