Claim Kipper, Carla D.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 Claimant: Carla D. Kipper
2. Address: 2506 Queen St., Dubuque, IA 52001
3. Telephone Number: 582 3549
4. Date of Incident: March 5, 2002
5. Time of Incident: 3:10 P.M.
6. Location of Incident (Be specific): Intersection of Queen St. & E. 22nd St.
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.)
A cover was missing from a manhole, but I couldn't see that it was missing because of a large pool
of water covering it. I drove through it with my car.
8. What were weather conditions like?
Sunny; a lot of melting snow puddles.
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
I don't know her name, but she gave me this case number: 02-9545
Police arrived at the scene shortly after I reported it.
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.)
My car is out of alignment. Also, I heart it drag through the manhole. Attached is an estimate from Dan Kruse Pontiac.
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?
See attached estimate
16. Why do you claim the City of Dubuque is responsible?
Manhole should have been covered or marked.
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 22nd day of March , 2002.
/s/ Carla D. Kipper
(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 Claimant: ~-O~Y'ic~ .~). ~/i~)~J/-
2. Address: ~--~0~ ~-~ [
3. Telephone Number:
4. Date of Incident:
5. Time of Incident: ,~: t ~ ~ V~
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.) ~ 0~V~/' ~OO.5 ~v~<~-~YO~ D~ V'~'b[,~j ~_'_'_'_'_'_'_'_'_'~-
8. What were weather conditions like? ~ ~/7 0L
I ~
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.) ~o~-
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 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? H0.~ ~ IQ ~ ~:>~. ~CLL~-~-
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) Nc) ·
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
day of
~Signature)
(Print N~e)
(Rev. 1/00 & 7/01)
Date: 3/21,~2 02:15 PM
Estimate ID:. 2719
Estiraate Version:
PreFmdnery
Profile ID: Mitche[;
Dan Kruse Pontiac, Nissan, BHW
600 Century Drive Dubuque, IA 52002
Fax: (563) 588-3874
D;mtage Asnessed By: Dave DeMoss
Deductible: UNKNOWN
Ineneed:
Address:
Telephone:
CARLA KIPPER
2506 QUEEN ST DUBUQUE, IA 520~1
Home Phone: (563) 582-3549
Description: 1999 Pontiac Bonneville SE
Body Style: 4D Sed
VIN: 1G2HX52KIXH24416'/
Mitchell Se~-~ice: 912489
Drive Train: 3.8L Inj 6 Cyl AC)
Line Entry Labor Line Item Part Type/
~ Number Type Operation Description Part Number
I 208330 MCH AUGN FRONT SUSPENSION -M
D~lar Labor
Amount Units
1.3
Remarks
CAR DROVE OVER MAN HOLE ?HAT D~D NOT HAVE A COVER ON IT.CAN NOT SEE
ANY VISIBLE DAMAGE ON SUSPENSION. OWNER STATES THAT CAR DOES PULL TO
THE RIGHT. FIGURED ALIGNMENT AND TO CI~-CK SUSPENSION PARTS
Add'l
Labor Sublet
L Labor Subtotals Units Rate Amount Amount Totals
Mechanical 1.3 62.00 0.00 000 80.60 T
Taxable Labor 80.60
Labor Tax ~ 6.0e~ % 4.84
Labor Smnmary 1.3 85.44
III. Additional Costs Amount
Total Additional Costs 0.00
II. Pa~t Replacement Summary
Total Replacement Parts Amount
IV. Adjustments
~u~ra~' R~l~neibilii~
0100
ESTIMATE RECALL NUMBER: 3J2'1/02 14'.02:11 2719
UltraMate is a Trademark of Mitchell Intema'donet
Mitchell Data Version: MAR_02_A Copyright (C) 1994 - 2000 Mitchell InterneUonal
UltraMate Version: 4.7.007 All R~t~ Reset, ed
Page 1 of 2
Date: 3/21/02 02:19 PM
Estimate ID:. 2719
EstArna~ Version: 0
Preliminary
Profile ID: Mitchell
L Tota~ Labor.
IL Total Replacement Parts:
IlL Total Additional Costs:
Gross Total:
IV. Total AdjJus~nants:
Net Total:
This is a preliminary estimate.
Additional chanqes to the estimate may be r~q~;~_red for the actual repair.
THIS DAMAGE REPORT IS BASED ON OUR INSPECTION AND DOES NOT
COVER ANY ADDIONAL PARTS OR LABOR WHICH MAX BE REQUIRED AFTER
THE WORK HAS BEEN OPENED UP THE INS,WILL BE NOTIFIED.
WE FEATURE A THREE YEAR WORKMANSHIP LIMITED WARRANTY- SEE OUR WRITTEN
WARRANTY FOR COMPLETE DETAILS. (EFECTIVE 10-01-01)
85.44
0.00
0.00
~44
ESTIMATE RECALL NUMBER: 3/21J02 14.'02:11 2719
UltraMat. e. is a Tr~ of Mitchell !ptemafional
Mitchell Data Version: MAR 02 A Copyright (C) 19~ - 2000.M~d~he~
UIt~aMate Version: 4.7.0~'-7 - AB Rights ~ed
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