Claim Frommelt, CindyCLAIM 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:
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific):
!
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.) -T~, ~.~ ~ ~_~~. (3~,~..~_ _~'~ ~
¢ .... e -. ¢ . ,-
8. What Were weather conditions like? ~%..¢~~ ~~~ ~
10. 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.)
13. What other damageS do you claim, if any.
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.)
15. What amount do you claim from the City of Dubuque? ~.~
16. Why do you claim the City of Dubuque is responsible? ~ ~'~ ~'-'~c~- ~.
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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.)
18. If the answer to Question 17 is yes, have you receiVed any payment from that source,
and if so, in what amount?
Dated at Dubuque, Iowa this 0~]~. day of
(Rev. 1/00 & 7/01)
(Signature)
(Print
HART AUTO BODY & PAINT
800 CEDAR CROSS ROAD DUBUQUE, IOWA 52003
PHONE: (319) 556-g323
DAMAGE REPORT
PRICES SUBJECT TO CHANGE
Items CIRCLED are not in the total in
our opinion, are not pe~t of th~s claim,
INSURANCE CO ADJUSTER PHONE CAR LOCATED AT DEDUCTIBLE
$ym. FRONT Sublet Service ! Sublet Servioe: Sublet Service $
Or Paint Or Hours Pa;ts Sym. LEFT Parts Sym. RIGHT
Or Paint Or Hours Or Paint Or Hours Pl~te
Bumper W/Pads Fender, Ert. Fender, Frt.
Bumper Abs, Fender Shield Fender Shield
Fender Ext. Fender Ext.
Fender Mldg. Side Fender Mldg. Side
Fender Stripe Fender Stripe
Fender Mldg, Fender Midg.
Bumper Reiot.
Bumper Brkt. Side Light ASmbiy Side Light Asmbly
Bumper Cushion Headlamp Headlamp
Valance Headlamp Door Heedlamp Dr.
Bumper Gd. Sealed Beam Sealed Beam
Frt. System Park Light Park Light
Frame Cowl Cowl
Cross Member D~or, Front D~or, Front
Wheel Door Hinge Door Hinge
H~d range REAR MISC.
Fan Shroud Valance Painting 2. (~
EPA WASTE DISP~___~_~;_ CHARGE ~'- d ~
Lic. Light PARTS (Prices Subject TO InVoice)
SERVICES~-b HRS.~?g HR. '1~4. O0
Windshield Gas Tank SUBLET OR PAINTING
Frame SUB TOTAL ~ J- "), ~
Whe*~ TAX ~. ~
Hub & Drum PAINT-MATRL-NDW. ~)~Y'. ~r
GRAND TOTAL g J/[ l, /~
Appraiser X
Symbols: A-Align N-New OP-Open P-Paiot I HEREBY AUTHORIZE THE ABOVE REPAIRS
S-Straighten R-Replace OH-Overhaul