Claim, Vann, Jerrell - JerryCLAIM 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: Jerrell M. (Jerry) Vann
2. Address: P.O. Box 416 Matthews Mo 63867
3. Telephone Number: 573 471 4641 - Cell 573 620 5819
4. Date of Incident: 8/21/02
5. Time of Incident: 11:55 - 12:00
6. Location of Incident (Be specific): North of Grandview overpass on North Bound side 151/61
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 was traveling north behind a traile home when he passed over manhole cover, it was stating up. I was able to miss hole, but hit cover... knock back axle out from undercar. Bent Frame, broke spring & shock, car run sideway must have bent frame, broke
oil line or hole in oil pan. What else it done I have not seen on rack.
8. What were weather conditions like?
Clear & hot
9. Give name and address of any witnesses:
Ed Polk, Matthews, MO, Marvin Tillely, Vernon Gluck, Wankla Vann... I don't have addresses...can get.
10. Did police investigate? (If so, give names of officers.)
Yes, R. Fairchild #12
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.)
List co. damage I know on #8 There has no been esimate of damage. I feel car is total loss. Cost move to fix than value of car.
13. What other damages do you claim, if any?
Need to be complete estimate of damage done on car.
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?
Salvage of car plus $3000.00. I used this car to escort wide loads. I had just put in service I had spent appox. $2500 to get serviced.
16. Why do you claim the City of Dubuque is responsible?
Lid on manhole not secured down, allowed to be up for me to hit and ruin my car. This car is at Tandem Auto & Tire in Dubuque, Iowa now.
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?
None
Dated at Dubuque, Iowa this 30th day of Aug. , 2002.
/s/ Jerrell M. Vann
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE;qOWA
iThis written report constitutes your claim against the city ~f DUbuque' iowa,, ~ou should
comp!ete th!s form :In full and atta~ffanY:a~ddition~i inf0r~ation that ~uPports your claim.
.The Clatm:m'dst be'flied With ~fi~'city'~le~k at citY'Hail,"50w. 13:h st.. Oubunu, IA 52001.
IT will then oe referred by the City ~Co._unciLto the appropriate-deoartment
OncpthatinvpstigaUOn is cbmpleted, a report and recommendation will be submitt-e~l~t-~'t-h'~
City Council. You will be provided with a copy of that report and recommendation.
THE FINAL DECISION ON ALL CLAtMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE
OF THE* CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO
1. Name of Claimant: ~--~-/~P~e // /)'/. C'YE-~Rt/ )
2. Address: ~. f3. Z~ ~-./v/ /)~R T?-~ ~ ~_~
3. Telephone Number: ._R?g- 47J - ~/~c/I ~,-~.
4. Date of Incident: ~/Z //o~_~ ~
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51 Time of Incident: //: ~-~- ~ /-~ o o
7.I.DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY ORDAMAGE. (Give
full details upon which you base. your claim. If a City emplOYee was Involved, give the
employee's name.)
8. Whet we're weather conditions like? dj~,~,~,
9. Give name and address of any witnesses:
_ ~/ ~/~ ~ ~=~. ~.. ~.a v,W ~1I~/~ . V~ ~Z~
',, ;' ' -
1 ~. Did pollc~ invee~gate? (1~ so, give names of officersfi
~-- ~, ~, ~: fd' ~1~ '
(1. W~s anyon~ i~jured? (If ~o, give names, addresses, and extent of i.juriee).
_
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.)
13. What other damaged do you claim, if any?
14. Have you ~en com~nsated for any pa~ or all of your claim by any insurance
company? (If so, give name and address of insurance company and amg~nt paid.)
15, What amount do you claim from the City of Dubuque?
16. ~y
17. Have you made any claim agaln~ anyone else tot damages es a result of this incident?
(If.y~? give name and address.)
18. If the answer to Question 17 is yes, have YOU receivedan¥ p~y~en_t~ from_that_sou~ce,~
end jr'so, in wilat~a-~6u~1t?- ...... '
Dated at Dubuque, Iowa this
day of.
~Sig n'~Mu r~
(Print Name)
(Rev. 1100 & 7/01)