Claim Lange, Kenneth & JaneCLAIM 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: Kenneth A. Lange & Jane J. Lange
2. Address: 1036 Bonnie Ct., Dubuque IA 52003
3. Telephone Number: HM #563 588 9207 Cell 563 580 0208
4. Date of Incident: 6 4 02
5. Time of Incident: 10:54 A.M.
6. Location of Incident (Be specific): Matthew John Dr. Dubuque IA
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.)
City Employee Philip A. Schoenberger was driving a city owned 1998 Intl' recycling truck and slid into claimants parked 2000 Chevy S-10 pickup.
8. What were weather conditions like? Unknown
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
Yes, City of Dubuque - copy of report attached Driver sited for failure to have control of vehicle.
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.)
Yes, our Insd's vehicle sustained damage where it was not driveable. West Bend Mutual Ins. Co. has to pay damages to vehicle, cost of a appraiser and rental car for insd.
13. What other damages 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 name and address of insurance company and amount paid.)
West BEnd Mutual Insurance Company, 1900 S. 18th Ave. West Bend, WI 53095
15. What amount do you claim from the City of Dubuque?
Damage to vehicle per estimate; rental car $840.00; appraisal $84.40
16. Why do you claim the City of Dubuque is responsible?
Your driver slid your truck into our insd's parked vehicle.
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/ Lori Dreher
Call Center ClaimRep.
262 335 7087
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Jun. 6. '2002 4:32PM BARRY A LINDAHL, ESQ~-z~z~-'~/~'~'~/~ No.7525 P. 3/4.
CLAIM 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. 13m 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.
3. Telephone Number:,,.~[~J~'':~t~:~ ~
4. Date of Incident: (.P ~' ~ 7' ~,-~'-~'~
$. Time of Incident:
6. Location of incident (Be specific):
7. DESCRIBE ACCIDENT OR ,OCCURRENCE THAT CAUSED INJURy OR DAMAGE. (Give
full* details upon, which, you base your claim. ,If a City employee 'was involved, give the
%_Tployee'$ name.)
9. Give name and address of any witnesses:
...~5. Did police investi~late? (If so, give names of Rfficers.). . ~'Y' ~---
U
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).:'"
L~o/,x ~r'?lO
Jun. 8, 2002 4:32PM BARRY A LINDAHL, ESQ No.7525 P. 4/4
-1~. Was any damage done to property? (if so, describe proper~ and the extent of damages.
Attach estimates of damages or describe basis for ascertaining extent of damage.)
~ ~ ~ ~ ,~ ....
· ,_ ~ s % ~~,~u~~.~,~
t
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.)
16. Why do you claim the Ci~ of Dubuque is. responsible?,
17~ Have yo0 re:ada any claim against a~yone else for damages as a result 0f this incideht?
(If yes, give name and address.) ~ . ..
18. If the answer to Question 17 is 'yes,' have you.. received any payment from' that s0uree,
and if so, In what amount?
Dated at 'Dubuque, Iowa this
day of
(Signature)
(Print Name) ,
(Rev. 1/00 & 7/01)
Bend Mutual
ffi E~Ab ~tCOMPANY · TIME TESTED SINCE 1894
Ms Jeanne Schneider, City Clerk
City Hall - City Clerk's Office
50 West 13th St
Dubuque, IA 52001
Our Claim #:
Our Insured:
Our Driver:
Date of Loss:
HH15312480 04 LO
KENNETH A LANGE & JANE J
Unattended, Parked Vehicle
06/04/2002
Your Claim or Policy #:
Your Insured:
Your Driver: Phitip A Schoenberger
Location: Matthew John Dr, Dubuque, IA
[] Under a policy of insurance carded with us by the above named insured, WEST BEND MUTUALh~Ot~r:~/..~
~ ~_,~._V~,.J~e~colted upon to pay for loss and damage to property as a result of the accident described
above.
nder a I~olLc~v of insurance carried with us by the above named insured, WEST BEND
MUTUAL
has
aid $1~/,6~or loss and damage as a result of the accident described above.
The total damages were $ . Deductible Amount: ~).
[] We have made an additional payment of $.__
Total damages to date: $ .
for
[] On we notified you or our subrogation interest in the above matter. To
date we have had no response from you. Please advise the status of our claim.
An investigation indicates this damage was caused as a result of your insured's negligence. Under the
terms of our policy, we are subrogated to the extent of our payment to any legal right which our
insured has against you, and we hereby claim a lien on any proceeds that may be paid by way of
settlement or judgment on said claim.
Sincerely,
LORI DREHER/Io
(262) 335-7087 or 1-800-236-5010 Extension 7087
1900 SOUTH 18TM AVENUE ,*WEST BEND, WI 53095
www.westbendmutual, com