Claim by Robert SarazinCLAIM 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
f WILLOR WILL NOT BE PAID.
1. Name of Claimant: R(012)04 L a Pc.,c 2, 1 r
2. Address: A((% 4-) g 1-6) c
sal Ib/ r �;.
3. Telephone Number: rim__ � �, O �.
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4. Date of Incident:
5. Time of Incident:
morYI ;75
6. Location of Incident (Be specific): (,;– our- Aoc -, (',;r t`; %v S (Lb oe
)r• 0110/1
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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.)
Car , i nC: Or) 1`'( "4/e `_;/1 t �G�`> S)0�11r)(1
o , a -C'r2 -\-ruck U-) r*. *. vP ,5 - Gac.i'Ld- / ct'�% •i1 v + tt)(%\:-
Ur^ 'our horn e,-r) z pole lS cili a f 1.� S - }r e� c ,nor Cur
8. What were weather conditions like? �h °w �i �[CV-'o) hT ww(-J,
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9. Give name and address of any witnesses: , - Cl�'c� � �I�p a -n �( �� 8t -06'd 1(-)a y
10. Did police investigate? (If so, give names of officers.)
/Jo C1 c C� {'10 + Cct. ( t
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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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.)
our
3ho'ne. \\I-IC Was
YCCV Ct a corner- o i cc e-' OF o D laI On
13. What other damages do you claim, if any? LLJC h)c I' 0 „ph or) C 0 ►'`
I' /1� -e CI- )171-1-1‘
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Cam\ .0 - %0 -f -.1'k 1 +, / her 1-i' 3 cl- c,)e_ ,rte Ei
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 clai fromnth City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible?
�� ► 3 G� u1 0-e 1 �I, e.v ,be/ c_JC -�c�, up p i L teed ��)- f
C �$\ -�y P —U 'Ed (�'1-4 I'^ nc_.) ,
17. Have you made any claim against anyone else for damages as a
(If yes, give name and address.) )
L _cc 1)j
result of this incident?
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 /�
�5�dayof C.hY' Uctr■_.1 20 .
C,
R 6C.vi ,t--61 1)'7
(Rev. 7/12)
(Signature)
(Print Name)
0
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Page 1 of 1
Pam McCarron - Robert Sarazin claim
AL
From: "Trowbridge, Sarah L." <STrowbridge@,dubuquebank.com>
To: "'pmccarro @cityofdubuque.orgt" <pmccarro @cityofdubuque.org>
Date: 03/12/2013 2:16 PM
Subject: Robert Sarazin claim
Attachments: Sarah Trowbridge.vcf; sarazin.pdf
Attached is the claim for Robert Sarazin. If you have any question, please let me know.
Sarah Trowbridge
C :ttm_r5era:eRep.
(563) 589 -1949 Direct
(563) 589 -1945
STrowbridgecdubuquebank. corm
1399 Central AVE
Nib ,Ile, L,S2CO1
,C:I; Ins
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file: / / /C:/ Users /pmccarro /AppData /Local /Temp/XPgrpwise /513F3 8C5DBQ_DOD... 03/12/2013