Claim Lyons, Robert J.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: Robert J. Lyons
2. Address: 1918 Ellis St. Dubuque IA 52001
`
3. Telephone Number: 563 556 5643 Cell for messages 563 542 0368
4. Date of Incident: 6 22 04
5. Time of Incident: Reported to Dispatch around 3:13 P.M.
6. Location of Incident (Be specific):
1918 Ellis St. Dubuque, IA 52001 Right in front of house
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.)
2 ft tree branch fell on my 88 Town Car Lic # 596MOS Iowa
8. What were weather conditions like?
Rained in morning - Sunny in afternoon
9. Give name and address of any witnesses:
Gene .... 1936 Ellis St; Pat .... 1918 1/2 Ellis St.; Myself - sag tree on my car
10. Did police investigate? (If so, give names of officers.)
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.)
My 88 Towncar Windshield Cracks, Rt Frt Fender, Deep Scratches on Hood; Muffler Fell off from impact.
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.)
No
15. What amount do you claim from the City of Dubuque?
$1,291.56
16. Why do you claim the City of Dubuque is responsible?
Its tree branch fell on my car.
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?
No
Dated at Dubuque, Iowa this 2nd day of July, 2004.
/s/ Robert J. Lyons
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
'tY-Y;f&l
.~/ . ,'5/0c{
CLAIM AGAINST THE CITY OF DUBUQUE,.IOWA at. ~(/
ÍÍ1 II {!L ç
This written report constitutes your claim against the City of Dubuque, Iowa. You sholítd l;~
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.
;P(}hpl'f
2. Address: N /g ELL /5 :; t
3. Telephone Number: S"(;J-S5-t - ç-r; t.¡?
G/~VJroq
5. Time of Incident: ~ P 11111' fr ,~
1
6. Location of Incident (Be specific):
!r. f tjA {-¡~ (-ro/v tot /-lOlL-> 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
employee's name.)
1. Name of Claimant:
.J Lx 0 IV S
/JJíI.[fke IA- !;jo(f/ ~.'
, ~")--UJ (.,'if
(el! (crr Iles.JAjrY ~Sc'3 -~/ .
4. Date of Incident:
to Vi ~ j)/¡..J-J. AroIJl,J i : /3 rM
(j
( 11«; [LLi c; ç r /Jd ~f IJ F J ¡¡
ç NO)
1ft
Tree
ßrlJ-lv Id
F eri 0 ¡(¡ fJ/
'(~
ìOWN C/Jr
Lr~ Ii
.[°'4
c; 'i(Jf 0 ç
8. What were weather conditions like? l~'/~J(J J ;/1/ l1ð/,/v/ kc{ '!:r),k/vJ IN
J
9. Give name and address of any witnesses: G'eÆ/é' ¡c¡,c FLus S T
fJ¡.f N¡t/j.- £ÜI' ~V\f/t1 SA-)' fler OM I'¿!j t/¡r
10. Did police investigate? (If so, give names of officers.)
A /!PfA1¡ØJV
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Aid
'\ ~'
. ,\
~1'~~\' ""
2. Was any damage done to property? (If so, describe property and the extent of damages.
,ttach estimates of damages or describe basis for ascertaining extent of damage.)
/L1 v 'lR' tòwN ('Ar Ú/¡¡vÙÂ,c/c{ Crxw/r;;, Æt ¡-If fe/VAtr -
/ j r./
~ê e¡] \c'¡-'J:j- ~ f~ ç (J 1\/ /1-0 0 11 (/ ~N e r fe/I ú Î f Frcr.vl J ;ry;/k:r
v /
3. What other damages do you claim, if any?
14. Have you been compensated for any part or all of your claim by any insurance
:ompany? (If so, give name and address of insurance company and amount paid.)
/JO
15. What amount do you claim from the City of Dubuque?
I
16. Why do you claim the City of Dubuque is responsible?
re/( ad Mv rAf
/
1 T~
Tret'
ß (' jJ;jr
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) JJO
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
:Þ
J /Á(r , 20~.
A~/
¡¿, .' (S;g~ture)
o/J err J t-yé Iv)
(Print Name)
Dated at Dubuque, Iowa this
day of
. (Rev. 1/00 & 7/01)
c
Date: 7/20/200404:22 PM
Estimate ID: 6048
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Riley's Auto Sales Co.
Damage Assessed By: KEITH KNIPPER
Deductible: UNKNOWN
4455 Dodge SI. Dubuque, IA 52003
(563) 588-2326
Fax: (563) 588-9286
Tax ID: 42-0957277 EPA #: 1AD051003184
Insured: ROBERT LYONS
Address: 1918 ELLIS ST DUBUQUE, IA 52001
Telephone: Home phone: (563) 556-5643
Description: 1988 Lincoln Town Car
Body Style: 4D Sed
VIN: 1LNBM81F5JY669930
Line Entry Labor
~ Number Type
1 206360 BDY
2 207000 BDY
3 AUTO REF
4 207750 BDY
5 AUTO REF
6 211600 GLS
7 900500 MCW
8 AUTO REF
9 AUTO
10 AUTO
Operation
REMOVE/REPLACE
REPAIR
REFINISH
REPAIR
REFINISH
REMOVE/REPLACE
REPAIR
ADD'L OPR
ADD'L COST
ADD'L COST
Mitchell Service: 912615
Drive Train: 5.0L Inj 8 Cyl AO
Line Item
Description
EXHAUST TAILPIPE
HOOD PANEL
HOOD OUTSIDE
R FENDER PANEL
R FENDER OUTSIDE
W/SHIELD GLASS
REPAIR WIRES
CLEAR COAT
PAINT/MATERIALS
HAZARDOUS WASTE DISPOSAL
Part Type/ Dollar Labor
Part Number Amount Units
-- --._u
ORDER FROM DEALER d123.09 0.8
Existing 2.0'#
C 3.2
3.0*#
C 2.2
d154.67 2.2 #
1.0'
1.7
Existing
EOVY 5403100 A
Existing
191.70 *
3,55 .
* - Judgement Item
# - Labor Note Applies
d - Discontinued by the Manufacturer
C -Included in Clear Coat Calc
L Labor Subtotals
Body
Refinish
Glass
Mechanical
Labor Summary
Add'i
Labor Sublet
Units Rate Amount Amount Totals II. Part Replacement Summary Amount
5.8 46.00 0.00 0.00 266.80 T Taxable Parts 277.76
7.1 46.00 0.00 0.00 326.60 T Sales Tax @ 7.000% 19.44
2.2 46.00 0.00 0.00 101.20 T
1.0 52.00 0.00 0.00 52.00 T Total Replacement Parts Amount 297.20
Taxable Labor
Labor Tax
16.1
@
7.000 %
746.60
52.26
798.86
ESTIMATE RECALL NUMBER: 7/20/200416:22:32 6048
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: JUL_04_A Copyright (C) 1994 - 2003 Mitchell International
UltraMate Version: 5.0.024 All Rights Reserved
Page 1 of 2
Date: 7/20/200404:22 PM
Estimate ID: 6048
Estimate Version: 0
Preliminary
Profile ID: Mitchell
III. Additional Costs
Taxable Costs
Sales Tax
Amount
3.55
0.25
IV. Adjustments
Customer Responsibility
@
7.000%
Non-Taxable Costs
191.70
Total Additional Costs
195.50
I.
II.
III.
Total Labor:
Total Replacement Parts:
Total Additional Costs:
Gross Total:
IV.
Total Adjustments:
NelTotal:
This is a Dreliminarv estimate.
Additional chances to the estimate mav be reQuired for the actual reDair.
THIS DAMAGE REPORT IS BASED ON OUR INSPECTION AND DOES NOT COVER ANY
ADDITIONAL PARTS OR LABOR WHICH MAY BE REQUIRED AFTER THE WORK HAS
BEEN OPENED UP THE INSURANCE COMPANY WILL BE NOTIFIED.
WE FEATURE A THREE YEAR WORKMANSHIP LIMITED WARRANTY - SEE OUR
WRITTEN WARRANTY FOR COMPLETE DETAILS.
LIFETIME PAINT PERFORMANCE GUARANTEE USING APPROVED PPG AND A
THREE YEAR GUARNATEE ON OVERALL WORKMANSHIP IS VALID FOR AS
LONG AS YOU OWN THE VEHICLE STATED HEREIN.
x
ESTIMATE RECALL NUMBER: 71201200416:22:32 6048
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: JUL_04_A Copyright (C) 1994 - 2003 Mitchell International
UltraMate Version: 5.0.024 All Rights Reserved
Amount
0.00
798.86
297.20
195.50
1,291.56
0.00
1,291.56
Page 2 of 2