Claim, Hanson, Barbara L.
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA j;: /J . . "
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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 West 13th St,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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: 13# /':~ /J /t'/l
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2. Address: /d.- 10
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3. Telephone Number ~6t3 :)-)- h / 7' d--"/
4. Date of Incident: 7& /c"
5. Time of Incident:
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6. Location of Incident (Be specific):
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7. Describe the accident or occurrence that caused injury or damage. (Give full
details upon which you base your claim. If a City employee was involved, give , '\
theemployee'sname.) ?'1t7l J'he..-J/iJl' (P'to <0"&7 )?J11v/ Bt/"S )
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8. What were weather conditions like?
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9. Give name and address of any witnesses:
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10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, 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 or describe basis for ascertaining
extent of damage.)
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13. What other damages do you claim, if any?
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 amount do you claim from the City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible? -
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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.)
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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 thi, ~:~ day of;L "--
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(Print Name)
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AVALON BODY SHOP, INC.
20680 HWY 52N RICKARDSVILLE, IA 52039
(563) 552-1656
Fax: (563) 552-1658
Tax ID: 42-1360561
Damage Assessed By: MERLIN WILGENBU$CH
Date:
Estimate 10:
Estimate Version:
Preliminary
Profile ID:
7/111200609:52 AM
5574
o
Mitchell
WE HAVE THE CAPABILITY TO E-MAIL DIGITAL PICTURES OF DAMAGE TO YOU!
Type of Loss: Property Damage
Deductible: NONE
Claimant: BARB HANSON
Address: 1210 PARK DUBUQUE, IA 52001
Telephone: Work Phone: (563) 580-0124
Home Phone: (563) 556-1925
Mitchell Service: 913529
Description: 2004 Jeep GrandCherokee Special Edition
Body Style: 4D Ut
VIN: lJ4GW48S44C390304
Mileage: 10,304
Color: BLACK MET.
Line Entry Labor
Item Numbe~ Type
1 302182 BDY
2 AUTO REF
3 305022 BDY
4 301542 BDY
5 305263 BDY
6 305052 BDY
7 900500 BDY'
8 900500 BDY'
g 301733 BDY
10 301743 BDY
11 301749 BDY
12 AUTO REF
13 AUTO REF
14 933005 BDY
15 933018 REF
16 AUTO
17 AUTO
18 AUTO
Operation
REPAIR
REFINISH
REMOVE/REPLACE
REMOVE/REPLACE
REMOVE/REPLACE
REMOVE/INSTALL
REMOVE/REPLACE
REMOVE/REPLACE
REMOVE/INSTALL
REMOVE/INSTALL
REPAIR
REFINISH
ADD'L OPR
ADD'L OPR
ADD'L OPR
ADD'L COST
ADD'L COST
ADD'L COST
Vehicle Production Date: 3/04
Drive Train: 4.0L Inj 6 Cy14WD
License: MRSBH IA
Line Item
Description
L1FTGATE SHELL
L1FTGATE OUTSIDE
L1FTGATE PULL HANDLE
LIFTGATE ADHESIVE NAMEPLATE
L1FTGATE ADHESIVE NAMEPLATE
L1FTGATE WIPER ARM
STRIPE DECAL
HITCH RECIEVER COVER BRAKE LITE
LICENSE LAMP
REAR BUMPER COVER
REAR BUMPER COVER
REAR BUMPER COVER
CLEAR COAT
RESTORE CORROSION PROTECTION
MASK FOR OVERSPRAY
PAINT/MATERIALS
SHOP MATERIALS
HAZARDOUS WASTE DISPOSAL
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 7/11/200609:52:39 5574
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: JUN_06_A Copyright (C) 1994 - 2003 Mitchell International
UltraMate Version: 5.0.215 All Rights Reserved
Part Type/
Part Number
Existing
55136699AC
5EM87SA 1
5EM89SA 1
Existing
New
New
Existing
Dollar
Amount
Labor
Units
2.0'#
2.6
0.2 #
0.2
0.2
0.2'#
0.3*
0.2*
0.3
1.3
3.0*
C 2.8
1.6
0.3*
C
66.10
33.45
26.70
15.00'
45.00'
8.00'
6.00'
210.00'
15.00'
3.43'
Page 1 of 2
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Date:
Estimate 10:
Estimate Version:
Preliminary
ProfilelD:
7/11/200609:52 AM
5574
o
Mitchell
I. Labor Subtotals
Body
Refinish
Add'l
Labor Sublet
Units Rate Amount Amount
--
8.2 49.00 8.00 0.00
7.0 49.00 6.00 0.00
@
186.25
7.000% 13.04
@
7.000 %
Totals
409.80 T
349.00 T
758.80
53.12
811.92
II. Part Replacement Summary
Taxable Parts
Sales Tax
Amount
Taxable Labor
Labor Tax
Total Replacement Parts Amount
199.29
Labor Summary 15.2
III. Additional Costs Amount IV. Adjustments Amount
Non-Taxable Costs 228.43 Insurance Deductible 0.00
Total Additional Costs 228.43 Customer Responsibility 0.00
I. Total Labor: 811.92
II. Total Replacement Parts: 199.29
III. Total Additional Costs: 228.43
Gross Total: 1,239.64
IV. Total Adjustments: 0.00
Net Total; 1,239.64
This is a Dreliminarv estimate.
Additional chanaes to the estimate may be reauired for the actual reDair.
Point(s) of Impact
~_._.- - --------
6 Rear Center (P)
AVALON BODY SHOP INC, agrees to perform repairs which serve to
restore the damaged vechicle to its preloss condition relative to
safety, functions and appearance and futher agrees to warranty
workmanship for a period of three (3) years; plus PPG or Autocolor
Lifetime Paint Performance Guarantee for as long as the customer owns
the vechicle from date of completion of repairs.
ESTIMATE RECALL NUMBER: 7/11/200609:52:39 5574
Ultra Mate is a Trademark of Mitchell International
Mitchell Data Version: JUN 06 A Copyright (C) 1994 - 2003 Mitchell International
UltraMate Version: 5.0.215 - All Rights Reserved
Page 2 of 2