Claim Splinter, PennyCLAIM 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: Penny Splinter
2. Address: 4948 Gabriel Drive, Dubuque IA 52002
`
3. Telephone Number: 573 528 4659
4. Date of Incident: 10-24-05
5. Time of Incident: 7:27 A.M.
6. Location of Incident (Be specific): Radford Road
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.)
Penny Splinter was southbound on Radford Road - stopped with traffic when a police car, driven by Michael Kane, rear-ended her.
8. What were weather conditions like? Clear
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.) Yes, Officer Robert Flannery (15a)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries). Penny Splinter (see above) neck and back pain.
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.)
Rear bumper is dented and truck is also damaged.
13. What other damages do you claim, if any? Loss of use while vehicle is being repaired.
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 payments have been made yet. Adj: Norm Sandell USAA P.O. Box 6759463, San Antonio, TX 78265
800 531 8222 x 32694
15. What amount do you claim from the City of Dubuque? unknown
16. Why do you claim the City of Dubuque is responsible? Officer rear ended Mrs. Splinter's vehicle which was stopped.
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 day of , 20 .
/s/ Norm Sandell
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
OCT 28 2005 11:34 AM FR USAA
Oct.27. 2005 IO:18AM CITY OF DBa LEGAL DEFT TO 8156N~~~:~~880r. L P.02
· . . It'/..<.f'k 5 CC .41 t/ /lJ
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA . ~
~t>>~;..
This written report constitutes' your claim against the City of Dubuque, Iowa. You should f'~
complete this form In fullllftd attach any additional Information that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50 W.13111 St.,Dubuque,'IA &2001.
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 wlll be provided with. copy of that report and recommenda,t!on.
THE FINAL DECISION ON AI-/... 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 Clalmant:---.fe(\l'\ ~~'n .\e{
2. Addr..s:-':t'JL{~ C"\>ri~\'\)r tAb~ -CA 5')(1)")....
3. Telephol'le Number: S 1 ~ ~ 5~K' Lf1c5c:r
4. Daleaflncident: tD-.:;lY-OS
5. Time of Intident: 7; J..l a...r1\'
G. LOCilItion of Incident (BespeciflC): R~fo(' d R ocJ
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DA""AGE. (Give
full details upon which you baSe your ob!im, If a City employee was Involved; give tb"
employee's neme.) , \ In, I r
Pef\(\,\ $~\~l\~ wG..5. ~uTI\~v..v\.~ "'" ~fo(c:\
R~ ~~ W~ .tra.q:',c. i.ohe,Y\ ~ p'\'Ce c..oS.}df ,"1m by
l'Y\ ,'r )..E'CL\ KM.~ ~ ~ ~nA.. d. \\d': ' .' ,
,8. What were weether conditions like? c.\-tG.;r
9. Give name and address of any witnesses:
;- ~.;
:)
J
11. Wu anyone Injured? (If so, give names, addruses, and extent of Inju~.
t>e..'\I'\'1 ~ \'rt+e-r C~ o...~\I") l"\eclt OJ'\d. ~l!-lft~};
OCT 28 2005 11:34 AM FR USAA
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TO 815635880880 P.03
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.
12. Was 8ny damage done to propenY? (11 so; deScribe property and the extent of damages:
Al!8Ch estimates of damages or de.cribe basla for aacertalnlng .xtent of daMage.)
~ bl.lM\)& is. rkhteJ qj) *unk is et.\so ~~
13. W~t other d~rnages c10yeu claim, ifany?J o~. J' ~e uJ'h,)e. \Je.\'h~ IS-
Del) r~ice.J . .. ". . .. . . .
.14. Have yau been compensated for any part or all of your claim by any Insurance
company? (N so, give name and address of insurance company and amount paid.)
(Ie .~~ 'ha."~~f(.f\ ~ ~f..t-. Adj : +JO(M ~
\j'tAA. ~ ~ 1.5"y'b3 ~ Mvn,^ ~ 1i?1b5 ~(1)-53Fg;}J)
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15. Whllt amount do you claim from the City of Dubuque? lA:I\K.l'\OUJ>'\
16. Why do you claim the City of Dubuque Is responsible?~..~. ('.e:;..V'.eJ,J f('k~,
-.2pliY\~a'5 vehiJe l\Jhic.h IUOS ~+D~'
,.
17. HaVe'ytlll m.~..any claim against anyone else for damages a$ . result Of this Incident?
(If yes~ve n~me and address.) . . . ..
1 i!.. 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_,
A.L ~ ~~~tl13~UsAA ~\r,
(Signature ""'I ~ \,~
~o("~ ~\\ . . .
(Prim Name)
(Rev. 1/l10 &: 7101)
** TOTAL PAGE.03 **
OCT 28 2005 11 :34 AM FR USAA
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1-1- SStJl./-O(
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BARRY A. LINDAHL, ESQ.
CORPORATION COUNSEL
300 t/lain Street, Suite 330 Harbor View Place
Dubuque fA 52001
te/e 563 583-4113
fax 563583.1040
bafuq@cityofdubuque.org
fax
10/271200510:16 AM
9v"a-rl'~: Norm Sandell
USM Casualty
Re: Claim Form Regarding Penny L. Splinter
Fax No.: (866) 547-3763
Pagea: 3
Mr. Sandell:
If YOu wish to file a claim against the City of Dubuque on behalf of your
insured, Penny L. Splinter, regarding a'!tged damage to her V.hicle~';"ld
III . dfuittoth C' of
DUbuque Ci4' Clerk at (663) 688~0 for filHJtamping. Once the claim haa
en m In rwarded to the Legal
Department for Investigation.
Feel free to call me if you have any questions.
Tracey Stecklein
Legal Secretary
cc; Jeanne Schneider, Ci4' Clerk
hn And...on, Account Clerk
Millie Kar
OCT 2 7 2005