Claim by Paul M. OlsonCLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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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 13"' 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 Ciry of Dubuque has the authority to
make any representation to you as to whether your claim will or will not be paid.
Name of Claimant: Paul M. Olson (Paul Olson)
2. Address:980 Jackson St. apt. #1, Platteville WI 53818
3. Telephone Number:
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4. Date of Incident: ~l _~2. L/g
5. Time of Incident:
6. Location of Incident (Be specific): Loras Blvd. 400 Block
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 employee's name.)
t~l~~'n ~~ ~~1 lp ~ 4~~ Y~IcCi! o~ llira:~ ~7h~ bus wa ~ c~astf.~xr.,d~~ ,~~,as
~1 ~r~ ~~s -~-~U i~_-{~t (,_ car 0.-r ram c ~~ C] 11 Q ~liYkl~~~i~ y.~y ~~ri-~ UI~, 4'Pa1r C~cx~r U~~r ~,
~~~~~1~'1P_. ~IVPY OF ll~rw. }. ~~S_ i r~ ~ ~1~ y , ~ r~ ~~r}ter TIC cL•~,~- ~15L~~~~~j welt ~.,~
8. What were weather conditions like? ~ ~ ~~~ ~~~s "' 1e'~ ~~h'uc: ice, ~ c~
~,,,,, ~ f'.(1 i' ~ W 1G~ ~~, ,1"lYll .1 ~f~.rl Icae.. _ ~`~
9. Give name and address of any witnesses: ~U~Y~ i/ i CL. ~~ u, l.~ ~ ~r~l'~ ~ ''~raS ~1 /d
I~ ~~;0 ~ Qa,1C~ ,fir" ~ ~e 41~{'Y~~ I11rc1~ Rivd 17~,~p. ~}1
10. Did police investigate? (If so, give names of officers.)
11^.Was anyone injured? (If so, give names, addresses, and extent of injuries.)
1. V
12. Was any damage done to property? (If so, describe properly and the extent of damages. Attach estimates of
damages or describe basis for 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? t r rC~ ~rl,~' ~ ~ .;)) j"(~~ ~~Q
17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and
adAd~r^ess.)
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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?
Dated this ~ 9 day of ~~ ~ . , 20
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MAIL REDARTS TA• ~~
~;.;,;~, loweDaparvnentclrransportsfion Iowa Department of Transportation ''a"'En'0AC°"' °"
otticedoriw-servicea ~ INVESTIGATING OFFICERS REPORT
Psrtc Fair Mal
100 Euclid Avenue x1-08-18127
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Box 9204
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OF MOTOR VEHICLE ACCIDENT
Dee Moines
bore 50308-9204 L
, txervention7^ ~ ^
Dated Time d Accidera County AoddaM amrred wMfdn corporab limits d (cit
)
L y
04!23/08 13:bs Fks. Dubtpw • 31 Dubuque - 2100 Locatial Literal Deaaiptlon
0
N aacldeM occtrred outside d dry IYnils LORAS BLVD
C above gertsral viclrlky'. "WA" d nearest dry "Wq"
On Raad, Saeet, a Highway: At kttetseUion ~:
A LORAS BLVD "WA"
T Note: Unless aceidsra occurred at an intersection which is comp btely described above, use eb space bebw to give Ote exact
~ beatlon trarrr a mibpoat or definable irrharsacsion, bridge, a reikoad crossing, using two distances and d:eclloru N necessary. X-Coord'atate: 00691 Z82
O Dbtartce Dirodfon Distance Direclion
100 Ft 7
"
" "
" Y-Coordlnate:0470848b
N -w and
WA
WA
d H Divided Hlghwsy
Pravida Route
Mibpost Nurturer Defstade intersection. txidge, or reitoad crossing ,
(Cardnal) Travel Direction
"WA" Or LORA$ AND BLUFF "WA"
Drivers Nams -Last Fint Midde Six p~
BRUNSMAN J HN BERNARD 3667-6471 x
26~361NDU1NASTREET UB 44 2001-0000
Date d Bkth Drivers License Number Citation Charge Code t Citstiwt Charge t
07/04/1938 024XX3976 32-321.288 CONTROL OF MV
Gender State Class EtWOraernerMS Restriclbne Citation Charge Cads 2 Cltetion Charge 2
Mob IA C P L
AkxAlol Teat
Dap Teat Citation Charge Coda 3
Ci4kion Charge 3
G^ron7 Test Rewks. Given? Tast Rawlts: Citation Chage Code 4 Citation Charge 4
1-None 1-None
IJ
N Sealing Position0l Injury stah,s b OceupeM Prdeetion9 Airbag Depbyment 6 Airbag Swflch Status 3 Ejection 1 Ejeaion Pelh 1 Trapped 1
reneparted to: Transported by.
T
Owners Name -Last
First
Midrib SuRuc part'
~
OF DUBUQUE
001 AOdi"$'
sow. 13TH Ci
DtlBUC1uE
w e
a2po1
Insurance Co. Name
IA COMM ABSURANCE POOL Insurance Pdicy # L icxgs Pbb # State Year
8 7361 ~ ~~
VIN No. Year Make Modal SryW T
7FOXE46832FW7eb7 2002 Font -FORD BUS BU ow #
NO Apprwdmete Coat b
Rspairor Rspleoe
ktitial Travel Vehicle Speed Print d Most Damaged Extent d lktderride/ P
Dh
ti
2 rivate?
ac
on
Adios 01 Limit 26 Initiallmpact 03 Arse 03 Damage 3 Override 1 ^ 14,000.00
Total Traffic Vahkb Cargo Body Vehkls Driver Vision C oMributktg Ciramsterxros
Occupants S
(;ontrda 01
Confg. 18
Type 02
Doled 01
Condition 1
Obsdsad 01 D ,
river (up to two) 08
SEOUENCE OF EVENTS First Event 23 Second Event 7tlird Event Fourth Event Moat Harrrltul Event (by vehicle) 23
Commercial Tracer Attached to Stab Year AMached to Stab Year Errlergerlcy Emergency
License Plate # Power Unit Troller Unk: Vehicle Type 1 Status 3
Cartier Name Address City State lap
US DOT # or MC # Nlsnber d Grog Vetide placard # Ha:erdous Materiels
Axba WsipM Rating Rebased?
Drivers Name - Last First Middle SuRor Phone
808 842298 x
Addrosa City State Zip
Date d BkMI Drivers License Number Citation Charye Cade 1 Ci4tion Charge 1
Gondar Smta Class EndoraemsMS Restrictions Citation Charge Code 2 Citation Charye 2
NONE NONE
Akdtol Teat
Dap Teat Citation Charge Code 3 -
Citation Charge 3
Given? Tact Rawlts: Given4 Test Reaulta: Citation Charge Code 4 Citation Charge 4
V Boating Positlon Iryury Status Oealpant Probction Airbag Deployment Airbag SwiMh Stator Ejection Ejection Path Trapped
N
I Trenaported oo: Transported br•
T OLSON~~ - Last ~L ~ spa Owner Company t4arrls
~2 Address
1100 HATHA
U zzIIpp
WAY P
4TTEVILLE VYI b3818
Irtstranu Co. Name
PROGRESSIVE CLASSIC Insurance Pdiq # L icanae Pbte # Stets Year
27868136.4 8 31LTY wl 2008
VIN No.
1O2tMt67JX2Ft2s~34 Year
2003 Make
Ptxttlac -FONT Model
GRAND PRIX Style T
4D N ow k
O ApprWdrnate Cost b
Regale or Replace
IMibl Trawl YN7Icla Speed Print d Most Demsgad Exbrrt d UrWertideJ P
Direction A
to
12 rivate?
c
n
LmR 26 In BIN Impact 07 Area 07 Damage 3 Override 1 ^ 12 600.00
Total Traffic VetYCb Cargo Body Vehicle Driver Vision C
Ocapants 0 Contrds 01 CorY
01 T
01 onU>'buting Ciramsterloss,
g.
ype
Oelect 01 Condibar Obscurod D river (up to two) 28
SEQUENCE OF EVENTS First Evert 21 Second Event Third Event FairMi Evert Most Harmful Event (by vehicle) 21
Cammxdal Troller Attached to State Year Attedrod to Stets Year
Lkerns Plate # Power UnH: Trail
UMt Emergency E
t
er
: Veltide Type 1 3
j
Carrier Name Addrosa City Bleb Zip
U8 DOT # ar MC 0 Number d Gress Vehicle Plaprd # Harardow Metsrisb
Axba V1lOiplt Ralkp Rabesed7
Printed At: Dubuque Pollee Departtrlent 04/24/2008 02:48 PM
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Page 1 Foam tk: 01-06-16127
ACCIDENT ENVIRONMENT ROADWAY CHARACTERISTICS WORKZONE RELATED? SEQUENCE OF EVENTS
MajorCorNritxNngCvunstancw: Np
Location d First Harmful Everx t Weather Conditbns Environment 1 ~~ Fnt Harmful Event d Craah
Manner d CraecYCdlieion g (uP a ~) 01 Roadway 01 Type (use codas 17 ~2 only) 21
Light t.anditlans 1 Surtaoe Conditions 1 Type d Roadway ,krtelionlFeahaa 01 111forkara Present?
D
1
A
Lams Bwd
G
R
A
M
-~ lei
lL~ ~ I
NARRATNE
Describe what happened (refer to vehkks by numbeh
UNIT 2 WAS PROPERLY PARKED IN THE 400 BLOCK OF LORAS BLVD. UNIT 1 WAS EASTBOUND ON LORAS BLVD. THE
DRNER REAR DOOR WAS OPEN ON UNIT 2 AS ITEMS WERE BEING TAKEN FROM THE CAR. UNIT 1'S DRNER DID NOT
SEE THE OPEN DOOR UNIT 1 STRUCK THE OPEN DOOR CAUSING DAMAGE TO BOTH UNITS. THE TUW LISTED
WITNESSES ARE NOT RELATED TO EITHER UNIT. BOTH WERE STANDING NEARBY. BOTH WITNESSES SAY THAT THE
DOOR WAS OPEN LONG BEFORE THE BUS CAME INTO THE AREA.
w s - roc x
I AAILLER KATEAYiA
T Adddrea Cky State Zip Cods
N
E 4221/2 LORAS DUBUQUE U1 52001
8 Home Plane I Work Phone A
8 (563) 513-3440 x (563) 513.1440 x
yy sore - t and
I LEE BUTCH
T Address City Store Zip Coda
N
E 4141f2 LORAS DUBUQUE IA 62001
S Home Phone a Work Ptarte M
8 (56315873876 x (663) 557-3878 x
Olfaer BadOe No. Time Oflicsr Ndtflad d Accident Time ONlosr Artivad At Scene
TUPPER JEFF 21A 14:05 Hre. 14:10 Hrs.
Name d AOancy Date d Report Inveatgation T.I. s+
Dubuque Pollee Depa 04/23/2008 mods ~ sairii7 Yas
Report Revk~wed By: Date 6 ~ AOertcY Spscfic Ovwr Tatlxtieal ktveatipation Agency
Printed At: Dubugw Polito Deparpnent 04l24f20p6 02:46 PM Page 2 Form M: 01-OB-i6t27