Claim Best Western Midway Hotel
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This written report constitutes your claim against the City of Dubuque, Iowa. You S~OUld , .J-/'
complete this form in full and attach any additional information that supports your claim.;.^::IU,if; ,1
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CLAIM AGAINST THE CITY OF DUBUQUEj'IOWA .
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:
Best 'Western Midway Hotel
2. Address:
3100 Dodge Street, Dubuque, Iowa 52003
3. Telephone Number: 563-557-8000
4. Date of Incident: November 3, 2005
5. Time of Incident: About 10:30am
6. Location of Incident (Be specific): Hotel Front Entrance -Building Overhang
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 trolley hit the building.
Driver's name is Chuck.
8. What were weather conditions like? Excellent
9. Give name and address of any witnesses:
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10. Did police investigate? (If so, give names of officers.) No - Private lot
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.)
Hotel front entrance canopy was damaged. Please see attached estimate.
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? $4,200.00
16. Why do you claim the City of Dubuque is responsible? Citv vehicle and city driver
caused the damage.
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
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day of
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(Signature)
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Dan Gaab - General Manager
(Print Name)
(Rev. 1/00 & 7/01)
KELLY CONSTRUCTION
12474 Barony Drive
Dubuque ,Iowa 52001
Phone 563-582-1987
Fax 563 582-7732
Mr. Dan Gabb
Midway Best Western
3100 Dodge Street
Dubuque, Iowa 52001
RE; CANOPY DAMAGE
Mr. Gabb:
Tbe canopy shall have damaged materials removed and installation of new metal studs,
plywood and foam board. Tbe affected area shall be meshed and have a base coat
applied.
Apply the finish NCB to the entire bulkhead. forty five feet (45'). Colors shall match
the current color.
Labors, materials, tools and equipment shall be furnished for the sum of Four Thousand
Two Hundred Dollars ($4,200.00).
This price does not include heat and enclosure should weather change and become
necessary.
Thank you.
Respectfully submitted;
KELLY CONSTRUCTION
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By: tsi~k Kelly Sr./
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