Claim Psihoyos, GusCLAIM 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: Gus Psihoyos
2. Address: 2398 Beacon Hill
3. Telephone Number: 563 582 7666
4. Date of Incident: 3 5 02
5. Time of Incident: 2:45 P.M.
6. Location of Incident (Be specific): City Hall on south side of Buliding.
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.)
Ice cycle fell from roof of City Hall onto front of my car
8. What were weather conditions like? Clear, sunny
9. Give name and address of any witnesses: Ken TeKippe
10. Did police investigate? (If so, give names of officers.)
No
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.)
Broken Headlamp and signal assembly -see attached estimate
13. What other damages do you claim, if any?
None
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?
$597.68
16. Why do you claim the City of Dubuque is responsible?
Prior knowledge of problem.
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 12th day of March, 2002.
/s/ Gus Psihoyos
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
.~ M~r.12..2002 3:3¢PM BARRY A LINDAHL, ESQ NoS7~ P. ~
·
This wri~en repo~ constitutes your claim against the City of Dubuque, Iowa. You shoulu~
complete this form in full and a~ach any additional information that suppoAs 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·
.amc of Claima.t: ~OS ~,/~o~o ~
3. Telephone Number: ~-~ ~-~
4. Date of Incident:
5. Time of Incident: ~ '. ~ 5- .~'->~'~
e. Location of i~cident (Be specific): ~_. ,~ h~/l
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.) JiL~ O
11, Was anyone injured? (If so, give names, addresses, and extent of injuries).
Bar.12. 2002 3:34P~/ BARRY ~ L[NDAHL. ESQ N0,6740 P 2/4
12. Wajs any damage done to property? (If so, describe property and the extent of damages.
A~tach estimates of damages or describe basis for ascertaining extent of damage.)
13. WhM 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 corn party and amount paid.)
15. What amount do you claim from the City of Dubuque? ~q-7, do c~
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.) ~] 0
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
(Rev. 1/00 & 7/01)
(Print Name)
Date: 03/11 200209 43A
Estimate ID: 5935
Estimate Version:
Preliminary
Profile ID: Mitchell :
MIKE FINNIN FORD, INC.
3600 DODGE STREET DUBUQUE, IA 52003
(563/556-1010
Fax: ~563) 690-1086
Tax ID: 42-1074463
Assessed By: JEFF LEICK
Home l~ho~e: {5631 582-7666
199~ Chrysler LHS
XqN: 2C3~ED~..6F6RH670104
Labor~ [q~! I
Type ~3pe~atio~
BDY CHECK/ADJUST
BDY REMOVE/REPLACE
BDY REMOVE/REPLACE
Line Item
Description
Mitchell Service:
911526
Drive Train: 3.5L lnj 6 C)I AO
Part Type/
Part Number
L H/LAMP ASSEMBLY
HEADLAMPS
L H/LAMP MOUNTING BRACKET
L PARK/SIGNAL/MKR LAMP ASSEMBLY
4778261
4584069
4746463
i # - Labor Note Applies
Dollar
Amount
257.00
98.35
114.00
Labor Sublet
45.00 iL00 0.0q
eLabor
~ 6'000%
Additional Costs
Totals
94.50 T
94.50
5.67
I00.17
0.00
II. Part Replacement Summary
Taxable Parts
Sales Fax
Total Replacement Parts Amount
IV. Adjustments
Customer Responsibility
6.000%
497.51
0.00
I. Total Labor:
II. Total Replacement Parts:
III. Total Additional Costs:
Gross Total:
03/11/2002 09:40:40 5935 i ~!
UItraMhte is a Tr~{Ihmark of Mitchefi International
MAR 02 A Copyright (C) 1~ - 2000 Mitchell International
- - All ~ights Reserved
4.7.007
Page
497.51
0.00
597.68
2
Date: 03/I 1/2002 09:43 A~
Estimate Version: 0
Preliminary
Profile ID: Mitchell
IV. Total Adjustments:
Net Total:
This is a preliminary estimate.
Additional chan~es to the estimate may be reouired for the actual repair.
o.oo
597.68
NU~IBER~ 03/11/2002 09:40:40 5935
UltraMate is a Trademark of Mitchell International
_MAR_02_A Copyright (C) 1 ~ - 2000 Mitchell International
4.7.007 Its Reserved
Page
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