Claim by Andrew StoeckenClaim Form 1 ~ <~,~i
Ct_AIM AGAINST THE CITY OF DUBUQUE, IOWA
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This written report constitutes your daim against the City of Dubuque, Iowa. You should complete this fiorm in
full and attach any additional information that supports your claim.
The daim 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 Coundl. You will be
provided with a copy of that report and recommendation.
The final dedsion on all daims is made by the City Coundl. No employee of the City of Dubuque has the
authority to make any re/p~res1entation to you as to w~,h~eth~//ea~r your daim will or will not be paid.
1. Name of Claimant: Andrew Stoecken
2. Address: 1730 Avoca
3. Telephone Number: ~~J J 7•? ""' 0~7~
4. Date of Inddent: ~ /~"~7`'"Q~
5. time of Inddent: /~ • S
6. Location of Inddent (Be spedfic): in front of house at 1730 Avoca
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.)
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10. Did police investigate? (If so, give names of
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.)
13. What other damages do you daim, if any? i~---
http://www.cityofdubuque.org/printer_friendly.cfm?pageid=294 2/25/2008
8. What were weather conditions like? C..~C Gi G'/IGL CIL~~t/J^ C~~~~_4"I~y1q~~,
9. Give name and address of any witnesses: ~ Ybavr~ Q,IG. LG rr~2- O~
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daim Form
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.)
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15. What amount do you daim from the City of Dubuque?
16. Why do you daim the City of Dubuque is responsible?..~ WaQS >Qari~d 1 Nr
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17. Have you mad~any claim against anyone else for damages as a result of this incident? (lr' 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?
Dated this day of , 2t>~~
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X
CROWN COLLISION CENTER INC. DAMAGE REPORT
Steve Saffran • Owner PRICES GOOD FOR ao DAYS ONLY
7812 Windy Ridge • Dubuque, Iowa 52003 Hems CIRCLED are in the total, in
our opinion, an: not part of this claim
563-588-0415
HIC E OWNER ~ DDR SS PHONE D TE
~EAq / ~ ~ MAKE,\ ~` ,MOD c C~` LIC~~SE /G't MILEAGE COLOR SERIAL NO. CONDITION
CC~/_ L~/ / n/ a C~ y lv s ~ L o.~v 7 7~7 ~'
INSURANCE CO ADJUSTER PHONE CAR LOCATED AT DEDUCTIBLE
;ym. FRONT Sublet
Or Paint Service $
Or Hours pans S m. LEFT
y Sublet
Or Paint Sen"ce S
Or Hours
Parts
Sym. RIGHT Sublet
Or paint service $
Or Hours
Parts
kmtper W J Pads Fender, Frt. Fender, Frt.
Fender Shield Fender Shield
Fender Mld . Fender
tamper Reinf.
r Brkt. Side L' ht Asm Sde L' t Asmbly
Headlam Headla
glance Headlamp Door Headlamp Dr.
umper Gd. Sealed Beam Sealed Beam
rt. System Park Light Park Light
~~ Cowl
Cowl
rams Hom Door, Front
Door, Front
ross Member Door Hin e
Door H'
:abilizer Door Handle Door HarMle
'heel Door Glass C-T
Door Glass C-T
ub Cap Disc Door Mkigs. Door Mldgs.
ub 8 Drum
Bindle
all Joint
Cont. Ann Center Post Center Post
Door Rear Door Rear
p. Cont. Arm Door Glass C-T Door Glass C-T
~o~ Door M Door M
~nng
e Rod
eedng Gear
eenng Wheel Rocker Panel Rocker Panel
~m Ring Rocker Mktg. Rocker Mldg.
indshield C-T Floor
Floor
Dog Leg Dog Leg
Quar. Panel . J Quar. Panel
gust Shield Quar. Ext. Ouar. Ext.
ills Quar. Glass C-T
Ouar. Glass C-T
ills Panel Quar. Mldg. Quar. Mldg.
Side light Asmbty Side Light Asmbly
-Condenser it Light C Tail Light
charge System EAR
MISC.
Compressor Bumper to Inst. Panel
Mme Plate Front Seat
~m Front Seat Adj.
ftle, UPper Bumper Reint. Trkrt
ck Plate, Lr. Bumper Brkt. Headlining
ck Plate, Up. Bumper Gd. Top Vyn~
god To Valance Tire % Wom
wd Hinge Lower Panel
Paintin fi , J
_
wd Lock Floor Aerial
Cc
nament Trunk Lid Tow & Storage
id. Sup.
Battery
td. Core
tti Freeze Back Up Lights r r
id. Hoses Lic. Light
n Blade Tail Pie HAZARDOUS WASTE
n Shroud - i
.n Belt Gas Tank NET PARTS ~; `~
ater Pump Frame SERVICES/ 'HRS. ~ HR. :s l'(., .GJ
ater Pump Pulley wheel PAINT - MATRL - HDW. L 9
~tor Mts. Hub & Drum
ans. Linkage
Axle SUBLET OR PAINTING
s rin TAX ON $ ,, fj . C:L7 ~ ~~
GRAND TOTAL ~~
lppraiser
Symbols: A -Align N -New OP -Open P -Paint
S -Straighten R -Replace OH -Overhaul
X
I HEREBY AUTHORIZE THE ABOVE REPAIRS
This Damage Report is based on our inspection
and does not cover any addRional pans or labor
which may be requimd after the work has been
opened up.