Claim Schramm, Karla KCLAIM 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: Karla K. Schramm
2. Address: 2311 Prince
3. Telephone Number: 583 0152
4. Date of Incident: 1 01
5. Time of Incident: 11:40 AM
6. Location of Incident (Be specific):
2300 Elm
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.)
Alliant was changing wires on Elm. Thgere truck had traffic temporarily blocked. Your dump truck stopped and I stopped behind him. He decided to back up. I honked to stop him he just kept backing.
8. What were weather conditions like?
Wet road
9. Give name and address of any witnesses:
Don't know it.
10. Did police investigate? (If so, give names of officers.)
Yes
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.)
1999 Alero Oldsmobile Fax est
13. What other damages do you claim, if any?
Rental Car $26.00 per day. My car is unsafe.
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?
Riley Estament amt plus daily car rental
16. Why do you claim the City of Dubuque is responsible?
Your driver was in the wrong and was charged.
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 so, in what amount?
Dated at Dubuque, Iowa this day of , 20 .
/s/ Karla Schramm
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE
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 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 wili 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 WR~T~ER YOUR CLAIM WILL OR WILL NOT BE
PAID.
2. ~£/' ~ ,_ ~__
6. ~'.ocation of incident.. (Be specific) _~ 3~
Name of Clermont:
TelePhone N~her:
Date of Incident:.
Time of Incident:
7. DESCRIBE ACCIDENT OR OCCOF~RENCE. THAT CAUSED INJURY OR DAMAGE.
(~ive full details u~n which you base your claim. If a City
employee was involved, ~ive the employee, s name. )
~. W~at were weather cona~tions like? ~ ~ ~ ~ ~ ~ ~ '
9. ~ive name a~d address of any witnesses, i ' ~~
10. Dxd police investigate? (If so. ~ive ri?es ~f officers.)
- · vi .
11. Was anyone injured? (If so ~ive ~i~' i'~'~"I'~ "--~ ~ f~ ~ ~
injuries.) ' ~ ----3' ==~=~s ~= ext~t of~ ~
12. Was any damage done to property? (If so, describe property
and the extent of damage. Attach estimates of dan~ages or
describe basis for ascertaining extent of damage.)
13.
14.
What other damages do you claim, if any?
Have You been compensated for any part or ~11 of your claim by
any insurance company? (If so, give name and address of
insurance company and amount paid. )
./
15.
16.
17.
What amount do you cIaim from the City of Dubuque?
Have you made any claim against anyone else for damages as a
result of this incident? ~4Q
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 so, in what amount?
Dated at Dubuque, Iowa, this day of
2001.
(Revised J~nuary, 2000)
( S ign~tur e)