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Claim by Donald L. Cherba
THE CITY OF DUB E MEMORANDUM Masterpiece on the Mississippi TRACEY STECKLEIN PARALEGAL To: Mayor Roy D. Buol and Members of the City Council DATE: October 21, 2010 RE: Claim Against the City of Dubuque by Donald Cherba Claimant Date of Claim Date of Loss Nature of Claim Donald Cherba 10/21/10 10/19/10 Vehicle Damage This is a claim in which claimant alleges that a limb fell from a city tree and struck the hood of claimant's 2010 Chevy Equinox causing a dent in the hood. 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 Marie Ware, Leisure Services Manager Donald Cherba 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 RPM /W CLAIM AGAINST THE CITY OF DUBUQUE, IOWA 1 1/;/,/,(e_ 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: Dorotv L, 2. Address: ` Shy - Icna CIS DL\OLc1.u-- 5 aOo) 3. Telephone Number - ©i5S 4. Date of Incident: E o abet' /93 Ic PV'` 5. Time of Incident: (` co w 9a.rvea mac- I:-3D 6. Location of Incident (Be specific): r-e-e-A cc\ ; r3ec� ; a We. c1 c --\ •r ; n rn -1 e r - ( i Cer PJ \ \ed 4i 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.) �4 \;rnV) - Qr rn 0 I oQLk -k rec. 4r . hr \mood erg_ c- r` calo @ m )L Ely trioX ael. LtS 1n3 c m e o kec c 8. What were weather conditions like? c,&-9 w t .gc me u 9. Give name and address of any witnesses: c Q c e r c Aun S \ c - On rn 0 c r - She Q\ lec\ me a-t `Nrt-kc Y,\-; o`[ - -z ucZ h� C LA -{-c ,See._ d i c e e. 'r\ 10. Did police investigate? (If so, give names of officers.) Sec c--A, ue_. 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). r1 d 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.) hood o Q a010 13. What other damages do you claim, if any? ymcr, -e 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.) A301 15. What amount do you claim from the City of Dubuque? ( 90 16. Why do you claim the City of Dubuque is responsible? (Y Q 1 c e r Zra W C1 o " 1 & cL \et. r v& we._ e v ; ryn cA. cr. . t) arc - n s b i I ■ef 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) A)G 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? n o Dated ' is I day of Ec 01j,- 7-- , 20 i c . o� ° M °- m ' 0 (Signature) rn o (Print Name) 10/21/2010 at 09:31 AM Job Number: 30799 Insured: DON CHERBA Owner: DON CHERBA Address: 2793 SHETLEND CT DUBUQUE, IA 52001 Day: (563)588 -0155 Inspect Location: Insurance - Company: BRIMEYER AUTO BODY License #:30799 Federal ID #:421438480 10709 COLLISION DR. DUBUQUE, IA 52001 (563)583 -4456 Fax: (563)583 -1838 1 HOOD 2* Rpr Hood 3 Add for Three Stage PRELIMINARY ESTIMATE Written By: KEVIN SMITH Adjuster: Claim # Policy # Deductible: Date of Loss: Type of Loss: Point of Impact: Days to Repair 2010 CHEV EQUINOX 4X4 LS 4- 2.4L -FI 4D UTV BURGANDY Int: VIN: 2CNFLCEW4A6254038 Lic: Prod Date: Odometer: Air Conditioning Rear Defogger Tilt Wheel Cruise Control Telescopic Wheel Intermittent Wipers Climate Control Keyless Entry Alarm Rear Window Wiper Message Center Tinted Glass Dual Mirrors Console /Storage Three Stage Paint Power Steering Power Brakes Power Windows Power Locks Power Mirrors AM Radio FM Radio Stereo Search /Seek CD Player Premium Radio Auxiliary Audio Connectio Satellite Radio Anti -Lock Brakes (4) Driver Air Bag Passenger Air Bag Head /Curtain Air Bags Front Side Impact Air Bag 4 Wheel Disc Brakes Traction Control Stability Control Communications System Cloth Seats Bucket Seats Automatic Transmission 4 Wheel Drive Overdrive Aluminum /Alloy Wheels NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT Subtotals = => 0.00 Parts Body Labor Paint Labor Paint Supplies 1 4.0 2.8 2.0 4.0 4.8 0.00 4.0 hrs @ $ 56.00 /hr 224.00 4.8 hrs @ $ 56.00 /hr 268.80 4.8 hrs @ $ 32.00 /hr 153.60 SUBTOTAL $ 646.40 Sales Tax $ 492.80 @ 7.0000% 34.50 GRAND TOTAL $ 680.90 ADJUSTMENTS: Deductible 0.00 CUSTOMER PAY $ 0.00 INSURANCE PAY $ 680.90