Claim Rupp, Kathryn E.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 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:
2. Address:
`
3. Telephone Number:
4. Date of Incident:
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.)
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
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.)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
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 day of , 20 .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
. .
(
5. Time of Incident: ~ [)
8. Whet. were wf3ather c50ns like?
CO, OSlo. Clou
9. Give name and address of any witnesses:
11.
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.)
nO
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
,mrt p';d.) ~ Vr\t(;( b
\~ 'Wrg~~ ryiY1j C(lrnpgll ~ M-Y
15. What amount do you claim from the City of Dubuque?
$ ~:;()D , \ \
16 Why do yo,d,;m lhe C", ofD:~.",.po",~[j~. - I / n'\.. '/nn
l~~~~~~~ "~~e?~~ G~ = V~,,'"'-
17. Have you made any claim against anyone else for damages as a result of
this inci~~? (If yes, give name and address.)
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
c'
Dated this eo!!) day of ~{(21'<1 bLr
(~5~ Q1kW
KPt~I\.\ k\..lW
(Print Name)
, 20.llia.-.
Damage Assessed By: NICK CLEVELAND
PIIIIESSIVE
(563) 585-2680
Fax: (563) 583-7096
Claim Rep: NICK CLEVELAND
(563) 585-2689
" Product Type Auto
. Date of Loss: 1210112006
. Deductible: 500.00
Policy No: 16370727
Insured: KATHRYN RUPP
Claimant: KATHRYN RUPP
Address: 475 KAUFMANN AVE, DUBUQUE, IA 52001
Telephone: Work Phone: (563) 582-9896 Home Phone: (563) 542-7876
Owner: KATHRYN RUPP
Address: 475 KAUFMANN AVE, DUBUQUE, IA 52001
Telephone: Work Phone: (563) 582-9896 Home Phone: (563) 542-7876
Date: 12/01/200604:33 PM
Estimate iD: 06-0462210-01
Estimate Version: 0
Committed
Profile 10: dubuq:allyart_types
. Claim Number: 06-0462210-01
Mitchell Service: 914623
Vehicle Production Date:
Drive Train:
License:
00100
2.0L Inj 4 Cyl5M
538RZP IA
Description:
Body Style:
ViN:
Mileage:
OEM/ALT:
Color:
Options:
2003 Ford ZX2
20 Cpe
3FAFP11353R109231
28,429
A
GunMetal Grey
AiR CONDITiONiNG, POWER STEERING, POWER BRAKES, POWER WINDOWS, POWER DOOR LOCKS
CRUISE CONTROL, 5 SPEED MANUAL TRANSMISSION, AM-FM STEREO/CDPLAYER(SINGLE)
2-DOOR, DRIVER-FRONT AIR BAG
Search Code: BETTENDOR 1
jne Entry Labor Line Item
!em Number Typ.,:,___ 9perati?_~_,._.__ Descriptio~._~__.__.____
1 200061 MCH
2
3
REMOVEIREPLACE
4 200224 BOY
5 REF
6 REF
7
8
9
10 401579 BOY
11 400573 BOY
12
13
14 400597 BOY
REMOVElREPLACE
REFINISH
REFINISH
REMOVE/REPLACE
REMOVEIREPLACE
REMOVEIINSTALL
15 400697 BOY
16 REF
17 REF
18 REF
REMOVEIREPLACE
REFINISH
REFINISH
REFINISH
GLASS & INTERIOR
REPLACE INSTRUMENT PANEL ASSY -M
Waterioo, 3192345207, Denny-'"Gray'''
LINE MARKUP %25.00
FRONT DOOR
L FRT REPLACE DOOR ASSY
L FRT DOOR
L FRT ADD FOR JAMBS & INTERIOR
Northend,5635560044
LINE MARKUP %25.00
... END OF ATG SECTION'"
L FRT DOOR ADHESIVE MOULDING
L FRT DOOR POWER MIRROR ASSY
Northend, 5635560044
LINE MARKUP %25.00
L FRT DOOR HANDLE
QUARTER PANEL
L QUARTER OUTER PANEL
L QUARTER PANEL OUTSIDE
L ADD FOR PILLAR
L QUARTER PANEL EDGE
ESTIMATE RECALL NUMBER: 12/011200616:30:42 06-046221lJ..01
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: NOV 06 A Copyright (C) 1994 - 2005 Mfichelllntemational
UttraMate Version: 6.0.019 - All Rights Reserved
Part Typel
Part Number
UsedlRecycled
UsedlRecycled
3S4Z 6320938 BAPTM
Qual Recycled Part
F8CZ 6327841 AA
Dollar Labor
Amount Units
175.00' 4.5 #
43.75
250.00' 1.6
C 2.4
C 1.0
62.50
67.98 0.2
50.00 0.3 #
12.50
0.6 #
534.50 17.0 #
C 1.9
C 0.5
C 0.5
pege 1 of 4
19 401645 BOY REMOVEIREPLACE L QUARTER ADHESIVE MOULDING
QUARTER GLASS
20 401476 GLS REMOVEIINSTALL L QUARTER GLASS
ADDITIONAL OPERATIONS
21 REF ADO'L OPR CLEAR COAT
ADDITIONAL COSTS & MATERIALS
22 ADD'L COST PAINT/MATERIALS
Date: 12/01/200604:33 PM
Estimate 10: 06-0462210-01
Estimate Version: 0
Commitled
Profile 10; dubuq:aILpart_types
3S4Z 6329076 BAPTM 43.08 0.1
INC #
1.9
246.00 .
. - Judgment Item
# . Labor Note Applies
C - Included in Clear Coat Calc
All manufacturers requirements regarding seat belt and supplemental
restraint system replacement must be adhered to_ If additional parts
or operations are necessary to properly accomplish this, please
contact the estimating claims rep.
I. Labor Subtotals
Body
Refinish
Mechanical
Add'l
Labor Sublet
Units Rate Amount Amount
.~._--
19.8 49.00 0.00 0.00
8.2 49.00 0.00 0.00
4.5 54.00 0.00 0.00
1,120.56
118.75
7.000% 86.75
@ 7.000 %
Totals
970.20 T
401.80 T
243.00 T
1,615.00
113.05
1,728.05
11. Part Replacement Summary
Taxable Parts
Parts Adjustments
Sales Tax @
Amount
Taxable Labor
Labor Tax
Total Replacement Parts Amount
1,326.06
Labor Summary 32.5
11/. Additional Costs Amount IV. Adjustments Amount
------ ~.-
Non-Taxable Costs 246.00 Insurance Deductible 500.00-
Total Additional Costs 246.00 Customer Responsibility 500.00.
I. Total Labor: 1,728.05
1/. Total Replacement Parts: 1,326.06
1/1. Total Additional Costs: 246.00
Gross Total: 3,300.11
IV. Total Adjustments: 500.00-
Net Total: 2,800.11
Point(s) of Impact
9 Left Side (P)
ESTIMATE RECALL NUMBER: 12/01/200616:30:42 06-0462210-01
UltraMate is a Trademark of Mitchell International
Mitchel/ Data Version: NOV 06 A Copyright (C) 1994 _ 2005 Mitchell International
UltraMate Version: 6.0.019 - All Rights Reserved
Page 2 of 4
.
Date: 12/01/200604:33 PM
Estimate 10: 06-0462210-01
Estimate Version: 0
Committed
Profile 10: dubuq:all.JJart_types
THIS IS A DAMAGE ASSESSMENT ONLY - NOT AN AUTHORIZATION TO REPAIR _
BASED ON DAMAGE VISIBLE OR CERTAIN AT THE TIME IT WAS WRITTEN.
IF FRAME OR UNIBODY REPAIR IS INCLUDED ON THIS ESTIMATE, THE AMOUNT
SHOWN INCLUDES TIME OR ALLOWANCE FOR MEASURING BEFORE, DURING AND
AFTER THOSE REPAIRS.
THE OWNER OF THE VEHICLE MAY SELECT THE REPAIR FACILITY OF HIS/HER
CHOICE.
TO ENSURE PROPER AND PROMPT PAYMENT FOR ADDITIONAL DAMAGE DISCOVERED
DURING THE COURSE OF REPAIRS, CONTACT PROGRESSIVE FOR SUPPLEMENT
HANDLING PROCEDURES.
PROGRESSIVE HONORS THE PREVAILING LABOR MARKET RATE IN YOUR AREA FOR
YOUR PROPERTY. IF YOU CHOOSE A SHOP THAT CHARGES IN EXCESS OF
PREVAILING LABOR MARKET RATES, YOU WILL BE RESPONSIBLE FOR THE
DIFFERENCE.
LIFETIME GUARANTEE FOR SHEET METAL AND PLASTIC BODY PARTS
The replacement parts written on the estimate are intended to return
your vehicle to its pre-loss condition with proper installation.
After repair, if any sheet metal or plastic body part included in the
estimate fails to return your vehicle to its pre-loss condition
(assuming proper installation), in terms of form, fit, finish,
durability or functionality, Progressive will arrange and pay for the
replacement of the part, to the extent not covered by a
manufacturer's or other warranty. This service will be performed at
no cost to you (including associated repair and rental car costs). To
obtain service under this Guarantee, call Progressive at
1-800-274-4641. This Guarantee applies as long as you own or lease
the vehicle. This Guarantee is not transferable and terminates if you
sell or otherwise transfer your vehicle.
THIS GUARANTEE DOES NOT COVER NORMAL WEAR AND TEAR OR DAMAGE CAUSED
BY IMPROPER MAINTENANCE, NEGLECT, ABUSE OR SUBSEQUENT ACCIDENT. THIS
GUARANTEE IS LIMITED TO ARRANGING FOR THE SELECTION OF REPAIR PARTS
THAT WILL RETURN YOUR VEHICLE TO ITS PRE-LOSS CONDITION. ACCORDINGLY,
PROGRESSIVE WILL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL OR
CONSEQUENTIAL DAMAGES THAT RESULT FROM THE INSTALLATION OR USE OF
THESE PARTS.
Part Type Terms and Abbreviations
NEW and OEM or part number displayed - These refer to a new, original
equipment manufacturer part.
NON-OEM and A/M and Qual REPL - These refer to an after-market part,
which is a new, non-original equipment manufacturer part.
USED/RECYCLED and LKQ - These refer to a used OEM part.
REMANUFACTURED and RECOND. and RECORE - These refer to used/recycled
OEM parts that have been refurbished.
ESTIMATE RECALL NUMBER: 12/011200616:30:42 06-0462210-01
Ultra Mate is a Trademark of Mitchel/International
Mitchell Data Version: NOV_06_A Copyright (Cl 1994.2005 Mitchelllntemational Page 3 of 4
UllraMate Version: 6.0.019 All Rights Reserved
"" .
Date: 12/01/200604:33 PM
Estimate ID: 06-046221Q.01
Estimate Version: 0
Committed
Profile ID: dUbuq:all...parLtypes
REPAIR SHOP'S AUTHORIZED REPRESENTATIVE'S SIGNATURE INDICATING
AGREEMENT ON COST TO RETURN THE VEHICLE TO PRE-LOSS CONDITION
INCLUDING TOW/STORAGE CHARGES:
SHOP SIGNATURE:
EST. COMPLETION DATE:
ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS
FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR
FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF
INSURANCE FRAUD.
Event Log
File Created:
Estimate Started:
Estimate Printed:
Estimate Committed:
Estimate Uploaded:
12/01/200604:10:05 PM
12/01/200604:18:03 PM
12/01/2006 04:29:54 PM
12/011200604:30:42 PM
Estimate not uploaded
ESTIMATE RECALL NUMBER: 12/01/200616:30:42 06-046221Q.01
Mitchell Data Version; NOV 06 A U~raM~te is a Trademark of ~itchell International
UltraMale Version" 60019 - opynghl (C) 1994 - 2005 Mltchelllnlernalional
. . . All Rights Reserved
Page 4 of 4