Claim, Strohmeyer, LaVerne
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against thecCiCyLof lJ)ul3/.lqifJe, Iowa. You
should complete this form in full and attach any additional information that
supports your claim.
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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 Claimant: j..4 Y <- {~ IV F 5"7 /C cJ // ,111 F Y F /(
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2. Address: J 7 ~ ..5'- () 4K cre es-;:-
3. Telephone Number r'? 3- 0',7 77
4. Date of Incident: r:;/f 0 /
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5. Time of Incident: If g <JV r s-: 0 d ;./.;t1
6. Location of Incid~Be specific):
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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
the employee's name.)
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8. What were weather conditions like?
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9. Give name and address of any witnesses:
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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.) ~
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13. What other damages do you claim, if any?
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 rount do you claim from the City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
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18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
Dated thZ 0 ~ay of
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(Signature)
,2006.
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(Print Name)
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SERVPRO OF DUBUQUE
FIRE RESTORATION, MOLD MITIGATION, & WATER MITIGATION
2006-07-01-1652
Room: DRYING
Dehumidifier (per 24 hour period) - Large - No monitoring
Air mover (per 24 hour period) - No monitoring
2.00 EA
8.00 EA
Room: SERVICE CALL
Emergency service call - after business hours
LOO EA
Grand Total
472.84
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00
Terry Lenstra
Grand Total Areas:
0.00 SF Walls
0.00 SF Floor
0.00 SF Long Wall
0.00 SF Ceiling
0.00 SY Flooring
0.00 SF Short Wall
i'(: \J;?,cJ l"j,tiAi '-"--
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ic!ay<
0.00 SF Walls and Ceiling _-
0.00 LF Floor Perimeter 7 h /
0.00 LF CeiL Perimeter / J tJ b
0.00 Floor Area
0.00 Exterior Wall Area
0.00 Total Area
0.00 Exterior Perimeter of
Walls
0.00 Interior Wall Area
0.00 Surface Area
0.00 Total Ridge Length
0.00 Number of Squares
0.00 Total Hip Length
0.00 Total Perimeter Length
2006-07-01-1652
07/06/2006 Page: 2
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SERVPRO OF DUBUQUE
FIRE RESTORATION, MOLD MITIGA TION,& WATER MITIGATION
Estimate for water mitigation and mud removal for Laverne Strohmeyer
25 man hours @ $35.00 dollars an hour
Total $875.00
Friday, July 07, 2006
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