Claim Thomas KehoeCLAIM AGAINST THE CITY OF DUBUQUE,101~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 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.
i . Name of Claimant. ~ tiQ~AA ct ~ SeSe~~ ~ ~n L'
2. Address: v2 ~ 51 W ~ ~~$'c~r 4~ ~
3. Telephone Number:•~~(c3~ 55~b "-2~ 3 3
4. Date of Incident: 1 ~ l~ 1 o?Oo'T
5. Time of Incident: ~ 0 ~ ~ oZ ~f s
6. Location of Incident (Be specific): l ~ ~ R 1~Lc ~~ ~~a~. ~ ye _,. C~ ~~ ~ec~ o~n
1~4 Scc~C ~-~' ~ S~c~e~
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.)
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Do.,Mn.,i~,c1 ~ ~, ;n,~,., ~ ~ n ~A ~ ?, ~ cQ - O`l ~ C'~~. a . ~ ~~ a ~ ~ ~l h~ 1\1d~ ~ ~r-~,e r
M'r~a~ ~~,~~ -~f~ry d~~ot ~L~1~~a~e tJar~~ ~ ~ ~~q~ ~f~,ti~ ~,~ ~~fSid~ ~>~v~l~
k'_~ 4 VR~ ;`t(c'f ~0. oy~~, ~c P~e~ f'~. ~S, c~lP ~ 1/~ iveC Na~`•~ 1T~,cA
lle~ecl~-
8. What were weather conditions like? t ~~~,~~ ~, ~
9. Give Warne and address of any witnesses:
..I c n e
10. Did poli/cle~investig^ate? (If so, give{ names of officers.)
E $ ~, ~T ~ t C Q t ~`'~ ~l ~ ~fP i~.~ ~ Q f d~C v9
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.)
~~.e, -~ ~
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.)
l~ ~
15. What amount do you claim from the City of Dubuque?
tom; e 1 ~ ~..;,~~t~ ~ ~-S ~-: w~.c~-4e ~ ~ ~ ~ ~n b-r ~;1~~ 5 .~~1<. Sees C~ m -~-~~s o ~~~.~0~
16. Why do you claim the City of Dubuque is responsible?
~e~~se +In~ Su~.oc~) iJ ~a.J (,~+-~- -M.~ e~,~r a~~ ~_ ~:r~e~r
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 Gluestion 17 is yes, have you received any payment from that source,
an~dJ ~f so, in what amount?
Dated at Dubuque, Iowa this ~+-h day of ~o.ny~~~l 20 0'1 .
- = (Signature)
_ (Print Name)
(Rev. 1/00 & 7/01)
,.
Date: 1!2212007 11:44 AM
Estimate ID: 7421
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Riley's Auto Sales Co.
4455 Dodge St. Dubuque, IA 52003
(563) 588-2326
Fax: (563) 588-9286
Tax ID: 42-0957277 EPA #: IAR0000005629
Damage Assessed By: Dave DeMoss
Deductible: UNKNOWN
Insured: TOM KEHOUE
Address: 2851 WINSER DUBUQUE, IA 52001
Telephone: Home Phone: (563) 556-2433
Mitchell Service: 915101
Description: 2001 Saturn L200
Body Style: 4D Sed Drive Train: 2.2L Inj 4 Cyl 4A FWD
VIN: 1G8JU52F11Y543376
Opt ions: ALUMlALLOY WHEELS, AIR CONDITIONING, POWER STEERING, POWER WINDOWS
POWER DOOR LOCKS, TILT STEERING WHEEL, CRUISE CONTROL, ELECTRIC DEFOGGER
AUTOMATIC TRANSMISSION, AM-FM STEREO/CDPLAYER(SINGLE)
Line Entry Labo r Line Item Part Type/ Dollar Labor
Item Number Type Operation Description Part Number Amount Units
1 500037 BDY REMOVE/INSTALL R SIDE MARKER LAMP 0.2 #
2 500192 REF BLEND R FENDER OUTSIDE C 1.0
3 502160 BDY REMOVE/REPLACE R FRT DOOR REPAIR PANEL 15232686 193.69 1.4 #
4 AUTO REF REFINISH R FRT DOOR OUTSIDE C 2.4
5 502164 BDY REMOVE/REPLACE R FRT DOOR POWER MIRROR 22707325 127.05 INC
6 AUTO REF REFINISH R FRT DOOR MIRROR C 0.5
7 500956 BDY REMOVE/REPLACE R FRT DOOR OUTSIDE HANDLE 15274963 16.59 INC
8 501032 BDY REMOVE/REPLACE R REAR DOOR REPAIR PANEL 22706775 155.56 1.2 #
9 AUTO REF REFINISH R REAR DOOR OUTSIDE C 1.8
10 503171 REF REFINISH R REAR COVER C 0.4
11 501363 BDY REPAIR R QUARTER OUTER PANEL Existing 4.0*#
12 AUTO REF REFINISH R QUARTER PANEL OUTSIDE C 1.6
13 501980 BDY REMOVE/INSTALL R REAR COMBINATION LAMP 0.3
14 AUTO REF ADD'L OPR CLEAR COAT 2,1
15 933005 BDY ADD'L OPR RESTORE CORROSION PROTECTION 10.00 * 0.3*
16 933018 REF ADD'L OPR MASK FOR OVERSPRAY 5.00 *
17 933019 BDY ADD'L OPR TAPED STRIPE 10.00 * 0.3*
18 AUTO ADD'L COST PAINT/MATERIALS 294.00 *
19 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 4.90 *
* -Judgement Item
# -Labor Note Applies
C -Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 1/22/2007 11:44:35 7421
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: DEC_O6_A Copyright (C) 1994 - 2003 Mitchell International
UltraMate Version: 5.0.215 All Rights Reserved
Page 1 of 2
r ~
I. Labor Subtotals
Body
Refinish
Add'I
Labor Sublet
Units Rate Amount Amount
7.7 50.00 20.00 0.00
9.8 50.00 5.00 0.00
Taxable Labor
Labor Tax @ • 7.000
Labor Summary 17.5
Date: 1/22/2007 11:44 AM
Estimate ID: 7421
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Totals II. Part Replacement Summary
405.00 T Taxable Parts
495.00 T Sales Tax @ 7.000%
900.00 Total Replacement Parts Amount
63.00
963.00
III. Additional Costs Amount IV. Adjustments
Taxable Costs 4.90 Customer Responsibility
Sales Tax ~ 7.000% 0.34
Non-Taxable Costs 294.00
Total Additional Costs 299.24
I. Total Labor:
II. Total Replacement Parts:
III. Total Additional Costs:
Gross Total:
IV. Total Adjustments:
Net Total:
This is a preliminary estimate.
Additional changes to the estimate may 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 LIFETIME WORKMANSHIP LIMITED WARRANTY - SEE OUR
WRITTEN WARRANTY FOR COMPLETE DETAILS.
LIFETIME PAINT PERFORMANCE GUARANTEE USING APPROVED PPG AND A
LIFETIME GUARANTEE ON OVERALL WORK1~~iNSHIP IS VALID FOR AS
LONG AS YOU OWN THE VEHICLE STATED HEREIN.
x
ESTIMATE RECALL NUMBER: 1/22/2007 11:44:35 7421
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: DEC_O6_A Copyright (C) 1994 - 2003 Mitchell International
UltraMate Version: 5.0.215 All Rights Reserved
Amount
492.89
34.50
527.39
Amount
0.00
963.00
527.39
299.24
1,789.63
0.00
1,789.63
Page 2 of 2