Claim Kress-Jordan, Amy J.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: Amy J Kress-Jordan
2. Address: 1941 Lagen St Dubuque IA 52002
3. Telephone Number: 563-583-0244
4. Date of Incident: 12/5/06
5. Time of Incident: 8:473 AM
6. Location of Incident (Be specific): Intersection of Keyway and Foothill
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.)
Daniel Starkey (employee). Mr. Starkey was driving a garbage truck and backed up on the street and backed into the right front of my vehicle.
8. What were weather conditions like?
Clear
9. Give name and address of any witnesses:
Jon Blaire 582-6228
10. Did police investigate? (If so, give names of officers.)
Yes. Robert Flannery, policy report # 01-06-53988
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.)
2004 Pontiac Minivan
Right front end damage: Light, hood, fender, bumper and passenger door.
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.)
Im in the process of being compensated by my insurance company.
No
15. What amount do you claim from the City of Dubuque?
Pending estimate
16. Why do you claim the City of Dubuque is responsible? Garbage truck driver was cited for accident
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?
Dated this 5th day of December, 2006
(Signature)
(Print Name)
-. .
Claim Form
Page 2 of2
14. 'Have you been companll8led for any part or all of your claim by any Insul'll1lca company? (If BO, give
name and addrellSof insurance company end amount paid.)
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15. What amount do you claim lrom the City of Dubuque?
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17. Hava you made eny claim agelnst anyone else for damages as a resuK ollhls Incident? (If yes, give name
and address,)
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18. If the answer 10 Ouastlon 17 it yea. have you received any payment from thaleouree. and II eo, In what
. amount?
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