Claim, Sulivan, John J.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: John J. Sullivan
2. Address: 1965 Alta Vista St.
3. Telephone Number: 556 8470
4. Date of Incident: 6-25-01
5. Time of Incident: 11 AM ??
6. Location of Incident (Be specific): In front of 1965 Alta Vista St. on the west side of the 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.)
A crew was filling cracks in the street. One of them must of hit my car because there is tar where the dent was found.
8. What were weather conditions like? Clear
9. Give name and address of any witnesses:
None
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.)
My 86 Chevy Monte Carlo received a dent on the side of the roof. There is tar on it which tells me the City crew did it.
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?
$232.94
16. Why do you claim the City of Dubuque is responsible?
I recently repainted my 86 Chevy and take extra care to keep it looking good. The City crew was working on the other side of the street but came all the way across to my 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 25 day of July, 2001 , 20 .
/s/ John Sullivan
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
West 13th Street, Dubuque, Iowa 52001-4864. It will then be
referred by the City Council to the appropriate Department for
investigation. Once that nvestlgatlon is completed, a report and
recommendation will be submitted to the City Council. You will be
provided with a copy of that report and reco~endation.
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.
4. Date of Incident:
5'. Ti~e Of Incident: ///Z/,,~
6'.
Location of incidant. (Be specific)
7. DESCRIBE ACCIDE~ OR OCC~CE T~T ~USED INJ0~Y OR D~E.
(~ive full details upon which you base your Claim. If a City
~loyee was involved, ~ive the ~ployee's n~e.)
8. ~at were weather conditions like?
9. ~ive n~e ~d address of any witnesses.
10. Did police lnvestzgate. (If so, give names of officers°)
11. Was anyone injured? (If so, give name, address and extent of
injuries. )
230
13.
14.
Was any d~m~ge done to property? (If so, describe property
and the extent of d~unage. Attach estimates of damages or
describe basis for ascertaining extent of d~mage.)
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 a~o~nt paid.)
What amount do you claim from the City of Dubuque?
15.
16. Why do you claim the City of Dubuque is responsible?
17. Have you ~de ~y claim a~a~nst ~yone else ~or d~a~es Zas a
result of this incident9
If yes, ~ive 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 a.t Dubuque, Iowa, this J~-- day of ~'--d~,/,,
2001. '~ ,
(signature)
(Print Name)
HART AUTO BODY & PAINT
gOO CEDAR CROSS ROAD DUBUQUE, IOWA 52003
PHONE: (319) 556-8323
DAMAGE REPORT
PRICES SUBJECT TO CHANGE
Items CIRCLED are not in the total in
our opinion, are not pert of ~;s cl~m.
INSURANCE CO A~U~ER PHONE CAR L~ATED AT
Or Pa;~t Or Ho.~ ~m sym. LE~ ~ s~m. RIGHT
~ Quar. Panel J: ~ Quar. Panel
H~d Hinee R~R MISC.
EPA W~ DI~ ~GE
SERVICE~. OHRS. O~ ~ HR
Windshield Gas Tank SUBLET OR PAINTING
Frame SUB TOTAL
Hub & Drum PAINT~ATRL-HDW.
APpraiSer X
~'ymbol$: ~-Align N-New OR-Open P-Paiot I HEREBY AUTHORIZE THE ABOVE REPAIRS
$-Btraighm R-Replace OH-Overhaul