Claim - Draper, David P.0CLAIM 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 P. Draper
2. Address: 2790 Sandhutton #2, Rockford IL 61109
3. Telephone Number: (H) 815 229 9504 (W) 847 747 3107
4. Date of Incident: 1/1/2002
5. Time of Incident: Approx. 4:00 P.M.
6. Location of Incident (Be specific): 3100 Block of Dodge St. Dubuque, IA
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.)
I was traveling west on the inside lane of U.S. Highway 20 (Dodge St.) in Dubuque. There was a fair amount of traffic. I came upon what appeared to be a large chunk of clay. I tried to avoid it, but had no time and I could not swerve to other lane. The chunk was concrete.
I called a tow truck - tire blew out right away - and called to Polilce to have them investigage and remove the other pieces of concrete. There was a trail of muddy tracks and debris. When I hit the chunk the tire immediately blew out and took a chunk right out of it. It also ruined the wheel. The officer that came out and was able
to trace it to a City of Dubuque truck that did not have the load secured, therefore, debris was falling out (See Police Report). I have saved the tire and whell if you want to see them.
8. What were weather conditions like?
Dry
9. Give name and address of any witnesses:
Gene Beenker, 2790 Sandhutton #2, Rockford, IL 61109 (passenger)
10. Did police investigate? (If so, give names of officers.)
Yes - Report filed - see attached - Strumaeger)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
Blew tire and ruined Alum. (Factory) Wheel, 2001 Pont. Grand Prix (New Car Nov. 2001)
13. What other damages do you claim, if any?
Cost for front end alignment
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?
Wheel tire $578.64
Front end Alignment $50.42 TOTAL $629.04
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.)
no
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
N/A
Dated at Dubuque, Iowa this 10th day of January , 2002.
/s/ David P. Draper
.
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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 Claimanti ]]b~ff,3
2. Address: ).'~qo .5~
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. Whst were westher conditions like?
9. Give name and address of any witnesses: ~¢,~-- ~k~ .277-~ -~e~,~h,~t4o,~
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 ail 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 y_es_ 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
(Signature)
(Print Name)
F & F TIRE WORLD-ROCKFORD
1610 S. ALPINE
9
HOME PHONE:
SALESMAN:
ROCKFORD, IL
61108
815/398-7867
CUSTOMER: DAVID DRAPER
2790 SANDHULTON
APT. ~ 2
ROCKFORD It_
61109
815/229-9504 VEHICLE:
TOM O'BRIEN
INVOICE
7R01988
PAGE~ i
TIME STARTED: 08:57:59
TIME CLOSED: 13:38:47
200i PONTIAC GRAND PRIX
LICENSE: 1924156 IL NILEAGE:
COLOR: GREEN ENGINE: 3.1L
DUE: 01/05/02
8728
V6 FI
INVOICE DATE: 01/05/02
PRODOCT ~ .......... MECHANIC QUANTITY PR I ~.l=n~- F.E. 'T~ EX' ' ~ '-~.N~ I ON'=
A ..... , .-0= 1 48.00 48 ~ 00
0005
5% SHOP MATL/SUPPLY SERVICE CHG 2.40 2.40
005S
ELAN (VISA/MC)
LABOR: 48.00
OTHER: 2~40
INVOICE TOTAL.: 50.40
50~40
3a~ lO 02 03:25p
25175
DAVID DRAPER
2790 SANDI-IUTTON
ROCKFORD, IL 61109
HONE: 229-9504
100CT2001
JRCK ~OLF PO~TIRC
BUS: 389-2620
el5 544 3808
115941
PAGE 1
JA.;K WOLF
PONTIAC - CADII'LAC - GMC TRUCK, INC.
· 1855 [ I. STATE ST.
P.O
BOX 560
BELVIDE RE, IL. 61008
· (8'15 544-3406
SERVICE ADVISOR: 1126 CHARLIE SECKINGER
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16:43 03JAN02 118:08 03JAN02 I
LIlqE OPCODE TEC~ TYPE HOURS
A P~EPLACE LEFT FRT. TLRE AND ~C4~EEL
AIST i I~7ET TOTAL
,-.. ,: n~7 c~ o.~o
:~!!~ :'i2362295 WHEEL 480.50
~: 706346034 P22560R16 102.34 102.34~34
:. ~,.~._.., ,~. ,:.,~,~,. JACK W0~ ~-
FA~RY
SER~CE
New Service Hours! ~.,,=~ ......
Mom~Thurs. 8:00 A.M, - 7:00 P,M. ,~* ,~, ~ ~,..*~-~ ~, .,.~s,~ou~
Tues., Wed., Fri. 8:00 A.M. - 5:00 P.M. ~,~...~,, ~,- ~ e,s,o~,~u~
Saturday 8:00 A.M. ~ 12:00 P.M. ~w~f~a mer~l~p~cular ~rp~. ~ 8UBL~ AMOUN~ 0.00
We want your service experience to rate ,~.
SAL~ TAX 36.12
a completely satisfied score, Please contact PL~SE PAY .
our Service Depa~ment if we don't measure up. TH~ A~OU~T~
CUSTOME~ COPY