Claim Stevens, Delmar 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: Delmar M. Stevens
2. Address: 8910 Boardwalk, Peosta, Iowa 52068
3. Telephone Number: 563 583 5010
4. Date of Incident: April 17, 2003
5. Time of Incident: 3:55 P.M.
6. Location of Incident (Be specific):
Intersection of Artierla nd Hwy 20 (corner of Mike Finnin Fort) (turning right onto Hwy 20)..
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.)
A worker had dropped some tools. I swerved to avoid them but ran over an object. When my tire popped it was a pair of needle nosed plirs that were stuck in my tire.
8. What were weather conditions like?
9. Give name and address of any witnesses: About 10 feet from Mike Finnin Ford, I stopped, examined the tire and found the pliers lodgedin my tire. I have enclosed the pliers.
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
My tire! It was ruined.
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.)
My tire was ruined. I have attached an estimate of replacing the tire from Team Tires
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?
$132.70
16. Why do you claim the City of Dubuque is responsible?
total amount
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 24th day of April, 2003.
/s/ Delmar M. Stevens
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
complete this form in full and attach any additional information that supports your claim.
The Claim m~t 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: .~o[rY~O~-
3. Telephone Number: ~gT' 5PS-
4. Date of Incident:
5. Time of Incident: ~: ~ ~ ~.~,
6. Location of'lnci~n~ (Be specific): ~_Ter.~!~
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?d~ ~[~z "f~ ~ S~ ~ ~ ~,
s. n.me a.d .ad, s of any
~0, Did polJ~ investigate? (Il sol give ~mes
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, if any? _~ ~Y3~-
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.) ~ O
18. If the ans~ver to Question 17 is yes, haveyou received any payment from that source,
and if so, in what amount? ~ ~
Dated at Dubuque, iowa this ~//~ day of
· ' '(signature~
(Print Name)
(Rev. 1/00 & 7/01)
4103 MCDONALD DR, DUBUQUE, lA 52002 (5~3)584-034i
WORK ORDER/ESTIMATE~ 81~=_~4--10694
Date: 04-24-03
Time: 1~:30
................................................................. ........
SOLD TO: SHIP TO:
STEVENS MARK
8872 BOARDWALK
PEO~TA~ IA 52068
(56~)583-5010 Bus(000)000-0000 (000)000-0000
TIME PROMISED: : METHOD OF PAYMENT: ( >CASH ( )CHECK ( )CHARGE ( )CREDIT CARD
)4AYE ~ YEiC{R HI~ T{~ L~ilT# (]tv,~r. NT~ Vitl
JEEP Wi~R ~X~ 1999 IA-
9L TC MFG ITB4 }tmi~BER 9UF BIZE I)ESCRIPTtON O]'Y FET$ L~IT({ EXTENI)$ (](I~t~(T~
SUB-TOTAL 1L~'5.19
SALES TAX 7.51
ESTIMATED TOTAL 13P_. 7~l
$ ADDITIONAL WORK WAS AUTHORIZED (*) BY
B~r-~ (Date) AT (Time).
EMPLOYEE NAM~'-~HORIZATION:
PLEASE READ CAREFULLY. CHECK ONE OF THE STATEMENTS BELOW, AND
SIGN: I UNDERSTAND THAT UNDER STATE LAW. I AM ENTITLED TO A
WRITTEN EGTIMATE IF MY FINAL BILL WILL EXCEED $100.
~ ! I REQUEST A WRITTEN ESTIMATE.
I DO NOT REQUEST A WRITTEN ESTIMATE AS LONG AS THE REPAIR
COSTS DO NOT EXCEED $ · THE SHOP MAY NOT EXCEED
THIS AMOUNT WITHOUT M~-l~ ORAL APPROVAL.
~ I DO NOT REQUEST A WRITTEN ESTIMATE.
SIGNED DATE
PARTS & SERVICE WARRANTIES ATTACHED - ALL LABOR FLAT RATE
STORAGE $10/DAY (BEGINS 3 WORKING DAYS AFTER NOTIFICATION)
ALL ESTIMATES ARE FREE UNLESS OTHERWISE LISTED OR POSTED.
THIS IS NOT AN INVOICE -- DO NOT PAY
I REQUIRE RETURN
OR INSPECTION OF
OLD PARTS
I BO NOT REQUIRE
RETURN OF OLD PARTS
CUSTOMER'S SIGNATURE