Claim Aseno, EvalyneCLAIM 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: Evalyne Aseno
2. Address: 260 Holly St., Dubuque IA 52003
3. Telephone Number: 563 583 5619
4. Date of Incident: 9/25/02
5. Time of Incident: 7:30 a.m.
6. Location of Incident (Be specific): Where Hill Street merges on/into highwy 20 West
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.)
Emplyee's name is Bev Gain (Keyline Minibus Driver) License Plate # 64528
I was at a stop sign with my right indicator signal on, waiting to join highway 20 W when it was clear of oncoming vehicles, and while still on my brakes I heard a bang
and my car moved forward. The Keyline minibus had hit me.
8. What were weather conditions like? Fine, perfect weather
9. Give name and address of any witnesses: Megan Nye, 155 Alpine St., Dubuque IA 52001
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
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, Dodge Dynasty, Crack in red tail light (right side) and a crack on the bumper.
13. What other damages do you claim, if any?
Bumper needs reinforcement as it loosened up due to the impact of the minivan on it.
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? $1130 i.e. One Thousand One Hundred and Thirty & 00/100.
16. Why do you claim the City of Dubuque is responsible?
Because the accident or damages was/were caused by a property of the City of Dubquue - Keyline Minibus
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?
N/A
Dated at Dubuque, Iowa this 10th day of October , 2002.
/s/ Evalyne Aseno
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE,qOWA
This written report constitutes your claim against the City of Dubuque, Iowa. you -
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
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7. DESCSIBE ACCIDENT O~ OCCUrrENCE THAT CAUSED IN~USY O~ DAMAGE. (Give
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10. Did police investigate? (If so, give names of officers.) ~
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12. Was any damage done to property? (If so, describe property and the extent of damages.
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14. Have you been compensated for ~n¥ part or all of your claim by any insurance
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15, What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for damages as a result of this incident?
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18. if the answer to Question 17 is yes, have you received any payment from that source,
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Dated at Dubuque, Iowa this
(Rev. 1/00& 7/01)
~_~ day of
(P¥i'nt Name)
Atlas Auto Body Shop
653 White .Dubuque, Iowa 52001 · (319) 588-2856 DAMAGE REPORT
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in the total, in i~ A~inio~. are not paff of this clam.
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