Claim by Nicole MorganL~
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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09 JAN ag P~~ 2~ 23
This written report constitutes your claim against the City of Dubuque, Iowa. You should conGpl~tq t 1i5~fgrai i~ ~~~
attach any additional information that supports your claim.
The claim must be filed with the City Clerk at City Hall, 50 West 13`h 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 o you as to whether your claim will or will not be paid.
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1. Name of Claimant: Nicole Morgan
2. Address: ~~q SeamV'~ ~~ C l} ~~ ' ~_ I ~ J~~
3. Telephone Number: `~[~ ~ ~Q j ~- ~~~
4. Date of Incident: 0 ~ ~ l S' c~~0 1
5. Time of Incident: ~c7~~~ ~ ~ ~ ~~~
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6. Location of Incident (Be
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7. Describe the accident or occurrence that caused injury or damage. (Give full details upon which you base your
cnlaim. If a City employee was involved, give the employee's name.)
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8. What were weather conditions like?
9. Give name and address of any witnesses:
10. id police investigate? (If so, give names of officers.)
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11. Was anyane injured? (If se, 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
dama~gaes or describe basi//s f--or ascertaining extent of damage.)
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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.) -
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? (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 this day of
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AMERICAN FAMILY
AMERICAN FAMILY INSURANCE GROUP
5500 WESTOWN PKWY SUITE I80 WEST' DES MOINES IA 50266-5271 PHONE: 515-233-I 1a5; FA?C~ 866 299-55;9
Mailing Addretis. PO I30X 65630 WEST DES MOINES IA 50265-0630
January 27, 2009
CITY OF DUBUQUE
50 W 13TH ST
DUBUQUE IA 52001-4805
27-NAM011
RE: Claim Number: 00-271-520027-0427
Our insured Name: Benjamin & Nicole Morgan
Date of Loss: January 15, 2009
Dear City Of Dubuque:
We have received notice of the above claim from our insured. Our preliminary investigation indicates you
or a person normally covered under a liability policy, were the cause of our insured's damages.
We anticipate making payment(s) to our insured. Once payment is made, our Subrogation Department will
send supporting documentation to you or your insurance company to reimburse our claim payment(s) and
our insured's deductible, if applicable. If you have a liability insurance policy, please complete the enclosed
form and return it to us. We can then handle this matter directly with your insurance company.
If you have any questions, please contact me at the number below.
Sincerely,
~~
Nancy A Muetzel
Casualty Claim Desk Senior Adjuster
American Family Mutual Insurance Company
5500 Westown Parkway Ste 180
W Des Moines, IA 50266
1-800-MYAMFAM (1-800-692-6326) X 60124
nmuetzel @ amfam.com
Fax: (800) 377-2596
www. amfam.com/claims
Enc:
INSURANCE INFORMATION FORM
January 15, 2009
Date of Loss:
American Family Claim Number:00-271-520027-0427
American Family Insured's Name:Benjamin & Nicole Morgan
My Name:
Name of My Insurance Company:
Address:
Phone
Number:
My Policy
Number is:
Insured's
Name on my
Policy:
My Agent's
Name:
Address:
Phone
Number:
I have reported this loss to my insurance company. Yes ^ No ^
Check Here ^ if you do not have a liability insurance policy.
Signed Date