Claim Shanahan, Jeremiah
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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
complete this form in full and attach any additional Information tPOlt supports your claim.
, '.
The Claim must be flied 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: J e.r (:lr\.\u...:VI S nQ V\ c~.\n Q "l
2. Address:J 7 5 Co L e0.., L'f\ < \~ l/'O'-flr~ )~ 5;< DO.;z
5Sd,-5873
(p/~d./O(P
/0: iq tAn-)
J-I-i//crcsf- Rei <4-JFk
,
3. Telephone Number:
4. Date of lricident:
5. Time of Incident:
6. Location of Incident (Be specific):
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.) J1 b
I
Jt=
8. What were weather conditions like? C \-Pfl. (' S() n Yl~
9. Give name and address of any witnesses;~ P\
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~
10. Did police investigate? (If so, give names of officers.)
C6.c:..,e ~ ()\ - 0(0- 0179)&
Yes )Johr'\ -\ \e~\
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
~o
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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.)
&Cl{Y'{JdV' .-tr; Du (Y,(x:'r Or) 6\CCf-/ TO';-jQK
C {A (Y\ I'J $ 7 L{ L{ ,,L-t 3
13. What other damages do you claim, if any?jJOn 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.)
No
15. What amount do you claim from the City of DUbUqUe?$ '1 L{ Lj .ll3
16. Why do you claim the City of Dubuque is responSible?]ne QCC \~('\\-
\ p()..S OUt- nS; ()\lj rOA-DoI CA~ --.:I G0~S sb~&-
aVl& \'fur enrQeLD p
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) N D
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 0 5
day of ;:ru L 'I
,20~.
8(p~ ~~
. (Signature)
;:(erem.-c,t.'t ~iAaj.1dir.a;f
(Print Name)
(Rev. 1/00 & 7/01)
. ~ Driver InfO~';2:~~~j~D~::~ange Report
563-589-4410
Driver's Name - Last I First I Middle I Sufftx I Date of Birth ~
U TULLY DEBY JEAN 11/2611963
N Address I City I Slate Zip I Phone
I 2188 ST JOHN DRIVE DUBUQUE IA 62002 (663) 667-8838 x
T Gender I Driver's License Number I Class I Slate I Endorsements I Restrictions Insurance Co, Name Insurance Co. Phone #
Female 787YY2808 B.M IA PS NONE IOWA COMMUNITIES INS (683) 6894196 x
001 Owner Company Name Insurance Policy #
CITY OF DUBUQUE KEYLINE TRANSIT
Ovmer's Name - Last I First I Middle --I Suffix
Address , City I State lip !
60 W 13TH ST DUBUQUE IA 62001. i
VINNo. I Year I Make I ~Od8) Style I Vehicle Configuration:
4RKJNTFA62R836662 2002 RTS 62VN BUS 18 :
License Plale # I State I Year I Most Damaged Area I Approximate Cost to Repair or Replace
86986 IA 2006 01 -Front
,
Driver's Name - Last I :irst I Middle I SuffIX I ~ate of Birth I
U SHANAHAN JEREMIAH WILLIAM 0410411939
Address I City I ~Iale Zip I Phone I
N i
I 1766 LEA LANE DUBUQUE IA 62002 (663) 682.6873 x I
T Gender i Driver's License Number I Class I Slate I Tndorsements I Restrictions Insurance Co, Name Insurance Co, Pl10ne # 1
Male 864ZZ6333 C IA NONE B ACUITY (608) 723-6441 x I
002 Owner Company Name Insurance Policy # I
N96298 i
ONner's Name. Last I First I ~iddle I Suffix
SHANAHAN JEREMIAH WILLIAM
Address I City [ State Zip
1758 LEA LANE DUBUQUE IA 62002.
VIN No. I ~ear I Make I Model Style I Vehicle Config uration
4T1BE32K14U334641 2004 TOYT CAM 40 I
License Plate # I State I Year I Most Damaged Area I Approximate Cost to Repair or Repiace I
097AWP IA 2007
,
County I tccident occurred within corporate limits of (city) I
Dubuque.31 Dubuque.2100
Literal Description
01 JOHN F KENNEDY RD and HILLCREST RO and NO NAME ST
X-Coordinate I tCoordinate
00667291 04708682
If accident occurred outside or city I ~irection I ~earest City . I.Route (Cardinal) I
limits show general vacinity: "NIA" "N/A" of "N/A" Travel Direction "NIA"
On Road, Street, or Highway: I At Intersection Vvith: I
HILLCREST RD "N/A" . --1
Distance JDirection I Distance I ~irection I Milepost Number
30 Fl 3.E aod "NIA" "N/A" of "N/A" 0, ,
Definable intersection, bridge, or railroad crossing
JFK RD.
Officer I ~adge No, I ~aw Enforcement Case Number I Date of Accident I Time of Accident I
HEFEL. JOHN 41A 01.08.27608 06/2212006 10:19 Hrs.
Printed At: Dubuque Police Department
Page 1
Form #: 01-06-27508
1982 ROCKDALE RD
DUBUQUE, IA 52003
PHONE: 563-583-9329
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CD LOG NO 700-1
DATE 06/22/06
SHOP:
ADDRESS:
CITY STATE:
ZIP:
WILLIS AUTO BODY
1982 ROCKDALE RD.
DUBUQUE, IA
52003-
INSP DATE:
CONTACT:
PHONE 1:
FAX:
OWNER:
ADDRESS:
CITY STATE:
ZIP:
SHANAHAN, JERRY
1756 LEA LANE
DBQ, IA
52002
POINT OF IMPACT: 8
LIC#:
BODY COLOR: MARRON
CONDITION: EXCELLENT
*=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
HOME PHONE:
06/22/06
MARK WILLIS
(563)583-9329
(563)583-9329
(563) 582-5873
DAYS TO REPAIR: 0
STATE: IA
VIN: 4TIBE32K14U334641
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
2004 TOYOTA CAMRY LE 4DOOR SEDAN
CODE: Y1743B/C OPTNS A/24BMCV
4CYL GASOLINE 2.4
OPTIONS:
TWO-STAGE - EXTERIOR SURFACES
DRIVER POWER SEAT
ALARM SYSTEM
OP GDE MC DESCRIPTION
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
TWO-STAGE - INTERIOR SURFACES
REMOTE KEYLESS ENTRY SYSTEM
U.S.A. BUILT VEHICLE
MFG. PART NO. PRICE AJ% BO HOURS R
'6
------------ ----- ----- -
52159AA903 229.04 1.6 1
REFINISH 3.7 4
52615AA050 53.13 0.3 1
REFINISH 0.5*4
ECONOt~Y PI',PT 3.00* 1
E 0566
L 0566 13
E 0567
L M15
EC M60
5 ITEMS
COVER,REAR BUMPER
COVER,REAR BUMPER
ABSORBER,REAR BUMPER
COLOR TINT
HAZARD. WSTE. REM.
?P.GE: 1
06/22/06
CD GnG "Nel 700-1
. .
MC MESSAGE (S)
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
FINAL CALCULATIONS & ENTRIES
GROSS PARTS
OTHER PARTS
PAINT MATERIAL
PARTS & MATERIAL TOTAL
TAX ON PARTS @
7.000%
282.17
3.00
126.00
411.17
19.96
LABOR
I-SHEET METAL
2-MECH/ELEC
3-FRAME
4-REFINISH
5-PAINT MATERIAL
LABOR TOTAL
TAX ON LABOR
SUBLET REPAIRS
TOWING
STORAGE
RATE
48.00
50.00
52.00
48.00
30.00
REPLACE HRS
1.9
REPAIR HRS
91.20
4.2
201.60
@
7.000%
292.80
20.50
GROSS TOTAL 744.43
NET TOTAL 744.43
ADP SHOPLINK U9956 ES CD LOG 700-1 DATE 06/22/06 01:04:06PM R6.37 CD 06/06
HOST LOG
(C) 1998 - 2006 ADP CLAIMS SOLUTIONS GROUP, INC.
1.1 HRS WERE ADDED TO THIS EST. BASED ON ADP TWO-STAGE REFINISH FORMULA.
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PI'.GE 2
06/22/06