Claim by Leonard_Hellen McIntire/ ~~9~C~
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 West 13th St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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 alJ 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.
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1. Name of Claimant: ~ n4 ~L Tv -4 5 5t-~2t> ~ Er< ~i
2. Address: PD ~ox l a ~(v l1/l~ NN r~l-,dD~G.'S ~-'1~ SsYyO
3. Telephone Number Asa -933 . '~S~Y ~~-~ ~-a7~- ~~~~
4. Date of Incident: 1M IqM~~, oZ~U
5. Time of Incident: ~ l: OO !q-. Wt
6. L cation of Incide t (Be specrf
7. Describe the accident or occurrence that caused injury or damage. (Give full
details upon which you base your claim. If a City employee was involved, give
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9. Give name and address of any witnesses:
No
10. Did police inve tigate? (If o, give names of officers.)
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8. What were weather conditions like?
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
of damages. Attach estimates of damages or describe basis for asce
extent of damage.) ~ ,~ ,
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13. What other damages do you claim, if any?
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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
Omni int n~irl 1 /9
16. Vey do you claim the City of Dubuque is, rgspon~ib
17. Have you made any claim against anyone else for damages as a result of
this incir~ent? (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?
Date this day of ~(.~/(/~ , 20~ --~
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(Print Name) ~ ~ . ' '.
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15. What amount do you claim from the City of Dubuque?
YAGER AUTO BODY INC
4488 DODGE ST
DUBUQUE, IA 52003-2600
PHN: 563 557 7376 FAX: 563 557 1709
*** SUPPLEMENT 2 ***
05/09/2007 09:11 AM
Sy 05/25/2007 02:22 PM
^
Owner: LEONARD 8 HELEN MCINTIRE
Address: 3233 LAKE RIDGE DR AP Home/Evening: (563)556-1410
City State Zip: DUBUQUE, IA 52003 FAX:
Claim #: 00271490827-OC Insured Policy #: 1641334701
Loss Date/Time: 05/08!2007 Loss Type: Collision
Deductible: $500.00
Ins. Company: American Family Insurance
Agent: CHARLIE MILLER
Insured: LEONARD 8 HELEN MCINTIRE
Address: Work/Day: (563)556-1410
.-
Inspection Date: 05!09/2007 01:38 PM Inspection Type: Direct Repair Program
Primary Impact: Left Front Comer Secondary Impact:
Driveable: Yes Rental Assisted:
Assigned Date/Time: Received DatelTime: 05/10/2007 01:34 PM
First Contact DatefTime: Appointment Date/Time: 05/10/2007 07:00 AM
Appraiser Name: MIKE YAGER Appraiser License #:
Orig Appraiser Name: MIKE YAGER Appraiser License #:
•.
Repairer: YAGER AUTO BODY Contact: MIKE YAGER
Address: 4488 DODGE ST Work/Day: (563)557-7376
FAX: (563)557-1709
City State Zip: Dubuque, IA 52003 Work/Day:
Target Complete Date/Time: Days To Repair: 6
2006 Toyota Camry LE 4 DR Sedan
4cyl Gasoline 2.4
5 Speed Automatic
LIc.Plate: MAC 937 Lic State: IA
Lic Expire: VIN: 4T16E32K96U111637
Prod Date: Mileage: 23,486
05/25/2007 03:27 PM Page 1 of 3
2006 Toyota Camry LE 4 DR Sedan 05/09!2007 09:11 AM
Clalm #: 00271490827-OC 05/25!2007 02:22 PM
Veh Insp#: Mileage Type: Actual
Condition: Code: Y17436
Ext. Color: GOLD Int. Color:
Ext. Refinish: Two-Stage Int. Refinish:
•. .
Alarm System Air Conditioning Anti-lock Brakes
Center Console Compact Disc Player Cruise Control
Dual Airbags Intermittent Wipers Keyless Entry System
Lighted Entry System Overhead Console Power Brakes
Power Door Locks Power Drivers Seat Power Mirrors
Power Steering Power Windows Rear Window Defroster
Rem Trunk-UGate Release Split Folding Rear Seat Strg Wheel Radio Control
Tachometer Tilt Steering Wheel Tinted Glass
U.S.A. Built Vehicle Velour/Cloth Seats
~. ..-
•. ~- ~•
1 E 5 Bumper,Front 52021AA040 $154.47 2.4 SM
2 EC 6 Cover,Front Bumper Replace Economy $166.00' 1.0 SM
3 L 6 13 Cover,Front Bumper Refinish 3.7 RF
4 E 13 Reinf,Frt Bumper Upr 52029AA030 $26.37 S2 1.0" SM
» AFTER REPAIRS WERE FINISHED
5 E 7 Absorber,Front Bumper 52611AA040 $54.36 INC SM
6 N 973 Headlamps Aim Additional Labor 0.4 SM
7 E 90 Lens,Headlamp LT 8117006180 $262.27' S1 0.3 SM
» PRICE PER INVOICE
8 E 152 Skirt,lnner Fender LT 53876AA011 $63.53 INC SM
9 E UT FRONT BUMPER RETAI Replace OEM $26.75' S1 SM*
» PRICE PER INVOICE
10 L L!T FRONT BUMPER RETAI Refinish 0.2" RF*
11 E NUT Replace OEM $0.63" S2 SM"
» PT#9017906274
12 E NUT, FLANGE Replace OEM $0.49" S2 SM"
» PT#90178A0046
13 E BOLT, WASHER Replace OEM $0.57" S2 SM'
» PT#9010506260
13 Items
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
Gross Parts $589.44
Other Parts $166.00
Paint Materials $117.00
Parts 8 Material Total $872.44
Tax On Parts Only @ 7.000% $52.88
Sheet Metal (SM) $49.00 4.7 0.4 5.1 $249.90
Mech/Elec (ME) $49.00
Frame (FR) $52.00
Refinish (RF) $49.00 3.9 3.9 $191.10
Paint Materials $30.00
Labor Totai 9.0 Hours
Tax on Labor @ 7.000%
$441.00
$30.87
05/25/2007 03:27 PM Page 2 of 3
2006 Toyota Camry LE 4 DR Sedan
Claim #: 00271490827-OC 05/09/2007 09:11 AM
05/25/2007 02:22 PM
51,397.19
Gross Total $500.00-
Less: Deductible
Net Total 5897.19
Actual Supplement Total $82.45
$814.74-
Less: Previous Net Total
Net Supplement Total (Final Bili) 582.45
Alternate Parts C/00100/00/00/00 CUM 00/00/00/00/00 Zip Code: 52003 Geo 52003
Recycled Parts Y/0/0 Zip Code: 52003 INV DATE: 05/09/2007
Audatex Estimating 4.0.469 S2 05/25/2007 03:27 PM REL 4.0.469 DT 04/01/2007 DB 05114/2007
Copyright {C) 2006 Audatex North America, Inc.
1.1 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWOSTAGE REFINISH FORMULA.
=User-Entered Value E =Replace OEM NG =Replace NAGS
EC =Replace Economy OE =Replace PXN OE Srpls UE =Replace OE Surplus
ET =Partial Replace Labor EP =Replace PXN EU =RECYCLED PART
TE =Partial Replace Price PM =Replace PXN Reman/Reblt UM =Replace Reman/Rebuilt
L =Refinish PC =Replace PXN Reconditioned UC =Replace Reconditioned
TT =Two-Tone SB =Sublet Repair N =Additional Labor
BR =Blend Refinish I =Repair IT =Partial Repair
CG = Chipguard RI = R 8 I Assembly P =Check
AA =Appearance Allowance RP =Related Prior Damage
This report contains proprietary information of Audatex and may not be disclosed to any
~# r~~ ~~~ third party (other than the insured and claimant) without Audatex's prior written consent.
: Soko Fow~psny Copyright (C) 2006 Audatex North America, Inc.
The Audatex is a registered trademark of Audatex North America, Inc.
05/25/2007 03:27 PM Page 3 of 3
Betsy Grahek 13:09:39 Tue Jun 'O, 2007
PAYMENT RECORD DISPLAY
ISSUED ACTIVITY
DRAFT 0094236070 CLAIM 00-271-490827 POLICY 16-413347-01 LKL012 SYSTEM
PAYEE: YAGER AUTO 05/25/2007 06/06/2007
IN PAYMENT OF: COLLISION LOSS OCCURRING 05/08/2007 DEDUCTIBLE PREVIOUSLY APPL
SUPPLEMENT - LEONARD & HELEN MCINTIRE
MAILED TO: YAGER AUTO SERIES:
PAGE:
4488 DODGE ST
DUBUQUE IA 52003
COMMENTS: SUPPLEMENT - MCINTIRE
LKL012
STATUS: 05 RECONCILED TYPE: O1 CLAIMANT LOSS ACCTG:
ID PERIL AMOUNT
00 025 82.45 TOTAL: 82.45 TIN: 421131724
TIN WITHHOLDING: 0.00 TYPE: 1
------------ HANDLING:
PAYMENT AMOUNT: $82.45
OPT -- POL -- ------ -- CLM -- --- ------ DRFT ----------
Betsy Grahek 13:09:49 Tue Jun '^. 2007
PAYMENT RECORD DISPLAY
ISSUED ACTIVITY
DRAFT 0094231973 CLAIM 00-271-490827 POLICY 16-413347-01 LMG050 SYSTEM
PAYEE: YAGER AUTO 05/15/2007 05/30/2007
IN PAYMENT OF: COLLISION LOSS OCCURRING 05/08/2007 500 DEDUCTIBLE APPLIED
MAILED TO: YAGER AUTO SERIES:
PAGE:
4488 DODGE ST
DUBUQUE IA 52003
COMMENTS: FINAL BILL
CRP LMG050
STATUS: 05 RECONCILED TYPE: O1 CLAIMANT LOSS ACCTG:
ID PERIL AMOUNT
00 025 814.74 TOTAL: 814.74 TIN: 42113 1724
TIN TiVITHHOLDING: 0.00 TYPE: 1
- ----------- HANDLING:
PAYMENT AMOUNT: $814.74
OPT -- POL -- ------ -- CLM -- --- ---- -- DRFT ------- ---
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6/19/2007 Betsy A Grahek