Claim Kaune, CarolCLAIM 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: Carol Kaune
2. Address: 835 Harlan St., Dubuque IA 52001
`
3. Telephone Number: 563 588 9474
4. Date of Incident: 12-1-04
5. Time of Incident: 11:02 AM
6. Location of Incident (Be specific):
South Judson St. about 35-40 ft before Hillcrest Rd. in Dubuque, IA
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 employee - Randall Koster - City Truck was parked/stopped on street curbside. No signals on.
Ms. Kaune drove by truck when truck pulled out and hit Ms. Kaune's vehicle.
8. What were weather conditions like? Not a factor
9. Give name and address of any witnesses: None
10. Did police investigate? (If so, give names of officers.)
Yes, Officer Patricia Folger, Badge Number 30A
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
None
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.)
Damage to 2004 Dodge Strautus, Damage to Right front door. Impact was to right rear door and rear quarter panel.
Total estimate $3,573.19
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?
100% rental charges; $238.48 and estimate $3,573.19
16. Why do you claim the City of Dubuque is responsible?
Per our insured, City truck pulled from curb side into our vehicle.
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?
No
Dated at Dubuque, Iowa this 3rd day of January, 2005.
/s/ Tanya Reis
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
, DEC-17-04' FRI 04:01 PM
DUBUQUE CITY CLERK
FAX NO, 563 5B9 OB90
P. 02
c!ê¡ g::; L
CLAIM AGAINST THE CITY OF DUBUQUEI'IOWA . /)oj } ílÛJí
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 depllrtment 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: C{l /'D / tCt L.L I~
2. Address: fßç ~ar\(l~ ~tt1ttbU\JlXll{!) It+- 5200 I
3. Telephone Number: tJLo3 '-5<6~ - ~~.
/;:)-/- oe/
5. Time of Incident: II . 0 d- 0. W)
6. Location of Incldent(Be specifIc): :5 CUi h JU d':)(J(J 'Sf-, â boll! ~. <-10 Fr
bePo~ HI/,('rQ'Df Qd l Vl llibU~LU'.,) lft
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon whIch you base your claim. If ~Clty emPlOyee;, 1a5 Involved" give the
employee's name.) l¡ L tYì l 7 ;;: Kanda / / <OS-ttr. I tv\Jcf::--
\.,~Œ) pcWled stet' I'd an . r~E:-t CÜfb~¡de .1\10 (1 tL(S
~D_,-_11~.J(lUrL dro\lt- b~ 1YLl~L LÙ~-hUct- ¡=uILtc1 OU.J 4 hLf .
8. What were weather conditions like? n4 o-ßc::hr "'H ,gi~lð.
9. Give name and address of any wltnesses:--Al () /1.f '
4. Date of Incident:
11. Was anyone Injured? (If so, give names, addresses, and extent of Injuril!l~).
tV ¿/1t
,i
-.J
(c'
12/17/04 FRI 15:31 (TX/RX NO 83~3] ~OO2
, DEC-11-04 FRI 04:01 PM
DUBUQUE CITY CLERK
FAX NO. 563 589 0890
p, 03
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.)
13. What other damages do you claim, If any? ~ttY1L.
14. Have you been compensated for any part or all of your claim by eny Insurance
company? (If so, give name and address of Insurance company and amount paid.)
.J\I D '
15Jt-What amount do you claim from the City of Dubuque? I 00%- (11 i 1 i& { CIl (y l?f S =--
'j]) /l3{; A,j r¡ (lrrJ ,Q'm Vl1Ctl:. ::: JJ <;, C;'7,3, / q
16. Why do you elalm the City of Dubuque Is responsible?W r [)U r ! !IS LLi'l'(~
~.tYULL Pl Wd mln C~nJ BIde iJ\-b !ler
jLth c ¡,¿
17. Have you made any claim against anyone else for damages as a result of this Incident?
(If yes, give name end address.) f'J C)
18. If the answer to Question II' Is yes, have you received any payment from that souree,
and if so, In what amount? 'tJ CJ '
Dated at Dubuque, Iowa this '31Ø-- day of ,Tci.M. Vl¿L~
tOll fc¡ j~::;y
1šÎgnature)
tANlflq ~E1\
(Print Name)
, 20.D5.
(Rev. 1100 & 7J01)
12/17104 Far 15:31 [TX/RX NO 83931 IlIOO3
. PAYMþNTIRECOVERY HISTORY
Page 1 of 1
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CLAIM STATUS: CLOSED
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ADJUSTER PHONE: (262) 338.72'
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CLAIM NUMBER
CLAIM ROSTER
8IDEAUX SMITH & WE8ER INS AGY (AGENT)
d
,"'"
AAZ643S
LOSS DESCRIPTION
CAROL GOING DOWN JUDSON TO HILL CREST WHEN RECYCLING VEHICLE PULLED FROM CURB SIDE STRIKING CAROLS PASSENGER
SIDE
LOSS ITEM DETAIL
CLAIMANT NAME:
UNIT DESCRIPTION:
CAROL KAUNE
2004 DODG STRATUS SX
RESERVE TYPE: LOSS
MAJOR PERIL: AUTO PHYSICAL DAMAGE. COLLISION
CAUSE OF LOSS: AUTO PHYSICAL DAMAGE COLLISION
RESERVE CATEGORY: GENERAL
TRANSACTION
DATE
12/16/2004
01/03/2005
TRANSACTION TYPE
PAYEE!S)
DRAFT NUMBER AMOUNT
0004056581 $3.073,17
UNASSIGNED $238.48
TOTAL PAYMENTS: $3,311.65
PAYMENT
FINAL PAYMENT
BRIM EYER AUTO BODY
HERTZ LOCAL EDITION
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https :llwww, wbconnect. com/CIaims/CIaimSummary 1 ASPDocuments/payment _history ,asp?". 1/312005
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Phone ,.888.777-3100
Fox "',775,"'3
E.""", CUSTOMEAOIWNG@HEATZCOM
HEATZ LOCAL EDITION
PO !IOX-5
OKI.AHOUA CITV, OK 731".""
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AI99%0O51
12/lSJ'2004
60_1103'10
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I18ntlor:
Account No,:
COP No.:
COP_:
CAROL KAUNE
~HCC
'51<26$
HlE WEST BEND MUTUAl. W£S
TAX ,<
'3'1$385611
REIS TANYA
WEST BEND MUTUAL INS
-ATTN BRENDA DICKMAN
1900 S 18TH AVE
WEST BEND. HI 53095-8796
Rt:NTAI, REn:Rt:NCt:
I18ntlo1 ~t No: Al 992005 I
-"",tion 10:
RENTAl, J)ETAII.s
Ratio PI..:
I18ntod On:
Aatu....,..¡ On:
!H, CRYe OUT,
12/06/2004 13,33
DUBUQUE, IA
12/15/2004 08,04
DUBUQUE, IA
CAVALIER 71S1iRC
CIIV
LOC1I 538839
LOC1I 538839
Car DMcripti....:
BltLiNG INt'ORMA110N
Chim Nol AA26435
Policy Nol
Oat. of Loss.
Type of Lo...
Repair Facility,
Authoriud Rate.
Authori... Day.,
Adjuater,
Inaured.
2004-12-01
0
BRII'IEYER AUTO BODY
30,00
10
REIS TANYA
o
CAR ClASS -rood' B HILEAGE In: 9,555
I18ntod: B Out: 9,460
-.-: 99 Ori-.: 95
RENTAL LliARm:S 45,00
DAYS 3 , 15.00
EXTRA DAYS 7' 23.99 167.93
SUBTOTAL 212,93
TAX 12.00% 25,55
Al'lOII"T DUE
238,48 US!>
MISŒI,LANEOlJS INFORMATION
PAYMENT DUE UPON RECEIPT
- -
mAN ( YOU fOR RENTING fROM HERT1,
- CHECK HFRE FOR ADDRF.~S CHANGE ON REVERSE SlOE
RÐIIT TO :
HERTZ LOCAL EDITION
PO BOX 268825
OKLAHOMA CITY, DE 73126-8825
UNITED STATES
DETACH ANO SEND WITH PAr"Em.DO NOT STAPLE OA fOLD
PI.EASE JNCI,U[)E RF.NTAL AGREEMENT NO. ON YOUR CHECI(, Rantal ~ No:
1a\'OÏ<t Date:
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I18ntlor:
Account No.,
AI9920051
12/l5i'20Ott
60_110390
CAROl. KAUNE
~HCC
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fa,.:
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1-88&-111-3700
405- 775-6413
CUSTtH:RaILU_RTZ.COH
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1- >~()m~I~~>E!_» BRIMEYER AUTO BODY
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Busines", (563)583-4456
IMAGE REPORT
12/07/2004, EST01,
12/07/2004, EST01,
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12/07/2004, EST01,
12/07/2004, EST01,
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