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Claim by Walter Joniec{ f5ana5 i;f- r56 »5a.. 5 a a.ai F I r V .' L. 515 85.y^e 3o xi i;" if RSdii 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 13 St., Dubuque, IA 52001. It will then be referred to the appropriate department for investigation and to the City Attorney's Office. 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 , L I 1f , - ✓ � / �( 2. Address: .YO j p ?�/�'r.1 (9 3. Telephone Number: r� `/7 ` (f 15 ,f3pS" 4. Date of Incident: /a -/4 - /Q f / 5. Time of Incident: / � /,7 - /„� I L-/ :"../ AA/ Ord,. 6. Location of Incident (Be specific): Tt U/c�...$ r/' / . 7. Describe the 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.) / � • 4 /)? p1 C( r , � llr�P C (/ 'tFrei Y�l 1 t' /Iii../` Yc�- �IJ clt / ©T / /7r (c ac �j (% De/74( - 5 .C7 /dG / 41 8. What were weather conditions like? f� /61 06r)4 - iv f /414 d pr(J! 9. Give name and address of any witn ses: /2 /7 (e / / r jcede � � 2 /. fc /2 a i i 1 r 77 brut /� Gu � 15 r'. Ii?i f C r• Yl. s a; / lr(� �7 P 6 � I 10. Did police investigate? (If so, give names of officers.) Cyr Ct' (iYt 7 `ff-i7 rG 11. Was anyone injured? (If so, give names add sses, and extent of injuries.) AI o 0i) e ! /Z J/ t it'; i i (It 6' 4i71( ) fl 0 i ✓l j l.er'c t'a (re J" em. A1 19 -?earl Ay ,r)r9 h cr 07 ,2 ((• d i ,7 7' Y7 %''0r4 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.) / /� C2 00 c S C D i 1 v vas i -f r1 T � -t J� L /'I I 5 3ari / r,L/c-S S( 1 't '1 it ( r ZR a '( ' y ` '1- � 12C,-) � �;F t'c'� lai� r�f' /li1D�.1J!% C.S11 fitrli(�It� �iiJ 1 /1'J _for ; rl "f J?' c: }, v_ , c; t�J v 7 i)kI".,it b.t' 5 (9I/ 3 c_. --- C'S a. t (1x d i r' tr)G i {1) - ( F S :h '1'4 (7 1)e �i lr<mtn, (L,...� pi;-I(rl . 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.) 0 15. What amount do you claim from the City of Dubuque? Ur? kri C ) Na; 11✓!' r Qf )10 . io pro is t s rYw. rep(' r o An 16. Why do you claim the City of Dubuque is responsible? W a A c' t �( 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) (VJ 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? Dated this / day of 48 20 !C ti (Signature) L.0. L7 c2 Jdn -'; (Print Name) �1 'enbngn0 eoiTK) s,jia1O A110 91 :1 148 6Z33OOL Accident Information — Walter Joniec - owner of Vehicle 800 Hyannis Ct. Schaumburg, I160194 847 - 885 -8505 12 -16 -2010 Note that was left on car Accident Report received 12 -27 -10 Called Police Dept and contacted Officer Griffin for Accident Report Accident report received via e-mail 12-27-10 Umceorlower services Wei?1 INVESTIGATING OFFICERS REPORT- P.O. Box 9204 Des Moines, have 53306-9204 'Now, MOTOR VEHICLE ACCIDENT --r�,.1''--? ry iYi 01-10-61378 Legal InterventiOn7❑ Private Properly? ❑ L Date of Accident 12/1612010 Time of Accident 12:13 Hrs. County Dubuque - 31 Accident ocarrtxl wen n carpetal? emits of (city) Dubuque - 2100 LORALoral S Literal Disc p8on S BtVD 0 If accident occurred show general mcirty: outside of city limits "N/A" of newest city "WA" C A On Road, Street, 483 LORAS or Highway. At intersection with "NIA" T Note: Unless accident location from a occurred at milepost or definable en intersection wilds is completely desoibed above. use the space below to give the exact aileraec;ion, bridge, or reamed crossing, using two distances and directions #necessary- X Caoelnate: 00691190 Ynale_ 04708453 O N Distance 20 Ft Direction 3-E Distance D'sectian end "N/A" "NiA" of d Divided Highway Provide Route (Cardinal) Travel Direction WB Milepost Nonber "NIA" Del -noble intersection, bridge, or railroad crossing Or LORASIMONTROSE Drivels Name - BRADLEY Last First Middle Suffer Home/Cell Phone DENNIS (563) 5894160 x Address 11 W 9TH ST Cly State Ztp DUBUQUE IA 52001 Date of Bath s, r, - i i _ ai' wnher Citation Charge Code 1 Citation Charge 1 Gender Male Slate Class IA 0 Endorsements NONE Restrictions 2 Citation Charge Code 2 Citation Charge 2 Citation Charge Code 3 Alcohol Test Given? 1-None Test Results Drug Given? 1-None Test Test Results. Citation Charge 3 Citation Charge Code 4 Citation Charge 4 U Seating Posilton01 injury Status 5 Occupant Protection2 Ai bag Deployment 5 Airbag Switch Status 9 Erection 1 I Ejection Path 1 Trapped 1 N I Transported to: Transported by T. Ownefs Name - Last First Middle Suffix Owner CITY of DUBUQComppaany Name (i01 Address 50 W.13TH ST CCit�yy DUBUQUE Slate IA 25 001 Insurance Co. Name CITY OF DUBUQUE Insurance Policy License Plate # 114490 State !A Year 2011 VIN No. 1HTMNML1AN193931 Year 2009 Make International -INTL Model AMB Style AMB ' Tow a Approximate NO Repair Cost to or Replace Instal Travel Direction 4 Vehicle Speed Action 88 Limit 30 Point Initial of Impact 04 Most Damaged Area 04 Extent of Damage 1 Undefr Override d f 1 Private? ❑ $0.00 Total Occupants 2 Traffic Controls 01 Vehiclee ConFig. 05 Cargo Body Type 02 Vehicle Defect 01 Driver Condition 1 Vision Obscured 01 Contributing C rcurratances, Drver (up to two) 27 SEQUENCE OF EVENTS i First Event 21 Second Event 23 Third Event Foul, Event Most Harmful Event [by vehicle) 23 Commercial Trailer License Plate at Attached to Power Unit State Year Attached to Trailer Unit State Year Emergency Vehicle Type 4 Emergency Status 2 Cartier Name Address City State Zp US DOT 4 or MC # - Number Axles of Gross Vehicle Weight Rating Placard e Hazardous Materials Released? Driver's Name - Last First Middle Suffer Horne/Cell Phone (847) 885-8505 x Address City Slate Zip Dale of Birds Drivels License Number Citation Charge Code 1 Citation Charge 1 Gender State Class Endorsements NONE Restrictions NONE Citation Charge Code 2 Citation Charge 2. Alcohol Test Given Test Resets Drug Test Given? Test Results: Citation Charge Code Citation Charge Code 3 Citation Charge 4 Citation Charge 3 4 U Seating Position In -joy Status Occupant Protection Airbag Deployment Airbag Switch Slag Ejection Election Path Trapped N Transported to: Transported by T JOnIECName-Last First R Middle Suffix Owner Company Name Ofl2 Address 800 HYANNIS CT City SCHAUMBURG State IL 60 60194 Insurance Co. Name ALLSTATE insurance 002-022-9400 Policy # License Pile # ' X953742 State IL Year 2010 VNt No. 3FAFP11392R194301 Year 2002 Make Ford - FORD Model Style 2D Tow it NO Approximate Cost to Repairer Replace Initial Travel Direction S Vehicle Action 13 :yen.1 Limit 30 Point metal of impact 08 Most Damaged Area 08 Extent of Damage 2 Underride! Override 1 Private? ❑ t100.00 Total Occupants 0 Traffic Controls 01 Vehicle Corsfg. 01 Cargo Body Type 01 Vehicle Defect 01 Driver Ccdeion Vision Obscured Contributing Circumstances, thtver {up to two) 27 SEQUENCE OF EVENTS' Fist Event 23 Second Event 21 Thud Event Fourth Fvent Most Harmful Event (by vehicle) 23 Commercial Trailer Attached to License Plata # Power Unit State Year Attached to Site Year Trailer Unit. Emergency Vehicle Type 1 Emergency Status 3 Carrier Name Address City State ?tip US DOTS or MC a Number of Axles Gross Vehicle Weight Rating Placard # Hazardous Materials Released? Printed At Dubuque Police Department 1211612610 0543 PM Page 1 Form #: 014-64374). ��, �ca�,'.