Claim Close, Dawn, date 9 11 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
`
3. Telephone Number: 583 4162
4. Date of Incident: 9-11-04
5. Time of Incident: around 2:00
6. Location of Incident (Be specific):
Corner of Rose & Walnut - Rose side in the street - curbside
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.)
Branch fell from tree at the curb onto my car parked there - heard cracking ripping sound & a crash - looked out window and branch was on car.
8. What were weather conditions like? Sunny
9. Give name and address of any witnesses:
Dawn Close & Brian Burch
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 & scratches on passenger side of vehicle.
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?
$495.77
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)
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
htlp://www .cityofdubuque.orglprinter ~ fiiendly.cfin?pag...
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Claim Form
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 fiied with the City Clerk at City Hall, 50 West 13th St., Dubuque, IA 52001. It will then be
referred to the appropriate department for investigation and to the Legal Department. 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 clams 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: 'Dú\")(\ Clœi2..
2. Address: 70S Ros..Q.
5S"3-L. {(ca
4. Date of Incident: '1-l1-ðl.f
5. Time of Incident: aX (YJ i'\.A d ; 00
6. Location of Incident (Be specific): c..ù írï.J2,\ O~ ROS<L + lili(1'\AJt- -
~S.Q :sè Å-L ..:. ~ r\ -tk-f. S+r.N..:.1--l' ,urbs,'d ""
3. Telephone Number:
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.)
~îl1,¡¡~ .~(( ~m +î.Q.-e.- at--i-h~ clXb ðt\.~ Mf ca.r
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8. What were weather conditions like? S u(\ Vi y
9. Give name and address of any witnesses: \)C!.\¡J() C l.o~!e -+- Rr,'ú VI ßurl.h
~¡\ Cîú.C.K\1\.Q r~~ì^C\ S(iVA.d. *- Cl(.-rR'S~_look.. ..dolJt wì~vJ+-l.J('c",,\.d\
~ \\ l;...>cL.<; Co"- c..o.., .
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.)
~~$ - A.~-\-- ~ '5crú--\ch-e.ç ()(\ ?a.s')~~í ~¡'d<Q crt \f~hìc 1'-'2
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9/15/2004 10:29 AM
Claim Form
http://www.cityofdubuque.orglprinter_fiiendly.cfin?pag...
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? ~5, 77
16. Why do you claim the City of Dubuque is responsible? -rk.~ -tr.Q..,Q L "
Cì~
?rOÇJi¿í'+y
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 this ~ day of :s .er+..QV1\,~ r
Ùl1l'Yì\ (k~
,20.Q!i.
(Signature)
D~w(\
( [0 S-e
(Print Name)
prinUl1i$ page
2 of2
~
9/15/200410:29 AM
09/17/2004 at 04:57 PM
24443
Job Number:
PRELIMINARY ESTIMATE
1993 MERC TOPAZ GS 4-2.3L-FI 40 SED TEAL Int:
Parts
Body Labor
Paint Labor
Paint Supplies
Sublet/Misc.
2.2 hrs @ $ 47.00/hr
4.4 hrs @ $ 47.00/hr
4.4 hrs @ $ 28.00/hr
4.
103.4
206.8
123.21 ,
34.0il
----------------------------------------------------
SUBTO'TAL
Sales Tax
348.20 @
$
7.00009,
471.4 :¡
24.r
----------------------------------------------------
GRAND TOTAL
ADJUSTMENTS:
Deductible
495.7
-----------------------------------------------------
CUSTOMER PAY
INSURANCE PAY
$
$
O.
495.
WARRANTY VALID ONLY WITH ORIGIONAL COpy OF YOUR RECEIPT PARTS SUBJECT
INVOICE NO GUARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED
Estimate based on t1GTGR CRASH ESTIMA':èNG
the Guide DE2Lt183 Catabase
"JEt1-parts manJ!actured by the venccles
OEiVehicle dealers'}i Asten"k I')
l~fomati()n provided
source. Tilde sigr
Unless otherwise notec all items aro deLved 1
Data Date 08/2004, and the parts selected ille
Equipment Manufacturer. GEM parts are avall
Double þ,sterisk : h ì ir:dicates thaT: the parts
been recodified or may have come frcIT. an eHernacs
Not- Inclcded Labor opera': ions. Non-Griglelal
as AM, Qual ReD I Parts Comp Rep] carts
')so:J parts are described as LKQ, Qual Recy Parts, RCv,
Rocoreo parts are descnbed as Recore. NAGS Pari
Auto Glass Speclficat'o:ls, Tnc. Pound sign!
t13n~facturer afceC",arKet
NUC10eés and
ma,"ual ener les.
- þ
of CCC InfolC13tcon Services Icc.
2
09/17/2004 at 04:57 PM
24443
Job Number:
ABRA - DUBUQUE
Federal ID #: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:
Address:
DAWN CLOSE
DAWN CLOSE
705 ROSE
DUBUQUE, IA 52001
(563)583-4162
Claim #
Policy #
Deductible:
Date of Loss:
Type of Loss:
Point of Impact:
Day:
Inspect
Location:
Insurance
Company:
Days to Repair
1993 MERC TOPAZ GS 4-2.3L-FI 40 SED TEAL Int:
VIM: 1MEPM36X4PK615544 Lie: 345NXC IA Prod
Intermittent Wipers Tinted Glass
Dual Mirrors Clear Coat Paint
Power Brakes Power Mirrors
Split Bench Seats Recline/Lounge Seats
Date: Odometer:
Body Side Moldings
Power Steering
Cloth Seats
-------------------------------------------------------------------------------
NO.
OP.
DESCRIPTION
QTY EXT. PRICE LABOR
PAINT
-------------------------------------------------------------------------------
1 FENDER
2* Rpr RT Fender 4 door 0 0,00 1.0 2.4
3 Add for Clear Coat 0 0.00 0.0 1.0
4 HOOD
5* BInd Hood 0 0.00 0.0 1.0
6# Rpr COLOR SAND & BUFF ROOF RT DOOR 0 0,00 1.0 0.0
7# Repl BAG / COVER CAR 1 4.00 0.2 0.0
8# Subl HAZARDOUS WASTE DISPOSAL 1 4.00 T 0,0 0.0
9# Sub1 TAPE STRIPE 1 30.00 T 0.0 0.0
-------------------------------------------------------------------------------
Subtotals ~~>
38.00
2.2
4.4
1