Claim Foley, David & Robin CLAIM AGAINST THE CITY OF DUBUQUE, IOWA /~l/~
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.
1. Name of Claimant:
2. Address: =-~
3. Telephone Number:
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.
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
emp_Loyee's name.) _
8. What were weather conditions like? N~---~,'~/--
9. Give name and address of any witnesses: ~,,'l~.,~t~
10. Did ,olice in_vestigate? (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 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.) MO
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
' ~9"~q/ dayof
/~t/.~- , 20 <~-~
(Signature) ~
/~"q*f'//~;?' ~ N~
(Print
(Rev. 1/00 & 7/01)
April 1, 2002
Thomas D. Felderman
550 8th Avenue
Dubuque IA 52001
Re: Claim Against the City of Dubuque
Dear Mr. Felderman:
If you wish to file a claim against the City of Dubuque for damages to your client's
vehicle, I would request that you fill out the enclosed claim form and return it to me. I
will retain your Report of Accident and Claim and attach it to the complaint form when it
is received.
Once the claim has been stamped in it will be forwarded to the Legal Department for
investigation. Enclosed is an addressed envelope for your convenience.
Sincerely,
o-/ Jeanne F. Schneider City Clerk
- CC:
Legal Department
Mark Munson, Transit Manager
Service People Integrity Resparm'oflity Innovation Teamwork
REPORT OF ACCIDENT AND CLAIM
~ COMPLETE FRONT ONLY
[] COMPLETE FRONT AND BACK
DATE OF
ACCIDENT (Year) __
ACCIDENT
REGISTEREDOWNER
HOME PHONE ~'*~'-~ _~/~ ~ WORK PHONE
DRIVEN BY
HOME PHONE ~_~S?- ~/ ~ ~ WORK PHONE
I FOR OFFICE USE ONLY
~ CLAIM NO.
TIME ~ ~:~ ~3/~'M'
.M. DARK [] LIGHT~
CI3~ STATE ZIp CODE
ODY UC.
STYLE & STATE ~ ' ~ ' "~
EMPLOYER ~ ~~
ADDRESS ~ ~~
DR~VER'S .~/ DRIVER'S f~y~__~ WAS DRIVER ON ANY YES ~ IFYES,
AGE DATE OF BIRTH MISSION FOR OWNER OF CAR? [] EXPLAIN.
DRIVER'S
LICENSE NO.
CAR WAS DA~GED?
~S ANY PART OF YOUR DAMAGE Y~ ~ ~ME OF YOUR
BEEN PAID BY YOUR COMPANY? ~ ~ AMOU~ $ INSURA~E CO.
~ME OF
IF CAR NOT DRIVEABLE,
ON YOUR CAR ~ ~ DEDU~IB~
HAVE REPAIRS YES NO
BEEN MADE? [] []
POLICY
NUMBER
LIC. PLATE NO.
& STATE ~:~?" ',-~
REGtSTEREDowNER C/ 7~ ~ ~ ~ ~:'~(~; ~'~"
POLICY NO. ~~~ HOME PHONE
~MEOF ~l ~X WHAT PART OF OTHER
AGENT ~ ~ ~ _ CAR WAS DA~GED?
/
ACCIDENT HAPPENED .
ADDRE~ 2~ ~ ~ ~
OWNE~DRIVER,
WORK P~NE
CALLED?
WAS ANYONE
INJURED?
NATURE OF INJURY:
POLICE DEPT. p~/~,l~ ~:~ f~
WHERE REPORTED
If SO, WHO?
REPORT
NUMBER
I HEREBY DECLARE THAT THE FACTS STATED ABOVE ON THE FRONT []
SIGNED X ~
FRONT AND BACK [] ARE TRUE:
DATE ~ "~"~:~--~ (Year) __
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Bate: 03/29/2002 03:il3 pM
Estimate ID: 6022
Estimate Version: 0
Preliminary
Profile ID: Mitchell
IWgB[E FINNIH I:ORD,
3600 DODGE STREET DEBt Q[ E, IA 52003
(563) 556-1010
Fax: (563) 690-1086
lax ID: 42-I074463
Assessed By: JEFF LEI(K
T NKNO'~¥N
DAVE FOLEV
206 DILLON DID, IA 52003
Home Phane: (563) 557-i912
i997 Ford Taurus GL
iSDIe: 4DSed
ViN: 1F~LP52U7VA ! 76024
Mitchell Service:
911623
Drive Train: 3.0L lnj 6 Cyl AO
RE!- REFINISH
BDY REMOVE/INSTALL
BDY REMOVE/REPLACE
BDY REMOVE/INSTAL!.
BDY REPAIR
REF REFINISH
REF ADD'L OPR
- .iudgell~ent Item
: - Labor Note Applies
C - included in Clear Coal Cale
Line Item
Description ~
L QEARTi,~R OUTER PANEL
L Q1 kR~ ER PANEL OUTSIDE
QUARTER ANTENNA ASSEMBLY
L REAR MARKER LAMP ASSEMBLY
REAR BUMPER COVER
REAR BII~/IPER COVER
REAR BEMPER COVER
(:LEAR COAT
PAINT/3dATERI<LS
H ~ZARDOUS WASTE DISPOSAL
Part Type/
Part Number
Existing
Existing
E6DZ 15A20I D
Existing
; ,Units Rate
Labor Sublei
0.00 0.01~ {~ 346.50 T
:5~ 6.000 % I }. 31.05
3~8 45.00
77 45.00
~axab e Labor
[ I : LaborTax
ECALL NUMBER: 03/29/2002 i 4:57:i9 6022
APR_02_
4.7.007
IL Part Replacement Summar~
Taxable Parts
Sales Tax
Total Replacement Parts Amount
T ItraMate is a Trademark of Mitchell International
Copyright (C) 1~94 - 2000 Mitchell International
All Rights ReServed
Dollar ~Labor
Amount ~U~its
~ L0*#
9.70
3.85 *
6.000%
Page
9.70
0.58
Date: 03/29/2002 03:~3 PM
Estimate ID: 6022
EstimaTe Yerslan: 0
Preliminary
Profile ID: Mitchell
kmount ix,'. Adjustments
219.45 Customer Responsibility
219.45
I. Iota! Labor:
IL Total Rep!acemen* Parts:
tll. Total Additional Costs:
Gross Total:
IV. Total Adjustments:
Net Totah
Th is is a oreliminarv estimate.
Addition~i chan~e~s to the estimate may be required for the actual repair.
548.55
10.28
219.45
778.28
03/29/2002 14:57:19 6022
APR_02 A
4.7.007
I ltraMate is a Trademark of Mitchell International
Coovrioht C) 1994 - 2000 Mitchell International
Ail Rights Reserved
Page 2i