Claim by Maddonna DelaneyTHE CITY OF
DUB UE MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
DATE: July 2, 2010
RE: Claim Against the City of Dubuque by Madonna Delaney
Claimant Date of Claim Date of Loss Nature of Claim
Madonna Delaney 07/01/10 06/25/10 Vehicle Damage
This is a claim in which claimant alleges that her vehicle was struck by a City of
Dubuque bus while parked in the Plaza 20 (2600 Dodge Street) parking lot.
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
Dave Heiar, Economic Development Director
Madonna Delaney
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
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. 13 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: plo
2. Address:
3. Telephone Number: , 5 f o r q — 3
4. Date of Incident: 7 3 7CY
5. Time of Incident: f I 4 ° t
6. Location of Incident (Be specific):
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
7. DESCRIB ACC r. ENT 0 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.)
tt i
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.)
•
f
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.)
Aok
15. W -t amount do you claim from the City of Du • . ue?
/,
•
. Why do you claim the City of Dubu
0
ue is respons
I
le?
(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 mount?
Dated at Dubuque, Iowa this ( day of
)1ta
(Rev. 1/00 & 7/01)
_a_e_t/ce‘-er
. Have yo made any im aga st anyone else for damages as a result of this incident?
, 20 ( �'
(Signature)
(Print Name)
W
0
ri
0
MODEL
LICENSE NO.
SERIAL NO. AND /OR MOTOR NO.
MILEAGE
PART
NUMBER
PARTS NECESSARY AND ESTIMATE OF LABOR REQUIRED
PAINT
ESTIMATE
LABOR COST
ESTIMATE
PARTS COST
ESTIMATE
....e4 _ , , .2. -4. r.,n Z - L
77-,
I
o/
y
00
1 , � k r { r
1 _.
'
�'� O
{
'. ✓S
t } % l_. '�
' .)
n , 9' &
(. ( ...E
Sub Total
,, / :
,) 's
Tax
R.
Materials
7
. 3
Total
r I f
f
THE ABOVE 15 AN ESTIMATE BASED ON OUR INSPECTION AND
ADDITIONAL PARTS OR LABOR WHICH MAY BE REQUIRED AFTER
OPENED UP OCCASIONALLY AFTER THE WORK HAS STARTED DAMAGED
PARTS ARE DISCOVERED WHICH ARE NOT EVIDENT ON THE FIRST
DOES NOT COVER ANY
THE WORK HAS BEEN SIGNED
OR BROKEN
INSPECTION.
BY
AUTHORIZATION FOR REPAIRS
YOU ARE HEREBY AUTHORIZED TO MAKE THE ABOVE SPECIFIED REPAIRS.
SIGNED DATE
NAME
ADDRESS
•
ROSS BODY SHOP
FARLEY, IOWA 52046
(563) 744 -3545
DATE
INSURED BY ADJUSTER PHONE
BELOW IS OUR ESTIMATE TO REPAIR YOUR ? Y ' i 1 r - 'rat t�l_
PHONE