Claim, Cottingham & Butler InsCLAIM 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: Cottingham and Butler
2. Address: 300 Security Building, Dubuque IA 52004
3. Telephone Number: 563 587 5294
4. Date of Incident: Repeating
5. Time of Incident: "
6. Location of Incident (Be specific): Iowa Street Parking
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.)
The Parking Ramp roof was leaking. I called the Parking Ramp to notify them. They sealed the cracks whatever they used ripped on to my car
causing damaged to the paint.
8. What were weather conditions like? N/A
9. Give name and address of any witnesses: N/A
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.)
Yes, Paint 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? $89.95
16. Why do you claim the City of Dubuque is responsible?
They are responsible for the ramp.
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?
N/A
Dated at Dubuque, Iowa this 31st day of May , 2002.
/s/ Chris Patrick
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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 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:
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of InCident (Be specific):
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.)
8. What were weather conditions like?
9. Give name and addres~ of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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 damaged.
Attach estimates of damages or describe basis for ascertaining extent of damage.)
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?
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 t°. Question 17 is yes, have you receiVed any paYment from that source,
and if so, in what amount?
Dated at Dubuque, Iowa this '3 ~ $~- day of
(Rev. 1/00 & 7/01)
(Signature)
(Print Name)
3255 University Ave. · P.O. Box 57
Toll Free 1 (800) 747-4042
Phone (319) 583-9121
Visit us at V~/VVV.birdchevrolet.com
DUBUQUE, IOWA 52004-0057
CUSTOMER COPY
COTTINGHAM & BUTLER CUST# 20169 RO# C163028 PG 1
P.O. BOX 28 DATE 5/31/02 5/31/02
300 SECURITY BLDG. PO#
DUBUQUE IA 52001- WRITER 414
PHONE: 563 587-5301/563-587-5294 APPROVAL 414 /912
OWNER 20169 UNIT# 1G208339 2001 CHEVROLET K1500 SUBU CURR MIL 25,000.0
DELIVERED: 5/30/01 TRANSMISSION: 4 SPD
VIN: 3GNFK16T31G208339 ENGINE: 5.3L 8 CYL
2ND KEY: S603E SERIES:
CYLINDERS: 8 CID:
GVWR: COLOR: INDIGO BLUE MET
LIST UNIT PRC EXT
(C) 1. CONCERN: LUBRICATION,OIL,FILTER CHANGE & 11 POINT INSPECTION
CORRECTION: LUBRICATION,OIL,FILTER CHANGE & 11 POINT INSPECTION
LABOR: LOFT 10.22 *
PARTS: 1.00 25014748 FILTER 01836 6.15 6.15 *
1.00 OIL BULK 5.80 5.80 *
SUBTOTAL LABOR 10.22
SUBTOTAL PARTS 11.95
(C) 2. CONCERN: INSPECT STAINS ON RIGHT REAR QUARTER PANEL
TRY TO BUFF OUT
CORRECTION: SUBLET TO CHUCK'S RECONDITIONING FOR REPAIR
LABOR: *
OTHER: SUBLET MEC 89.95 *
SUBTOTAL OTHER 89.95
(C) 3. CONCERN: CLEAN FUEL INJECTORS AND THROTTLE BODY SERVICE
CORRECTION: CLEAN FUEL INJECTORS AND THROTTLE BODY SRERVICE
LABOR: 15TU *
LABOR: 15TU 60.45 *
PARTS: 1.00 206 INJ CLNR *
SUBTOTAL LABOR 60.45
SUBTOTAL PARTS 60.45
TOTAL LABOR 70.67
TOTAL PARTS 72.40
TOTAL OTHER 89.95