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Claim by Margaret_Alan Jones„r, `; ~ `;ill" 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. 13~' 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 Clai 2. Address: ~ c~~ 1~1.! ~l~ fs o-r~ S~ re.o~ ~D ,~o~C .J ~u rri a/c ~~o Z~- ~~~ g 3. Telephone Number: ~ lob `~ o `~0 4. Date of 5. Time of Incident: !Jr ~ ~ "`f' 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.) ~ ~, , i ~, ~ 1~ n f ~ - 1_ ~_ ~are~~l ~ r~' a~'t~eav ~ RXS ~ C ~ pan w~-~a was G ~a~ w~ S ctrdss ~h ~_ _ ~~ r- - ,~ ~a k,~ S , r !~ a `f ~S i.v i~'~ v~ fj ~ vt ~ ~ ('z~- r - Q~'1 cue ~Q s°''~ ~e .. 8. What were weather conditions like? (~9~Jiirr> `~ ~~~?~ lr' 9. Give name and address of any witnesses: ~ 10. _Did police investigates (If so, give names of officers.) 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). /~o 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? r~/o-,~P . 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?~ -~v ~~~r ,rP~r 16. Why do you claim the City of Dubuque is responsible? ~'a ~ ~l e_ r Gl~ 'Y~.v~ 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) , / 0 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 t'fr~.cX 20~. ( nature) bl "an~nc~na ar Jo e~l~p S,y~~~7 ~i~ (Print Na e) h S ~~ Nd 1 I ddb LQ CJ~/11~~~~1 (Rev. 1/00 & 7/01) ~~ Driver Information Exchange REport Dubuque Police Department 563-589-4410 Drivers Name -Last First Middle I Suffix ~ Date of Birth I~ U ROUSSEL TERRANCE --~-RAYMOND I 106/01/1952 N Address j I 12216 WINDSOR AVE T i Gender ~ Driver's License Number Class i Male j 456W W0214 D ~ 001 Ov~ner Company Name CITY OF DUBUQUE ' Ovrner's Name -Last First I j Middle i Suffix I ress City State Zip - - - i 50 WEST 13TH ST, i DUBUQUE IA 52001- ~ I VIN No. Year Make Model j i St le Y ~+ ~ Jehicle Ca~t~u~~+_<ic j 2B7KB31Z91K519646 2001 ~ DODG RAMVANAB3L12 I 03 'License Ptate # I ~! 64467 ~ State I IA Year 19 i Most Damaged Area 01 F i Approximate Cost ;o Repair or Faplaca - ront I $300.00 I Drivers Name -Last First Middle Suffix :Date of Birth U ;JONES ALAN DAVID ' ~ 04/26/ 1983 N j Address i DUBUQUE City State Zip Phone I IA IA 52049 (563) 581-77;,6 x T Gender Driver's License Number Class State j Endorsements Restrictions ~ Insurance Co. Name --- Insurance Co. Phone # Male 852ZZ0360 C IA NONE B GRINNELL MUTU AL (877) 467-2252 x 002 O,Nner Company Name Insurance Policy # 0002552795 Ovdner's Name -Last ~ First Middle Suffix 'JONES ':MARGAR ET MARY ' Address ~ City State Zip PO BOX 5 GARNAVILLO IA 52049- VIN No. Year Make Model Style Vehicle Cornic;u~ah~_ n i 1MEFiv150U6Wu641943 1993 ib1ERC 13A8 4D G1 i License Plate # 370AOW State Year Most Dama ed Area g ate Cost to Repair o; Repiac~ IA 2007 05 - Rear $200.OO ' ~.oumY Accident occurred within corporate limits of (city) Dubuque - 3~ Dubuque - 2100 Literal DescriF~ion t W 17TH ST X-Coordinate Y-Coordinate 00691213 04708782 If accident occurred outside of city Direction ~ Nearest City 'Route (Cardinan hmds show general vacinity: "N/A" "N/A" of ~ "N/A" Travel Direction "N/A" On Road, Street, or Highway: At Intersection with: W. 17TH ST W. LOCUST Distance ,. " Direction ~ Distance Direction Milepost Number N/A "N/A" and i ,.N/A" "NIA" of "N/A" or Definable intersection, bridge, or railroad crossing "NIA" Officer BASTEN DANIELLE Badge No I Law Enforceme t Ca Number Date of Accident Tune st %+r ; ua:, , 23A j 01-07-9833 , 03/12/2007 15:04 City State Zip ~ Phone I DUBUQUE IA 52001 {563) 589-4142 x Slete i~ndorserr.e ~tei Restrictions i Insurance Ca Name '~su a~ ~' - IA I :'. ~ B 'IOWA COMMUNITIES .ASSURA (@63 rs3-942 x - j Insurance Policy # Printed At: Dubuque Police Department 03/12/2007 03:37 PM Page 1 Form #: 01-07-9833 04/05/2007 at 10:51 AM 24443 Job Number: ABRA - DUBUQUE Federal ID #:420782245 DBA: ANDERSON-WEBER INC 3400 CENTER GROVE DR DUBUQUE, IA 52003 (563)556-0696 Fax: (563)556-1899 PRELIMINARY ESTIMATE Written By: KEN GREEN #24443 Adjuster: Insured: Owner: Address: Evening: Business: Inspect Location: MARGARET JONES MARGARET JONES 104 rr7ATSCN ST. GARNAVILLO, IA 52049 (563)964-2452 (563)556-3310 Insurance GRINELL MUTUAL Company: 1998 MERC SABLE GS 6-3.OL-FI 4D SED RED Int: Days to Repair VIN: 1MEFM50U6WG641943 Lic: 370 AOW IA Prod Date: 05/1998 Odometer: 80871 Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Body Side Moldings Dual Mirrors Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Mirrors AM Radio FM Radio Stereo Cassette Search/Seek Driver Air Bag Passenger Air Bag Cloth Seats Bucket Seats Recline/Lounge Seats Automatic Transmission Overdrive N0. OP. ----------------- DESCRIPTION ---------- ------ QTY EXT. PRICE LABOR PAINT 1 - -------------- REAR BUMPER ---- -------------------- ------- 2 O/H bumper assy 0 0.00 2.0 0.0 3* Rpr Bumper cover 0 0.00 2.5 3.0 4 Add for Clear Coat 0 0.00. 0.0 1.2 5# Subl ----------------- HAZARDOUS WASTE DISPOSAL -------------------------- 1 4.00 T 0.0 0.0 ----- Subtotals =_> ---- --------------------- 4.00 4.5 ------ 4.2 Claim # Policy # Deductible: Date of Loss: Type of Loss: Point of Impact: 1 04/05/2007 at 10:51 AM 24443 Job Number: PRELIMINARY ESTIMATE 1998 MERC SABLE GS 6-3.OL-FI 4D SED RED Int: Parts 0.00 Body Labor 4.5 hrs @ $ 51.00/hr 229.50 Paint Labor 4.2 hrs @ $ 51.00/hr 214.20 Paint Supplies 4.2 hrs @ $ 31.00/hr 130.20 Sublet/Misc. ------------------ -------- -- ----- ------ 4.00 SUBTOTAL -- ---- $ ------- 577.90 Sales Tax ------------------- $ ------- 447.70 @ - --- 7.0000% -- --- 31.34 GRAND TOTAL ----- - ---- $ ------- 609.24 ADJUSTMENTS: Deductible ------------------- ------- -- - 0.00 CUSTOMER PAY ------- -- ------- $ ------- 0.00 INSURANCE PAY $ 609.24 WARRANTY VALID ONLY WITH ORIGIONAL COPY OF YOUR RECEIPT PARTS SUBJECT TO INVOICE NO GUARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DE2LN96 Database Date 02/2007, CCC Data Date 02/2007, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the-OEM vehicle dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount. OPT OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships. Asterisk (*) or Double .Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (~) items indicate MOTOR Not-Included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned pants are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries. Some 2006 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The Pathways estimatdr has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership. CCC Pathways - A product of CCC Information Services Inc. 2 AUTO COLLISION SPECIALISTS Federal Tax ID: 60-0002123 Estimate 20752 HIGH STREET Customer No: 2482 Elkader, IA 52043 Report No: 2610 4/9/2007 Phone #: (563) 245-1523 Claim #: Fax #: (563) 245-1523 Assign No: E-Mail: scottw@alpinecom.net Vehicle Information Owner - Margaret Jones Accident Location 1998 Mercury Sable PO Box 5 Style: 4D SED GS/LS Gamavillo, IA 52049 Color: Red Home Phone: (563} 964-2452 Color Code: Work Phone: (563) - Phone #1: - Production Date: / 0 Fax #: (563) - Phone #2: - License: 370AOW State: IA Insured - Claimant - VIN: 1 MEFM50U6WG641943 Miles In: 0 Miles Out: 0 Condition: Estimator: Scott W. Torkelson Insurance COmDanV Home Phone: (563) - Work Phone: (563) - Fax #: (563) - Insurance Information Home Phone: (563) Work Phone: (563) - Fax #: (563) - Agaraisal Comoanv Phone #: - Fax #: - Date Assigned: 4/9/2007 Adjuster: Claim #: Policy #: Deductible: $0.00 Claim Rep: Date of Loss: 4/9/2007 Phone #: - Fax #: - Date of Inspection: 4/9/2007 REAR BUMPER. SEDAN -BUMPER 8 COMPONENTS 1 R&I Rear Bumper cover 1.1 body 2 Repair Rear Bumper cover 3.0" body 3.0 +Clearcoat (1.2) 1 2 DEFAULT CHARGES 3 "Hazardous Waste Disposal $4.00' nontaxed Sub Totals This estimate has been prepared based on the use of one or more crash parts supplied by a source other than the manufacturer of your motor vehicle, warranties applicable to those parts are provided by the parts manufactured or distributor rather than by the manufacturer of your vehicle. ALL DEDUCTIBLES WILL BE PAID IN FULL BEFORE VEHICLE WILL BE RELEASED. Hours Rate Total Body Labor 4.1hrs $48.00/hr $196.80 t Paint Labor 4.2hrs $48.00/hr $201.60 t Paint Supplies 4.2hrs $30.00/hr $126.00 Misc Non-Taxed $4.00 Tax $398.40 @ 7.0000% $27.89 Grand Total $556.29 THANK YOU FOR LETTING US SERVE YOU Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not inGuded. Guide used is (DE2LN96). 9106 "Indicates Estimator's Judgment t Indicates Taxed Item WE WILL E-MAIL DIGITAL PHOTOS UPON YOUR REQUEST-CONTACT AUTO COLLISION SPECIALISTS (563) 245-1523 WITH YOUR E-MAIL ADDRESS. Page 1 of 1