Claim, Paul, Carol J.CLAIM AGAINST THE
CITY OF DUBUQUE
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 musu be filed with the City Clerk at City Hall, 50
Wesu 13th Street, Dubuque, Iowa 52001-4864. 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 J. Paul
2. Address: 22 Collins St.
3. Telephone 563 556 4219
4. Date of Incident:Jan 2001 til present - April 13, 2001
5. Time of Incident:
6. Location: in Alley behind Collins & Gondolfo Streets - towards Dodge - Hwy 20.
7. DESCRIBE ACCIDENT OR OCCURENCE:
While driving in and out of alley - the entrance are on Lomboard & St. Josephs St. my van will hit the cement. I have explained
in letter - due to entrance & exit of alley
8. Weather: snow snow & Ice & Clear.
9. Witnesses: Husband, Doug Paul, Son Steven Paul,,, Mother : Mary ?
10, Police Investigate: No.
11. Injury: No.
~ployee was involved, ~ive the employee's n~e.)
8. ~at were weather conditions like? ~ ~ ~% ~;
10. Did police investigate? (If so, g~ve n~es of offxoers.)
11. Was anyone injured? (If so, give
injuries.)
address and extent of
12. Was any damage done to property? (If so, describe property
and the ex~en~ of 'damage. Attach estimates of damages or
describe basis for ascertaining extent of damage.)
No.
13. What other d~ges 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.
What amount do you claim from the City of Dubuque?
15.
Why do you
claim the City of DUbuque is responsible?
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 to Question 17 is yes, have you received
payment from that source, and if so, in what amount?
any
Dated at Dubuque, Iowa, this day of
20
/s/ Carol J. Paul
Date:
Estimate ID:
Estimate Version:
Supplement:
Preliminary
FINAL
Profile ID:
4113101 11:24AM
t5-3055-4070t
0
1 (F) 4/13/01 11:24:07AM
SERVICE FIRST
10.
Labor Subtotals Units
Body 8.0 40.00
Refinish 4.8 40.00
Taxable Labor
Labor Tax
Add'l
Labor Sublet
Rate Amount Amount
Labor Summary 12.8
0.00 0,00
0.00 0.00
@ 6.000%
Additional Costs
Non-Taxable Costa
Total Additional Costa
Totals II. Part Replacement Summary
320.00 T
192.00 T Total Replacement Parts Amount
512.00
30.72
542.72
Amount IV. Adjustmenta
105.60 Insurance Deductible
105.60 Customer Responsibility
I. Total Labor:
II. Total Replacement Parts:
II1. Total Additional Costa:
Gross Total:
Amount
0,00
Amount
100.00-
542.72
0.00
105.60
648.32
Total Adjustments:
Net Total:
Less Origir~al Net Total:
Net Supplement Amount:
S1: JEFF LEICK
100.00-
548.32
54~32
0.00
0.00
This is a preliminary estimate.
Additional chanqes to the estimate may be reuuired for the actual renair.
Inspection Site: MIKE FINNIN FORD
BodyShop: MIKE FINNIN FORD
Address: 3600 DODGE ST
DUBUQUE, IA 52003
*** PART PRICES SUBJECT ~0 INVOICE ***
ESTIMATE RECALL NUMBER: 41ttl0t 17:18:34 15-3055-40701
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