Claim by Paul Swartzel~..~
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T THE CITY OF DUBU UE, IOWA ~,~,~:~, ~ ,
CLAIM AGAINS Q ~.
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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
'AUL SIVAI~'TZEL
2. Address: ? ? "" =ilLJN iTl'EET ~ !)U9UQUE ~ ~ UVIA _
3. Telephone Number r~3 ~7-?~?r.,
4. Date of Incident: Oc-roaER zuo~
5. Time of Incident: ? ?: `-` r'r~`
6. Location of Incident (Be specific):
~rTH STREET R SYCAMORE
7. Describe the accident or occurrence that caused injury or damage. (Give full
details upon which you bast your claim. If a City employee was involved, give
the employee's name.)
HIT AN ELEVAT~O MAfJHOLE COVER ACID PJTHULE IN THE ~URTHBUUNG
LANE.
8. What were weather conditions like?
CLEAR
9. Give name and address of any witnesses:
P~'ARV SWARTZEL l PASSENGER IN VFHIf t F'~
10. Did police investigate? (If so, give names of officers.)
'~U
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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.)
(Ji01DOlAGED LEFT FRONT WHEEL AND ALIGNMENT.
NEW WHEEL AND ALIGNMENT $2,E30•~~S
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.)
ALLSTATE INSURANCE CUMPAPdY PAID $~•630.~~5
15. What amount do you claim from the City of Dubuque?
$1,000•OO (THE DEDUCTIBLE AMOUNT?
16. Why do you claim the City of Dubuque is responsible?
RATHER EGREGIOUS OBSTACLE TU TRAVEL.
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?
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Dated this 11 da of
y ~JANUARV , 2 ~~ r~
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(Signature) ~'~ - L;. ~" ~
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F~AUL SWARTZEL m w
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(Print Name)
Mechanical Advantage Automotive Services
3135 Cedar Crest Ridge Suite B
Dubuque, IA 52003
563-557-7663
Name !Address
Swartzel Paul
1998 Ferrari F350 Spider
Estimate
Date Estimate #
11/12/2008 478
~ wiz ~-rz Z i 32~
Description Qty Rate Total
Rim 7 1/2 J X18
4Wheel Alignment.
mount and balance wheel 1
1
1 2,348.38
79.99
29.99 2,348.38T
79.99T
29.99T
All Parts and Labor include a 12 month or 12,000 mile warranty SubtOta~
$2,458.36
Sates Tax (7.0%) $172.09
Signature ~ TOtal $2,63o.as