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Claim Ott, Lyle & PatriciaCLAIM 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: Lyle & Patricia Ott 2 Address: 17367 Sageville Rd. Dubuque IA 52001 3. Telephone Number: 563 582 0041 4. Date of Incident: Sat. July 26, 2003 5. Time of Incident: Approx. 3:15 P.M. 6. Location of Incident (Be specific): Flora Park Parking Lot closest to Pennsylvania 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.) Car was parked in parking lot & several large trim limbs fell on the hood. Limbs were rotten. 8. What were weather conditions like? Windy & very hot 9. Give name and address of any witnesses: 10. Did police investigate? (If so, give names of officers.) Claim # 03-3075H Park Range Robert Papenthien 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.) No 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? $920.41 16. Why do you claim the City of Dubuque is responsible? Tree was on city property & was not trimmed of the dead limbs. 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 28 day of July, 2003. /s/ Patricia Ott (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: /'~, 2. Address: ~ / 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.) ~ OK' ~ ~, ~P,//~'-&C_/ /,~ ./~'/~/~J ~0~ o 8. What were weather conditions like? ~,~J/ 9. Give name and address of any witnesses: 10.~)~id poll. ce invr~stigate? (If so, v~ na~s of ~fficer~ 11. Was anyone injured? (If so, 9ire names, addresses, and extent of injuries). 12. Was any damage done to property? (If so, describe property and the extent of dama~ges. 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? ~.~ 423 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 to Question 17 is yes, have you received any payment from that source, and if so, in what amount? Dated at Du~b~uque, Iowa this c~ o° day of , (Signature) (Print Name) (Rev. 1/00 & 7/01) 07/28/2003 at 09:37 AM 30799 Job Number: BRIMEI~ER AUTO BODY License $:30799 Federal ID ~:421438480 10727 JO~N F. F~ENNED¥ RD DUBUQUE, IA 52001 (569)583-4456 Fax: (563)583-1838 Written by: ERIC WINCH Adjuster: AARON ACELA ~ Claim #14Q59859 policy ~ Deductible: 50.00 Point of I~act: 16. Non-Collision Insurance ALLIED INSURANCE Day: (800) 532-1212x2027 Company: 7600 OFFICE PLAZA DH SOUTH Days to Repair DEPT 2016 DES MOINEE, IA 50391 1998 DODG ER1500 4X4 8-5.gL-FI 2D SHORT BLK Iht:ELK YIN: 1E7HF16Z1WS556148 Lic: 344AXI Prod Date: Odo~eter: 22000 Intermittent Wipers Dual Mirrors Clear Coat Paint Power Steering Power Brakes Ax/ti-Lock Brakes (2) Driver Air Bag Passenger Air Bag Split Bench Seats Rear Step Buyer NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT 1 HOOD & GRILLE 2** Repl A/M CAPA Hood from 12-6-93 1 370.00 1.5 3.2 3 Add for Clear Coat 1.3 4 Add for Underside(cou~lete) 1.6 5 OTHER CEARGES 65 E.P.C. 1 2.00 Subtotals ==> 372.00 1.5 6.1 Parts 370.00 Body L~bor 1.5 hfs ® $ 44.00/hr 66.00 Paint Labor 6.1 hrs @ $ 44.00/hr 268.40 Paint Supplies 6.1 hrs @ $ 27.00/hr 164.70 Other Charges 2.00 SUETOTAL $ 871.10 Sales Tax $ 704.40 @ 7.0000% 49.31 G~AND TOTAL $ 920.41 ADUESTME~TS: Deductible 50.00 CUSTOMER PAY $ 50.00 INSURANCE PAY $ 870.41 Estimate based On MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR3TA94 Database Date 3/2003 and the parts selected are OEM~parts manufactured by the vehicles Original Equipment Ma/lufacturer. 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 si~n ($) items indicate manual entries. Pathways - A product of CCC Information Services Inc.