Claim Kivlahan, JohnCLAIM 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: John Kivlahan
2. Address: 4922 Wild Flower Dr. Dubuque, IA 52002
3. Telephone Number: 563 582 1626
4. Date of Incident: March 2, 2002
5. Time of Incident: 2:15 p.m.
6. Location of Incident (Be specific): Apt. 21, 280 West 17th St., Tenant - Charles Frost
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.)
City Employeee Tom Pregler of the police dept. forced entry to the apt. having to break glass and screen in storm door and entrance door,of
deceased tenant.
8. What were weather conditions like?
9. Give name and address of any witnesses: Richard Mastin, 1669 Main Apt 4 Dubuque IA 52001
10. Did police investigate? (If so, give names of officers.)
Officer Tom Pregler
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.)
Damage to two doors, glass and screens
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 and amount paid.)
None
15. What amount do you claim from the City of Dubuque?
$262.60
16. Why do you claim the City of Dubuque is responsible?
Employee did damage -r our deductable is $250. Our insurance will not subrogate claims.
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 29th day of April , 2002.
/s/ John Kivlahan (Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
T is 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. Nameof Claimant: John K±vlahan
2. Address:
4922 Wild Flower Dr~ Dubuque, IA 52002
3. Telephone Number:
4. Date of Incident:
563 582 1626
March 2~ 2002
5. Time of Incident:
2:15 pm
6. Location of Incident (Be specific):
APt 21. 280 West 17th St.
Tenant-Charles Frost
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.)
City employee~ '2om Pregler of the police dept
forced entry to the apt. having to break glass and screen in storm
door and entrance door~ of deceased tenant.
8. What were weather conditions like?
9. Give name and address of any witnesses:
Richard Mastin, 1669 Main Apt4
Dubuque, Iowa 52001
10. Did police investigate? (If so, give names of officers.)
Officer Tom Pregler
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 damage.)
Damac~ to two doors. _~lass and screens
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 and amount paid.)
15. What amount do you claim from the City of Dubuque? $262.60
16. Why do you claim the City of Dubuque is responsible?
employee did damage L 0U~ d~Uctable is $250. Our insurance
will not subrogate claims.
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 29 day of Apr±l , 20 02
(Rev. 1/00 & 7/01)
(Signature)
John Kivlahan
(Print Name)
KIVLAHAN & SONS, INC.
HOMES, ADDITIONS, GARAGES, DECKS,
WINDOW REPLACEMENT, ROOFING & SIDING.
JOHN KIVLAHAN (;RE(;
,,.~:--582-1626 588 031 0
4922 $~ild Flower: Dr.
DUBUQUE, IOWA 52001
STATEMENT
April 22, 2002
City Of Dubuque
Damages on Emergency Call
Location - Apartment 21, 280 West
Tenant - Charles Frost
17th St.
Labor & materials to replace damaged glass and screen
Storm door - screen and sash 60.39
Interior door - window insert 92.21
caulking and misc, materials 10.00
Labor 4hr. @ $25.00 100.00
Total due $262.60
PHONE: 319-588-2036
FAX: 319-588-4355
ALUMINUM PRODUCTS, INC.
PLEASE PAY
FROM THIS INVOICE
555 HUFF STREET
P.O. BOX 936
DUBUQUE, IOWA 52004-0936
30XN NIYLAXAN CONST
4922 YILD FLONEH ORIVE
i}HRH~HE, IA H2RR2
s 20HN HIVLAHAN CONOT
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L 0 4922 i~ILO PCONER HRIVE
DURHqUE, IA H2ARH
CYST POi WALNUT gROVE APARTNENTS
PLEASE REFER TO]
"iNVOICE NO." ON
ALL PAYMENTS AND
CORRESPONDENCE.
136433
ORDERED B~O.
LABOR REP/SC AF 1,HR 1,HA ALHN ERANE/FIHERGLASS SC 9.H~HNO EC .ON 9,RH
REPAIR
SCREEN 6REY FINER G,3R 6.3H 29 112 X 28 1/2 SCREEN .25OO0 SqET .52 1.66
1IH Ct TEflP 6.28 6.28 RH X SD lJ4 TENP GLASS 7.72DHG SqFT 18.95 31.91
LAROR SHOP ,HN .Se REGCAZING SASH 3e.eoeee HR ,AR 15.60
IR SALESTRH 2.85
DU CITY TAX .57
TOTAL 6R.39
TERMS: NET 30 DAYS. A FINANCE CHARGE OF 11/~% PER MONTH APPLIES ON INVOICES
30 DAYS PAST DUE, THIS IS AN ANNUAL PERCENTAGE RATE OF 18%.
THANK YOU! - we Sincerely Appreciate Your Business.