Claim, Chevalier, H. DianeCLAIM 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: H. Diane Chevalier
2. Address: 274 South Grandview Avenue
3. Telephone Number: 319 583 4183
4. Date of Incident: Sunday, July 15, 2001
5. Time of Incident: 9:30 - 9:45
6. Location of Incident (Be specific):
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.)
I was walking with my son on South Grandview. I was a block within my house when I tripped on a raised sidewalk - officer investigated (blood was there)
8. What were weather conditions like? Hot and humid
9. Give name and address of any witnesses: Jon-Paul Chevalier, Son, 1188 Bishop St., Suite 1101, Honolulu, Hawaii
10. Did police investigate? (If so, give names of officers.) Yes, Josh Abitz
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
H. Diane Chevalier
** Mouth Cut - Lipts - * Teeth Chipped - Stitches required Dr. Zimmerman, Finley Emergency;
Bruised Knee and (muscle aches after fall).
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 - Just to me! Faulty raised sidewalk.
13. What other damages do you claim, if any?
Emergency Room Services - Finley Hospital - Chipped Teeth
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.)
Not Yet
15. What amount do you claim from the City of Dubuque?
Emergency Room & Dr. Expenses & Dental Work
16. Why do you claim the City of Dubuque is responsible?
Faulty Sidewalk - RAised.
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?
No.
Dated at Dubuque, Iowa this 19th day of July 2001 , 20 .
/s/ H. Diane Chevalier
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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:
,~. Address:
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific):
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.)/' ~ ~
//
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.) ,
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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;)
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 insurance company and amount paid.).,
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
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, inwhat amount?
Dated at Dubuque, Iowa this /~'~/~. day of ~-----~- ~/.~ , 20- :.
(Print Name)
(Rev. 1/00 & 7/01)
MARIA T. LOCNER-CLAUS D.D.S.
Fl3es Professional Park
0 AsburB Road · Suite 3
Dubuque, IA 52001
Phone: (319) 58Z-0114
Fax: (319) 588-8670
July 19, 2001
To Whom It May Concern:
Re: Diane Chevalier
Diane Chevalier was seen in the office 7-19-01. Diane stated that a few days ago she
tripped on the sidewalk on South Grandview while she was walking with her~.~ She said
'~the sidewalk was raised" which was the cause of her tripping and falling. She was seen in the
emergency room that day by Dr. Zimmerman.
Upon evaluation of her oral cavity, she fractured the enamel off of teeth 9, 10 to the point
that they are extremely sensitive. Tooth #10 has fracture lines through the clinical crown. Teeth
9 and 10, also, have a Grade 1 Mobility to them, (these teeth are slightly loose). Her lower
anterior teeth were unharmed but teeth 7 and 8 (upper right lateral and central) were, also,
slightly chipped in the fall. Diane's lip is very swollen and the inner lip has been cut and sutured
above teeth 9 and 10. It was difficult to do a very thorough examination at this point. We did
take radiographs and, at this point, they show no evidence of fracture. But, fracture-lines are
difficult to diagnose on radingraphs. I did state to Diane that in the £uture any of these teeth that
have been traumatized could die requiring root canal treatment or extractions. There were no
other lacerations in the mouth.
Once again, I was unable to do a thorough examination, at this point, due to the fact that
it was difficult to manipulate her lips. I will see Diane next week to do another examination.
If yowhav~any questions, please call me.
S inc er ~e~-57~)/
~& IS~cher-Claus, D.D.S./