Claim Hosch, Charles & VondaCLAIM 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: Charles N. +/or Vonda L. Hosch
2.Address: 4918 Red Violet Dr. Dubuque, IA 52002
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3. Telephone Number: (563) 588 2584 (563) 580-1522
4. Date of Incident: 5/14/04
5. Time of Incident: 2:14 or 2:45
6. Location of Incident (Be specific):
1500 Delhi St. Dubuque, IA Dr. Wards Bldg / office
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.)
Keyline Minibus was stopped, blocking curb cut for the wheelchair access
into bldg. Vonda pulled head of mini-bus to get her husband out of the vehicle into wheel
chair and into building. Did all of this and came back out to move vehicle and minibus stoppped to pull away.
Vonda yelled at driver. He kept going and hooked her bumper with minibus causing damage.
8. What were weather conditions like? Clear
9. Give name and address of any witnesses:
None came forward?
10. Did police investigate? (If so, give names of officers.)
Case # 04-20717
They came to scene, not sure on investigation.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No, vehicle parked no one in vehicle.
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.)
2002 Dodge Dakota S/T 187gg42n125625776
Estimate attached, rear bumper.
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.)
None at this point.
15. What amount do you claim from the City of Dubuque?
$700.42
16. Why do you claim the City of Dubuque is responsible?
Vehicle was parked. Keyline minibus driver decided to put out any way.
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?
None
Dated at Dubuque, Iowa this 17th day of May, 2004. , 20 .
/s/ Vanda L. Hosch
Charles N. and/or Vonda L. Hosch
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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, ' " _". CLAIM AGAINST THE CITY-ÖF DUBUQUE,., A'.
This written report constitutes your claim against the City of Dubuque, Iowa. You should
complete tNs form in full and attach any additional information that supports your claim.
The Claim m1l5t be flied 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, Ii report and recommendation '1'1111 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:- c.~ 'V'{~ ,-v, Wo/' VOA./d..... i.., z7!Q.,rc.¡(
2. Address: tt7/1 ¡(~¿ V'/ole,¡- ¡;¡.-" ,¡Ju8""Ji'--'-5- ~GI::7Á'
3. Telephone Number: ..s,?;,j) J,ð'c!'~"lJ(f'7' J(g.y.rð'O-Æ>7~
4. Date oflncident: .,s-//'Y/oy
5. TIme otlncident: ;l!rs- 0;'" ,,?/ Y S'
6. Location of Incident (Be specific): l~ æ /h'
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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
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8. What were weather conditions like?
9. Give name and address 01 any witnesses: /\/C~
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1/), "Did police investigate? (If so, give names 6f officers.) C. ""-5 ~ *' 0 « -Jd71' '?
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11. Was anyone injured? (if $0, give !lames, addresses, and extent of injuries).
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05/17/2004 MaN 2: 05 FAX 5635894342 Keyline Transit
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12. Was any damage done to property? (If so, describe property and the extent of damagE:!s.
Attach estimates of damages or describe basis for ascertaining extent of damage.)
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13. What other damages do you claim, if any?
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14. Have you been compensated for any part or all of 'your claim by any insurance
company? (If so, give name and address of insurance company and amount paid.)
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15. Whatam9¥!.lt. qo you claim from the City of Dubuque? -!'.. 7ðð, y,,/
16. Why do you claim the City of Dubuque is responsible? V ~ '-/"<.$ £'V'kr:!..
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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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is. 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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Dated at Dubuque, Iowa this l?rI, day of
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HABERKORN AUTO CENTER
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GRAVEL SHIELD FENDER MLDG, FENDER MLDG,
WINDSHIELD FENDER MLDG, FENDER MLDG,
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NAME PLATE 1/4 PANEL 1/4 PANEL
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