Claim by Dirk VoetbergEMORANDUM
Masterpiece on the
To:
DATE:
RE:
Claimant
Mayor Roy D. Buol and
Members of the City Council
January 2, 2008
Claim Against the City of Dubuque by Dirk Voetberg
Date of Claim
Dirk Voetberg
12/21 /07
Date of Loss
12/11 /07
Nature of Claim
Vehicle Damage
This is a claim in which the claimant alleges that while his vehicle was parked in front of
his residence of 779 University Avenue, a passing vehicle struck his driver's side mirror,
knocking the mirror off of the vehicle. Claimant states that a narrow area of the street
had been plowed after a snowfall.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
BAL:tIs
cc: Michael C. Van Milligen, City Manager
Jeanne Schneider, City Clerk
John Klostermann, Street & Sewer Maintenance Supervisor
Dirk Voetberg
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 3OO MAIN STREET DUBUQUE, IA 52001-6944
TELEPHONE (563) 583-4113 / FAx (563) 583-1040 / EMAIL balesq@cityofdubuque.org
BARRY LINDAHL
CITY ATTORNEY
_,
CLAIM AGAINST THE CITY OF DUBUQUE,
-~
AA~h
IOWA
-vV ~ ,
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 St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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: ~.
E T1g~~
2. Address: 7 ~~ ~~i ~t~'~c- ~~ ~~
3. Telephone Number SSA - 5~~ S~ -
4. Date of Incident: ~c_~ /~ a o~' ~7
5. Time of Incident: ~ n~
6. Location of Incident (Be specific):
7. Describe the accident or occurrence that caused injury or damage. (Give full
details upon which you base your claim. If a City employee was involved, give
F
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
8. What were weather conditions like?
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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`d/amage.) /~
~~cl~SiG`r° mi~rra~; ~7` m u C`~ Q' ~,~,~~ ~S
13. What other damages do you claim, if any?
~U/l
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?
~~ ~5
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?
C7 °
Dated this ~_ day of ~ ~ ,~ , 20~~ ~~ r°~
c ~-,
~ ~- C:~ ;
~ c-. rv -~
s_:7
c~ s~ ;.-
(Sig ture) ~ ~" '~
SRK ~~,~Eti~ ~ c„
(Print Name) --
~..
1
INVOICE
Dave s Downtown Vonocv
5th & Locust Streets INVOICE
Dubuque, Iowa. 52001 10633
Phone - 563-582-2122
Print Date : 12/21/2007
2001 Chrysler -Sebring LXi
Voetberg, Dirk 2.7L, V6, VIN (U)
779 University Avenue Lic # : 779 AXV Odometer In :84500
Dubuque, IA 52001 Unit #
Home 563-556-5252 ---- Cellular 563-584-0500 Vin #
Cust ID : 372 Ref # : Hat #
Part Description /Number Qty Sale Extended Labor Description Extended
Shop/Haz Materials CHECK MIRROR 50.00
ShopMaz Materials 1.00 3.00 3.00 LABOR TO REMOVE AND REPLACVE
LEFT OUITSIDE DOOR MIRROR DOOR MIRROR
ASSEMBLY **** Recommendations ****
CH132021 1 [NS) 1.00 144.99 144.99 C}_:NTER CAPS AND WHEELS
[ Technicians : OGLESBY, RICH
Org. Estimate S211.85 Revisions 50.00
[Payments -
Current Estimate S 211.85 Additional Revised Estimate
Labor:
Parts:
Sublet:
Sub:
Tax:
Total:
Bal Due:
50.00
47.99
`Q.00
197.99
13.86
211.85
5211.85
1 hereby authorize the above repair work to be done along with the necessary material and hereby grant you and/or your employees
permission to operate the car or truck herein described on street, highways or elsewhere for the purpose to testing and/or inspection. An
express mechanic's lien is hereby acknowledged on above car or truck to secure the amount of repairs thereto. Warranty on parts and labor is
one years or 12,000 miles whichever comes first. Warranty work has to be performed in our shop & cannot exceed the original cost of
repair.
SIGNATURE ................................................................................................. Date.......................................
.. Time ......................
Written By <none> Page 1 Of 1
O1 77 07 Copyright Mitchetf t Invoict