Claim by State Farm for Shaw Troester and Mirah RoathCLAIM 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 West 13"' St., Dubuque, IA 52001. It will then be referred to
the appropriate department for investigation and to the City Attorneys Office 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. ,, _ ^7—
1. Name of Claimant: S'f0 FaFarm t nS. &- S rna ee O S► t ^Oe -Si'r
2. Address: ?Q 60x a31l 1 0001 1na,{riA JL ( t70a -3
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6. Location of Incident (Be specific): n r`N R■d l_ I . b0duAL L4 e /A
3. Telephone Number:
4. Date of Incident
5. Time of Incident:
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7. Describe the accident or occurrence that caused injury or damage. (Give full details upon Mich 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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9. Give name and address of any witnesses, /1// tr
10. 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
damages or describe basis
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to property? (If so, describe property and the extent of damages. Attach estimates of
for ascertaining extent of damage.)
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13. What other damages do you claim, if any?
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 ? b a7. O q
16 Why do you claim the City of Dubuque is responsible? k re r- e,n to
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17. Have you made any claim against anyone else for damages as a result of this incident's (If yes, give name and
address )
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
Dated thisv day of
(Print Name)
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