Claim by Michael ElliottCity of Dubuque
ITEM TITLE:
SUMMARY:
SUGGESTED DISPOSITION:
ATTACHMENTS:
Description
Elliott Claim
Goin Claim
Manternach Claim
Merz Claim
Reisdorf Claim
Skrocki Claim
Stewart Claim
Wiegel Claim
Copyrighted
October 2, 2017
Consent Items # 2.
Notice of Claims and Suits
Michael and Vi Elliott for property damage, Heidi Goin for
property damage, Sue Manternach for vehicle damage,
Kelly Jean Merz for personal injury, Joseph Reisdorf for
personal injury, Aaron and Ashley Skrocki for property
damage, Sydney Stewart for Toss of property, Jade Wiegel
for vehicle damage.
Suggested Disposition: Receive and File; Refer to City
Attorney
Type
Supporting Documentation
Supporting Documentation
Supporting Documentation
Supporting Documentation
Supporting Documentation
Supporting Documentation
Supporting Documentation
Supporting Documentation
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 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.
Name of Claimant:
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2. Address: "5 0( $ graktd u t'e ci4v
3. Telephone Number: ,575—b 611K
4. Date of Incident: VL 4Z, heiVC h4X7r/elfeCi 0)4-
5. Time of Incident: ei ao.,"
6. Location of Incident (Be specific): The o //e1 1)4 iid or
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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.)
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9. Give name and address of any witnesses: 144 -in eSSe
10. Did police investigate? (If so give names of officers.)
8. What were weather conditions like?
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
711 ri'es
12. Was any damage done to property?
damages. Attach estimates of damages
damage.)
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13. What other damages do you claim, if any?
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(If so, describe property and the extent of
or describe basis for ascertaining extent of
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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.)
15. What amount do you claim from the City of Dubuque?4
16. Why do you claimthe City of Dubuque is responsible?
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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.)
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 o
(Rev. 7/12)
20/1.
(Signature)
(Print Name)