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Claim by Micah Mork
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 West 13 St., Dubuque, IA 52001. It will then be referred to the appropriate department for investigation and to the City Attorneys 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: Micah Mork 2. Address: 579 Quigley Lane Apartment 3 3. Telephone Number: - 70 J 15 ' (� 6 Li ',2,c1 I . ce II /563 55(,- 929. w ( s - rk- 4. Date of Incident: /J1:5 0 - 1 / - ( A 1 1 � Z -1 (niri'l ti t e rd '2010 5. Time of Incident: l J1f- V' in i \INk 6. Location of Incident (Be specific): .S 4"Y'e,eA i V\ TrOfkT L5 1 - 1 © LAS 1 Lt, 7. Describe the accident or occurrence that caused injury or damage. (Give full details upon which you base your claim. pp If �� a City employee was involved, give the employee's name) , c L Q k 4vv22 �w C i 7 . p r o p , (\ MI . "I k szotr Q to "C YO h t" t,& 7-4-A- r (oy, 200 © Fasrol -)( 1 ®Y`R , r CkV\G\ c a nokck . Y10 ( 9 n‘ C)Yl `fk A ilukv11-"Awa ov3A t n 8. What were weather conditions like? Je V$N`t_ /10 Y� UYIV�' S 11-r 9. Give name and address of any witnesses: f O.f fcl� e;, cAS(M'� I Q w e 11� t kr f +P Z S YIUVIVI(M ito�V'(1�k - . 57 I Om i ) (.� � J 1 L 1 10. Did police investigate? (If so, give names of officers.) Nips CC, e, \< SI�I�� use 4 AJo 11. Was anyone injured? (If so, give names, addresses, and extent of injuries.) 12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of 1) damages or describe basis for ascertaining extent of damage.) OUVI AL-6 C>1).41-ZA A 1( bin' n ` .) ' � f\cr�u 1 diavno vtQLc,L Sv-0$, b)'lA Das S , 2nrcS, C. ra_ike . �; yds1►1'�,Iok l U CO h eCtS SenC,(ir irk i VaSV1 i Je..A I ,J ∎ b ro � cs h Ankh 1 8n key, C�Y i JAS coo ( I 60.1 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.) AkNA, 15. What amount do you claim from the City of Dubuque? 16. Why do you claim the City of Dubuque is responsible? r rc rn 1,0 61:k 8CAA k(A f 0%1 e Sf�ch -c_e- 1l c rkr,0 os (' cs-r l o y n� , 2d 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) Ala 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 r d of _Selo (Signature (Print Name) O p r� H.3 1 o ° ° 40—L\ ,20 ) O C (n CO Prcff (-g/ JJ n m 0 To Whom It May Concern: My vehicle compensation was determined by first consulting with Willis Auto Body in Dubuque, IA. They determined the vehicle to be totaled. I then consulted www.kbb.com for a reasonable value of my 2000 Ford Explorer. Kelly Blue Book value = $4,038.00 The gutter compensation was determined by consulting with Keith Dolan of K & L Dolan Construction. He was able to determine the cost of replacing the damaged gutters and trim to $275.00. Their business card is enclosed. Also enclosed are pictures of the incident cited in case #10- 34981. Thank you for your time. SHOP: ADDRESS: CITY STATE: ZIP: EMAIL: OWNER: ADDRESS: CITY STATE: POINT OF IMPACT: 13 LIC #: XBL 020 BODY COLOR: GOLD CONDITION: FAIR WILLIS AUTO BODY 1982 ROCKDALE RD. DUBUQUE, IA 52003 - MARKWILLIS58 @AOL.COM MORK, MICAH QUIGLEY LN APT 3 DBQ, IA *= USER - ENTERED VALUE EC= REPLACE ECONOMY UM =REMAN /REBUILT PRT OE= REPLACE PXN OE SRPLS TE =PARTL REPL PRICE I= REPAIR TT= TWO -TONE N= ADDITIONAL LABOR AA= APPEAR ALLOWANCE STATE: IA * ** *COST OF REPAIR EXCEEDS THE VALUE OF THE CAR * * * * * * ** 2000 FORD EXPLORER XLS 4DOOR WAGON CODE: P8433G/F OPTNS A /24SPFECXO OPTIONS: TWO -STAGE - EXTERIOR SURFACES 4 -WHEEL DRIVE POWER DOOR LOCKS LUGGAGE RACK REAR WIPER OP GDE MC DESCRIPTION MFG.PART NO. E 0341 WILLIS AUTO BODY 1982 ROCKDALE RD DUBUQUE, IA 52003 PHONE: 563 - 583 -9329 CD LOG NO 228 -1 E= REPLACE OEM UE= REPLACE OE SURPLUS EU= REPLACE SALVAGE PC =PXN RECONDITIONED ET =PARTL REPL LABOR L= REFINISH CG= CHIPGUARD RI =R &I ASSEMBLY RP= RELATED PRIOR PANEL,ROOF R &I ASSEMBLY 1 ITEMS FINAL CALCULATIONS & ENTRIES PARTS & MATERIAL TOTAL DATE 08/10/10 INSP DATE: CONTACT: PHONE 1: FAX: CELL PHONE: TYPE OF LOSS: /FLD VIN: MILEAGE: ACCTNG CTL #: 6CYL GASOLINE 4.0 08/05/10 MARK WILLIS (563)583 -9329 (563)583 -9329 (701)866 -4329 1FMDU72X3YZB31886 157,000 NG= REPLACE NAGS UC= RECONDITIONED PRT EP= REPLACE PXN PM =PXN REMAN /REBUILT IT= PARTIAL REPAIR BR =BLEND REFINISH SB= SUBLET P =CHECK UP= UNRELATED PRIOR TWO -STAGE - INTERIOR SURFACES ELEC REMOTE CONTROL MIRRORS POWER WINDOWS HEATED TAILGATE GLASS PRICE AJo Bo HOURS R * INC *1 PAGE 1 08/10/10 Frame 2 Finish I(eitl1 & Laurie Dolan Phone CL.3 S57- 7 20^ 2,61 r.o, o_d Or o■tu3,E r 5.001 Licensed & Fully Imwed /