Claim, Klauer, Jody
. ~/q
CLAIM AGAINST THE CITY OF DUBUaUE;'loWA:.;if.~ )
~j/~lj
This written report constitutes your claim against the City of Dubuque, Iowa. -Yo.1should
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 Halt, 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: .::lOPY' ;:::LAU~R...
2. Address: 24/0 Asa.Uf2.Y;+rs
3. Telephone Number: 6"3- ogO - 7-Co 4 q
PBGL :I::;4 52002.
4. Date of Incident: 2-2B-0(,.
5. Time of Incident: ~ 2: 40 pm. - {s A-
6. Location of Incident (Be specific): in FilOIVT of 2AAavQ()E Infc.encd.
M(dICl;'~. 1515 De/hi. C.uIlBS/De
.. r
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.) . MINI ~;?5l1>'f
e. b c 0 ~ e BvoS#- 9~l./6(j +-;,~
IVAS A-ik",p-hh, fr>. ~ 11',/71 De/hI meal t:Z C7le. "'move pn:r- r-.
(7""iIJ.fAU....('J7'1Ctn?1N1p /l'e{rlc/t!_p14J/t'd pn"r77n. 'fi:o'I fldnn'l +~n"<<:"""'1
f)'::':: 1'1'111 cltf!.tv~ ,slOt!: nt,rr?:r,. /?1y V't' h,c/t: yVI(.f ~e.,ud hi
1H.Ik!i r~d- ~t1 I7njr" M.r,;rat
r r u--.
8. What were weather conditions like? t1/{)j(,.I?/A l- (" tf)Y("rcCl>~)
9. Give name and address of any witnesses:..1/m /I1r '-UJ Y tfi'"1'-5 v.4./k,., hr'l< J2r/
'D(J(;;.:L4 ~ VI tJ Z- Cd,.., ~ r-,.f' I'H '" , . h CJ S )
10. Did police investigate? (If so, give names of officers.)
. ~D
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
11/0
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.)
tksr clR.{V~r"f S ;tI~ ""Irro'- ICI1t1c ttt'cI u r~ (1J,M,/~Ir/v J rck~ 4
I ,
.$ce A-lhU/'t:d ~J~"..k..s
13. What other damages do you claim, if any? /VtJjVt:..
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? FULL AAtfnlN"T "RJ.e
port)".,.
1?1J1c{c~nt('"f- -- ,.n.r-AI(,.~n-, of- (.;601"" n/( W/lrrcN2.
,
16. Why do you claim the City of Dubuque is responsible? t::Ry/'~ "",./Vi ,av~.1
C( Iv 0 r:: DB tR / ;? In ~ cI,,:-t11.. t- n~ VV4J" I"'~ >7H}t},~1c-- ~ ~e
;'Q""fA'~ -h J'J'tj vo(~,e/e
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name an~ address.)
/I/O
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
i3
day of
AlA reh
, 20.Jlk..
I
~~/~
(Signature)
$py L, ~~~r-
(Print Name)
-;f11 C!'
'! -
(Rev. 1/00 & 7/01)
"
Date:
EstimatelD:
Estinate Version:
Preliminary
ProfilelD:
3/1112006 09: 11 AM
2140
o
Mitchell
,
BIRD CHEVROLET
3255 UNIVERSITY AVE DUBUQUE, IA 52001
(563) 583-8121
Fax: (563) 556-4482
Damage Assessed 8y: john klotz
Deductible: UNKNOWN
Insured: JODY KLAUER
Address: 2410 ASBURY HEIGHTS DUBQUE, IA 52002
Telephone: Home Phone: (563) 580-7649
Mitchell Service: 910500
Description: 2002 Pontiac Aztek
Body Style: 4D Ut Drive Train: 3AL Inj 6 Cyl AWD
VIN: 3G7DB03E725688685
Options: ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER WINDOWS, POWER DOOR LOCKS
CRUISE CONTROL, AUTOMATIC TRANSMISSION, AM~M STEREOICDPLAYER(SINGLE)
Line Entry Labor
Item Number Type
1 001490 BDY
2 000826 BOY
3 900600 BDY .
4 935007
Operation
REMOVEJREPLACE
REMOVE/lNST ALL
REPAIR
ADD'L COST
Une lIern
Description
L FRT DOOR REAR VIEW MIRROR
L FRT DOOR TRIM PANEL
POLISH DOOR
SHOP MATERIALS
Part Type!
PartN_r
10322468 GM PART
Dollar
Amount
123.14
Labor
Units
0.3 #
0.4
0.6*
Existing
6.00 *
. . Judgement Item
# . Labor Note Applies
Add'l
labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
- -
Body 1.2 52.00 0.00 0.00 62.40 T Taxable Parts 123.14
Sales Tax @ 7.001I% 8.62
Taxable Labor 62.40
Labor Tax @ 7.000 % 4.37 Total Replacement Parts Amount 131.76
Labor Sunvnary 1.2 66.77
III. Addllional Costs Amount IV. Adjustments Amount
Taxable Costs 6.00 Customer Responsibillly 0.00
Sales Tax @ 7.000% 0.42
Total Additional Costs 6.42
ESTIMATE RECALL NUMBER: 3/1112006 09:11:30 2140
Ultra Mate is a Trademark of Mitchell International
Mitchell Data Version: FEB_06_A Copyright (CI1994, 2003 Mllchelllntemational
Ultra Mate Version: 5.0.214 All Rights Reserved
Page 1 of 2
Date:
Eslimale 10:
Estimate Version:
Preliminary
Profile 10:
.
3/1112006 09: 11 AM
2140
o
Mitchell
I.
II.
111.
Total Labor:
Total Replacement Parts:
Total Additional Costs:
Gross Total:
IV.
Total Adjustments:
Net Total:
This is a preliminarv estimate.
Additional chanaes to the estimate mav be reauired for the actual repair.
ESTIMATE RECALL NUMBER: 3/1112006 09:11:30 2140
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: FEB 06 A Copyright (C) 1994.2003 Milchelllntemational
UltraMate Version: 5.o.f14 - All Rights Reserved
Page 2 of 2
66.77
131.76
6.42
204.95
0.00
204.95
MAKE=P
YEAR=02
MODEL=B;2BT46
3G7DB03E72S588685
LIST PRICE
SELECTED PARTS LIST
PRICES EFFECTIVE FEB 01, 2006
PART #
USAGE
GROUP DESCRIPTION
YEAR QTY H
LIST
10322468 10.185 Bois ELEC RlcON PAINTED MIR(DG7)
MIRROR,ols RR VIEW - LH
02-05 01 L
123.14
Totals for Displayed Quantities:
123.14
!-<-zbor
;;;~oo
~:~~~~~e,DU9~o~
1\.61025 I~
Chevrolet
Cars&TI'UCkI
U.od
CIlI'5&TI'l,JC\(S
JASON MOOTZ
Parts Manager
\
1_600-947-6633
L' . (615) 747-3346
Parts Ine. www.rundechevrolel.com