Claim, Harbin, Robert L.CLAIM AGAINST THE CITY OF DUBUQUE
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 Street, Dubuque, Iowa 52001-4864. 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: Robert L. Harbin
2. Address: 1890 Chaney Rd.
3. Telephone Number:
4. Date of Incident: March 1, 2001
5. Time of Incident: Apr. 4:30 P.M.
6. Location of incident. (Be specific) Employee Entrance at ?? Laundry
7. DES~IBE ACCIDE~ OR OCC~RENCE T~T CAUSED INou~Y OR D~GE.
(Give full details upon which you base your claim,
~loyee was involved, ~ive the employee's n~e.)
Sidewalk over storm drain gave way as I was walking on it. My leg went down in to storm drain. This caused
many cuts and bruises.
10. Did police investigate? (If so, give n~es of officers.)
F
11.
Was anyone injured? (If so, give name, address and extent of
injuries.)
/ J /
12.
Was any damage done to property? (If so, describe property
and the extenu of damage. Attach estimates of damages or
describe basis for ascertaining extent of damage.)
13. What other damages do you claim, if any?
any insurance company? (If so, give name and address of
insurance company and amounu paid.)
15. What amountt do you claim from the City of Dubuque?
Hospital bill and pain and suffering.
16. Why do you claim the city of is responsibls?
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17. ~ave you made any claim against ~yone else for d~ges as a
result of this incid~t?
If yes, give name and address:
18.
If the answer ~o Question 17 is yes, have you received any
payment from that source, and if so, in w~at aznount?
Dated at Dubuque, Iowa, this day of
20
',,x 'enbnqna
(Revised January, 2000}
/s/ Robert L. Harbin
~Sig~ature)
(Print Name)