Claim, Fox, Mark D.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: Mark D. Fox
2. Address: 2644 Pinard St.
3. Telephone Number: 563 557 1550
4. Date of Incident: 7 3 01
5. Time of Incident: Around 5:00 P.M.
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 employee's name.)
On the date of July 3, 2001 I was leaving Eagle Discount Super Market the exit on the Dupaco side of the building
upon leaving the driveway a large piece of cement flipped up and struck my Harley-
Davidson, Heritage Soft Tail 2000. Which caused damaged. At that time I went into Eagles and talked to the Manager. The Manager came out and witnessed the damage and filled out an accident report.
He also took pictures of the bike and the driveway.
At that time the Manager stated that he thought the City was liable because it was
the property.
Enclosed is a copy of the estimate for the Damage done to my Harley Davidson
Heritage Soft Tail 2000. I'm hoping this matter can be resolved. Thank you,
/s/ Mark Fox.
8. What were weather conditions like? Clear - Sunny
9. Give name and address of any witnesses: Sheila Kelly, 911 Tressa, Dbq. IA
Paul Wiebemann, Mgr. Craig Besler Eagles Store, JFK
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.)
See Estimate
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.)
No
15. What amount do you claim from the City of Dubuque? $558.46
16. Why do you claim the City of Dubuque is responsible?
City Property, not maintained.
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 16th day of July 2001. .
/s/ Mark D. Fox
(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.
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. 13~h 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: ~{~ L~L~ ~ [~Ji~ ~.
3. Telephone Number: ~l~'.~)~ ~'1~.~0
4. Date of lncJdent: ?/,~ 0l
5. Time of lncident: ~P~.~//~? _~,~ ~t~'
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
employee's name.,~ (~,~ ~_~~
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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 dar~age~.
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,~give 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
~- ~J?-(~i~ng ng~ture)
(Rev. 1/00 & 7/01)
WILWERTS IMC.
15 NIGHTENSALE LANE
DUBUQUE, IA 52003-
(319> f~7-8040
SEAr!CE ESTIMATE
for FO×~ MARK (571550) Date Printmd 7/ 5/01
2644 PINARD ST, Date In 7/ 5/01
DUBUQ~UE~ IA 52001 Prooised 7/ 5/9!
Home Phone 557-1550
Make Model
.. ula~s Pia~ ~ YIN Re? Board<{ Hr~/Odao
r o r.
Unit N.aop Dea~/CC k~ ..... .~ ,qd~, Eogine N'~ober Kev Nuob~'
Par ~ ~ 3iE,38-08
t.abor
Supplie~
Rose!ut io~
ESTIM~FE 0~ OF~N~GE.
~Reoo~eT~dat i~ns*
~-,,~,.ukET HD HOP ..'
ROSOEBER HO H~P
TOUCH-UP Hi3 HOP 5,25
~ORK RB 3.. 'Z~ 177. E,0
Job Subtotal
Job Pa~ts [_abo~ ~~ ~; Other
Breakdown -> ~o := ~- ~,~
Total nf ali Jobs 58~.85
Before Tax Total 526.85
Repair [~rder Total 558.46