Claim Bird ChevroletCLAIM 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: Bird Chevrolet
2. Address: 3255 University Ave.
`
3. Telephone Number: 563 583 9121
4. Date of Incident: June 26, 2006
5. Time of Incident: 6:45 A.M.
6. Location of Incident (Be specific): Lincoln & Stanford
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.)
Driving down Lincoln Street and City Garbage Truck went through Stop-Sign and hit passenger rear
quarter - employee at Kennedy.
8. What were weather conditions like? Rainy
9. Give name and address of any witnesses: None
10. Did police investigate? (If so, give names of officers.)
Yes, Officer Hernandez #5
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.)
No
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?
$1413.42
16. Why do you claim the City of Dubuque is responsible?
Driver of City Truck ran Stop Sign.
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?
No
Dated at Dubuque, Iowa this 27th day of June, 2006.
/s/ T.J. Blocklinger
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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.-r-DUBUQUE,IOWA
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CUC}o;;FOR PRl;.lTl'R
Home _ : IleDartmenb : City Clerk: CI..ims _inst the City: Clai m Form
City Clerk
Rrst floor of City Hall, 50 W 13th Street
Phone: (563) 589-4120
Fax: (563) 58S-0890
Hours: 8 a.m. to 5 p.m. Monday through Friday
Email: ischneid&itvofdubuaue.ora
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,
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the City of Dubuque, Iowa, You should comple
full and attach any additional information that supports your claim.
The claim must be filed with the City Clerk at City Hall, 50 West 13'" St, Dubuque, IA 52001. It'
referred to the appropriate department for investigation and to the City Attorney's Office. Once I
is completed, a report and recommendation will be submitted to the City Council. You will be pre
copy of that report and recommendation.
The final decision on all clams is made by the CIty Council. No employee of the City of Dubuqu.
authority to make any representation to you as to whether your claim will or will not be paid.
1, Name of Claimant
(:,\(to tf\t"n.OLCT
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2, Address:
3, Telephone Number.
4, Date of Incident:
5, Time of Incident
6. Location of incident (Be specific):
LiNco\"'" a s.~.fu.u:>
7, Describe the accident or occurrence that caused injury or damage, (Give full details upon whi
your claim, If a City employee was involved, five the employee_s name,)
DLiiliN~ JA,dUJ /..1#~u/11J ~~ee/ /??Vt> C/7y ,b'~~
'1IiurcX tv~AI-r -r7/!:-~ ,57;P-5iv41 /'9-,el/? ff;7
P.4-Ss-e",-Ceft- tZt'~ J<1I~'" - 5.t/1.y7!'t! /1-;" K/!!MflE.Y,1
8, What were weather conditions like? r2A- r'~ f
9. Give name and address of any witnesses: AI Cl A/6-
10. Did police investigate? (If so, five names of olJicers,)
f-j-e;, (.J? ~h'ce.", Ite;t,(/tf~vez-
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http://www,cityofdubuque,orglindex.cfm?pageid=155
6/26/2006
Claim Form
Page 2 of 3
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
PO
12. Was any damage done to property? (If so, describe property and the extent of damages. All
damages or describe basis for ascertaining extent of damage.)
ttJo
13. What other damages do you claim, if any?
/lJ (u/ ~
14. Have you been compensated for any parlor all of your c1sim by any insurance company? (11
and address of insurance company and amount paid.)
#0
15. What amount do you claim from the City of DUbuque?;5 / Jf /3, 9'''<
16. Why do you claim the City of Dubuque is responsible? .a. /.; -e;t. P Jl
c./TI /Zt,.{,./C J2~.o %;7 .":J't'~d/
17. Have you made any claim against anyone else for damages as a result oflhis incident? (If y
and address.)
Co
18. If the answer to Question 17 is yes, have you received any payment from that source, and IT
amount?
tf"lo
Dated this cJ(;
day of
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(Signature)
7J ~/oJcj',vG6I/
(Print Name)
Home _: De....rt_: city Clerk: Claims _inst tl1,!.QJY: Claim Form
http://www.cityofdubuque.orglindex.cfm?pageid=155
6/26/2006
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Date: 612612006 03:07 PM
Estimate 10: 2555
Estimate Version: 0
Preliminary
Profile 10: Mitchell
BIRD CHEVROLET
3255 UNIVERSITY AVE DUBUQUE,IA 52001
(563) 583-8121
Fax: (563) 656-4482
Damage Assessed By: john klolz
Deductible: UNKNOWN
Insured: bird chevrolet co
Address: 3256 university ave dUbuque,1A 52001
Telephone: Horne Phone: (563) 583-8121
Mitchell Service: 910501
Description: 2006 Chevrolet TrailBlazer LS
Body Style: 40 Ut Drive Train: 4.2L Inj 6 Cyl4WD
VIN: lGNDT13S962145123
Options: ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER WINDOWS, POWER DOOR LOCKS
CRUISE CONTROL, AUTOMATIC TRANSMISSION, AM-FM STEREOICDPLAYER(SINGLE)
Line Entry Labor Linettem Part Type! Dollar Labor
lIem Number Type Operation Description PartN_r Amount Units
1 003845 BOY REMOVElREPLACE ALLOY WHEEL Remanufactured 192.00 . 0.3
2 003958 BOY REMOVEIREPLACE WHEEL VALVE STEM 274288 GM PART 2.00
3 006106 BOY REPAIR R REAR DOOR SHELL Existing 2.0*#
4 AUTO REF REFINISH R REAR DOOR OUTSIDE C 2.0
5 002790 BOY REMOVEIINST ALL R REAR OTR BELT MOULDING 0.3
6 001139 BOY REMOVEIREPLACE R REAR UPR DOOR AIltIESIVE MOULDING 15008701 GM PART 69.28 0.4
7 AUTO REF REFINISH R REAR DOOR MOULDING C 0.7
8 001241 BOY REMOVEIINSTALL R REAR DOOR HANDLE 0.6 #
9 005304 BOY REPAIR R QUARTER OUTER PANEL Existing 5.0*#
10 AUTO REF REFINISH R QUARTER PANEL OUTSIDE C 1.6
11 001547 MCH ALIGN REAR SUSPENSION -M 0.8
12 001549 MCH ALIGN ADD TO ADJUST FRONT SUSPENSION -M 1.1
13 001639 BOY REMOVEIINSTALL R REAR COMBINATION LAMP 0.3
14 001663 BOY REMOVEIINSTALL REAR BUMPER COVER 0.5*
15 loosen for painting
16 AUTO REF ADD'l. CPR CLEAR COAT 1.3
17 AUTO ADD'l. COST PAINT/MATERIALS 173.60 .
18 AUTO ADD'l. COST HAZARDOUS WASTE DISPOSAL 6.60 .
. - Judgement Item
# - Labor Note Applies
C -Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 6126J2006 16:07:07 2555
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: JUN 06 A Copyright (C) 1994 - 2003 Milchelllnlemational
UttraMate Version: 6.0.216 - All Rights Reserved
Page 1 of 2
Date:
Estimate 10:
Estimate Version:
Prelininary
Profile 10:
6/26/2006 03:07 PM
2555
o
Mitchell
Add1
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount
-
Body 9.4 52.00 0.00 0.00
Refinish 5.6 62.00 0.00 0.00
Mechanical 1.9 58.00 0.00 0.00
Taxable Labor
Labor Tax @ 7.000 %
Labor Sunmary 16.9
Totals
488.80 T
291.20 T
110.20 T
890.20
62.31
962.51
II. Part RepIacemenI Sunmary
Taxable Parts
Sales Tax @
7.000%
Amount
263.28
18.43
Total Replacement Parts Amount
281.71
III. Additional Costs
Non-Taxable Costs
Amount
179.20
IV. Adjusbnents
Customer Responsibility
Amount
0.00
Total Additional Costs
179.20
I.
II.
III.
Total Labor:
Total RepIacemenl Parts:
Total Additional Costs:
Gross Total:
952.51
281.71
179.20
1,413.42
IV.
Total Adjusbnents:
Net Total:
0.00
1,413.42
This is a oreliminarv estimate.
Additional chanaes to the estimate mav be reauired for the actual reoair.
ESTIMATE RECALL NUMBER: 6/26/2006 15:07:07 2555
UilraMale is a Tradernartc of MiIcheIllntemational
Mitchell Data Version: JUN 05 A Copyright IC) 1994 - 2003 Mitchelllntemalional
UltraMate Version: 5.o.i15 - All Rights Reserved
Page 2 of 2