Claim - Ackley, MonicaCLAIM 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: David and Monica Ackley
2. Address: 335 Nevada St.
3. Telephone Number: 319 556 8552
4. Date of Incident:
5. Time of Incident: About 11:00 A.M.
6. Location of Incident (Be specific): 491 W. 4th 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.)
City garbage truck backed into our parked vehicle
8. What were weather conditions like? Clear
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
Yes, incident report prepared.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No, vehicle was unoccupied.
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, front bumper was damaged.
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, our deductible will have to be paid if we were to file a claim.
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
It's employee was negligently operating a City garbage truck thereby causing damage to our 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?
N/A
Dated at Dubuque, Iowa this 31 day of December , 2000
/s/ Monica Ackley
(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 ~ AUTHORITY TO MAKE ANY
REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE
PAID.
1. Name of Claimant: ~/d sd
4. Date 02 InCident:
5. Time o~ Incident: CLUO~ ~, // '00 aM
6. Lo=at~0~ of incident. (~e speei~io~-~9? %~. 94~'L~C
DESCRIBE-ACCIDENT OR OCCURRENCE'THATCAUSED INuuKY OR DAMAGE.
(~ive~fulldetails upon~,which you base your claim, If a City
give the employee's m~e.)
employee was involved,
8. What were weather conditions like?
9. ~ive ~Une and addre~s of any witnesses.
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give name, address and extent of
injuries.)
F. Jo. 6(x_ uwC. U OO.o(;Dtad.
12. Was any damage done to property? (If so, describe property
and the extent of damage. Attach estimates of damages or
describe basis for ascertaining extent of damage.)
13.
14.
What other damages do you claim, if any?
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 a~d amount paid.)
15. wqa' y e ~i~ oz uu~uque. '
16. Why do you claim the City of Dubuque is responsible?
17 y .~ ~y ~alm a~a%n~ ~yone else for d~ages as a
result of ~h~ ~ncld~t? /~ ~
If yes, give name and address:
18. If the answer to Question 17 ~s ~!f.~es~. ~9 you received any
' payment f~ that source; ~d"i~'~"z~ ~a~ amour?
ated at D .que;Zowa, this j day
20 O0
(Revised January, 2000)
(Print Name) /
Date: 12/29/00 07:23 AM
Est~nntoKi: 323
Estimate Version: 0
Pr~_ry
Profile ID: Mitchell
Damage Assessed By:
600 Century Drive Dubuque, tA 52002
(319) 983-7345
aF~x; ~lltl) 5~8~7349
Dave DeMoss
Deductible: UNKNO~
Insured: DAVE ACKLEY
~diJ~',~=* ,~,~ ~c UAUA uUUU~tuc, IA--~,2001
Telephone: Work Phone: (319) 583-7345
Mitchell Service: 911329
Description: 2000 BMW 328 i
VIN: WBAAM9340YKG18777
Dt~v-e T-rain: ~ I-n]-6~ SA
Line Entry Labor
item Number Type Operation
Line item
Description
Part Type~
Part Number
Dollar Labor
Amount Units
100001 REF
100003 BDY
180021 BDY
AUTO REF
AUlC~
AUTO
REFINISH FRT BUMPER COVER COMPLETE
REMOVE/INSTALL FRT BUMPER ASSY
RE~LACE L FRT BUMPER ~;,~ ~ACT STRIP
ADD'L OPR CLEAR COAT
AJ~U'L r~Jt~ ! .... PAI~J UMp. ~ =I~JALS
ADD']. COST HAZARDOUS WASTE DISPOSAL
$1118t~89
1.0
16.20 0.3
0.9*
7-3.60 *
3.50 *
Ju~ge~nt-ltem_
Included in Clear Coat-Calc
III.
Labor Subtotals Urns
Body 1.3
Refinish 3.2 38.00
Labor Sublet
Rate Amotmt Amount
Tex=h!e Labor
Labor Tax
TotaLs
0:0~ 0.00 4~,4~ T
0.00 0.00 121.60 T
Labor Sunmmry 4.5
Add~onal Costs
Non-Taxable Costs
Total Add~onal Costs
~ 6.0~ %
1711OO
10.26
it. Part Replacement S~,m..~J
Taomble Pmts
Sales Tax ~
Totel Replac~'nerrt Parts Amount
IV. Adjustments
Customer Resp~nsibitity
77.10
ESTIMATE RECALL NUMBER: 12/12/00 12:0~:30~ 323
U~aMate i-$~ '~aG~emar~ or MI~CRell
Mitchell Data Version: DEC_00_A Copyright (C) 1994 - 2000 Mit~chell International
UitraMate Version: 4.6.004 All Rights Reserved
6.000%
Page I 'of
.20
--~1~.97
17.17
Date: 12129100 07:23 AM
Estimate ID: 323
Estimate Uersto~: 0
PrOfile ID:. M~c~IL...
I. Total Labor:
II. Total Replacement ParLe:
Gross Toga P.
IV. Total Adjustments:
Net Total:
This is a preliminary estimate.
Additienal chanqes to the estimate m~y be required for the actual repair.
THIS DAMAGE REPORT IS BASED ON OUR INSPECTION AND DOES NOT
COVER ANY ADDIONAL PARTS OR LABOR WHIC~ MAY BE REQUIRED AFTER
THE WORK HAS BEEN OPENED UP T~E INS,WILL BE NOTIFIED.
;161.20
17.17
77.10
225.$3
0.00
ESTIMATE RECALL NUMBER: l?Jt2/061r2:0~[:30 323
U~ ts-a T~r'a~--mar[~ or M=cn-ellTr~fnatiopal
Mitchell Data Version: DEC_00._A Copyright (C) 1994 - 2000 Mitchell International
UitraMate Version: 4.6.004 AU Rights Reserved
Page 2 Of