Claim - Heiberger, ElizabethCLAIM 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: Elizabeth Heiberger
2. Address: 3419 Sunset Park Circle
3. Telephone Number: 563 556 8594
4. Date of Incident: August 12, 2001
5. Time of Incident: Discovered Problem about 10:15 a.m. Sunday morning
6. Location of Incident (Be specific): The basement was flooded with sewage A City official
located someone to clear the main sewer line since it was blocked.
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.)
Basement was flooded with sewage, the City sewer line was blocked.
8. What were weather conditions like? Fair
9. Give name and address of any witnesses: A city employee cleared the line
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
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.)
See No. 13
13. What other damages do you claim, if any?
Clearing out water and wiping up water - 6 hours ($5.00 = $30.00
Scrubbing and washing wet items 16 hours ($5.00) = $80.00
Set of CHristmas ornaments $3.00
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
15. What amount do you claim from the City of Dubuque? $115.00
16. Why do you claim the City of Dubuque is responsible?
The City failed to keep the main sewer line clear which caused sewage to back up into our basement. This is not the first time this has happened. It should be
cleared periodically.
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 4th day of September , 2001.
(Signature)
/s/ Elizabeth Heiberger
(Print Name)
(Rev. 1/00 & 7/01)
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. 13m 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.
3. Telephone Number:
4. Date of Incident: ~r~u¥~. /~) .,
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
e_mployee's ~ame.) ,, .
,
8. What were weather conditions like? -~r(
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.) /UO
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, ~ what amount?
D at;.~ub~ Iowa this day of~.~-~ 20 ~) /
(Signature) ~
(Print Name)
(Rev. 1/00 & 7/01)