Claim by Tim Kelly- r _
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 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 cf Claimant: Tim Kelly
2. Add ress:,2770 White St. Dubuque
3. Telephone Number j~ ~ y/~ ~.//~~
4. Date of Incident: _~ ~ 7 ' ~ g
5. Time of Incident: ~"- 1~ ~~
6. Location of Incident (B,e specific): 22 Central in front of Knickers Tap
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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
the employee's ~r~rr~ )
8. What were weather conditions like?
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9: Give name and address of any witnesses:
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10. Did police investigate? (If so, give names of officers.)
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.
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13. What other damages do you claim, if any?
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 a~iu
amount paid.) _
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15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
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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 this day of ~ 7 _ ___ _ _, 20~
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Abra Auto Glass
3400 Center Grove Dr.
Dubuque, IA 52003
(563) 556-0696 /Fax (563) 556-1899
Fed. ID# 42078224
TIM KELLY
2770 WHITE ST
DUBUQUE, IA 52001
(563) 495-1159
Inv. # Quote #001016 Date 04/28/2008
Cust. # 4951159 Biucode WI
P.O. # Sold By
Fed. Tax # Inst'I By
Year 1982 Make FORD policy #
Model
MUSTANG Body
Sryle
2 DOOR HATCHBACK Author-
ized By
Lic. # V.I.N. Claim # Loss Date 04/28/2UU8
p oue (563) 495-1159 Phone O - Cause /
Qty. part Description Block Size List Price Total
1 DW00900GBNN Windshield 26.5x57.5 184.00 159.00 159.00
1 LABOR Labor 1.80 hours 20.00 20.00
1 HAH000004 2.0 Urethane, Dam, Primer 20.00 20.00 20.00
SPECIAL INSTRUCTIONS Subtotal 179.00
Labor 20.00
All material sold on this invoice is guaranteed to be as specified, and is not saferi Blazed material unless so marked. Tax 13.93
[t is sold with the understanding that this material will not be Blazed in a "hazardous location" as defined by the Total 212
93
Consumer Product Saferi Commission. All merchandise returned for credit, refund or exchange must be in resaleable .
condition, authorized for return, accompanied by this receipt, and may be subject to restocking fee. No returns will be
authorized for special orders or cut flat glass.
Balance 212.93
RECEIVED BY The glass listed has been replaced / renaired with like kind and quality to my entire satisfaction,
and I authorize my Insurance Company to pay Abra Auto Glass
directly for the glass and installation charges, or repairs.
AUTO GLASS CENTER
2828 UNIVERSITY AVE
DUBUQUE, IA 52001-5674
(563) 556-0873
Remit To: AUTO GLASS CENTER, PO BOX 4927 DES MOINES, IA 50305-4927
Quote: RG11-12835042
Date: 04/28/2008
FederallD: 42-1513432
Phone: 1 X00-942-0012
Account: 319989 Agent: PO#: Time: 11:10:25 AM
Adv Code: WALK IN CL Salesman ID: 51 Unit: Taken By: JAS Installed By:
Bill To: Sold To:
KELLY, TIM
2770 WHITE ST
DUBUQUE, IA 52001-1969
CELL PHONE: (583) 495-1159
Insurance Co: Policy#:
Ins Co Phone: Claim#:
Policy Name: Cause of Loss:
Agent Name: Date of Loss:
Agent Phone: Verified By:
Year: 1982 Make: FORD Model: MUSTANG Doors: 2 DOOR HATCHBACK'
Odometer: License: Vin:
Oty LocaOon Part Number Vendor Description List Net Total
1 DW01095 GBN PPG WINDSHIELD GREEN TINT/BLUE SHAD 183.35 117.34 117.34
1 RETAIL LABOR MGM LA80R (1.8 HOURSI ON DW01095 GBN 100.00 65.00 65.00
1 HAH000004 MGM 2.0 ADHESIVE (URETHANE.DAM,PRIMER) 100.00 20.00 20.00
1 DISPOSAL FEE MGL DISPOSAL FEE 6.00 6.00 6.00
QUOTED PRICE HONORED FOR 30 DAYS
Urethane Brand Part DOT #
Urethane Lot # Safe Dr'rve Away Time ,
CERTIFICATE OF SATISFACTORY REPAIR
new persan.nr n•d me •bow bs.:da,m.HOn .aa dxbrs m.f H,ev •n, Hue. i andem.nd m.f m wnd•nbld bwwma: my wnicl. Sub Total 5208.34
nnol be down defo~e ne •bow s.re Gme Aw.r rms. me viu: n.b~d m .bow n.. b.en mvbaed m my S.HM.aon, ,na 1 nerebv
uHwdre Mymenl for Mis work b be rtwde d"vecHY b Aub Gbu CBnbf. Ml fuH udbmenl o(Hie hw,•n compenY s ablgedans undx
ny poYCy far uid Lou,1 undershnd i em HnsncbHy resp•nsibb for any cn•,eea not mwred by tnb ep,eanent TaX 514.58
COMPLETED DATE INSTALLER
Terms
CUSTOMER'S SIGNATURE Total 5222.92
seRVicE cn.•ee iscxnuiEO ox • PE•ia•ic ••n: ov 3%vE• xi•m, wfcH n.N.x•u.l vE~Prt.•E n•rE of xA
WARRANTY INFORMATION
^ AUTO GLASS installations carry a limited lifetime warcanty for water leakage and workmanship defects. Auto glass sold and
installed by our company carries a 30 day warranty for unexplainable breakage.
^ Some glass installations require tape to be applied to painted surfaces. We are not responsible for paint that pulls loose from tape
removal nor do we carry insurance to cover faulty paint.
^ PICKUP REAR SLIDING WINDOWS carry a one year warranty on parts and materials and a limited lifetime warranty on our
workmanship.
^ RESEALS carry no warcanty.
^ RESET auto glass (not purchased from our company) carries a warranty, on our workmanship, for water leakage only.
All warcanties are void if rust, deterioration, collision, tinting, or tampering occurs.
All warranties apply only to the owner of the vehicle at the time of installation.
Insulated glass units carry a 5 year manufacturers limited warranty for unit failure due to air or moisture penetration.
Warranties apply to retail installations only.
WINDSHIELD REPAIR WARRANTY
We GUARANTEE 100 % customer satisfaction for as long as you own your vehicle. In the event you
are not satisfied with your repair for any reason, we will credit the amount of the repair when you replace your windshield
at curcent market value at any of our company service centers.
Our repair process has been very successful. However, in the event the repair would fail in process, or you would be dissatisfied for
any reason, our warranty would apply. Our warranty is limited to the cost of the repair only. Repair cost is credited toward the
purchase of the new windshield at any of cur company shops.
The majority of insurance companies waive deductibles for repair. However, if replacement is necessary your deductible may apply
at the time of replacement.
The repair process is an attempt to improve the condition of your present damage. Your present windshield damage could spread
further at any time. If you are not completely satisfied, or the repaired damage still interferes with your vision, please notify us at
your earliest convenience.
I have read and understand all of the above....
DATE
(This section applies only when original job was not performed
by our company.)
ABSENCE OF OBLIGATION
I, the undersigned, understand that we the company assume
absolutely no responsibility for the glass if it should be broken or
damaged while performing their service. They have advised me
that my insurance does not cover breakage or damage to the
glass caused by them during the performance of service. Also,
they have advised me that they have no insurance to cover
breakage or damage to the glass while the work is being
performed.
Signature Date
Witnessed by:
SIGNATURE
This Warrerrty will be honored by Seller at all locations where Seller mnduds
business, upon presentation of this WanaMy. It shall be the responsibility of
Purchaser to bring the vehiGe to one of Sellers business locations. Purchaser
will be required to show proof of ownership of the vehiGe.
LIMITATION OF WARRANTY. DAMAGE DUE TO COLLISION,
NEGLIGENCE, VANDALISM, THEFT AND NATURAL DISASTERS ARE
SPECIFICALLY EXCLUDED FROM THIS WARRANTY. ANV IMPLIED
WARRANTY OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR
PURPOSE ON THIS PRODUCT IS LIMITED IN DURATION TO THE
DURATION OF THIS WARRANTY. SOME STATES DO NOT ALLOW
LIMITATIONS ON HOW LONG AN IMPLIED WARRANTY LASTS. SO THE
ABOVE LIMITATION MAY NOT APPLY TO YOU.
LIMITATION OF DAMAGES. IN NO CASE SHALL SELLER BE LIABLE FOR
ANV SPECIAL, INCIDENTAL OR CONSEQUENTIAL DAMAGES BASED
UPON BREACH OF WARRANTY, BREACH OF CONTRACT, NEGLIGENCE,
STRICT TORT OR ANY OTHER LEGAL THEORY. SUCH DAMAGES
INCLUDE, BUT ARE NOT LIMITED TO, LOSS OF PROFITS, LOSS OF
SAVINGS OR REVENUE, LOSS OF USE OF THE WINDSHIELD OR ANV
ASSOCIATED EQUIPMENT, COST OF ANY SUBSTITUTE EQUIPMENT,
FACILITIES OR SERVICES, DOWN TIME, THE CLAIMS OF THIRD PARTIES
AND INJURY TO PROPERTY. SOME STATES DO NOTALLOW THE
EXCLUSION OR LIMITATION OF INCIDENTAL OR CONSEQUENTIAL
DAMAGES, SO THE ABOVE LIMITATION OR EXCLUSION MAY NOT
APPLY TO VDU.
This W artanty give you sprcific legal ripJris, and you may also have uthv rights