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Claim by Walter Joniec{ f5ana5 i;f- r56 »5a.. 5 a a.ai F I r V .' L. 515 85.y^e 3o xi i;" if RSdii 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 , L I 1f , - ✓ � / �( 2. Address: .YO j p ?�/�'r.1 (9 3. Telephone Number: r� `/7 ` (f 15 ,f3pS" 4. Date of Incident: /a -/4 - /Q f / 5. Time of Incident: / � /,7 - /„� I L-/ :"../ AA/ Ord,. 6. Location of Incident (Be specific): Tt U/c�...$ r/' / . 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.) / � • 4 /)? p1 C( r , � llr�P C (/ 'tFrei Y�l 1 t' /Iii../` Yc�- �IJ clt / ©T / /7r (c ac �j (% De/74( - 5 .C7 /dG / 41 8. What were weather conditions like? f� /61 06r)4 - iv f /414 d pr(J! 9. Give name and address of any witn ses: /2 /7 (e / / r jcede � � 2 /. fc /2 a i i 1 r 77 brut /� Gu � 15 r'. Ii?i f C r• Yl. s a; / lr(� �7 P 6 � I 10. Did police investigate? (If so, give names of officers.) Cyr Ct' (iYt 7 `ff-i7 rG 11. Was anyone injured? (If so, give names add sses, and extent of injuries.) AI o 0i) e ! /Z J/ t it'; i i (It 6' 4i71( ) fl 0 i ✓l j l.er'c t'a (re J" em. A1 19 -?earl Ay ,r)r9 h cr 07 ,2 ((• d i ,7 7' Y7 %''0r4 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.) / /� C2 00 c S C D i 1 v vas i -f r1 T � -t J� L /'I I 5 3ari / r,L/c-S S( 1 't '1 it ( r ZR a '( ' y ` '1- � 12C,-) � �;F t'c'� lai� r�f' /li1D�.1J!% C.S11 fitrli(�It� �iiJ 1 /1'J _for ; rl "f J?' c: }, v_ , c; t�J v 7 i)kI".,it b.t' 5 (9I/ 3 c_. --- C'S a. t (1x d i r' tr)G i {1) - ( F S :h '1'4 (7 1)e �i lr<mtn, (L,...� pi;-I(rl . 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.) 0 15. What amount do you claim from the City of Dubuque? Ur? kri C ) Na; 11✓!' r Qf )10 . io pro is t s rYw. rep(' r o An 16. Why do you claim the City of Dubuque is responsible? W a A c' t �( 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) (VJ 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? Dated this / day of 48 20 !C ti (Signature) L.0. L7 c2 Jdn -'; (Print Name) �1 'enbngn0 eoiTK) s,jia1O A110 91 :1 148 6Z33OOL Accident Information — Walter Joniec - owner of Vehicle 800 Hyannis Ct. Schaumburg, I160194 847 - 885 -8505 12 -16 -2010 Note that was left on car Accident Report received 12 -27 -10 Called Police Dept and contacted Officer Griffin for Accident Report umce or urrver services P.O. Box 92 �� INV O REPORT Des Moes, Iowa 53306-9204 MOTOR VEHICLE ACCIDENT -r, ``7 )l ; 01- 10-61378 Legal Intervention ?❑ Private Properly? ■ Date of Accident 12/1612010 Time of Accident 12:13 Hrs. County Accident occurred wines carpoale limits of (oily) Dubuque - 31 Dubuque - 2100 LOR I L S Literal AS BLVD Desc piton If accident occurred outside Of city limits mow general vicinity: "W of nearest city "N/A" On Road. Sheet, or Highway. At 483 LORAS "NIA" Intersect ion with Note: Unless accident occurred at an intersection which a completely described above. use the space below to give the exact location from a milepost or definable ileraec;ion, bridge, or railroad crossing, using two distances and directions ?necessary- X Caodinate: 00691190 04708453 Distance Direction Distance Direction 20 Ft 3-E end "N/A" "NIA" M Ynate: If Divided Highway, Provide Route Direction WB Milepost Number Definable intersection, bridge, or railroad crossing "N/A" Or LORASIMONTROSE (Cardinal) Travel U N I T 001 Driver's Name - Last First Middle Suffix Home/Cell Phone BRADLEY DENNIS (583) 5894160 x Address City State Zip 11 W 9TH ST DUBUQUE IA 52001 Date of Birth 07104!1959 Driver's License Number 946AA4046 Citation Charge Code I Citation Charge t Gender Ma le Slate Crass Endorsements tiestractions IA 0 NONE 2 Citation Charge Code 2 Citation Charge 2 Citation Code 3 Alcohol Test Given? 1 -None Test Resets Drug Test Gwen? 1 - None That Results: Charge Citation Charge 3 Citation Charge Code 4 Citation Charge 4 Seating Posfuen01 teeny Status 5 Occupant Protection2 At bag Deployment 5 Airbag Switch Status 9 Eedion 1 I Ejection Path 1 Trapped 1 Transported to: Transported by Owner's Name - Last First I Middle Suffix Owner Company Name CITY OF DUBUQUE Address 50 W. 13TH ST City State DUBUQUE IA 25 0 01 Insurance Co. Name CITY OF DUBUQUE Insurance Policy* License Plate 114490 # i State Year IA 2011 Approximate Cost to Repair or Replace $0.00 VEN No. Year Make IHTMNAALIAH193931 2009 International - INTL Model Style AMB AMB Tow # NO Private? ❑ Maier Travel Direction 4 Vehicle AxilM 88 Speed Point of Limit 30 Initial Impact 04 Most Damaged Extent of Underside/ Area 04 Damage 1 I Override 1 Total Occupants 2 Traffic Controls 01 Vehicle Conlig. 05 Cargo Body I Vehicle Driver Vision Type 02 Defect 01 Condition 1 Obscured 01 Contributing C raumstances, Dover (tip to twv) 27 SEQUENCE OF EVENTS Fist Event 21 Second Event 23 Third Event Fourth Event Most Harmful Event (by vehicle) 23 Commercial Trailer Attached to State Year Attached to State Year license Plate # Power Unit Trailer Unit Emergency Emergency Vehicle Type 4 Status 2 Cartier Name Address City State tip US DOT # ar MC # - I Number of Aides Gross Vehicle Placard # Hazardous Materials Weight Rating Released? U N I T l)a2 Driver's Name - Last First Middle Suffer Horne/Cell Phone (847) 885-8505 it City Stare ZS, Address Dale of Birth Driver's License Number Citation. Charge Code 1 Citation Charge 1 Gander Sta Class Endorsemen ts Restrictions NONE ,NONE Citation Charge Code 2 Citation Charge 2 Alcohol Test Given'' Test Reseda Drug Test Given? Test Resets: Citation Charge Code 3 Citation Charge 3 Citation Charge Code 4 Citation Charge 4 Seating Position Injury Status I Occupant Protection - Airbag Deployment Airbag Switch Stag peed= I Ejection Pam Trapped Transported to: Transported by Owner's JOnIEC -Las, TER Mt-Idle Suffix Owner Company Name Address 800 HYANNIS C7 City State Tap SCHAUMBURG IL 60194 Insurance Co. Name ALLSTATE Insurance Policy # 002 - 022. 9400 Licensa Plate q State Year X953742 IL 2010 VIN No. Year Make 3FAFP11392R194301 2002 Ford • FORD Model Style 20 Tow # NO Approximate Cost to Repairer Replace $100.00 Initial Travel Direction 9 Vehicle Adorn 13 Speed Point of Most Damaged I Extent of Urderridel Limit 30 I Ineeai impact 08 Area 08 Damage 2 Override 1 Private? U Total Occupants 0 Traffic Controls 01 I Vehicle Config. 01 Cargo Body Type 01 I Vehicle Driver Vision Dated 01 Condition Obscured Contributing Circumstances, Driver (up to two) 27 SEQUENCE OF EVENTS' First Event 23 Second Event 21 Third Event Fourth Event Most Harmful Event (by vehicle) 23 Commercial Trailer Attached to State Year Attached to Stale Year License Plate # Power Unit Trailer Unit: Emergency Emergency Vehicle Type i Status 3 Carrier Name Address City Slate Zip US DOT # or MC F Number of Axles Gross Vehicle Placard Hazardous Materials Weight Rating Released? Accident report received via e-mail 12 -27 -10 Printed At Dubuque Police Department 12{161201005:3 PM Page 1 Form 8: 01404437+. ��, �ca�,'.