Claim, Kruse, Edward M.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: Edward M. Kruse
2. Address: 2626 Marquette Place
3. Telephone Number: (319) 583 4796
4. Date of Incident: 12/20/2000
5. Time of Incident: Approx. 9 a.m.
6. Location of Incident (Be specific): In front of St. Mary's Rectory
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.)
Parked curbside at St. Mary's Recotry. City Bus came along and hit my left rear view mirror
Bus drivers name in officer OD 45944 Report.
8. What were weather conditions like? Very cold
9. Give name and address of any witnesses:
Kathleen C. Kruse, 2626 Marquette Po.
10. Did police investigate? (If so, give names of officers.)
Yes, Officer 00 45944 Ed Baker?
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
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?
$153.17 for rear view mirror
16. Why do you claim the City of Dubuque is responsible?
I was legally parked and Bus struck 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 22nd day of December, , 20 .
2000.
/s/ Edward M. Kruse
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST
THE CITY OF DUBUQUE
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 13th Street, Dubuque, Iowa 52001-4864. 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 TOWHETHER YOUR CLAIM WILL OR WILL NOT BE
PAID.
1.
2.
3.
4.
5.
6.
Se
10.
Name of Claimant:
Address: ~0~
Telephone ~er:
Date ~ Incident:
Time of Incident:
11.
LoCa~ Of incident. (Be peclf~c) / ~ ~/~ o ~// o~
DESCI~IBE ACCTDENT O~ OCCUERENcE'THAT CAUSED INGUI~y 0~ DAMAGE,
(Give full details upon. which you base your claim. If a City
employee was involved, give the employee, s Da~-e. )
~at were weather conditions
Oive ~e and address of a~y
Did police investigate? (If so, ~ive names of officers.)
Was ~yone injured~
injuries. )
(If so, give name, address and extent of
12.
Was any damage done to property? (If so, describe property
a~d the extent of damage. Attach estimates of damages or
d~scrib~ basis for ascertaining extent.of damage.)
What other damages do you claim, if any?
/Jo
Have you been compensated for any part or all of your claim by
.any insurance company? (If so, give name and address of
nsuran~e company and amo~J2nt paid.)
15.
What ~mo~nt do you claim from the City of Dubuque?
J / f '7'
~,~y do yo~t cla~ the City of D~u~e i~ responsible?
17.
Have you made any c. laim aga],ns.t anyone else for damages as a
result of this ~nc~dent? . ~t/~
If ye~, give name and address:
If the answer tO Questi0~ !7 is yes, 'have you received
pa~%~me~t fr6m, thatsource, and if so, in"what amount?
any
(Revi~d JanU~,~Y, 2000)
/'"%)
(Signature)
(Print Name)
~ YA®ER AUTO BODY INC
4488 DODGE STREET DUBUQUE, IA 52003
FEDERAL ID ~ 42-1131724
PHONE: 319-557-7376 FAfg: 319-557-1709
CD LOG NO 0004537 DATE 12/22/00
SHOP CONTACT: GAYLE PURMAN
Page
INSP DATE 12/22/00
OWNER ED KRUSE
ADDRESS MARQUETTE PLC
CITY STATE DBQ IA
ZIP 52001
HOME PHONE
WORK PHONE
INS CO CONTACT
C~AIM# PHONE
POLICY~ CLAIM REP
LOSS DATE DEDUCTIBLE
WHEELBASE VAN
1998 CHEV VENTURE 120"
LIC#
BODY COLOR
VIN
MILEAGE
(319)583-4796
1GNDX03E2WD188923
DAMAGE REPORT
LINE REPAIR DESCRIPTION
1 REPLACE NEW PART
LEFT OUTER R/C MIRROR
AD J%
PARTS$
125.00
LABORS
19.50'
TOTALS
PARTS
PAINT MATERIAL
BODY LABOR-SM
MECH/ELEC LA~OR-ME
FRAME- FR LABOR
REFINISH-RF LABOR
SUBLET
TOWING
STORAGE
TAX
ESTIMATE TOTAL
INSUtLANCE PAY
CUSTOMER PAY
125.00
.00
19.50
.00
.00
.00
.00
.00
.00
8.67
153.17
153.17
.00
Copyright, 2000 Automatic Data Processing