Claim Mi-T-M Corp Jeff GansenCLAIM 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: Mi-T-M Corp Jeff Gansen
2. Address: 8650 Enterprise Dr. Peosta, IA 52068
3. Telephone Number: 319 556 7484
4. Date of Incident: 2 26 01
5. Time of Incident: 8:30
6. Location of Incident (Be specific): Land Fill
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.)
Unloading junk at Landfill and botl doser was pushing the Junk beside me and turned away from my truck and the tooth bar hit my truck.
8. What were weather conditions like? Nice
9. Give name and address of any witnesses:
Jesse Begle, 1665 Bies Dr., Apt. 2 Dubuque IA 52002
10. Did police investigate? (If so, give names of officers.)
Vogt, Case # 01-6942
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.)
99 International Straight Truck Ripped a hole in right side of bot
13. What other damages do you claim, if any?
None
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?
All $1,304.81
16. Why do you claim the City of Dubuque is responsible?
Because my truck was parked and I was not in it.
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 day of , 20 .
/s/ Jeff Gansen
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE
Date of Incident:
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~H~ll,~0
West 13th Street, Dubuque, Iowa 52001-4864. It wili~en ~ge
referred b~ the City Council to the a~propriate Department
investigatl~n. Once that investigation is completed, a re~
recommendation will be submitted to the City Council. YoWl
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: N;--7-~ ~f 7~
Telephone Zm -
4.
5. Time of Incident: ~, ~ O
6. Location of incident. (Be specific)
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.)
/
8. What were weather conditions like?
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give name, address and extent of
injuries. )
12.
Was any damage done to property? (If so, describe property
and the extent of damage. Attach estimates of damages or
describe basis fcr ascertaining extent of damage.)
13. What other d~mages 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 n~une and address of
insurance company and amount paid. )
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
17.
Have you made any claim against
result of this incident? ~/ 6g
If yes, give name and address:
anyone else for damages as 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
20
(Revised January, 2000}
~i~nature)
(Print Name)
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