Claim Blatz, Joseph L.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: Joseph L. Blatz
2. Address: 9094 Military Rd., Dubuque IA 52003
`
3. Telephone Number: Home 582 2064 cell 542 4194
4. Date of Incident: 4/07/06
5. Time of Incident:
6. Location of Incident (Be specific): City Landfill
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.)
A John Deere bulldozer driven by Jason Hoerner backed into my trucks rear right side of the box, when I had backed up to the
landfill with my truck and trailer.
8. What were weather conditions like? Fair weather with overcast
9. Give name and address of any witnesses: Jerome Welsh, 12670 North Cascade
Road, Dubuque IA 52003
10. Did police investigate? (If so, give names of officers.) Yes, Officer Jason Hoerner
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No, Thank God.
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? 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? $6973.67
16. Why do you claim the City of Dubuque is responsible? City employee was at fault, backed into my 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?
Dated at Dubuque, Iowa this 18th day of April, 2006.
/s/ Joseph L. Blatz
Thank You!!
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
_ 4v/l;>v?/
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA ;:ff:t/{fU~
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: ~OSe. ~_ L ~ ~C\:i L-
2. Address: /tJ f~ d1./.h,V'y Pi
3. Telephone Number: 1-1:81-<- ? r ;)-').0 " f/
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4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific): {!r"l L A"""lr./I
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If a City..,emp_loy~e was involved, give the
employee's J!ilD'!e.) xr~ by J Q!!4f. 1NT'rner_
.,
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~ fiN/pi/ t.;J/, ~ -frt(fj~,ad- -frCl/~. ,
8. What were weather conditions like? -fAr u.Jf~ /IJ;.}h Oltff('IlS!-
9. Give name and address of any witnesses: S.A. ~ CI W\le.... W-e- 1<; ~
/2. C. 7 tJ Not-of J,.. &sLJ. -e.. r-J DJ,.. e '''..... 4./4 S-()CJt7 ~
10. Did police i~stigate? (If so, give names of officers.)
Y<') Qtt... Q. ~ ~ .~ "-,5" ",.J tic. oC. t<. KJ-e it-
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
NtJ -rItA.J<.... free!
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?
mN./
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.)
/UJ
15. What amount do you claim from the City of Dubuque?
J (p 973. &1
16. Why do you claim the City of Dubuque is responsible? ~7 t ..vrv--p bop./
LA )Ll~ at- ftUJJJ) b ~ I ~ rflt {JfJvct / '
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
(Ill
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 /I?
day of
4pY1'/
, 20.iliL.
(Signature)
JCTS'~pk L- ~ \",'+"2
(Print Name) I
~ /j'tV.
(Rev. 1/00 & 7/01)
CROWN COLLISION CENTER INC.
Steve Saffran. Owner
7812 Windy Ridge. Dubuque, Iowa 52003
563-588-0415
DAMAGE REPORT 1
PRICES GOOD FOR 30 DAYS ONLY
Items CIRCLED are in the total, in
our opinion, are not part of this claim
(el//I <;//:J -1//9't/
VEHICLE O~tj~ 1-7. 9ik) 12,/ f)" hDRESS/! 38;/0';// /, V DATE
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"_EAR V 0", ,C;E 1)_ MODEL LICENSE MILEAGE COLOR I I 7 J-!U /E~~;L;, '.,. '/, CONDITION
Q,oo' /5"0 ,,, p" P" A (.) , J!!, 'j 7 L tf";;2.-.
INSURANCE CO , ADJUSTER PHONE CAR LOCATED AT DEDUCTIBLE
Sym. FRONT Sublet Service $ Sym LEFT Sublet Service $ Sym RIGHT Sublet Service S
Or Paint Or Hours Parts Or Pain! Or Hours Parts Or Pain! Or Hours Parts
Bum er W I Pads Fender, Frt Fender, Frt
Fender Shield Fender Shield
FenderMldq, FenderMldn,
Bumper Reinf.
BumoerBrkt. Side LiqhtAsmbly Side Linhl Asmblv
HE'<ldlamn Headlamn
Valance HeadlampDoor HeadlampDr.
BumperGd Sealed Beam Sealed Beam
Frt.System Park Liaht Park Liaht
Frame Cowl Cowl
Frame Horn Door, Front Door, Front
Cross Member Door Hinae DoorHm e
Stabilizer Door Handle Door Handle
Wheel Door Glass C- T Door Glass CoT
HubCap Disc DoorMldgs DoorMldgs
Hub& Drum
Spindle
Ball Joint
Lr, ConI. Arm Center Post Center Post
Door Rear Door Rear
Up. Coni Arm Door Glass CoT Door Glass C-T
Shock DoorMlda DoorMldo,
Spring
Tie Rod
SleeringGear
Steering Wheel Rocker Panel Rocker Panel
Hom Ring AockerMldg. RockerMldg
WindshieldC-T Floor Floor
Dog Leg DogLeg
Quar. Panel Ouar.Panel
Gravel Shield Quar. Ext Ouar. Ext
Grille Ouar. GlassC.T QuarGlassC-T
Grille Panel Ouar,Mldg. Quar.Mldg
Side Light Asmbly Side Light Asmbly
Air Condenser Tall Light Tall Light
Recharge System REAR MISC,
Air Compressor Bumper Inst. Panel
Name Plate A--fl'-i:.4o 3- Y(.'J(J"e7i/ Front Seat
Hem Front Seat Adj
Baffle, Upper Bumper Reinl Trim
LockPlale, Lr. BUffirll"rBrkt HeadlinIng
Lock Plate, U Bem cGd TopVynl1
Hood Top Valance Tire %Wom
Hood Hinge Lower Panel Pa.ntlnn //J.C"'-'4. cJ Jo n
Hood Lock Floor Aerial ~.
Ornament Trunk Lid Tow & Storage
Rad.Sup _'I J+,.,A/ a..S
Rad.Core rl-N /5 1'7,<; ~{.7,7
Anti Freeze Back Up Lights
Rad, Hoses Lic.Light
Fan Blade Tall Pipe HAZARDOUS WASTE L/.,'OO
Fan Shroud NET PARTS 5'/;)500
Fan Belt Gas Tank
Water Pump Frame SERVICES 1/,.(}jRS, @ V? HR 7.<',200
Water Pump Pulley Wheel PAINT - MATRL - HOW, -; LO "',c-'
MotorMts Hub& Drum SUBLET OR PAINTING
Trans. Linkage "" hi lI!tJO (h:7i. ?
Sprino TAX ON $
GRAND TDTAL ill (,"'7".6?
,
Symbols A - AJign N - New OP - Open P - Paint
S . Straighten R - Replace OH - Overhaul
I HEREBY AUTHORIZE THE ABOVE REPAIRS
This Damage Report is based on our inspection
and does not cover any addillonal parts or labor
which may be required aflerthework has been
opened up
Appraiser
x
. "Damage Report
105937
NAMl :2V':>'rfft)/tl/z:..
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'DATE /2-.J.i'f/lj3 / .ik'f.'6
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INS. CO
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LINE RE- RE.
NO. PAIR PLACE
DETAILS OF REPAIR
R = Repair S = Straighten
R/e = Recycle/RechromefRecore
PARTS INDEX
A = Aftermarket N = New
U = Used R = Rebuilt
2
3
4
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'~()P\"LTIMi::::,. Af'TEH ,HL WOHK >1AS 8E'Fr\1 ST"',illl:D, P":'DITlnNf\II.Y f.:i'lMAGL'J 01 ',.!(Hirj PI'"j':::; AR[
nlSCOVFHED \NHICH \NlRF r,cn ~:V'Dt:NT ON ~-IRS! JjSi'l:crIGrJ Irw~ UAMAGF. I It. "'UI-ir ,_'OES W:T '>:)\i;'F,: Of' L
!NC~~JDF. f\'jy ArlDITIONAL. PAil r.', OFi AIJOR W~IICH MAY Gf: fll DUIRf'O. 11,i..L rAin,_; ,'filC!:. ;C,fi[ '.itmJE':.T Ti) i"-jUler A
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I hereby authorize irK' i,hove vvork and acknowlwj(::W IH:l;ipt of copy
Signed X
Uate
DUEHR AUTO BODY REPAIR
You Bend 'em, We'll Mend 'em
16678 Carmen Oaks Dr.
Durango, IA 52039
Phone (563) 552-1043
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filL NO
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LABOR HOURS
BODY PAINT FRAME MECH
PARTS
SUBLET/MISC,
y~,.
3.0
- -
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..+-1- -: ,_ -+ n ...--
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. -! ---!---r... i
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:::::; i~:':~ im'~~~..1 ~/;
FR/\ME __ _0__ _ II!', ~.
I',~ECH I
svre._ It:..~
Pf\RTS !-'Ii(:(,s ,-,';(;i.JIC'(IIO invo,,'::e___
,'3\JB,.r r !'v11~CcL.L^!~EOuS___
f'"i'lt ::;UPP!IO'; li_5nr:; ;:;,('__
.. 'f05,.
HOrJy Supplies _ "r::. 'i'
li)ww:J Sloraqe
1__6;13 ~ <?
,
I
--- - I --- - _
TAX Z. % on S g, 31.}1 6.t2I__ .'1.'/1,- 157_
[PA I/Ihste [J,spoSClI Chdrge --- 1_ __ _ (:, ~(..'
TOTAL $ 7/ /, 6 i55
SUB TOTAL
lilJ'f='A ,'j( I irip ',"',,' 1.,,,1: 10 fUh'15. '.,A, i IUt: FHLE ~ P.OO-63'i 'l?61' Itp," r~(, Ffl rJ23