Claim Metz, MaryCLAIM 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: Mary Metz
2. Address: 2725 Broadway Dubuque, IA 52001
`
3. Telephone Number: 563 556 0889
4. Date of Incident: 12 2 03
5. Time of Incident: about 9:45 AM
6. Location of Incident (Be specific):
Parking lot of Dr. Strohmeyer's office on Windsor.
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.)
I was parked in Strohmeyers lot when the minibus backed up and hit the rear bumper of my car. I was not in the car. Minibus #2555 - Driver Antonio Lesale
8. What were weather conditions like?
Good
9. Give name and address of any witnesses:
--
10. Did police investigate? (If so, give names of officers.)
No, However, the Transit Manager, Mark Munson, came up and looked it over.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
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.)
Rear bumper damaged of my 1996 Volkswagon Passat
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?
$946.22
See attached estimate from Kieler Auto Body
16. Why do you claim the City of Dubuque is responsible?
It was the fault of the Minibus. I was parked correctly.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No
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 3rd day of December, 2003.
/s/ Mary J. Metz
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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 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: f~¢'~( /"~l~'~'T-'z~
2. Address: ~ 25 ~ b~~
3. Telephone Number:
4. Date of Incident: / ~,- ~- - :~ ~ ~ ~
5. Time of lncident: O~'~~L O ~/~'- ~/~
6. Location of Incident (Be specific): Pc~v~-~vJ~j~ /~ fy//!/~'- ~'~,--~' ~
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If a Ci~ employee was involved, give the
emplOyee's name.) j ~ ~~ ~ /'
9. Give name and address of any witnesses:
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 da~mageS;~
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?
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
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Business Address Kieler Auto Body
3644 Hwy HHH
P.O. Box 89
Kieler, WI 53812 REPAIR ESTIMATE
(608) 568-3704
Name ~o.~-..~ ~w-~-~ Date ~_ 2. -~3
Address ~-"~ ~ ~5 ~ Ci~ ~% State ~ ZIP %z~ ~
Year ~%c~ Make V ~ Model ~ ~
Color ~ V-I-N-~ '~ ~ ~ 3 ~ ~~
REPAIR REP~ P~NO, DESCRIP~N P~
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
TOTALS %~ '). o
FIN: 39-2012916 Estimate Valid for 30 Days
PA~S ................................................................
Authorization for Repair
~BOR N-~ hrs.~ $ N~.~
ESTIMATE SHEET AND REPAIR ORDER
This estimate is based on our inspection and does not ~ver PAl NT & M ATE RIALS ...~.:~..-~-~2---~.~
additional matedal or labor which may be requir~ after the work
has been ~a~ed. After the wo~ has s~rted, damaged material
which was not evident on first inspection may be discovered. MISC ...................................................................
Naturally, this estimate ~nnot ~ver such ~ntingencies. This
estimate is for immediate a~eptance. MISC..
This Work A~orized by TAX ......................................................................
TOTAL ................................................................