Claim Maas, Marty & LindaCLAIM 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: Marty and Linda Maas
2. Address: 2665 Springreen Dr.
3. Telephone Number: 319 588 1625
4. Date of Incident: 12/20/01
5. Time of Incident: 11:30 a.m.
6. Location of Incident (Be specific):
Jackson nd East 12th 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.)
Officer Ed Baker pulled from a Stop Sign on Jackson St. N/B, collided with me, was headed west-bound on E. 12th
8. What were weather conditions like? Clear
9. Give name and address of any witnesses:
NA
10. Did police investigate? (If so, give names of officers.)
Yes, Thomas Schonieck, Sr.
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.)
1992 Dodge Dakota, approx. 83,000 miles. Passenger side rear wheel and bok damages totalled 2743.50 plus 500 deductible,
13. What other damages do you claim, if any?
NA
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? 3243.50
16. Why do you claim the City of Dubuque is responsible?
Officer was cited for failure to yield from a Stop Sign.
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 25 day of February , 2002.
/s/ Sunshine Allen - Claims Rep. for Allied Insurance
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST TI~E CITY OF*DUBUQUE,
IOWA
001802
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= !/~ _~/~ ~"/.-{~/)X. /~/~/~
3. Telephone Number: 7/~) - C~*
5. Time of Incident: // :~ 0'
6. Location of lncident (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 n.ames of officers.) ~ :: i~,,~
12. Was any damage done to property? (If so, describe property and the extent of damages.
Attach estimates of damages or describe basis for e~Sbe~aining extent of damage.)
13. What other damages do you claim, ifany? ~: /-
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 :~-~ dayof
_~.,/. (Signature)
(Print Name)
(Rev. 1/00 & 7/01)
P0020117.LWS Pa~e 2
Allied
insurance
a member of Nationwide ~summ:e
Jenuav/16, 2002
Des Ii.dries Reglenal
~ Mo;nes, JA 50~91-2U04
FAX (5151 ~32
F~X
Ed Baker
1020 Hawkcyg Dr.
Dubuque, IA 52001
Oor Insured: ~ Mnn_~
Our Cl~mNo.: 14P79655
Datc orlon: 12720/01
Dear Mr. Baker:
This letter will serve as final notification of our submgatien rights concerning the ahaw
captioned los that oemured on December 20, 2001.
Our investigation has determined flint you are responsiDle for the damag~ gaused to our
insured's auto as you ran a amp sign and hit our insured.
We have s~ttl~d ~he clnlm with our insured. We issued paym~t ~o oar insured for
$2,7~3.50. This mnount does not include our insured's $500.00 deductible. Therefore,
we are looking to you for a total reimbursement of $3,243.50.
Includod are the supporting documents.
If you had appropriate automobile insurance in force at thc time of thc accident, please
forward this leU. er to your insurance comwany, tf you did not have aatomobile insuranc~
at the time of thc accident, please conlzx:t our office and advise us of yom'intentions for
payment.
If y~u have any qnesti~s concerning ff~is rn~; please con'~r..t us at
g00-532-1212 ex~ 5542.
~unshine AlLen
C]~im~ Representative
DepositorS Into Go.
Alleasl3@vnalimnvkle~eom
(A) Passport - PASSPORT February 25, 2002, 16:50:08
P/N POLICY AXD 0009648889 3 LOSS DATE 122001 CLAIM 14P79685
AUTOMATED CLAIMS SYSTEM - PAYMENT HISTORY
CO 04 EFF 08/10/01 EXP 02/10/02 TERM 06 AGENT 74 14 20397
INS1 MAAS, MARTY INS2 MAAS, LINDA
UNIT: 0002 COV: 554 COLLISION CLASS: 801227 CLMNT: 000
CHECK CLM TRAN CHECK M CC TY CA ADJ
NUMBER AMOUNT CODE DATE DATE T CF R DEPOSIT LS LS TY IRS NO.
471180617 2,743.50 05 010802 010802 I CP 00 000000000
PAY TO: MA_AS, MARTY 000
2,743.50 TOTAL PAID
2,743.50 NET PAID
UNIT: 0002
CHECK
NU~4BER
471179628
COV: 554 A COLLISION CLASS: 801227 CT~T: 000
CLM TRAN CHECK M CC TY CA A DJ
AMOUNT CODE DATE DATE T CF R DEPOSIT LS LS TY IRS NO.
10.00 05 122701 122701 P CC 00 000000000
PAY TO: DUBUQUE POLICE DEPARTMENT 000
10.00 TOTAL PAID
*** 10.00 NET PAID
P00201 IO.ILH
Contact RUSS OTTING
Allied Insurance
7600 OFFICE PLAZA DR, STE 130
W DES MOINES IA 50266
CD Log No 352 Date
Owner MAAS, MARTY
Address 2665 SPRING~EEN DR
City State DUBUQUE IA
Zip 52002-2429
Claim# 14P79685
Insured MARTY
Loss Date 12/20/01
Impact P~ght Rear
Destination
DEPOSITORS INSURANCE COMPANY
Insp Date 01/08/02
Home Phone
Work Phone
(319)588-1625
(000)000-0000
Policy# 000009648889
Claim Rep URBAIN & ASSOCIATES L.L.
Claimant
Type of Loss COLL/FLD
Lic# 400FPQ STATE IA
Body Color
Condition GOOD
Contact
Deductible 500.00
VIN 1BTFL26X4NS632397
Mileage 83,380
Acct'ng Ctl #FOLKERJ
Pacle 1
E NEW PB-RT
EP SEE PX REPORT
L REFINISH
ET LABOR/PARTIAL P~EPLACE
RP RELATED PRIOR DB~AGE
EC ECONOMY PART
P C~CK
N ADDN'L LABOR OPERATION
IT LABOR/PARTIAL REPAIR
UP UNRELATED PRIOR DAMAGE
EU SALVAGE PART
I REPAIR/ALIGN/SUBLET
TE PART/PARTIAL REPLACE
AA APPEARANCE ALLOWANCE
* USER ENTERED VALUE
1992 DODGE
Options:
DAKOTA 6.5 FT BED PICKUP N8412AB OPTNS 6/24FG
Two-stage - Exterior Surfaces Two-stage - Interior Surfaces
ANTI-LOCK BRAKE SYSTEM POWER STEERING
E 496
E 565
E 573
E 575
EC M999
I M999
OP GDE MC Description Part Number Price
E 549 Pipe,Exhaust 52019193 54.20
E 138 01 Stripe Assembly LT 4636433 93.85
E 139 01 Stripe Assembly RT 4636438 46.00
EP 824 Wheel,Rear RT PXN Part 184.93
I 177 Panel,Bodyside Front LT Repair/Align
L 177 10 Panel,Bodyside Front LT Refinish
L 178 10 Panel,Bodyside Front RT Refinish
E 390 Panel~Bedside Outer RT 4335068 612.00
L 390 Panel,Bedside Outer RT Refinish
2.7 Surface
0.5 Edge
0.6 Two-stage
4482576 81.25
52005942 439.00
4432201 20.00
55027398 9.10
Economy Part 4.00*
Repair/Align
Taillamp Assembly RT
Bumper,Rear Step
Brkt,Rear Bumper Mtg RT
Supt,Rear Bumper Mtg RT
}IAZARDOUS WASTE DISPOSAL
FkAME SETUP
Aj%
10
Hours R
0.42
1.61
1.41
0.21
1.5'1
3.8*4
2.4*4
t0.8 1
3.84
INC t
t.8 1
INC 1
INC 1
1'
2.0'1'
P0020110.1LH
Paee 2