Claim Chase, Chad M.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: Chad M. Chase
2.Address: 654 Kane Street, Dubuque IA 52001
3. Telephone Number: 563 556 5264
4. Date of Incident: April 14, 2003
5. Time of Incident: 4:05 P.M.
6. Location of Incident (Be specific):
Directly in front of (Address) 915 Kane Street. I you are going toward Wahlert it is on the right side of the street.
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.)
There was a pot hole in the middle of the street. App. 2 ft x 3 ft. big. There was no baracade or warning around at that time. I went over the pot hole.
8. What were weather conditions like?
Great, no wind, no rain, no snow.
9. Give name and address of any witnesses:
Chelsey Chase, 654 Kane Street, Dubuque IA 52001
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, the front bumper was cracked and it also through my car out of alignment, impact bar (dented), front right head light was broken.
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?
$1437.01
16. Why do you claim the City of Dubuque is responsible?
There was no barriers around tyhe pot hole and if the street would have been fixed right the first time it wouldn't have hapopened.
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 14th day of April, 2003. .
/s/ Chad M. Chase
(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.
3. Telephone Number:
4. Date of Incident: ~Z[
5. Time of Incident: ~ ,
6. Location of Incident (Be specific):
7. DESCRIBE ~CClDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE, (Give
full details upon which you base your claim. If a City employee was involved, give the
e?/~oyee's name.) ,
II-
8. What were weather conditions like? f~CL~',. .~ ,~), .... /'~r~ f~ar/--7; J/~O ~
9. Give name and address of any witnesses: 6~t~---~_.~' (/~/.,v~?~ . ~ ~--4 Y~,-~
~, --
10. ~_~lice 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 damages.
Attach estimates of damages or describe basis for ascertaining extent of damage.)
13. What other damages do you claim, {f any? ~r~(~_,
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? / L~ ~7o ~)//
16. Why do y°u claim the City of Dubuque is responsible? I~,~?, &)~.~, ~
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 at Dubuque, Iowa this / ~h day of
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
04/21/2003 at 09:04 A~
30799
Insured: CHAD CEASE
Owner: CFL~D CEASE
Address: 654 KAi~E ST
DUBUQUE, IA 52001
Day: (563)558-5264
Inspect
Locationz
BRIMEYER AUTO EODY
License ~:30799 Federal ID %:421438480
10727 J0~ F. KENNEDY RD
DUBUQUE, IA 52001
(563)583-4456 Fax: (563)583-1838
Written by: ERIC WINCH %
Adjuster:
Claim #
Policy #
Tyge of LOSS:
Job Number:
Days to Repair
1993 PONT GRAArD A24 GT 6-3.3L-FI 2D Iht:
VIN: 1G2NW14NgPC786748 Lic: Prod Date:
Tinted Glass Body Side Moldings
FOg Lamps Clear Coat Paint
Power Brakes Power Locks
Cloth Seats Bucket Seats
Aluminum/Alloy Wheels
Dual Mirrors
Power Steering
Anti-Lock Brakes (4)
Recline/Lounge Seats
NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT
1 FRONT BUMPER
2 O/H front bumper 2.8
3** Repl A/M Bu/nper cover w/GT 1 328.00 Incl. 2.5
4 Add for Clear Coat 1.0
5 Repl Impact bar 1 189.97 Incl.
6 Repl RT Molding w/GT 1 23.31 Incl.
7 Repl LT Molding w/GT 1 23.31 Incl.
8 R&I License bracket all 0.3
9 Bepl Emblem w/GT 1 23.11 Incl.
10 FRONT LAMPS
1t** Repl A/M RT Beadlamp assy 1 160.00 0.8
12 Aim headlamps 0.5
13'* Repl A/M RT Park/turn lamp 1 23.00 0.3
14'* Repl A/M RT Marker lamp 1 28.72 0.3
15 FRONT SUSPENSION
16 Repl Align front wheels 1 m 1.9 M
Subtotals ==> 799.42 6.9 3.5
Parts 799.42
Body Labor 5.0 hfs ~ $ 44.00/hr 220.00
Paint Labor 3.5 hfs @ $ 44.00/hr 154.00
Mechanical Labor 1.9 hfs ~ $ 49.80/hr 93.10
Paint Supplies 3.5 hfs @ $ 27.00/hr 94.80
SUBTOTAL $ 1361.02
Sales Tax $ 1266.52 @ 6.0000% 75.99
GR3LND TOTAL $ 1437.01
ADJUSTMENTS:
Deductible 0.00