Minutes City Council 10 17 05
14/ k 6, /!:1 () /J1
CLAIM AGAINST THE CITY OF DUBUQUEtIOWAS::::Jwiad
This written report constitutes 9~;;blaim against the City of Dubuque, Iowa. Yo;;~
complete this form in full and attllch?~ny additional information that supports your claim.
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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 CCh'y\.€ouncil to the appropriate department for investigation.
Once that investigation is compltlt'eB; la 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 WIL 0 BE PAID.
6. Location of Incident (Be specific):
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1. Name of Claimant:
2. Address: ~
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
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7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon whi~h you base your claim. If a City employee was involved, give the
emp' 0 ee's na .) , /. '
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8.
9. Give name and address of any witnesses:
10.
icers.)
11. W
s, addresses, and extent of injuries).
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12. Was any damage done to property? (If so, describe property and the extent of damages.
Attach estimates of damages describe b,asis for ascertaining extent of da age.)
13. What other damages do you claim, if any?
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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.)
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15.
What amou~t dO, you claim from t~ity of Dubuque?
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
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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 3./--- day of
(S' ature)
,,13 ~ I-- h elf- .... I
. (Print Name)
€.-- -e.-
(Rev. 1/00 & 7/01)
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Date: 7/27/200604:05 PM
Estimate 10: 6195
Estimate Version: 0
Preliminary
Profile 10: Mitchell
MIKE FINNIN FORD
Damage Assessed By: RICK STUMPF
Deductible: 0.00
3600 DODGE STREET DUBUQUE, IA 52001
(563) 556-1010
Fax: (563) 690-1086
Tax 10: 14.1862673
Insured: BARB SCHNEE
Address: 2257 CHANEY RD APT6 DUB, IA 52001
Telephone: Home Phone: (563) 543-6488
Mitchell Service: 915529
Description: 2004 Chrysler PT Cruiser
Body Style: 40 Wgn Drive Train: 2.4L Inj 4 Cyl 4A FWD
VIN: 3C4FY48B24T305945
Mileage: 8,173
Options: ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER WINDOWS, POWER DOOR LOCKS
CRUISE CONTROL, AUTOMATIC TRANSMISSION, AM-FM STEREO/CDPLAYER(SINGLE)
Line Entry Labor
Item Number Type
1 502628 BOY
2 AUTO REF
3 502840 BOY
4 501288 BOY
5 502392 BOY
6 AUTO REF
7 AUTO REF
8 933005 BOY
9 933018 REF
10 AUTO
11 AUTO
Operation
REPAIR
REFINISH
REMOVE/REPLACE
REMOVE/INSTALL
REPAIR
REFINISH
ADD'L OPR
ADD'L OPR
ADD'L OPR
ADD'L COST
ADD'L COST
Line Item
Description
R QUARTER OUTER PANEL
R QUARTER PANEL OUTSIDE
R REAR COMBINATION LAMP
REAR BUMPER ASSY
REAR BUMPER COVER
REAR BUMPER COVER
CLEAR COAT
RESTORE CORROSION PROTECTION
MASK FOR OVERSPRAY
PAINT/MATERIALS
HAZARDOUS WASTE DISPOSAL
Part Typel
Part Number
Existing
Dollar Labor
Amount Units
3.0*#
C 2.1
80.70 0.2
1.2 #
1.0.
C 2.0
1.2
12.00 * 0.3*
12.00 . 0.3.
148.40.
2.65*
5288742AG
Existing
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 7/271200616:05:23 6195
UltraM~te is a Trademark of Mitchelllntematlonal
Mitchell Data Version: JUL_06_A Copyright (C) 1994 - 2003 Mitchelllntemational
UltraMate Version: 5.0.215 All Rights Reserved
Page 1 of 2
Date:
Estimate 10:
Estimate Version:
Preliminary
ProlilelD:
7/27/200604:05 PM
6195
o
Mitchell
I. Labor Subtotals
Body
Refinish
Add'l
Labor Sublet
Units Rate Amount Amount
- -
5.7 48.00 12.00 0.00
5.6 48.00 12.00 0.00
Totals
285.60 T
280.80 T
566.40
39.65
606.05
II. Part Replacement Summary
Taxable Parts
Sales Tax @
7.000%
Amount
80.70
5.65
Taxable Labor
Labor Tax
Total Replacement Parts Amount
86.35
@ 7.000%
Labor Summary 11.3
III. Additional Costs Amount IV. Adjusbnenls Amount
Non-Taxable Costs 151.05 Insurance Deductible 0.00
Total Additional Cosls 151.05 Customer Responsibility 0.00
I. Total Labor: 606.05
II. Total Replacement Parts: 86.35
III. Total Additional Cosls: 151.05
Gross Total: 843.45
IV. Total Adjusbnenls: O.oe,
Net Total: 843A5':
This is a Dreliminarv estimate.
Additional chanaes to the estimate may be reauired for the actual reDair.
ESTIMATE RECALL NUMBER: 7/271200616:05:23 6195
UltraMate is a Trademark of Mitchell International
Mitchell Data Yersion: JUL_06_A Copyright IC) 1994 - 2003 Mltchelllntemational
UltraMate Version: 5.0.215 All Rights Reserved
Page 2 of 2
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Date:
Estimate 10:
Estimate Version:
Preliminary
Profile 10:
Riley's Auto Sales Co.
Damage Assessed By: Dave DeMoss
Deductible: UNKNOWN
4455 Dodge 51. Dubuque, IA 52003
(563) 588-2326
Fax: (563) 588-9286
Tax 10: 42-0957277 EPA #: 1AD051003184
Insured: BARB SCHNEE
Address: 2257 CHANNEY RD APT 6 DUBUQUE, IA 52001
Telephone: Home Phone: (563) 543-6488
Mitchell Service: 915529
Description: 2004 Chrysler PT Cruiser
Body Style: 40 Wgn Drive Train: 2.4L Inj 4 Cyl4A FWD
VIN: 3C4FY48B24T305945
Options: ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER WINDOWS, POWER DOOR LOCKS
CRUISE CONTROL, AUTOMATIC TRANSMISSION, AM-FM STEREO/CDPLAYER(SINGLE)
Line Entry Labor
Item Number Type
1 502628 BOY
2 AUTO REF
3 502840 BOY
4 501287 BOY
5 502392 BOY
6 AUTO REF
7 AUTO REF
8 933005 BOY
9 933018 REF
10 AUTO
11 AUTO
Operation
REPAIR
REFINISH
REMOVE/REPLACE
REMOVE/INSTALL
REPAIR
REFINISH
ADD'L OPR
ADD'L OPR
ADD'L OPR
ADD'L COST
ADD'L COST
Line Item
Description
R QUARTER OUTER PANEL
R QUARTER PANEL OUTSIDE
R REAR COMBINATION LAMP
REAR BUMPER COVER
REAR BUMPER COVER
REAR BUMPER COVER
CLEAR COAT
RESTORE CORROSION PROTECTION
MASK FOR OVERSPRAY
PAINT/MATERIALS
HA2ARDOUS WASTE DISPOSAL
" - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 7/27/200616:13:21 7113
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: JUL_06_A Copyright (C) 1994 - 2003 Mitchell International
UltraMate Version: 5.0.215 All Rights Reserved
Part Type/
Part Number
Existing
5288742AG
Existing
7/27/200604:13 PM
7113
o
Mitchell
Dollar Labor
Amount Units
1.5*#
C 2.1
80.70 0.2
1.0
1.5*
C 2.0
1.2
10.00" 0.3"
5.00'
159.00 '
2.65'
Page 1 of 2
.
1
Date:
Estimate 10:
Estimate Version:
Preliminary
ProfilelD:
7127/200604:13 PM
7113
o
Mitchell
Add'l
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount
Body 4.5 49.00 10.00 0.00
Refinish 5.3 49.00 5.00 0.00
Taxable Labor
Labor Tax @ 7.000 %
Labor Summary 9.8
Totals
230.50 T
264.70 T
495.20
34.66
529.86
II. Part Replacement Summary
Taxable Parts
Sales Tax @
7.000%
Amount
80.70
5.65
Total Replacement Parts Amount
86.35
111. Additional Costs
Taxable Costs
Sales Tax
@
7.000%
Amount
2.65
0.19
IV. Adjustments
Customer Responsibility
Amount
0.00
Non-Taxable Costs
159.00
Total Additional Costs
161.84
I.
II.
III.
Total Labor:
Total Replacement Parts:
Total Additional Costs:
Gross Total:
529.86
86.35
161.64
778.05
IV.
Total Adjustments:
Net Total:
0.00
778.05
This is a preliminarv estimate.
Additional chanQes to the estimate mav be reQuired for the actual repair.
THIS DAMAGE REPORT IS BASED ON OUR INSPECTION AND DOES NOT COVER ANY
ADDITIONAL PARTS OR LABOR WHICH MAY BE REQUIRED AFTER THE WORK HAS
BEEN OPENED UP THE INSURANCE COMPANY WILL BE NOTIFIED.
WE FEATURE A THREE YEAR WORKMANSHIP LIMITED WARRANTY - SEE OUR
WRITTEN WARRANTY FOR COMPLETE DETAILS.
LIFETIME PAINT PERFORMANCE GUARANTEE USING APPROVED PPG AND A
THREE YEAR GUARNATEE ON OVERALL WORKMANSHIP IS VALID FOR AS
LONG AS YOU OWN THE VEHICLE STATED HEREIN.
x
ESTIMATE RECALL NUMBER: 7127/200616:13:21 7113
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: JUL_06_A Copyright (C) 1994 . 2003 Mitchell International
UltraMate Version: 5.0.215 All Rights Reserved
Page 2 of 2