Claim Riedl, Kara - Progressive Inc.
08/21/2006 16:41 FAX 318 318 1683
Claim Form
PROGRESSIVE CR
IiiI 0021004
rage 1 ofl,
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report oollSlltu188 your claim Iglin.tthe CIty of Dubuqua, lowe. You llhculd oomplete this form In
lUll and etlIch eny additional infllrmatlon that 6UIlJlO/l8 your cI8Im.
The claim muat be ftled with the City Clelk at City Hall, eo West 13"' St., Dubuque. IA 62001. It wllllhan be
rafemed to Ihe epprop~. department rot in..otigetion and to the City Attomey', OIftce. Once that
InveeUgetion is completed, a report and reoommendaUon wiD be submitted to the City Council. You wll be
provided with a copy of that repott and rea:lmmendatJon.
The ftnaf decision on eU clams i& made by \he CIIy Council. NO employee of the City of Dubuque hils tilt
authorily to make any representation to you as to attllf your claim will or will not be P!!d, ;l(( _
1. Nam. of Claimant' ~i I (i r1 '1 .WI - ftt-!:)1.1S_ F1S111C-'j \Vii ~tSlYl )
2. AcIdlll&8: '2JJ11OHa.mw l( 1rI i I
3. Telephone Number. ~ r;:\,'m. I10UI
4. Date of Incident: tl"~l'WOLR
5. TlmeOllncident~pfDii~
6. Location 01 Incident (Be 6IleclflC):~fl'llfl'i6'1~
~.
7. Desc:~e \he aoddent or OCCUmlnce thet O8lJsed injury or damage. (<31.. full details upon which you base
your cIIlim. If a City employee was Involved, givll the emptayeens name.)
t-1<Z,,~\rd.I~ 'V: i Ie. lY\ lAm, fW -rl'b u '!l1I0il \<IS
dill . c. It..ll oil' (, naHO
. ll..i 'f i See. :b(Ap~
8. Whalwere wea\her conditions like? ~
9. Gi~a nameand address ofeny witn_: C;h I HC\j_OMlJi..
~1t\J1d l2J~~wt*., f;ttb.f1i2.' tJ!JlIg
10. Did police inveotigate'l (If 10, glw names of ofIICel8.)
VlJ..l?~e. Po --,"V. 4("11/"'. I IJnj(()o.lln Wh'IC"h (}/f..Lf.'(' r-tf{J{-Ir4
11. Wa. .nyone Injured? (II eo. gl~ names, eddrases, and men! of injuri..).
lY\S.IL\r~V)LI1tli~a. 0'e 1lC.f..l'.1. fil.lJL. lJnl41tNln )f
~ 19() 'r1'~1fI"ll;tMtn:t.
12. Was any dsmage done to properly? (If 80. deecr1be property and the llldBnt of damages. AttllCh utimalil.
of damages or deecrlbe basis fOr ascertaining extant of damage.) .
~~f'I
~..'\
13. What other d8megea do you claim. If any? ~OOV
-~
http://www .cityofdubuquc.orglprinter_friendly.cfm~ageid= 1 SS
\":
. 09127/2006
08/27/2006 16:41 FAX 318 378 1683
PROGRESSIVE CR
IdI 003/004
Claim Fonn
Page 2 ore
17. Have you ma(!. any claim against anyone _ for demages e8 a result of thle Incldent? (If yes, give name
and address.)
~
18. If the amlWer to Quellllan 17" ye.. h.... you received any payment from \he! source, end Irso, In what
amount?
Deled thl. '1-.1.,n day of ~
. 201il.
(Slgnlllure
~ "J"~C\SDn
(Print Name)
prlnt.lh'~. p....
http://www.cityofdubuque.ot.i.printeUiiendly .ctin?pageid~155
09/27/2006
. 08/2712006 16:41 FAX 318 378 1683 PROGRESSIVE CR 1li004/004
~ ~OO)
-/i')C, ~11 'WS,fI1c. \?L-tSYYIOBCti)rrfu tt.{J~J5 Janr....IYK./lictLffrkd
-to 0..1/6\0. -tv1c tu' by suJCV\il~ It'ltO itc Q1CD~ ifttft1c.s Ia.nc OlLt
* t% 9'11\ ~--lf1c, ~hr tt{1r Db HG./ZlcdJs vctu.Lk:. 'IiJlUr ay',I/ey-
:1lfOCS Hc\I~ -fflltl 116. elcIl I1ettAtI. not 5cc. 11;. elcLtJS vcnwc.
Wiwcrs;1y i'Wcnuc 'Ib ()lC \1x):" ro+n cii rett1~ ',n "1fl~S fllrl1alLCV1
\DCLttllY'\ .
U am 1tt-i'''1 L1rvi 1Y'(W.l-' (;tiff'( ll--tn,s UUM.-hX,y
lrat1(YLU.
A911~ ~1\~eWJ