Claim, Kelly, Daniel K.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: Daniel K. Kelly
2. Address: 2244 Delmonaco Drive
3. Telephone Number: (563) 556 8137
4. Date of Incident: 6/4/02
5. Time of Incident: 1754
6. Location of Incident (Be specific): University Avenue / Walnut St. (On University Ave.)
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.)
I was driving west on University Ave., left tire entered washed out piece of roadway in the driving portion of the road.
This caused tire rim to be bent, hubcap to fly off and hit oncoming car (headed East on Univ. causing damage to other
cars' bumper and my vehicle
8. What were weather conditions like?
Weather clear at this time - Severe Rainstorms of 6/3/02 & 6/4/02 Road Repaired after my accident as police called.
9. Give name and address of any witnesses:
Angela Ann Cady, 747 Harvard Dubuque IA 52001
10. Did police investigate? (If so, give names of officers.)
Yes, Morrissette Badge No. 77B
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, 99 Toyota Corolla Car - replaced damaged left front wheel steel; Mount and balance & realign left front wheel;
see Brimeyer Auto Body Final Bill that we paid.
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? $144.21
16. Why do you claim the City of Dubuque is responsible?
Hole in driving portion of roadway was left unrepaired.
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?
No
Dated at Dubuque, Iowa this 13 day of June , 2002.
/s/ Daniel K. Kelly
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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:
2. Address: c~/-/
3. Telephone Number:
4. Date of Incident: (¢ / ¢/0-~-
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
9. Give name and addl
10. Did polic~e investigate? (If so, give ytames pf officer, s.)
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.)
Yes; 99 Toyota Corolla Car-- replaced damaged left front wheel steel; mount and balance and
realign left front wheel; see Brimeyer Auto Body Final Bill that we paid
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?
$144.21
16. Why do you claim the City of Dubuque is responsible?
Hole in driving portion of roadway was left unrepaired.
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?
No
Dated at Dubuque, Iowa this 13 day of June , 20 02.
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
06/06/2002 at 07:40 AM 3ob Number: 1728
30799
BRI~YER AUTO BODY
License #:30799 Federal ID #:421438480
10727 JOHN F. KENNEDY RD
DUBUQUE, IA 52001
(563)583-4456 Fax: (563)583-1838
ESTIMATE OF RECORD
Written by: ERIC WINCH # 06/06/2002 07:40
Adjuster: 11-004 #
Insured: DANIEL K KELLY
Owner: DANIEL K KELLY
Address: 2244 DELMONACO DR
DUBUQUE,, IA 52002-0000
Day: (563)556-8137X0000
Claim #11W05421A-AD1
Policy #080A516657
Deductible: 250.00
Date of Loss: 06/04/2002
Type of Loss: Other
Point of Impact: 21. undercarriage
Inspect
Location: INSURED RESIDENCE
DUBUQUE, IA R
Day: O-
Insurance PRUDENTIAL INSURANCE COMPANY
Company: PO BOX 9314
MINNEAPOLIS, MN 55440
Business: (810)733-2544
Days to Repair
1999 TOYO COROLLA LE 4-1.8L-FI 4D SED
VIN: 1NXBR12EXXZ283650 Lin: 762GZA
Air Conditioning
Intermittent Wipers
Clear Coat Paint
Power windows
Driver Air Bag
Bucket Seats
GREEN Int:
IA Prod Date:
Rear Defogger
Body Side Moldings
Power Steering
Power Locks
Passenger Air Bag
Odometer: 21612
Tilt Wheel
Dual Mirrors
Power Brakes
Power Mirrors
Cloth Seats
NO. OP. DESCRIPTION Ql%{ EXT. PRICE LABOR PAINT
I FRONT SUSPENSION
2 Repl Align front wheels 1 m 1,0
3 Repl Adjust toe-in 1 m 0.6
4 WHEELS
06/06/2002 at 07:40 AM
30799
ESTIMATE OF RECORD
1999 TOYO COROLLA LE 4-1,SL-FI 4D SED
Job Number: 1728
GREEN Int:
NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT
5* Repl LKQ LT/Front Wheel, steel 1 43.75 m 0.3
type 3 +25%
6# Repl MOUNT & BALANCE 1 12.50 T
Subtotals ==> 56.25 1.9 0.0
Parts 43.75
Body Labor 1.9 hrs ~ $ 42.00/hr 79.80
Sublet/Misc. 12.50
SUBTOTAL $ 136.05
Sales Tax $ 136.05 ~ 6.0000% 8.16
~.GRAND TOTAL $ 144.21
ADJUSTMENTS:
~ Deductible 250;00
CUSTOMER PAY $ 250.00
INSURANCE PAY $ -105,79
Estimate based on MOTOR CRASH ESTIMATING GUIDE, Unless otherwise noted all items are derived from
the Guide ARM8426 Database Date 3/2002 and the parts selected are 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 AM
or Qual Repl 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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