Claim by Thomas RuffCLAIM 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:
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2. Address: f> % ti& 574 L.� o C ttS �4 h 4 9 �t len/4 1,2
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3. Telephone Number: ° 3 U
4. Date of Incident: / /01
5. Time of Incident: /11
6. Location of Incident (Be specific):
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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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9. Give name and address of any witnesses: AM 14 W 2/e
8. What were weather conditions like?
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).
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?
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? 0,
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16. W y do you claim the City of Dubuque is responsible?
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17. Have yo Ynade any claim againstanyo a else Ise for damages as a result of this incident?
(If yes, give name and address.)
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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 /� 6� ,
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February 09, 2012
CITY OF DUBUQUE
CLERK OF COURTS
50 W 13TH ST
DUBUQUE IA 52001 -4805
RE: Our File No.:
Our Insured:
Date of Loss:
Amt. Of Loss:
47-KKH003
00- 471 - 512651 -0322
Stephen & Renee Schreiner
January 20, 2012
2,412.00
This letter is being submitted to you pursuant to Sec. 893.80 of Wisconsin State Statutes as a claim due to
an accident that occurred on January 20, 2012, involving a vehicle owned by American Family Insurance
Company's insured, Stephen & Renee Schreiner, and a 2012 International 7000 Series Plow Truck. The
accident occurred at the intersection of Asbury Rd and Crissy Drive in Dubuque, IA.
As a result of the negligence of the operator of the 2012 International 7000 Series Plow Truck, the vehicle
insured by American Family Mutual Insurance Company was damaged in the sum of $2,412.00.
Pursuant to the policy of insurance existing between American Family and its insured, American Family
made payment of $1,912.00 and the insured incurred a deductible loss of $500.00.
Pursuant to statute, American Family Mutual Insurance Company is presenting its claim for payment in the
amount of $2,412.00.
Respectfully,
—"--)CAL12-obr_4.ey
Karen K Hendrickson
Casualty Claim Desk Senior Adjuster
American Family Mutual Insurance Company
1- 800 - MYAMFAM (1- 800 -692 -6326) X 44818
khendric @amfam.com
Fax: (866) 847 -7975
www.amfam.com /claims
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