Claim by Ira DementMasterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
MEMORANDUM
To: Mayor Roy D. Buol and
Members of the City Council
DATE: January 18, 2012
RE:
Claimant Date of Claim
Ira Dement 01/17/12
Claim Against the City of Dubuque by Ira Dement
Date of Loss
12/19/11
This is a claim in which claimant alleges that a City of Dubuque
driver's side mirror of claimant's parked vehicle.
This claim has been referred to Public Entity Risk Services of Iowa,
Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager
Dan Brown, Fire Chief
Ira Dement
Nature of Claim
Vehicle Damage
ambulance struck the
the agent for the Iowa
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001 -6944
TELEPHONE (563) 583 -4113 / FAx (563) 583 -1040 / EMAIL tsteckle @cityofdubuque.org
CLAIM AGAINST THE C,TY 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 than 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:
2. Address: 1), 7,1 )( di/ (od L,77
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
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6. Location of Incident (Be specific): ) r)
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.)
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8. What were weather conditions like? 1.
9. Give name and address of any witnesses: ‘
10, Did police investigate? (If so, give names of officers.)
anyonc-:", injured? (if so, give names, addresses, and extent injuri
12. Was any damage done to property? Of so, describe property and the extent of damages.
Attach estimates of damages or describe bAsis for ascertaining extent of d mageo)
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13. What other damages do you claim, if any? .1 )C )-(
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 is responsible?
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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.)
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 ,J , 20
ItO
(Signature)
1/4/(-- t
(Print Name
CUSTOMER TEX DEMENT
ADDRESS 236 BRYANT ST
DUBUQUE, IA.52001
1' DR. SIDE MIRROR
2- LABOR
3- TOTAL
TAX INCLUDED
CEDAR HILL AUTO
17301 GARDNERS LN
DUBUQUE, IA.52001
PH.563-495'1362
53.00
30.00
83.00
VEHICLE 1994 JEEP GRAND CHEROKEE