Claim - Bay, MattCLAIM 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: Matt Bay
2. Address: 2570 Asbury Rd., Dubuque, IA 52001
3. Telephone Number: (563) 588 8000 ext. 2315
4. Date of Incident: 9/7/01
5. Time of Incident: Afternoon
6. Location of Incident (Be specific): Back Parking lot of Emmaus Bible College 3 rows west of golf course
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.)
My car was hit by a golf ball in the lower left side of the windshield. The car was facing Bunker Hill Golf Course
at the time of the incident.
8. What were weather conditions like?
Sunny, clear, cool breeze out of the west
9. Give name and address of any witnesses:
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.)
Yes, the windshield had to be replace, with a $100 co-payment
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.)
They paid for the replacement but $100 co-payment was required.
15. What amount do you claim from the City of Dubuque?
$100
16. Why do you claim the City of Dubuque is responsible?
The Bunker Hill Golf Course is owned and maintained by the city and it is their liability
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 24th day of September , 2001.
/s/ Matt Bay
(Signature)
(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: /~ ~
3. Telephone Number: ~/~ ~-~-~-~
4. Date of Incident:
/ /
5. Time of Incident:
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 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.)
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
(Signature)
//~ ~'~ (~ri%~ Name)
(ReV~ 1/00 & 7/01)
[] Repair
Windshield Repair Disclaimers
A windshield repair is to prevent the chip from cracldng further. The
result may not be optically clear.
D When repairing your windshield, we cannot guarantee against it breaking.
By signing the pre-thspection disclaimer, I authedze Auto Glass Specialists,
Inc; to perform glass repair work on my vehicle and agree that the cost of
replacing any glass broken dudng such repair shall be solely my
responsibility.
j Installation Disclaimers
~Ropla~ment
[] No Disclaimers Apply
We are sorry but your vehicle presents the special situation checked below:
[] In replacing your glass, we found the pinchwe[d was rusted.
Therefore our installation cannot be guaranteed against leaks, or breakage
due to the rust.
]When removing, replacing, and/or resealing glass other than our own, we
cannot guarantee it against breakage. If breakage occurs, the cost of
replacing any broken glass will be your rssponsibility.
[] Other (e.g. VissrJinyl Top)
Pre-installation Inspection
~o apparent body damage
[] Prior vehicle body damage:
Dent/Scratch / Interior
[] Rust
[~ Not applicable; body repair
required or in progress at body
shop
Other
This signature verifies that I have been informed on all of the above
checked items where disclaimers apply.
X
Customer Signature
Installation Report
Pre-/Post-Job Checklist
Date: 09/13/2001
Work Order#: 00000301030
Customer Name: DIANE BAY
Adhesive Checklist -- Record at time of application.
Primer Lot Numbers
Other
Urethane LotNumbera: Cimlethe~/~ethatapplies.
U208EP U418 ~U400H~) U1500HV
U216 A
U216
U216 B
Time of reading gauge: ~'"~.' ~ C~ Temp. O-~ OF
Humidity: %('-/ %RH Gauge Number: ~(~'
F Walk-around Checklist (Circle one)
NA Leak Detector Test
NA Vehicle/Araa
Cleaned
~/P F N~,,~/iper Test (front or back)
P F ~N~,,.,,~asher Test (front or back)
P F ~A Mirrors Tight/Positioned
~"'~F NA Moldings Secured
P F ~"-~,.~Praper Mechanical Operation Test
P F ,~,~,ElectricaI/Antenna Hookup Test
P F ~qA Door Air Bag Test (REF: ARG / PR / 04)
~'~"F NA Interior Trim Secure
Comments:
Met with customer in person:
Before work performed Y .,1('~.
After work performed Y
Technician Certification:
I hereby certify that this installation has been completed in accordance
with and in support of the AGS Quality Policy and Quality System.
Date: ¢//3/o/
Customer information on this sheet is a documentation of what
we used and inspected on your vehicle,
Figura# UPS 3.3 Revision: 11/I 5/99 White: Customer Yellow: Service Center Page 1 of 1
DUBUQUE
3345 Hiitsrest Rd. 800-282-6700
Dubuque IA 52002 319-557-7455
* * * WORK ORDER - THIS IS NOT AN INVOICE * * *
WORKORDER NUM: 00000301030
SCHEDULED DATE: 09/13/2001
OWNER:
DIANE BAY
MATHEW BAY
EMAUS COLLEGE
ASBURY ROAD
DUBUQUE IA 52001
Other: (319) 588-8000 Ext. 2315
BILL TO: 182050A
STATE FARM-LYNX EDI
C/O AGS
MADISON WI 53715
Business: (941) 47~-6000
1994 FORD THUNDERBIRD 2 DOOR
COUPE V1N
VEHICLE/PART INFORMATION
INSTALLATION
* PART NUMBER /..~ I~/ S~IP DESCRIPTION QTY
DW01190 GBN '") Windshield (Solar Controlled)(36.8 1
K HAH000022 2 TUBE 1
SCHEDULED TIME: /
LOCATION:
DUBUQUE IA 52001
SHELTER: NO HEATED: NO
CSR ADVISED CUSTOMER OF CURE TIME: NO
CUSTOMER AVAILABLE FOR PRE-INSPECTION: NO
DIRECTIONS/COMMENTS:
PARKED IN SACK OF SMITH HALL. BLACK CAR
CERTIFICATE OF SATISFACTORY REPAIR
The work referred to has been completed to my satisfaction and I hereby authorize [~ayment
for this work to be made to Auto Glass Specialists, ]nc. in full settlement of the insurance
company's obligation under my policy for said loss. ~ understand ] aro financially
responsib]e for any charges not covered by his aesignroenL
A service charge is assessed on ail checks returned by your bank.
ACCOMPANYING WARRANTY INFORMATION LEFT WITH CUSTOMER
SIGNATURE: DATE:
In Wisconsin, roctor vehicle repair practices are regulated by Chapter ATCP 132, Wisc Adm
Code, administered by the Bureau of Consumer Protection, Wisconsin Department of
Agr]culbare, Trade, and Consumer Protect[on, P.O. Box 8911 Madison, W]sesnsin
53708-8911
LOSS REPORT STATUS: <NONE>
TRAVEL INFORMATION:
START TIME:~, ~--C~
START M LES: 7 OE.DM.ES:
DEDUCTIBLE: $100.00
WAIVED DEDUCTIBLE FOI~REPAIR: YES
AMOU.TCOLLEC ED:.. DE...,
PAID BY: ~/ CASH CHECK CREDIT CARD
EXP
CHK/CC NUMBER: DATE:
RECEIWDSY:7
MISSED OR LO~T REASON:
04 COMP DID JOB 08 CAN'T COLLECT
05 WEATHER/SHELTER 09 CUBT NOT AVAIL
06 DRIVE TIME 10 TOO LATE
07 WRONG INFO 11 NOT REPAIRABLE
9/12/2001 2:56:36 PM
FigureCf OPS 3.2 Revision: 11/15/99 White: Customer Yellow: Service Center
Page 1 of I
Go..