Claim by Amy Keierleber GrochalaCity of Dubuque
City Council
ITEM TITLE:
SUMMARY:
SUGGUESTED
DISPOSITION:
ATTACHMENTS:
Copyrighted
March 17, 2025
CONSENT ITEMS # 2.
Notice of Claims and Suits
Tim Connolly for personal injury; Amy Keierleber Grochala for
vehicle damage.
Receive and File; Refer to City Attorney
1. Claim by Tim Connolly
2. Claim by Amy Keierleber Grochala
Page 337 of 848
ni\J m
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' at., Dubuque, IA 52001. It
will then be referred by the City Council to the appropriate dep department for investic J 3tion.
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 REPRESENTATWIM TOO YOU
AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1.
2.
Name of Claimant:
Address:
City. -var
State-,
Zip: 516 q '•
3.
Telephone Number:
•
4.
Date of Incident.
�
5.
Time of Incident:
`� W
S.
Location of Incident (Be specific): WO;_
r
f
- -
-
FVJ
-- -------=-- _ -, --- ---fib.
--
LaCg,r
7.
full
DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
Beta is upon which you base your claim. If a City employee was involved,
employees
name.)
give the
8. What were weather conditions fike? cle av-- onC
go Give name and address of any wKnosses. 1�l
% Did paflc o inwas dgate? QK SO giwo names of officers.)
1 Was anyone injured? (If so, give names, addresses, and extent of injuries}.
Page 340 of 848
M.M.-
ny damage done to property? (If so. describe property and the extent of damages.
Aes ttacWas ah timates of damages or describe basis for ascertaining extent of damage.)
dries t ' C'armf .
13 What other damages do you claim, if any? _
14. Have you been compensated for any part or a I of your claim by any insurance company?
Of so, give name and address of insurance company and amount paid.)
15. W at amount do you claim from the City of Dubuque?
I6e Why do you COMM MB MW off Dubuque is Fes 0 InsobpQ`P
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 sd, in what amount.
Dated at Dubuque, Oowa this day off '�
K cl'v- 0 C'� 0 cA,
prints [Memo)
Page 341 of 848
Page 341 of 848