Claim Lang, Christopher JCLAIM 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. 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: Christopher J. Lang
2. Address: 19386 Mud Lake Rd., Dubuque, IA 52001
3. Telephone Number: 552 -2029
4. Date of Incident: 4/13/03
5. Time of Incident: Does not say time of accident
6. Location of Incident (Be specific): Putnam & Muscatine
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 was traveling north on Muscatine while your city vehicle was traveling east on Putnam and we collided in the intersection. Mr. Jeff Tupper did not yield the right of way (police vehicle)
8. What were weather conditions like?
Dry
9. Give name and address of any witnesses: None
10. Did police investigate? (If so, give names of officers.)
Yes Does not say Accident Case #03-14258
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
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.)
Yes, 1985 Ford F-150 pickup; minor sheet metal damage now needs front wheel alignment; 1 - hubcap smashed
13. What other damages do you claim, if any?
None
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?
Cost of wheel alignment and a hub cap $100.00
16. Why do you claim the City of Dubuque is responsible?
The officer did not yield right of way
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 18 day of April, 2003.
/s/ Chris Lang
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE,'IOWA ' C/~/- ~'~;'q'~.-
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.
5. Time of Incident:
6. Location of Incident (Be specific):
3. Telephone Number:
4. Date of Incident:
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 nam e~_~ .
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 proFerty 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?
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?
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
(Rev. 1/00 & 7/01)
MIKE FINNIN FORD INc ~ No REFUNDS W,T.OUT T.,S ,NVO,CE.
J · 20% HANDLING CHARGE ON APPROVED
3600 Dodge St. RETURNS. NO RETURNS AFTER 15
DUBUQUE, IOWA 52003 DAYS. NO RETURNS ON ELECTRICAL OR
PARTS DIRECT 556-2494 SPECIAL ORDER ITEMS.
PARTS TOLL FREE 800-747-5470 ~HE SEU. ING DEALER MAJ(FS NO WARRANTY OF ANY KrND WHATSOEVER AS TO T
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PARTS F.A.X (563) 588-2927 pM~RR~U~UU~T~O~_T~ROw~A~ LISTED HEREON OR AS TO THErR F TNERS FOR A~YE
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FIRST
Form 433003 MAIL REPORTS TO:
01-0' Iowa Deoartment of Transportation
~h~ice of Driver Services
Park Fair Mai 100 Euclid Avenue
P.O. Box 9204
PLEABE TYPE OR PRINT Des Moines iowa 5030g-9204
Iowa Department of Transportation
INVESTIGATING OFFICER'S REPORT
OF MOTOR VEHICLE ACCIDENT
Sheet t of ~
-- [] Property?
Y=Coordinate:
T~me of Accident County ] Accident occurred within
c~[y,m~tssnowgeneralwcm~[y re.es O O O O O O O O ofnearestclty
Number
Feet Miles "i NE E SE S SW W NW Feet Miles ~ ~IE E SE S SW W NW If Divided Highway, Provide Route
or O O O O O O O O and or O O O O O O O O of (Cardinal)TravelDirection
NB SB EE WB
O O O O
Ddver's Name Last. First. Middle Address City State Zip
Test Given? b~ 2. Bleed 4. Breath 9. ReEIsed ., Test Given? b.d 2. Diced 9. Refused O O
Make
initial Travel veRicle Speed Point of Most Damaged
Birection Action I I i Limit I I I ~niti~Hmoa~ I I .
[]
· Damage Override I I
--CondiEon[d O ..... dl I Ddver(uptetwo) II II II
State Year Emergency Emergency
US DOT# or MC# I Number [ Gross Vehicle
O O , I I I I I I efAxlesl I weight Rating
Ddver's Name Last· First. Middl6
Address
City State Zip
City State Zip
Date of Birth Driver's License Number citation
Charge
C E 2
O O ~cohol [ ~ I. None 3. Udne 5. Vitreous Test Results
I Drug !. None 3. Udne
__ Test Given? LJ 2. Blood 9. Refused O
City State Zip
Name Policy #
Direction I ] ACtion I I I Limit] I I~"~ ........ I I I Ar~a I.
o--..,,,Tr'c ,l=;t ,L II
I Vehicle Typeb~ I Status
NameCarrier I Address
US DOT# or MG# I Number I Gross Vehicle
O 0 II, I . . ] ofAxles Weight Rati.g
f Properly otzar man Object
Damaged
Owner's FuTI Name
Last· First. Middle
Street or I City State.
RFD I & zio Code
Unit1 Unit2 SEQUENCE OFEVENT~
ACCIDENT ENVIRONMENT
Manner of Crash/Collision U III
ROADWAY CHARACTERISTICS WORK ZONE RELATED?
Major Contributing Cimums~ances: O Yes O No
I I II I I Third Event
IIIIII Most Harmful Event
(by vehicle)
I I I First HarmfulEvent of Crash
(use codes 1142 only)
Officer's Name Badge No.
SOLD TO ~
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Date: ~4--i
Time: i3:i
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TiPi££ ~'RO~IISED: :~ ~EET,~SD f? PAY71EN'7: < )CAS~ ( )CHECK ( )CHARGE
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i 8.88 5,7~ ' 5,74
SdB-TOT~L ~5. S3
SA~S T~X ~. 94
EST i M_qTED TOTAl 69.57
~ H.~,~,i,IUN*~L WORK WAS AUTHORIZED
BY ~-huNE u~'~ (Date) AT
Ef4PLGYEE NAME o:.,,iNo AUTHORIZATION:
(~) BY
(Time)
ALEASE READ uAR~rUL~Y~ CHECK ONE OF 7'HE b,w.~[,~NIb BFi OW AND
SIG~ I ...... u ..... T~AT o~'~ ..... ~u A
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i RETURN
WRITTEN ESTIMATE IF >!Y FINAL BiLL WiLL EXCEED
ICTZON OF
~ F---~
~ ' i REQUEST A ....... wn~ ~ ~N ESTimATE,
~ ~ DO NOT RGQUEST A WRITTEN ESTIMATE AS LON~ AS THE REPAIR
A=uUiR~
L ; COSTS DO NOT EXCEED ~ TH~ SHOP :~AY NOT EXCEED
~F OLD ~ARTS
~H~., AMOUNT WITHOUT MY WRITTEN OR ORAL A~hROVAL.
~ , i DO NO7 r~=L4Uib~ A WRITTEN ~S~iMATt.
S i ¢=NATU RE
SIGNED
DATE
PARTS & SERVICE WARRANTIES ATTACHED - ,~ LABOR r=Ai R**,=
STORAGE $IO/DAY (BEGINS ~ wO,)<r, IN,.~ UH¥~ AFTER NOTiFICATiON)
ALL ~S~ir~E~ ARE FREE ONL~O~ OTHERWISE LISTED OR -0~ =D~
~_.d OR
L--.--~ RE'
CUST~
Hanley @Bodylnc.
1030 Century Circle Dubuque Iowa 52002
Phone: (563) 583-7220
DATE
AFTER MAKING AN INSPECTION WE ARE PLEASED TO SUBMIT THE FOLLOWING ESTIMATE Of
LABOR & MATERIAL FOR REPAIRS ON YOUR .~. g~ ~ ~
AUTOMOBILE. FOR IMMEDIATE ACCEPTANCE ONLY:
PAINT &
WORK TO BE DONE LABOR PARTS SUBLET
:
REMARKS: ...................................................................................................................................................
:..,..!!~ .......................................................................................... ~ ...... ~ ....... ; .....................................................
above is an estimate based on our inspection and does not cover any additional parts or labor which
',~aY be required after the work has been opened up. Occasionally, after the work has started, worn parts
a~e discovered which were not evident on the first inspection: Because of this the above prices are not guar-
anteed.
By