Claim Kimberly (Nelson) KohlCLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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 W. 13th 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 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: Kimberly Kohl (Nelson Kohl - son)
2. Address: 1665 1/2 Elm
3. Telephone Number: 319 582 0932
4. Date of Incident: June 25, 2001
5. Time of Incident: 12:00 p.m. (aorund)
6. Location of Incident (Be specific): 1665 1/2 Elm St. (right in front of house)
7. DESCRIBE ACCIDENT 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.)
Nelson (son) was riding his bike in front of house. A ladder that was laying in the grass. He hit the ladder with his .....
He fell to the side and fell head first into a hole.
8. What were weather conditions like? Sunny
9. Give name and address of any witnesses: Kim Kohl, 1665 1/2 Elm
10. Did police investigate? (If so, give names of officers.) Yes, Officer Flannery
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Nelson Kohl (1665 1/2 Elm) black and ...... Eye scraped up and cuts and bruises on legs.
12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.)
No
13. What other damages do you claim, if any?
Nelson's bike - tires bent.
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.)
hospital bills
15. What amount do you claim from the City of Dubuque?
$1000.00 plus medical bill
16. Why do you claim the City of Dubuque is responsible?
Because there was a ladder laying in the grass and the hole didn't have anything covering it or
surrending it.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
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, Iowa this 9th day of July , 20 .
/s/ Kimberly Kohl (Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AC=AINST THE CITY OF DUBUQUE
This ~rritten report constitutes your claim against the City of
Dubuque, Iowa. You should complete this form in full ~d attach
azxy additional information that supports your claim.
The Claim must be filed with the City Clerk at Cit~z 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
p~O,V.~ed with a copy of that report and recommendation.
'A'~um FINAL DECISION ON ALL CLAIMS IS MADE BY THE cIT~/ COUNCIL.
NO" ~MPLOYEE OF THE- CITY OF DIrBUQUE ~ T~ Au','~ORITY TO MAKE ANY
REi~R~]~TATION TO YOU AS TO WR~T~R YOUR CLAIM WILL OR WILL NOT BE
!
4.Date of' moO\
~. ~.oca~ion of ~c~d~t. (He spscifi~) \ ~/D ~_\~'
?. DESCa~HE .ACCIDENT Oa OeeUa~ENCE TAAT CAVS~D ~NjOaY Oa DAmAgE..
(Give full details UPon which you base your ~la~m, ~f a City
e~ployee was involved, give the employee,s name.)
8. wna= were wea~er conditions l~ke? ,/~LL~'%~-%tA '
9. eive name and ad~L~ess of any witnesses..
10. Did police investigate? (If so,~ve names of officers.)
11.
Was anyone
injuries. )
(If so, i
g ve name, address and extent of
12. Was any damage 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.
14.
What other damages do you claim, if any?
Have you bee~ compensated for any part or all of your claim by
· any in. sura~ce company? (If so, give n~une and address of
ins~r_a~.,ce c .om~any~ and amount paid. 1__, '
15. What amount do you claim from the City of Dubuque?
I6. Why do you =laim the City of Dubuque is responsible?
r~sult of tb~s inuid~t? ~,~
if. yeS, give name an4 address:
18. If the a~swer to 'Q~estion 17 is yes, have .you received ,any
payment from that 'SOUrCe, a~d: if s.o, in. what
day
{Rewised January, 2000)