Claim Boynton, RobertCLAIM 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: Robert Boynton
2. Address: 2050 Blake St.
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3. Telephone Number: (563) 583 2801
4. Date of Incident: 10-6-04
5. Time of Incident: 9:30 AM & 9:45 AM
6. Location of Incident (Be specific):
Asbury Rd - 2787 in front of Fountain Complex
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.)
Truck Driver - Truck 3242 Loose gravel fell off top of end gate.
8. What were weather conditions like?
Nice
9. Give name and address of any witnesses:
None
10. Did police investigate? (If so, give names of officers.)
None
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.)
Stones cracked windshield.
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?
Because the rocks fell off truck No. #3242 and it is the driver's responsibility to see that
his truck is safe to be on the street or Roadway.
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?
No & None.
Dated at Dubuque, Iowa this 8th day of 10th month, 2004.
/s/ Robert T. Boynton
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Claim Form æ. fi? VII¡
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CLAIM AGAINST THE CITY OF DUBUQUE. IOW~ j\t
Page I of2
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 ciaim must be filed with the City Clerk at City Hail, 50 West 13th St., Dubuque, IA 52001. It wiil then be
referred to the appropriate department for investigation and to the Legal Department. Once that investigation
is completed, a report and recommendation wiil be submitted to the City Council. You will be provided with a
copy of that report and recommendation.
The final decision on ail clams 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 wiil or will not be paid.
1. Name of Claimant~,A'¡¿Í'-t ~(J V /1) -10 Al
2. Address: ð-o Sl) tSlAJ:--e! ¥
3. Telephone Number:CcJG"3 ) 5-;? ,f - cÂf,1 /
4. Date of Incident: /i)- ~:. () V
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5. Time of Incident:
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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.)
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8. What were weather conditions like?
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g. Give name and address of any witnesses:
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1 O. Did police Investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimat~s
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13. What other damages do you claim, if any?
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10/7/2004
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Claim Form
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Page 2 of2
14. Have you been compensated for any part or ail 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?
print this paQe
http://www.cityofdubuque.org/printer_friendly.cfm?PageID=155
10/7/2004
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Quote for 1997 GMC Pickup K3500 - Mileage:
SCHUELLER AUTOMOTIVE
"PROMPT PROFESSIONAL SERVICE"
1735 RADFORD RD
DUBUQUE, IA 52002
Phone: 5635882245
J
BOYNTON,ROBERT
Type Description
Part windshield
QtyfHrs
1.00
Part No
Unit Price Subtotal
197.72 197.72
Tax Subtotal
13.84 211.56
0.00 0.00
Grand Total 211.56
Part $
Labor $
Works~e~
197.72
~...pplies
0.00
Ha_~!!!.i!!
0.00
0.00
Friday, October 08,20043:12:52 PM
Page 1
@ 2004 Mitcheil Repair Information Company, LLC.