Claim by Kerry RobeyTHE CITY OF
DUB E MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
4d:'
To: Mayor Roy D. Buol and
Members of the City Council
DATE: June 4, 2010
RE: Claim Against the City of Dubuque by Kerry Robey
Claimant Date of Claim Date of Loss Nature of Claim
Kerry Robey 06/03/10 05/29/10 Vehicle Damage
This is a claim in which claimant alleges that he ran over a manhole cover while driving
west in the 200 block of Kaufmann Avenue, and popped his tire.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager
John Klostermann, Street & Sewer Maintenance Supervisor
Kerry Robey
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001 -6944
TELEPHONE (563) 583 -4113 / FAx (563) 583 -1040 / EMAIL tsteckle @cityofdubuque.org
0‘)(11,5-.
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA 4 it tit
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 13 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:
2. Address:
8. What were weather conditions like?
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3. Telephone Number 66 � 4 / 9_5 -,1-3
4. Date of Incident: /0 9//0
5. Time of Incident: 9 yD
6. Location of Incident (Be specific):
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7. Describe the 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.) � �
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9. Givp name and addr ss of any witnesses:
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10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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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.)
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13. What other damages do you claim, if any?
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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.)
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15. What amount do you cl im from the City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible?
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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?
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06/01 /2010
RUBE-01:
563.495.. 850:1.
Alt. Author Name & Phone:
btore #
Description
PRIMEWELL TIRE PACKAGE
REPLACE REAR TWO TIRES.
122613 PRIMEWELL PS830/850 BL
205/65815 94H 40,000 Mile Limited
Warranty
DOT#
NEW TIRE WHEEL BALANCE PARTS
NEW TIRE WHEEL BALANCE LABOR
RUBBER VALVE STEM
TIRE DISPOSAL FEE (1)
TIRE INSTALLATION
COURTESY CHECK.
COURTESY CHECK
ALIGNMENT CHECK
Symptom:-
ALIGNMENT CHECK.
LBR- -DISC DISCOUNT ALIGNMENT CHECK
Flat rate charged per internal & Mitchell labor manuals
Time In 03:45PM 06/01/2010 Parts Return: No
Cust Status: Waiting Appt: Yes Pay Type: Unspecified
Hub Cap Lock:
Malibu
OE: P205/65R15 PSI 30
Torque 100
EXPERT TIRE
555 JFK. RD
DUBUQUE, i(.. 52001
2004 CHEVROLET MALIBU
#_. I C # VIN #
IN 06/01/10 03:45P EST. MILEAGE 87,000
DUE: 04 :4 ;Ph# 06/01 Waiting APPT„ Yes
INITIAL ESTIMATE
Article
Number TO Qty
1E2613 2 65.99 131.98
;'t:18708
007018716
7015040
007075078
047015016
DOT#
017046930 1
067015342 1
007001681 -1
2 2.99
2
2 2.00
1
2
SERVICE ADVISOR
22 JONATHAN
563.557.7321
Extended
Part Labor Price
Mounting Instructions
LF RF
LR
CI RR
5.:8 .a
P• r
6.99 13.98
4.00
2.50 2.50
N/C N/C
N/C N/C
21.99 21.99
21.99 - 21.99
Parts
Labor
ShopSupply
Sub
Tax
Job
Total.
158.44
0.00
0.00
141.96
16.48
0.84
159.28
10.92
Total 170„ 20
ACKNOWLEDGE
AND LABOR, AND PROMISE TO PAAY THIS ESTIMATE OF REPAIR AND S HqREBY AUTHORIZE THE ABOVE WORK FOR ALL SUCH WORK. 1 GRANT �SIDN1 - 0 OPERATE THE REFERENCED CAR, TRUCK E 9 IQ I
PARTS PROMISE ST IGHWAYS
OR ELSEWH E FOR THE PURPOSE OF INSPECTION AND /OR TESTING. I UNDERSTAND THAT ALL CLAIMS MUST BE ACCOMPANIED BY AN INVOICE. I UNDERSTAND IF ADDITIONAL
WORK I R UIRED, YOU ► OBT IN MY VERBAL OR WRITTEN AUTHORIZATION BEFORE ANY ADDITIONAL WORK IS BEGUN, UNLESS OTHERWISE SPECIFIED ON THIS ESTIMATE.
WM/WMler a
YOU HAVE ?1= ;.;;1'' ;':1 A RiTTEN OR ORAL. ESTIMATE IF THE EXPECTED COST OF REPAIRS OR SERVICE WILL SE MORE THAN
FIFTY DOLLARS. RS. Y!::dl ;:SL WILL NOT BE HIGHER THAN THE ESTIMA.TE BY MORE THAN TEN PERCENT UNLESS YOU APPROVE A
HIGHER AMOUNT BEFORE REPAIRS ARE FINISHED. INITIAL YOUR CHOICE:
Written Estimate _ _ Drat S,t:ma:.; .._ N Estimate __.._._ Ca!! me it repairs and service wi' be more than $ ._. _
Please do not leave Cell Phones, CDs, Money. Jewelry. or any other valuables in your vehicle.
:xpert The is not and will not be held responsible for missing or stolen stems