Claim, Lange, Joseph J.CLAIM 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: Joseph J. Lange
2. Address: 2302 Windsor Ave., Dubuque, IA 52001-0626
3. Telephone Number: 563 556 2302
4. Date of Incident: 6/9/01
5. Time of Incident: 3:15 P.M.
6. Location of Incident (Be specific): Curb on Suzanne Dr. between 2190 & 2188
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.)
Stepped off curb into Street and sprained ankle.
8. What were weather conditions like? Sunny
9. Give name and address of any witnesses: Louise Lange - 2302 Windsor, Scott Young, 2190 Suzanne Dr.
10. Did police investigate? (If so, give names of officers.) Officer took report
at Emergency Room
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Joseph Lange
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?
Medical bills + lost wages
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.)
No. Insurance Co. told us to contact City.
15. What amount do you claim from the City of Dubuque?
Medical bills and lost wages?
16. Why do you claim the City of Dubuque is responsible?
There was water sitting in the gutter and did not see the different (unevenness)
see raised portion of gutter in street.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) No
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 30th day of June , 20 01.
/s/ Joseph J. Lange
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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 a~d
reco~,endation 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 WHET~ER YOUR CLAIM WILL OR WILL NOT BE
PAID.
1. Name of Claimant:
2. Address: ~ O~
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of incident·
DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INdoRY OR DAMAGE.
(Give full details upon which you base your claim, if a City
employee was involved, give the employee's name.)
y
8. What were weather conditions like?
9. Give name and address of any witnesses.
10. Did police investigate? (If so, ~ive n~es of officers.)
11. Was ~yone injured? (If so, ~ive n~e, address ~d extent of
injuries. )
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. 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
·
znsu~ran~ com_D~ny and amount_Da_A,)
/
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
resul~ of ~his 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 Z ~ day of
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(Revised Janua~, 2000)