Claim by Lauren Schnip/J ~ /
CLAIM 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 West 13th 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: ~(~.LLti'eVl <> ~ ~~~-~,~
2. Address: ~~~ ~~~1~1`'~ ~~ ~ ~~
3. Telephone Number j ~p~?~ ~ S~~ U ~ ~ ~ ~
4. Date of Incident: ~ ~ a ~ ~ ~ ~
5. Time of Incident: 3 ~ y S ~ ~~
6. Location of Incident (Be specific): .
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8.~
were weather conditions like?
Give name and address of any witnesses:
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.) ,,, , , ~ ,
11: Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
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13. What other damages do you claim, if any?
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14. Have you been compensated for any part or all of your claim by any
insurance company? (If so, give name end address of insurance company and
amount paid.)
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15. hat amount do ou claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for damages as a result of
th~i ~ci~dent? (If yes, give name and address.)
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18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
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Date this ,~ CZ day of ~I `~ ~ , 20 ~ ~. b1 '~n~~q~~
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Driver Information Exchange Report
Driver's Name - Last
U MILI ER
N Address
218 BRYN
Gender I Drivers License Number
T Male
001Owner Company
CITY OF DUBUQUE
Dubuque Police Department
563-569-4410
1 First _ l Middle Suffix
NATHAN I M
City State Zip
l PEOSTA IA 52068
Class Th tateTEndorsements RestrictioInsurance Ca. Name
D 1 IA l L2 1 nsNONE CITY OF DUBUQUE
Insurance Policy IF
Owner's Name - L..st
1 First
Address
60 W. 13TH
VIN No Year Make
1 HTMKAD N25H685900 12005 INTL
License Plale I
# Ste e I Year
88792 1 1A 2007
!Middle
City
DUBUQUE
Drivers Name - Last
N Address
002
Gender
Owner Company Name
I First
Model
j 4400
Most Damaged Area
04 - Right Rear
7-City
li
Driver's License Number Class Stale 1 Endorsements Reslriclians Insurance Co. Name
1 NONE 1 NONE WEST BEND
Insurance Policy #
HHI6650190
[Middle
Suffix
Date of Birth
Phone
(563) 582-9393 x
Insurance Co. Phone g
Slate 1 Zip
IA I 62001-
Style
TK
Suffix
Fiehicle Confrguration
6 --
Approximate Cost to Repair or Replace ,I
3300.0D
Date of Birth
State Zip
1 Phone
Owner's Name - Last
TOBIN
Address
710 FENELON PLACE #3
First Middle
LAUREN SCHRUP
1-••
City
!DUBUQUE
VIN No. Year I Make
WAUEH64B81N025551 2001 AUDI
License Plate # State Year Most Damaged Areir
1486FTX i IA 2007 04 • Right Rear
County lAccident occurred within corporate limits of (city)
Dubuque-31 iDubuque•2100
Literal Description
"NIA"
X-Coordinate
1, "NIA"
If accident occurred outside of city
limits show general vacinrly. "NIA"
On Road. Street, or Highway'
FENELON
1 Model
AA6
'Direction 'Nearest City
"NIA" of J NIA"
Distance Direction Distance
"N/A" NIA" and "Al/A"
Definable •nlerseclion, bridge, or railroad crossing
"NIA"
Officer
MCCLIMON, TED
suffix
Insurance Co. Phone
(563) 556-0272 x
Stale
IA
Zip
52003-
i Style
I 40
f Vehicle Configuration 1
01
1 Approximate Cost to Repair or Replace
$500.00 — — — • --
Fr -Coordinate
NIA"
1 At intersection with
SUMMIT
'Direct on Milepost Number
of "N/A"
N/A
1 Route (Cardinal)
Travel Direction "N/A"
Or
[Badge No. Law Enforcement Case NumbeTJ Date of Accident
i 61B 07-21165 061221007
Time of Accident
16:46 Firs
HART AUTO BODY & PAINT
003
800
0
O
2
563) 5 6 8324
FAX
3
PHONE: (563) 5 6 83
EHICLE OWNER ADDRESS 1
MODEL LICENSE MILEAGE
Ml~lC J
ry
0 O u
Y,
PHONE
J ~
INSURANCE CO ADJUSTER
--
FRONT .__
Subiet Servir
Sublet Servioe i LEFT Or Paint Or Hr
Or Paint Or Hours Parts Sym.
8~, Fender, FrL
Bumper W/Pads Fsndsr Shield
Bumper Abs. Fender Ext.
Fender Mldg. Side
Fender Stripe
Fender Midg. _
`'"'" ~' poor Hinge
Wheel ~-
Door Panel
Hub Cap Disc poor Strip
Lr. Cont. Arm poor Mldg:
nper Filler
Is
le Panet
u Panel MI
guar. Panel
guar. Ext.
Air Condenser
guar. Wheel Hou
Recharge System guar. Mldg. Side
Name Plate ouar. MIdB.
Tail Li ht
!food Top REAR
Hood Hinge
Bumper
Hood Lock
Bumper Abs.
Ornament
Bumper Cusl
Rad. Sup.
Bumper Reir
Rad. Core
Bumper Brk1
Anti Freeze Bumper Gd.
Rad. Hoses i
l
l
e
Bumper F
Fan Blade
Fan Shroud Valance
„___,
Pulley Trunk Lid
Trunk Mli
Lic. Light
Gas Tank
Frame
Wheel
Hub & Di
Park
Cowl
poor,
poor
Door
Door
Door
M
loon
og Le8
war. Panel
Side Ligl
Tail Li h
MISC.
Inst. Par
Front Se
Front Se
Top
Headlini
Top Vin!
Tire
Painting
Aerial
Rust Pr
PARTS (Prices subject To In
SERVICE 7 )HRS. @~~
SUBLET OR PAINTING
SUB TOTAL _
TAX
PAINT-MATRL-HDW.
~~
. ~-/ 2
Y
U-7y4~-
COLOR
S. I ~'`
DAMAGE REPORT
PRICES SUBJECT TO CHANGE
Items CIRCLED aro not in tfie toot in
our opinion, aro not part of this da1m.
DATE ~ ~ L~ _ Q
~, RIGHT
°ender, Frt.
=ender Shield
Fender Ext.
Fender Midg. Side
Fender Stripe
Fender Mfdg.
Dr.