Claim Uhlrich, Paul J.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: Paul J. Uhlrich
2. Address: 489 Olympic Heights Road
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3. Telephone Number: 563 585 2133 H 563 556 5790 W 563 599 7200 cell
4. Date of Incident: 1 12 06
5. Time of Incident: 1:05 P.M.
6. Location of Incident (Be specific): NE Corner of 9th & Locust
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.)
Parking pickup truck backed in along curb a piece of steel sticking out of curb cut the tier.
8. What were weather conditions like? Good
9. Give name and address of any witnesses: City Employee came and looked at it & Driver from McCann Towing.
10. Did police investigate? (If so, give names of officers.)
No
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.)
No
13. What other damages do you claim, if any?
N/A
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?
$101.61
16. Why do you claim the City of Dubuque is responsible?
Steel was sticking out of City Curb. The tires were purchased 12 8 05.
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 12 day of January, 2006.
/s/ Paul J. Uhlrich
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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This written report constitutes your claim against the City of Dubuque, Iowa. You J.~IUld
complete this form in full and attach any additional information that supports your claim.
.
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CLAIM AGAINST THE CITY OF DUBUQUE, 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: P /f-V L J: L/ h L- R r'C h
2. Address: t-{- g 1 (!) L- Y 1-1 PI'C !-f ,; ," G-h rs R 1:>
3. Telephone Number: S-C3-S-?lS--:J-r:s'3 J+ S-ro3--~5-,,-.5-7ft9 ~&5 -!>Y'y-'7.Jt?19 r:Nt
/-(;;--0&
I -' (!J j- P fV/
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4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific):
r!h 1- !-O e U 5' T
AI E Co f:! rvER C9F
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
el!!P10y"ee's name.) "
Vlr-NlrJa/{y 'P1"Or C/P n....Vvl( Blt-elrED /;1/ /f-f-.Olf/& C [)~8
fr PI<EC/~ or=FSiEEL- STd,fr,-jl/{;- (9U1o(-'=CV'RB cur
Th E T/ R r;
8. What were weather conditions like?
G-otY D
9. Give name and address of any witnesses: C;- r- y
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Ail/D L.f7t9I,!::P ,41 I(. 'f- D7(>-v{;~
EMpLoyE (!.ANE
,-12(91U MCC,A.IVIY to Wrcvc;..
10. Did police investigate? (If so, give names of officers.)
(V{!)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
lVo
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.) ,
jv'()
'.
13. What other damages do you claim, if any?
IV/A-
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.)
fV,b
15. What amount do you claim from the City of Dubuque?
/tJ/, t I
16. Why do you claim the City of Dubuque is responsible? 5' TIS' El~ W r+ )
S' T rC: Fe- ; IV G- (J u T cJ F t r' rye V R Ii~. Tn F T; 'If: E 5 ~
'~pvRC-hlr'i/~ b rj.-'?-&S-
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) ,A/ CJ
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
t:J- day of t//l-IvLl-fi-;e r , 20~
(?d~ ~
(Signature)
pj{vL J; i/hJ.-R/~CI,
(Print Name)
I"
)
(Rev. 1/00 & 7/01)-
....
...... "
HAWKEYE TIRE & RETREADS
690 E 14TH ST
DUBUQUE, IA 52001
(563)585-2388
Gooofi'EAR
PAGE: 01
01/12/06
02:02 PM
TERR: 1635
NONSIG: 132448
ESTIMATE
014662
~ESTIMATE/WORK ORDER-DO NOT PAY-
BILL TO: UHLRICH ELECTRIC COMPANY
PO BOX 354
DUBUQUE, IA 52004
PHONE 1.......
PHONE 2.......
DATE REQUESTED
TIME REQUESTED
RETURN PARTS. .
SALESMAN..... .
PRIOR INVOICE.
(563)556-5790
(563) 599-7200
01/12/06
AM/PM
NO
012 / 012
014000
VEH YEAR/MAKE.
VEHICLE MODEL.
VEHICLE COLOR.
LICENSE/STATE.
ODOMETR IN/OUT
VEHICLE INFO..
96 DODGE TRUCK
DAKOTA
/
/
ACCOUNT # COB TC CUST#
163501332 4 01 01332
INSTRUCTIONS. . . .
SLSM TECH PRODUCT CODE BC OTY DESCRIPTION CORE PARTS LBR/EXCISE LINE TOTAL
012 --- 357-406-099-0 R 1 P235/75R15 105S KEL SAFARI TREX OWL 11 B4.47 .00 84.47
012 --- 044-263 R 1 WHEEL BALANCE - COMPUTER SPIN .00 7.50 7.50
012 --- 041-263 R 1 NEW VALVE STEM 2.99 .00 2.99
012 --- 012 R 1 OLD TIRE WAS CUT ON SIDEWALL JUNK .00 .00 .00
YOU HAVE THE RIGHT TO A WRITTEN OR ORAL ESTIMATE IF THE EXPECTED COST OF REPAIRS OR SERVICE
WILL BE MORE THAN FIFTY ($50) DOLLARS. YOUR BILL WILL NOT BE HIGHER THAN THE ESTIMATE BY
MORE THAN TEN (10%) PERCENT UNLESS YOU APPROVE A HIGHER AMOUIIT BEFORE REPAIRS ARE FINISHED.
INITIAL YOUR CHOICE.
I request a written estimate.
I request an oral estimate.
No estimate.
Call me if repairs and service will be greater than $
I DO want parts returned (signature)
I DO NOT want parts returned (signature)
~----------- ---------------------
CUSTOMER AUTHORIZATION TO PROCEED WITH REPAIRS EST I MA TE
AUTHORIZED BY,
AUTH PHONE....
REVISED TOTAL.
TREAD L/F... /32
/
SALES TAX 6.~
TOTAL $101_6
DTY / II) DTY / ID
BALL SPEC L/'). BALL SPEC L/L.
BALL ACTL L/ I. BALL ACTL L/L.
MANNER REG'D
AUTH TIME. ,1M/PM
REPAIRS DESC.
TREAD R/R. /32 TREAD L/R. /32
-
REGISTRATION. DTY
BALL SPEC R/U.
BALL ACTL R/U.
ID
OTY
BALL SPEC R/L.
BALL ACTL R/L.
AUTH REG' 0 BY.
AUTH DATE..
ADD'L ,lMDUNT..
TREAD R/F..... _/32
/ID
ALL PARTS ARE NEW (AFTER-MARKET REPLACEMENTS) UNLESS OTHERWISE SPECIFIED.