Claim Jones, Jame H.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. 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: James H. Jones
2. Address: 630 Greenfield
3. Telephone Number: 563 556 7815
4. Date of Incident: 7 12 02
5. Time of Incident: 10 a.m.
6. Location of Incident (Be specific):
630 Greenfield, Dubuque IA 52001
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.)
Minibus driver pulled in to make PU of Virginia Brandonbergh, backed up and hit 1994 Chevy Sid PU Parked in front of Houses.
8. What were weather conditions like? Clear & Sunny
9. Give name and address of any witnesses:
James H. Jones, 630 Greenfield
10. Did police investigate? (If so, give names of officers.)
Yes, Jon J. Burkley
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.)
Rear of 1994 Chevy Pickup was hit while parked $672.94 damage.
13. What other damages do you claim, if any?
No
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
16. Why do you claim the City of Dubuque is responsible?
Driver backed up improperly (vehicle was parked that he hit)
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 18th day of July, 2002.
/s/ James H. Jones
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
JUL-12-02 FRI 04:05 PM DUBUQUE OITY OLERK FO,× NO. 583 589 0890
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 he flied with'the City Clerk at City Hall, 50 W, 13th St., Dubuque, IA 52001.
' O
It will then be referred by the City Council to the appropriate department for inveshgatl n.
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 .... ~9jJ~;:2~L~,2%,.~'~ ~
2, Address:_.~
3. Telephone Number:
4. Date of Incident:
17-, 'OZ.,.
5. Time of Incident: _
6. Location of Incl~dent (86 SCec~fic):
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? ~¢
9. Give name and address of any witnesses:
10. Did police in?~esti~gate? (if s~.~ give~a_a_~es ~ officers.)
11. Was anyone iniured? (If so, give names, addresses, and extent of iniuries).
JUL-12-02 FRI 04:08 PM DUBUQUE OITY OLERK FaX NO, 563 589 0890 ?, 02
12. Was any damage done to property? (If so, describe property and the extent of damages.
A~ach estimates of damages or describe basis for ascertaining extent of damage.)
~ ~ Z~q ck=~v _~ ~..
13. What other damages do you claim, if any?__.~_ o
14. Have you been compensated for any part or all o! 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?_
16, Why do you claim the City of Dubuque is responsible?
17, Have you made any claim against anyone else for damages as a result of this incident?
o' ye , nam a.J addr, ss.)
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 /~ ''T/J
__ day of. ~,~'v/- ~-/_ -- --, 20"~ ?
nature) ~ ~
(Print Name)
LE,~ U UU"U/P~U i~
The Body Shop
2990 Jackson Street
Dubuque, Iowa 52001
(563) 583-3520
T~ a~e ~ ~ e~ ~d on ~r ins~aon and d~ n~ ~r any
ad~al pa~ or la~ may ~ ~ui~ a~r ~e ~ h~ ~n ~d. TOT~ P~TS ................
O~ionally. ~m or damag~ ~ am dis~v~d ~i~ may not be
evident on ~e flint impe~on. Be~ ~ ~is, ~e a~ pH~ am ~ TOT~OR, .~.
make the above re~im: T~ . .~ ...........
Sign~:
.......................
Iowa Department of TransportatiOn
INVESTIGATING OFFICER~'S REPORT
OF MOTOR VEHICLE ACClDE~NT
Or bridge, or mi]road cr~sing
;Las, Fimt,
Address . -":~¢~ ~ City
Insurance License f
Sheet
Law Eefarcement Case Numbem:
Legal P fivate
Intervention? [] properS?
County: Route:
X-Coordinate:
Y-Coordinate:
If Divided Highway, Provide Route
(Cardinal) Travel Direction
NB SB EB WB
O O O O
State Zip
1. None 3. Ubne Pos. Ne~
2. Blood 9. Refused O 0
Mode]
State Zip
Repair or ReplaCe
Private?
Initial Impaa I J j Mast DamagedUnderdde/
Vehicle J Cargo Body VehiCle J Driver Co~ribuflng Circumstances,
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Trailer Unfi' I~1 Vefiicle Type Status
Calder J Address City State Zip
Name J
City State Zip
Ddver's Name (Last. F~rst, Middle) AddreS~
3
Initial ~ravel J S~ed j Point of Most
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ooc.,~.~l I I ~.~,1 I Ilco**.. I I
Attached to
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Name
US DOT# or MCr J Number
o o I I I I I I I I~A~esl
1. None 3. Udne 5. Wtreous TeSt Results:
2. Blood 4. Breath 9 Refused
JDrug ~. None 3. Urine
Test Given? L] 2, Blood 9, Refused
O
o%
~ (up to two) Environment id ~ Location
Manner of Crash/Collision La III Readw.y II I II Type
LightCondifions bi SurfaceCondittans U TypeofRoadwayJuncttan/Feaurel I ii j j WorkersPresent~
Estimat~ e¢~ j/ /
f-¥.g-Unfino~n IIIII Fir~tEw~t
III I IS~ndE~ent
III I ITh~rdEYent
I I II I I MostNarrcdulEvent
(by vehicle)
,' J I I First HarmfuI Even[ ef Crash
.Officer's Name ,t b¢2 '-d. Badge No.