Claim, Kaiser, Judy K.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 reco~endation.
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
REPRESWm~fATION TO YOU AS TO WHETHER YOUR CL~__T~_ WiLL OR ~.~-/LL NOT BE
PAID.
1. Name of Claimant: Judy K. Kaiser
2. Address: 2171 North Star Dr.
3. Telephone: 319 557-1983
4. Date of Incident: Feb. 6, 2001
5. Time: Between 5-6 o'clock
6. Location: Intersection of Camelot & Embassy West
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED IN~uaY OR DAMAGE.
(~ive full details upon which you base your claim, if a City
employee was involved, ~ive the employee's name.)
I was out walking, as I crossed the street, there was water that froze after running
in the street. I was down before I could think what happened.
8. What were weather conditions like? Chilly.
9. Witnessess
10. Police investigage: Lady cop came to Finley hospital & took a report.
11. Anyone injured: I busted my knee open when I fell. I needed 7 stitches.
9. Give name and address of any witnesses. -- ~-
10.
11.
police investigate? (If so, give names or.officers.) ~
s anyone injured? (If so, give name, address and extent of
injuries. )
12. Was any d~mage done to property? (If so, describe property
and the extent of damage. 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 Dame and address of
ins~Dnce company and amount paid. )
No.
15. What amount do you claim from the City of Dubuque?
16.Why do you claim the City of Dubuque is responsible?
Because it happened on the City property.
17.Have you made any claim against~a~yone
result of this incident? ~ No.
If yes, give name and address:
else for damages as a
18.
If the answer to
payment from that
Question 17 is yes, have you received any
source, and if so, in what amount?
Dated at Dubuque, Iowa, this
day of
/s/ Judy Kaiser