Claim Kohnen, Shawn M.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: Shawn M. Kohnen
2. Address: 1175 Highland Pl Dubuque IA 52001
3. Telephone Number: 563 583 4361
4. Date of Incident: April 8
5. Time of Incident: 3:15 P.M.
6. Location of Incident (Be specific): Loras Blvd
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 was going up Loras Blvd. and a blue car stopped in front of htat. I hit my brakes to avoid hitting him then Officer Tyler hit the back of my care.
8. What were weather conditions like? Rainy
9. Give name and address of any witnesses: None that I know of.
10. Did police investigate? (If so, give names of officers.) Officer Abitz
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
The following morning my neck hurt so I went to the ER doctor at Finley.
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.)
My 84 Skylark Buick was damaged in the read (see attached estimates).
13. What other damages do you claim, if any?
None at this time.
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?
Enough to fix or replace vehicle.
16. Why do you claim the City of Dubuque is responsible?
Cause I was rear end from behind by Officer Tyler
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?
None
Dated at Dubuque, Iowa this 8th day of April, 2002
/s/ Shawn M. Kohnen , 20 .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
'tin
This written report constitutes your claim against the City of Dubuque, Iowe. You should
complete this form in full and attach eny edditionel 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)~~
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
._~ploye~e's.
9. Give name and address of any witnesses:
1 id p~sti~at~(l[so, ~ive names of officers.)
11. Was anyone injured? (If so, giv ames, addresses, and extent of injuries).
12. Was any damage done to property? (If so, describe property and the extent of damages.
A~tach 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 C,ty of' Dubuque.~ ~.~-~
16. Why 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.
and if so, in what amount?
If the answer to Question 17 is yes, have you received any payment from that source~
Dated at Dubuque, Iowa this
dayof
(Signature)'
(Print Name)
(Rev. 1/00 & 7/01)
04/10/2002 at 09:28 AM
30799
]ob Number:
BRI~EYER AUTO BODY
License #:30799 Federal ID #:421438480
10727 JOHN F. KENNEDY RD
OUBUQUE, IA 52001
(563)583-4456 Fax: (563)583-1838
PRELIMINARY ESTIMATE
Written by: ERIC WINCH
Adjuster:
Insured: SHAWN KOHNEN
Owner: SHAWN KOHNEN
Address: 1175 HIGHLAND PL
DUBUQUE, IA 52001
Day: (563)583-4361
Claim #
Policy #
Deductible:
Date of Loss:
Type of Loss:
Point of I~pact:
6. Rear
Inspect
Location:
Insurance
Company:
Days tO Repair
1984 BUIC SKYLARK LIMITED 6-2.8L-2 2D SILVER Int:
VIN: 1G4AC37XSEW442207 Lic: Prod Date: Odometer: 83000
Clear Coat Paint Power Steering Power Brakes
Cloth Seats Deluxe wheel Covers
NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT
1# ****COST OF REPAIRS EXCEED 1
2# THE VALUE OF THE VEHICLE****
Subtotals ==> 0.00 0.0 0.0
04/10/2002 at 09:28 AM ]ob Number:
30799
PRELIMINARY ESTIMATE
1984 BUIC SKYLARK LIMITED 6-2.8L-2 2D SILVER Iht:
Parts 0.00
GRAND TOTAL $ 0.00
ADJUSTMENTS:
Deductible 0.00
CUSTOMER PAY $ 0.00
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from
the Guide DOiAE80 Database Date 10/1998 and the parts selected are 0EM-parts manufactured by the
vehicles Original Equipment Manufacturer. 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. Non-Original Equipment Manufacturer aftermarket parts are described as AM
or Qual Repl Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned
parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Prices
are provided from National Auto 61ass Specifications, Inc. Pound sign (#) items indicate manual
entries.
Pathways - A product of CCC Information Services Inc.
2
Date: 4/10/02 08:48 AM
Estimate ID: 3843
Estimate Version: 0
Preliminary
Profile ID: Mitchell
LENNY VALENTINE & SONS, INC.
923 PERU RD DUBUQUE, IA 52001-8604
(663) 588-4659
Fax: (563) 588-4650
TWO CONTINENTAL FRAME M~CHINES
GENESIS II COMPUTERISED MEASURING SYSTEM
PRICE IS EASY TO BEAT/QUA.LIT¥ IS NOT
UNIBOD¥ SPECIALISTS
Damage Assessed By: DICK VALENTINE
Deductible: UNKNOWN
Owner SHAWN KOHNEN
Address: '1t75 HIGHLAND PL DUBUQUE, IA 52001
Telephone: Home Phone: (563) 583-4361
Mitchell Service: 918479
Description: 1984 Buick Skyhawk Limited
Body Style: 2D Cpe
Drive Train: 2.0L lnj 4 Cyl
Line Entry Labor Line Item Part Type/
Item Number Type Operation Description Part Number
900500 BDY* REPAIR
COST OF REPAIRS EXCEEDS VALUE
* - Judgement Item
Existing
Dollar Labor
Amount Units
0.0~
Add'l
Labor Sublet
[. Labor Subtotals Units Rate Amouht Amount Totals
Labor Summary 0.0 0.00
Ill. Additional Costs Amount
Total Additional Costs 0.00
]L Part Replacement Summary
Total Replacement Parts Amount
IV. Adjustments
Customer Responsibility
Amount
0.00
Amount
0.00
ESTIMATE RECALL NUMBER: 4/10/02 08:46:16 3843
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Mitchell Data Vemion: Copyright (C) 1994 - 2000 Mitchell Intemafional
UltraMate Version: 4.7.007 All Rights Reserved
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