Claim by Chad FuryTHE CITY OF
DUB TE MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
40
To: Mayor Roy D. Buol and
Members of the City Council
DATE: August 21, 2010
RE: Claim Against the City of Dubuque by Chad Fury
Claimant Date of Claim Date of Loss Nature of Claim
Chad Fury 08/18/10 08/14/10 Vehicle Damage
This is a claim in which claimant alleges that a City of Dubuque bus struck his vehicle
while it was parked at 793 Clarke Drive.
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
Barbara Morck, Transit Manager
Chad Fury
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
/ 9 % .
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA /7
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: k CCL
LLB
2. Address: I c 4 C tc r Imo-- r
3. Telephone Number 5`' l c )--C - 85 53
4. Date of Incident: , � � 0 1
5. Time of Incident: 1 fJ S
6. Location of Incident (Be specific):
7 iJ C1 it hr
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.)
rr Cc, � �`x�S /,ter -I-
�
-41 b- S �' r I . L Lh'45
8. What were weather conditions like?
9. Give name and address of any witnesses:
n , o-{ 1, LA's ;e/l - 7 `13 C L 62 /,)
l
10. Did police investigate? (If so, give names of officers.)
�/.� IL rAvec\c, (45
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
X11
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.)
Y"
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.)
/tA
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.)
J)
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
Dated this
(Signature)
(Print Name)
day of , 20 j . Q o}•
CrZ c DJ
C CO 0
%�
Fri
i 0 3 m
> o 0
: o
PHON
OWNER DATE
VEHI LE a (
7�i / .-� /Jl' 1 L / 9 , .1-17.2
C -het.I Fo - MAKE
�jY MODEL LICENSE MILEAGE COLOR SERIAL NO. CONDITION
I 7 / Ye" C C' 6�v
INSURANCE CO ADJUSTER
PHONE
Sym. LEFT
Fender, Frt.
Sublet
Or Paint
- r
Service $
Or Hours
nli
CAR LOCATED
Parts
r' ..?
AT
RIGHT
Sym. R
Fender, Frt.
Sublet
Or Paint
DEDUCTIBLE
Service $
Or Hours
Parts
Sym. FRONT
Bumper W /Pads
Sublet
Or Paint
Service $
Or Hours Parts
yk ,
Bumper Abs.
Fender Shield
Fender Ext.
--
Fender Shield
Fender Ext.
Fender MIdg. Side
-
Fender Mldg. Side
Fender Stripe
--
Fender Stripe
Fender MIdg.
--
Fender Midg.
- _
Bumper Reinf.
--
Bumper Brkt.
Side Light Asmbly
-_
Side Light Asmbly
Bumper Cushion
- /mom
. 02
Headlamp
-_
-_
Valance
Headlamp Door
-_
Headlamp Dr.
Bumper Gd.
Sealed Beam
--
--
Sealed Beam
Park Light
Frt. S tem
Park Light
Frame
Cowl
--
Cowl
Cross Member
Door, Front
Door Hinge
--
--
Door, Front
Door Hinge
Wheel
Hub Cap Disc
Door Panel
--
Door Panel
Lr. Cont. Arm
Door Stripe
--
Door Stripe
Door Midge.
Door Midg.
Up. Cont. Arm
-111011111
Center Post
-
Center Post
Door Rear
Door Rear
Bumper Filler
Door Mldg.
--
Door MIdg.
Grille
F 0. 27
Grille Panel
--
-�
Grill Panel MIdg.
Rocker Panel
--
Rocker Panel
M ,
= Rocker Midg.
C IM
`
Rocker MIdg.
Floor
Floor
Dog Leg
Quar. Panel
_-
--
Dog Leg
Quer. Panel
Air Condenser
Quar. Ext.
--
Quar. Ext.
-_
Recharge System
Quar. Wheel House
--
Quar. Wheel House
Name Plate
Quar. MIdg. Side
--
Quar. Midg. Side
Baffle, Upper
Quar. Midg.
--
Quar. MIdg.
==
Lock Plate, Lr.
Quar. Stripe
_-
Quar. Stripe
Lock Plate, Up.
Side Light Asmbly
--
Side Light Asmbly
Tail Light
Hood Top
Tail Light
Hood Hinge
REAR
MISC.
Hood Lock
Bumper
Inst. Panel
Ornament
Bumper Abs.
Front Seat
Rad. Sup.
Bumper Cushion
Front Seat Adj.
Rad. Core
Bumper Reinf.
Top
Anti Freeze
Bumper Brkt.
Headlining
Rad. Hoses
Bumper Gd.
Top Vinyl
Fan Blade
Bumper Filler
Tire % Worn
Fan Shroud
Valance
Painting
I
G. r
Fan Belt
Lower Panel
Aerial
Water Pump
Floor
Rust Proof
Water Pump Pulley
Trunk Lid
Battery
Motor Mts.
Trunk Mldg.
EPA WASTE DISPOSAL CHARGE
• 0
Lic. Light
PARTS (Prices Subject
To Invoice)
@,fo HR.
1 : 14 • ,4
i,7 #,,S 1
SERVICESI71HRS.
Windshield
Gas Tank
SUBLET OR PAINTING
c1, q N. qJ
Frame
SUB TOTAL
Wheel
TAX
( 7 •4L
Hub & Drum
PAINT - MATRL -HDW.
a, l 6. 6 7
Axle
\
Spring
GRAND TOTAL
a, $ T 9 .S
•
•
HART AUTO BODY & PAINT
800 CEDAR CROSS ROAD DUBUQUE, IOWA 52003
PHONE: (563) 556 -8323 FAX: (563) 556 -8324
Appraiser
Symbols: A -Align N -New OP -Open P -Paint I HEREBY AUTHORIZE THE ABOVE REPAIRS
S- Straighten R- Replace OH-Overhaul
X
DAMAGE REPORT
PRICES SUBJECT TO CHANGE
Items CIRCLED are not in the total in
our opinion, are not part of this claim.
u
N
T
001
Driver's Name - Last
STROHMEYER
First
WAYNE
1 Middle 1 Suffix
LOUIS
Address
3403 WALLER ST
City
DUBUQUE
1 State
IA
Z'p
52002 - 0000
Home /Cell Phone
(563) 589 x
Gender
Male
Class
A
State
IA
Endorsements
P
Restrictions
M
Insurance Co. Name Insurance Co. Phone #
IOWA COMM. ASSURANCE (563) 589 -4196 x
Insurance Policy #
i
Owner Company Name
CITY OF DUBUQUE KEYLINE
Owner's Name - Last
First
Middle
Suffix
Address
50 W 13TH ST
City
DUBUQUE
State
IA
Zip
52001 -
VIN No.
4RKJNTFA22R835550
Year
2002
I Make
RTS
Model Style
,62VN L BU
Vehicle Configuration)
18
License Plate #
85985
State
IA
Year Most Damaged Area
2020 1 04 - Right Rear
Approximate Cost to Repair or Replace
$250.00
U
N
T
002
Driver's Name -Last
First
Middle
Suffix Date of Birth ,
Address
City
State
Zip
Home /Cell Phone
Gender 1 Drivers License Numbe;
I
Class
r State
` NONE
Endorsements
Restrictions
NONE
Insurance Co. Name
NONE
Insurance Co. Phone #
#
Owner Company Name
Insurance Policy
Owner's Name - Last
FURY
First
CHAD
Middle
MICHAEL
r Suffix
Address
793 CLARKE DR
City
DUBUQUE
State
IA
Zip
52001
VIN No.
1ZWFT61L4X5613984
Year
1999
Make
MERC
Model
COU
Style
2D
Vehicle Configut
01
License Plate # , I State
470XBJ I IA
Year
2011
11 Most Damaged Area
1 08 - Left Front
Approximate Cost to Repair or Replace
$2,000.00
X Coordinate
00690371
Y Coordinate
04709086
If accident occurred outside of city
limits show general vacinity: "N /A"
Direction
"N /A" of
Nearest City Route (Cardinal) 1
"N /A" i Travel Direction "N /A"
On Road, Street, or Highway:
CLARKE DR
At Intersection with:
"N /A"
Distance
50 Ft
!Direction Distance
3 - and 1 "N /A"
Direction
"N /A" of
Milepost Number
"N /A" Or
Definable intersection, bridge, or railroad crossing
CLARKE/WOODWORTH __�_
Officer
AVENARIUS, KATHERINE
Badge N
38
Law Enforceme t Ca Number Date of Accident
01 - 10 - 39055 1 08/14/2010
Time of Accident
14:57 Hrs '
•
County
Dubuque - 31
Literal Description
CLARKE DR
. u -,. _ ce .. 08,14/2010 03:32 PM
1:8N
Driver Information Exchange Report
Dubuque Police Department
563 -589 -4410
Accident occurred within corporate limits of (city)
Dubuque -2100
Printed At: Dubuque Police Department 08/14/2010 03:32 PM
Page 1 Form #: 01 -10 -39065
Page 1 Form #: 01 -10 -39055