Claim Michels, RichardCLAIM 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: Richard Michels
2. Address: 25312 Cornerstone Sherrill IA
3. Telephone Number: 552 2803
4. Date of Incident: 15 Feb. 2001
5. Time of Incident: Approx. 4:00 PM
6. Location of Incident (Be specific):
In alley behindBehr Funeral Home, 1491 Main
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.)
While plowing snow down the alley the snow plot hit the drivers side rear view mirror and broke it
8. What were weather conditions like? Cold
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
Yes on Fri 16th
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.)
Rear View Mirror on Car
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?
$314.98 (See attached estimate)
16. Why do you claim the City of Dubuque is responsible?
See previous statements
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 19th day of February, 2001 , 20 .
/s/ Richard Michels
(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 THE A~T~ORITY TO MAKE ANY
REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE
PAID.
4. Date of Incident: ~/,~
7. DESCRIBE ACCIDENT OE OCCURRENCE THAT CAUSED INJURY OR DAMAGE.
(~ive full details upon which you base your claim, if a City
employee was involved, give the employee's n~me.)
8. ~at were weather conditions like?
9. ~ive n~e and ad. ess of ~y witnesses.
10. Did police investigate?
11. Was anyone injured? (If so, give name,
injuries. )
(If so, ~ive names of officers.)'
address and extent of
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 THE A~T~ORITY TO MAKE ANY
REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE
PAID.
3. Telephone N,,~ber:
4. Date of Incident: ~/-~
Location of incident. (Be specific)
7. DESCRIBE ACCIDENT OR OCCURRENCE T~AT CAUSED INJURY OR DAMAGE.
(Give full details upon which you base your claim, if a City
employee was involved, ~ive the employee's name.)
8. What were weather conditions like?
m/D
9. Give name and address of any witnesses.
10. Did police investigate?
11. Was anyone injured? (If so, give name,
injuries.)
(If so, give names of officers.)'
address and extent of
12. Was any damage done to property? (If so, describe property
and the extent of daunage. Attach estimates of danuages 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 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?
/
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 /~ day of
~0m I
' - (S~nature)
Print Name)
02/19/2001 at 06:46 PM
30799
Job Number:
BRIMEYER AUTO BODY
License #:30799 Federal ID #:421438480
10727 JOHN F. KENNEDY RD
DUBUQUE, IA 52001
(319)583-4456 Fax: (319)583-1838
PRELIMINARY ESTII~ATE
written by: ERIC WINCH #
Adjuster:
Insured: DICK MICH~ELS
Owner: DICK MICHAELS
Address: 25312 CORNERSTONE
SHERRILL, IA 52001
Day: (319)552-2803
~uslness: (319)582-2297
Claim%
Policy #
Deductlble:
Date of Loss:
Type of Loss:
Point of Impact: 10.
Inspect
Location:
Left Front Pil
Insurance
Company:
Days to Repair
1989 CADI DEVILLE 8-4.SL-FI 4D SED SIL/GREY Int:
V'/N: 1G6CDS150K436t378 Lic: ~rod Date:
Air Conditioning
Telescopic wheel
Climate Control
Bumper Guards
Power Steering
Power Locks
Power Mirrors
Tilt Wheel
Intermittent Wipers
Tinted Glass
Dual Mirrors
Power Brakes
Power Driver Seat
Power Trunk
Odometer:
Cruise Control
Auto Level
Body Side Moldings
Clear Coat Paint
Power Windows
Power Antenna
Split Bench Seats
NO. OP. DESCRIPTION Ql~f F_)C~. PRICE LABOR PAII~
FRONT DOOR
2* Repl LT Mirror electric w/heat 1 231.00 0.4 O.S
3 Add for Clear Coat 0.1
4* R&I LT Trim panel 0.3
Subtotals ::> 231.00 0.7 0.6
02/19/2001 at 06:46 PM ]ob Number:
30799
PRELIMINARY ESTIMATE
1989 CADI DEVILLE 8-4.SL-FI 4D SED SIL/GREY Int:
Parts 231.00
Body Labor 0.7 hrs ~ $ 40.O0/hr 28.00
Paint Labor 0,6 hrs ~ $ 40.O0/hr 24.00
Paint supplies 0.6 hfs ~ $ 25.00/hr 15.00
SUBTOTAL $ 298.00
Sales Tax $ 283.00 ~ 6.0000% 16.98
GRAND TOTAL $ 314.98
AD3USTMENTS:
Deductible 0.00
CUSTOMER PAY $ 0.00
INSURANCE PAY $ 314.98
Estimate based on MOTOR CRASH ESTIMATING GUIDE. unless otherwise noted all items are derived from
the Guide DE1BAS5 Database Date 10/2000 and the parts selected a~e OEM-parts manufactured by the
vehicles Original Equipment Manufacturer. Asterisk (*} or Double Asterisk (**) indicates that the
parts and/or labor information provided by MOTOR may have been modified or may have come from an
alternate data source. Non-Original Equipment Manufacturer aftermarket parts are described as A~
or Qual Rept Parts. used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned
parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Prices
are provided from National Auto Glass Specifications, Inc. Pound sign (#) items indicate manual~
entries.
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