Claim Francois, MichaelCLAIM 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: Michael Francois
2. Address: 13673 Mueller Parkway, Sherrill, IA
3. Telephone Number: 552 1092
4. Date of Incident: July 14th
5. Time of Incident: 2 30 - 3:00
6. Location of Incident (Be specific): At the intersection of NW Arterial and Chavenelle Dr. on the west side of Artieral in front of Carlisle
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 driving East on Chavenelle approaching light, when I heard a loud noise inside my car. There were city employees mowing the grass on the median. A piece of rubber shot through my window and tore up the ceiling. - Mr. Strohmeyer
8. What were weather conditions like? Clear
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
No
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, my interior ceiling was ripped and the two back side windows displayed rubber markings.
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?
What ever it takes to fix it.
16. Why do you claim the City of Dubuque is responsible?
Because the City employee was riding the lawnmower, and unfortunately the piece of rubber was shot out from under the mower. (I would make a suggestion that they pick\
up the deck when cars are passing.
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 22nd day of July, 2003.
/s/ Michael Francois
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
'
This written report constitutes your claim against the City of Dubuque, Iowa. You S~ou?d
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
1. Name of Claimant:
3. Telephone Number: -~--~"-~::~
4. Date of Incident: ~
5. Time of Incide,t: ~
6. Location of Incident (Be specific):
full details upon which you base your claim. If a City employee was involved; give the
employee'~ n~e.)
. a wXweather~s 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.)
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 .t Du~tJqu~ Iowa this
LLJ ....
__ day of ~~
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Toys Done 9 ht Body Shop
Complete Collision Body Shop
Dan Steffercs-- Owner
11941 SHERRILL ROAD · DUBUQUE, IOWA 52002 · (563) 552-1601
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Parts
Repair Labor
Refinish Labor
Sub Total
Tax
sub Total
Matedals
Hazardous Waste
Total
SYMBOLS: A - Align NA - New After-market part Est~rnate must ~ ~:~ke~ ThL~ Damage Report m C
P - Paint U · Used~0art wl~n 30 days for at)ova I)nce. ~ ~s ~ ~r ~y add~o~l ~ or ~r
R - Repot NF - New Fa~o~ Pa~ Rust not wa~anteed ~ ~
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ST., DUBUQUE, IOWA 52001
DA~D'tlNI( · 563-556-4216
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