Claim by Thurston, Joyce Marie~~z~ fir'.: ~ ,
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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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 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 DUBUGIUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO
YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: _ ,.~ b~-lC~ ~ C~ 1~ ~ E? ~ ~, r('`~
2. Address: ~ ~~
3. Telephone Number: ~~~ J~ `- ~~ ~ 5 ~ ~ ~ o~-Q
4. Date of Incident: ~ ' ~ ~ - Q
5. Time of Incident: ,) ~-L ~~.~ .S '~6 2,,~ ~ ~; f~`~
6. Location of Incident (Be specific): e-Q.~S ~ (~ f Yn c~ ~1.~ S ~- oh q ~c -~ S~C•~v~.c~.
~ G,U` ~ (-l r~t~ 4h P~- F.t/" tsh ~ 2~, ~-- ~~ r ~ t~ ~~ ~ .5 -~-u~~e_.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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8. What ere weather conditions like?
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.)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible? !~ u,b~ 0.,C ~S ~, ~~kP~,.
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 at Dubuque, Iowa this day of 20
(Signature)
~t7~tC~ ~~ ~` i ~. ~.U~~'~5 ~C~h
(Print Name)
(Rev. 1 /00 & 7/01)
a
Date: 2114/2007 01:05 PM
Estimate ID: 12
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Add'I
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
Body 4.4 50.00 0.00 0.00 220.00 T Taxable Parts 427.70
Refinish 3.0 50.00 0.00 0.00 150.00 T Sales Tax ~ 7.000% 29.94
Taxable Labor 370.00 Total Replacement Parts Amount 457.64
Labor Tax a~ T.000 % 25.90
Labor Summary 7.4 395.90
III. Additional Costs Amount IV. Adjustments Amount
Taxable Costs 3.00 Customer Responsibility 0.00
Sales Tax @ 7.000% 0.21
Non-Taxable Costs 96.00
Total Additional Costs 99.21
I. Total Labor: 395.90
II. Total Replacement Parts: 457.64
III. Total Additional Costs: 99.21
Gross Total: 952.75
IV. Total Adjustments: 0.00
Net Total: 952.75
This is a preliminary estimate.
Additional changes to the estimate may be required for the actual repair.
ESTIMATE RECALL NUMBER: 2/14/2007 13:05:00 12
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: FEB_07_A Copyright (C) 1994 - 2005 Mitchell International
UltraMate Version: 6.0.021 All Rights Reserved
Page 2 of 2
s
Lenny Valentine and Sons
923 PERU RD, DUBUQUE, IA 52001
(563) 588659
Date: 2/14/2007 01:05 PM
Estimate ID: 12
Estimate Version: 0
Preliminary
Profile ID: Mitchell
TWO CONTINENTAL FRAME MACHINES
GENESIS II COMPUTERISED MEASURING SYSTEM
PRICE IS EASY TO BEAT/QUALITY IS NOT
UNIBODY SPECIALISTS
Damage Assessed By: WAYNE VALENTINE
Deductible: UNKNOWN
Owner: JOYCE THURSTEN
Address: 540E 16TH ST, DUBUQUE, IA 52001
Telephone: Work Phone: (563) 588-0630 Home Phone: (563) 495-6620
Mitchell Service: 916491
Description: 1993 Oldsmobile Cutlass Ciera S
Body Style: 4D Sed
VIN: 1 G3AG55N7P6412943
Line Entry Labor Line Item
Item Number Type Operation Description
1 603460 BDY REMOVE/REPLACE GRILLE
2 603530 BDY REMOVE/REPLACE GRILLE HEADER PANEL
3 AUTO BDY CHECKIADJUST HEADLAMPS
4 AUTO REF REFINISH HEADER PANEL
5 AUTO REF REFINISH HEADER PANEL EDGE
6 604430 BDY REMOVEIREPLACE L HILAMP ASSEMBLY
7 605160 BDY REMOVE/REPLACE L MARKER LAMP ASSEMBLY
8 605260 BDY REMOVE/REPLACE L MARKER LAMP BULB
9 AUTO REF ADD'L OPR CLEAR COAT
10 AUTO ADD'L COST PAINT/MATERIALS
11 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL
* -Judgment Item
# -Labor Note Applies
C -Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 2/14/2007 13:05:00 12
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: FEB_07_A Copyright (C) 1994 - 2005 Mitchell International
UltraMate Version: 6.0.021 All Rights Reserved
Drive Train: 3.3L Inj 6 Cyl A
Part Type/
Part Number
** QUAL REPL PART
** QUAL REPL PART
** QUAL REPL PART
** QUAL REPL PART
9421330 GM PART
Dollar Labor
Amount Units
100.00' INC #
155.00 * 4.0 #
0.4
C 1.8
0.5
153.00 * INC #
19.00 * INC
0.70 INC #
0.7*
96.00
3.00
Page 1 of 2