Claim, Bird, Virginia 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: Virginia A. Bird
2. Address: 801 Davis St., Apt. #117
3. Telephone Number: 563 583 7876
4. Date of Incident: Nov. 10, 01
5. Time of Incident: 10:30 A.M.
6. Location of Incident (Be specific): In front of St. Vincent De Paul Unloading Door. I was parking at a meter between 13th & 14th on Iowa St.
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.)
Damage to right front tire. The tire had to be replaced with a new tire. Rocks produding from curb which
punctured the tire.
8. What were weather conditions like? partly cloudy
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.)
Yes, punctured right front tire. The tire had to be replaced with a new tire.
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.)
Towing charge into dealership. Provided customer with towering service.
15. What amount do you claim from the City of Dubuque?
$107.43
16. Why do you claim the City of Dubuque is responsible?
If the curb was properly maintain with cement covering, the rocks would not have been produting (sharp rocks). I was parking at a meter.
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 14th day of November0 , 2001.
/s/ Virginia Bird
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA /~b~ K.
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.
1. Name of Claimant:
2. Address: ~(~ )
3. Telephone Number:
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: -~/g //' /4 G
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.) ~ . _
, ~ d~,~
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.) /~/O
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
~12. Was any damage done to property? (If so, describe ~roperty 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?n,~
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 /'~7L
day of
nature)
(~rint ~ame)
(Rev. 1/00 & 7/01)
3255 University Ave. · P.O. Box 57
Toll Free I (800) 747-4042
Phone (319) 583-9121
Visit us at WWW.birdchevrolet.com
DUBUQUE, IOWA 52004-0057
CUSTOMER COPY
VIRGINIA A BIRD CUST# 33132 RO# C154197 PG 1
801 DAVIS ST APT 117 DATE 1t~10701 11/12/01
WARR VEN GM PO#
DUBUQUE IA 52001 WRITER 864
PHONE: 563 583-7876/ APPROVAL 864 /912
OWNER 33132 UNIT# 21389 2000 CHEVROLET MALIBU LS
DELIVERED: 1/27/00 LIC#: 797AVT
VIN: 1G1NE52J5Y6140248 ENGINE: LG8 3.1LV6
2ND KEY: A091 m SERIES:
CYLINDERS: CID:
GVWR: COLOR: DK CHERRY RED
20125
CURR MIL 12,861.0
LIST UNIT PRC EXT
(W) 1. CONCERN: TOW IN TO DEALERSMI?
CORRECTION: PROVIDE CUSTOMER WITH TOWING SERVICE
COMPLAINT TYPE:
FAILED PART:
ODBII CODE:
AUTHORIZATION CODE:
COMPLAINT CODE: MJ
FAILURE CODE: 98
COMMENT ROUTING:
AUTHORIZED AUTHORIZER:
0090
OTHER: WARR RENTA INV: 00792
(C) 2. CONCERN: INSPECT RF TIRE FLAT ADVISE
LABOR:
PARTS:
OTHER:
CORRECTION:
DIAG,REPL RF TIRE
11.25 *
1.00 31026386 TIRE 05880 86.48 86.48 *
1.00 STEM VALVE 1.50 1.12 1.12 *
HAZARD WAS 2.50
SUBTOTAL LABOR 11.25
SUBTOTAL PARTS 87.60
SUBTOTAL OTHER 2.50
TOTAL LABOR 11.25
TOTAL PARTS 87.60
TOTAL OTHER 2.50
REPAIR ORDER SUBTOTAL 101.35
*SALES TAX 6.08
REPAIR ORDER TOTAL 107.43
r'HEVEOLET
VIRGINIA A BIRD
3255 University Ave. · P.O. Box 57
Toil Free 1 (800) 747-4042
Phone (319) 583-9121
Visit us at WWW.birdchevro[et.com
DUBUQUE, IOWA 52004-0057
CUST# 33132
CHARGED TO
RO# C15419.7
YOUR ACCOUNT
CUSTOMER COPY
PG 2
107.43