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Claim by Sally A. Lang for Courtney MeyerCLAIM AGAINST THE CITY OF DUBUQUE, IOWA ~ ~Z~ 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. 13~' 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: Sally A Lang -Courtney Meyer(minor Child) 2. Address: 1470 Adair St Dubuque, Iowa 52001 3. Telephone Number: 563-542-0805 4. Date of Incident: 12/17/09 5. Time of Incident: 8:52am 6. Location of Incident (Be specific): W and and Cardiff Stand Summit 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.) i-u Q~nn ~i o ~ 1F P ~ n ~) o l i re r9 c ~a_S ~'r:, w, ~ S 'R , 1A~c"_ l ~-`.t - Co ~ }-r~ e.~ •~-c~.r n eo~ m m i t ~~ M t ~ •~ m e l e b~ r~ G~.nGI \ C,c~-F ~ ~ bc~cjC. 8. What were weather conditions like? Cloudy and cold 9. Give name and address of any witnesses: none 10. Did police investigate? (If so, give names of officers.) Yes Officer Dan Sabers 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). Yes Courtney Meyer she was treated for cervical strain(whiplash), Contusion(deep bruisinQl. and meral~tia aaresthetica(disordereaused by comaression of a nerve in the Thioh) address is 1470 Adair h-e s a~ dl 1r-i ~ ~ •~s~- ~ ~ ~ ~~ l ~~ cxand~- ~ ~~u e_q,c, ~ ro eec. J --{v ' ~ ~u ~~ ro e,ed ec~ d,.C~n ~ h-r r 1 ~p ~.~~ ~(:t.S v~,ln 0.b ~ e ~ ~ C~ (~ S~-~C'v C:~- G Y''~ Cl ~ ~ ~k- -~,~ ~o `~'Y" 1.1 Q~- ~ ~ ~ ~ ~ ~ ~~ S O ~~OV~e C~: ~ ~(l~ ~-ov~-c E-he~ 5 CC~.~C a ~~^-~- C ~- 1 ~e `'C1r~-Q C~-(~vna- ~-a ~ ~ ~. Cc~uX~-~n ex`~~ Ca_,r 1o~~1r~ C~-~' ~v~e~ s ~ r~.e ~;dors ~ ~r©h~- ~e~d.~ ~,cg`n S Z S ~-- C~ ~r ,,I ~ (~l.-~ C.~e- ~ `~ti i Z 1 S 1~~ L ~- c~ s `~=-Q IJUt(~l GLIB-~~ pSS ,\ ~~ ~Q~1 ,~ ~~ ~-- In a.u-e... ` ors ~-sc-~ ~r-5 S L ~ ~~ r~e ~t,5 1 ~ eCJn t ~ OJ r ~ ~©rn ~.-~n ~ ~ ~c:~.~.x. s.~.. ` ~ ~~~~ v,~ot~~ cal 1/1.C3~ `~-~c'~ '~ (~..~' '~3 p~~ • ~-~ ~ 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.) [a~fo Fan- ('c~~~w'' - ~~-~. C~,rr~'S Srde ~~~ors . ~°'~Y~~~'- ~~~ , ~r~f 6~ ~ ~`~ uPX s~ arc ~.~ ~ne~~ ux~s ~ eQn irc whir caused f rG~i ~' ~-o ~'1ru~ on . 13. What other damages do you claim, if any? lr~ss o,~ ~aQes ,e` ~bo~-h ('~ \!n. i .~ n 1 ~~.. _ _. _ ~..n .~ ~.~~ i.~ ~tiivi ~.. r~. ,_1n1 1J tf. _~. _ \ .. r'1A ..~ L ~'t 1 J /!n ..~ T...~ 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? ~ ~ nnlc,rnc~ 1~ ~ c~~ ~, ti S ~- ~ m4. - c1 ~,~ 4yr ~~ f~ 1.1 ~~ ~', ;11 c , ti 16. Why do you claim the City of Dubuque is responsible? Because it was clearly the fault of your driver James Welty he admitted itto the officer 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 ~ ~l day of ~CP~~i~ 20 Owl . ignature) n r%` ~- - c~ r-~ J tint Name) ~ 1:.;. ~ -'~ c -_ _; ~ '1 'y'r ~-'~ _ l ~_• `0. rr `` W . '~ r~~~ ~-~.l (Rev. 1 /00 & 7/01) • Driver Information Exchange Report Dubuque Police Department 563-5e9-4410 u N T 001 Drivers Name - Last yWELTY First TMiddle JAMES Suffer ROBERT Date of giRE--- Address 16436 OLD HWY ROAD City PEOSTA 1 State i IA Zip 620430-0000 Horne/Cell Phone Gender Male Driver's License Number Class A State IA 1LN Endorsements Restriction° NONE Insurance Co. Name IOWA COMM-ASSURANCE Insurance Co. Phone 4 pop589-0101 x /ix Owner Company Name insurance Policy V ICAP0300 \>Y( Owners Name - Last CITY OF DUBUQUE First �-- I Mddle Suffix Address 926 KERPER BLVD City OUBUQUE Slate IA LP 62004- VIN No. 1FVABXAK71HJ17234 Year 2001 Make FROT Model Style TK Vehicle Configuration License Plates 84633 i State r IA Year I 2029 Most Damaged Area Approximate Coat to Repair or Replace U N I T 04$ Drivers Name - List -- — First M le Suffix Date of Birth Addreaa City Slate Zap HoineCell Phone Gender 1 Drivers License Number _ Class State Endorsements NONE Restrictions `NONE Insurance Co. Karns Insurance Co. Phone. Owner Company Name insurance Policy I Owners Name - Last BURDS First RONALD ' Middle JOHN Suflk Address 1311 N GRANDVIEW City DUBUQUE State IA Zip 52001- ViN No. 13CC51967281e4068 Year 2002 Make CHEV Model Style Vehicle Configuration License Plate S 633LQP Stale IA Year 2003 Most Damaged Area Approximate Coat to Repair or Replace u N T 003 OrMers Name - Last MEYER Fiat COURTNEY Middle MARIE Suffer Date of Birth Address 1470 ADAIR ST CO' DUBUQUE I State zip k IA 52001 Horne/Cell Phone pas) 542-0806 x Gender Female License Number Driver'sw State IA Endorsements NONE Restrictions Insurance Co- Name Insanoe Co. Phone NONE PROGRESSIVE CASUALTY (6831, 66$-0886 x Owner c insurance Polley 0 30917609-0 Owners Name - Leal MEYER Freed COURTNEY • Middle MARIE Sutfht - Addre°s 1470 ADAIR ST Coy DUBUQUE State IA Yip 62001- VIN No. 1FALPe634T1t164200 Year 1996 Make FORD Model CNT Style 40 Vehicle Configuration License Plate S S21WRP State IA Year 2010 Must Damaged Area Approx heat° Cost to Repair or Replace -- RD ' O A P tN E A R G T C Y - itProperty other then vehicles damaged explain Object Damaged ELECTRICAL - - ----- POLE Estero la of Damage $6,090.00 Wee Owner cr Tenant Netfiud? Yes Owner's Name - Last ALLIANT ENERGY First 1 Middle Suffix Company Owners Name ALLIANT ENERGY Street or RFD City Slate Zip Code DUBUQUE r IA 62001 Printed At: Dubugus Pei ice Department 12)17f•200110:1 a AM Page I Form 0: 01-09-0$e16 County IAoridanl ocourred within corporate limits of (city) Dubuque -31 , Dubuque •2100 Uteral Description W 3RD ST and CARDIFF ST and SUMMIT ST X-Coanfinate 00691318 Y1;acrdinale 04707324 If aooident occurred outside of city knits show general vacint y: 'WA" Direction "N/A" of Nearest City "NIA" Route (Cardinal) Travel Direction NB On Road, Street, or Highway: CARDIFF ST At Intersection with: W. 3RD ST Distance Direction "NIA" "N/A" and Demos "NIA" Direction Milepost Number "WA" of "N/A" Or Definable intersection, bridge, or reamed crossing "NIA" OFficer SABERS, DAN �badge No. v Ealor0ment Case Number 1 I0 101-09.68416 Dale of Accident 12/1712009 i Time Of Accident 1 08:62 Hrs.