Claim Gibbs, Constance LeeCLAIM 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: Constance Lee Gibbs
2. Address: 1030 West Fifth, Dubuque
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3. Telephone Number: 563 585 1236
4. Date of Incident: August 25, 2004
5. Time of Incident: 11:45 A.M.
6. Location of Incident (Be specific): 4th & Main in front of City Mission
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 parked in front of City Mission - reached in my back door for bag to give to mission, trolley came/drove by & hit my door.
8. What were weather conditions like? Clear/warm
9. Give name and address of any witnesses: Annette Haas 557 2946; Gerry Borheim? 557 7362 (McKesson employed)
10. Did police investigate? (If so, give names of officers.)
No - I called Police Dept. and talked with Dispatcher Bob.
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, back rear car door, Dents & door is sprung and bent.
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?
16. Why do you claim the City of Dubuque is responsible?
Yes, because the trolley hit 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 30 day of August, 2004.
/s/ Constance Lee Gibbs
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
/
/;
CLAIM AGAINST THE CITY OF DUBUQUEj'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.
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1. Name of Claimant:
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9. Give name and address of any witnesses:
11. Was anyone injured?
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12. Was any damage done to property? (If so, describe property and the extent of damages.
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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. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque 'a ...ponslble?~ '
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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.) r'\O
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
30 day of
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(Print Name) ~
(Rev. 1/00 & 7/01)