Claim, Scheffert, BruceCLAIM 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: Bruce Scheffert
2. Address: 1020 Garfield
3. Telephone Number: 563 583 1482
4. Date of Incident: July 4, 2001
5. Time of Incident: 11:30 A.M.
6. Location of Incident (Be specific): on street in front of 1020 Garfield
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.)
Was stepping off curb, stepped onto street where curb and street mee and street is 2 in higher than the gutter and
he hit the uneven part and snapped his ankle.
8. What were weather conditions like?
Beautiful summer day - sunny
9. Give name and address of any witnesses:
Steven Scheffert, 1020 Garfield
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Bruce Scheffert, 1020 Garfield, Severe sprained ankle w/bone chipped on ankle/ w possible
bone separation.
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.)
n/a
13. What other damages do you claim, if any?
n/a
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.)
our medical insurance will question this claim.
15. What amount do you claim from the City of Dubuque?
medical bills and loss of wages for 2 weeks - approximately - not sure how long
16. Why do you claim the City of Dubuque is responsible?
Because it is because of street needing repair, if street was even it would not have happened. Street is uneven.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
N/A
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 6th day of July , 2001.
/s/ Bruce Scheffert
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE (D ¢~)
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 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 T~F, CITY OF DUBUQUE HAS THE AuTnORITY TO MAKE ANY
REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE
PAID.
1. Name of Claimant:
3. Telephone Number: ,~L~3-- --
s. *.ocation of incident. (~e spec~fic~ ~ $--~ee7~ ?'~ o%~7~l
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INOu~Y OR DAMAGE.
(Give full details upon which you base your claim, if a City
employee was involved, ~ive the employee's name.)
/
IO~b ~1~
10. Did police investigate?
(If so, give names of officers.)
11.
Was anyone injured? (If so, give name, address and extent of
injuries.)
/
12.
Was any damage
and the extent
'describe basis
done to property? {If so, describe property
of damage. Attach estimates of damages or
for ascertaining extent of damage.)
13.
14.
What other damages do you claim, if any?
Have you been compensated for any part or all of your claim by
any insurance company? (If so, give name and address of
insurance c~mpany and amount paid.).
U
15. What amount do you claim from the City of
16. ~y do you claim the City of D~u~e is responsible?
17. result of this incident? ~/~ else for d~ges as a
Have you made any claim against ~yone
If yes, give n~e and address:
18. If the answer to QUestion 17 is yes, have you received any
payment from that source, and if so, in what ~mount?
Dated at Dubuque,
C~
;.~'~; /2,
(Revised January, 2000)
Iowa, this day of
/
(Signa
Print Name)