Claim by Everett Corley&fir 0/#7
CLAIM 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 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
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:� 40
2. Address: Z Y /9 ,) Y-1 e k5oW 6 d - ae
3. Telephone Number 5 3 — 67 3-Y
4. Date of Incident:
5. Time of Incident: 2Zo,//
6. Location of Incident (Be specific):
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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.)
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8. What were weather conditions like?
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9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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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.)
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13. What other damages do you claim, if any?
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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.)
(Print Name)
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15. What amount do you claim from the City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
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18. If the answer to Question 17 is yes, have you received any payment thaw
source, and if so, in what amount? 0 c m
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Dated this day of _ , 20 /M . > • m
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Ziaffel ad*-*
(Signature)
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Estimate of Material and Labor Required
Material
Labor
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ESTIMATE SHEET AND REPAIR ORDER Totals
This estimate is based inspection does
on our and not cover additional material or
labor which may be required after the work has been started. After the work has
damaged
started, 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.
Thie w..d. e...t....:...I 1... Grand Total
BUTCH VALENTINE E S T I M A T E
Address
Model
Valentine Bros. Body Shop
375 EAST 9TH STREET • DUBUQUE, IOWA 52001
PHONE (563) 556 -3484
Name F1e77 Co AL17 Date
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5W YY
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�f 7jr'/ /, c 1/ /'License No
Phone
TERRY VALENTINE
DATE
CITY STATE
PO a-0
VEHICLE MAKE YEAR
DAMAGE
TOWIN
'1 Li / 7 - 0
PHONE NUMBER
AUTO ACCIDENT INFORMATION
TIME LOCATION
DRIVER'S NAME uot-ole-s DATE OF BIRTH
ADDRESS CITY STATE ZIP COI
1 6
DRIVER'S LICENSE NUMBER STATE TYPE RESTRICTIONS
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OWNER'S NAME ADDRESS
ZIP CODE
13 1 45
BODY
PASSENGER
c y (CPau-
INSURANCE COMPANY
INVESTIGATING OFFICER(S)
VEHICLE t LICENSE STATE /YEAR
INJURED - NAME
VIN NUMBER
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COLOR
BADGE 1 0.