Claim HAB Carriers, Todd AveryCLAIM 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: HAB Carriers, Inc. (Todd Avery)
2. Address: 1270 E. 12th St., Dubuque IA 52001
`
3. Telephone Number: 563 583 6610
4. Date of Incident: 1/17/05
5. Time of Incident: between 3:00 p.m. and 5:00 p.m.
6. Location of Incident (Be specific): 425 Hill St., DBQ, IA
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 Bus was traveling south when the bus struck the HAB Carriers Tractor #1021
(2001 Mack Vision), on HIll St. in Dubuque, IA. Bill Gibson was the Keyline Bus Driver.
8. What were weather conditions like? Dry
9. Give name and address of any witnesses: Bill Gibson reported the incident
to Mark Munson (563) 589 4196
10. Did police investigate? (If so, give names of officers.)
No
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.)
Property damage done to the driver's side mirror on a Class A
Commercial Mack Tractor, HAB Carriers, Unit #1021 VIN #W005021
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
15. What amount do you claim from the City of Dubuque?
$690.96
16. Why do you claim the City of Dubuque is responsible?
It wasa Dubuque City Bus caused the damage.
17. Have you made any claim against anyone else for damages as a result of this incident?
(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 at Dubuque, Iowa this day of , 20 .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
. , /' //.
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CLAIM AGAINST THE CITY OF DUBUaUE;\OWA . '. /;;/-b-/?Z.-(/
. . . ., . '/~///J;
This written report constitutes your claim against the City of Dubuque, Iowa. You sh~ld I
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. 1'3th 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:~. CQrr/eeL<. .-:Lnc. . L IDJd Avery)
2. Address.:-J ~7D E. I 'J. th S t: DkbUt ue J 711 Sd:J:;>/
,3. Telephone Number: . C5fo3) r5r?3 -~~/6
4. Date of InCldent:~ 17/;;rx;Q ,
5. Time of Incident: 'De.:: wee" 3; OO~ffi - :5: OOpf'0
6. Location of Incident (Be specific): 4;).5 . H-\\\ 5\; D~ ,.rf)'
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.). . -
. . . kelfl~f\e 5USWlLS +ro.ue\l~ Sou.~ \))"'~~ ~J bl.l~
. 5tru.ck "'e. >>.1tI3> Co,f'f\1~ 1{uj-or.f J Oa L( .?-cof f10Jr 0Sion) _) Oft ttdl sf:
.mJ)tt.hllt \lf3J -:J;.4. '. \)l U G-ibx>Vl waS +hekel/'\'~~ lSiJS DrJwf'
8. What Were weather conditi~ns like? -Dr,-!
9. Givename and address of any witnesses:-12iL1 cr,bso!\ fepor-h/ fk
. Jl\ eLl d.ro:.Lto ~11C)~'A (SrI) 3) 589- 4/9 ~
10. Did police investigate? (If sO,give names of officers.)
A/C/ .
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
.."
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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.)
Pro{)tllty d(),ffia-~e.- dOI)e.. ~ ~e dt\\)er"~ s(ae J1.r/or 0(\
Cl c.l tiSS cg C () J)) ty\e f' 1':,' Q t t1 tU:1c ..,- ta.Jo r ) 1-+ A- 6 ~r I) e IS . {)M If 1f, O;;}1
.J1NW WOO50l\
13. What o,ther damages do you claim, if any? fUMe
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.)
NoY\-(~
.\
15. What amount do you claim from the City of Dubuque? fJ (g~ O. <1 to
. 16. Why do you'claim the City of Dubuque is responsible?J +WCl~
'.D. DlL~(~ CJty &u..5 cau~ ~ ~Clil't\tltje I
17. Have you made any claimsgainst anyone else for damages as a result of this incident?
(If yes, give name and address.)
18. If the answer to Question 17 is yes, have you received any payment from that source,
arid if so, in what amount?
. Dated at Dubuque, Iowa this
day of
, 20_.
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92,
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(Rev. 1/00 & 7/01)
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