Claim for Miller..,
`~
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. 13~' 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: /7 A ~ D 1. 7~ O - /~/ ~ L e/~
2. Address: 30 / moo, ~l. Go NA .~~" ~~d u~ ~~t ~A . S-? ao l
3. Telephone Number: .r~ ~ - .J ~Z -' J J ~a.
4. Date of Incident: ~L ~eM h 2 /2 ~7 ~ ovG
5. Time of Incident: API' R oX % //1.?~e L, ~/ /o~ ; {.~ P/Y/
6. Location of Incident (Be specific): ~N7`~/Z -~ eC T'/onl O F p~ ~i/yJ _~t,pc<T
/~ I~l D C ~ ti_ V e ~ /~N a /'~ ~e ,
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.)
~~ CA Se .S~e /~ ftf~rr {//~'f 2N*'
R_ What were weather conditions like? ~~ /, r° R R /-?N D ~/v~ d
I/eRvN ,J. MiG~LeK -m'1 r,~rF"e~~t /n¢
9. Give name and address of any witnesses: ~'1 ~ R / ~. ti J/ $AL[. ~ ~ ~ T3kft D key ('A~ . -
s~ePNan're 1<.~'-t~,g7'z %~~tc~ne-t3celle't So~~psa~<eAve; /~t,~r~eAAot.,s,
rlntS.S"~{®~-aoty /-Gla-,~7G-/8/6 An!>a 7'wu of.v~k oecuP~~vt~ /M Neri; Can.
10. Did police investigate? (If so, give names of officers.) ~®
11. Was anyone injured? (If so, give names, addresses, and extent of injure` ~).
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.)
7Ne ~er+/4 ~~uMPe~ oK !~I ti C'~~'s SNczL ~~as ~R~aeKe~ ~Nb
'Uc,vteD- ~S~rM~7`~- F,~arr !~1,~'D ~~/ey,C~~e~ ~it~~L'Xea,
13. What other dams es do you claim, if any? s- ~ you L~,~ ~e 7'0 ~o i+t Pe.vsA f~ Me Fa,~
'~f~e s¢'RCss~ ~NeonrJl~~v~2 ,g,v/j 7~Me .~ SPeNT C.9 useD by 7"Nls iN~jDN//t
S yP 7"® `THP C~~ty.
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.)
,/ Y®
15. What amount do you claim from the City of Dubuque? ~~ b ~•-~-
16. Why do you claim the City of Dubuque is responsible? ~He TRUCK 7`if/tt CRU S e D TNT
. N~~bcNT io~rs l~ Ce7"y oF~yhuycr~-7R~C((/'~~tve,v by ,
~ lqw !le Sf{oul.'D ft~R/e- ~-l-o ppGD 7'o Gtvc Y"Nc 2~GtP1oFWA~
yp2dc eSSla.v t3k~t' !/c DiaN`t-o
~i7"y~nlP~oy~C•
4 T~Je F'v a ea ~ ~-
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) ~Be
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount? i1/o.T. ~~~~~ ~ ~ 61, ~
Dated at Dubuque, Iowa this gYN day of ~~ N u R R ~ 20~.
_ ~~ ~~~
(Signature
/l~,~m ~.a o, l~%~ 1, e ~c
(Print Name)
(Rev. 1/00 & 7/01)
..
A
ATTACHMENT
CLAIM AGAINST THE CITY OF DUBUQUE, IA.
HAROLD O. MILLER - 301 NORTH ALGONA ST. - DUBUQUE, IA.
~. We were in a funeral procession leaving St.Columbkille Church. The
procession went east on Rush Street to Plum Street, turning left onto
Plum Street to Cleveland Avenue. The procession turned left onto
Cleveland. All cars in the procession had headlights on and funeral
procession flags visible. I was following the car ahead of me turning
left onto Cleveland. I noticed a City Park Department trash truck coming
from the right (East) on Cleveland. I presumed he would stop to give
the right of way to the Funeral. He did not stop as he should have.
I blew my horn and put the brakes on quickly. He continued following
the car ahead of me. The lady driving behind me in the procession tried
to stop but hit my rear bumper causing $604.83 damage. We could not
get out of the cars at that time so I followed after the truck passed.
If I had not stopped by being alert, we could have been hit broadside
causing thousands of dollars damage and possibly bodily injury to the
occupants in my car. I caught up to the truck and blew my horn a few
times. He finally pulled to the right curb and stopped until the rest
of the procession passed.
When we arrived at Linwood Cemetery, we checked the damages to
my car. The lady driving the car that hit me gave me her business card
- Stephanie K. Statz of Minneapolis, MN, a niece of the lady whose
funeral we were attending.
On December 28, 2006 I called the Sanitation Dept. and Paul Schultz
advised me to call the Park and Leisure Service Dept. I called that
department and talked to Bob Fritch. We talked about the incident and
I said he should talk to Gil Spence. He talked to Gil, and Bob called
me on Friday, December 29, 2006 and said that I should file a claim
with the City. They verified that they knew who was driving the truck
and that he was in that area. He did not give me the name of the driver.
BIRD CHEVROLET
3256 UNNERSITY AVE DUBUQUE, IA 62001
(583) 5033121
Fax: (563) 5564482
Damage Assessed By: KEN JAEGER
Deductible: UNKNOWN
Insured: HAROLD O MILLER
Address: 301 NORTH ALGONA DUBUQUE, IA 52001
Telephone: Home Phone: (663) 682-7742
Mitchell Service: 810565
Description: 2006 Chevrolet MnpaW LT
Date: 12Yt8/2006 02:17 PM
Estimate ID: 3256
Estimate Verson: O
Prelkrw~ary
Profile ID: Mitchell
Body StyM: 4D Sed Omre Train: 3.5L Inj 6 CyI4A FWD
VIN: ZG1Wi66K069S{2627
Options: ALUM/ALLOY WHEELS, AIR CONDRKINING, POWER STEERWG, POWER WINDOWS
POWER DOOR LOCKS, TILT STEERING WHEEL, CRUISE CONTROL, ELECTRIC DEFOGGER
AU70MATK: TRANSMISSION, AM-FM STEREO/CDPLAYER(SINGLE)
Line Entry Labor Line ttem Part Type! Dollar Latror
Item Number Type Operation Description Part Number Anaunt Units
1 002272 BDY OVERHAUL REAR BUMPER ASSY p,y #
2 001841 BDY REPAIR REAR BUMPER COVER Existing 3.0'#
3 AUTO .REF REFINISH REAR BUMPER COVER C 2.6
4 AUTO REF ADD! OPR CLEAR COAT 1,0
6 AUTO ADDL COST PAINT/MATERULLS 111.60'
6 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 3.60'
" -Judgement Rem
# -Labor Note Applies
C -Included in Clear Coat Calc
Add'1
Labor Sublet
I. Labor Subtotals Units Rale Amount Amount TMals 11. Part RepWcemerrt Summary Amount
Body 5.2 52.00 0.00 0.00 270A0 T
Refinish 3.6 52.00 0.00 0.00 187.20 T Total Replamnent Parts Amount 0.00
Taxable Labor 457,60
Labor Tax ~ 7.OOD % 32.03
Labor Summary 8.8 488.63
ttl. Addiional Costs Amount N. Adjustments Amount
Non-Tazable COSts 115.20 Customer Responsib8ity 0.00
Total Additional Costs 115.20
ESTIMATE RECALL NUMBER: 12126!2006 14:16:08 3266
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30/ nG..~-~G~~'~ S I
Dale: 12/28/2006 02:77 PM
Estimate ID: 3256
Estimate Version: 0
Prel'arcnary
Profile ID: Mitchell
1. Total Labor: 489.07
11. Total Replacement Parts: 0.00
III. Total Additional Costs: 176.20
Gross Total: 604.83
IV. Total Adjustments: 0.00
Net Total: 604.87
This is a Dreliminarv estimate.
Additional chances to the estimate may be required for the actual reoair.
ESTIMATE RECALL NUMBER: 72Y18/2006 14:16:08 7266
URraMate is a Trademark of Mitchell tmemationat
Mitchell Dafa Version; DEC_06_A Copyright (C) 1894 - 2007 Mitche8 International Page 2 of 2
UBraMale Version: 6.0.216 All Rights Reserved