Claim by Greg DroesslerTHE CITY OF DUBUQUE, IOWA
CLAIM AGAINST
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 'mil
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 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: Greg Droessler
2. Address: 1290 Kelly Lane
3. Telephone Number 563-556-07624.
4. Date of Incident: Approx. 10-29-07/10-30-07
5. Time of Incident: 2:45 p.m.
6. Location Rockdale Rd bridge/& Kelly Ln. bridge
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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
the em/ployee's name.) / / /~, /
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8. What were 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.) ~ lU
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.) > l
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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
amount paid.)
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15. ..h/at amyount do you claim from the/City of Dubuq
u/e?
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16. Why do you claim the City of Du>bugue is responsible? /
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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 this ~l-~~ -O7day of , 20
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11/06/2007 at 08:52 AM
30799
Job Number:
BRIMEYER AUTO BODY
License #:30799 Federal ID #:421938480
10709 COLLISION DR.
DUBUQUE, IA 52001
(563)583-4956 Fax: (563)583-1838
PRELIMINARY ESTIMATE
Written By: TOM BRIMEYER
Adjuster:
Inspect
Location:
Insured: GREG DROESSLER
Owner: GREG DROESSLER
Address: 1290 KELLY LN
DUBUQUE, IA 52003
Day: (563)556-0762
Claim #
Policy #
Deductible:
Date of Loss:
Type of Loss:
Point of Impact:
Days to Repair
Insurance
Company:
2003 DODG RAM 1500 4X4 QUAD CAB B-5.9L-FI 4D SHORT Int:
VIN: UNK Lic: Prod Date: Odometer:
Air Condit ioning Intermittent Wipers Dual Mir rors
Clear Coat Paint Power Steering Power Br akes
AM Radio FM Radio Stereo
Cassette Search/Seek Anti-Loc k Brakes (9 )
Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes
Rear Step Bumper Automatic Transmission 4 Wheel Drive
Overdrive
----------
------ Styled Steel Wheels
---------------------------
NO.
----------
OP.
------ -------------------
DESCRIPTION QTY EXT. PRICE
------------------- -----------------
LABOR PAINT
1# ------------------
BUFF COMPLETE & WAX 1 --------- -----------
8.0 ------
2#
----------
------ MATERIALS 1
--- 20.00
----------------------------------
Subtotals =_> ---------
20.00 -----------
8.0 ------
0.0
Parts 20.00
Body Labor 8.0
--------------------------- hrs @ $
------ 51.00/hr 408.00
SUBTOTAL -- -----------
$ ------
428.00
Sales Tax $
--------------------------- 428.00 @
-------- 7.0000
----- 29.96
GRAND TOTAL ------
$ ------
457.96
ADJUSTMENTS:
Deductible
---------------------------
----- 0.00
CUSTOMER PAY --- -----------
$ ------
0.00
INSURANCE PAY $ 457.96
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from
the Guide DR3TA02, CCC Data Date 10/01/2007, 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 parts are described as
Recond. 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 estimator has
a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the
local dealership.
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