Claim Hume, SarahCLAIM 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: Sarah Hume
2. Address: 2811 JFK Apt 1 Dubuque, IA 52002
`
3. Telephone Number: 563 481 8700
4. Date of Incident: 4/26/06
5. Time of Incident: about 12:30 P.M. Police filed 12:42 P.M.
6. Location of Incident (Be specific): Outside my house right by the bus stop
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.)
Adam the bus driver try to fit between my car and another and hit the left mirror
and scratches on my car.
8. What were weather conditions like? Sunny
9. Give name and address of any witnesses: The other bus driver and people on the bus.
10. Did police investigate? (If so, give names of officers.) Yes
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No, John Hefel
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, I need a new left mirror and scratches buffed out.
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?
All of the damages
16. Why do you claim the City of Dubuque is responsible?
Because my car was parked outside myhouse and the bus thought he could make it and didn't
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 8th day of May, 2006.
/s/ Sara Hume
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
a; MV/.,1
CLAIM AGAINST THE CITY OF DUBUQUE;'IOWA 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: SO:. r '! h it ltyyr('
4101..2
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fDl'" '/-T'
2. Address: :?ftll (y-r h
3. Telephone Number{S'(>3/ l{S'J- g)o G
4. Date of Incident:Jd -;;c, 10 C
5. Time of Incident: Q b 0 u.}- I d: SO ()~.fd/t'e-({i l-eJ I,) '-/.71'/>)
6. Location of Incident (Be speCifiC):~ cx4-~ e. mt fuJ~R e
b1 fk bC1 5' SloP
1'/9 J I-
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
WJ?loy"~s n~me.) L <N1 j
~ A.~Qf"lfnC' bLtS d~;V<< 1(1 16 J',-J w#3I<)'1'<1l "11
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8. What were weather conditions like? SJ(A/11 11..1f-
9. Give name and address of any witnesses: 1Jv:> ~.. Gr h 4\S'
II) I'h -r' bys
6tf;-uu- ifll:s, Pe9pk
.
10.
(If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
~n6
(JOhn '~ e~f I
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.)
'f.eS 'E nf? t" J. q he w le f2rf rVJi I 101'
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&trY ~ .",. Rc,~ ~J (Yea/--
13. What other damages do you claim, if anY?I1~
,
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? --Jd [
ckm CY-{{' S'
dPrYfvc
16. Why do you claim the City of Dubuque is responsible?
COt q Vcrs ~ q rk t 1 cnJ:$:/d ,i.- ]/Y) I
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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.)
/12&
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
n-,
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day of m q f , 200 G.
,~~ ~C
(Signatu~~
3 Q('ceA !Lu,!Y2 C
(Print Name)
Dated~at Du'~uque; rowa this
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(Rev. 1/00 & 7/01)
.
Date: 4127/2006 11 :52 AM
Estimate 10: 5991
Estimate Version: 0
Preliminary
Profile 10: CUSTOMIZED
MIKE FINNIN FORD
3600 DODGE STREET DUBUQUE, IA 52001
(563) 556-1010
Fax: (563)690-1086
Tax 10: 14-1882873
Damage Assessed By: RICK STUMPF
Deductible: 0.00
Insured: SARAH HUME
Address: 2811 JFK RD APT#l DUBUQUE, IA 52002
Telephone: Home Phone: (563) 451-8700
Mitchell Service: 911623
Description: 1997 Ford Taurus GL
Body Style: 40 Sed
VIN: lFALP52U2VG161511
Drive Train: 3.0L Inj 6 Cyl AD
Line Entry Labor
Item Number Type
1 101527 BOY
2 AUTO REF
3 100877 BOY
4 AUTO REF
5 AUTO
6 AUTO
Operation
REMOVElREPLACE
REFINISH
REMOVE/INSTALL
ADD'L OPR
ADD'L COST
ADD'L COST
Line Item
Description
L FRT DOOR REAR VIEW MIRROR
L FRT DOOR MIRROR
L FRT DOOR TRIM PANEL
CLEAR COAT
PAINTIMATERIALS
HAZARDOUS WASTE DISPOSAL
Part Type/
Part Number
XF1Z 17682 EAA
Dollar Labor
Amount Units
139.56 0.3 #I
C 0.8
0.5
0.2
28.00*
0.50*
. - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
Add'l
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount
~ -~
Body 0.8 50.00 0.00 0.00
Refinish 1.0 50.00 0.00 0.00
Taxable labor
Labor Tax @ 7.000 %
Labor Summary 1.8
Totals
40.00 T
50.00 T
90.00
6.30
96.30
II. Part Replacement Summary
Taxable Parts
Sales Tax @
7.000%
Amount
139.56
9.77
Total Replacement Parts Amount
149.35
ESTIMATE RECALL NUMBER: 4/27/200611:52:51 5991
Ultra Mate Is a Trademark of Mitchell International
Mnchell Data Version: APR_06_A Copyright (C) 1994 - 2003 Mllchelllnlematlonal
UItraMate Version: 5.0.214 All Rights Reserved
Page 1 of 2
.
Date: 4/27/2006 11 :52 AM
EstImate ID: 5991
Estimate Version: 0
Preliminary
Profile ID: CUSTOMIZED
Total Additional Costs
Amount IV. Adjustments Amount
28.50 Insurance Deductible 0.00
28.50 Customer Responsibility 0.00
I. Total Labor: 96.30
II. Total Replacement Parts: 149.35
III. Total Additional Costs: 28.50
Gross Total: 274.15
IV. Total Adjustments: 0.00
Net Total: 274.15
III. Additional Costs
Non-Taxable Costs
This is a DreliminalV estimate.
Additional chanaes to the estimate may be reauired for the actual reDair.
ESTIMATE RECALL NUMBER: 4/27/200611:52:51 5991
UltraMate is a Trademark of Mitchell International
Mitchell Data Veraion: APR_06_A Copyright (C) 1994 - 2003 Milchelllnternational
UltraMate Version: 5.0.214 All Rights Reserved
Page 2 of 2
..
Oate: 6/1012006 02:62 PM
Estimate 10: 11946
o
Preliminary
Profile 10: Mitchell
Hanley Auto Body Inc.
1030 Century Circle Dubuque, IA 62002
(683) 883-7220
Fax: (683) 683-41366
Damage Assessed By: Robert Hanley
Deductible: 0.00
Claim Number: 0
OWner Jean Hume
Address: 2833 Van Buren Dubuque, IA 62001
Telephone: Horne Phone: (683) 461-41700
Mitchell Service: 811823
Description: 1887 Ford Taurus GL
Body Style: 40 Sed
VIN: lFIULP62lr.rVG181611
Color: Blue
Drive Train: 3.0L Inj 6 Cyl AO
License: 448 ROK IA
Line Entry Labor
Item Number Type
1 101827 BIlY
2 AUTO REF
3 AUTO REF
4 AUTO
6 AUTO
OperaUOn
REMOVEIREPlACE
REFINISH
ADD'L OPR
ADD'L COST
ADD'L COST
Line Item
Description
L FRT DOOR REAR VIEW MIRROR
L FRT DOOR MIRROR
CLEAR COAT
PAINT/MATERIALS
HAZARDOUS WASTE DlSPOSIUL
Part Type!
Part Number
-Qual RepI Part
Dollar Labor
Amount Units
102.00 . 0.3 #
C 0.8
0.2
27.00 ...
6.00.
. - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
Add'1
Labor Sublet
I. Labor Sublolals Units Rate Amount Amount Totals II. Part Replacement Sunmary Amount
Body 0.3 46.00 0.00 0.00 13.60 T Ta..bIa Parts 102.00
Refinish 1.0 46.00 0.00 0.00 46.00 T Sales Tax @ 7.000% 7.14
Taxable Labor 68.60 Total Replacement Parts Amount 108.14
Labor Tax @ 7.000 % 4.10
Labor Summary 1.3 82.80
III. Additional Costs Amount IV. Adjustments Amount
Non-Taxable Costs 32.00 Insurance Deductible 0.00
TotalAdditionalCosls 32.00 Customer Responsibility 0.00
ESTIMATE RECALL NUMBER: 6/1012008 14:62:33 11946
UltraMaIe is a Trademark of Mitchell International
Mitchell Data Version: APR_08_A Copyright (C) 1884 - 2003 Mitchell International
6.0.214 All Rights Reserved
Page 1 of 2
..
Date: &/1012006 02:&2 PM
Estimate 10: 11946
o
Preliminary
Profile 10: Mitchell
I.
II.
III.
Total Labor:
Total Replacement Parts:
Total Add~ional Costs:
Gross Total:
IV.
Total Adjustments:
Net Total:
This is a preliminarv estimate.
Additional chanaes to the estimate mav be reauired for the actual reDair.
ESTIMATE RECALL NUMBER: &/10f2006 14:52:33 11946
UllraMate is a Trademark of Mitchell International
M~chell Data Version: APR 0& A Copyright (C) 1994 .2003 Mitchell International
5.D.214 - All Rights Reserved
Page 2 of 2
62.80
109.14
32.00
203.74
0.00
203.74