Claim Vaske, DonnaCLAIM 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: Donna Vaske
2. Address: 2595 White St., Dubuque IA 52001
3. Telephone Number: 563 582 1504 Home; 563 585 6196 Work
4. Date of Incident: 7 16 02
5. Time of Incident: 10:30 P.M.
6. Location of Incident (Be specific): On the street directly in front of 2595 White St.,
near the curb, as I was parking the car.
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.)
I ran over a piece of debris left by a city worker crew who have been working on the street.. It was a piece of word with a large nail sticking out of it and it puncture the passenger rear tire on the car.
8. What were weather conditions like? Clear, warm, dark.
9. Give name and address of any witnesses: No one saw me run over the wood, but several neighbors gave assistance just moments after.
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No, but it was close. I don't know how to change a tire.
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.)
The rear passenger side tire of the car was punctured by the nail. This left a gash in the sidewall that can't be patched. The tire must be replaced.
Estimate is enclosed.
13. What other damages do you claim, if any?
I want to be compensated for all costs incurred in replacing the tire. (see estimate total).
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? $88.63
16. Why do you claim the City of Dubuque is responsible? Because a crew that was working for the city created the condition (debris left instreet) under which the car
was damaged. The piece of wood should have been removed from the street.
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?
No
Dated at Dubuque, Iowa this 19th day of July , 2002.
/s/ Donna M. Vaske
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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:
2. Address:
3. Telephone Number:~-~0~'
4. Date of Incident:
5. Time of Incident: [C)
6. Location of Incident (Be specific): O~ *~,~
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.)
S. What were weather conditions like? ~]~a%
9. Give name and address of any witnesses:
10. Di~li, ce investigate? (If so, give names of officers.)
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 dama~e~.
Attach estimates of damages or describe basis for ascertaining extent of damage.)
13. What other damages do you claim, if any? ~ ~J35 ~ ~g cam~~
]4. Have you been oompensnted for nny part or nil of your olnin by nny insurnnoe
company9 {1t ~o, ~ive namo and addre~ ol insuranoo oompan~ and amount paid.)
16. Why do you claim the City of Dubuque is responsible? k~~.~ O._
17. Have you made any claim against anyone else for damages as a result of this incident?
(1~, 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
dayofv ,
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)