Claim, Pickel, Gerald F.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: Gerald T. Pickel
2. Address: 2800 Oak Crst Dr., Dubuque, IA 52001
`
3. Telephone Number: 563 582 3506
4. Date of Incident: June 30, 06
5. Time of Incident: 4:30 P.M.
6. Location of Incident (Be specific): Family room, laundry room and garage in basement.
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.)
Water main break and sewer backup full of mud.
8. What were weather conditions like?
Beautiful sunny day.
9. Give name and address of any witnesses:
The whole neighborhood, 2 City employees took pictures and advised us. John Klostermann
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.)
Mud from laundry drain and garage drain filled our family room, i.e. under our steps, furnace, water/dryer
and etc. See attached form.
13. What other damages do you claim, if any?
See attached statement
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.)
Westfield Group ,6005 Rockwell Dr., NE Ste. A., Cedar Rapids, IA 52402-7240 $5000
15. What amount do you claim from the City of Dubuque?
$ 965.00 see enclosed statement
$1174. - Total: $2139.00
16. Why do you claim the City of Dubuque is responsible?
We have lived here 48 years and never had mud come out of our drain.
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 31st day of July, 2006.
/s/ Gerald F. PIckel
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
!A,sf' 1& (c ,;11 t;~
8().1/1
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA !/~'f.-n~"
This written report constitutes your claim against the City of Dubuque, Iowa. You 2;11C/
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.
1. Name of Claimant:. ~ rG ~>>
2. Address: 02;-60 cU-/ ~ A'-. ~~~. ";:j~-< 00/
3. Telephone Number -S-C: .2 - ~J",J_ ...j ~O c:,
4. Date of Incident: ""~a_~...30 - <1 ?
/'
5. Time of Incident: l -;L; .:3 (1 ~ /it
"'
6. Location of Incident (Be spee<ific):
c.! (f.. ,,'" L<.' .' to -c n); .,l...r<', ,'-C<!~ -i-~-<'..;v 6,,<..) 1.~ 'iV-:l.iU
~ ,:,) J-'-4'~ ./-n..Jl ~ /1'- :/;/
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.) !
j-~'~-lm,-c~ ,~t,~c" L. 'i~-u L,,~
!
L;
.,(~(' Jd<.1, /ui
,; I
8. What were weather conditions like?
",)L<'A u+;LO CJJLcr<r'i" ~
9. Gj',@ name and address of any liVitnesses: ,
LA,?, ,-<- ,,/z...c_LL .--;?'2.J/ --'--;{t.~.l-{;-C c'l...
~ .1' 'n . I I J
1.-. /:J..cd:i, lr.v ,.~ ,,-,, ~".... --'oW..', Ju....f"....)
10. Did police investigate? (If so, give names of officers.)
_1\0
"
...R 'r< ~1f.i'LJ
.",.. ~~.v .
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
-1 Q
-
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:.~"
_'L_.',-, '- #-.:;1-
/
'6l. ~u.i..j
Ihjn/ .' ~_
< ,
-<"J ~
13. Wha~ other da[l1ages do you claim, if any?
..-1.>/ CfL4.x:t.. ^ "" ,:I:::d;: .~y-^
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
arnou~t a'.) ~. n ~ j d II 1\
. f.O:,J u.L..o-. ~ _ Ii q (! .~\.Jr::.1-€:. hA.~J./~ ' e.
-:tJj_ _ ~_A.A..J ,~_..s.~$L(J.,)..-7...1..-W
.,. ~ ..... I'
,~60V
15. ~hat am~~~t do you c1aim,from the City of DUbuq~e? .
i (~~..~ .'" u' ,.. ,t " ~ c' A l~;; ;"0< fd;P
-~'-71-'-
1?, ~hY d~ you clai. ity of 0 bU~ is ~7,onsible? ~ ~ ~Q.
(l...v'-.....6l.J"""ZU'
17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
~Cl
"
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
..DW;~L7
c-- (Signature) ,
, 20Cc:.; "
,-
'c'
'J
06.P Ai p
(Print Name)
r
2c.KFL
\
c:IlJ;;fYl4J ?'Lf'--k.. _I-;y1_{>jL.,J.z".~ I-;"J
~I .
'-<'7'~_~.JU ~~..~.
-, ~ ~-"
" . (/ ,
!.. t' (J --
./ ..:zS'. .'L';':"
, .
,)6 d ~
~ i. , "ff d. t:( (^ ,_ J ,., ".;
. .. -.0-', C --\ J~ H '\.
"~ - (. 6/ "'i j , ;- Y'
/ &<!rJ. J ~ -+ ,: .1 / ....-t-..
, ;p "j" " <'.( ( ''-: .... _I'u ..' t.,' " r &t-f-,<-cL<'".J
(7;';..{ a+ h',,-~ J<'L~~
.-y~ ,~~ ~ ~.,J~
r (4J ::fc- __L '-~~-t-nL.)..)
d-d-~7'"'( ~t-fLA~"
q J L<)!..Y
'../"'
()",/ CJd?/
,.' ~~/ "/J-
:J. i?'<P <, O,,~
...:,.:.:.."
'~'I"'..,
".' ......
. ...
WESTFIELD
INSURANCE
A member of Westfield Groups"
July 19, 2006
GERALD F PICKEL
and ROSEMARY PICKEL
2800 OAK CREST DR
DU8UQUE IA 52001-0924
Re: Insured:
Claim No.:
Date of Loss:
GERALD F PICKEL and ROSEMARY PICKEL
NR-WNP-7272767-063006-A
June 30, 2006
Dear GERALD F PICKEL:
Please sign the enclosed Proof of Loss aRB the H.tomont 35 Lv I~ll Cnt gf
R~p,ir nr Repl,remeRt ~n the presence of a Notary Public and return them to us.
The Proof of Loss verifies your claim and the amount of payment you will
receive for your damages. fflt Statement ., to F~ll Co,t of ROD"ir nr
R...,laeement li,t, aRe vCfifics tRg roploromont Co,+ cQ"erage tRat applies to
)6tll cldim.
Yours truly,
We will send you a check for the agreed amount once we have received the signed
and notarized forms. If you have any questions concerning your claim or our
requests, please call me at (319)393-1032. Thank you.
Tlfe C f f .f)J.~7'4e k) .
?flte fk~ )/q ~/ /, 7 4f-1d :rAe, v
;YJSur4VJC'i! eQ.rr;er S'Jco...../d},-4?
e.... ;/ ,''''-7 Y.&I.-( rd> h}e... ~q; rC ;;---
rite I as r It.:;) 4J c.. A..c:( U~ ;<l ;:, ;--
Replacement (CO 216) fCf'd for Y.i!>v{.
Proof of Loss (CD 193)
Statement of Repair and
Self-addressed envelope
~H~~~~
Claims Manager
Enclosure -
6005 Rockwell Drive N.E., Suite A
Cedar Rapids. IA 52402 (319) 393-1032 or 1-8(X)-243-0239
FAX (319) 393-4293 www.westfieldgrp.com
CD 822 (Rev. 11-89)
Estimate
File No.
EAS07409
Insured
Gerald and Rosemary Pickel
Loss Address
Eastern Iowa Claims
P.O.Box 5
Bellevue, IA 52031
Office: (563) 872-3477
Report
First
Claim No. WNP 7272767
Adjuster
Phil Paxson
Policy No.
WPN 7272767
Home
(563) 582-3506
FAX
FM
Contact
::J'Mt-------
Office
Address
2800 Oak Crest
Dubuque. IA 52001
2800 Oak Crest
Dubuque, IA 52001
Address
F",:.,x--
Sewer Back up Lim;t: $5,000.00 Deduct;'.'" ,250.00
Main Room
Floor 0 SY Wall 0 SF Ceiling 0 SF Floor Perim. 0 FT Ceiling Perim. 0 FT
Room.standard Length 0.00 FT, Width 0.00 FT, Height 0.00 FT
Addr~ss
Operation
Clean
Treat
Charge
Remove
Replace
Remove
Replace
Replace
Remove
Replace
Fee
Qty Unit
580 SF
580 SF
580 SF
580 SF
649.6 SF
580 SF
580 SF
13 EA
32 SF
35.84 SF
4 Hrs
Description
Flooring, tile
Germicide and mildewcide treatment
Extract water from carpet
Wet carpet and pad
Carpet
Carpet pad
Carpet pad
Carpet installation on stairs, per step
Tile floor, Vinyl
Tile floor, Vinyl
Contents manipulation
Cost RC DE? ACV
0.25 145.00 0.00 145.00
0.15 87.00 0.00 87.00
0.26 150.80 0.00 150.80
0.49 284.20 0.00 284.20
3.09 2,007.26 501.82 1,505.44
0.07 40.60 10.15 30.45
0.59 342.20 85.55 256.65
6.10 79.30 19.82 59.48
0.47 15.04 2.26 12.78
3.58 128.31 19.25 109.06
26.00 104.00 0.00 104.00
3.383.71 638.85 2.744.86
Main Room Totals:
Bath/Laundry
Floor 0 SY Wall 0 SF Ceiling 0 SF Floor Perim. 0 FT Ceiling Perim. 0 FT
Room.standard Length 0.00 FT, Width 0.00 FT, Height 0.00 FT
Operation
Clean
Treat
;,,<.:moli.;
Replace
Fee
Qty Unit
56.4 SF
5e.4 SF
56.4 "F
63.17 SF
8 Hrs
-
Description
Flooring, tile
Germicide and mildewcide treatment
Cost
0.25
0.15
RC
14.10
8.46
26.51
226.15
208.00
DE?
0.00
0.00
ACV
14.10
S.46
Tile rieur. \- :n:/
Tile floor, Vinyl
Contents manipulation
J.4~
:'.9C
:::.5._
3.58
26.00
33.92
0.00
192.23
208.00
445.32
Bath/Laundry Totals:
483.22
37.90
Garage
Floor 0 SY Wall 0 SF Ceillng 0 SF Floor Perim. 0 FT Ceiling Perim. 0 FT
Room-standard Length 0.00 FT, Width 0.00 FT, Height 0.00 FT
Operation
Clean
ACV
92.00
Qty Unit
368 SF
Description
Flooring, concrete
Cost
0.25
RC
92.00
Created using Power(;:alm lTM1. 1-800.736.1246
DE?
0.00
Page 1
Estimate
File No
EAS07409
Treat
Fee
368 SF
8 Hrs
Policy No.
WPN 7272767
Germicide and mildewcide treatment
Contents manipulation
Report
First
Claim No. WNP 7272767
Adjuster
Phil Paxson
0.00
0.00
55.20
208.00
Garage Totals:
355.20
355.20
0.00
General
Operation
Qty Unit
k:V
Rent
4 day
Rent
16 day
Fee
Fee
Fee
1 EA
1 EA
48 Hrs
Oescdption
Dehumidifiers, Large
Note: 1 unit, 4 days
Drying fan
Note: 7 units, 4 days
Emergency Service Call
Debris removal
General clean up
Cost
RC DE?
500.00 0.00
400.00 0.00
140.40 0.00
125.00 0.00
480.00 0.00
1,645.40 0.00
NR DE?
0.00
0.00
0.00
0.00
0.00
0.00
125.00
25.00
140.40
125.00
10.00
General Totals;
500.00
400.00
140.40
125.00
480.00
1,645.40
Sewer Back up Loss:
Subtotal
Overhead
Profit
Tax
RC
5,867.53
28.42
28.42
250.02
6,174.39
R DEP
676.75
0.00
0.00
43.67
720.42
ACV
5,190.78
28.42
28.42
206.35
5,453.97
T olal.:
6,174.39
720.42
Maximum Recoverable Depreciation
Total Loss
less Deductible Applied
Less participation by the Insured
Total Claim
ACV Claim
5,453.97
720.42
6,174.39
250.00
924.39
5,000.00
5,000.00
Creale<luSH'lg POWl!rC:alm \TMll-eOO-136-1246
Page 2: