Claim Steffen, CatherineCLAIM AGAINST THE CITY OF DUBUQUEFJOWA
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:
4. Date of Incident:
5. Time of Incident: /O ~ 5 ~
6. Location of Incident (Be specific):
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.) ..
8. What were weather conditions like?
9.. GiTM name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
t1!
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 damages.'
Attach estimates of damages or describe basis for ascertaining extent of damage.)
13. What other damages do you claim, if any?
~4. H~ve you been compensated for ~ny p~rt or ~1 of your el~im by ~ny insurance
company? (If so, give n~me ~n~ ~d~ress o~ insurance ~omp~y~d)~mount p~id.)
15. What amount do you claim from the City of Dubuque?
lB. 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 at Dubuque, Iowa this
~day of ~~
,20 0.':3,
(Signature~~?'
(Print Name)
(Rev. 1/00 & 7/01)
ROSS BODY SHOP '
FARLEY, IOWA 52046
(563) 744-3545
ADDRESS . ~
INSURED BY
__PHONE
ADJUSTER __ PHONE
BELOW I$ OUR J~STIMATE TO REPAIR YOUR
Sub To~
T~x
Materials
Total
BY
AUTHORI~TION FOR REPAIRS
SIG~ED DATE