Claim Millard, DarleneCLAIM 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: Darlene Millard
2. Address: 2375 Roosevelt
3. Telephone Number: 556 3493
4. Date of Incident: Monday, April, 15, 2002
5. Time of Incident: 9:30 P.M. - 10 P.M.
6. Location of Incident (Be specific): Corner of Central & 20th Street
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.)
Upon turning off Central Ave. onto Central a temporary stop sign blew over and hit my car on the driver's side. Stop sign was not wieghted. TEmporary signs were in use due to the power outage on Monday, April 15, 2002.
8. What were weather conditions like?
9. Give name and address of any witnesses:
Cares in are, but drove by without stopping.
10. Did police investigate? (If so, give names of officers.)
Not at that time. Officer Olson completed a report on Tuesday, April 16th. The # included with this report - Officer Olson 50A 02 17103
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.)
Door on Driver's Side dented and scratched.
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?
$485.04
16. Why do you claim the City of Dubuque is responsible?
City sign was not secured and blew over hitting car.
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 26th day of April, 2002. , 20 .
/s/ Darlene Millard
(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: Eugene Conklin
2. Address: 1950 Coates
3. Telephone Number: 583 0538
4. Date of Incident: 4 19 02
5. Time of Incident: around 10 - 11 a.m.
6. Location of Incident (Be specific): 1950 Coates front parking area
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.)
Loss of screw of top of large garbage container. The last time of day seen intact 9 a.m.
8. What were weather conditions like? good
9. Give name and address of any witnesses:
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.)
No
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?
$8.00 x .06 = $8.48
16. Why do you claim the City of Dubuque is responsible?
Because it was seen prior to collection, and was gone when I came home a littler after 111 a.m.
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 29th day of April , 2002.
/s/ Eugene Conklin
(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 she Id
complete this form in full and attach any additional information that supports your claim. ~k~
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.
1.
2. Address:
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific):
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: ~-~(/~ t'~FI ~, /F~!/~,~--
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
, mployee'~ name,.)
-'~ -*-I' - ' - ' ' ~ ' ' ~ ' O0
8. What we~ weather condit~ns like? a --
9. Give name and address of any witnesses: ~¢ ~ ~F~ ~
id police investigate? (If so, give names of officers.) ,
11. ~as anyone injured? (If se, 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. 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, giy~ 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?
Dated at Dubuque, Iowa this ~ day of
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Date: 4/t7/2002 10:59 AM
Estimate ID: 370
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Damage Assessed By:
MIKE RUNDE
RUNDE CHEVROLET INC.
780 RT. # 35 NORTH EAST DUBUQUE, IL 61025
(815) 747-3011
Fax: (815) 747-772t
Tax ID: 36-4320504
Accident Date: 4/17/2002
Deductible: UNKNOWN
Insured: DARLENE MILLARD
Address: 2376 ROOSEVELT ST. DUBUQUE, IA 52001
Telephone: Home Phone: (563) 556-3493
Description: 1997 Chevrolet Lumina
Body Styte: 4D Sed
ViN; 2G1WL52MOV9182724
Color: BROWN
Mitchell Service: 913493
Drive Train: 3.1L Inj 6 Cyl AO
Line Entry Labor Line Item Part Type/
Item Number Type Operation Description Part Number
Dollar Labor
Amount Units
1
2
3
4
5
6
7
8
9
10
12
13
14
15
16
17
19
20
300982 BDY REPAIR
AUTO REF REFINISH
301024 BDY REMOVE/INSTALL
301026 BDY REMOVE/INSTALL
302506 BDY REMOVE/REPLACE
301084 BDY REMOVE/INSTALL
900500 BDY* REMOVE/REPLACE
990500 BDY* REMOVE/REPLACE
900500 REF * REPAIR
301196 BDY REPAIR
AUTO REF REFINISH
301200 BDY REMOVE/INSTALL
302572 BDY REMOVE/REPLACE
301222 BDY REMOVE/INSTALL
900500 BDY * REMOVE/REPLACE
AUTO REF ADD'L OPR
AUTO ADD'L COST
AUTO ADD'L COST
L FRT DOOR SHELL
L FRT DOOR OUTSIDE
SCRATCHES & DENTS
L FRT REAR VIEW MIRROR
L FRT BELT MLDG
L FRT UPR DOOR ADHESIVE MOULDING
L FRT OTR DOOR HANDLE
STRIPE L FRT DR
DR EDGE GUARDS
TINT COLOR
L REAR DOOR SHELL
L REAR DOOR OUTSIDE
SCRATCHES & DENTS
L REAR BELT MLDG
L REAR UPR DOOR ADHESIVE MOULDING
L REAR OTR DOOR HANDLE
STRIPE L REAR DR
CLEAR COAT
PAINT/MATERIALS
HAZARDOUS WASTE DISPOSAL
Judgement Item
Labor Note Applies
- Included in Clear Coat Calc
Existing
10281686
GM PART
**Qual Repl Part
**Qual Repl Part
Existing
Existing
10281699
*~Qual Repl Part
GM PART
2.0*#
C 2.2
INC #
0.6 #
41,00 0.2
0.7 #
10,00 * 0.3*
8.00 * 0.4*
1.0'
3.0*
C 1.8
0.3
38.70 0.2
0.7 #
10,00' 0.3*
1.2*
61.20 *
3.10'
ESTIMATE RECALL NUMBER: 4/17/2002 10:59:30 370
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: APR_02_A Copyright (C) 1994 - 2000 Mitchell International
UItraMate Version: 4.7.007 All Rights Reserved
Page I of 2
I. Labor Subtotals
Body
Refinish
Units
Add'l
Labor Sublet
Rate Amount Amount
Totals
8.7 40.00
6.2 40.00
Non-Taxable Labor
0.00
0.00
0.00 348.00
0.00 248.00
596.00
596.00
Additional Costs
Taxable Costs
Sales Tax
Non-Taxable Costs
Total Additional Costs
@ 6.250%
Amount
16t.20
10.08
3.10
174.38
Date: 4/17/2002 t0:59 AM
Estimate ID: 370
Estimate Version: 0
Preliminary
Profile ID: Mitchell
II. Part Replacement Summary
Taxable Pads
Sales Tax @
Total Replacement Parts Amount
6.250%
Amount
107.70
6.73
114.43
IV. Adjustments
Customer Responsibility
Amount
0.00
I. Total Labor:
I1. Total Replacement Parts:
10. Total Additional Costs:
Gross Total:
IV. Total Adjustments:
Net Total:
This is a preliminary estimate.
Additional chanqes to the estimate may be required for the actual repair.
596.00
114.43
174.38
884.81
0.00
884,81
ESTIMATE RECALL NUMBER: 4/17/2002 10:59:30 370
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: APR_02_A Copyright (C) 1994 - 2000 Mitchell International
UltraMate Version: 4.7.007 All Rights Reserved
Page 2
of 2
Date: 4/t7/02 09:24AM
Estimate ID:, 6378
Estimate Version: 0
Preliminary
Profile ID: Mitchell
BIRD CHEVROLET
3255 UNIVERSITY AVE. P.O. BOX 57 DUBUQUE, IA 52001
(~3) 5~3-9t2t
Fax: (563) 556-4482
Tax ID: 42-0400210
Damage Assessed By: JOHN KLOTZ JR.
Deductible: UNKNOWN
Owner DARLEEN MILLARD
Address: 2375 ROOSEVELT DUBUQUE, IA 52001
Telephone: Home Phone: (563) 556-3493
Mitchell Service: 913493
Description: 1997 Chevrolet Lumina
Body S~IS: 4D Sed
VIN: 2GtWL52M0V9182724
Drive Train: 3.1L Inj 6 Cyl AO
Line
Item
1
2
3
4
5
6
7
8
9
10
11
12
Entry Labor
Number Type Operation
300960 REF BLEND
301024 BDY REMOVE/INSTALL
301026 BDY REMOVE/INSTALL
302496 BDY REMOVE/INSTALL
301098 BDY REMOVE/INSTALL
30t196 BDY REPAIR
AUTO REF REFINISH
301200 BDY REMOVE/INSTALL
301206 BDY REMOVE/INSTALL
AUTO REF ADD'L OPR
AUTO ADD'L COST
AUTO ADD'L COST
Line Item
Description
L FRT DOOR OUTSIDE
L FRT REAR VIEW MIRROR
L FRT BELT MLDG
L FRT UPR DOOR ADHESIVE MOULDING
L FRT DOOR KEY KIT
L REAR DOOR SHELL
L REAR DOOR OUTSIDE
L REAR BELT MLDO
L REAR UPR DOOR ADHESIVE MOULDING
CLEAR COAT
PAINT/MATERIALS
HAZARDOUS WASTE DISPOSAL
Part Number
Dollar Labor
Amount Units
Existing
ErJsting
Existing
Existing
C 0.9
INC #
1.0 #
0.5'
0.3*#
1.0'
C 2.2
0.3
0.5*
1.1
t 09.20 *
3.78 *
Labor Subtotals
Refinish
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
Add'l
Labor Sublet
Units Rate Amount Amount
3.6 45.00 0.00 0.00
4.2 45.00 0.00 0.00
Taxable Labor
Labor Tax ~ 6.000 %
Labor Summary 7.8
ESTIMATE RECALL NUMBER: 4/17102 09:21:27 6378
Mitchell Data Version: APR_02_A
Ultretdate Version: 4.7.007
Totals
16Z00 T
189.00 T
351.00
21.06
37~06
II. Part Replacement Summary
Total Replacement Parts Amount
UltraMate is a Trademark of Mit=bell International
Copyright (C) 1994 - 2000 M~chell International
All Rights Reserved
Amount
0.00
Page 1 of 2
III. Additional Costs
Non-Taxable Costs
Total Additional Costa
Amou~
11~98
112.98
Date: 4/17102 09:24 AM
Estimate ID: 63?8
Estimate Version: 0
Preliminary
Profile ID: Mitchell
IV. Adjustments
Customer Responsibility
0.00
I. Total Labor:
II. Total Replacemen~ Parts:
II1. Total Additional Costs:
Gross Total:
372.06
0.00
112~.98
485.04
IV. Total Adjustmenta:
Net Total:
This is a oreliminary estimate.
Additional changes to the est mate may be required for the actual repair.
PARTS PRICES ARE Sb'BJECT TO CHANGE
ESTIMATE RECALL NUMBER: 4/'17102 09:21:27 6378
UltraMate is a Trademark of Mitchell InternaUonal
Mitchell Data Vemion: APR_02_A Copyright (C) 1994 - 2000 Mitchell International
UltraMate Version: 4.7.007 All Righta Reserved
~ 2 of 2