Claim Welu, David - Printing Co.
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CLAIM AGAINST THE CITY OF DUBUQUE,.IOWAp,j\o-lt> - ~
This written report constitutes your claim against the City of DUb~a:- YO~Uld
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.
N f CI . ,DAVID J. l~ELU / WELU PRINTING COMPANY
1. ame 0 almant:
2. Address: office at 1685 Central Avenue
3. Telephone Number:
Office: 582-1332
4. Date of Incident:
June 13, 2005
5. Time of Incident:
2:00 p.m. in the afternoon
13th and Iowa Street, by City Hall
6. location of Incident (Be specific):
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.) o' h S t d Od t th k 0 th Od'l
Drlvlng Sout on Iowa tree, 1 no see e roc ln e ml a e
right side of the street. Construction was in progress in that block and surrounding
streets.
8. What were weather conditions like?
Brite and Sun was shining
9. Give name and address of any witnesses:
NONE
10. Did police investigate? (If so, give names of officers.)
NO
11. Was anyone injured? (If so, give names, addresses, and extent of i{ljuries).
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.)
Copy of Estimate from Richardson to replace oil pan
13. What other damages do you claim, if any?
NONE AT THIS TIME
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?
$ 866.63
16. Why do you claim the City of Dubuque is responsible?
YES --- SEE ESTIMATE AND
PICTURE OF ROCK. (I STILL HAVE THE ROCK, IF ANYONE HAS TO SEE IT.)
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 July 5 day of
July 5,
, 20 005.
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(Signature)
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(Rev. 1/00 & 7/01)
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It h -J 1475 John F. Kennedy Road
. Dubuque, IA 52002-5299
~S Jl~MC ,teH!! (563) 582-5411
SERVICE
INVOICE
Co.# 01
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WELU INC
1685 CENTRAL
DUBUQUE IA 52001
Cadillac Certified Warranty
Business Phone: (563) 582-1332
Home Phone: (563) 582-1332
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BRONZE
2003 CADILLAC DEVILLE
237 AWB
LDB 4.6LVB
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29194/ 29194
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6/22/2005 16:07
6/22/2005 16:53
A/R#:
70846
LINE 1
GIVE EST ON REPLACING OIL PAN
REPAIR 1
OPCODE: 999
PARTS AND LABOR WOULD BE 866.63/PLUS TX
SALE TYPE: INTERNAL
INT
PRIMARY TECH: 005
CUSTOMER SIGNATURE
CUSTOMER TOTAL ......
$.00
LAI
The seller hereby' pressTy'disc I s, either express or
implied, including any implied warranty of merchantability or fitness for
a particular purpose, and neither assumes nor authorizes any other person
to assume for it any liability in connection with the sale of said products.
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