Claim Martin, MargueriteCLAIM 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: Marguerite H. Martin
2. Address: 1953 Chaney Rd.
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3. Telephone Number: 583 8173
4. Date of Incident: Jan. 28, 04
5. Time of Incident: 2:30 P.M.
6. Location of Incident (Be specific):
Hillcrest Road & MorningView
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.)
City Truck making a left hand turn from Morningview onto Hillcrest crashed into my car going west on HIllcrest
Truck driver was Alfred J. Hakanson, City Employee.
8. What were weather conditions like?
Fine
9. Give name and address of any witnesses:
None
10. Did police investigate? (If so, give names of officers.)
Yes...??
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Marguerite Martin - Driver (No Passengers)
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 car totaled.
13. What other damages do you claim, if any?
Injuries to myself.
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? ?
16. Why do you claim the City of Dubuque is responsible? City truck driven by A.J. Hananson, City Employee, caused the accident. Also, my injuries & totaled my car.
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 17 day of March, 2004.
/s/ Marguerite H. Martin
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
.FE~-2o--04 :FNI O~:29 PI1 DUBUQUE CITY CLERK FAX NO. 563 589 0890 c-c: )b °If°}t1
CLAIM AGAINST THE CITY Of' DUBUQUEfiOWA' f)oAl .fí::;f+
This written report constilutc$ your claim against the City of Dubuque, Iowa. YOll should
complete this form in full and ättach any IiIddilional information that supports your claim.
The Claim muÐt 00 filed with the City Clerk at City Hall, 50 W.131ñ St., Dubuque, fA 52001.
It will then be referred by the City Council to th<! appropriate department for Investigation.
Once that invcsUgation l:s COmplfJlßd, a teport and recommendation will be submitted to the
City Council. You will be provided with a ropy 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 AUTIIORI1Y TO MAKE ANY REPRESENTATION TO
YOU AS 'fO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
'I. Name of GIß¡mant:_~ i4J1! G-u "-æ r-rF"- ..JL.-JJ:J../9...Rf;~
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6. Location (If Incident (Be specific): 1-/ í'/.. i... e ¡e £3 S'r
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7. DESCRIBE ACCIDENT OR OCCURRENCE TfIAT CAUSED INJURY OR DAMAGE. (GIve
full details upon which you base your claim, It a City employee was Involved, give the
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8- What were weather conditions Iike?____ß ,.,/é' ,--
9. Give name fond address of any wltnesses:~ fÝ e
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W, Did police i.l1vestigate? (If so, give names of officers.)
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11. Was anyone Injured? ~f so, give nan'lCS, addresses, and extent of Injuries).
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. ~B-20-0HRI 02:29 PI1
DUBUQUE CITY CLERK
FAX NO. 563 589 0890
P. 03/03
. 12. Was any damage done to property? (If $0, describe property and tl1e extent of d:amages.
Attsçl1 estImates of dmTlagés O( dc5cribe basis for ascertaining extent of damage.)
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13. What other damages do you claim, if any?
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14. Have you been compensated for any part or all of your claim by any insurance
company? (If so, give name and addtcss of Insurance company and amount paid,)
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15. What amount do you claim from the Cily of Dubuque?
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16. Why do' you ~Iaim the City of Dubuque is responsible? ~ ~-I ~
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17. Have you m¡lda any claim agaln:st anyone cls~ for damages as a result of tl1is incident?
(If yes, give nnme and address.) j\Í~
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18. If the an$wer to Question 17 is yes, have you received any payment from that source,
and if so, In what amount?
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