Claim by William MillmanMasterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
cc: Michael C. Van Milligen, City Manager
Marie Ware, Leisure Services Manager
William Millman
MEMORANDUM
To: Mayor Roy D. Buol and
Members of the City Council
DATE: October 4, 2010
RE: Claim Against the City of Dubuque by William Millman
Claimant Date of Claim Date of Loss Nature of Claim
William Millman 10/01/10 09/28/10 Vehicle Damage
This is a claim in which claimant alleges that a City dump truck struck the driver's side
mirror of claimant's vehicle as claimant's vehicle was legally parked in front of 1504
Garfield Avenue.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
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
2. Address: 6 1d. A if e"
3. Telephone Number
4. Date of Incident:
5. Time of Incident: ,
CLAIM AGAINST THE CITY OF DUBUQUE, IO
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: /-/ / �/ / pi �J. /V1 I () Ic'3'L e1 h
6. Location of Incident (Be specific): Ave_ D tk-e-
c_r
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.)
7YLA_—
8. What weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.
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— tJL� i l (
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.) /7
v
15. What amount do you claim from the City of Dubuque?
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9 s
16. Wh _ do you claim the C'ty of Dubuque is responsibl
17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
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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 .
te
day of
Wiethzn-y-?
(Signature)
\ * I Intl 37 /V' I VI-L.- ck
(Print Name)
, 20 /I 'enbn
80 1110 s:1- A110
61'8 WY I -10001
Cft1.9038
U
N
T
1 001
Driver's Name - Last II First
MAIDEN V CHRISTOPHER
Middle
JOHN
Suffix
1 Date of Birth
L11/03/1961
Address TCity 7 State I Z'p
3528 ECLIPSE CIRCLE 1 DUBUQUE 1 IA ; 52003
Home /Cell Phone
(563) 599 - 9009 x
Gender
Male
Driver's License Number 1 Class
018AA4256 C
State
IA
1 Restrictions
NONE j NONE
Insurance Co. Name Insurance Co. Phone # H
IOWA COMMUNITIES ASSURA
Owner Company Name
CITY OF DUBUQUE
Insurance Policy #
"
Owner's Name - Last
First
Middle
Suffix
Address 1 City State 1
50 W 13TH ST I DUBUQUE I IA 52001 -
VIN No.
1 FDWF36538EE12291
Year
2008
Make
FORD
' Model
I F35
Style
CB
Vehicle Configuration
12
License Plate #
6446 1
State
IA
Year
2010
Most Damaged Area
Approximate Cost to Repair or Replace
$0.00
u
N
T
002
Driver's Name - Last
MILLMAN
1 First ' Middle Suffix
I WILLIAM J JOSEPH
Date of Birth
05/22/1940
Address
1504 GARFIELD AVE
City 1 State T Z'p Home /Cell Phone
DUBUQUE IA _52001 - 0000 1 (563) 582 - 0766 x
Gender
Male
Driver's License Number
767ZZ9334
Class
C
State
IA
Endorsements! Restrictions
NONE 1 NONE
Insurance Co. Name Insurance Co. Phone #
FARMERS INSURANCE (563) 588 - 1139 x
Owner Company Name
Insurance Policy #
184111798
Owner's Name - Last
MILLMAN
First I Middle 1 Suffix
WILLIAM I JOSEPH 1__ —
Address 7
1504 GARFIELD AVE
City State I Zip
DUBUQUE 1 IA 152001 - 0000
VIN No. Year Make Model Style
1 GNDM19X04B111743 12004 CHEV 1 AST 1 VN
Vehicle Configuration
03
__
License Plate # State lYear ' Most Damaged Area
Y4074 IA 2011 07 -Left Side
Approximate Cost to Repair or Replace
$30.00
rCounty
Dubuque - 31
Literal Description
GARFIELD AVE
X Coordinate
00692538
If accident occurred outside of city
limits show general vacinity:
On Road, Street, or Highway:
GARFIELD
Distance 1 Direction
90 Ft 3 - E
Definable intersection, bridge, or railroad crossing
GARFIELD AND MARSHALL
Officer
BAUER, BRANDON
Accident occurred within corporate limits of (city)
Dubuque - 2100
Direction
"N /A" " /A" of
and
Distance
"NIA"
formation Exchange Report
Dubuque Police Department
563- 589 -4410
Y Coordinate
04710491
Nearest City
"N/A"
At Intersection with:
"N /A"
F Direction Milepost Number
NIA" of "N /A"
Printed At: Dubuque Police Department 09/28/2010 03:58 PM Page 1
Or
Route (Cardinal)
Travel Direction "N /A"
Badge No. Law Enforcement Case Number Date of Accident Time of Accident
72 01 0 9/28/2010 14:55 Hrs.
Form #: 01-10-47598
Customer Receipt
Safe lite® AutoGlass
AUTO GLASS CENTER, INC
2828 UNIVERSITY AVE
DUBUQUE,IA 52001
** SERVICE QUESTIONS **
** CALL 800 -835 -2257 **
Qty Part
1 REDMIR273S
Technician Name
SLATER, JOSEPH A.
Technician Note:
Part Subtotal: 20.00
Flat Labor Subtotal: 0 . 00
Subtotal: 2 0 .00
Sales Tax: 1.40
Deductible: 0 . 00
Amount to Collect: 21.40
Amount Paid: 21.40
Amt Remaining: 0 . 00
Paid Cash, In amount of $21.40
Signature:
Date & Time: 10 /01 /10 08:10AM
Customer: Home Phone:
MILLMAN, WILLIAM Work Phone:
1504 GARFIELD AVE Contact Phone:
DUBUQUE,IA 52001 Work Order #: 01526_235475
(05511_235475)
Year Make --
Model
License Style Stock /Unit#
Y4074
Mileage VIN Purchase - Order#
76745 1GNDM19X0413111743
List Selling Flat
Price Price Labor Kit MTRL
20.00 0.00 0.00 0.00
Tech ID
1526 -706
/•r
Safel a Auto Glass
AUTO GLASS CENTER, INC
2828 UNIVERSITY AVE
DUBUQUE,IA 52001
** SERVICE QUESTIONS **
** CALL 800 - 835 -2257 **
Qty Part
1 REDMIR2735
Technician Name
SLATER, JOSEPH A.
Technician Note:
Part Subtotal: 20 . 00
Flat Labor Subtotal: 0 . 00
Subtotal: 2 0 . 0 0
Sales Tax: 1 .40
Deductible: 0 . 0 0
Amount to Collect: 21 .40
Signature: �''
Date & Time: 10/01/10 08:09AM
Customer: Home Phone:
MILLMAN, WILLIAM Work Phone:
1504 GARFIELD AVE Contact Phone:
DUBUQUE,IA 52001 Work Order #: 01526_235475
(05511_235475)
Year Make Model
License Style Stock /Unit#
Y4074
Mileage VIN Purchase - Order#
76745 1GNDM19X04B111743
List Selling Flat
Price Price Labor Kit MTRL
20.00 0.00 0.00 0.00
Tech ID
1526 -706
Estimate: $21.40. I authorize Auto Glass Center & Safelite AutoGlass to
provide the above - referenced goods and services and to install or repair
glass and related parts that are manufactured by AGC /Safelite or another
aftermarket manufacturer. Subject to completion of the work, I assign to
AGC /Safelite any claim that I have under my Insurance policy to recover,
and authorize my Insurance company to pay AGC /Safelite the balance due.
If said amount Is not paid In full by my Insurance company, I agree to pay
any unpaid balance. If paying by check, and your check Is unpaid for
Insufficient or uncollected funds, we may electronically debit your
account for the principle check amount and a service fee as allowable by
law. You have the right to select the repair facility of your choice. I
have read and understand the Adhesive Cure Time Caution on the attached
form. In most cases, the approximate length of time to complete the tasks
detailed on thls work order Is 45 minutes to 1 hour.