Claim by William MillmanMasterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
cc: Michael C. Van Milligen, City Manager
Marie Ware, Leisure Services Manager
William Millman
MEMORANDUM
To: Mayor Roy D. Buol and
Members of the City Council
DATE: October 4, 2010
RE: Claim Against the City of Dubuque by William Millman
Claimant Date of Claim Date of Loss Nature of Claim
William Millman 10/01/10 09/28/10 Vehicle Damage
This is a claim in which claimant alleges that a City dump truck struck the driver's side
mirror of claimant's vehicle as claimant's vehicle was legally parked in front of 1504
Garfield Avenue.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
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
2. Address: 6 1d. A if e"
3. Telephone Number
4. Date of Incident:
5. Time of Incident: ,
CLAIM AGAINST THE CITY OF DUBUQUE, IO
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: /-/ / �/ / pi �J. /V1 I () Ic'3'L e1 h
6. Location of Incident (Be specific): Ave_ D tk-e-
c_r
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.)
7YLA_—
8. What weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.
!',��
— tJL� i l (
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.)
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.) /7
v
15. What amount do you claim from the City of Dubuque?
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9 s
16. Wh _ do you claim the C'ty of Dubuque is responsibl
17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
CT
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 .
te
day of
Wiethzn-y-?
(Signature)
\ * I Intl 37 /V' I VI-L.- ck
(Print Name)
, 20 /I 'enbn
80 1110 s:1- A110
61'8 WY I -10001
Cft1.9038
formation Exchange Report
NIP
N
T
001
Driver's Name - Last
MAIDEN
Address
3528 ECLIPSE CIRCLE
Gander
Male
Driver's License Number Class
C
Owner Company Name
CITY OF DUBUQUE
❑wner'sName- Last
Address
50 W 13TH ST
First
Dubuque Police Department
563-589-4410
CHt 7Middle JSuffix LDate of faint'
I HFiISTOPWER JOHN
.. Iity , State I Z'p
DUBUQUE IA ; 52003
State IEndorsements ; Restrictions Insurance Co. Name
IA NONE J NONE IOWA COMMUNITIES ASS URA
Insurance Policy #
City -
DUBUQUE
Middle Suffix --
Tstate rZip
IA 52001-
T(m Hoe(Celi Phone
563) 599-9009 x
Insurance Co. Phone #
--1
VIN No
I FDWF36538EE12291
Year
2008
Make
FORD
Model
F35
Style
CB
Vehicle Configuration
12
License Plate
6446
U
N
T
002
State Year Most Damaged Are
IA 2010
Driver's Name - Last
MILLMAN
Address
1504 GARFIELD AVE
Approximate Cost to Repair or Replace
$0.00
First ' Middle Suffix pate of Birth
WILLIAM JOSEPH
[City I State 7 Zip
DUBUQUE IA ' 52001-0000
State Endorsement Rs estrictions Insurance Co. Name
IA NONE INONE FARMERS INSURANCE
Gender
Male
Driver's Class
C
Owner Company Name
Insurance Policy #
184111798
Home/Cell Phone
(563) 582-0766 x
Insurance Co. Phone*
(563) 588.1139 x
Owner's Name - Lest
MILLMAN
Address
1504 GARFIELD AVE
VIN No.
1 GNDM19X04 B111743
License Plate*
�.. Y4074
First
WILLIAM
City
DUBUQUE
County
i Dubuque - 31
Middle !Suffix
JOSEPH T I
State I Zip
IA L52001.0000
Year Make Model
2004 CHEV FAST
State�ar Most Damaged Area
IA 2011 07 • Left Side
Style
VN
Vehicle Conifguradon
03
Approximate Cost to Repair or Replace
$30.00
Accident occurred within corporate limits of (city)
Dubuque - 2100
Literal Description
GARFIELD AVE
X-Coordinate
00692538
Y Coordinate
•04710491
If accident occurred outside of city I Direction
limits show genera[ vicinity. "NIA" : "NIA" of
On Road. Street. or Highway:
GARFIELD
Nearest City
"NIA"
Al intersection with:
"NIA"
!Route (Cardinal)
I Travel Direction "NIA"
Distance
90 Ft
Direction
3-E
Distance Direction Milepost Number
and "N/A" 1'N!A" of "WA" Or
Definable Intersection, bridge, or railroad crossing
GARFIELD AND MARSHALL
Officer
BAUER, BRANDON
Badge No. r Law Enforcement Case Number TDate of Accident Time of Accident
72 01.10.47598 09128/2010 14:55 Hrs.
1
Printed At: Dubuque Police Department 09/28/2010 03:58 PM Page 1
Form #: 01-10-47 598
Customer Receipt
Safe lite® AutoGlass
AUTO GLASS CENTER, INC
2828 UNIVERSITY AVE
DUBUQUE,IA 52001
** SERVICE QUESTIONS **
** CALL 800 -835 -2257 **
Qty Part
1 REDMIR273S
Technician Name
SLATER, JOSEPH A.
Technician Note:
Part Subtotal: 20.00
Flat Labor Subtotal: 0 . 00
Subtotal: 2 0 .00
Sales Tax: 1.40
Deductible: 0 . 00
Amount to Collect: 21.40
Amount Paid: 21.40
Amt Remaining: 0 . 00
Paid Cash, In amount of $21.40
Signature:
Date & Time: 10 /01 /10 08:10AM
Customer: Home Phone:
MILLMAN, WILLIAM Work Phone:
1504 GARFIELD AVE Contact Phone:
DUBUQUE,IA 52001 Work Order #: 01526_235475
(05511_235475)
Year Make --
Model
License Style Stock /Unit#
Y4074
Mileage VIN Purchase - Order#
76745 1GNDM19X0413111743
List Selling Flat
Price Price Labor Kit MTRL
20.00 0.00 0.00 0.00
Tech ID
1526 -706
/•r
Safel a Auto Glass
AUTO GLASS CENTER, INC
2828 UNIVERSITY AVE
DUBUQUE,IA 52001
** SERVICE QUESTIONS **
** CALL 800 - 835 -2257 **
Qty Part
1 REDMIR2735
Technician Name
SLATER, JOSEPH A.
Technician Note:
Part Subtotal: 20 . 00
Flat Labor Subtotal: 0 . 00
Subtotal: 2 0 . 0 0
Sales Tax: 1 .40
Deductible: 0 . 0 0
Amount to Collect: 21 .40
Signature: �''
Date & Time: 10/01/10 08:09AM
Customer: Home Phone:
MILLMAN, WILLIAM Work Phone:
1504 GARFIELD AVE Contact Phone:
DUBUQUE,IA 52001 Work Order #: 01526_235475
(05511_235475)
Year Make Model
License Style Stock /Unit#
Y4074
Mileage VIN Purchase - Order#
76745 1GNDM19X04B111743
List Selling Flat
Price Price Labor Kit MTRL
20.00 0.00 0.00 0.00
Tech ID
1526 -706
Estimate: $21.40. I authorize Auto Glass Center & Safelite AutoGlass to
provide the above - referenced goods and services and to install or repair
glass and related parts that are manufactured by AGC /Safelite or another
aftermarket manufacturer. Subject to completion of the work, I assign to
AGC /Safelite any claim that I have under my Insurance policy to recover,
and authorize my Insurance company to pay AGC /Safelite the balance due.
If said amount Is not paid In full by my Insurance company, I agree to pay
any unpaid balance. If paying by check, and your check Is unpaid for
Insufficient or uncollected funds, we may electronically debit your
account for the principle check amount and a service fee as allowable by
law. You have the right to select the repair facility of your choice. I
have read and understand the Adhesive Cure Time Caution on the attached
form. In most cases, the approximate length of time to complete the tasks
detailed on thls work order Is 45 minutes to 1 hour.