Claim McDermott Excavating
.
FROM :MCDERMOTT EYCAlJRHNG
o~r~9/2t~e fRt 08:Se FAX
FR>< NO. :5635835858
Ma~. 23 2006 01:08PM P3
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CLAIM AGAINST THE CITY OF DUBUQUE.,~IOWA .
This written report constltutGs your claim agBinst Ihe City of D~l)lIque, Iowa. You IIhould
complete this form In full and attach any additlolHll information that suppOI1$ your elalm.
The C1eim must be filed wIth tho City Clork " City HaU, 50 W. 13m St., Dubuque, IA 52001.
It will then be referred by lhe City Council to the appropriate department for Investigation.
Once thet investigation Is completed, II report and recommend..Uon will be submitted to the
City Counctl. You will be provided with a lO'Opy of that report and recomMendation.
THE FINAL DEClSION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL NO EMPLOYEE
OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY RI;PRE$ENTATION TO
YOU AS TO WHETHER YOUR CLAIM WIU OR WILL NOT BE PAID.
1. Harne of Claimant: McDermott Excavating
2. AddrelSS: 14407 Hwy 20 West Dubuque. Iowa
3. Telephone Number: 563-583-4633
4. D"te oflncident; 04-16-06
5. Time of Incldeht: A M
52003-9709
6. Location oflncldam (8e ~mc): St. Joseph Street
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (GIWI
full detefllil upon whiOh yOu baoe your claIm. If.. Cny llmployaMl was Involved, give the
employee's name.}
Water Department did not locate main properly.
8. What were weather lO'ondltlons like? Sunny
9. Give namel and address of eny witnes....", McDermott employees -
Larry McDermott - Water Department employees
10. Olef police inve$tigate? Of 80, give nemes of offioel'$.)
No
, 1. Was anyone Inlured? (If so, give names, addrelO~et:;. and ext()l\t of InJUria,).
No
FROM : MCDERMOTT EYCRVAT ING
Q"J19/3006 FRI 08:56 FAX
FAX NO. '5635835858
May. 23 2006 01:08PM P2
~OO~/OO~
12. Was any damage done to property? (If 110, describe properly IInd the extent of damages.
Attach estimates of damalles or describe tIllSls for ascertaining IllItent of dllm~.)
Concrete street was removed and replaced unnecessarily.
13. Whet other clamagec do you claim, if any?
Several hours of machine and labor time
14. Haw you been compensated 10r any part or all of your claim by IIny insurance
company? (It so, Qive name and addres:s of !naU'lInell company and amount paid.)
No
11i. What amount do YOIl claim from the CItV of DUbUque?
$ 3000.00
16. Why do you claim the City of Dubuq_ls reeponsllillll?
Water main was not properly located.
17. Have you made any claim allllinst anyone el:se for damages ElS a result 01 this incident'!'
(tf YIIS. gIve name IInd addre8S.)
No
18. If t'he answer to QUGliti0fl17 is yes, have you reGelved any payment frllm that source,
and il so, in what amount?
Dated .t DubUque, Iowa thIs
23
day of
, May
.20~.
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" ~klnalul'll)
Larrv E. McDermott
(Print Name)
, (Rev. 1/00 & 7101)