Claim - Healy, KarenCLAIM 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: Karen A. Healy
2. Address: 4241 Swan
3. Telephone Number: 563 588 0957
4. Date of Incident: 02-14-01
5. Time of Incident: Approximately 10:15 A.M.
6. Location of Incident (Be specific): Block 7, MID Limited Partnership #47
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.)
Went to check parking meter. Under snow there was ice, slipped & fell down on my right arm.
8. What were weather conditions like? Clear
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
Yes, In Hospital Report, Finely Hospital
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Karen A. Healy, 4241 Swan, Dubuque, IA 52001 Bruised right elbow
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?
None
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, Wellmark Blue Shield & Blue Cross of Iowa,
836 Grand Ave. Des Moines, IA 50309 2565
15. What amount do you claim from the City of Dubuque?
Full Amount of HOspital Bill
16. Why do you claim the City of Dubuque is responsible?
This portion of the sidewalk was not shoveled. See picture enclosed. Nextd day sidewalk was completely shoveled
with now snow or ice remaining.
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 12th day of September , 2001.
/s/ Karen A. Healy
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CC
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 and
recommendation will be submitted to the City Council. You will be
provided with a copy of that report and recoa~endation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL.
NO EMPLOYEE OF THE CITY OF DUBUQUE HAS %'~ AUTHORITY TO MAKE ANY
REPRESENTATION TO YOU AS TO W~T~ER YOUR CLAIM WILL OR WILL NOT BE
PAID.
1.
2.
3.
4.
5.
6.
Name of Claimant:
.ocation ie?dent. %h n
7. DESCRIBE ACCID~ OR OCC~ENCE ~T CAUSED INJuaY OR D~GE.
(~ive full details upon which you base your cla~. if a City
~ployee was involved, ~ive the ~loyee's n~e. )
8. ~at were weather con~tions like? ~
9. Give n~e ~d address of any witnesses.
10.
11.
Did police investigate? (If ~so, give names of o~cers.)
Was anyone injured? (If so, give name, address and extent of
12. Was any d~mage done to property? (If so, describe property
and the extent of damage. Attach estin~ates 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.)
16. Why do you claim the City of Dubuque is responsible?
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?
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