Claim - Shot Tower InnCLAIM 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: The Shot Tower Inn
2. Address: 390 Locust
3. Telephone Number: 556 1061
4. Date of Incident: October 19, 2000
5. Time of Incident: morning
6. Location of Incident (Be specific): 300 block of IOwa
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.)
A gas line was cut by construction in the AM of the 19th. Could not open for business until 5:30 P.M.
8. What were weather conditions like? Clear, fair
9. Give name and address of any witnesses: Rob Kunnert, John Sprague
10. Did police investigate? (If so, give names of officers.)
No
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.)
No
13. What other damages do you claim, if any?
Loss of business until 5:30 P.M.
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?
16. Why do you claim the City of Dubuque is responsible?
$1200.00
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 9th day of 1 , 2001
/s/ James J. Kunert
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST
THE CITY OF DUBUQUE
This writtenreport 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 THE CITY COUNCIL.
NO EMPLOYEE OF THE CITY OF DUBUQUE F. AS '£n~ AUTHORITY TO MAKE ANY
REPRESENTATION TO YOU AS TO WHET~R YOUR CLAIM WILL OR WILL NOT BE
PAID.
2. addrese ,%90 +
3. Telephone N,,mher: ~0--~__2 /_0~./
4.
e
Location of incident. (Be specific)-
7. DESCRIBE-~%CcIDENT OR oCcuRRENcE'THAT-CA-uSED INouRY OR DAMAGE,
(Give f=ll. details upo~.which ~you base your claim. If a City
employee was involved, give the employeeCs name. ) -
atw' 'w'ath'rc°ndi ion'li '?
9. Gi and a w es ~ ~
10.
11.
Did police investigate?
(If so, give names of officers.)
Was anyone injured?
injuries. )
(If so,
give name, address and extent of
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?
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 clalm from the City Of Dubuque?
Why do you claim the City of Dubuque is responsible?
16.
17.
Have.you ,made~ any~ claim again, s~anyone else r for~e~r
result of _this incident?~%.1~ ·
If yes, give name and address:
as a
18. If the answer to Question 17 is yes, have you receiv~d
Dated at'DubuqUe~ Iowa,
(Revised January, 2000)
this day of ,
.(Print Name)