Claim, Wefel, DesaCLAIM 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: Desa Wefel
2. Address: 33253 160th St., Plainfield, IA 50666
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3. Telephone Number: 319 276 4615 Home; Cell 319 404 3935
4. Date of Incident: 3-3-06
5. Time of Incident: 13:18 Hrs.
6. Location of Incident (Be specific): Booth St. & University Ave.
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.)
Mr. Paul Stohlmeyer. I was going down the street whenMr. Stohlmeyer either pulled away or
didn't stop at a controlled intersection and I hit him.
8. What were weather conditions like? Normal, dry.
9. Give name and address of any witnesses: A lady called it in, but don't know her info.
10. Did police investigate? (If so, give names of officers.)
Dubuque Police Dept.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
I was (stiffness)
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.)
94 Pont. Front End Damage. And Air Bag. I'm sure it is totaled.
13. What other damages do you claim, if any?
Medical Bill/Rental Car.
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?
All medical, towing, storage, rental, vehicle.
16. Why do you claim the City of Dubuque is responsible?
Mr. Stohlmeyer failed to yield and was charged such.
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 13 day of March, 2006.
/s/ Desa Wefel
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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F AK NO. 563 568 OB96
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CLAIM AGAINST THE CITY OF DUBUQUE,IOWA :;-
This wrltlen report constitutes your claim against U. City of Dubuque. IOWa. You shOldd.:;
COMplete this form In fullllllcl attach any addlUonllllnformatton that suppo",your, claim.
The Claim must be filed with the City Clerk at CitY Hall, 50 W. 13" st., Dubuqlle, IA 52001.
It will then be ,efwrr*d by the City Council to the appropriate department fOr Investigation.
Once that IrlVfttIgatIon Is complatecl, a report and reaommenc:laUon will be lubmlu.d to the
City Council. You will bl provided with I copy of that report and recO\'ll\'ll8ndadcn.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY '1'HE CITY COUNCIL. NO EMPLOYBIl!
OF THE CITY OF DUBUQUE HAS THE AUTHORfTY TO MAn ANY REPRESENTATION TO
YOU AS TO WHI!THER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Nmne of Claimant: Ju SA Lv.e +e L
2. Adcll'fllS: 33..d5~ /~()/:!:J5+ .oltii(1f:.(ld I Ztl- SOUUA
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3. Telephone Number: 319 -.;17(p - -l_[j!~!/dln( ~ U /I 3/<1 -101-'3133
4. OIte of Incident: 3 - :3 - 0 y, W:
6. Time of Inoldent: /.3 : J <j !f v .5
6. Location of Incident(Se spectfto): 13~ 5+. Ah)- l111;V~rs:-ht M~
7. DeSCRIBE! ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGe. (GIve
full details upon which YOl! base your claim. If a City employee waa involved, give the
employee'. name.) J). I
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8. Whatwel'llweathercondltlonlJlke? MvYl1J'YL, '})r7
8. GI~nameandaddrssofanYWltne..s: If 1,417 f"A-lkd ,'./... )11/ 'B"",+
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10. Dld'"f.2lice inve.UlIate? (If sa, gIve nam., of officel'8.)
(,j J;>IA iU..( tJ<>/ ,'c-< ])....-.1-'
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11. Was anyone injured? (If 80, give nlmes, addres..., and extern of InJuries).
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MAR-13-2006 NON 03:06 PM DBQ. crTY CLERK
FAK NO. 563 589 0890
P. 02/02
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12. Wa. any dIlmage done to prop-rty? (If so, describe property and th8 extent or damagee.
AUach estimates of damages or describe basil lor BScurtllnlngllXlBnt,of daltHlge.)
9'1 frMf, FPVYl-!-P/14,.} DA-m~. .~ Ad A-z,e fJAj.
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13. What other damages do you claIm, If any? J1V J; c: #-L 1&,' ( ~ J k 4t. c ~
14.. Have you been compensated for any part or an of your claim by any insurance
compeny7 (If so, give namB and address of InsuranCe company and amount paid.)
vo
15. What amount do you claIm from thlJ City of Dubuque? Ct ) I /"fY'j,. (A-L/ -kw,'/1 1
5~,tiy ~4rL. l-k h'.c k. '
I / .1 I
18. Why do you clelm the City of Dubuque Is rwsponsible? II? rf.. 5'V 11 ( ~ r
-J;: \-<J --Iv Yr:.erd 411/ W#5 C ha/'}-<J S4.c ( .
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17. HIMI you made any claim against anyone .... for damages as a re8Ult of thle lnaidllnt?
(If yes, give name and .dd......) IJ 0
18. "tlnl .nswer to Question 17 I. ytI8, have you recelved.ny payment from that source,
and " so, In what amount?
DIItlKl at ~..It"II".. Iowa tI'lls
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13
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(Signature)
ne.jc; {A)e Ie!
(Print Name)
(Rev. 1/00 & 7J01)
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