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Claim by Chad FuryTHE CITY OF DUB TE MEMORANDUM Masterpiece on the Mississippi TRACEY STECKLEIN PARALEGAL 40 To: Mayor Roy D. Buol and Members of the City Council DATE: August 21, 2010 RE: Claim Against the City of Dubuque by Chad Fury Claimant Date of Claim Date of Loss Nature of Claim Chad Fury 08/18/10 08/14/10 Vehicle Damage This is a claim in which claimant alleges that a City of Dubuque bus struck his vehicle while it was parked at 793 Clarke Drive. This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa Communities Assurance Pool. cc: Michael C. Van Milligen, City Manager Barbara Morck, Transit Manager Chad Fury OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001 -6944 TELEPHONE (563) 583 -4113 / FAX (563) 583 -1040 / EMAIL tsteckle @cityofdubuque.org / 9 % . CLAIM AGAINST THE CITY OF DUBUQUE, IOWA /7 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 13 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: k CCL LLB 2. Address: I c 4 C tc r Imo-- r 3. Telephone Number 5`' l c )--C - 85 53 4. Date of Incident: , � � 0 1 5. Time of Incident: 1 fJ S 6. Location of Incident (Be specific): 7 iJ C1 it hr 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 employee's name.) rr Cc, � �`x�S /,ter -I- � -41 b- S �' r I . L Lh'45 8. What were weather conditions like? 9. Give name and address of any witnesses: n , o-{ 1, LA's ;e/l - 7 `13 C L 62 /,) l 10. Did police investigate? (If so, give names of officers.) �/.� IL rAvec\c, (45 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). X11 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.) Y" 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.) /tA 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, give name and address.) J) 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 (Signature) (Print Name) day of , 20 j . Q o}• CrZ c DJ C CO 0 %� Fri i 0 3 m > o 0 : o PHON OWNER DATE VEHI LE a ( 7�i / .-� /Jl' 1 L / 9 , .1-17.2 C -het.I Fo - MAKE �jY MODEL LICENSE MILEAGE COLOR SERIAL NO. CONDITION I 7 / Ye" C C' 6�v INSURANCE CO ADJUSTER PHONE Sym. LEFT Fender, Frt. Sublet Or Paint - r Service $ Or Hours nli CAR LOCATED Parts r' ..? AT RIGHT Sym. R Fender, Frt. Sublet Or Paint DEDUCTIBLE Service $ Or Hours Parts Sym. FRONT Bumper W /Pads Sublet Or Paint Service $ Or Hours Parts yk , Bumper Abs. Fender Shield Fender Ext. -- Fender Shield Fender Ext. Fender MIdg. Side - Fender Mldg. Side Fender Stripe -- Fender Stripe Fender MIdg. -- Fender Midg. - _ Bumper Reinf. -- Bumper Brkt. Side Light Asmbly -_ Side Light Asmbly Bumper Cushion - /mom . 02 Headlamp -_ -_ Valance Headlamp Door -_ Headlamp Dr. Bumper Gd. Sealed Beam -- -- Sealed Beam Park Light Frt. S tem Park Light Frame Cowl -- Cowl Cross Member Door, Front Door Hinge -- -- Door, Front Door Hinge Wheel Hub Cap Disc Door Panel -- Door Panel Lr. Cont. Arm Door Stripe -- Door Stripe Door Midge. Door Midg. Up. Cont. Arm -111011111 Center Post - Center Post Door Rear Door Rear Bumper Filler Door Mldg. -- Door MIdg. Grille F 0. 27 Grille Panel -- -� Grill Panel MIdg. Rocker Panel -- Rocker Panel M , = Rocker Midg. C IM ` Rocker MIdg. Floor Floor Dog Leg Quar. Panel _- -- Dog Leg Quer. Panel Air Condenser Quar. Ext. -- Quar. Ext. -_ Recharge System Quar. Wheel House -- Quar. Wheel House Name Plate Quar. MIdg. Side -- Quar. Midg. Side Baffle, Upper Quar. Midg. -- Quar. MIdg. == Lock Plate, Lr. Quar. Stripe _- Quar. Stripe Lock Plate, Up. Side Light Asmbly -- Side Light Asmbly Tail Light Hood Top Tail Light Hood Hinge REAR MISC. Hood Lock Bumper Inst. Panel Ornament Bumper Abs. Front Seat Rad. Sup. Bumper Cushion Front Seat Adj. Rad. Core Bumper Reinf. Top Anti Freeze Bumper Brkt. Headlining Rad. Hoses Bumper Gd. Top Vinyl Fan Blade Bumper Filler Tire % Worn Fan Shroud Valance Painting I G. r Fan Belt Lower Panel Aerial Water Pump Floor Rust Proof Water Pump Pulley Trunk Lid Battery Motor Mts. Trunk Mldg. EPA WASTE DISPOSAL CHARGE • 0 Lic. Light PARTS (Prices Subject To Invoice) @,fo HR. 1 : 14 • ,4 i,7 #,,S 1 SERVICESI71HRS. Windshield Gas Tank SUBLET OR PAINTING c1, q N. qJ Frame SUB TOTAL Wheel TAX ( 7 •4L Hub & Drum PAINT - MATRL -HDW. a, l 6. 6 7 Axle \ Spring GRAND TOTAL a, $ T 9 .S • • HART AUTO BODY & PAINT 800 CEDAR CROSS ROAD DUBUQUE, IOWA 52003 PHONE: (563) 556 -8323 FAX: (563) 556 -8324 Appraiser Symbols: A -Align N -New OP -Open P -Paint I HEREBY AUTHORIZE THE ABOVE REPAIRS S- Straighten R- Replace OH-Overhaul X DAMAGE REPORT PRICES SUBJECT TO CHANGE Items CIRCLED are not in the total in our opinion, are not part of this claim. ,... _ ce-,epariment 08,1412010 03:?2 PM Page 1 Form #: 01-10-39055 �1 Driver Information Exchange Report Dubuque Police Department 563-589-4410 u Driver's Name - Last STROHMEYER First Middle I Suffixi~ ate of Birth WAYNE 1. LOU_ IS N Address 3403 WALLER ST _ City i State DUBUQUE + IA Zip 52002-0000 Home/Cell Phone (563) 589.4196 x T Gender Male Driver's License Number i Class A State IA Endorsements P Restrictions M Insurance Co. Name IOWA COMM. ASSURANCE Insurance Co. Phone # (563) 589-4196 x 0i31 Owner Company Name CITY OF DUBUQUE KEYLINE Insurance Policy* Owners Name - Last First l Middle Suffix Address 50 W 13TH ST City DUBUQUE State IA Zip 52001• I VIN No. 4RKJNTFA22R835550 Year L2002 Make RTS [ Model 62VN Style r BU Vehicle Configure/eon 18 License Plate # 85985 I Stale IA I Year 1 2020 1 Most Damaged Area 04 - Right Rear I Approximate Cost to Repair or Replace $250.00 U Driver's Name - Last First 1 Middle 1 Suffix Date of Birth N Address City State Zip HometCell Phone T Gender i Driver's License Number Class �_ L t Endorsements State 1NONE Restrictions NONE Insurance Co. Name Insurance Co. Phone # NONE 002 Ovmer Company Name Insurance Policy # Owner's Name - Last FURY First CHAD Middle MICHAEL r Suffix _ Address 793 CLARKE DR ,1 City DUBUQUE State IA Zip 52001- i VIN No. 1IWFT81L4X5613984 Year I Make 1999 I MERC Model Style COU r 2D Vehicle Corrfigenateofr 01 •e. License Plate # I Stale 470XBJ IA Year Most Damaged Area 2011 1 08 - Left Front Approximate Cost to Repair or Replace $2,000.00 i County Accident occurred within corporate limits of (city) Dubuque - 31 'Accident - 2100 1_1[Crdr VCSGfi[]1ir]rr CLARKE DR X-Coordinate 00690371 Y-Coordinate 1 04709086 I If accident occurred outside of city limits show general vaolnity: "NIA" Direction "NIA" of Nearest City Route (Cardinal) I "NIA" i Travel Direction "NIA" ' On Road, Street, or Highway: ' CLARKE DR At Intersection with: "NIA" Distance !Direction Distance : Direction 50 Ft 13.E and I "NIA" "NIA" of Milepost Number "N/A" Or Definable intersection, bridge, or railroad crossing CLARKE/WOOD WORTH . Officer AVENARIUS, KATHERINE Badge N . 38 Law Enforceme t Ca Number I Dale of Accident I Time of Accident 01-10-39055 t 02/14/2010 114:57 Hrs Printed At: Dubuque Police Department 08M1412010 03:32 PM Page 1 Form #; 01.10.39065