Claim for Lally.~ ~ /' /
CLAIM AGAINST THE CITY OF Di~BUQUE, 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 West 13t" 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: JU ~}nf L-~ %o'~ L.C.Y
2. Address: 4~~ ~i7~~ D:e ~f}sT ~uG~u4u~ ~G- ~10~5
3. Telephone Number ~ l 5 ~ ~{ ~ ~ ~nno1 `'~~~'
4. Date of Incident: ~~ U GG/S i /0 ,~6a
5. Time of Incident: 3 ; ~ O ~ M
6. Location of Incident (Be specific):
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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 employee's name.)
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9. Give name and address of any witnesses:
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THE Ct_A/M S/,c/cF TtlE ~~iPan/S/BLL~ ~~~'Sat/ ov;.FS N ~'/^ 7I 'fEl~+°MP<OYcE,
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10. Did police investigate? (If so, give names of officers.) Nam E ~~~ D r TN~~
i CJ MUV E Tj{E C~/L'T'S W l./~,(J T'NE rQc~i>~ CR2 ~rS GO'1- A/r'f1Y ~F
oownl 'r^N>= cu2~cu-r ~e/T'o /ri y cat Doo2 - PA~s~n/oe2 sryE.
8. What were weather conditions like?
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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.)
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13. What other damages do you claim, if any?
74. Have yeu been compensated for any part or al! 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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MOJ/NG- cR2Ts
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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Dated this ~_ day of p ~C~ n~ ~ ~ 2 , 20 a ~ .
~~~~
(Signs ure)
~/ A n~ c ~ L, R 1,~-- y
(Print Name)
C8/30/2006 at 01:26 PM
24943
' ABRA - DUBUQUE
F~,deral ID #:920782295
DBF: ANDERSON-WEBER INC
3400 CENTER GROVE DF
DUBUQUE, IA 52003
(563)5:6-0696 Fax: (563)556-1899
PRELIMINARY ESTIMATE
Written By: KEN GREEN #29493
Adjuster:
'Ensured: THOMAS LALLY C1 a.im #
Owner: THOMAS LALLY Policy #
Address: 1101 PRAIRIE DU CHIEN Deductible:
IOWA CITY, IA 52245 Date of Loss:
Day: (815)747-6295 Type of Loss:
Cellular: (563)599-1204 Point of Impact:
Inspect
l.~cation:
Job Number:
Insurance
t;ompany: Days to Repair
2001 TOYO CAMRY SOLARA SE 6-3.OL-FI 2D CPE DK BLUF Int:
VIN: 2T1CF22P91C 538382 Lic: 517 3898 IL Prod Date: 06/2001 Odometer:
A:'_r Conditioning Rear Defogger Tilt Wheel
Cruise Control IntFrmittent Wipers Body Side Moldings
Dual Mirrors Roof Console Fog Lamps
Clear Coat Paint Power Steering Power Brakes
Power Windows Power Locks Power Driver Seat
Power Mirrors AM Radio FM Radio
Stereo Cassette Search/Seek
CD Player Anti-Lock Brakes (9) Driver Air Bag
Passenger Air Bag 9 Wheel Disc Brakes Cloth Seats
Bucket Seats 5 Speed Transmission
------ Overdrive
NO. OP. ----------
DESCRIPTION
-- ------
QTY ----------------- ----
EXT. PRICE LABOR PAIN:'
1 -----------
DOOR --- -------------- - -------
2* Rpr RT Outer panel 0 0.00 1.5 2.0
3 Add for Clear Coat 0 0.00 0.0 0.8
9* A&I RT Body side mldg blue 0 0.00 0.5 O.G
5 R&I RT Mirror assy unheated beige 0 0.00 0.4 0.0
6 R&I RT Handle, .outside blue 0 0.00 0.5 0.0
7# Repl BAG / COVER CAR 1 10.00 0.0 0.0
8# Repl CORRISON PROTECTION 1 10.00 T 0.0 0.0
9# Subl HAZARDOUS WAS'iE DISPOSAL 1 4.00 T 0.0 0.0
Subtotals =_> -----------------
29.00 2.9 ----
2.8
1
,:
08/30/2006 at 01:26 PM
'?4943
Job Number:
PRELIMINARY ESTIMATE
2001 TOYO CAMRY SGLARA SE 6-3.OL-FI 2D CPE DK BLUE Int:
Parts 10.00
Body Labor 2.9 hrs @ $ 99.00/hr 142.10
Paint Labor 2.8 hrs @ $ 49.00/hr 137.20
Paint Supplies 2.8 hrs @ $ 30.00/hr 84.00
Sublet/Misc.
------------------
------ 14.00
SUBTOTAL --- --- --- -- ----------
$ --------
387.30
Sales Tax
------------------- $
------- 303. 30 @ 7.000Oo 21.23
GRAND TOTAL - ---- -- -- ----------
$ -------
908.53
ADJUSTMENTS:
Deductible 0.00
CUSTOMER PAY $ 0.00
INSCIRANCE PAY $ 408.53
WARRANTY VALID ONLY WITH ORIGIONAL COPY OF YOUR RECEIPT PARTS SUBJEC" TO
INVOICE NO GUARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED
Esrimate based on MOTOR CRASH ESTIMATING GUIDE. Unless of ~e rwise noted all items are de r.i ved
from the Guide ARM8513 Database Date 08/2006, CCC Data Date 08/2006, and the parts selected are -
OEM--parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available
at )E/Vehicle dealerships. OPT OEM (Optional OEM) parts are OEM parts that may be provided by or -
through alternate sources other than the OE/Vehicle dealershi-ps. OPT OEM parts may reflect some
specific, special, or unique pricing or discount. Asterisk (*) or Double Asterisk (**1
indicates that the parts and/or labor information provided by MOTOR may have been modified or
may have come from an alternate data source. Tilde sign (-) items indicate MOTOR Not-Included
Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described as AM,
Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts
are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned parts are described as
R=con. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are 'S
prc ,-ided by Natimiai Auto Glass Specifications. Labor operation times listed on the line with J'"^
the NAGS informa*_ion are MOTOR suggested labor operation times. NAGS labor operation times are
not included. Pound sign (#) items indicate manual entries. Some 2006 vehicles contain minor
changes from the previous year. For those vehicles, prior to receiving updated data from !.he
vehicle manufacturer, labor and parts data from the previous; year may be used. The Pathways
estimator has a complete list of applicable vehicles. Parts numbers and prices should be I
confirmed with the local deale r:~.~ip. ',
CCC Pathways - A product of CCC Information Services Inc.
2
. - .
Claims Management, Inc.
October 19, 2006
Nancy Lally
82 Ford Drive
East Dubuque, IL 61025
RE: Nancy Lally
File #: 5044483
Date of Loss: 08!10/2006
Store#: 2004
Dear Ms. Lally:
Claims Management, Inc. is the claims handler for Wal-Mart Stores Inc. and for their insurance carrier,
concerning customer incidents.
We have given your claim careful consideration, and according to our investigation, the incident was not
caused by any negligence of Wal-Mart Stores, Inc. We must therefore respectfully deny your claim for
damages. The city bus service, Key Line Transit ph# 563-589-4196.
If you have any questions regarding this matter, please feel free to contact me at 888-213-7534+62671.
Thank you for understanding.
Sincerely,
Donna Rose
Case Manager
Claims
Inc.
P. O. Box 1288 -Bentonville, AR - 72712-12F
CLAIMS MANAGEMENT, INC. (DBA) CLAIMS MANAGEMENT,
ARKANSAS CLAIMS MANAGEMENT, INC.
PHONE: (SS8) 213-7534• FAX: 479-204-9711
INC. OF ARKANSAS