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Claim by Sally A. Lang for Courtney MeyerCLAIM AGAINST THE CITY OF DUBUQUE, IOWA ~ ~Z~ 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. 13~' 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: Sally A Lang -Courtney Meyer(minor Child) 2. Address: 1470 Adair St Dubuque, Iowa 52001 3. Telephone Number: 563-542-0805 4. Date of Incident: 12/17/09 5. Time of Incident: 8:52am 6. Location of Incident (Be specific): W and and Cardiff Stand Summit St 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.) i-u Q~nn ~i o ~ 1F P ~ n ~) o l i re r9 c ~a_S ~'r:, w, ~ S 'R , 1A~c"_ l ~-`.t - Co ~ }-r~ e.~ •~-c~.r n eo~ m m i t ~~ M t ~ •~ m e l e b~ r~ G~.nGI \ C,c~-F ~ ~ bc~cjC. 8. What were weather conditions like? Cloudy and cold 9. Give name and address of any witnesses: none 10. Did police investigate? (If so, give names of officers.) Yes Officer Dan Sabers 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). Yes Courtney Meyer she was treated for cervical strain(whiplash), Contusion(deep bruisinQl. and meral~tia aaresthetica(disordereaused by comaression of a nerve in the Thioh) address is 1470 Adair h-e s a~ dl 1r-i ~ ~ •~s~- ~ ~ ~ ~~ l ~~ cxand~- ~ ~~u e_q,c, ~ ro eec. J --{v ' ~ ~u ~~ ro e,ed ec~ d,.C~n ~ h-r r 1 ~p ~.~~ ~(:t.S v~,ln 0.b ~ e ~ ~ C~ (~ S~-~C'v C:~- G Y''~ Cl ~ ~ ~k- -~,~ ~o `~'Y" 1.1 Q~- ~ ~ ~ ~ ~ ~ ~~ S O ~~OV~e C~: ~ ~(l~ ~-ov~-c E-he~ 5 CC~.~C a ~~^-~- C ~- 1 ~e `'C1r~-Q C~-(~vna- ~-a ~ ~ ~. Cc~uX~-~n ex`~~ Ca_,r 1o~~1r~ C~-~' ~v~e~ s ~ r~.e ~;dors ~ ~r©h~- ~e~d.~ ~,cg`n S Z S ~-- C~ ~r ,,I ~ (~l.-~ C.~e- ~ `~ti i Z 1 S 1~~ L ~- c~ s `~=-Q IJUt(~l GLIB-~~ pSS ,\ ~~ ~Q~1 ,~ ~~ ~-- In a.u-e... ` ors ~-sc-~ ~r-5 S L ~ ~~ r~e ~t,5 1 ~ eCJn t ~ OJ r ~ ~©rn ~.-~n ~ ~ ~c:~.~.x. s.~.. ` ~ ~~~~ v,~ot~~ cal 1/1.C3~ `~-~c'~ '~ (~..~' '~3 p~~ • ~-~ ~ 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.) [a~fo Fan- ('c~~~w'' - ~~-~. C~,rr~'S Srde ~~~ors . ~°'~Y~~~'- ~~~ , ~r~f 6~ ~ ~`~ uPX s~ arc ~.~ ~ne~~ ux~s ~ eQn irc whir caused f rG~i ~' ~-o ~'1ru~ on . 13. What other damages do you claim, if any? lr~ss o,~ ~aQes ,e` ~bo~-h ('~ \!n. i .~ n 1 ~~.. _ _. _ ~..n .~ ~.~~ i.~ ~tiivi ~.. r~. ,_1n1 1J tf. _~. _ \ .. r'1A ..~ L ~'t 1 J /!n ..~ T...~ 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? ~ ~ nnlc,rnc~ 1~ ~ c~~ ~, ti S ~- ~ m4. - c1 ~,~ 4yr ~~ f~ 1.1 ~~ ~', ;11 c , ti 16. Why do you claim the City of Dubuque is responsible? Because it was clearly the fault of your driver James Welty he admitted itto the officer 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? Dated at Dubuque, Iowa this ~ ~l day of ~CP~~i~ 20 Owl . ignature) n r%` ~- - c~ r-~ J tint Name) ~ 1:.;. ~ -'~ c -_ _; ~ '1 'y'r ~-'~ _ l ~_• `0. rr `` W . '~ r~~~ ~-~.l (Rev. 1 /00 & 7/01) ExitCare® Patient Information -Courtney Meyer - ID# - MR# THE FINLEY HOSPITAL UDWA HEALTH s~~M 350 North Grandview Ave., Dubuque, IA 52Q01, Main (5b3) 582-1881, ED (563) 589-24b0 EXITCARE® PATIENT INFORMATION ED DISCHARGE INSTRUCTION SUMMARY Patient Information Patient Name: Courtney Meyer Sex: F DOB: Address: Telephone Number: ( ) - Visit Information Discharge Date/Time: 12/17/2009 / 1:09:25 PM Provider: Tonya Elvidge, P.A. Other Providers: Diagnosis/Impression: cervical strain (Whiplash) Contusion (Contusion) Discharge Instruction Sheets Provided: Contusions zzz -About Your Care Whiplash Patient Instructions: Followup Appointments/Instructions: Primary Follow-up Information As Needed: Cory L. Dietz, MD -Dubuque Family Practice, P.C. 320 N Grandview Avenue Dubuque IA 52001 (563)583-9300 ©2009 ExitCare, LLC 1/1 12/17/2009 1:09:25 PM ExitCare® Patient Information -Courtney Meyer - ID# - MR# LENGTH OF ILLNESS Generally, the prognosis for individuals with whiplash is good. T'he neck and head pain clears within a few days or weeks. Most patients recover within 3 months after the injury. However, some may continue to have lasting neck pain and headaches. :RESEARCH BEING DONE The NINDS conducts and supports research on trauma-related disorders such as whiplash. Much of this research focuses on increasing scientific understanding of these disorders and finding ways to prevent and treat them. Research is continually being done to learn more about this problem. Provided by: The National Institute of Neurological Disorders and Stroke. FOLLOW-UP INSTRUCTIONS As Needed: Cory L. Dietz, MD -Dubuque Family Practice, P.C. 320 N Grandview Avenue Dubuque IA 52001 (563)583-9300 Document Released: 9/27/2006 Document Re-Released: 10/14/2008 Document Reviewed: 7/24/2008 "Best Outcome for Every Patient Every Time" www.finleyhospital.org ©2009 ExitCare, LLC 5/5 12/17/2009 1:09:25 PM ExitCare® Patient Information -Courtney Meyer - ID# - MR# THE FINLEY HOSPITAL IOWA HEALTH svsreM 350 North Grandview Ave., Dubuque, IA 52001, Main (563) 582-188:1, ED (563) 589-2460 EXITCARE® PATIENT INFORMATION Patient Name: Courtney Meyer Attending Caregiver: Tonya Elyidge. P.A. Whiplash Whiplash is a soft tissue injury to the neck. It is also called neck sprain or neck strain. It is a collection of problems (symptoms) that occur after damage to the neck, usually because of sudden extension and flexion. It may ~~ include injury to intervertebral joints, ,1 discs, ligaments, cervical muscles, and ,~-~°''~~"`" nerve roots. a~r~.ansrrars 1 :~ MACK CAUSES The disorder commonly occurs as the result of an automobile accident. SYMPTOMS y Neck pain maybe present directly after the injury or may be delayed for several days. ~- In addition to neck pain, other symptoms may include: Neck stiffness. Injuries to the muscles and ligaments. Headache. Dizziness. Some people experience conditions such as: Memory loss. Concentration impairment. Nervousness. Irritability. 1 !! HKA[i 1`li~tfJtVN l._ ~ ~ x3" :, ~ -- O SEIf & ASSOCIATES, INC., 2U04 Abnormal sensations such as burning or prickling (paresthesias). Shoulder or back pain. Sleep disturbances. Fatigue. Depression. TREA~I'N9EhT Treatment for individuals with whiplash may include: Pain medications. y Nonsteroidal anti-inflammatory drugs. .- Antidepressants. Muscle relaxants. Cervical collar (usually worn for 2 to 3 weeks). Range of motion exercises. r Physical therapy. y A cervical traction may also be prescribed. r Supplemental heat application may relieve muscle tension. ©2009 ExitCare, LLC 4/5 12/17/2009 1:09:25 PM ExitCare® Patient Information -Courtney Meyer - ID# - MR# 0 THE FINLEY HOSPITAL IOWA HEALTH s~ 350 North Grandview Ave., Dubuque, IA 52001, Main (563) 582-1881, ED (563) 5$9-2460 EXITCARE® PATIENT INFORMATION Patient Name: Courtn~ Meyer Attending Caregiver: Tonya Elvidge. P.A. About Your Care You were examined and treated today in the emergency department on an emergency basis only. Your care was directed primarily to your emergent problem and was not intended to be a substitute for, or an effort to provide, the complete and comprehensive medical care provided by a personal physician. We cannot recognize and treat all the elements of an illness or injury in one emergency department visit. It is also difficult to treat anon-emergent or chronic condition in an emergency department setting. In many instances you must let your doctor check you again. It is therefore essential that you arrange a follow up appointment with your own physician or the physician indicated in your discharge materials. If any new or worsening symptoms should develop and you cannot reach your physician, return to the emergency department. The condition which brought you to the emergency department has stabilized and you are being discharged. Tests performed today have been interpreted by your emergency care provider. The hospital will review some tests such as X-ray studies and EKGs again after your visit and we will contact you if there are any new recommendations. Some laboratory tests, such as culture studies, may not be available for several days. It is important that we have a correct telephone number in case it is necessary to contact you. If you had X-rays taken today you may need to pick them up to take with you to a follow up appointment. For your convenience you may call ahead to have your X-rays available for you to pick up. The Finley Hospital radiology department: (563) 589-2402 We are concerned about you and your health care needs and invite those patients without a personal physician to contact The Finley Hospital's "My Nurse" at 1-877-242-8899. My Nurse is a free health information service available 24 hours a day, seven days a week and can help you secure a doctor and answer your health questions. You may receive a survey in the mail asking how the service was in our emergency department. Your comments are very important to us. Please take a few moments to complete this survey and let us know how we are doing. r _ -- -- --- - _ --- _ - -- - ---- - - -- - If you feel unsafe in your relationshipplease call 1-800 332-5899 FOLLOW-UP INSTRUCTIONS As Needed: Cory L. Dietz, MD -Dubuque Family Practice, P.C. 320 N Grandview Avenue Dubuque IA 52001 (563)583-9300 ©2009 ExitCare, LLC 2/5 12/17/2009 1:09:25 PM ExitCare® Patient Information -Courtney Meyer - ID# - MR# THE FINLEY HOSPITAL IOWA HEALTH 5vsreM 350 North Grandview Ave., Dubuque, IA 52001, :Main (563) 582-1881, ED (563) 589-2460 EXITCARE® PATIENT INFORMATION Patient Name: Courtney Meyer Attending Caregiver: Anthony Markham. M.D. Meralgia Paresthetica Disease Meralgia paresthetica (MP) is a disorder characterized by tingling, numbness, and burning pain in the outer side of the thigh. The disorder is caused by squeezing (compression) of a nerve in the thigh. It occurs in men more than women. MP is generally found in middle-aged or overweight people. People with the disorder often report that it appears or worsens after walking or standing. The skin maybe sensitive to touch. MP maybe associated with tight clothing, pregnancy, diabetes, and obesity. TREATMENT Treatment for MP is based on your symptoms and supportive care. Treatment usually involves wearing looser clothing, weight loss, and avoiding prolonged standing or walking. Your caregiver will prescribe a medication for you. In very few cases in which pain is persistent or severe, surgery maybe needed. Sometimes, the disorder may disappear all of the sudden. t~Vl-IAT WILL 1IAPPEN MP usually eases or disappears after treatment. Surgery is not always fully successful. Research is being done to learn more about this problem. FOLLOW-UP INSTRUCTIONS 02-03da s: - - Document Released: 12/8!2003 Document Re-Released: 3!26/2009 Document Reviewed: 12/18/2006 "Best Outcome for Every Patient Every Time" www.finleyhospital.org ©2009 ExitCare, LLC 1 /3 12/18/2009 2:19:08 AM . ExitCare® Patient Information -Courtney Meyer - ID# - MR# THE FINLEY HOSPITAL IOWA HEALTH 5vsreM 350 North Grandview Ave., Dubuque, IA 52001, Main (563) 582-1881, ED (563) 589-2460 EXITCARE® PATIENT INFORMATION Drug Summary Take these medications: 'Status , Drub Name .Form ~_ NEW Ibuprofen .;Tablet (Oral) _- -- _ 1- - ___ Directions/Notes:by mouth as needed -Take as needed for pain -- _ - - Drug Allergies: None Entered ;Strength Dose Frequency 800mg - 1 tab orally Ild3aimes a ~~, 1_ Y _ ~ Take with food. Call your doctor for medical advice about side effects. You may report side effects to the Food and Drug Administration (FDA) at i-800-FDA-1088, the FDA does not provide any medical advice. ©2009 ExitCare, LLC 1/1 12/17/20091:09:25 PM ExitCareO Patient Information -Courtney Meyer - ID# - MR# THE FINLEY HOSPITAL IOWA HEALTH SYSre~t 350 North Grandview Ave., Dubuque, IA 52001, Main (563) 582-1881, ED (563) 589-2460 EXITCARE® PATIENT INFORMATION Patient Name: Courtney Meyer Attending Caregiver: Tonya Elvidge, P.A. Contusions You have a deep bruise (contusion). Contusions are areas of tenderness and swelling in the soft tissues. They are the result of damage and bleeding in the injured area. Minor trauma will give you a painless bruise, but more severe contusions may stay painful and swollen for a few weeks. HOME CARE INSTRUCTIONS Rest the injured area until the pain and swelling are better. Apply ice packs every few hours for 2-3 days, then use moist heat. Elevate the injury to reduce swelling. Compression bandages also help reduce swelling and motion. A hematoma may form in large contusions. This is a collection of blond in the deep tissues. Hematomas are usually reabsorbed by the body naturally. Sometimes they need to be drained. SEEK II~~IMEDIATE MEDIC'AI. CARE IF YOU DEVELOP: r Signs of infection (increased redness, swelling, or pain) r Numbness or coldness. FOI_,L.OVV-UP INSTRUCTIONS As Needed: Cory L. Dietz, MD -Dubuque Family Practice, P.C. 320 N Grandview Avenue Dubuque IA 52001 (563)583-9300 Document Released: 1/25/2006 Document Re-Released: 10/4/2007 Document Reviewed: 12/18/2006 `Best Outcome for Every Patient Every Time" www.finley6ospital.org ©2009 ExitCare, LLC 1/5 12/17/2009 1:09:25 PM ExitCare® Patient Information -Courtney Meyer - ID# - MR# THE FINLEY HOSPITAL IOWA. HEALTH SYSreM 350 North Grandview Ave ,Dubuque, IA 52001, Main (5b3} 582-1881, ED (563) 589-2460 EXITCARE® PATIENT INFORMATION Drug Summary: Status Dru Name Form. Steen Y~ Dose Fre uenc NEW Ultram Tablet (Oral) 50mg 1 to 2 tabs every 6 hours ~Directions/Notes:as needed for pain - _ y _ __ _ _ _ _ _ -_ _ NEW T lerial Tablet (Oral) 325rng . 2 tabs every 4 ~..- --_ __ - ~ _~:~_ .~~_.__, hours wow 'Directions/Nates:as nee~le~4 for pain - - _ _ _ __ Drug Allergies: Patient confirmed they were not allergic to any medications. Call your doctor for medical advice about side effects. You may report side effects to the Food and Drug Administration (FDA) at 1-800-FDA-1088, the FDA does not provide any medical advice. ©2009 ExitCare, LLC 1/1 12/18/2009 2:19:08 AM ExitCare® Patient Information -Courtney Meyer - ID# - MR# ~~ THE FINLEY HOSPITAL IOWA HEALTH sYSrEM 350 North Grandview Ave., Dubuque, IA 52001, Main (563) 582-1881, ED (563) 589-2460 EXITCARE® PATIENT INFORMATION Patient Name: Courtney Meyer Attending Caregiver: Anthony Markham, M.D. About Your Care You were examined and treated today in the emergency department on an emergency basis only. Your care was directed primarily to your emergent problem and was not intended to be a substitute for, or an effort to provide, the complete and comprehensive medical care provided by a personal physician. We cannot recognize and treat all the elements of an illness or injury in one emergency department visit. It is also difficult to treat anon-emergent or chronic condition in an emergency department setting. In many instances you must let your doctor check you again. It is therefore essential that you arrange a follow up appointment with your own physician or the physician indicated in your discharge materials. If any new or worsening symptoms should develop and you cannot reach your physician, return to the emergency department. The condition which brought you to the emergency department has stabilized and you are being discharged. Tests performed today have been interpreted by your emergency care provider. The hospital will review some tests such as X-ray studies and EKGs again after your visit and we will contact you if there are any new recommendations. Some laboratory tests, such as culture studies, may not be available for several days. It is important that we have a correct telephone number in case it is necessary to contact you. If you had X-rays taken today you may need to pick them up to take with you to a follow up appointment. For your convenience you may call ahead to have your X-rays available for you to pick up. The Finley Hospital radiology department: (563) 589-2402 We are concerned about you and your health care needs and invite those patients without a personal physician to contact The Finley Hospital's "My Nurse" at 1-877-242-8899. My Nurse is a free health information service available 24 hours a day, seven days a week and can help you secure a doctor and answer your health questions. You may receive a survey in the mail asking how the service was in our emergency department. Your comments are very important to us. Please take a few moments to complete this survey and let us know how we are doing. If ou feel unsafe in our relationship please call 1-800-332-5899 FOLLOW-U[' 1NSTItliCZ'IONS 02 - 03 da s: - - Document Released: 11/2/2009 Document Re-Released: 11/4/2009 ©2009 ExitCare, LLC 2/3 12/18/2009 2:19:08 AM c ExitCare® Patient Information -Courtney Meyer - ID# - MR# LL iC THE FINLEY HOSPITAL IOWA HEALTH sr~s,~M 350 North Grandview Ave., Dubuque, IA 52001, Main (563) 582-1881, ED (563) 589-2450 EXITCARE® PATIENT INFORMATION ED DISCHARGE INSTRUCTION SUMMARY Patient Information Patient Name: Courtney Meyer Sex: DOB: Address: Telephone Number: ( ) - Visit Information Discharge Date/Time: 12/18/2009 / 2:19:08 AM Provider: Anthony Markham, M.D. Other Providers: Diagnosis/Impression: Meralgia (Meralgia Paresthetica Disease) Discharge Instruction Sheets Provided: Meralgia Paresthetica Disease zzz -About Your Care Patient Instructions: Followup Appointments/Instructions: Primary Follow-up Information 02 - 03 days: - ( ) - ©2009 ExitCare, LLC 1 /1 12/18/2009 2:19:08 AM BUTCH VALENTINE ESTIMATE TERRY VALENTINE Valentine Bros. Body Shop 375 EAST 9TH STREET DUBUQUE, IOWA 52001 PHONE (563) 556-3484 Name ~~ u~.r~,~~'y ~,~~~~~~ Address ~ ~ 7G~ ~~~~~ ~~ Date ~-~ ,;z ~' ^ r~ ~ _ ~j ~ Phone ~3 ~~~~~ ~~-U~~ Model / y~'~ ~~' Njaul7 ~I//r f3~G'~~a` License No. Estimate of Material and Labor Required Material Labor .., ~~C ESTIMATE SHEET AND REPAIR ORDER Totals Thi ti t i b d i d s es ma s e ase on our nspection and oes not cover additional material or labor which may be required after the work has been started. After the work has d d d starte , amage material which was not evident on first inspection may be dis- covered. Naturally this estimate cannot cover such contingencies. This estimate is for immediate acceptance. Grand Total *~'- W k A th ' d b r u e 0 onz y Ex~itCare® Patient Information -Courtney Meyer - I~# - MR# ~- THE FINLEY HOSPITAL IOWA HEALTH svsren~ 350 North Grandview Ave., .Dubuque, IA 52001, Main (563) 582-1881, ED (563) 589-2460 EXITCARE® PATIENT INFORMATION Patient Name: Courtney Meyer Attending Caregiver: Anthony Markham, M.D. Excuse fram Work ar School Courtney Meyer needs to be excused from Work School Physical activity Beginning now and through the following date: 12/19/2009 ^ He/she may return to work/school but still avoid physical activity from now until: ^ He/she may return to full,physical activity as of: r~~lU Caregiver's Signature Date Document Released: 6!13/2002 Document Re-Released: 1!29/2008 Document Reviewed: 12/18/2006 ©2009 ExitCare, LLC 1 /1 12/18/2009 2:19:08 AM • ~ THE FINLEY HOSPITAL IOwA H1F.ALTH slrsnat 350 North Grandview Ave., Dubuque, IA 52001, Main (563) 582-1881, ED (563) 589-2460 EXITCARE® PATIENT INFORMATION Patient Name: Courtney Meyer Attending Caregiver: Tonya Elvidge_P.A. Excuse from Work or School Courtney Mew needs to be excused from ^ Work School ^ Physical activity Beginning now and through the following date: 12/17/2009 ^ He/she may return to work/school but still avoid physical activity from now until: ^ He/she may return to full physical activity as of: Caregiver's Signature ;~ Date Document Released: 6(13/2002 Document Re-Released: 1/29V2008 Document Reviewed: 12/18/200G riC,.,.- ~~ ~ "Z ©2009 ExitCare, LLC 1 /1 12/17/20091:09:25 PM ,.1 -~ /~_ F t g L ~~~ tit '- ~ , `~-- ~. a '~ `~ < ~ . , 1 ~ `, ~ ~- ~~, ,~~ vim. _ ~ 1 1~.~... ~.. ,L., r ..` , i q~ ~~.... `_ ii" i ~. 1 1 ~ ~.y;, ~ ~ ~~. r_ r.. .1_ LL.~ ~ 1 ~lLL ~ ~~ ~ ~,...~~ L.l„_lC~~;.~~ ~ ~ LL i. ~ ~ ~ ~.. ~... ~ ~ ~'~ t.~..r~,}~,~t l-~_~ r~+ ~~ Driver Information Exchange Report Dubuque Police Department 563-589-4410 .-----~ \'n~,a. ~ ,~0 ~+~ Drivers Name -Last First Mkldle Suffa Date of Binh ~`--~- V WELTY JAMES ROBERT 10108/1888 N Address Cily State Zip HonrelCell Phone 16435 OLD HWY ROAD PEOSTA U1 52088-0000 I Gender Drivers License Number Class State Endorsements ResMdions Inwrenoe Co. Neme Insurance Co. Phone # T Male 854223738 A IA LN NONE IOWA COMM.ASSURANCE (563) 588-0101 x ~~ 001 Owner Comparty Name Inwrence Polley # W`(~~~ ~ ICAP0300 v _ __ Owners Name -Last First Middle Suflb: CITY OF DUBUQUE Address CMy State Zip 825 KERPERBLVD DUBUQUE IA 62004- VIN No. Year Meke M odel Style Vehicle Configuration 1FVABXAK71HJ17234 2001 FRGT TK License Plate # State Year Most Damaged Area Approximate Cost to Repair or Replace 84833 IA 2020 Drivers Name -Last First Middle Suffa Date of Birth U N Address Cily Slate Zip Home/Cell Phone T Gender Drivers Lioense Number Class State Endorsements Restrictions Inwrence Co.. Name Inwrence Co. Phone # NONE NONE 002 Owner Company Name Inwrence Policy # Owners Name -Last First Middle Suffa BURDS RONALD JOHN _ Address City State Zip ~ 1311 N GRANDVIEW DUBUQUE IA 52001- VIN No. Year Make M odel Style Vehicle Configuretan 1GCC3186728184088 2002 CHEV License Plate # State Year Most Damaged Area Approximate Cost to Repair or Replace 833LQP IA 2003 Drivers Name -Lest First Middle Sulfa Date of Blrth U MEYER COURTNEY MARIE 05H8/1893 N Address Cily State Zip Home/Cell Phone 1470 ADAIR ST DUBUQUE U1 52001 _ (683) 542-0805 x I Gender Drivers License Number Class Stale Endorsements Restrid'ans Inwrence Co. Neme Insurance Co. Phone # T Female 120AC53S4 C IA NONE NONE PROGRESSNE CASUAr_TY (563) 668.6888 x ~3 Owner Cortrpany Name Inwranoe Polley # 30817599-0 Owners Name -Last First Middle Sulfa MEYER COURTNEY MARIE Address City State Zip ~ 1470 ADAIR ST DUBUQUE IA 52001- 1 VIN No. Year Melee Model Style Vehicle Configuration 1FALP6634TK194280 1996 FORD C NT 4D '. License Plate # State Year Most Damaged Area ~ Approximate Coat to Repair or Replace 921WRP IA 2010 If Property other than - Object Damaged Estimate of Damage Was Cwner or Tenant Noted? R p vehicbs damaged expkin ELECTRICAL POLE :6,000.00 Yea O A Owners Name -Last Flrat Middle Suffa e AN e n ALLUINT ENERGY ALLI T ENERGY R G Street or RFD Cky State Zip Code T E DUBUQUE IA 52001 Y Prlrtted At: Dubuque Police Deoartmertt 12117/2008 70:18 AM Page 1 Form #: 01-08.68rNe County Accident occurred within corporate limds of (city) Dubuque - 31 Dubuque - 2100 Literal Description W 3RD ST and CARDIFF ST and SUMMIT ST XCoortlinate Y1:oordinate 00881318 04707324 _ If accident occurred outside of city Dired'ron Nearest City Route (Cardinal) kmits show general vecinity: "NIA" "N/A" of "NJA" Travel Direetbn NB On Road, Street, or Hghway: At Intersection wkh: CARDIFF ST W. 3RD ST Distance Direction Distance ~ Direction Mibpost Number "NIA" "NiA" and "NIA" "NIA" of "N/A" Or Definable intersection, bridge, or railroad crowing "N/A" _ Officer Badge No. haw Enforcement Case Number Date of Accident Time of AakleM SABERS, DAN 80 01-08-68416 12117/2008 08:52 Hrs. 'D~