Claim Wagner, Robert L.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:
2. Address:
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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)
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
e)ltent of damage.)
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13. What other damages do you claim, if any?
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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.)
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15. What amount do you claim from the City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible? .
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17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
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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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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?
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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.)
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15. What amount do you claim from the City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible? .
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17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
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18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
Dated this 31
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This explanation of the incident and events which followed will be explained
in the sequence in which they occurred and should answer the questions in
the form for the claim against the City of Dubuque, Iowa.
On July 12 and 13 of2005, St Celia Street was resurfaced. During this
process our house got splattered with tar. This splattering happened either
when they were spraying the overlay on the street, or most likely when the
equipment was parked overnight on the dead end side street of Westway St.
which is 20 feet from my house which is on the comer of St. Celia and
Westway Street. It could have happened over night, or when an employee
was cleaning up after the day. There were employees there, of course, but I
doubt if they knew the incident occurred. The wind could have blown it on
the house; there could have been a leaky valve on one of the sprayers or
there could have been any numbers of ways the tar could have been deposited
there. One thing is for sure. It is tar splatters, and the above explanations are
the only possible way it could have gotten where it is or come from.
I always do major housecleaning, inside and out every fall and spring, and I
would have discovered this in the fall of2005, but I didn't get to it in 2005
because I have had 2 major back surgeries and in the fall of2005, my back
would not allow it. So I intended to do it all in the spring of 2006, but my
wife was diagnosed with cancer in March of 2006 and had major cancer
surgery in April of 2006, so of course this consumed all of our time until
September of 2006 when I finally got around to my outside house cleaning
when this tar splattering was discovered. So then I phoned Street
Maintenance Supervisor John Klostermann. He looked at it and took some
photos, but he couldn't say precisely how the tar got there. So I phoned City
Council member Ric Jones who observed the damage and advised me to go
through the Claim Procedure, and "shouldn't have a problem" because it is a
legitimate claim. I also phoned City Council member Karla Braag, but did
not receive a return call.
So, having worked at John Deere for 34 years as a machinist and dealing with
all sorts of spills, smudges, etc etc, and a home owner for 46 years, I thought
this would be a relatively easy cleanup with some sort of cleaning agent. I
phoned Servicemaster cleaning specialists and they gave me an estimate (enc)
and came to the house, tried a few things, and told me they could not get it
off. I then phoned Kanndo cleaning service and they gave me an estimate of
$396. They sent up 2 men who worked on the side of the house for 3 hours
and they couldn't get it all off either. So, by then, I thought I would give it a
try. I used the materials: GOO GONE, OOPS, MINERAL SPIRITS, GAS,
LIGHTER FLUID AND WILL-BOND. A couple of the cleaning agents will
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'SetviceMASTERo.
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CUSTOMIZED WALL CLEANING ESTIMATE
Customer's Name h()l0 Wo~ l'\e'C
Today's Date If) -1/ - a
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OUR GOAL, , . Is to provide you with the BEST possible service for the most reasonable price.
Areas to be serviced:
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DEGREE OF SOILING:
o Light overall soiling.
l'tJ Moderate overall soiling.
o Heavy overall soiling.
TYPE OF SURFACE:
)Xl Washable.
o Dry treatable.
o Hypersensitive.
FURNITURE MOVED BY:
o ServiceMaster.
o Customer.
~ No furniture to be moved.
Notes:
CLEANING SPECIFICATIONS, , , ServiceMaster is committed to and has worked closely with
manufacturers to develop these cleaning procedures to correctly clean your walls:
BrushIVacuum
Dry Sponge
PRE CLEANING STEPS:
o Dust, brush or vacuum clean
to remove loose soil particles.
o Treat to remove attached loose
soil using a dry cleaning
sponge.
!Xl Pre-treat spots and stains.
Pre-treat Spots
Wash
Rinse
DrylBuff
CLEANING STEPS:
~ Apply cleaning solution to
emulsify and remove soil,
using gentle mechanical action.
o Rinse to remove heavy soil and
detergent residues.
o Acid-treat and rinse surfaces
having conditions that are best
treated by acid-based cleaning
agents.
POST CLEANING STEPS:
iXJ Post-treat spots and stains.
o Dry!buff using adsorption
pads to allow for a uniform,
bright, non-streaked
appearance.
ORe-oil, seal, or apply other
protective treatments to
natural wood surfaces.
~ Inspect all areas.
ServiceMaster Satisfaction
GUARANTEE
. .
THE COST. . . To provide you with the best possible service for the most reasonable price:
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Tax: Total: #',So 7. ()
Preventive Maintenance:
We Have Time On:
Mon. - Tues.- W ed.- Thurs.-Fri. -Sat.
Job Scheduled:
Method of Payment:
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D Check
Date:
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ServiceMaster Approval
AUTHORIZATION:
Customer Approval
FOR ADDED VALUE. . . Purchasing more than one service, more than once a year means your furnishings
will look cleaner, longer. Protect your investment with value-added services from ServiceMaster.
D Carpet cleaning
D Furniture cleaning
D Soil protection treatment
~ Windows ana mirrors
D Woodwork and cabinets
D Floors
D Kitchen and bathrooms
D ather
I ,onow-up 'ER,"CE,
48 hours
3 to 4 months
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YOUR SATISFACTION IS IMPORTANT TO US:
Our objective is your complete satisfaction, so you can recommend ServiceMaster with confidence to
others! Thank you.
SPECIAL NOTES:
@ 1990, The ServiceMaster Compan}', L.P.
Form #69151
TOP LINE
HOME IMPROVEMENTS
Administrative Offices
Phone: (563) 773-8261 . 1-800-728-7956 . Fex: (563) 773-8406
P. O. Box 44 . St. Donatu81 Iowa 52071
, hereby
sells and,
(Name and Business address of SELLER. herein after referred to as SE
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purchases from SELLER the following described GOODS AND SERVICES:
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WE PROPOSE to furnish labor and material ~ compl~te in accordance with above specifications, and subject to conditions found
on this agreement, to be delivered and installed at:
Home Phone: 5& 3
~S-& -~d-3.d--
Work Phone:
Total Contract Price $
Down Payment Ooa::;.~Mls:w:.81C:C::::- $
Due Upon Completion Windows $
Due U on Com letion Sidin $
Due Upon Completion Gutters $
Directions to Customers House:
YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO
MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS
TRANSACTION: SEE ATTACHED NOTICE OF CANCELLATION FORM FOR AN
EXPLANATION OF THIS RIGHT.
ACCEPTED: The above prices, specifications and conditions are satisfactory and are
hereby accepted. You are authorized to do the work as specified. Payment will be made as
outlined above.
BY: , ~
Sales Representative
ID~5/Dh
Date
Date of Accaptanca
NOTICE
This proposal does not become a valid and binding
co.ntract unless signed, accepted and alroved by
~OMEIMPROVEMENTS. (
~c~l~r~~ ID ;?5jD(p
Signature also acknowledges receipt of NOTICE OF CANCELLATION Authonzed Signature, Topllne Home Improvements Date
All litigations, law suits and/or arbitrations from this contract will be governed by the laws of the State of Iowa.
White. Top Une Home Improvements Yellow. Customer Pink. Sales Representative
By
By
Tear Off
NOTICE OF CANCELLATION
(date of transaction)
You may cancel this transaction, without any penalty or obligation, within three business days from the above date.
If you cancel, any property traded In, any payments made by you under the contract or sale, and any negotiable Instruments executed