Claim Sampson, JessicaCLAIM 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: Jessica Sampson
2. Address: 1672 White Street
`
3. Telephone Number: 5563 1945 495 3242
4. Date of Incident: 6-27-06
5. Time of Incident: 9:45 P.M. - 10:00 P.M.
6. Location of Incident (Be specific): Sports Complex by Area 3 (Maclay's field - McAleece?)
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.)
A player hit a ball out of the park and it landed on my windshield and busted it.
8. What were weather conditions like? Nice
9. Give name and address of any witnesses: Dara Michalson - 554 W. 5th, Apt. 1
Grace Baptist Church Softball Team - 39666 Asbury Rd. - Pastor Bob Harbin)
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.)
Yes, windshield
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.)
None
15. What amount do you claim from the City of Dubuque?
$245.24
16. Why do you claim the City of Dubuque is responsible?
Happened at a City Park
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?
N/A
Dated at Dubuque, Iowa this 28 day of June, 2006.
/s/ Jessica Sampson
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA lJ~
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 West 13th St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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 ClaimanL '~.qm ,~j\-
2. Address: ~~ c~t![i~ ~~
3. Telephone Number efJ- Q \~.@ y~ ~
4. Date of Incident: W -;;Tl- 0 L 0
5. Time of Incident: C) LV;~ - ) ():tt>(Y'vl
6. Loc tion of Incident (
7. Describe the accident or occurrence that caused injury or damage. (Give full
details upon which you base your claim. If a City employee was involved, give
~e employee's n~, . . ~
~~~~~~' ~~\~\~<if~~~(~~[1\I-vI~ Q
8. w~ere weather conditions like?
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9. Give nall)e an~dress of any witnesses:,01, ~
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10. Did police investigate? (If so, give names of officers.)
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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.) . 'c-ld
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13. What other damages do you claim, if any?
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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.)
-~ \\")
15. What amount do you claim from the City of Dubuque?
r9{).6U
16. Why do you claim the City of Dubuque is responsible?
-m\)~~\\))O (1\ n. C~\ lucY---
17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
(1\ )
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
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Dated this
day of )\ ;1\.9
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(Print Name)
AUTO GLASS CENTER
2828 UNIVERSITY AVE
DUBUQUE,IA52001-5674
(563)556-0873
Remit To: AUTO GLASS CENTER, P.O. BOX 78687 MILWAUKEE, WI 53278-0687
Quote: RG11-1 1 487268
Date: 06f28/2006
FederallD: 42-1513432
Phone: 1-800-942-0012
Account: 319989
Agent:
POI:
Time: 10:06:53AM
Adv Code:
Salesman 10: 51
Unit:
Taken By: JMW
Installed By:
BiUTo:
SAMPSON, JESSICA
Sold To:
Insurance Co:
Ins Co Phone:
Policy Name:
Agent Name:
Agent Phone:
Policy#:
Claim#:
Cause of Loss:
Date of Loss:
Verified By:
Year: 2000
Make: PONTIAC
Model: SUNFIRE
Doors: 2 DOOR COUPE
Odometer:
License:
Vln:
Qty
1
1
1
1
Location Part Number
DW01269~Y;
RETAIL.I:A:BOA
HAHOQlm04
DISPOSAL FEE
Vendor Description
FPG WI~SHtELD CiREEN TlfliIif3l.,lJ,E, SHAQ
~\I LAElQR (2.3 HDpRS) qlll,owor26Sl'yBY
M~ 2.():.AOHESIVE~I1iRE:rHA.NE,DAM,~ER)
MG\i: DISPoSAL FE~""" ,"
List
Net
144.20
60.00
20.00
5.00
Total
144.20
60.00
20.00
5.00
20.00
Urethane Brand
QUOTED PRICE HONORED FOR 30 DAYS
Part DOT #
Urethane Lot #
Safe Drive Away Time
CERTIFICATE OF SATISFACTORY REPAIR
In.... p_n.lly",od 111. .t.o... Io..info"".'"" "ndd_ "'"t1lNl~... .......' und......nd 111.' in wind""ilHd in....."""' m~...~iclo
nno'b.dn...n""fo"'tt...bo...S.IeDn..........lim..Thogl..."""rT'Odto.t.o...n.."".....p.._tom~....factio",.ndlll...b~
"1110""" p...".ntfor OIl'......rl< to be mad. ~_lly"''''ulo GI... C."Ie,. inM ..Olem",,' of1lNl ""...".noo """'P."~'.obllg."""'"nd..
m.P<>licyfor..OIlloos,'und._"~I.mfin.naolly...Potl..b..fo'.".c~.'V..MI"".....db.1hI.......m.nt
Sub Total
$229.20
COMPLETED DATE
INSTALLER
rox
$16.04
CUSTOMER'S SIGNATURE
Terms
Total
$245.24
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