Claim First Supply LLC Jason CullumCLAIM 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: First Supply LLC
2. Address: 2400 Kerper Blvd.
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3. Telephone Number: 563 582 1895
4. Date of Incident: 9 29 06
5. Time of Incident: 7:30 A.M.
6. Location of Incident (Be specific): Roosevelt approx. 100 yards before
Peru Rd.
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.)
See attached
8. What were weather conditions like? 51 clear (no rain or snow)
9. Give name and address of any witnesses: Tim Hilvers
10. Did police investigate? (If so, give names of officers.)
Jason Hoerner Case #06-44021
11. Was anyone injured? (If so, give names, addresses,
and extent of injuries).
No personal injury
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.)
See attached
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.)
No
15. What amount do you claim from the City of Dubuque?
$772.80
16. Why do you claim the City of Dubuque is responsible?
City tree was not trimmed to allow for clearance.
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 11th day of October, 2006.
/s/ Jason K. Cullum, General Manager
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Claim Form
Page I of2
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This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this form in .Jf~-
full and attach any additional information that supports your claim.
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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 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: 1='\(5~ S\lf\llu, LLt.
2. Address ;/ '-\ D D v.u \If ~ so1iU1,
3. Telephone Number: C) (0 ~, c:; '1, J' \ ~ q C;
4. Date of Incident: q - ;) q - D (",
5. Time of Incident: 'I[ t, 3, 0 AM.
6. Location of Incident (Be specific): .~ OD'S f' AI-e 1. J,.
~~).... c 'i> {' Cl..l \A ri .
r\fra,C lex) "r.r<k
7. Describe the accident or occurrence that caused injury or damage. (Give full details upon whicih you base
your claim. If a City employee was involved, give the employeeOs name.)
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8. What were weather conditions like? . c::; I
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9. Give name and address of any witnesses:
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.)
S-e-e.. a.:t-t(J..( \"'-ed .
13. What other damages do you claim, if any?
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http://www .cityofdubuque.org/printer _friendly .cfm?PageID= 155
09/29/06
Claim Form
Page 2 of2
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?
Jt 7"7 J. g-C
16. Why do you claim the City of Dubuque is responsible? C. '\ .\-"'-\- r f' e. ~...:o... <:.
{in-t--\-\\ {Y\\Y'\E>'\ -Ii::> !H\ow ~6r df'D.J\Wf\c.e.....
17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name
and address.)
1\1 ()
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what
amount?
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09/29/06
FIRST SUPPLY
The Midwest's Premier Distributor I Since 1897
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#7
At approximately 7:30 am on 9-29-06 our First Supply LLC city delivery driver
was delivering a whirlpool- tub/shower unit. He was driving on Roosevelt;
approximately 100 yards before Peru Rd. The shower unit clipped low hanging tree.
Tree broke off and hit car that was driving behind our flat bed truck. Car owner Tim
Hilvers.
# 12
When measured with tub/shower unit on truck from ground up to top of unit
measures 10.5 feet, impact on unit occurred at 9.5 feet.
Our cost of tub/shower whirlpool unit is $772.80 per attached invoice * .
Damage to whirlpool- tub/shower unit
Top corner = piece broken off, with crack in unit running 1 foot vertical on unit.
Noticed damage to Tim Hilvers vehicle = Tim is filing his own claim.
Attached you will find page 1 of the police report we filed with Officer Jason Hoerner.
We were unable to obtain a copy of page 2 (the detail of the police report) the record
department at the Law enforcement center said it is considered "Investigative
information" and to obtain the second page we must have it subpoenaed -even though we
filed the report.
First Supply LlC I 2400 Kerper Blvd., PO Box 88. Dubuque, IA 52004-0088 I Phone: (563) 582-1895 Fax: (563) 582-0612
www.lsupply.com
RightFAX
9/19/2006 3:35:24 AM
AKER PLASTICS COMPANY INC.
2121 Walter Glaub Dr., Plymouth, Indiana, 46563, USA
Tel: 674.936.3B38 Fax: 674-941-5653
::!::::"!!~~i:;l!~i!~f:!:::::::!::::!::;!:::!::!::::!::~i!~:$:!:!:~~~~::!:!:!:
:::!!::i""'~I~~f'~!l-Gi~~:~!:!:!!::!t~:~~~::!':;:::ffi:i~:~~ii!!:!:!!::
2400 KERPER BOULEVARD
DUBUQUE IA 52001
. USA
'IPAGE 001/004
Fax Server
Invoice
No. 91241712
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Date 2006/09/18
p.o'l No. 5723505
P.O. Data 2005/09/08
Paoliing liot No. 81342793
Bill bf lading 357970- 1
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Freight terma FOB DESTINA nON
'Shipped by MAAX Carrier {Plymouth)
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Sale. agent CENTRAL SALES. INC
YoUI may deduct 198.07
If paid by 2006/1 0/1 0
paylnent term 2% 10 days, prox 30th
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of
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Item Material / Description aJantity Unit Price Extenaion Amount
I
0010 1141 000-L-000-002-00 1 ICM60LWH) 1 EA 606.00 605.00 212.10
CM-50 WHI LH
DISCOUNT I 58.00- % I 292.90-
0020 141 004-L-000-002.00 1 IGB60LWHI 2EA 553.00 1,106,00 464.52
GB-50 WHI LH
DISCOUNT I 58.0Q. % ) 641 .48.
.
0030 141004-R-00O-OO7-002 (GB60RBT) 2EA 563.00 1,106.00 464.52
GB-50 BISe RH
DISCOUNT I 68.DQ- % } 641.48-
0040 141042-000-002-003 (KDS32WH) lEA 562.00 662.00 236.04
KDS-32 ,WHI SEe
DISCOUNT I 68.00- % } 326.96-
..
0060 141 002.L-000-002-00 1 ISBW3360lWH) 3EA 680.00 1.740.00 730.80
SBW-3360 WHI LH
DISCOUNT I 58.00. % ) 1,009.20-
0060 141006-R-057-002-302 (SBW3672RWH BWSCHI lEA 1,840.00 1,840,00 772.80
SBW-3572 WHI RH BWS CHR TRIM .
DISCOUNT I 5a.OO- % } 1.067.20-
With the foUowing confIguration:
TRIM-KIT WHIRLPOOL COLORS POLISHED CHROM
0070 141 033-L-000-002-00 1 ISH.48) 4EA 539.00 2,156.00 905.62
SH-48 WHI LH SEAT
DISCOUNT I 58.00- % I 1.260.48.
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PLEASE REMIT TO THE FOLlQWlNG ADDRESS, MER PLASTICS COMPANY INC., Dept CH 10956. Pelatlne, IL. 60055-0956
10/04/2006 WED 13:45 FAX 5635873849
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