Claim Kohl, Tyler - Ken KohlCLAIM 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: Tyler Kohl (Ken Kohl)
2. Address: 2413 Windsor
`
3. Telephone Number: 582 0639
4. Date of Incident: 9/4/05
5. Time of Incident: 8th Street - alley - west of Main
6. Location of Incident (Be specific):
8th Street - Alley west of Main
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.)
The Police Car was in alley and put car in reverse and when he came out and
around corner hit car in front driver side bumper.
8. What were weather conditions like? None
9. Give name and address of any witnesses:
None
10. Did police investigate? (If so, give names of officers.)
Yes, Officer Ed Baker
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.)
Front side of Drivers Side bumper was hit. Estimate attached from Lenny
Valentine and Sons.
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?
$337.92
16. Why do you claim the City of Dubuque is responsible?
Dubuque Police Car was in the wrong backing out of an alley.
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?
Dated at Dubuque, Iowa this 9th day of October, 2006.
/s/ Ken J. Kohl
I gave just an estimate and that is what they told my son to do. No one informed us that there was a claim form to be filled out.
This is the 2nd this claim was filed. 1st time the claim (Estimate) was taken to Law Enforcement Office and they said they would take care of it. I waited patiently and after 8-0
months decided to check on it. They told me they have the accident report, but
no claim or estimate was found.
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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Claim Form
This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this form in
full and attach any additionai 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 finai decision on all clams is made by the City Council. No employee of the City of Dubuque has the
authority to make any representation~o you as to whether your ciaim will or will not be paid. )
1. Name of Claimant: f71LI::::. r<. /(0 HL ( Itw /(O/rL.
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2. Address:
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific):
lJJPst of tIl1l4-itJ
7. Describe the accident or occurrence that caused injury or damage. (Give full details upon which you base
your ciaim. If a City employee was involved, give the employeeDs name.)
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8. What were weather conditions like? C /~() I( a'1 r:R )"IJin e WJM
g. Give name and address of any witnesses: NON E
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10. Did police investigate? (If so, give names of officers.)
~) office\L eJ. Bet. ~e ..
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,)
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13. What other damages do you claim, if any? j\!O/U E
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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 amount do you claim from the City of Dubuque? $ 33 7 9.;;;:t
16. Why do you claim the City of Dubuque is responsible? --0'" h{I Ou 0 Poll're
Gr I)HS 1/1 The Wt'"Ol7' had:::,ny o"f 0'+
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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.) N ()
18. if the answer to Question 17 is yes, have you received any payment from that source, and if so in what
amount? '
Dated this t:fI-h day of Ocfv he ~
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10/6/2006
Date:
Estimate 10:
Estimate Version:
Preliminary
Profile 10:
Lenny Valentine & Sons, Inc.
923 Peru Rd. Dubuque, IA 52001
(563) 588-4659
Fax: (583) 588-4650
TWO CONTINENTAL FRAME MACHINES
GENESIS II COMPUTERISED MEASURING SYSTEM
PRICE IS EASY TO BEAT/QUALITY IS NOT
UNIBODY SPECIALISTS
Damage Aseessed By: DICK VALENTINE
Deductible: UNKNOWN
Owner KEN KOHL
Address: 2413 WINDSOR AVE DUBUQUE,IA 52001
Telephone: Home Phone: (563) 582.0639
Mitchell Service: 918620
Description: 1994 Ford Taurus GL
Body Style: 40 Sed
VIN: 1FALP52U3RG212844
Line Entry Labor
Item Number Type
1 801190 BOY
2 AUTO REF
3 AUTO REF
4 AUTO
5 AUTO
6 AUTO
Operation
REPAIR
REFINISH
ADD'L OPR
ADD'L COST
ADD'L COST
ADD'L COST
Drive Train: 3.0L Inj 6 Cyl AO
Line Item
Description
FRT BUMPER COVER
FRT BUMPER COVER
CLEAR COAT
PAINTIMATERIALS
SHOP MATERIALS
HAZARDOUS WASTE DISPOSAL
Part Type!
Part Number
Existing
. - Judgement Item
C - Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 9/6/200508:33:08 6201
UltraMate Is a Trademark of Mltchelllntematlonal
Mitchell Data Version: AUG_05_A Copyright (C) 1994 - 2003 Mnchelllnternational
UltraMate Version: 5.0.211 All Rights Reserved
9/6/200508:33 AM
6201
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Mitchell
Dollar Labor
Amount Units
1.0.
C 2.4
1.0.
102.00'
2.50.
2.55*
Page 1 of 2
.
I. Labor Subtotals
Body'
Refinish
Units
1.0
3.4
Rate
49.00
49.00
Add'l
Labor
Amount
0.00
0.00
Sublet
Amount
0.00
0.00
Taxable Labor
Labor Tax
@ 7.000 %
Labor Summary 4.4
III. Additional Costs
Taxable Costs
Sales Tax
@
7.000%
Non-Taxable Costs
Total Additional Costs
Date:
Estimate 10:
Estimate Version:
Preliminary
Profile 10:
91 612005 08:33 AM
6201
o
Mitchell
Totals II. Part Replacement Summary
49.00 T
166.60 T Total Replacement Parts Amount
215.60
15.09
23Q.69
Amount IV. Adjustments
2.55 Customer Responsibility
0.18
104.50
107.23
I. Total Labor:
II. Total Replacement Parts:
III. Total Additional Costs:
Gross Total:
IV. Total Adjustments:
Net Total:
This is a Dreliminarv estimate.
Additional chanaes to the estimate mav be reauired for the actual reDair.
ESTIMATE RECALL NUMBER: 9161200508:33:08 6201
UltraMate is a Trademark of Mitchelllntematlonal
Mitchell Data Version: AUG_05~ Copyright (C) 1994.2003 Mltchelllntemational
UltraMate Version: 5.0.211 All Rights Reserved
Amount
0.00
Amount
0.00
230.69
0.00
107.23
337.92
0.00
337.92
Page 2 of 2
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INTERSECTION OF 8TH AND THE ALLEY WEST OF MAIN OPERATOR A UNIFORMED POUCE OFFICERS OBSERVED
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