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Claim - Buelow, 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 Buelow 2. Address: 2340 Wintergreen Dr., Dubuque IA 52002 3. Telephone Number: 319 556 1781 4. Date of Incident: 9 26 01 5. Time of Incident: 12 PM Noon 6. Location of Incident (Be specific): Corner of Locust and W 6th by the Post Office 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 crossing the street toward the corner of Locust and West 6th when I tripped (because of a crevice in the asphalt) and fell breaking my elbow. 8. What were weather conditions like? Clear, sunny day 9. Give name and address of any witnesses: There was a witness that helped me but I didn't get his name 10. Did police investigate? (If so, give names of officers.) No 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). I broke my elbow. Surgery was needed. I will be in a cast for at least 6 weeks. Physical therapy will be needed. 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? $1500 in lost wages and $1500 in helath care costs ($1500 is my deductible) 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.) I have claims pending with my health care provider Unicare. I don't have disability insurance. 15. What amount do you claim from the City of Dubuque? The amount of my claim is at least $3000 16. Why do you claim the City of Dubuque is responsible? The asphalt at the corner of W. 6th and Locust by the Post Office is in a state of disrepair. Obvious tripping hazard. 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) No, other than health care claims. 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 3rd day of October , 2001. /s/ Karen Buelow (Signature) I have taken pictures of the sight if they are needed. (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. 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. 2. Address: ~ 3. Telephone Number: 4. Date of Incident: 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: /~ rca/0 5. Time of Incident: /a~ P/~ 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). k), Ii be I, 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 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? ~ 4rn~xtT~ 49~° 16. Why do you claim the City of Dubuque is responsible? 11; Have Y°U made an~ claim against anyone else for damages ee ~ result ~ this incident? (If yes, give name a~d address.) 18. If the answer to QUestion 17 is yes, have you received any payment from that source, a_~d if so, in what amount? Dated at Dubuque, Iowa this ..~ t-~/ day of (Rev, 1/00 & 7/01) 4- , 20~/. (Print Name) eded.