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Claim by Tim Connolly
City 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 �J i-Fi- CLAIM AGAINST THE CITY OF DUBUQUE, IOWA ; v1z" 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: ✓ / fil %'// iq ()/ l C 2. Addre City: 3. Telephone Number: 6 00 7 l %% 4. Date of Incident: D o1 �lif' i'�G // 5. Time of Incident: �_ T �?Cf 6. Location of Incident (Be specific): SXI-7-,, c)h 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.) S ©-�'tc�0S ' ®rl (CV 51 cj(,4-) r c-' < I - f�(�$� r� l �1 /U � "C P�-a � -f—> I h � A u-f' k v e-€- � sk�a E ,(Tt.r s G (/"/ d X �.. ,,� ,,I„ <,A i 8. What were weather conditions like? / 1006411, 2 9. Give name and address of any witnesses: LO 10. Did police investigate? (If so, give names of officers.)/up 11. Was anyone injured? (If so, give names, addresses, and extent of injurie ). ✓ e %1 ri I lGt bow (:A, (no n-� (M 1 -S,�e of S o iY► � �7�D �J c,,-la 0/o 4a /A ' �� a�61 e u0-0 LJ rn 10A 6 q n ") -i' h e n S -r1-.0 r- < to . —r-A, l( l k de-, v<` 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.) 13. What other damages do you claim, if anyl (�2AO h -2 r 14. Have you been compensated for any part or all of your claim by any i urance company? (If so, give name and address of insurance company and amount paid.) �c)n l nc)vj A A*ci 1 f C� re- n :T. 15. What amount do you claim from the City of Dubuque? o0 16. Why dp4ou claim the City of Dubuq 13' -C A vse / X e/^ e 1,16's 17. Have you made -any (if yes, give name and address.) is rncr�nncihln7s' "_ r no-P O- �t:4p eh�c d o&A 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 day of _�� LA 20 (Rev. 9/24) Signature) Print Name),. ( �{'" 4, ~�,�i 5 . .. Page 339 of 848