Claim Bellevue, CityCLAIM 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: City of Bellevue
2. Address: 106 N. 3rd St.
`
3. Telephone Number: 563 872 4456
4. Date of Incident: June 24, 2006
5. Time of Incident: Between 15:50 and 16:10
6. Location of Incident (Be specific):
Mercy Health Center Emergency Department Garage
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.)
Whilte the Bellevue ambulance was parked at the Mercy Ed Garage, a Dubuque Firefighter
opened a Cabinet containing Back Boards. A board fell out striking
the RF Fender of the Bellevue Ambulance, denting it.
Brian Bormann, Bellevue Attendant, witnessed the incident but did
not realize any damage occured until getting home and washing the vehicle off.
8. What were weather conditions like? (Indoors)
9. Give name and address of any witnesses:
Brian Bormann, 600 N. 7th St., Bellevue, IA 52031
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.)
Yes. 1996 Ford Ambulance - Dent on R Front Fender
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?
$213.32
16. Why do you claim the City of Dubuque is responsible?
Damage was caused by a Dubuque firefighter.
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?
N/A
Dated at Dubuque, Iowa this 3rd day of July, 2006. , 20 .
/s/ Max L. Reed, VP, Bellevue EMS
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
(r~ ' /
~~~A/J1
I
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA LrI/t1 t)~
/'/, '
/1'
L.,../ ,
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 West 13th St,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office, 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,
2. Address:
)t) b
Clr'1' OF ~Ej..LEVVE
N. :3 J<.!> 3'V:.
5b3 -87"J...- 44-Sb
JUAfE ,;(4- ) ;{IJb/a
,
6t:--'-tuEl:-jJ" 15 :'5,0 A-Af)) /b: J D
1. Name of Claimant:
3. Telephone Number
4, Date of Incident:
5, Time of Incident:
6. Location of Incident (Be specific):
/lI{ERCJt' flEJ4.L"nJ c!.EAfTl:1< E/YIEI?GcAfCY./JEJ>ARTWlrnJT
a41?~Gt;
7, Describe the 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,)
(SEE hTTA-CNt::-b StfcET.i___,.._
C')
8. What were weather~onditions like?
/0.1 ,'j) ~ /) 1(5 J
~ r
9. Give name and address e;f i}ny witnesses:
li R Ilul ~bJ( J'Y/4 AI)} , _
~('> AI. 7TH 5r.) BELl Ell /) 1::. / ft
r
., :
, i
,
--...-..;
l,
,J,- aD~ f
10. D~Olice investigate?'(lf so, give names of ;fficers,)
11. W anyone injured? (If so, give names, addresses, and extent of injuries).
o
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.)
'I ES, /'7'th FCJ1(/) A-MFg,L-AAfC6 - ,)))rA!T
ON R./c:./-fr J:RMlr FENllER ,
13. What other damages do you claim, if any?
NOA(c
14. Have you been compensated for any part or all of your claim byany
insurance company? (If so, give name and address of insurance company and
amount paid.)
Nt)
15. What amount do you claim from the City of Dubuque?
~J,~,32
16. Why do you claim the City of Dubuque is responsible?
d:>IfMA-C,g;:- IAJA <; <!:.~tJ:SE:D BtJ A IJo/.3.,UcPUt.
1=1 RE F Jc;;,.f1Tc R ,
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?
- AlA
31?b
Dated this - day of
~~~.
(Signature)
111 A X i..
(Print Name)
.,JU L L/
P~oQ
Vp)
,2otJb.
&LLEV.u b- t= /Ill 5
R Ir f::;7:J
A '6"4- CUe)) SHE!:;I
7. 0W/LE rifE BELLEVUE A-mMLJ4.AfCE. w4.s
PARKe)) AT Tl-fE MER.c.,l/ E]) ca4R4C;;E) IJ
J2A.; )~Q U E F 1 f(~ F I GN-rEI<. ,0 P EJJ cJ:> -4
(! 4 ~ uJ Ey ~ tJI...ITA- /J..J I AJ G ~ G t< J3 Z> It R. b 5 .
If B-04R.J> FELL 6>ur .5TR1KIAf0 Tl+E: R F
F E;J1>c--r<. ~F THE BbLLEVU/:;.- A-M.. B VLA^.rCE)
j)~pJTI NG II.
f3RI4-JJ /:;.Dk#t4Aid, ~6ZLEVUE ATTt.-JJbItAiT;
?z}),NE55&-b TI:f6 INCIDENT &r eVil)
NOI RE4L-1ZE 4N'-I a9A-M4G&;- oc-CvRR.c:~
UAfTIL ~e-TnAf0 !-Itn116 A-Af..D W45L-IIAf~
I/-JE Vcj.fICL~ OFF
.
TILL'S GARAGE, INC.
BELLEVUE, IOWA 52031 PHONE (563) 872-3350 FAX (563) 872-5780
BUICK - PONTIAC - CHEVROLET Email: tills@tillsauto.com
DAMAGE REPORT
PRICES SUBJECT TO CHANGE
Items CIRCLED are not in the total, in
our opinion, are not part of this claim.
V~:CLJ OWNER A.~.J...I.'.\.Lt..L ADDRESS ']j /I c o,J.; PHONE O~
e/eut...uL S.('~., U~. ((. e e V /..UL '-'-- ........ ,;) 7 c>("
t~RqL" ~V'd. E. MODEL LICENSE MILEAGE COLOR SERIAL NO. CONDITION
"3.:<>"0
INSURANCE CO ADJ USTER PHONE CAR LOCATED AT DEDUCTIBLE
FRONT Sublet ' Service $ LEFT Sublet Service $ RIGHT SUblet Service $
Srm. Or Paint Or Hours Parts 8ym. Or Paint Or Hours Parts Sym. Or Paint Or Hours Parts
Bumper WI Pads render, Frt. I -< Fender, frt. 1.1"> "'.0
Bumper Abs. Fender Shield Fender Shield
Fender Ext. Fender Exl.
Fender Mldg. Side Fender Mldg. Side
~ender Stripe 1"- Fender Stripe _ '2 I.~V':'. CO
Fender Mldg. Fel\der Mldg.
Bumper Reinf.
Bumper Brkt. Sid~ Light Asmbly Side Light Asmbly
Bumper Cushion Headlamp . Headlamp
Valance Headlamp Door Headlamp Dr.
Bumper Gd. Sealed Beam Sea led Beam
Frt. System Park Light Pa~k Lis:;ht
Frame Cowl Cowl
Cross Member Door, Front Door, Front
Wheel Door Hinge Door Hinge
Hub Cap Disc Door Panel Door Panel
Lr. Cont. Arm Door Stripe Door Stripe
Door Mldgs. Door Mldg.
Up. Cont. Arm
Ce:"lter Post Center Post
Door Rear Door Rear
Bumper Filler Door Mldg. Door Mldg.
Grille
Grille Panel
Grill Panel Mldg. Rocker Panel ROcker Panel
Rocker Midg. Rocker Mldg.
Floor Floor
Dog Leg Dog Leg
Quar. Panel Quar. Panel
Air Condenser Quar. Ext. Quar. Ext.
ReCharge System Quar. Wheel House Quar. Wheel Hou~
Name Plate Quar. Mldg. Side Quar. Mldg. Side
Baffle, Upper Quar. Mldg. Quar. Mldg.
Lock Plate, Lr. Quar. Stripe Quar. Stripe
Lock Plate, Lip. Side Ught Asmbly Side Light Asmbty
Hood Top Tail light Tail Light
Hood Hinge REAR MISC.
Hood Lock Bumper I nst. Panel
Orna ment Bumper Abs. Front Seat
Rad. Sup. Bumper Cushion Front Seat Adi.
Rad. Core Bumper Reinf. Top
Anti Freeze Bumper arkt. Headlining
Rad. Hoses Bumper Gd. Top Vinyl
Fan Blade Bumper Filler Tire
% Worn
Fan Shroud Valance I......
PaintinR
Fan Belt Lower Panel
Aerial
Water Pump Floor Rust Proof
Water Pump Pulley Trunk L.id Battery
Motor Mts. Trunk. Mldg.
Lie. Light PARTS (Prices Subject To Invoice) .::JS Ol)
SERVICES".f.ll HRS.@I./t.I"HR. I/~-;;I..o
Windshield Gas Tank SUBLET OR PAINTING [-;"'PA 3. u<>
Frame SUB TOTAL
Wheel TAX I Z ,'-
Hub & Drum PAINT.MATRL-HOW. d( >? Vi)
Axle
Spring
GRANO TOTAL L")/-2"'''
Appraiser
SymbOlS: A-Align N-New OP-Open P-Paint
S-Strai~hten R.Reolac:e OH_Ov..~k....l
x_
I HEREBY AUTHORIZE THE ABOVE REPAIRS
This Damage Report is based on our. inspection
an~ does not co....er. any additional parts or labor
;:,,!1~S~....~,'!.y be requited after the work has been
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