Claim Bruse, StevenCLAIM 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: Steven Bruse
2. Address: 220 N Grandview
`
++-++++++++++++++
3. Telephone Number: 583 5414
4. Date of Incident: August 20, 2003
5. Time of Incident: 6:30 P.M.
6. Location of Incident (Be specific):
1696 W. 3rd (My car was parked directly in front of this residence)
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.)
A large "road closed" sign was blown down West Third a hit the left rear portion of my car resulting in damage to left rear fender panel.
8. What were weather conditions like? Extremely gusty winds
9. Give name and address of any witnesses: Mary Kate Bristow, 1696 W. Third St.(582 4608)
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No (fortunately)
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.)
The left rear fender of my vehicle sustained damages requiring repair.
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?
No
16. Why do you claim the City of Dubuque is responsible?
Because access out of my driveway was limited due to city street (Grandview) construction I needed to park my car on side street. Also the sign that hit my vehicle was placed there
by the City.
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 Dubuque, Iowa this 8th day of September, 2003.
/s/ Steven Bruse
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE;-.IOWA ~ ~"-~
o bu ~
This written report constitutes your claim against the Cit- f Du Ue Iowa
Y q , . 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: ,,~T~ ~ ~-
2. Address: ~D /ti. /~--,~.d-,'~/.)! E/.&P
3. Telephone Number:
4. Date of Incident:
J
5. Time of Incident: ~; ~
6. Location of lncident (Be specific): f~ ~)- ~-~'
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
empl.~oyee's name.)
9-Givenameandaddressofanywitnesses: ~'~ l~-~
10. Did police investigate? (If so, give names of officers.)
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.)
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?
16. Why do you claim the City of Dubuque is responsible? ~E~- ~ ~
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 Dubuque, Iowa this <~ day of
, 20 o-~.
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
09/03/2003 au 03:44 PM
24443 Job Number:
;~BRA - DUBUQUE
Federal ID a:4207~2245
DBA: ANDERSON-WEBER INC
3430 CENTER GROVE DR
DUBUQUE, IA 52003
(563,556-0696 Fax: (563)556-1899
PRELIMINARY ESTIMATE
Wri5uen By: KEN GREEN #24443
AdjusEer:
Insured:
Owner: STEVE BRUSE
Address: 220 N. GRANDVIEW
DUBUQUE, IA 52001
Evening: {563 583-5414
Business: (563 583-5414
Inspect
Location:
AVE.
Claim #
Policy #
Deductible:
Date of Loss:
T!r~e of Loss:
Point of Impact:
Company:
Days 5o Repair
2000 TOYO RAV4 4X2 4-2.0L-FI 4D UTV
VIN: JT3GP10V6Y0046315 Lic: Prod Date:
Tilt Wheel Intermit5en5 Wipers
Body Side Moldings Dual Mirrors
Power Steerzng Power Brakes
Passenger Air Bag Cloth Sea~s
Styled Steel Wheels
Odome=er:
Rear Wiper
Clear Coa5 Paine
Driver Air Bag
Bucke5 Seats
NO. OP. DESCRIPTION ....................
-_ QTY EXT. PRICE LABOR PAINT
· 1 QUARTER PANEL ......................
2~ Rpr LT Quarser panel w/o bumper 0 0.30 0.3 2.5
exL
3 Add for Clear Coa~ 0 0.00 0.0 t.~
4 REAR LAMPS
5 R&I LT Tail lamp assy 0 0.00 0.8 0.0
6~ Subl HAZARDOUS WASTE DISPOSAL 1 4.00 T 0.0 0. ~
7** Repl A/M BAG / COVER CAR 1 4.00 0.2 0.0-
SubtoTals ==>
8.00 1.3 3.5
09/03/2002
24443
au 03:44
PM
PP.E L II~I NAR~ ESTIt4~TE
2000 TOYO RAV4 4X2 4-2.0L-FI 4D UTV
Job Number:
4.00
Body Labor 1.3 hfs @ S 43.00/hr 55.90
Painn Labor 3.5 hfs @ s 43.0D/hr 150.50
Pain5 Supplies 3.5 hfs @ s 26.00/hr 91.00
Sublet/Misc.
...... $ 30= a
GRAND TOTAL
S 305.40
ADJUSTMENTS:
Deductible
INSURANCE PAY
S 0.00
$ 305.40
WARRANTY VALID ONLY WITH ORIGIONAL COPY OF YOUR RECEIPT PARTS SUBJECT TO
INVOIiE NO GUARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF AFTERMARKET CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY
WARRANTIES APPLISABLE TO THESE REPLACEMENT PARTS ARE PROVIEgD BY THE
VEHICLE.MANUFACTURER OR DISTRIBUTOR OF THESE PARTS RATHER THAN THE MANUFACTURER OF YOUR
WARRANTY VALID ONLY WIYH ORIGIONAL COPY OF RECEIPT. PARTS SUBJECT TO INVOICE.
NO GUARANTEES ON RUST. ALL PARTS NEW, UNLESS OTHERWISE SPECIFIED.
Estimate based sn MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from
the Guide ARMS~13 Oatabase Date 6/2003 and the parts selected sre OEM-parYs manufagrured by the
vehicles Original Equipment Manufacturer. Asterisk l~ or Double Asterisk '**. indicates that the
parts and/oz labor inforraat±on provided by MOTOR may have been modified or may have come from an
alternate data source. Non-Original Equipment Manufac~urei aftermarket pares are described a~ AM,
Qua/ Repl Parts or Comp Repl Parts which stands for Competitive ReplacemenE Parts. Used parts are
described as LKQ, Qual,Recy Parts, RCY, or USEE. Reconditioned parts are described as Recon.
Recored parts are described as Recore. NAGS Part Nurmbers and Prices are provided from National
Auto Glass Specifications, Inc. Pound sign ~,) items indicate manual entries.
Pathways - A Eroduct of CCC Infozlnation ServiDes Inc,