Claim by Katherin Ann Dietzel
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 West 13th 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 Dubua,~te has the authority to make any representation to yoga as to
whether your claim will or will not be paid.
1. Name of Claimant: Katherin Ann Dietzel
2. Address: 15946 Lore Mound Road
3. Telephone Number: 563-556-1192
4. Date of Incident: 6/19/2009
5. Time of Incident: 9:00 am
6. Location of Incident (Be specific):
7. Describe the 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 emglovee's name.)
8. What were weather conditions like?
9. Give name and address of any witnesses:
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10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, 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 damages or describe basis for ascertaining
extent1of 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.)
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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?
17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
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18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
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FILING A CLAIM AGAINST THE CITY OF DUBUQUE
When Should I File a Claim?
If you have sustained an injury or damage for which you believe the City or one of its employees
is responsible, you may file a claim against the City.
How Do I Request a Claim Form?
In order to obtain a claim form, please contact or visit one of the following City offices:
City Clerk's Office City Attorney's Office
City Hall Harbor View Place, Ste. 330
50 W. 13th St. 300 Main St.
Dubuque, IA 52001 Dubuque, IA 52001
563.589.4120 563.583.4113
Can I Send in Additional Information with the Claim Form?
Yes. It is recommended that you send in as much information as possible with your claim form
in order to expedite the investigation of the claim. This includes, but is not limited to, estimates,
receipts, medical bills, pictures and any other information you feel may be relevant to your
claim. It is also recommended that you send in copies of these items and keep the originals for
your records.
What Happens After I File My Claim?
Once a claim has been received and file-stamped by the City Clerk, it is forwarded to the City
Attorney's Office for investigation. Claims involving personal injury or substantial property
damage will be forwarded to the City's claims agency for investigation. You will receive a letter
from the City Attorney's Office indicating that your claim has been forwarded to the claims
agency. This letter will also contain the claims agency's contact information.
A claims adjuster will then contact you regarding your claim. At that point, any questions
regarding your claim should be addressed to the claims adjuster. All other claims will be
forwarded to the appropriate City department for investigation. After speaking with employees
and consulting department records, the department manager /supervisor will make a
recommendation as to whether the claim should be approved or denied.
Based on that information, the City Attorney will then make a recommendation to the City
Council as to whether the claim should be approved or denied. If the City Attorney recommends
that the claim be denied, you will receive a copy of the department manager /supervisor's
report along with the City Attorney's report to the City Council.
If the City Attorney recommends that the claim be approved, you will receive the City Attorney's
report to the City Council as well as a release form to be signed and returned to the City
Attorney's Office. These are only recommendations. It is important to note that the final decision
on all claims is made by the City Council.
No employee of the City has the authority to make any representation to you as to whether your
claim will or will not be paid. If the City Council approves the claim for payment at its City
Council meeting, a check will be mailed to you provided the City Attorney's Office has received
your signed release form.
What if My Claim is Denied by the City Council?
The City Council makes its determination at City Council meetings, which are held the first and
third Monday of each month. We recommend writing a letter to the City Council indicating why
your claim should not be denied and any additional information that you have to support your
claim.
It is not necessary to appeal the City Attorney's recommendation for denial of your claim before
the City Council makes its determination, however, you may do so. You are invited to attend the
City Council meeting when your claim will be decided; however, your attendance is not
mandatory and you still have the right to appeal the City Council's decision any time after it has
been made.
If your claim or appeal is denied, you have the option of filing a lawsuit in a court of appropriate
jurisdiction.
How Long Do I Have to Wait Before My Claim is Resolved?
The length of time it takes to investigate and resolve a claim depends largely on the nature of
the claim and the amount of damages involved. Some claims may take a few weeks to resolve,
while others may take longer. If you wish to check on the status of your claim or if you have any
questions or concerns about the process, contact the City Attorney's Office at 563.583.4113.
How Long Do I Have to File a Claim?
You may file a claim at any time. However, if your claim is denied by the City Council and you
wish to file a lawsuit, you should be aware that state law may limit the time in which to file a
lawsuit.
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WESTSIDE AUTOMOTIVE
1010 CENTURY CIRCLE
Dubuque, IA 52002-0000
Shop Phone: (563) 582-4253
Fax: (563) 582-9328
Hat/Ref: WESTSIDE AUTOMOTIVE
Estimate
~ 793 ~
Estimate Ref #793
Date Printed: 06/25/2009
Printed Time: 10:57 am
Time Promised:
DIETZEL, KATIE 2000 DODGE NEON L4 2.OL 1996CC 122CID FI GAS N C
VIN:
License: NEW Mileage In: 0 Date Written: 06/25!2009
Home: (563) 556-1192 unit#: Mileage Out: 0 Written By:
Cell: DOM: Save Old Parts: No
Job Name Description Technician Qty List Extended
Job #1
Part NFG Windshield 1.00 242.37 242.37
Payment Date Type Method Amount
Payment Totals:
Parts: $242.37
Labor: $0.00
Sublet: $0.00
Misc: $0.00
Hazmat: $0.00
Supplies: $19.39
Tax: $18.32
Invoice Total: $280.08
"...Yes We Can"
I hereby authorize the above repair work to be done along with the necessary material and hereby grant you and/or your employees permission to operate the
car or truck herein described on streets, highways or elsewhere for the purpose of testing and/or inspection. An express mechanic's lien is hereby
acknowledged on above car or truck to secure the amount of repairs thereto.
Authorized By Date Time