Claim, Maro, JerryCLAIM 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
reconu~endation will be submitted to the City Council. You willbe
provided with a copy of that report and recommendation, _
T~ FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL.
NO EMPLOYEE OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO HAKE ANY
REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILLNOT BE
PAID.
1. Name of Claimant: Jerry Maor
2. Address: 10358 Timothy St., Dubuque, IA
3. Telephone Number 319 556 2606
4. Date: 4 18 01
5. Time: Approx. 11:45
6. Location - City Hall Annex Stairway
7. Describe: Walking down stairway, stepped on marking pen laying on steps,
pen rolled and my foot went out under me, fell 8 or 10 steps, hit floor and door
at bottom.
8. Weather:
9.
10.
11. Injuries: myself, I'm having problems with my neck and hip, problems and
balance being dizzy.
Ad, ess:
Date of Incident: j--/~-~ )
Location of i=cid~t. (Be specific) C,'~/ ~4k/ ~W~f
a= w~r~ w~a=h~ =onai~ions l~k~ ~em/ /~
Was ~yone inj~ed? (if so, give n~e, ad,ess ~d extent of
injuries. )
12. Was any damage .done to property? (If so, describe property
and the ex~enu 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 name and address of
in~%urance company and amo.unt paid.)
15. What amount do you claim from the City of Dubuque? unspecified, do not know how long
I'll be under doctor's care.
16. Why do you claim the City of Dubuque is responsible?
It was your property, your stairway and the City was responsible
for keeping stairways free of objects that could cause someone to fall.
17. Have you ~de any =laim again~ ~yone else for d~ges as a
If yes, give name and address:
18. If the answer to Question
payment from that source,
Dated at Dubuque, Iowa, this 8th day of May, 2001.
17 is yes, have you received any
and if s0, ln_.~hat amour~t.
/s/ Jerry Maro-
(Print Name)-
(Revised January, 2000)
May 8,2001
City Of Dubuqne
Clerks Office
13th & Main St.
Dubuque, Ia 52001
Enclosed you will find the claim form that I ~as advised
to fill out and return to your office. As a result of this
fall on city property, I have been under chiropratic care
since that time. I'm havin~3 problems in my back and neck
having real problems with being dizzy and b~ance problems.
I'm hoping that this problem can be taken care of with
treatments and that there is no lon(3 term problems. The
problem I have is my current insurance will only pay for
12 chiropratic visits within any (.~iven year and I have al-
ready been there six times. My question to you is do you
have liability instance to cover my doctor bills and if so
do I have permission to receive these treatments or do I
have to quit, since my insurance won't pay and I canno~
afford to (3o and pay this bill myself.
Please advise me in regards to the above as to what your
willin(3 to do at this time, so I can hopefully get this
problem with my back and neck taken care of withont any
long term problems. Thank you.
/s/ Jerry Maro
10358 Timothy St.
Dubuqne, Ia 52003