Claim Kelly, StevenCLAIM 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: Steven Kelly
2 Address: 9976 Laudeville Rd., Dubuque IA 52003
`
3. Telephone Number: (563) 556 1815
4. Date of Incident: 11 17 04
5. Time of Incident: Between 12 Noon & 1 P.M.
6. Location of Incident (Be specific): Truck was parked in parking place in front of
Operations and Maintenance Building.
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.)
Truck was parked. It was obvious that City Truck backed into side and drove away.
8. What were weather conditions like? Cloudy
9. Give name and address of any witnesses: None
10. Did police investigate? (If so, give names of officers.)
Yes, Officer Ahlers
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.)
Side of truck box was pushed in and hole torn in side.
13. What other damages do you claim, if any?
None
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?
$2,250.77
16. Why do you claim the City of Dubuque is responsible?
Truck was backed into by recycling truck. Police Officer checked and makes match of rear of truck.
Refuse Dept. manager agreed it was one of their trucks.
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 22nd day of November, 2004.
/s/ Steven J. Kelly
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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: < \ 'H~J.e tI.I /{..¿ ¡I c¡
,
2. Address: 99 7 b L ~v KJ-< ¡}¡ t/~ )fa
3. Telephone Number: (.165) J~~t <. /f'¡ Y--
4. Date of Incident: 1/- / 7 - 0 c¡
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5. Time of Incident: ß~¡-'».-t..ß1I1 /,7. /Vðc¡l1! ;L /,f'4r7
6. Location of Incident(Be specific): fifJé.-/< Ú/4---S ?-1-/.. /é.dJ ¡::A{ /-?4.~ 1ft /<16
f{.AL~ t:--n. ¡~1 ()¡?~ r- Anf~~(_/ 13 ed9/'
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
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8. What were weather conditions like? é~ ./
9. Give name and address of any witnesses: ,/lltJlll-Þ
10. Did police inVe;(.¡:t~? (If s~ive names of officers.)
-V ~ ;(~ II f.. '¿I<.r
11. Was anyone Injured? (If so, give name:;, addresses, and extent of Injuries).
11/0
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.)
}c;k 1
7 f&u-lt ð elf
w~ ~~D/ ~ -¡-- //~ ~~ r;; Jcdt
13. What other damages do you claim, if any? lIð/'l.?
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.)
/1/0
.
15. What amount do you claim from the City of Dubuque? t"2,, d- ~ó f 7 ì
{
16. Why do you claim the City of Dubuque is responsible? Ttßud.. ---. w llc 13~ ~
ßlj-- j¿p/j~<cJryl~ / P~I ~{Jù~ ckL;~~Jøø1itCi ~1F~/
p~ ÆMJ t fJ,¡f/ ArI ~k- ~ t:r W.r4> ~ /If ~ T~ ,
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
;YO
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 ;-~
day of IV ~
, 20-I2Y
f ~na~~
Sr.:e.vt!jo/ ,r. /.( .¿~t/
(Print Name
(Rev. 1/00 & 7/01)
Toys Done Right
11941 sherrill rd
Dubuque, IA, 52002
Tel: 563-552-1601 Fax: 563.552-2207
toys@logonia.net
RepairMate Estimate
Estimate Prepared by:
Accident Date:
Date of Loss:
Arrival Date:
Type of Loss:
Policy Number:
Claim Number:
Appraised for:
Date: 11/2212004
Estimate#:
Owner:
Contact: STEVE KELLY
Address: 556-1815,589-4251
Year I Make I Model Color I Trim
1999 GMC Pickup
Unit Number Lieense Plate # I Mileage Serial#NIN# '
Sup Seq Qty Labor Labor Description Part Part List Extended Labor
Type Op Type Number Price Price Units
I I Body Rem/lns R&I Bumper Assy Exist .s
2 I Body RemlRep w/Towing Pkg Add to Exist .3#
R&IIR&R or O/H
Bumper Assy
3 I Ref Ref 6-1/2 Foot Bed Exist 3.2
Refinish Outer Side
Panel L
4 I Body RemlRep 6-1l2FootBed New 15120160 $754.31 T $754.31 13.0#'
Panel, Outer Side L
5 I Body RemlRep Chrome Sierra 6-1/2 New 15744376 $41.50 T $41.50 .2
Foot Bed GMC
Moulding, Side
(Adhesive) L
6 I Body RemlRep "4x4" Decal L 99 New 15707440 $10.67 T $10.67 .4
7 I Body RemlRep rust proof New $10.00 $10.00 .s'
8 I Body Remllns bed cap Exist .5'
9 I Body RemlRep REPLACE BED CAP New $10.00 $10.00 .5'
TOP PROTECTOR
FILM
10 I Ref Ref Refinish Tailgate Exist 1.0*
Outside Refinish
Tailgate (Complete)
[BLEND]
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Sup Seq Qty Labor Labor Description Part Part List Extended Labor
f Type Op Type Number Price Price Units
1--. 11 I Ref Ref 3 Door Refinish Exist 1.2'
Outer Side Body
Panel L [BLEND] .
12 I Ref Ref Add for Inside 6-112 Exist 1.4
Foot Bed Refinish
Outer Side Panel L R
13 I Body RemlRep CLEAR COAT New 3.5'
14 Paint Materials $190.40
. - Judgement Item
# - Labor Note Applies
Labor
Body
Refinish
Labor Total
19.4 Hrs @
6.8 Hrs@
$42.00
$42.00
$814.80
$285.60
$1,100.40
Parts
Parts Subtotal
Less Adjustments
Parts Total
$826.48
$826.48
Additional Costs
Add!. Costs/Ops Total
Tax
$190.40
Labor Tax
Parts Tax
@
@
7.00%
7.00%
$77.04
$56.45
$133.49
Tax Total
Totals
Sub Total:
Customer Resp.
$2,250.77
$0.00
52,250.77
Net Total
e above is an estimate based on our inspection and
oes not cover any additional parts or labor which may
e required after the work has started. Occasionally,
om or damaged parts are discovered which may not
e evident on the first inspection. Because of this, the
ove prices are not guaranteed. Quotations on parts
d labor are current and subject to change.
RepairMate does not automatically include items required by many business repair partners. This application
allows the author to manually enter line items such as overlap deductions.
1999 GMC Pickup Sierra CI500 New
Version Ll
Database Edition CPL 04-10
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