Claim, Ludovissy, DavidCLAIM 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
recomme, ndation will be submitted to the City Council. You will be
provided with a copy of that report and reconunendation.
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: David Ludovissy
2. Address: 787 West Locust, Dubuque, IA
3. Telephone Number: 319 556 6661
4. Date of Incident: 4/9/01
5. Time of Incident: Early AM
6. Location of incident. (Be specific) Ludovissy & Assoc., 787 West Locust, Dubuque, Iowa
7. DESCRIBE OCCURENCE:
Sewer backed up. Neighbors advised that it had happened before. 8 structures
on block affected.
8. . What were weather conditions like? Rain
9. Give name and address of any witnesses. Sewage witnessed by office employees &
Steamatic that performed cleaup.
10. Did police investigate? No
11. Anyone injured: No.
Was ~yone injured?
injuries.)
(If so, give names of offic~,So)~c~
(If so, give name, address an~.~en~of
12. Was any damage done to property? (If so, describe property
and the extent of dmnage. Attach estimates of damages or
describe basis for ascertaining extent of damage.)
Carpeting in front 1/3 of building damaged & removed; Damages for moving & cleanup;
Damages for new carpet.
13.What other damages do you claim, if any?
14. Other compensation: Claim has been submitted to Allied Ins., Des Moinea IA (Claim number can be furnished when
obtained).
15. Amount claimed from City: My $500 ded.
16. Why City responsible: In discussion with neighbors they advised
that it had happened before.
17. Any claim against anyone else? No.
18. No.
Dated this 12th day of April, 2001.
/s/ David Ludovissy
17.
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. )
What amount do you claim from the City of Dubuque?
Why do you claim the City of DubuqUe is responsible?
Have you mad~ any ~iaim against .anyone else for damaues as a
result of
If yes, give name and address:
18.
If
payment, from that source, a~d if so, in what mnount?
t~= ans'wer to '~aestion 1~ is yes, have you received any
Dated at Dubuque, Iowa, this
2001.
(Print Name)
(Revlse~ January, 2000)