Claim Luther ManorCLAIM 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: Luther Manor
2. Address: 3131 Hillcrest
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3. Telephone Number: 563 588 1413
4. Date of Incident: 9-16
5. Time of Incident: 9:20 a.m.
6. Location of Incident (Be specific):
Luther Manor Canopy
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.)
City bus hit canopy
8. What were weather conditions like?
Clear
9. Give name and address of any witnesses:
Cheryl Doller, Luther Manor Employee
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, damage to underside of canopy and 2 clearance signs (not too bad)
I will send you a copy of the bill after repair.
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?
16. Why do you claim the City of Dubuque is responsible?
Your bus hit our canopy
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 21st day of September, 2004.
/s/ Mark S. Noble
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF DUBUQUE,IOWA
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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:
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2. Address:
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4. Date of Incident:
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6. Location of Incident (Be specific):
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7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
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8. What were weather conditions like?
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9. Give name and address of any witnesses:
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10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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12. Was any damage done to property? (If so, describe property and the extent of damages.
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13. What other damages do you claim, if any?
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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.)
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15. What amount do you claim from the City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
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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
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LUTHER MANOR
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3131 Hillcrest. Dubuque, Iowa 52001-3999
www,luthermanor,com
(563) 588-1413
Fax (563) 588-2770
September 28, 2004
To Whom It May Concern:
Enclosed is a signed estimate for repair of our apartment canopy that was hit by a city
bus, Please reimburse Luther Manor for this expense,
I am available if you have any questions,
S,incerely, - ,,\
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Mark S, Noble
Executive Director
G 01 ~",Iro";" loc
JOD ~st¡mate
Pro~osal
General Contractor
p,O, BOX 567 DUBUQUE. IA
52004
563-582-9003
Fax 563-582-7747
E-Mail gerardyconstruct@mcleodusa,net
SUBMITTED TO:
Attn: Mark Noble
Luther Manor
3129 Hillcrest Road
Dubuque, IA 52001
DATE: Sept 27, 2004
JOB DESCRIPTION:
Repair Apartment Canopy
JOB LOCATION:
3129 Hillcrest Road
COST ESTIMATE:
$398
INCLUDES:
Material and labor
Payment terms:
Payment due upon completion of job,
ACCEPTANCE OF PROPOSAL: All material is guaranteed to be as specified, All work to be completed in a workmanlike manner according to
standard practices, This estimate and any additions, omissions, changes or verbai agreements shall not become binding unless confirmed in writing
and accepted by the contractor. Clerical errors subject to correction,
Any alteration or deviation from the above specifications involving extra costs will be done only upon a written change order. The costs will become an
extra charge over and above the estimate, This is to include, but is not limited to, hidden damages that are uncove<ed during the course a! the job and
additional work required by local building inspectors,
All elements of this agreement are contingent upon strikes, accidents or delays beyond our control. This estimate is for completing the job as described
above, It is based on our evaluation and does not include additional labor and materials which may be required should unforeseen problems or adverse
weather conditions arise after the work has started,
The above prices, specifications and conditions are satisfactory and are hereby accepted, You are authorized to do the work as specified, Payment will
be made as outlined above,
Signature:
Date:
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Signature:
Date:
(rhis proposal may be withdrawn by GCI if not accepted within 15 days.)