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Claim - Ernst, CarolCLAIM 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: Carol Ernst 2. Address: 5125 Roller Coaster Rd. Epworth IA 3. Telephone Number: 563 876 5506 Work 563 589 5942 4. Date of Incident: 28 Dec 2001 5. Time of Incident: 7:45 to 8:00 A.M. 6. Location of Incident (Be specific): US 20 & Wacker Drive Dubuque, IA 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.) Key Line City bus threw rock and cracked windshield 8. What were weather conditions like? 30 degrees F & Clear 9. Give name and address of any witnesses: None 10. Did police investigate? (If so, give names of officers.) No 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.) 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? 16. Why do you claim the City of Dubuque is responsible? City bus threw rock 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 2nd day of January, 2002 , 20 . /s/ Carol A. Ernst (Signature) (Print Name) (Rev. 1/00 & 7/01) 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): ~.4/~ ¢~0 ~) ~ ~)~ / 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.) /~.~ F~ ~.. ~-~-~ ~2~ 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. Wh~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 t° 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~-~ -~ © - (Signature) (Print Name) (Rev. 1/00 & 7/01) G 0 C Auto Glass Center 2828 University Dbbuq ue, IA 52001 PH: (3 1 9) 556--0873 (800) I~IIT TO:~'T0 GIJtS9 CENTER INC, Box 78687, Itil~ukee, iii ~78~7 942--0012 138999 CUSTOMER STATE TAX OR EXEMPT NO. CUSTOMER FEDERAL T,~ I.D. NO. BILL TO: ERNST, GARY EPI,~ORTH, IA 5E~045 Ha: 563-87G-55~E, Quote 01-03-~00~ QUOTE BOLD TO: INSURANCE CO. INSURANCE CO. PHONE NO. POLICY NAME AGENT NAME AGENT PHONE POLICY NO, CLAIM NO, CAUSE & LOBS LOCATION VERIFIED BY DATE OF LOSS DEDUCTIBLE. Pa~t Number DW01105 GBNMGV Part Numbe~ W~T DllO~ B G~een/Blue 16.95-~U & Dam 2.8H ~8.00 ~30.00 Desc~igtion List Moulding(Black)(Top)(W/Retaine~s) 5~.50 378.00 Sell CERTIFICATE OF SATISFACTORY REPAIR ] have personally read the aDove oss infonmafion and declare that they are true. The glass referred to above has peen reD~aceo to my satisfaction, and [ hereby authorize payment lor this work to be made directly to Auto Glass Center. in full settlement of the insurance company's obligations under my policy for said loss, I understand I am financially responsible for any cna~Jes not covered by this agreement SERVICE CHARGE IS COMPUTED ON A PERIODIC RATE OF 2% PER MONTH, WHICH IS AN ANNUAL PERCENTAGE RATE OF 24%. Subtotal 475. 6.00% Tax ~8. TERMS Cash 583 DUBUQUE 3345 Hillcrest Rd. Dubuque IA 52002 800-282-6700 319-557-7455 * * * PRICE QUOTE * * * · PRICE QUOTE NUM: QUOTE DATE: 00000406070 1/3/2002 OWNER: GREG ERNST BILL TO: DBCASHA DB RETAIL CASH CUSTOMER 5125 ROLLER COASTER ROAD EPWORTH IA 52045 Home: 563-876-5506 1998 PONTIAC BONNEVILLE 4 DOOR SEDAN VlN 3345 HILLCREST ROAD DUBUQUE ia 52002 Business: (319) 557-7455 Fax: (563) 556-2480 VEHICLE/PART INFORMATION PART NUMBER DW01105 GBN 5560321 HAH000448 DESCRIPTION Windshield (Solar Controlled)(33 x DW1105/6/34/6 MLD, CHRM GM FAST CURE ADHESIVE SYSTEM QTY LIST PRICE MATERIAL LABOR I 630.00 220.50 62.30 1 58.00 58.00 0.00 1 0.00 24.95 0.00 SUBTOTAL TOTAL 282.80 58,00 24,95 365.75 THIS QUOTE SUBTOTAL IS WITHOUT TAX OR ANY POSSIBLE PARTS THAT MAY BE REQUIRED TO COMPLETE THE INSTALLATION CONDITION OF A PRICE QUOTE The pdce for authorized repairs will not be exceeded if the motor vehicle is delivered to the shop or otherwise made available for service within 10 days of the date on this price quote. If a "P" appeam in the "~" column, it indicates that the respective part may be necessary to complete the job. The price for this part is NOT included in the total amount. QUOTED BY: 1/3/2002 4:19:55 PM FIGURE # OPS 3.9 REVISION: 7/25/2001 Page 1 of 1