Claim, Saylor, ChrisCLAIM 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 TEE CITY COUNCIL.
NO EMPLOYEE OF THE CITY OF DUBUQUE HAS T~E AUTHORITY TO MAKE ANY
REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE
PAID.
1. Name of Claimant: Chris Saylor
2. Address: 4137 Long Branch Rd., Potosi, WI 53820
3. Telephone 608 763 4042
4. Date of Incident: 7 28 2000
5. Time of Incident: 11 a.m.
6.
(Be specific)
Location of incident.
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.)
Mr. Saylor was sitting in a truck when it was struck by one of your
vehicles.
S. What were weather conditions like? ~t~,~,6t~,~,n~
9. Give na~e and address of any witnesses.
10.
11.
Did police investigate? (If so, give names of officers°)
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.)
13. What other damages do you claim, if any?
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 an4 amount paid.) . ~ '
This claim is being presented by American Home Ins. Co., the WC Carrier for Mr. Saylor.
15. What amount do you claim from the City of Dubuque? $161.68
16.Why do you claim the City of Dubuque: Your driver hit our vehicle causing
Mr. Saylor's injury.
is responsible?
17. Have you made a~,y ~iaim against anyone else for damages as a
result Of this lnc~dent? ~0
If yes, give name.and address:
18. Tf the answer to ~st'
_ Q_- ion 17 is yes, have you received any
payment from that source, and if so, in what amount?
Dated at Dubuque, Iowa, this day of
2001.
A1 Recovery
1230 East Diehl Rd.
Suite 204
Naperville, IL 60566
630 505 7108
/s/ Barbar Ceranec
(Print N~une )
(Revised January, 2000)
April 19, 2001 ~
METROPOLIT~ID WASTE
925 KERP.~BLVD.
D~IE, IA 52001
A'i-I-ENTION: DON VOGT
Re:
Our insured
Our File No.
Claimant
Date of Loss
Lien to Date
: ALLIED WASTE INDUSTRIES, INC
: 000436 - 000000019561
: SAYLOR CHRIS
: July 28, 2000
: $161.68
Dear Mr. Vogt:
We have been advised that an employee of our insured has sustained an injury. Based
on information contained in our file, we believe that you may be liable for damages to
the above emploYee. In brief, the cimumstances of the accident are that one of your
vehicles struck our insUred's employee who sustained injury.
Please be advised that AMERICAN HOME ASSURANCE CO, the workers'
compensation carder for ALLIED WASTE INDUSTRIES, INC has made payments to or
on behalf of this employee. Under the appropriate statutory provisions, we hereby claim
a lien upon the proceeds of any claim that the employee may have against any party as
a result of the occurrence giving rise to his Worker's Compensation claim.
Please forward the odginal of this letter to your insurance agent, broker or company so
they may be give this claim proper attention. In addition, please enter the requested
insurance information on the enclosed form and return it to us in the enclosed envelope.
Your prompt reply will make it unnecessary for us to inconvenience you further.
If you are self-insured, please advise where we should address our claim details. Thank
you for your cooperation.
Sincerely,
Barbara Ceranec
Recovery RePresentative