Claim Sharkey, Thomas I Jr.10/21/04
cc: MVM
Barry
Engrg
O & M
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: Thomas L. Sharkey Jr.
2. Address: 1264 Langworthy
3. Telephone number: 563-557-9856
4. Date of Incident: October 17, 2004
5. Time of Incident: 2:12 PM
6. Location of Incident (Be specific): Traveling est on Hill St coming from downtown area towards
hospital/Langworthy St.
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.) While traveling up HIll St. driving 20 mph I hit a hole cut in by construction crew. The hole was
half filled. There were total of 6-8 holes that were back filled with gravel. The hole shook the truck violently. Engine
light immediately went on. No construction signs were posted. I verified this 2-3 times
8. What were weather conditions like? Clear/sunny-day
9. Give name and address of any witnesses: Kathy Sharkey 1264 Lanworthy Dubuque
and Todd Sharkey 1665 McPoland Dubuque
10. Did police investigate? (If so, give names of officers.) I notified the police at 5 :10 Pm to file report. They refused
to file report until I talk to City's road divison. They would not mark roads either.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries). No Injury, vehical damage and I
couldn't drive vehicle until Tuesday
12. Was any damage done to property? (If so, describe property and the extent of dal1\ages.
Attach estimates of damages or describe basis for ascertaining extent of damage.) Vehicle damaged
$623.79 for loose wire, alignment & leaking oil.
13. What other damages do you claim, if any? I was without a vehicle until Tuesda, Anderson Weber
-Weber provided loaner.
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 compensation
given.
15. What amount do you claim from the City of Dubuque? $623.78
16. Why do you claim the City of Dubuque is responsible? Improperly marking construction area.
There was nothing marking area.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No - Not at this time
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount? N/A
Dated at Dubuque, Iowa this 21 day of October, 2004.
/s/ Thomas L. Sharkey Jr.
(Rev. 1/00 & 7/01)
ANDERSON - WEBER, INC. @ TOYOTA
3450 CENTER GROVE DRIVE
P.O. BOX 933
DUBUQUE, IOWA 52004.0933
(600) 776.3261
(563) 556.3261
www.andersonweber.com
Free Service Loaners (appointment recommended). Free 011 (with new car purchase). Free Body Estimates (ABRA ,sS6dH1gq).
The selling dealer makes no warranty of any kind whatsoever as to the meochantability 01 Iha products listed haraon or as 10 their fitness lor any particular purpose, any warranty which may
exist is en agreemenl solely between tha manulacturer and the puochaser.
"I hereby authorize the 'epair work herein set Iorth 10 be done (including parts and materials) and agree 10 make paymenllherelore in CASH, unless it is otherwise a9reed and so sel forth in
Ih;" order. lIthe work is chaoged, I agree to pay a finance charge 0116% annually il not paid in 30 days. I untleBtandth.t... mottar 01 low. '-you moy _In _Ion oIth. _'c18
u""l.uch C88h poy""",,'. mode. You are not responaJt;elor.ny delays caueed by unaveilability 01 p.rts or deiays in parts shipmants nor lor ioss or demage to vehicle or articles ie' in
vehicle in case of lire, Ihe' or any other ceuse beyond your conlrol." Permission is granled 10 operatelhis vehicle on any slreel or road lor lhe purpose of lesting and inspection.
Dale Signed
20-
PLEASE PAY FROM INVOICE, STATEMENT SENT BY REQUEST.
On beha. of servicing dealer, I heraby certify that the inlormation conlained hereon is accurate. Unless otherwise shown, services described were pertormed al no chaoge 10 owner. There was
no indication from Ihe appearance of the vehicle or oIheowise that any part repaired or replaced under Ihis claim had been connected in any way wi1h any accident, negligence or misuse.
Records supporting this claim are aveilat;elor (1) year from the date of paymenl notO/cation allhe servicing deaJer lor inspection by representalives of Ford.
(Signed)
8
Dealer, General Manager or Authorized Pe"",n
CUSTOMER COpy
8
(Date)
. .
ftr\: AUTO
"BRÄ GLASS
'----'
ANDERSON - WEBER, INC. ¡<2S), TOYOT'A
3450 CENTER GROVE DRIVE ~ '"
1'0. BOX 933
DUBUQUE, IOWA 52004.0933
(800) 776.3281
(563) 556.3281
www.andersonweber.com
Free Service Loaners (appointment recommended). Free 011 (with new car purchase). Free Body Estimates (ABRA556.0696) .
IIIBiI
..
æ
, l~
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The selling _lor mek8s no wsrranty of any kind whalsoever as 10 the merchantability of the productslisled heraen or as 10 their fitnass lor any particular purpose, any warranty which may
exist is an agreemool -Iy batween the manufacturer and the purohaser.
'1 hereby authorize ths ,apair wo'" herein set torth 10 bs done (inctuding parts snd mste,isls) and a9ree 10 make payment therelore In CASH, unless il is olhe..,ise agreed and so set tooth in
thisordor. "the work is cherged, I agree to pay a tinence charge of 18% annually" nol paid in 30 days.' undenoland \hot es a mo...rol_a'aw you may _In poeeooton 01.... vehicle
untl""",,- poyment Is maœ. You are nof responsibielo,anydelayscaused by unavailability of parts or delays in parts shipments nor lor loss or damage to vahiclo orartictesleftin
"",,leIe in coso of fire, thoft or any other cause beyond your conlrol.' Permission is grenled 10 operate this vehicle on any slreet or road lor the purpose of lasting and inspection.
Da'e Signed
2°-
x
PLEASE PAY FROM INVOICE, STATEMENT SENT BY REQUEST
On bahalt 01 servicing dealer, I hereby certify thai the inlormation contained hereon is accurele. Unless othe"'se shown, services described wore porlormed sl no charge to owner. There wss
no Indication from the appearence of lhe vehicle or olhe..,ise that any part repaired or raplaced under this claim had baen connected In any way wilh any accident, negligence or misuse.
- supporting this claim are available lor (1) yea' from Ihe date of paymenl notification allhe servicing deale, 10, inspection by represenlatives of Ford.
CUSTOMER COpy
.
(Date)
(Signed)
.
Dealer, General Manager or Authorized Person