Claim Steve VinsonCLAIM AGAINST THE CITY OF DUBUQUE
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
West 13th Street, Dubuque, Iowa 52001-4864. 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.
N&me
of
Claimant:
1
2
3
4
5
Telephone Number:
Date of Incident:
Time of Incident:
Location of incident.
(Be specific)
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? ~0~
9. Give name and address of any witnesses.
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give name, address and extent of
injuries. )
12.
Was any damage done to property? (If so, describe property
and the extent of damage. Attach estimates of damages or
describe basis for ascertaining extent of damage.)
!3. 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.)
What amount do you claim from the City of Dubuque?
15.
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 ~ncldent. /~/O
yes, ~ive 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 a~ount?
Dated at Dubuque, Iowa, this ~-21-~! day of ~/~BSP/%~
20
(Revised January, 2000)
(Signature)
(Print Na~e)
DRIVER EXCHANGE INFORMATION
Dubuque Police~epartment
(319) 589-4410
Unit 001
Drivefis Name ~ Last First Middle
CRUSE lAN MICHAEL
Address City
50 WEST 13TH STREET DUBUQUE
Gender License Number Class/Type License State
Male 481048481 D IA
Restrictions/Endorsementa Complied With? insurance Company
Yes CITY OF DUBUQUE
Owner's Name - Last First Middle
Address City
50 WEST 13TH STREET DUBUQUE
Year Make Model Style
1993 INTL FIRE ENGINE
Plate State Plate Year Plate Number
IA 2001 77386
YIN Number
1HTSDN6N9PH473939
Su~x Work Phone Home Phone
(319) 589-4270 x
State Zip Code Date of Birth
IA 52001 07/22/1971
License Endorsements License Restrictions
3 B
Insurance Policy Number Insurance Company's Phone Number
N/A (319) 689-4270 x
Suffix Company Owner's Name
CITY OF DUBUQUE
State ZiG Code Approximate Cost to Repair or Replace
IA 52001- $10.00
Vehicle Type
Other
Damaged Area(s~ of Vehicle
02
Unit 002
Driver's Name - Last
PARKED
Address
First V~iddle
City
Suffix Work Phone Home Phone
State Zta 0ode Date of Birth
Gender License Number ClasstType
Restrictions/Endorsements Complied With? Insurance Company
Owner's Name - Last First Middle
VlNSON STEVEN G
Address City
i601 GARFIELD DUBUQUE
Year Make Model Sbde
1986 PLYM CARMELLA SEDAN
Ptate State Plate Year Plate Number VIN Number
IA 2001 770GZB 1P3BJ46D6GC271984
License StaTe License Endorsements License Restrictions
NONE NONE
Insurance Polic, Number Insurance Company s Phone Number
Suffix Company Owner's Name
State Zip Code Approximate Cost to Repair or Replace
IA 52001 - $250.00
Vehicle Type
Passenger Car
Damaged Area(s) of Vehicle
06
I County
I Dubuque - 31
Literal Desedption
Accident occurred within coroorata limits of fcity)
Dubuque - 2100
x Coordinate Y Coordinate
"N/A .... N/A"
k
If Accident Occurred Outside of Direction Nearest City
City Limits Show General Vacinity "N/A .... N/A" of "'N/A"
On Road, Street or Highway
JOHNSON
Road Class
4 - City Street
At [fltersestion With
GARFIELD
Road Class
4 - City Street
Distance Direcfion I Distance Direction
Milepost Number
or
Definable Intersection, Bridge, or Railroad Crossing
Officer's Name
I SCHMIT MICHAEL
O1-09839
Date of Accident Time of Accident
0312112001 01:12
Printed At: Dubuque Police Department Page t Case #: 01 ~09839