Claim, Toth, Phill
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: Phil Toth
2. Address: P.O. Box 1366
3. Telephone Number: 583 6958
4. Date of Incident: 7 6 01
5. Time of Incident: 9:45 A.M.
6. Location of Incident (Be specific): 3rd & Locust
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.)
Officer Prine accidentally hit me while I was riding my bike to work
8. What were weather conditions like?
Sunny
9. Give name and address of any witnesses:
Officer Prine
10. Did police investigate? (If so, give names of officers.)
Yes, Mr. Prine
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, Phil Toth, Groin pull, bruised arm, Bruised 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.)
13. What other damages do you claim, if any? Yes, Mountain Bike Tire, Sproket, Parks, Handlebars;
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.)
Yes, Medicare #478 82 8727 A Medicaid #1289624C
15. What amount do you claim from the City of Dubuque?
Medicare Bills, Hospital, $1500.
16. Why do you claim the City of Dubuque is responsible?
Police Officer, At Work
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 11th day of July, 2001 , 20 .
/s/ Phil Toth
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
This written report constitutes your clmm against the City of Dubuque, Iowa. Y6u-'-~h6uld
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. 13~ 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:
2. Address:
3. Telephone Number:
4. Date of Incident:
5. Time of lncident: ~; !/~* ,~'~
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? /~ ~V- j~//~ ~.~'. F~-~ 4~/~r~
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?
//7" ,'ord
ft'
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 ~//~ day of ~/~ ~d~ / , 20 ~* ~.
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)