Claim Cheung,Margaret L.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 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: Margaret L. Cheung
2. Address: 3065 Foothill CRT Dubuque IA 52001
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3 Telephone Number: 563 582 6327
4. Date of Incident: 1 29 04
5. Time of Incident: 1:45 P.M.
6. Location of Incident (Be specific): JFK Rd & JFK Circle
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.)
Mrs. Cheun was south on JFK when Thomas Kopp in a City of Dubuque snowploy, pulled out of Kennedy Circle and hit her. Snow plow didn'tstop at Stop Sign.
8. What were weather conditions like? Fresh snow on ground.
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
Yes, snow ploy driver lwas ticketed for failure to yield right of way.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Claim was taken to the hospital by ambulance.
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.)
03 Toyota Corrolla was a total loss
13. What other damages do you claim, if any?
Medical, rental car
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.)
Yes, State Farm has paid for veihcle; Clm # 15-3219-995 Phone #1-888-248-6961 Team 2
15. What amount do you claim from the City of Dubuque?
Not sure of total cost
16. Why do you claim the City of Dubuque is responsible?
Driver was ticketed, also because he failed to stop at stop sign.
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 16th day of February, 2004.
/s/ Margaret Cheung
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Feb..13.2004 5:47PM BARRY A LINDAHL, ESQ No.3:i29 P.2/3
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA l!f)fhOY~
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.
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4. Date of Incident
5. Time oflncident;
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6. Location 0,1 Incident (Be specific):
J F K Rd
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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.)' .' . '.'
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8. What were weather conditions like?' ~~4 ) ç{'p<'" 5hl)(A) on 5mtAhc(
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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11. Wa$ anyone injured? (If so, give names, addresses, and extent of Injuiies).-
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Feb.,13. 2004 5:47PM
BARRY A LINDAHL, ESQ
No.3529
p. 3/3
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 clàim, if any? fA f Pi Å ,('~ ) /I e n+o. f) r A ý'
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.)
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15. What amount do you claim from the City of Dubuque? No-t 5 ~ ~, -tòf-ø...Q
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16, Why do you claim the City of Dubuque Is responsible? 1) r j V en. w CI.(1
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17. Have you made any claim against anyone else for damages as a result of this 'incident?
(If yes,.J ive 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?
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(Rev. 1100 & 7/01)