Claim Meyer, BillCLAIM 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: Bill Meyer
2. Address: 1185 Wood St Dubuqeu IA 52001
3. Telephone Number: 319 582 3734
4. Date of Incident: January 26, 2001
5. Time of Incident: 8:00 a.m.
6. Location of Incident (Be specific):
1185 Wood St., Dbq.
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.)
A snow plow was plowing Wood Street and hit the drivers side mirror on my car (1992 Buick Century). The mirror
and holder are no longer functionable.
8. What were weather conditions like? There was a light snowfall the night before and early that morning.
9. Give name and address of any witnesses:
Myself
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.)
Drivers' Side mirror 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
15. What amount do you claim from the City of Dubuque?
$102.29
16. Why do you claim the City of Dubuque is responsible?
Because the snow was the property of Dubuque.
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 23 day of February , 20 .
/s/ Bill G. Meyer
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST T UQUE
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
reconunendation 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 AbTaORITY TO MAKE ANY
REPRESENTATION TO YOU AS TO WH~TnER YOUR CLAIM WILL OR WILL NOT BE
PAID.
2. Address,
3. Telephone Number:
4. Date of Incident:'
5. Time of Incident:
~,'00 ~.
Locatio~ of incident' (Be specific~
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.)
mU
8. ~at were weather conditions like?
9. ~ve n~e ~d address of ~y witnesses.
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give name, address and extent of
injuries.)
/V0
12. Was any d~m~ge done to property? (If so, describe property
and the extent of d~mage. Attach estimates of damages or
describe basis for ascertaining extent of d~mage.)
13.
14.
What other damages do you claim, if an~?
Have'you been compensated for any part or all of your claim, by
any i~t~r~_~e ~ompany? (~f so, give name and address of
insurance company and ~mount paid.)
What smount do you Claim from the City Of DUbuque?
$
15.
16.
Why do you claim the City of Dubuque is responsible?
17.
Haveyou ~de_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 ~s yes,. have you received any
''paymen~f~!that's0urce,' ~d"i~-'~-'~'"~
Dated at Dubuque',- Iowa,
20
this
(Signature)
(Print Nme)
(Revised January, 2000)
CLAIM AGAINST THE CITY
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 TO WHETHER YOUR CLAIM WILL OR WILL NOT BE
PAID.
3. Telephone Number: ~/~
4. Date of Incident:' J~/M/x~W~. aC .t
5. Time of Incident: ~,~O
6. Locatio of incid&nt, specific)
7. DESCRIBE'AcCIDENT OR OCCURRENCE THAT CAUSED INou~Y OR DAMAOE.
(~ive 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? 7~
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give name, address and extent of
injuries.)
12. Was any a~m~ge 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 d~m~ges do you claim, if any?
Have'you been compensated for any part or all of your claim, by
amy i~ra~o~ comp~? (~f so, give name and address of
insurance company and amount paid.)
What amount do you claim from the City of Dubuque?
$ /o ~ ~-~-~
15.
16.
Why do you claim the City of Dubuque is responsible?
17.
result of ~his incident?
If yes, give name and address:
18.
If the answer to Question 17 is ye~.~,.~_aYe._you received any
-pa~ent f~0~ithat~s0urCe,- ~d"if so, in. what amount?
Dated at Dubuque~ Iowa, this
~0 PO
e~O o,,
(Revised January, 2000)
(Signature)
(Print Na~e)
Date: 2/2310t t1:10 AM
Estimate ID: 4308
Estimate version: 0
Preliminary
Profile ID:. Mitchell
FED ID ~42-0813744
RICHARDSON MOTORS
1476 J.F.K. ROAD DUBUQUE, IA 52002
(3t8) 682-541t
Fax: (3t9) 582-4129
Damage Assessed By: AL COGHLAN
Deductible: UNKNOWN
Owner BILL MEYER
Address: 1185 WOOD ST DUBUQUE, IA 52001
Telephone: HomePhone: (3t9)582-3734
Mitchell Service: 913490
Description: 1992 Buick Century Special
Body Style: 4D Sed
VIN: t G4AG54N4N6432126
Drive Train: 3.3L Inj 6 Cyl A
Line Ent~ Labor Line item Part Type/ Dollar Labor
Item Number Type Operation Description Part Number Amount Unite
332338 BDY REMOVE/REPLACE L FRT DOOR REAR VIEW MIRROR ORDER FROM DEALER 67.75 0.5' #
332430 BDY REMOVE/REPLACE L FRT DOOR PLATE GASKET t02267t7 GM PART 8.75
* - Judgement Item
# - Labor Note Applies
Add'l
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary
Body 0.5 40.00 0.00 0.00 20.00 T Taxable Parts
Sales Tax ~
Taxable Labor 20.00
Labor Tax ~ 6.000 % 1.20 Total Replacement Parts Amount
Labor Summary 0.5 2'1.20
6.000%
18. Additional Costs Amount IV. Adjustments
Total Additional Costs 0.00 Customer Responsibility
I. Total Labor:,
II. Total Replacement Parts:
IlL Total Additional Costs:
Gross Total:
ESTIMATE RECALL NUMBER: 2/23/01 11:05:55 4308
UltraMata is a Trademark of Mitchell International
Mitchell Data Version: FEB_0t_A Copyright (C) 1994 - 2000 Mitchell Internatio. nal
UltmMata Version: 4.6.004 All Rights Reserved
Page I
Amount
76.5~
81.09
Amount
21.20
81.09
0.00
102.29
of 2
Date: 2/2310t 11:10 AM
Estimate ID: 4308
Estimate Version: 0
Ptatiminary
Profile ID:. Mitchell
IV. Total Adjustments:
Nnt Totah
0.00
t02~9
This is a preliminary estimate.
Arlditional chanqeS to the estimate may be required for the actual repair.
ESTtMATE RECALL NUMBER: 2/2310~ 11:05:55 4308
UltraMata is a Trademark of Mitchell International
Mitchell Data Version: FEB_01_A Copyright (C) 1994- 2000 Mitchell Intarn .atto. nel
UtiraMate Version: 4.6.004 All Rights Reserved
Page 2
of 2