Claim by Bruce OhnesorgeClaim Form
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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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. ~ ~
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1. Name of Claimant: Bruce W. Ohnesorge
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2. Address: ,2279 Chaney Road #4-~ ~ ~•" d
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3. Telephone Number: .)) ~- ~ ~ _ t) ~ ~ - ~ ~ ,) _~ t_. ~n- ..~ ~_,--
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4. Date of Incident: '~'l / l ~ ! ~' ~ - ~ ' __-
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5. Time of Incident:
6. Location of Incident (Be specific): `Right between 1905, 1909 & 1918 Asbury going east
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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 officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries.)
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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 claim, if any? ~~~Gl`l.S~
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9. Give name and address of any witnesses: ? 1~L~11C._
Claim Form
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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 and address of insurance company} and amount paid.)
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15. What amount do you claim from the City of Dubuque? ~~ ~~- ~' fJ
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16. Why do.}you claim the City of Dubugiue is responsible? ~-~-1~ C~`~-1 ~~~~1,~~~~.. `~"'n--~ ~~~-t`I C>L=~ ~~~~~~
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17. Have you made any claim against anyone else for damages as a result of this incident? (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?
Dated this ~ ~ T day of L{' a I ~ , 20 ~ -' { .
(Signature)
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(Print Name)
print this page
http://www.cityofdubuque.org/printer_friendly.cfm?pageid=155 6/16/2008
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I ACKNOWLEDGE THAT I HAVE REVIEWED THIS ESTIMATE OF REPAIR AND SERVICE WORK. I HEREBY AUTHORIZE THE ABOVE WORK TO BE DONE, INCLUDING THE INDICATED,
PARTS AND LABOR, AND PROMISE TO PAY FOR ALL SUCH WORK. I GRANT PERMISSION TO OPERATE THE REFERENCED CAR, TRUCK OR VEHICLE ON STREETS, HIGHWAYS
OR ELSEWHERE FOR THE PURPOSE OF INSPECTION AND/OR TESTING. I UNDERSTAND THAT ALL CLAIMS MUST BE ACCOMPANIED BY AN INVOICE. I UNDERSTAND IF ADDITIONAL
WORK IS REQUIRED, YOU WILL OB Y ERBAL OR WRITTEN AUTHORIZATION BEFORE ANY ADDITIONAL WORK IS BEGUN, UNLESS OTHERWISE SPECIFIED ON THIS ESTIMATE.
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