Claim by Rhonda GassmanTHE CTTY OF
DUB E
Masterpiece on the Mississippi
BARRY LINDA
CITY ATTORN
MEMORANDUM
To: Mayor Roy D. Buol and
Members of the City Council
DATE: October 10, 2007
RE: Claim Against the City of Dubuque by Rhonda Gassman
Claimant Date of Claim Date of Loss Nature of Claim
Rhonda Gassman 10/09/07 09/20/07 Property Damage
This is a claim in which the claimant alleges that as she was driving across the railroad
tracks intersecting with Bell Street, the railroad arm came down, striking and scratching
"her vehicle.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
BAL:tIs
cc: Michael C. Van Milligen, City Manager
Jeanne Schneider, City Clerk
Gus Psihoyos, City Engineer
Rhonda Gassman
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944
TELEPHONE (563) 583-4113 / FAx (563) 583-1040 / EMAIL balesq@cityofdubuque.org
C~m Form
GLAIIUI AGAINST THE GITY OF E-UBUQUE, IO~IIIA
Page 1 of 2
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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: ~ tiT~l~ ~xj~~n(.,)~~
2. Address:
3. Telephon
4. Date of Incident: r~' ~ C '~ f
5. Time of incident: / ~ ~ ~ ~ • ~~ `
6. Location of Incident (Be specific): 1~JC' ~ ~ ` ~ 1 ~~.~~ rCC~c'~C~ "T~'(~.C~~`~
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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i0. Did police investigate? (if so, give names of officers.)
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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9. Give name and address of any witnesses:
` Claim Form
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 amount do you claim from the City of Dubuque? (,~ ~ -~ T F ~C ~ ~~-4l. f1e j
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.) ~~ ii
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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?
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Dated this day of JC'~i", , 20~.
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(Signature)
(Print Name)
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