Claim Lang, Christopher JCLAIM 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: Christopher J. Lang
2. Address: 19386 Mud Lake Rd., Dubuque, IA 52001
3. Telephone Number: 552 -2029
4. Date of Incident: 4/13/03
5. Time of Incident: Does not say time of accident
6. Location of Incident (Be specific): Putnam & Muscatine
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 was traveling north on Muscatine while your city vehicle was traveling east on Putnam and we collided in the intersection. Mr. Jeff Tupper did not yield the right of way (police vehicle)
8. What were weather conditions like?
Dry
9. Give name and address of any witnesses: None
10. Did police investigate? (If so, give names of officers.)
Yes Does not say Accident Case #03-14258
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.)
Yes, 1985 Ford F-150 pickup; minor sheet metal damage now needs front wheel alignment; 1 - hubcap smashed
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?
Cost of wheel alignment and a hub cap $100.00
16. Why do you claim the City of Dubuque is responsible?
The officer did not yield right of way
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 18 day of April, 2003.
/s/ Chris Lang
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE,'IOWA ' C/~/- ~'~;'q'~.-
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.
5. Time of Incident:
6. Location of Incident (Be specific):
3. Telephone Number:
4. Date of Incident:
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 nam e~_~ .
8. What were weather conditions like?
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 names, addresses, and extent of injuries).
12. Was any damage done to property? (If so, describe proFerty 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.).
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)
MIKE FINNIN FORD INc ~ No REFUNDS W,T.OUT T.,S ,NVO,CE.
J · 20% HANDLING CHARGE ON APPROVED
3600 Dodge St. RETURNS. NO RETURNS AFTER 15
DUBUQUE, IOWA 52003 DAYS. NO RETURNS ON ELECTRICAL OR
PARTS DIRECT 556-2494 SPECIAL ORDER ITEMS.
PARTS TOLL FREE 800-747-5470 ~HE SEU. ING DEALER MAJ(FS NO WARRANTY OF ANY KrND WHATSOEVER AS TO T
~.flnninautos.cor~-' Ii~v~ T.E =^.UE^C~U.ER ^HDT~.~W'~,".~rs~ ,S ^. ^=.EEME.T SOLEL1
PARTS F.A.X (563) 588-2927 pM~RR~U~UU~T~O~_T~ROw~A~ LISTED HEREON OR AS TO THErR F TNERS FOR A~YE
os ACCOUNT NO. 9 s ~
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CALL
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FIRST
Form
stofN Iowa Department Of Transportation
01-01 3 Iowa Department
a1-01 laws Depttrunent of Transportation Office of Driver Services
Park Fair Mall, 100 Euclid Avenue 'VP INVESTIGATING OFFICER'S REPORT
P.O. Box
50306-9204 OF MOTOR VEHICLE ACCIDENT
ETYP PRINT
Sheet "`
Law Enforcement Case Numbers:
f
Legal
Private
7
Date of ide
P $ g
Tana of Accident
Firs:;
County
f ,5,„ -,,, r__ I r ?
Accident occurred within
axporate limits of (oily) 0;h FTu c?t.. if. .
ion? 0
Property'
County: Rode -
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If accident occurred outside of N NE E SE S SW W NW
city limit show general vicinity mites 0 0 0 0 0 0 0 0 of nearest city
X-Coordinate:
... On Road, Street,
.7 or Highway: p i;.--r s
Al Intersection
with:
Coordinate:
Note: Unless accident occurred at an intersection which Is completelydescribed above, use the spaceY
to give the exact location from a milepost
or definable intersection, bridge, or railroad crossing, using two distances and directions if necaeaery.
If Divided Highway, Provide Route
(Cardinal) Travel Direction
NB SB EB Ws
Q ❑ O 0
ry Feel Miles N NE E SE S SW W NW Feet Miles N NE E SE S SW W NW
or 0 0 0 .0 .0 0 0 0 and or 0 0 0 00 0 0 0 of
Milepost Or Definable intersection,
Number - bridge, or railroad crossing
Drivers Name (Last. First, Middle)
Address City Slate Zip
Date a Birth 'Driver's Liocriso Number
Citation
1. 3.
Charge
2. 4,
Mate Female
o
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....
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mAricti t .-
Alcohol1. None 3. Urine 5. Vitreous Test Results:
Test Given? U 2. Blood 4 Breath 9. Refused
Dos 1. None 3. Urine Pis. I'leg
Test Given? U 2. Blood 9. Refused ❑ 0
Owner's Name (Last, Frirset, Middle)) }
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Address /� /Y �}�J City f , �State Zip
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Appros mate Cost
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Inital Travel
Direction L,J
Vehicle
Action I I i
Speed
L. mit L
Point of
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L
Moat Damaged
Area L_L_I
Extent of
Damage U
Utxterrider
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Private?
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$
-
Total
Occupants LL�
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Controls I I
Vehicle I I ITyedyI
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Contributing mstances,
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UQe[fst• Plate#
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State Year
Attached to
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State Year
Emergency
Vehicle Typel_I
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Status U
Carrier
Name
-
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City
State
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US AOT# or MC*
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IIIIIII
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Number
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Gross Vehicle
weight Rating
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U
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Address
Oily
State
Zip
Date of Birth
Driver's litmrrce Number
Citation
1.
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Slate
Class -
Eretorsements
Resiricuons
2.
4.
Male Female
O O
Alcohol
Test Given?
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2. Blood 4. Breath 9. Refusedt
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Test Given? U 2. Mood
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Owner's Name (Last,
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Address
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City
State
Zip
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Insurance Co.
Name •
Insurance
Policy It
License
Plate*
State
Year
T
VIN # -
- -
Year
-
Make
Model
Style
Tow 4
Appnsxtmate Cost to
Repair or Replace
2
Initial Travel
Direction 11
Vehicle I
Action I • I I
Speed
Limit 11' I
point of
initial Impact I I J
Most Eternaged
Area • I I I
Extent of
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Underrldef
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Occupants 1 L. J
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Config. I I I
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Type I I I
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Defect I I I
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Condition U
Vision
Obscured UU
Contributing Circumstances,
Driver (up to two) -
UJ UJ
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Commercial Trailer meow to • Stale Year Attached to State Year
License Plate # Power Unit Trailer Unit
Emergencye
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Status U
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-Name
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I I I.( 11 I I
Aber
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Gross Vehicleeight
W
Placard #
I I I I I_I—I
Hazardous
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If Property other than
vehicles damaged explain
Ohjctd
Damaged
Estimate of
Damage $
Unit I Unit2 SEQUENCE OFEVENI S
I I I I First Event
Owner's Full Name
(Last. First Middle)-
Was owner or 1- Yes 9 -.Unknown
• tenant notified'? Li 2 - No
1�
I I I I I I Second Event
Street or
RFD
City, State,
& Zlp Code
-
I I I I I I Third Event
ACCIDENT ENVIRONMENT
Location of First Harmfu! Event U Weather Conditions I I 1
ROADWAY CHARACTERISTICS
Major Contributing Circumstances: •
U
WORN ZONE RELATED?.
0 Yes Q• No
1 I I I I I • Fourth Event
(up to two)
Manner of Crash/Collision j I_ I I
Environment
• Roadway I I I
U Location
U Type
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( I l l i t
{by vehicle}
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Light Conditions I_I Surface Candtions 1 I
Type of Roadway JunatronlFeature I I I
Workers Present?
LI
I I I First (armful Event of Crash
(use codes 11-42 only)
Officer's Name
Badge No.
SOLD TO ~
uA%iG C~- R i S
!930 FULLER
DiJBU&'.'UE~ ZA 520EiL
(5S~) 55~-2-20~9 Bus {000) 000-~3~i~0
Date: ~4--i
Time: i3:i
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TiPi££ ~'RO~IISED: :~ ~EET,~SD f? PAY71EN'7: < )CAS~ ( )CHECK ( )CHARGE
CARD
i 8.88 5,7~ ' 5,74
SdB-TOT~L ~5. S3
SA~S T~X ~. 94
EST i M_qTED TOTAl 69.57
~ H.~,~,i,IUN*~L WORK WAS AUTHORIZED
BY ~-huNE u~'~ (Date) AT
Ef4PLGYEE NAME o:.,,iNo AUTHORIZATION:
(~) BY
(Time)
ALEASE READ uAR~rUL~Y~ CHECK ONE OF 7'HE b,w.~[,~NIb BFi OW AND
SIG~ I ...... u ..... T~AT o~'~ ..... ~u A
. u:'~¢~IND UNDER o ~= ~AW~
i RETURN
WRITTEN ESTIMATE IF >!Y FINAL BiLL WiLL EXCEED
ICTZON OF
~ F---~
~ ' i REQUEST A ....... wn~ ~ ~N ESTimATE,
~ ~ DO NOT RGQUEST A WRITTEN ESTIMATE AS LON~ AS THE REPAIR
A=uUiR~
L ; COSTS DO NOT EXCEED ~ TH~ SHOP :~AY NOT EXCEED
~F OLD ~ARTS
~H~., AMOUNT WITHOUT MY WRITTEN OR ORAL A~hROVAL.
~ , i DO NO7 r~=L4Uib~ A WRITTEN ~S~iMATt.
S i ¢=NATU RE
SIGNED
DATE
PARTS & SERVICE WARRANTIES ATTACHED - ,~ LABOR r=Ai R**,=
STORAGE $IO/DAY (BEGINS ~ wO,)<r, IN,.~ UH¥~ AFTER NOTiFICATiON)
ALL ~S~ir~E~ ARE FREE ONL~O~ OTHERWISE LISTED OR -0~ =D~
~_.d OR
L--.--~ RE'
CUST~
Hanley @Bodylnc.
1030 Century Circle Dubuque Iowa 52002
Phone: (563) 583-7220
DATE
AFTER MAKING AN INSPECTION WE ARE PLEASED TO SUBMIT THE FOLLOWING ESTIMATE Of
LABOR & MATERIAL FOR REPAIRS ON YOUR .~. g~ ~ ~
AUTOMOBILE. FOR IMMEDIATE ACCEPTANCE ONLY:
PAINT &
WORK TO BE DONE LABOR PARTS SUBLET
:
REMARKS: ...................................................................................................................................................
:..,..!!~ .......................................................................................... ~ ...... ~ ....... ; .....................................................
above is an estimate based on our inspection and does not cover any additional parts or labor which
',~aY be required after the work has been opened up. Occasionally, after the work has started, worn parts
a~e discovered which were not evident on the first inspection: Because of this the above prices are not guar-
anteed.
By