Claim by Mercy One Medical Center Copyrighted
October 16, 2023
City of Dubuque Consent Items # 02.
City Council Meeting
ITEM TITLE: Notice of Claims and Suits
SUM MARY: Jill Boge for vehicle damage; Mary Burke for vehicle damage; Linda I rish
for vehicle damage; J P Gasway Co I nc for vehicle damage; Lori Meyer
for property damage; Mercy One Medical Center for property damage;
Erica Nelson for vehicle damage
SUGGESTED Suggested Disposition: Receive and File; Referto CityAttorney
DISPOSITION:
ATTACHMENTS:
Description Type
Claim by Jill Boge Supporting Documentation
Claim by Mary Burke Supporting Documentation
Claim by Linda Irish Supporting Documentation
Clim by Mercy One Medical Center Supporting Documentation
Claim by Lori Meyer Supporting Documentation
Claim by Erica Nelson Supporting Documentation
Claim by J P Gasway Co Inc Supporting Documentation
�1
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA Fi�r�C�.�rs
This written report constitutes your claim against the City of Dubuque, lowa. You should
complete this form in full and attach any additional information that supports your claim.
li The Claim musfi be filed with the City Clerk at City Hall, 50 W. 13t" 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 I
THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU
AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. I
'I. Name of Claimant: �cq, (3n-c. W�i(-e'�„�f C��' I
, 2. Address: �Sv ✓�'r� �vw•c. _ '
City: 7l � c.�-�.. State: l� Zip: �Z��
3. Telephone Number: __$ k � ` S��/ - $O�0
4. Date of Incident: �� � � � � 3
5. Time of Incident: 19 : 1 q
6. Location of Incident (Be specific): _�1..,.1� �.,..1 �� `-c Si A.,�a�vc �'v o�f"'
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7. DESCRIBE ACGIDENT 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.)
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8. What were weather conditions like? In,v�,(.v,.�e,.a •-�
9. Give name and address of any witnesses: �}���" � c� q'C-r'a..-�
10. Did police investigate? (If so, give names of officers.)
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� 11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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12. Was any damage done to property? (If so, describe property and the extenfi of
damages. Attach estimates of damages or describe basis for ascertaining extent of
damage.)
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13. What other damages do you claim, if any? I
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? 5� �,.� ` , a�- �
, 16. Why do you claim the City of Dub que is responsible?
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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.)
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'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, lowa this � day of C�[.�I-ah-�— , 20�.
�(�� w4 (Signature)
��'l6'` �l'v`'��`''�"""""�"_- (Print Name) 4'
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I� (Rev. 5118)
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