Claim Union Ins - Breitfelder, B.
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,:.Jp.n,.6, 2006 12:58PM
CITY OF DBQ LEGAL DEPY No, 6240 p, 3
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA ~_ >1
This written report Constitutes your claim against the City of Dubuque, Iowa. ~~~OUld
complete this form in full and attach any additional Information that supports your claIm.
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The Claim must be flied ~ith the City Clerk at City Hall, 50 W.13U1 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 tecommenda,tion.
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: Union Ins. Co. as Subrogee of ,Bernice Breitfe,lder
2. Address: PO Box 1737, Bettendorf, IA 52722
3. Telephone Number: 563-355-6161
4. Date of Incident: 12 - 15 - 0 5
5. Time of Incident:
6. Location of inciderit (Be specific): '280.5 Oak Crest Drive, Dubuque, .IA 52001'
7. DESCRIBE ACCIDENT O~ OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (GIve
full details upon which you bas$your cl~im, . Ir a City. employee was Involved; give th~
employee's name.) . .
City sewer on Berkley Street became pluqqed causiriq ~ackuD of
sewage into ba$ement~.
8. What were weather conditions like? Not applicable.
9. Give name and address of any witnesses: Employees of City of Dubuque.
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
OAVENt'ORT SERV OFF.
JAN e 6 2tltl6
H. BAlTlN
.., :..J~n..~, 200~ 12:58PM
CITY OF DBO LEGAL DEPT
No. 6240 p, 4
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.)
See attached.
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 ins'urance
company? (If so, give name and address of Insurance company and amount paid.)
$1,321.00 by Onion Insurance Co., PO Box 1737,' Bettendorf, IA 52722.
15. What amount do you claim from the City of Dubuque? $1 , 571 .00
16. Why do you claim the City of Dubuque is responsible?
City failed to
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maintain sewer to prevent blockage.
17. . Have 'yo U maCleanyclalfri against anyone else for damages asa resUlt oHhisincident? .
(If YeS, give name and address.) , " , ,
No
18~ If the answer to, Question 17 Is yes, hOve you received any payment from that souroe,
and If so, in what amount? " .
No
Dated at Dubuque, Iowa this J {, r# day of JI"rf"'r./I'.PeY
Union Ins. Co. AI
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(Rev. 1/00 & 7/01)
DAVENPORT SERV OFF
JAN 0 6 2006
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EMC Insurance Companies
PROPERTY LOSS WORKSHEET
InsurB ~ Building Personal Property
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location of Loss I Telephone No.
1-8<> S- O Ad G' /,ffs'/ $ $
Policy No. I Claim No. , 711 Date of Loss Type of Loss Estimated Replacement Cost Estimated Replacement Cost
A-/' .~..- 3,.;) j $ $
Type of Building 1 Type of Construction Building Age Less Depreciation Less Depreciation
$ $
Building Measurements I Total Feef Actual Cash Value Actual Cash Value
Item Description Quantity Units Unit Cost Replacement Depreciation ACV
No. r- Price Cost
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. If you have purchased replacement cost coverage you may have additional money TOTALS )57/.
due you after the repairs or replacement is completed,
LESS DEDUCTIBLE IF APPLICABLE 7-50.
PLEASE REFER TO YOUR POLICY FOR THE EXACT TERMS AND CONDITIONS . AMOUNT RECOVERABLE PRIOR
OF THE REPLACEMENT COST COVERAGE, /:R-:ZI
TO REPAIRS BEING MADE ...
ADJUSTER I INSURED SIGNATURE & DATE DATE OF INSPECTION I DATE OF REPORT
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Form 21 D3C (Rev. 4-93) FST