Claim - State Farm,Vicki BechenState Farm
December 21, 2000
Insurance
Companies
State Farm Insurance Claim Office
3490 Hillcrest Road
P. O. Box 795
Dubuque, Iowa 52004
City Clerk of Dubuque
City Hall
50 West 13th Street
Dubuque, IA 52001 ~4864
RE:
Claim No.:
Date of Loss:
Our Insured:
15-E031-352
September 20, 2000
Vicki Bechen
Dear Sir or Madam:
I am writing regarding the water main break that occurred on White Street on September 20,
2000. We are the rental dwelling insurer for the building located at 2741 Jackson Street, owned
by our insured, Vicki Bechen.
On September 20, 2000, our insured~s basement was flooded by water escaping from the White
Street water main. Our insured sustained damage to two water heaters, a furnace, and sump
pump. Also, cleanup charges were incurred to return the basement to normal. State Farm
Insurance has estimated these damages at $2,654.14, which includes our insured's $500.00
deductible.
Enclosed is a completed Claim Against the City Form with information regarding the loss. If you
have questions, please contact me at the number listed below.
Sincerely,
Daniel Green
Claim Representative
State Farm Fire and Casualty Company
(319) 582-2619
023/1220024
NOME OFFICE; BLOOMINGTON, ILLINOIS 61710-0001
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: State Farm Insurance on behalf of Vicki Bechen
2. Address: 3490 HIllcrest Rd.
3. Telephone Number: 582 2619 Attention Dan Green
4. Date of Incident: 9-20-00
5. Time of Incident: 2741 Jackson ST., Dubuque, IA 52001
6. Location of Incident (Be specific): 12" water main break occurred on White Street. Water traveled through
insureds' back yard and into her rental home. The main that broke was 80 years old and is up for replacement with the White Street project.
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.)
See above
8. What were weather conditions like?
Mld, warm & dry
9. Give name and address of any witnesses:
Betty Loeffelholz, 2741 Jackson St. Tenant
10. Did police investigate? (If so, give names of officers.)
Knocked on door to inform tenant
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.)
Two hot water heaters and 1 furnace were damaged. Basement was flooded and required cleanup. Sump pump was damaged
13. What other damages do you claim, if any?
Additional expense to convert the water heater demanded by doe (insured expense)
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.)
State Farm Insurance 2154.41
15. What amount do you claim from the City of Dubuque?
The total amount paid above plus our insureds' deductible of $500
16. Why do you claim the City of Dubuque is responsible?
Water main was of significant age.
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 20 day of December , 2000 .
/s/ Dan Green
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
0ct.24. 2000 lO:43AM BARR~ LINDAHL, ESQ ~-- No.l&lO P. 2/3
CLAIM AGAINST THE CITY. OF DUBUQUE
This written report constitutes your clalm against the City
Dubuc/ue, Iowa. You s~euld ~on~plete this form in ~ull an~ attac~%
any additional ~nformation that supports your claim.
The Claim must be filed with the .City Clerk at City Hall, 50
West 13t~ Street, Dubuc~ue, Iowa 52001-4864. It will then be
re£erre~ By the City Council to the appropriate Depart~enb for
investigauio~. O~oe that investi~ation is com~lete~, & report and
recn~endatlon will he s,.~-4 tted to the City Co~n0il. You %~ill be
provided with ~ copy of that report and recommendation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY T~E CITY COUNCIL.
NO EMPLOYEE O~ THE CITY OF DUBUQUE ~AS THE A~ORiTY T0 ~E ~
~P~S~ATION ~ YOU ~ TO ~R YO~ C~IM ~LL OR WILL NOT BE
PAID. '~
5. T~e of Incld~t: ~
7. DESCRIB~ ACCIDENT OR OCCqIR~ENCE THAT CAUSED INjury OR DAMAGE.
(Give full details upon which you base your cla4~. If a City
~lo7ee was ~volve~, g~ve the ~oyee's n~e. ~
V
v
,,
10.
Did police investigate? (If So, give names of officers.)
11. Was a~yone injure~? (If so, ~ive name,
injuries. )
address an~ extent of
00t.2¢. 2000 10:43AM BARR?~ L]NDAHL, ESQ .(~- No. I410 P. 3/3
12.
1:3.
14.
Was any damage done to property? (If so, ~escrlbe property
and the extent of damage. Attach est/~O~tes of damages or
describe basis for ascertaining extent o~ damage.)
what other damages do you claim, if any?
Have you been co~..pens~te~: for any part or all of your olalm by
any £nsura~0e u,,,,~.ny? (If so, give name a~d .address of
insurance company and amount paid.).
15. 1~hat a~noxL~t ~.0 yOU cla£m from the City of Dubuque?
17.
Ha~e you .made any ?l&im, against ~nyone else £o= dam=gee a~ a
result o.f this ine:~l, ent? ' (~/0 ......
18. If the answer to Question 17 is yes, have you received any
payment from that source, and if so, in what ~moun~?
Da=ed at Dubuque, Iowa, this ~9 day o£ ~d~z
20 ~0
2000)
/(Signature)
(~rint Name)
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: Vicki Bechen State Farm Insured
2. Address: 575 English Lane Dub IA 52003
3. Telephone Number: 319 588 1701
4. Date of Incident: Sept. 20, 2000
5. Time of Incident: Morning
6. Location of Incident (Be specific): 2741 Jackson
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.)
Police came to door and told tenant a City water main broke and they should check their basement - it was flooded almost up to the first floor.
8. What were weather conditions like?
Mild, Warm and Dry.
9. Give name and address of any witnesses:
Betty Loeffelholz, 2741 Jackson, tenant
10. Did police investigate? (If so, give names of officers.)
Just knocked on door to inform tenant
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.)
2 Hot water heaters and 1 furnace were ruined. BAsement was flooded and all tenants belongings were ruined. Basement was a muddy mess, sump pump failrue because it flooded too fast
13. What other damages do you claim, if any?
All repairs and labor
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.)
State Farm Ins. $2,154.41
15. What amount do you claim from the City of Dubuque?
$917.43
$500.00 deductible + $417.43 not covered by insurance, change in city code for new heaters.
16. Why do you claim the City of Dubuque is responsible?
Their water main was at fault and ruined my property.
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 20th day of November, 2000 .
/s/ Vicki Bechen
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
~ct.~4, 2000 IO:&3AM BARR~ LINDAHL, ESQ (C No,l¢lO P. 2/3
CLAIM AGAINST THE CITY Op DUBUQUE ~0V 2 I Z000
This written report constitutes your claim against the City
Dubuque, Iowa. You shoula aomplata this form in ~ull an~ &tt&oh
any a~itional inform~tion tBat supports your cla{m.
The Claim mus= be filed wi~h the City Clerk at City Hall, 50
Wes~ 13th Street, Dubuque, iowa ~2001-4864. I~ will ~h~ be
re~erre~ ~y ~e City C~1 ~o ~e appropriate Depar~ent for
proviaed with a copy of ~U re~rt ~d rec~en~tlon.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY w~u~ CITY COUNCIL.
NO ~M~LOY~E OF THE CITY OF DUBUQU~ IlAS THE AUTHORITY TO. ~ ANY
REP~SENTATION TO YOU A~ TO W~ETHEI~ YOUR CLAIM WILL OR WILL NOT BE
Name of Claimant:
PAID
Telephone
Date of Inoident:
Time of Incident=
Location of
2.
3.
4.
5.
7. DESCRIBE ACCIDEI~T OH O~u~lt~NCH T~AT CAUSED ~du~Y OR D~.
(Give f~ll de,ails ~ w~ch you base ~ cla~.
l~ee was ~lv~, ~ve ~he ~oyee's ~.~
9. Give n~e ~ ad, ess of ~y witnesses.
~. Was ~e ~n~ured? (~ so, ~ve n~e,
- 0ct.24. 2000 10:43AM ~ARR~/ LiNDAHL, ESQ
and the extent o~ damage, Attaoh ast4,aXtee of damages or
describe basis for ascertaining ~xten~ o£ d---ge.)
14. Have you been compenei~ted: ~Cor --,y pa~ or a~ o{ ~our o~a~ b~
~y ~nsuranOe a~? (~ so, ~ve n~e ~d .ad~eaa
17.
a
Z~.'~.~.m, ;9:Lv~ nn'ne aud.- adclresm~
Z~ the answer to ~ue~tion 17 is yes, have ~ou received any
payment from that source, and if so, in wh~t amount?
(ae~ised J~nua~'y, 2000)
S. ignature )
Klein Electric
16635 Union Park Lane (319) 557-1345
Dubuque, Iowa 52001
KLEIN
ELECTRIC
inVoice Invoice O: S-001911
Date: 10/2/00
Bill To: Ship To: Page: 1
B & W PROPERTIES, L.C. B & W PROPERTIES, L.C.
$75 ENGLISH LaN. 575 ENGLISH LN.
DUBUQUE, IA ~2003 DUBUQUE, IA 52003
DeScription of Work: SERVICE CALL & WIRE WATER HEATERS AT 2741 & 2743 JACKSON: WATER DAMAGE
Catagory Type Qty Item DeScription Unit Price Total
Material
Labor
I 30.00 980010-02001-CRE 1/2" EMT CONDUIT $0.263 $7.89
! 9.00 781747-00920-CRE 1/2" EMT STRAP ~ $0.084 $0.76
I 2.00 781747-01025-CRE 1/2" EMT LB $5.476 $10.95
I 1.00 781747-09240-CRE 1/2" SS EMT COUP $0.218 $0~2
I 2.00 781747-09260-CRE 1/2" RT EMT COUP $0.517 $1.03
I 5.00 781747-15250-CRE 1/2" RT EMT CONN $0328 $1.64
I 2.00 786210-03201-CRE 1/2" ROMEX COlqN $0255 $0.51
I 2.00 785901-40094-CRE QO TANDEM BREAK.I~ $28.510 $57.02
I L00 783164-20986-CRE AC DISCONNECT $25.780 $25.78
I 90.00 980100-23000-CRE TI-II-tN 10 ~ $0.112 $10.08
I ' 2.00 755901-40042-CRE QO DP B~ $20.400 $40.80
1 , 45.00 980100-26310-CKE ROMEX 10/2 WIRE $0.336 $15.12-
I 5.00 781747-15230-CRE !/2" EbtT SS CONN $0.199 $1.0~
· - Material Sub-total $172.80
I 2.75 Labor-R~-l.0 Labor-Reg-l.0 S26.000 $7t.50
I 3.00 Labor-Rag- !.0 Labor-Reg-l.0 S~26.000 $78.00
I 2.75 Labor-R~g-l.0 Labor-Reg-l.0 $26.000 $71.50
Labor Sub-total $221.00
Invoice Subtotal $393.80
Invoice Subtotal $393.80
Sales Tax $23.63
Total Invoice 5417.4~
All accounts due 30 days./u:ctmnts not paid in 30 days will be charged i 1/2.% finance charge. Minimum charge 50e. Customer responsible for collection.
Moored& Sons
HEATING AND AIR CONDITIONING
483 S. Blackjack Road · Galena IL 61036
(815) 777-6202 or (815) 747-3373
1913
CUSTOMER ! PHONE DATE
STREET CiTY
(~JAN. PARTS AND MATERIAL AMOUNT
~',~.~ _~ ~/~-~.,J ~,,~ m~/~Ioo~~
It,~";v"W/ ,,,
TOTAL ~O~T
GEN
GEN
GEN
GEN
GEN
GEN
CURRENT INVOICE
INVOICE DATE '.~--.INVOICE HO~-:" JOB A~T.NO.
08/22/00 ~ ~ 011723593386 .' ' 001545 GEN
QUAHTZTY UNTT ::-. ' ITEM DESCRIPTION
1'~ EA" 000010167 24X18 HART OA~ VAN W/TOP C10124A1
1' EA 000012220 TACOMA W~LL CAB 12"
1, EA 000012795 TACOBA IALL CAB 30"
1, EA 000012692 TACOMA WALL CAB 36"
1, EA , '. 000012933 · · TACOMA WALL CAB W3018 ,, W3018
1~-'~: -.~-. EA ~,'-'*~-'¢~000013254-.,;~;TAC~ WALL-CAB W3615 ' ?-'W3615
1' , EA , '~ 000013361 ~:.~TACOflA CNR WALL CAB ~ CW2430
1, * - EA ~*~; ~-~: OOO013718'~,~.TACO~A BASE CAB 30' '.. ~B30
1' .~*. - EA*~:~, 000013956 '- TAC~ BLND BASE $6/89' /BLB36/39
I-'~ .~ EA;:::~::' 000112800 'CNTRTOP MYST;~UE MOONLGT 8'4757T8
1~ EA ,~.~ ..: 000112803 ': CNTRTOP MYSTIQUE MOONLGT 6'LU4757
I EA *,,~.~;. 000112807 ' CNTRTOP MYSTZGUE UOONLGT 6 RM4757
2, ' EA¢~.~000112817 MYSTZGUE MOOflL~GHT END GAP KIT
~,*¢:,,'* ** DELIVERY CHA~GE .
09/15/00 ;,, 01~72 294419 ,:,, .~..001~545 GEN * '
~NVOZCE I~TE~
09120100
99ANT1rTy
1
I
1
1
1
1
1
-1
XNYOXC~ NO. : J~ A~T.NO. · JOB
011726494507 ': . 001545 * GEN
UNIT - * ITEM DE~RXPTZON
EA .. , 000024420 BALL~ 12 TYJ. P PP23010
EA ~ 000024466 FAUGT HOLE COVER LPP21501PP815-1
EA 000024467 FCT HLE COVR SNP LPP21511PP515-11
~ 000024650 P-TRAP PVC 1-1/2'LPP20940/PP940 . -
EA , 000025002 11/2X12~E $L JT LPP205512 :
EA 000025032 16"E~ OUT CT WAST LPP20925/PP925 ' '.
EA 0000.30361 1-5/8 9RIGHT A/T OR~YW.'~;~.L NA. TL 5~
BOX --- ~000060038 - DRY/~4-t. 8CREW COARSE 2 -1LB .........
SALES TAX
INVOICE DATE
09/20/00
QUANTITY
2
INVOICE NO. JOB ACCT,NO. JOB NAME
011726494558 001545 GEN
UNIT ITEM DESCRIPTION
EA 000026314 40G W/HTR NTGAS 6YR ENVZROTEMP
SALES TAX
DEL[VERY CHARGE
INVOICE DATE
09/21/00
QUARTXTY
2
INVOICE NO. JOB A~T.HO. JOB
011726594573 001545 GEN
UNIT ITEM DE6CRXPTXOH
EA 000026302 40G W/HTR ELEC 6',fR ENVZRO DBL/ELE
SALES TAX
AMOUNT
-:-=:!j;TXMWOOG' ·
MBX ~:~:"~ ~'" '
T PRICE' ok- EXT PRICE
89.oo...-;'"~" eo.oo
61.,7 J.- 6,.47
9g.47 [~IU"f~ 99,47
109.88 109.88
~ ,z. ?9.88 86.9~-:'~-
120.00
120.00
47.35
46.31
'46.31
' 8.4,3
125.88
120.00
46.31
16.86
82.04
20.00
~;469.41
PUROHABED BY
'RICE
69.98
~*.7.56
'7.46
6.97
5.52
S97.49
BY
NNXT PRICE
8.71
1.28
0.98
1.68
2.25
4.10
5.~
2.7Z
TOTAL:
P.O. NUMBERS
UNIT PRICE
148.00
TOTAL:
P.O. NUMBERS
UNIT PRICE
138.00
TOTAL:
EXTPRXCE
8.71
1.28
0.98
t.68
2.25
4.10
5.53
2.77
1.64
528.94
PURCHASED BY
VICKI BECHEN
EXTPRXCE
296.00
17.76
20,OQ"~
$333.76',,~
PURCHASED BY~
VICKI BECHEN
EXTpRXCE
276,00
16.56
$292.56
O~23,2000
2741-43 Jackson
Dub.,Ia~ 52001
Replace pump and fitting in basement-dug out mud fxom pit (motor was full of water and water
came in too fast) Labor - Tim Wood $78.00
Material 108.00
4.69
$191.16 sub-total
Clean out basement, mud on planks, old plastic on floor,
old water heaters etc. and haul off, re-lay new plastic on
floor. Labor- Tim Wood
88.00
JBC Services- help with cleaning out basement 184.00
$489.85
C
Use Your o
Dubuque Store
3925 Dodge Street
Dubuque. IA 52003
(319) 556-5222
Sale Transaction
16X25X1 FIBERGLASS F
6331210 12 ~0.49 5.88
WINDOW-CONTROL KIT
2219035 1.49
WINDOW-CONTROL RIT
2219035 1.49
WIHOOW-CONTROL KIT
2219035 1.49
WINDOW-CONTROL KIT
2219035 1.49
1.5 VOLT BATTERY 1/C
2109527 O. 88
1.$ VOLT BATTERY 1/C
2109527 ;, 0.88
PRIVLOCR P/B BEL605
221402~ 12.35
SCREW GALVANIZED 1-1
2296359 ~ ' :
..... 2.79
PL LTE~ 16
6331074 3 B1.96 5.88
5NIL rXlOO'. BLUR- P
16~'lrm*'' ' 25.19
LT. AA?AC A
2107~5 ' ~ 9.98
I*I/2"PL~TIC CHECK
6911~ ~ 4.69
l-U2 X 1-1/4 P~ B
6891~5 0.47
1/2tip C~T PUNP FPSC
6913~5 108
TOTAL 182.95
TAX AT 6~ 10.98
TOTAL SALE 193.93
VISA 1573 193.93
030148 EXP: 01/03
OUEST COPY
The Cardholde~ acknowledges receipt of
goods/services tn 'the total amount sho~n
hereon and agrees to pay the card Issuer
according to Its curr~nt terms.
THIS IS VOUR CREDIT CARD SALES SLIP
PLEASE RETAI~ FOR YOUR RECORDS.
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