Claim Tully, David & JudithCLAIM 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: David & Judith Tully
2. Address:
`
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific):
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.)
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
13. What other damages do you claim, if any?
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.)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
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 day of , 20 .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Claim Ponn
Page 1 of2
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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 ciaim 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.
4. Date of Incident:
The final decision on all clams 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: DR II I n "Ii.:\ U\C'~ ; + k -clJ '(;"
2. Address: ~ ~ 9 ~ Rr'{)() ), N r' ) 1/)\0 SlY'
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""_ e ephone Number: _ ~ t' ~ ~
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5. Time of Incident:
6. Location of Incident (Be specific): ,)1' {"< ~ T f''>Q + w" e i\ J) c., P y. C.
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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 employeels name.)
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9. Give name and address of any witnesses:
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8. What were weather conditions like?
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10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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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.)
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13. What other damages do you claim, if any? [\( n,.,-<
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Page 2 of2
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14. Have you been compensated lor any part or all 01 your claim by any insurance company? (II so, give
name and address of insurance company and amount paid.)
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15. What amount do you claim lrom the City 01 Dubuque? l4+t A J. -'" .\J
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16. Why do you claim the City 01 Dubuque is responsible? C",II<!.<~ 1,1,.)0 ~ tfO){,~
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17. Have you made any claim against anyone else lor damages as a result 01 this incident? (II yes, give name
and address.)
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18. II the answer to Question 17 is yes, have you received any payment from that source, and il so, in what
amount?
Dated this
day 01
,20_.
(Print Name)
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file://C:\Documents and Settings\David Tully\Local Settings\Temporary Internet Files\Co... 08/31/2006
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Left work (DGP&C) at 3:10am.
Took 16th Sl. to Elm
Elm to 17th
17th to Locust
Locust to Asbury
Asbury to home
Date:
Estimate 10:
Estimate Version:
Preliminary
Profile 10:
Lenny Valentine & Sons, Inc.
923 Peru Rd. Dubuque, IA 52001
(563) 588-4659
Fax: (563) 588-4650
TWO CONTINENTAL FRAME MACHINES
GENESIS II COMPUTERISED MEASURING SYSTEM
PRICE IS EASY TO BEAT/QUALITY IS NOT
UNIBODY SPECIALISTS
Damage Assessed By: DICK VALENTINE
Deductible: UNKNOWN
Owner DAVE TULLY
Address: 3299 BROOK HOLLOW DR ASBURY, IA 52002
Telephone: Home Phone: (563) 588-41153
Mitchell Service: 912494
Description: 2003 Buick Century Custom
Body Style: 40 Sed Drive Train: 3.1L Inj 6 CyI4A FWD
VIN: 2G4WS52J031203935
Options: ALUM/ALLOY WHEELS, AIR CONDmONING, POWER STEERING, POWER WINDOWS
POWER DOOR LOCKS, TILT STEERING WHEEL, CRUISE CONTROL, ELECTRIC DEFOGGER
AUTOMATIC TRANSMISSION, AM-FM STEREO/CDPLAYER(SINGLE)
Line Entry Labor
Item Number Type
1 900500 BOY'
2 AUTO
Une ttem
Description
RUB OUT LEFT SIDE YELLOW PAINT
SHOP MATERIALS
Part Type!
Part Number
Existing
Operation
REPAIR
ADD'L COST
. - Judgement Item
ESTIMATE RECALL NUMBER: 8/311200615:21:53 6717
Ultra_Is a Trademark of MlIchelllntemational
Mitchell Data Version: AUG_06-" Copyright (C) 1994 - 2003 Mltchelllntemational
UItra_ Version: 5.0.215 All Rights Reserved
8/31/2006 03:21 PM
6717
o
Mitchell
Dollar Labor
Amount Units
6.0"
15.00'
Page 1 of 2
Date:
Estimate 10:
Estimate Version:
Preliminary
Profile 10:
8131/2006 03:21 PM
6717
o
Mitchell
Add'l
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary
-
Body 6.0 50.00 0.00 0.00 300.00 T
Total Replacement Parts Amount
Taxable Labor 300.00
Labor Tax @ 7.000 % 21.00
Labor Summary 6.0 321.00
III. Additional Costs Amount IV. Adjusbnents
Non-Taxable Costs 15.00 Customer Responsibility
TotelAddmonalCo~ 15.00
Amount
0.00
Amount
0.00
I.
II.
III.
Total Labor.
Totel Replacement Parts:
Total Addmonal Costs:
Gross Total:
321.00
0.00
15.00
336.00
IV.
Total Adjusbnents:
Net Total:
0.00
336.00
This is a preliminary estimate.
Additional chanQes to the estimate mav be required for the actual repair.
ESTIMATE RECALL NUMBER: 81311200615:21:53 6717
UItraMate is " Trademark of Mitchell Intematlonal
Mitchell Date Version: AUG_06_A Copyright (c::) 1994 - 2003 MItcheJJ International
UItraMate Version: 5.0.215 All Rights Reserved
Page 2 of 2