Claim - Saboe, Karen A.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: Karen A. Saboe
2. Address: 2217 Woodland Dr., Apt. 3
3. Telephone Number: 563 556 9492
4. Date of Incident: Sunday, August 5, 2001
5. Time of Incident: 10 A.M.
6. Location of Incident (Be specific): Exiting north driveway of apartment complex onto Woodland Dr.
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.)
When I was exiting the driveway and turning right onto Woodland Dr., rear right tire of car hit a large depression in ground and jagged edge of curb causing tire to blow.
8. What were weather conditions like? Dry, hot, humid.
9. Give name and address of any witnesses: Sara Saboe - daughter.
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.)
Right rear tire immediately blew upon impact. Tire had tear along wall. Unable to repair. New Tire needed to be
purchased.
13. What other damages do you claim, if any?
None, only payment for the tire that was purchased.
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?
Cost of tire $62.90
16. Why do you claim the City of Dubuque is responsible?
Depression in ground needs to be filled in and curb fixed - Street Maintenance Dept. - notified on Monday, August 6th.
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?
None
Dated at Dubuque, Iowa this 19 day of August , 2001
/s/ Karen A. Saboe
(Signature)
* Photos included along with recept from tire purchase.
(Print Name)
(Rev. 1/00 & 7/01)
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:
2. Address=
3. Telephone
4. Date of Incident:
5. Time of Incident:
6. Locationoflncident (Be specific): ~.~.,-{-[ ~, n~ ~-~ ~ ~,!,~ ~ ¥
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 damages~
Attach estimates of damages or describe basis for ascertaining extent of damage.)
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?
d
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
day of
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
ANDERSON - WEBER, INC.
m0 c r Rp.o. BoxG"°VE 3 D.,VE TOYOTA
DUBUQUE, IOWA 52004-0933
(8001 776-3281
(~831 556-3281
www. andersonweber, com
FreeServiceL~anefs(app~intmentrec~mmended~F~ee~i~newcarpurchase)~FreeB~dyEst~mates(A~RA55~OMER COPY
MARK AND KAREN SABOE CUST~ ,3467 ROff C-~8403
1980 ADMIRAL ST ~AT~ 8/06/0:~ - 8/06/01
POUf
DUBUQUE IA 5~002'- WRITER
PHONE: 563 557-132-/ APPROVAL BS /KAS
TIME IN: 915
OWNER 3467 UNITW PTi38546 1993 CHEVROLET LUMINA CURR MI 111, t88.0
VtN: 1ONDUO6DSPTi38546
2ND KEY:
CYLINDERS:
OVWR:
ENGINE= 3.1L 6 CYL
SERIES:
CID:
COLOR: RED
TRANSMISSION: 3 SPD
(C) 1. CONCERN: REPLAC.:E RR It's_' ~'P' 2.05 /70 R 15
LABOR:
PARTS:
:l. 00 ........ ,.~ :t I:'205/75
9.
:~9.14 '49.14
SUI~TOTAL LABOR 9.80
~L~ T -. I' Al. F~AR-I'S 49.14
TOTAL
REPA]:R OFtDEF, t TOTAL
PLEASE PAY FROM INVOICE. STATEMENT SENT BY REQUEST.
On behalf of semicing dealer. I hereby cer~ that the infonriation contained hereon is accurate. Unless o~enVise shown, se;vices descn'bed were performed at no charge to owner. '~lere was
no indication fro~ the appearance of the vehicle or o~ent~se that any part repaired or replaced under this claim had been connected in any way with any accident, negligence or misuse.
Records suppoflfng this claim are available f~r (1) year from the date of payment notification at the servicing deele~ for inspeclion by representatives of Ford.
(Signed)
Dealer, General Manager or A~ Person (Date)
CUSTOMER COPY