Claim Brennan, Patrick
CLAIM 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: Patrick Brennan
2. Address: 267 Tomahawk Trail SE Cedar Rapids, IA 52403
`
3. Telephone Number: NA
4. Date of Incident: September 27, 2006
5. Time of Incident: 1:25 PM
6. Location of Incident (Be specific): 1000 Blockof University Ave. Dubuque, IA
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.)
Our Insured was traveling on University. Bus was parked along the side of the Road. Our Insured begain to drive past the
parked bus and the bus merged into our insured.
8. What were weather conditions like? Clear, and Dry
9. Give name and address of any witnesses:
Shirly Daack, 509 Woodland Ridge, Dubuque, IA 52001
10. Did police investigate? (If so, give names of officers.)
Yes, Officer Martin Steil
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, Karla Riedl
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, Damage was caused to our insured. 2003 Kia Sorento. The damage is located on the right rear.
13. What other damages do you claim, if any?
N/A
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.)
Yes, Progressive Casualty Ins. Co. P.O. Box 89440 Cleveland OH 44101 $2963.15
15. What amount do you claim from the City of Dubuque?
The City of Dubuque bus driver failed to yield ROW entering the flow of traffic from Parked position.
16. Why do you claim the City of Dubuque is responsible?
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 19th day October, 2006.
Valerie Blanchard
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
L1ann rorm
. .
SEARCH
~DUBUQUE,IOWA
M>jj,jS''ttt;it'Ji'fEC''EO N THE MISSISSIPPI !filCKfOil.-PR1NTIiR rniEN[)Lyi~ii~
Home Paae : Departments: Citv Clerk: Claims aaainst the Citv : Claim Form ~//1 ~~
City Clerk V~1f1Y
First floor of City Hall, 50 W. 13th Street . .
Phone: (563) 589-4120
Fax: (563) 589-0890
Hours: 8 a.m. to 5 p.m. Monday through Friday
Email: jschneid(ci)citvofdubuaue,ora
CLAIM 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 ciaim.
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 clams 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: Rl\1\e..lL bre. (\(\0.0
2. Address: 0loi IbMC\. \rvLWV-.. -rvCli\ SF- r.ab( Ro.pidSTt+5)..~O~
3. Telephone Number: J /1'-\
4. Date of Incident: l )Q ~ n'L'oe r- -:)'1, ''2{jj to .
5. Time of Incident: ~ : Z ~ '? \'--\
6. Location of Incident (Be specific): JOM b\ncJ( Of U nivJ V~ I ~.J1V-€..
\)ubU Q0t J To. .
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 employeeLJs name.)
i~i~ &.:6 ()(IV.ee,
~nuJ:\ (I"\-t l \cj
\.;~niY.u'&-
\~' '\JJ 0 l(
b.~s. t\lll\ '\-:1\.Q.. be, n~h~~i
8. What were weather conditions like? C\eQr I P-j\J\:l D ~.\ I
9. Give name and address of any witnesses0h I r \U 0 ClClLK
50 C\ \JJeod In. nc\ tiel 1)"'''' \)dW ~\jf' T.A
10. Did police investigate? (If so, give names of officers.)
'Yr.S, 6("fj(fr WOr+in 5. -rtl \
')ljzal
1(,,11 JL. ftU;1-
i 11+0 ()L\ r InSu..iV6 -
")d-Ob
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
~6 I h(ly/t\ J<,lfd (
http://www .cityofdubuque.org/index.cfm?pageid= 155
09/29/2006
Claim Form
~t
13. What other damages do you claim, if any?
filA-
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.)
.!I:. " Pfo:J ( ~", S;{.L r ~O"(\ l~ 1 a~ Coil]!' "-1"
~ . OK <2>qtND ~\f:IN,tond(Jlt +rlol 1/1 ~Cj~3,/j
15. What amount do you claim from the City of Dubuque? (1 \3 %1 3, /5
17. Have you made any claim against anyone else for damages as a result ofthis incident? (If yes, give name
and address.)
tJi)
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what
amount?
Dated this
~/f\
If!iJyof cJr!hd!U
,20..af,
Home Paae : Deoartments : City Clerk: Claims aaainst the City : Claim Form
priQt~rJriertQl'l]:,_~ge
http://www .cityofdubuque.org/index.cfm?pageid= 155
09/29/2006
FAX
TRANSMITTAL
SUBROGATION
October 19, 2006
To:
Company:
Our Insured:
Our Claim#:
Date Of Loss:
Your Insured:
Your ClaimfPolicy#:
City Clerk
CIty of Dubuque
Patrick Brennan
069384240
09/27/2006
City of Dubuque
Unknown
Progessive Casualty Ins CO
P.O. Box 89440
Cleveland, OR 44101
Facsimile:888-792-5922
Progressive.com
Total Subrogation Balance: $3463.15. This includes our insured's $500.00 deductible.
We are seeking reimbursement at 100 'Yo, for a total of$ 3463.15.
Please take this as formal notice of our subrogation rights with regards to the above captioned
claim. We have completed our investigation into the facts of the above captioned loss and find
that your insured was the proximate cause of the accident.
Please make draft payable to "Progessive Casualty Ins Co as Subrogee of Patrick Brennan ", in
the amount stated above and mail it to the attention ofthe undersigned.
All supporting documentation is enclosed. I have diaried my file ahead fifteen (15) days. Thank
you for your anticipated, prompt attention to this matter.
Progessive Casualty Ins Co
Valerie Blanchard
Subrogation Representative
Toll Free 1-877-818-0139 ext. 37519
Valerie _ Blanchard@Progressive.Com
**PLEASE INCLUDE MY NAME AND CLAIM # ON ANY AND
ALL CORRESPONDENCE**
PROGRESSIVE"
Not what you'd expect from an insurance company.'"
AUTO. MOTORCYCLE. WATERCRAFT. RV . COMMERCIAL VEHICLE
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PACMAN
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CMSD2340 /CMSM2340
OPID: EXA0032
INSD: BRENNAN, PATRICK
DOL : SEP 27 06 IA-CR336
PAC MAN
CLAIM PAYMENT INQUIRY
PAY TO THE ORDER OF:
TOTAL DRAFT AMOUNT:
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IN PAYMENT OF: SUPPLEMENT, 2003 KIA
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