Claim Close, Dawn, date 8 22 04CLAIM 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: Dawn Close
2 Address: 705 Rose Street, Dubuque, IA 52001
`
3. Telephone Number: 563 583 4162
4. Date of Incident: 8-22-04
5. Time of Incident: between 10:30 and 12:30 P.M.
6. Location of Incident (Be specific): Out front of my house (705 Rose) on Rose Street -1st tree from the corner of Walnut & Rose
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.)
Tree liimb fell from first tree from the corner of Walnut and Rose. Fell on my car that was parked on the street.
Put a dent & scratch in fender of my car.
8. What were weather conditions like?
Had rained earlier.
9. Give name and address of any witnesses:
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
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.)
Yes, dent & scratch in left front fender of my car.
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?
$362.81
16. Why do you claim the City of Dubuque is responsible?
The tree is City property.
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 17th day of September, 2004.
/s/ Dawn Close
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
., í;/»/Ol¡' (l('~ A? ¿/1J1
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: l"hWf\ Close..
2. Address: iD5 Rose 5h-IL.e-t Oubu,~u.e.. J:.+- 5d-oo/
3. Telephone Number: 5~3 -5B,~-l-( ) (â d
4. Date of Incident: '8" - dd.-O~
5. Time of Incident: b~-tw~¡{\ IO:,sOa.m + t'd:30 p.m.
6. Location of Incident (Be spec.ific): () ùi- ~Ol'\-\- of ('f\~ h,ous.e.lzos Ros.eJ On ~ ~
5tr¡¿~+ -1-~ -\-r.e.~ ~ -th~ LO({\.(1,r,* WolMJ-\-+ RbS.R...
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 na~.) ~
--r('.e.~ lL~ :.ç-.QJ \ ..çmrY\ .çt~-\f'«- ~ ~ Corf\~ Uh,\ n~
QL'ßQ.. ;::-.ell ~(\ ('(\~ (ß,\ ~~ wa.s Çßck~ ()\. ~i-r.e--é-+,
\)lJ+ a. rlM+ -4- Sc:Iì1.~ 'I 1\ S;~er ~ MY Co.-r.
8, What were weather conditions like? -B(it~ ffiÌRe(\ ..(2cul i er
9, Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
~O
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
~O
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.)
~.e,5. rk+ q.5C,\1ltch ì (\ till- \{-ÖA+ ~.e-(' ~('{\y car.
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.)
NÒ.
15. What amount do you claim from the City of Dubuque? t'3tOd, 0 I
16. Why do you claim the City of Dubuque is responsible?
~('op~ .
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 11th.
day of
S.Qr+-PÚv\~er , 20d:/-.
~1 ~;-V\ ( fæe-e
(Signàture)
DClWVI, CI()5~
(Print Name)
CJ
(Rev. 1/00 & 7/01)
09/10/2004 at 12:58 PM
24443
Job Number:
ABRA - DUBUQUE
Federal 10 #:420782245
DBA: ANDERSON-WEBER INC
3400 CENTER GROVE DR
DUBUQUE, IA 52003
(563)556-0696 Fax: (563)556-1899
PRELIMINARY ESTIMATE
Written By: DAVE BIGELOW
Adjuster:
Insured:
Owner: DAWN CLOSE
Address: 705 ROSE
DUBUQUE, IA 52001
Day: (563)583-4162
Claim it
Policy it
Deductible:
Date of Loss:
Type of Loss:
Point of Impact:
Inspect
Location:
Insurance
Company:
Days to Repair
1983 CHEV CAMARO Z28 8-5.0L-4 2D CPE BLACK Int:
VIN: 1G1AP87H5DL153254 Lie: 489 MOl IA Prod Date:
Dual Mirrors Rear Spoiler
Power Brakes Power Trunk/Tailgate
Recline/Lounge Seats Aluminum/Alloy Wheels
Odometer: 11682"
Power Steering
Bucket Seats
-------------------------------------------------------------------------------
NO.
OP.
DESCRIPTION
QTY EXT. PRICE LABOR
PAINT
-------------------------------------------------------------------------------
1 FRONT LAMPS
2 R&I LT Side marker lamp 0 0.00 0.3 0.0
3 FENDER
4* Rpr LT Fender 0 0.00 1.5 2.8
5# R&I MOD GUARD 0 0.00 0.3 0.0
6# Subl HAZARDOUS WASTE DISPOSAL 1 4.00 T 0.0 0.0
7# Repl BAG / COVER CAR 1 4.00 0.2 0.0
8# Repl CORRISON PROTECTION 1 4.00 T 0.3 0.0
-------------------------------------------------------------------------------
Subtotals ==>
12.00
2.6
2.8
Parts
Body Labor
Paint Labor
Paint Supplies
Sublet/Misc.
2.6 hrs @ $ 47.00/hr
2.8 hrs @ $ 47.00/hr
2.8 hrs @ $ 28.00/hr
4.
122.
131.6ii
78.4
8.
----------------------------------------------------
SUBTOTAL
Sales Tax
$
265.80 @
$
7.0000%
344.2
18.
1
-,
09/10/2004 at 12:58 PM
24443
Job Number:
PRELIMINARY ESTIMATE
1983 CHEV CAMARO Z28 8-5.0L-4 20 CPE BLACK Int:
-------~--------------------------------------------
GRAND TOTAL
$
362.8
ADJUSTMENTS:
Deductible
o.
----------------------------------------------------
CUSTmlER PAY
INSURANCE PAY
$
$
O. O(]
362.8:
WARRANTY VALID ONLY WITH ORIGIONAL COpy OF YOUR RECEIPT PARTS SUBJECT
INVOICE NO GUARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED
Estmate on HOTOR CRASH "STH1ATING C;uIDE. unless otherwise noted all items are derived
the GUlaG DEICD82 Database Date 08/20:4, CCC Data Date 08/2004, and the parts selected are
DEn-parts manufactured by the vehicles Or iginal Equipment Hanufacturer. OEH parts are available
OElVehicle dealerships. Astensk í' ì Double As~erisk í **) indicates that the parts and/or
idcrmatic~ provided by MOTOR been modified or may have come from an alternate
Ti~oe srq~ í-ì items Inchoate HOTCJR Not-Included Labor opera'ions, Non-Original
,1u~ufacturer after-no rket parts are descL bed as AH, Qual Repl Parts or Camp Repl Pare s
for Competitive Replacement ?arts. uöed parts are described as LKQ, Qual Recy Parts, RCY, or
ReconditIoned parts are described as Recon. Recared parts are descnbed as Recore. NAGS
N\J:nbers and Prices are orovided by National Auto Glass Specifications, Inc. Pound sign í#ì
manual entries.
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of CCC Information Services Inc.
2