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Claim, Hank's SpecialtiesCLAIM 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: Hank's Specialties 2. Address: 1471 1st Ave. NW, New Brighton, MN 55304 3. Telephone Number: 651 633 5020 4. Date of Incident: 9/26/01 5. Time of Incident: 12:30 P.M. 6. Location of Incident (Be specific): Elm & 13th 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.) Our delivery truck was traveling north on Elm ST. The southbound land was closed to traffic. Our truck hit a low hanging limb over the street. 8. What were weather conditions like? Clear 9. Give name and address of any witnesses: Chevy Callahan, 2521 Windsor, Dubuque, IA 52001 563b 582 3832 David Jaeger, 5088 St. Catherines, Bellevue, IA 2031 563 556 6415 10. Did police investigate? (If so, give names of officers.) Yes Officer Ehlers Bade #22 (Police Report #01-38480) 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, Box on truck was tore apart upon impact with tree, $12,879.95 to repair box; $9,250.54 to replace box 13. What other damages do you claim, if any? Replace smoke stack and paint new box $770.81 + truck rental $1724.68 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.) Yes, 9,250.54 Unitrin Ins. (copy enclosed) 15. What amount do you claim from the City of Dubuque? $2724.68 or $1000 insurance deductable + 1724.68 for truck rental 16. Why do you claim the City of Dubuque is responsible? Tree hanging over street was not trimmed to allow traffic below. 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 14 day of November , 2001. /s/ Randy Grachek 651 633 5020 We have several pictures of the truck, the tree that was hit and also the road as they were working on it if you need them. Thanks. (Signature) (Print Name) (Rev. 1/00 & 7/01) NOV-08-O1THU 04:49 PM DUBUQUE CITY CLERK FflX NO, 563 589 0890 P, 02 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 end 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. ,. ,ame o, C,.ima.,.' 4. Date of Incident: <::~/,-~ (~/O[ 5. Time of Incident:_ /2'~ ~J~ 6, Location of incident (Be specific): ~--//,~ +- /A'~- ~'-~-... 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). _ ,///D B~NT BY: HANK~B BP~O~ALT~8; 8Bi 888 NOV-08-Ol THU 04:49 PM I)UBQQUE OITY CLERK FAX NO, E63 589 08~0 NOV-t4-01 tO:~tAM; PAG~ t P. [12 CLAIM AGAINST THE CITY OF DUBUQUE, IOWA. This wriUen report constitutes your claim against the City of Dubuque,:lowa. You should complete this form In full and attach any additions! Information that supports your The Claim must be filed with the City Clerk at City HMI, 50 W. 13th St., Dubuque, IA 52001. It will then be referred by the City Council to the appropriate department for Invsatigatlon. Cane that investigation is completed, a report and recommendation wlllibe submitted to the City Council. You wi)l be provided with a copy af that report end 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. 2. kddress: 3. Telephone Number: ~.~/-- ~,.~-._~-~,~ 5. Time o! Incident:. /~:~. ~ 6. Loostion of Incident (Be,paCific): ~"'//,t'~ + ,/,~ --"~ ~"tL .... 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give full demil~ upon which you besa your claim, ff a City employee was Invol.~:l, glv~ the employee's name.) --/. 8, What were weather ~onditions like? 10. Did ~li~ln~tiga~? (If ce. ei~ Was anyone Injured? (If so, give names, addresses, and extent of injuries). NOV-08-O] THU 04;49 PM DUBUGUE CITY OLERK FAX NO, 563 589 0890 P, 03 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, ifany? ~.-~)/~_~¢ ~w~.~[4~ C~ ~ 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 ia responsible? 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) z:~/'~ 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 ,/Z-/'~-~- dayof //~[/E~w/3~_~v~ , 20C~[. ~Signature) . ' - / (Print Name) (Rev. 1100 & 7101) Hawkeye Idealease The Tmnspo~ Specialist 3865 W. 83~-d St. Oavenl~t IA Phone 3'1g-326-4002 Fax 31~-326-2998 Cel! 563-210-0435 Leased To: Hank Specialties Inc. Atfll: Bill Carstetts/North Star Idealease 909 Shaver road NE Cedar Rapids Iowa 52402 319-298-8950 Quotation Comments or Special Instructions: 24' Straight Van DATE 10/9/01 Quotation # 45216 Custm"ner ID N~'~S~rk~aease Quotation ,,,'arid unf/7:10/17/01 Lea~'e Manager Jim Woodison Description AMOUNT Van Body New 24' US Van Body From Stock $ 8,2.05.00 Installationat Removal and Salvage of Damage I~x VIN:YH220414 lr~ta~l New Van Box i $ 1,045.54 Includes Tax TOTAL $ 0,250.54 [f you have any questions concerning this quotation conta~ Jim, 563-210~435 THANK YOU FOR YOUle, BUSINE$SI V~a Fax: 612-379-342~ Te~ms: A~ charges ~' Lea~8 and Refffa[ ~4ces am due aha ~ble ~ ~i~ of I~. ~~ ]I'~'~{tNATIONAL 2~40 65T ~ Cr~DAR l~d~ll~q, IA 52404 Tel: $I9,364-21.91 Fmx: 3194~8-1966 CUml~uy: BANKS ~FECIALTIE$ Add~s: Cit~, SUle, ~ip T~iel~me, F~x: 1.4 TruckP~ ig a Trm~q~srk ~'Mitci~ll In~-a~c~m2 Pate Additional C~ ~ T~ ~ ~.00~ $229.4~ Add.I, ~Tax (~ 5.000% $2~.00 T~x Total ~13.34. Tot~s Auth~,~i~ ~r Rep~jr~ All ~ Reserve. Pag~ 2 cf 2 Hawkeye Idealease 3665 West 83rd St. Davenport, IA 52806 Phone (563) 326-4002 Remit Payment to:.. Hawkeye International Trucks P.O. Box 8810 Cedar Rapids, IA 52408-8810 Please pay from this invoice. HANK HANK'S SPECIALTtES RENTAL ACCOUNT 909 SHAVER RD HE CEDAR RAPIDS, IA 52402 OROERED BY DRIVER INFORMATION PO# APPLICATION: SS# BIRTH RENTED: WITH FUEL L[C WITH LIABILITY PHN STATE WITH COLLISION LIC CLS EXPtR WITH DAMAGE LIFT GATE LIMIT RENTAL DAY IS hfs GVC GV~ PAYLOAD MtNtMUM CBARGE $ 0.00 LICENSE# 103IDL ST FUEL REIMBURSE O.O000/gal MAKE IRTL OOOMETER START 11~667 DESCR ODDMETER END 123663 METER START 0.0 BUB(~METER START 0 METER END 0.0 HUBOMETER END 0 FLRi COBTRACT# 6537 INVOICE# R2647 INV DATE 10/31/2001 PAGE 1 DATE OUT 09/27/2001 DATE DUE 11/30/2001 TIME OUT TiME DUE VEHICLE 103IDL SUB VEB BRK BEG BRK END BRK MtLE BILL FROM 09/27/2001 BILL TO 10/31/2001 0 HOURS @ 0.00 0.00 0 DAYS @ 0.00 O.O0 5 WEEKS @ 265.00 1325,00 0 MONTHS @ 0,00 0,00 4996 MILES @ 0.0800 399,68 0 FUEL GALS @ 0.0000 0,00 UNITS 103/104 SWAPPED ON 10-31-01 SUBTOTAL 1724.68 *** TOTAL DUE *** ** 1724.68 ** TetTnS: All charges for Lease and Rental services are due and payable on receipt of this invoice, Payments not received o with in 15 days of invoice are subject to a fee of 1.5% per month on the unpaid invoice. All unpaid invoice are subject to fur[her collection fees and legal cost. Thank You For Your Patronag9 PAYABLE TO: HANKS SPECIALTIES, ~NC. & HAWKEYE iNTERNATIONAL TRUCK BANK ONE NA, CHICAGO, IL 70 Nine thottsand :wemy one and 35/100 Dollars MAIL HANKS SPECIALTIES, INC. TO: 1471 1 ST AVE. NW. NEW BRIGHTON, MN 55112 Check No. 0460051180 Poricy No. CPP3079514 Claim No. 046000046028615 DATE AMOUNT 10/19/01 .... $9,021.35 TRINITY UNIVERSAL INSURANCE COMPANY 10(300 N. Central Expw~. ' Da/la~, TX 75231 ^ Tear Here" Check No. 0460051180 Policy No. CPP3079514 Claim No. 046000046028615 UNITRIN CLAIM OFFICE # 46 MINNEAPOLIS AGENT # 2103066 ADJUSTER CODE ZGN DATE OF LOSS 09/26/01 PAYEE: HANKS SPECIALTIES, INC. & HAWKEYE INTERNATIONAL TRUCK INSURED: HANKS SPECIALTIES, INC. CLAIMANT: HANKS SPECIALTIES, INC. FOR: COLLISION LOSS LESS DEDUCTIBLE NOTES: AL COVERAGE TYPE AMOUNT 9,021.35 TOTAL 9,021135 Fare' 433002 Ct a: Did accident occur on • fAl Iowa Department of Transportation REPORT OF MOTOR VEHICLE ACCIDENT Ste• 1. See Instructions on completing (please print or type) r_Y iNLL Accident Date (Mo/Day(Year) r� - , Step 2. i - - • e • • b ( Sex ,A Or Lic. Day e Week 11 [Ave c.. NO.1 (YOUR VEHICLE) Stat. • ' - - - - Tim ❑ AM / 71 d s4 PM - - - - - ' - - - Number of Vehicles [ D Date of Birth R Total Killed �.. Sex NO.2 Dr.L Total Injured (OTHER c. State VEH Driver License I l Total Estimated Damage $ li • i Cc c5 0 CLE) No. as Printed on License i€ I I l l Last Name of Driver 1 irs ' me w i. • e Initial - 6.- r - I Last Name of Driver 2 First Name Middle Initial v Number and ySi.reet J d 7_l fr€�'/Il if i. -A)E( 1 State Zip Cod- iZergii:15 .5,, ° E Number and Street R City State Zip Cc:. Last NaAne f O/wner 1 First Name Middle Initial —6-f.,,,e_k 1...-e.71 5 ; ))State O Last Name of Owner 2 First Name Middle fndi Number and Street 00 NE �� city Zip od=, / , C( ll Zip ff Number and Street R City State Zip Cc:, No. of Occupants 1J Plate Nummber_ � if .JL 7 State o stration Year V No. of Occupants E PIate Number State of Registration Year V t N. i SC ��N ^6�t Est. Cos{ of Repairs C V.I.N. Est. Cost of Repairs Vehicle Year & Make J mil Vehicle Type Cod E Vehicle Year & Make Step 3. Vehicle Type Coe �i/1l 'Urldl L buf) Step 4. - County •[ j �� v Q V LOCATION Accident occurred within corporate limits of (city) If OF ACCIDENT V U tf accident occurred outside of N NE E SE S SW W NW city limits, describe distance to city miles El ii El ❑ • ❑ ❑ El of nearest city Name of Road, Street Highway Al Intersection with - r vt/" ,ram11— Note: Unless accident occurred at an intersection which is completely described above, use the space below to give the exact location from a milepost or definable intersection. bridy or railroad crossing. using two distances and directions if necessary Fegt0 Miles �NNE E SE S SW W NW Feet Miles N NE E SE S SW W NW or In, ❑ ❑ El ❑ ❑ ■ • ❑ • ❑ ❑ ❑ ❑ El , and or of Milepost Number Definable Intersection, bridge, or railroad crossing Dr %3-6 S 1. ar1-1°1,-4cc• ti,.., Step S. Accident Codes (on 2) For page your own vehicle �, Ir.) Location of Accident I [ I F3 Manner of Crash di Vehicle Action I P I I D First Harmful Event Al/i 1r Type of Roadway 1 Junction/Feature 1.D 1 I L1 Traffic Controls ftl ! t I © Light Conditions 1 I j it Weather Conditions I "I ill I I 1 U Surface Conditions I 1 I In Vision Obscured IQ ) I M Driver Condition 1 I j A Contributing Circumstances U� 7 identify Damaged Property Other Than Vehicles Owner Amount of Damage step p, Injury Section: Fill Out Space Below For Every Person njured Or Killed In The Accident its if necessary) Insert Correct Code (See Slap 7 of hrslrucli0ris) D .. • • (Altaclr add:Florial she & Address In Vehicle Number Bate of Birth Gender Describe Injuries InjuryStatus Occupant Protection c 0 E T ' Ejection g N eQ I— Zwo.Det m 0 cv DahNane (Complete reverse side) -3- Indicate On ;l'hls Diagram What Happened INDICATE Use one or these outlines to sketch the scene of your accident. NORTH BY ARROW (lPri°r t° c°ded Vehicle Ami°n) XE ~) Original Direction of Travel: (Exanlple Vehicle going n~dh then turoing left, code 'N' for Original Directio¢~ of Ttevel) Vehicle 1 . Vehicle 2 Street or Highway Did Peace Officer investigate? ~',Yes [] No Department if you did not have automobile liability'insurance coverage for this accident, please check this box [] ff you had autornobiIe liability insurance coverage for this accident, please complete insurance information below: Failare To Complete Insuraoce Coverage Information Requested Below May Result In A Suspension Of Your Driving And/Or Regist~a', Privileges. Name o~nsufance Company (Not ,~/,gent) Providing Name of Agent Who Sold Policy insurance To Cover Your Liability For Damage Or Injury To Others: Agent Address .. ¢2 / If Signed By Person Other Than Dver, Give Reason PORTANT: ~Ms accident should also be repdded dPecfly to your insurance company. Failure to repod may jeopardize your au~omobfi 'abiJity insurance -4. • Form 433003 • - - MAIL REPORTS TO: . : 01-0i1 - _ Iowa Department of Transportation ....ee Iowa Department of Transportation e Office of Driver Services .• . �, = ; :: park Fair Malt. 100 Euclid Avenue - ' \� INVESTIGATING OFFICER'S REPORT - P.O. Box 9204 •. ' Des Moines, Iowa.50306.9204 OF MOTOR VEHICLE ACCIDENT ... PLEASE TYPE OR PRINT - - - - _ - Sheet / of Law Enforcement Case Numbers: 0 /— � �K1� Legal - Intervention? ❑ Private Property? '. �{f vol.. J - '� }Time of dent ! c� OHis , cZ fo)at - k3 / :f Accident occurred within /}) .6 - corporate limits of (city) �lrr 14 L 5u _r Route t If accident occurred outside of °,- N NE E SE S SW W NW pity limits show general vicinity . mikes`' r . . ' g tv O 0 0 0 0 0 0 • 0 . of nearest city • .. • �� X-Coordinate: X-Coon: - On RodaStreet,. r ( or Highway: H C Y}v • :. At intersection with: . .. - Y Co dinate: { I. Note: Unless accident occurred at an intersection which is completely described above, use the space below to give the exact location from a milepost or definable intersection, bridge, or raikoad crossing, using two distances and directions if necessary.. ' • - x F Miles . N NE E - SE S •SW W NW • Feet . Mlles N . NE E SE S SW W NW ` . or • O O O O O O O 0 and or O O O 00 0 0 0 'of 1f Divided Highway, (Cardinal) Travel Direction NB SB . O O Provide Route -• EB WB O O . • / Milepost or Definable intersection, .q f- / E- / r Number bridge, or railroad crossing 1 1 r�-1 ..„. may, Driver's Name (Last, First, Middle) Ar-9fe- . . ....• Address City - - State ' Zip `i{ - Pat? of Birth i Citation • 1. 3. Z Charge max 2 4 . " Male emale - 0 e ss n orsemen_ s Q/ t� estrictions Alcohol Teat Given? 1. None 3. Urine 5. Vitreous Test Results: 2. Blued 4. 8reath 9, Refused Drug 1. None 3. Urine Test Given? I 12. Blood 9. Refused Pos. Neg. 0 - 0 y ►.e Owner's me (Last First. M• die) r .4 H Act. Lease Y Address • City . • • State ?cif* NE 1R '! lrhC'�l�ti �5 /'/�V Zip < 3 �Slf '';`_[k^ insuran k,s in,/ f Insurance `� Ye25 E r Name 11 .0{rt 19 1 / Policy # t � �y s �y / f F ! 3O 7 5r %V f 0� .' 7 y Plate # f a /\ �1. "'1"' .�v4 VIN # /� �/ {j /( IrS4f`f/Y'�fJ7��-�f�d,•+rvi�%v� /I -yyea[� •' Ma fModel �rJ~ Style / /"�lnh Tow # Approximate Cost la Repair or Replace - Initial Travel 1 i Direction • I Vehicle r Action 1-' 1 1 Speed L mit I I I Point of initial Impact I I I Mast Damaged f Area I I I Extent of Damage I I Underridel ' Override U Private? © $ - Total . -- [ t Occupants 1. 1 Traffic I Controls I• I Vehicle - I Config, 1- -1 1 Cargo Type Body I I I Vehicle Defect I' I 1 Driver Condition I i' 1 Vision Obscured r I I' j Contributing Circumstance Driver (up to two) , { 1 I LLJ Commercial Trailer License Plate # Attached to Power Unit:, Slate Year Attached to Trailer Unit: State Year Emergency Vehicle Type/ - I • Emergency ,, Status Carrier .. Name . _ .. Address - - - • City .:. State .; Zip s . ' US DOT# or MC# • 0 0 . 1 1 1 1 1 1•1 1 Number ofAxres - ' Gross Vehicle : Weight Rating Placard # • • I - 1 1 1 1.•.F•-I--I' Hazardous Materials Released? 1 1 - • Driver's Name (Last, First, Middle) ,- Address 4 - a v City . . State ' Zip Date of Birth .• - - Driver's License Number - -- Citation 1 3 . - • Charge 2 _ . - Male Female State • Class Endorsements Restrictions 4• O O- Alcohol Test Given? I 1. None 3. Urine 5. Vitreous Test Results: 1 2. Blood 4. Breath 9. Refused Drug • 1. None Test Given? Li 2. Blood 3. Urine Pos. Neg, 9. Refused 0 0 u Owner's Name (Last, First, Middle) Address - ' City Slate Zip N Insurance Ca. Name Insurance Po icy # License Plate # State . Year T VIN # - - Year Make Model Style - Tow 4 Appros mate Cost to Repair or Replace initial Travel Direcjion 1 1 Vehicle- Action 1 I I Speed Limit 1 1 1 Point of ! Initial Impact I 1 I Most Damaged Area • 1 1 1 Extent of Damage 1 1 Underridel Override I Private? : Total- Occupants 11 I Traffic Controls 1 1 I Vehicle Config. I 1 1 Cargo Body Type 1 I 1 Vehicle Defect I I I Dover Condition 1 I Vision f Obscured I 1 I Contributing Circumstances, Driver (up to two) I I 11 1 I Commercial Trailer Attached to . State Year Attached to License Plate # Power Unit: Trailer Unit: Stale Year Emergency Vehicle Type! I Emergency Status I I Carrier Nameo Address City State Zip US DOT# or C# I € I 1 1 1 1 I 0 0 Number of Axles Gross Vehicle Weight Rating Placard # L 3 - 1 1 I 1 -I I Hazardous Materials E Released? ! If Property other than vehicles damaged explain Object ^' �7 - - - Damaged • -J �- ` e ,. Estimate of t'J�' Damage S firs Unit 1 Unit 2 SEQUENCE OFEVENTS 1 1 I I I . I l First Evert Owner's Full Name [ 11 (Last, First, Middle) 1 i --' 0 1 — u !,, ,,f,yUI ` Was owner or 1 • Yes 9 - Unknown tenant notified? I 2 - No [Second Event 1 1 1 1 ! 1 Street or _ City, State, (` & Zip Code Lk C•fli Di RELATED? l 1 1 I I Third Event ACCIDENT ENVIRONMENT - Location of First Harmful Even!' I I Weather Conditions I ` 1 ROADWAY CHARACTERISTICS . . Major Contributing Circumstances: WORK ONE . 0 Yes ng No `T .1 -- -- 1 1 F I I 1 I Fourth Event 11 �.fl - 11 J _1 t Most Harmful Event 1 (up to two) Manner of CrashlCoilision F1.9 I. 1 1 1 - Environment " id Roadway I J I I I Location . 1 I Type. (tiyvehicle) Light Conditions f ' 1 Surface Conditions . • 1 I :: . Type of Roadway JunctionlFeature I I .' 1 . 1.. 1 Workers Present? First Harmful Event of Crash I I ' 1 (use codes 11-02 only) - .. - Officer's Name .Badge NO. ' ~ TRUCK TRIP SHEET III ISPECIALTIES.'"c. d~ ~. ~ .~ / ! IV z:~t~buto~ot DATE: Floor Cove6ng Supp#es Main Office and Warehouse t471 - 1st Avenue N.W. New Brighton, MN 55112 Pl~-one: 651/633-5020 Fax: 651/633-8723