Claim by Lauren Schnip/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 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: ~(~.LLti'eVl <> ~ ~~~-~,~
2. Address: ~~~ ~~~1~1`'~ ~~ ~ ~~
3. Telephone Number j ~p~?~ ~ S~~ U ~ ~ ~ ~
4. Date of Incident: ~ ~ a ~ ~ ~ ~
5. Time of Incident: 3 ~ y S ~ ~~
6. Location of Incident (Be specific): .
~-I0 ~e41~e1~~~ p~~ ~ey~e~t~t,~ ~ S'~~r~~ti~~-f- i ~1-I~~S~~-h`_~~~ ;
8.~
were weather conditions like?
Give name and address of any witnesses:
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.) ,,, , , ~ ,
11: Was anyone injured? (If so, give names, addresses, and extent of injuries).
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?
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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 end address of insurance company and
amount paid.)
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15. hat amount do ou claim from the City of Dubuque?
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
th~i ~ci~dent? (If yes, give name and address.)
I
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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Date this ,~ CZ day of ~I `~ ~ , 20 ~ ~. b1 '~n~~q~~
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(Print Name) Q.~~lf~~,~c~
Driver Information Exchange Report
~1 Dubuque Police Department
563-589-4410
First Middle Suffix Date of tsirtn ~
~ Drivers Name - fast M 09125/1979
U MILL FR NATHAN
Y
State Zip Phone
9393 x
582
3
N Address
RYN ~ pEOSTA
1 -
)
IA 52068 ~ (56
------ ' --------
~ 218 B
T-____
r's License Number
i
D - -
-_-
~-- -- - -- -- -- Insurance Co. Phone #
---
~--
-
Class State Endorsements Restnchons I Insurance Co, Name
T ~ r
ve
Gender
Male 946AA0179 D I IA L2 ,NONE CITY OF DUBUQUE
001 I Insurance Policy #
Owner Company Name
CITY OF DUBUQUE
' Owner's Name - L-,st
First Middle
_ --
Suffix
- _-_--
-- -
Address
----- City
DUBUQUE State Zip
___ __ _
IA 52001-
-_ _ __
50 W. 13TH
-TMake TModel
~ ___ _ -
-_ ___-
5hicle Confiyuia(wn
Style V
I Year
VIN N~o.
MKADN25H685900 2005 INTL ~ 4400
1HT 0
TK _~
Approximate Cost to Repair or Replace
License Plate # State Year Most Damaged Area
i
IA 2007 04 -Right Rear $300.00
88792 _ - -____ --
_ -_
Drivers Name -Last
~ --
Middle
First
- Suffix Date of Birth
U - -
- - --
~-City State Zi Phone
p
N ss
~
Gender Driver's License Number ~-- -
Class ' S1ateTEndorsemenis. ResViction Insurance Co. Phone #
s Insurance Co. Name 563 556-0272 x
WEST BEND ( 1
T
1 NONE NONE
002 Ovmer Company Name Insurance Policy #
HHI6550190
Owner's Name -Last First Middle
SCHR Suffix
UP
TOBIN LAUREN _ _ y
Address City
UQUE State Zip
IA 52003-
~~n FFNt=1 c~N PLACE #3 ,DUB
VIN No.
~~ WAUEH64B81N025551
License Plate #
1486PTX
County
Dubuque-31
_ _- - --
Literal Description
^nue ••
X-Coordinate
"NIA"
Style
4D
Y-Coordinate
N/A"
venue wnnyuw.~~~
~~ 01
Approximate Cost to Repair or Replace
$500.00
If accident occurred outside of city Direction 'Nearest City
limits show general vacinity: "N/A" NIA" of "N/A"
---- -- - -
_ ---- - - -
- -- -
On Road• Street or Highway, At Intersection with
FENELON SUMMIT
-- ----
--
Distance Direction Distance i Direction Milepost Number
-_---- ~, .. ~••ui)n•• i•'N/e" nr "NIA" Or
Year ~I Make it Model
2001 AUDI i AA6
Stale Year TMost damaged Area
~ IA _2007 04 -Right Rear
~cident occurred within corporate limbs of (city)
~ Dubuque - 2100
Rf1U lC tl. c..unia~)
Travel Direction __ ".NIA"
Definable ntersection, bridge, or railroad crossing
..NlA" _ -------- --
--
Officer Badge No. Law Enforcement Case Number ?Date of Accident Tune of Acadenr
MCCLIMON, TED '~ 61B ~ 07-21165 05~ !22/2007 15:46 Hrs
HART AUTO BODY & PAINT
003
800
0
O
2
563) 5 6 8324
FAX
3
PHONE: (563) 5 6 83
EHICLE OWNER ADDRESS 1
MODEL LICENSE MILEAGE
Ml~lC J
ry
0 O u
Y,
PHONE
J ~
INSURANCE CO ADJUSTER
--
FRONT .__
Subiet Servir
Sublet Servioe i LEFT Or Paint Or Hr
Or Paint Or Hours Parts Sym.
8~, Fender, FrL
Bumper W/Pads Fsndsr Shield
Bumper Abs. Fender Ext.
Fender Mldg. Side
Fender Stripe
Fender Midg. _
`'"'" ~' poor Hinge
Wheel ~-
Door Panel
Hub Cap Disc poor Strip
Lr. Cont. Arm poor Mldg:
nper Filler
Is
le Panet
u Panel MI
guar. Panel
guar. Ext.
Air Condenser
guar. Wheel Hou
Recharge System guar. Mldg. Side
Name Plate ouar. MIdB.
Tail Li ht
!food Top REAR
Hood Hinge
Bumper
Hood Lock
Bumper Abs.
Ornament
Bumper Cusl
Rad. Sup.
Bumper Reir
Rad. Core
Bumper Brk1
Anti Freeze Bumper Gd.
Rad. Hoses i
l
l
e
Bumper F
Fan Blade
Fan Shroud Valance
„___,
Pulley Trunk Lid
Trunk Mli
Lic. Light
Gas Tank
Frame
Wheel
Hub & Di
Park
Cowl
poor,
poor
Door
Door
Door
M
loon
og Le8
war. Panel
Side Ligl
Tail Li h
MISC.
Inst. Par
Front Se
Front Se
Top
Headlini
Top Vin!
Tire
Painting
Aerial
Rust Pr
PARTS (Prices subject To In
SERVICE 7 )HRS. @~~
SUBLET OR PAINTING
SUB TOTAL _
TAX
PAINT-MATRL-HDW.
~~
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COLOR
S. I ~'`
DAMAGE REPORT
PRICES SUBJECT TO CHANGE
Items CIRCLED aro not in tfie toot in
our opinion, aro not part of this da1m.
DATE ~ ~ L~ _ Q
~, RIGHT
°ender, Frt.
=ender Shield
Fender Ext.
Fender Midg. Side
Fender Stripe
Fender Mfdg.
Dr.