Claim, Hemesath, Ralph G.
At//?~.Jl~~ I
CLAIM AGAINST THE CITY OF DUBUQUE, IOW'A ~~
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: 'R l>-- If h. Cr,;J e;./l-e 5A~
2.Address:~() J3(JX ,Is/if ~d) J: ~.26(J)-L
3. Telephone Number .!;;6 :.<( s'~/:Z 'b -3.;;z::s
4. Date of Incident: r:X ('/ cd ~ ~ !) ~
/,' 1'+-7: /1 /1 /1
5. Time of Incident: t;.;;;> u u r::r / v .
6. Loca~ of 'n~ke 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
the employee's n me.)
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8. What were weatt\iih~~ditions Ite? sf J^'sr.:~ "l\^d"...J/J:~~'::t:Jt(,:;,;;;oJ~
,.;../"}'t. jA,?,'.v&A ~ <f \AAJ~\r nY'/V'\ ~~~-th.,.~"1C~
9. Give name and address of any witnesses: r 6'ro.NL\'\)
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& /j~ +rJIJ't "- do~ /olJ/C
c-.:t -t ~ d.~ 10 {a.M~,
10. Did police investigate? (If so, give names of officers.)
/I)t:?
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
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13. What other damages do you claim, if any?
Nb,)..x.
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 ,e City of Dubuque?
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17. Have you made any claim against anyone else for damages as a result of L h a.V'~ +1
this incident? (If yes, give name and address.) tJ t..AM. f?"u' L
_ /10 fr1 ~ ) JL-t. f..v~,
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
,200t. .
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TRUCK BUILDERS INC..
265 35th STREET
MARION, IOWA, 52302
Tel: 319-377-5670 Fax: 319-373-5859
TRUCKB@MSN.COM
Estimate
Estimate Prepared by: TIM WENTZ
Accident Date:
Date of Loss:
Arrival Date:
Repair Start:
Repair End:
Type of Loss:
Policy Number: HIT BY TREE
Claim Number: STORM DAMAGE
Appraised for:
Date: 7/24/2006
Last Commit Date: 7/24/2006
Estimate#: 20083
Supplement: 000
Owner:
Contact: RALPHHEMESATH
Address: 8355 JECKLIN LANE
City, State, Zip Code: DUBUQUE, IOWA 52003
Telephone, Fax: 563-542-8323
Year Make Model Color Trim
1978 DODGE CAMPER WHITE XXXX
Unit Nnmber License Plate # Mileage Serial#NIN#
I 867 RON B25BF8X 196677
Sup Seq Qty Labor Labor Description Part Part List Extended Labor
Type Op Type Number Price Price Units
I I Body Repair FIBER GLASS Exist T 8.2*
ROOF CAP
2 I Body Repair STR RIGHT SIDE Exist T 4.5'
PANEL REAR
3 I Body Ref MASK FOR OVER Exist T .5*
SPRAY
4 I Body Ref PREP, PRIME, & Exist T 7.4'
REFINISH
REPAIRED AREAS
5 I Body RemlRep RESEAL ROOF AS New T .5'
NEEDED
6 Paint Materials $195.00 $195.00 ,
7 Shop Materials $85.00 $85.00 ,
8 Hazardous Waste $2.00 $2.00 ,
Version 1.91
Database Edition PHT 06-02
TruckEst is a Trademark of Mitchell International
@1998-2005 Mitchell International, Inc.
All Rights Reserved.
Page I of 2
,.-
,-.
· -Judgement Item
# - Labor Note Applies
Labor
Body
Labor Total
21.1 Hrs@ $75.00
$1,582.50
$1,582.50
he above is an estimate based on our inspection and
oes not cover any additional parts or labor which may
e required after the work has started. Occasionally,
om or damaged parts are discovered wh ich may not
e evident on the first inspection. Because of this, the
bove prices are not guaranteed. Quotations on parts
d labor are current and subject to change.
Parts
Parts Subtotal
Less Adjustments
Parts Total
Additional Costs and Operations
Add!. Costs/Ops Total
Tax
Labor Tax @
5.00%
Tax Total
Totals
Sub Total:
Customer Resp.
Net Total
Estim . e Pr ~red B
~~
Signature
Anthorization for Repairs:
Signatnre
Date
TruckEst does not automatically include items required by many business repair partners. This application allows
the author to manually enter line items such as overlap deductions.
1978 DODGE CAMPER
Version 1.91
Database Edition PHT 06-02
TruckEst is a Trademark of Mitchell International
@1998-2005 Mitchell International, Inc.
All Rights Reserved.
Page 2 of 2
$0.00
$0.00
$282.00
$79.14
$79.14
$1,943.64
$0.00
$1,943.64
ct-ob
.
HABERKORN AUTO CENTER
602 PERU ROAD. DUBUQUE IOWA52001 . PHONE (319) 556-8872 03
11041
OWNER ,f;>p// ~RESS 5c,. 2 ~3~lrE ~ 1.0.-19 tJ
r"IY J. .r/ , '71 MODEL I~.-A IDENTIFICATION NO. I MILEAGE I "j''60'7R CJ N I
14-,
FRONT OF CAR '" "ee SUBLET/\ PARTS LEFT SIDE '" "ee SUBLET & PARTS RIGHT SIDE '" ""' SUBLET & PARTS
MATERIAL MATERIAL MATERIAL
BUMPER HEADLIGHT HEADLIGHT
BUMPER SRKT. COMPOSITE COMPOSITE
BUMPER GUARD
GRILL PARKING, LIGHT PARKING, LIGHT
GRILL FENDER, FRONT FENDER, FRONT
GRILL MLDG. FENDER, APRON FENDER, APRON
FENDER MLDG, FENDER MLDG.
GRAVEL SHIELD FENDER MLDG. FENDER MLDG.
WiNDSHIELD FENDER MLDG FENDER MLDG,
HEADER PANEL FENDER MLDG. FENDER MLDG.
DOOR, FRONT DOOR, FRONT
COWL DOOR, MLDG, DOOR, MLDG.
RAD. SUPPORT DOOR GLASS DOOR GLASS
RAD. CORE VENT GLASS VENT GLASS
ANTIFREEZE CENTER POST CENTER POST
FAN BLADE
FAN SHROUD DOOR, REAR DOOR, REAR
DOOR, MLDG. DOOR, MLDG.
DOOR GLASS DOOR GLASS
HOOD
HOOD HINGES
HOOD MLDG. ROCKER PANEL ROCKER PANEL
ROCKER MLDG. ROCKER MLDG.
FLOOR FLOOR
ORNAMENT 1/4 PANEL 1/4 PANEL ~ R ~f -1/J
NAME PLATE 1/4 PANEL 1/4 PANEL ,
LOCK PLATE, LR. 1/4 PANEL 1/4 PANEL
LOCK SUPT. WHEEL HOUSE WHEEL HOUSE
1/4 MLDG. 1/4 MLDG.
REAR OF CAR
BUMPER
BUMPER BRKT.
BUMPER GUARD TAILLIGHT TAILLIGHT
TAILLIGHT TAILLIGHT
TAILLIGHT TAILLIGHT
GRAVEL SHIELD TAILLIGHT TAILLIGHT
LOWER PANEL BACK-UP LIGHT BACK.UP LIGHT
FLOOR BACK-UP LIGHT BACK-UP LIGHT
TRUNK LID CLEAR COAT P ".? .,-
TRUNK HINGE CLEAN-UP
TRUNK MLDG. LABOR HAS.@ ,:1.. 0 ()O
MISC. ITEMS PARTS
TOP {; FlJi 10. (J IDENTIFICATION PAINTING L. ~O 00
LICENSE LIGHT FRAME KEY TOWING
TIRES MATERIAL '-t/?O &0
HUBS CAPS N NEW HAZARDOUS j 0 00
R REPAIR WASTE
WHEEL DISC. OH OVERHAUL
A ALIGN I , 7 t, 0
P PAINT TAX
S SUBLET
TOTAL 17Cf7 6
The above;$ an estimate based on our Inspection and does not cover additional parts or labor which may be required alter work has begun, Occasionally, when work is
opened up, we discover worn. broken or damaged parts not evident in the first ins ection. Quotations on arts and labor are current and sub'ect to chan e
6
cJ
ESTIMATED BY
, 0
WORK AUTHORIZED BY
ESTIMATE