Claim Clancy, Sheri etcCLAIM 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: Sheri Clancy - Cody & Courtney Clancy - Passengers
2. Address: 2691 Marywood Dr., Dubuque, IA 52001
`
3. Telephone Number: 563 582 6659
4. Date of Incident: 1/9/2005
5. Time of Incident: 8:05 A.M.
6. Location of Incident (Be specific): Close to corner of JFK & Asbury Rd., by B.P. Gas Station
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.)
Francis Marshall was driving a salt truck up JFK Rd. spreading salt and I was traveling up JFK behind him. When
he hit the red light at JFK & Asbury he threw the truck in reverse and bashed into my truck. I had stoppoed
below the entrance to the B.P. Station and laid on the horn but couldn't get
the truck in reverse fast enough to get away.
8. What were weather conditions like?
Roads were slick and wet
9. Give name and address of any witnesses:
Clark & Lynn Johnson, 3030 Castlewood, Dubuque, IA 52001
10. Did police investigate? (If so, give names of officers.)
S. Kreyer & Officer S. O'Brien. O'Brien wrote up the report - Badge 51
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, I am being treated by Dr. Quinlan for back, neck, right shoulder, arm and wrist strain. I'm wearing a soft collar and getting
treatments daily for adjustments, ulstrasound and therapy.
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.)
13. What other damages do you claim, if any?
My 97 Chevy Pickup sustained front end damage. It is undrivable so I have to
rent a loander vehicle to get to work and appointments.
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?
Unknown at this time. Truck getting estimates for repair and I'm still
treating for my injuries.
16. Why do you claim the City of Dubuque is responsible?
Mr. Marshall threw the salt truck in reverse and accelerated back into my vehicle. He was cited with unsafe
backing by police.
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 11th day of January, 2005.
/s/ Sheri A. Clancy
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
",' /
-J- >
CLAIM 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: S hp,\ C\o..nc( - CO{Jy ~ G,U('hH'-'{ C-lQrlcy--Gsce/lde(s
2. Address: 26q \ f(\o,.y wood \) r, D,\6lt~ue :LA 5.mol
c::-/ ::z '(1
3. Telephone Number: :::JIC-J -58;). -lo("S
I /cr!d.005
I '
?S' 05 o. m.
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific): C lcr)" ~ c.or1\U 0+ 3'FIc. '" AsbUrY RoJ..
,
"by b.{) Gas St", {.., on
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.) ,
F'.-nr\C.',<"V'f\o...-SNAU WG\.S dr\v\\I\.J 0, :')0..\+ .t,.C(L-{c. u.p :jFt::. 12&
'=) d'acL"" ~:,()..\-\- <>I TvJQs +V(1.Vt' I ( i..l -:JFK 6ehlf\.ct h.im,Wlten
he. \c, \. -VY\{l ,f \; h -\: 0... <3fh ~ l\'SbiAC 4-h~ +hrec2' +he -tvudc'
\..... 'f'f:Vt.i"e ~ \::JQSne-t1if'\W .""1 t~UL-k>:I Ywcl S+opped -Llow...f'ht e,,+.-a,iU'-
8. What were weather col)Clitions like? " *\\-e. b S+-(\'-\-l oj Ie' J4,f. ' 'lOvn OlA\-
roo..d.3 \.Due s. \, c.tC..I{fit+~ ee\!..l. ",\ ~~ -th<. +-r\.\(.I:.,,, ,..:ven;e C{<;-\ "-,\"":::,\",,,,
9. Give name and address of any witnesses: ..'}+ (/<J\Y
C-.\Qr Ie- ~ Lyn" 'J~fI(\50r\ 30:':>0 Co<,-\- leOoo.:J \)L.\.Io'..~ue, Tf-l .5;;;'00 {
10~ Did police investiga~e? (If ~o, gi,ve names of o~icers.)
'5 K> e.- .. Ot+lLe.r J IOrte". 6.-,en WrQ-\.< r+.
f,C\l~~< '5 \
11. Was anyone injured? (If so, give name~, addresses, and extent of injuries).
. - ~- l 0 f".. (' \r;r,ct:-
...::j.e5 I 1- OIY'JeI~J .he",+-ecY bi r. L)ql(\(an tDd\(\ec.k., Y-<J~+
5\'vJl,,-\de~ Ou'(Y'o. d, wrl';-Ic S-\.r"'--'r\, -::C.'0 \A!<:Q.-[\'\! C\. SoIt-e..o\lor k-
SJ(.++'.~ -I.-re,,,,-I,- m en+S 60..,\"1 ,(:,,,y' Cl..6~ush""-Ul+S) U \' rQ SNlrtd J +hhttpy,
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.)
13. What other damages do you claim, if any? ffi y
R C ~ u,(D S(rs+c{; ne j)
, Lf
+0 yen + 0< 11X{1')(7r
15. What amount do you claim from the City of Dubuque? Ul\knOlvn af -M,s f/(}1(" ,
\(\Ad t.+'\11\ e~-+I ,,^,,--\e<, .kV' r-'(', IV <J \'{Y\ s+;/( -frea-l-n
16. Why do you claim the City of Dubuque is responsible? rrl r, (Y(cxrs hC/ I( I1i re r.J
*ke sC\.l-\- +(\Jc((ll'. rtve(-oe q. [!..CU(QrlAhd! back. In-/-v my Vff!{(Je
I
\~{ WQs c',+ed VJ',*h Unsa+( b:(ck.,~ by pOlice.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
lVa
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
IlJ+\
day of -:fD..AIAQr( ,20D5.
~ (), &~
(Signature) 1
Sheri A [l(vu_';!
(Print Name) J
'.~)
,-
. .
L. '
i'
,-
,
c'
(Rev. 1/00 & 7/01)