Claim by John CorbetCLAIM 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. 13t" 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: John t. Corbett
2. Address: ~% ~ ~,~ ~~~ ~:,c~~~-~i
3. Telephone Number: ,~~.~ -~ .5' t~ > .2
4. Date of Incident: ~ !~ - L tL ~, ~ ~r
5. Time of Incident: ~° ; ~~
6. Location of Incident (Be specific): ~ ~ ~ b f'i~ ,ns ~ .~
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. Give name and address of any witnesses: ~, ~,,.~,~ ,
10. Did police investigate? (If so, give names of officers.)
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.)
/ W ~>
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.)
`~'~ d
15. What amount do you claim frgrn 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.) /_
18. if the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
,~~i~
Dated at Dubuque, Iowa this ~ day of ~~z~ v' ~ ~~, /3,~~ 20,x,.
(Signature)
~~rl ~,~/ ~ `J ~~ /~ ,N ~ i (Print Name)
(Rev. 1100 & 7/01)
~! '~il~nt~n(]
2~i~~n s;`.1~~,~, f~i~
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Printed At: Dubuque Police Department 10/14/2009 09:09 AM Page 1 Form #: 01-09-48365
~~ Driver Information Exchange Report
Dubuque Police Department
563-589-4410
Driver's Name -Last First Middle Suffix Date of Birth
U DUVE LUKE STEVEN 07/04/1960
N Address Cily State Zip Phone
i 2698 UNIVERSITY AVE DUBUQUE IA 52001-0000 (563) 663-0848 x
.I. Gender Drivers License Number Class State Endorsements Restrictions Insurance Co. Name Insurance Co. Phone #
Male 313VV2118 A IA LN NONE IOWA INSUR. POOL (563) 589250 x
001 Owner Company Name Insurance Policy #
CITY OF DUBUQUE ICAP 0300
Owners Name -Last First Middle Suffix
Address City State Zip
50 W. 13 TH DUBUQUE IA 52001-
VIN No. Year Make Model Style Vehicle Configuration
1FDWF36R48EA76718 2008 FORD F350 TK
License Plate # State Year Most Damaged Area Approximate Cost to Repair or Replace
110153 IA 2009
Drivers Name -Last First Middle Suffuc Date of Birth
U CORBETT JOHN THOMAS 01/21/1919
N Address City State Zip Phone
i 873 LOWELL ST DUBUQUE IA 52001-0000 (563) 583-5412 x
.r Gender Drivers License Number Class State Endorsements Restrictions Insurance Co. Name Insurance Co. Phone #
Male 706XX1652 C IA NONE NONE NONE
002 Owner Company Name Insurance Policy #
Owner's Name -Last First Middle Suffix
CORBETT JOHN THOMAS
Address City Gtate Zip,. _
873 LOWELL ST DUBUQUE IA 52001-0000
VIN No. Year Make Model Style Vehicle Configuration
1G4AG55MOS6510918 1995 BUIC CEN 4D
License Plate # State Year Most Damaged Area Approximate Cost to Repair or Replace
899AVS IA 2010
Counly Accident occurred within corporate limits of (city)
Dubuque-31 Dubuque-2100 _ _.
Literal Description
°'N/A"
X-Coordinate Y-Coordinate -
..N/A" "N/A"
If accident occurred outside of city Direction Nearest City Route (Cardinal)
limits show general vacinity: "N/A" "N/A" of "N/A" Travel Direction "N/A"
On Road, Street, or Highway: At Intersection with:
PIERCE ST. "R!!A"
Distance Direction Distance Direction Milepost Number .,.
200_ Ft 5-S and '°N/A" "N/A" of "N/A" Or
Definable Intersection, bridge, or railroad crossing
PIERCE ST. AND WEST LOCUST
Officer Badge No. Law Enforcement Case Number Date of Accident Time of Accident
VOGT, JOE 85 01-098365 10/14/2009 08:34 Hrs.