Claim Splendid Valley Nursery
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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.
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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: Splendid Valley Nursery
2. Address:
14973 Rte. 20, Peosta, IA 52068
3. Telephone Number:
563-557-8325
4. Date of Incident:
November 28. 2005
5. Time of Incident:
Approx. ):00 p.m.
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6. Location of Incident (Be specific):
Splendid Valley Nursery roadway to
compost site
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.)
City of Dubuque dump truck was dumping a load of leaves at
our compost site and backed off the roadway and caused
damage
8. What were weather conditions like?
somewhat muddy
9. Give name and address of any witnesses: T(')p Sm; rh mvTwr
14973 Rte. 20, Peosta, IA 52068
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.)
Damage was done per attached invoice
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.)
No
15. What amount do you claim from the City of Dubuque? $ 7 2 3 . 37
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16. Why do you claim the City of Dubuque is responsible? Damage was done
by City of Dubuque dump truck, driven by City employee
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
Nn
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
N/A
Dated at Dubuque, Iowa this 28th
day of
January
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