Claim Wild, Robert CCLAIM 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: Robert C. Wild
2. Address: 1025 Grove Terrace
3. Telephone Number: 563 556 3094
4. Date of Incident: 2 Dec. 01
5. Time of Incident: 1:42 P.M.
6. Location of Incident (Be specific): On Sidewalk on 5th St. Between Bluff and Locust, South Side of 5th, 10 Ft. West of Alley.
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 wife on the sidewalk towrd the Five Flags. As I stepped on the manhole cover in the sidewalk, it pushed to to the left allowing me to fall into the hole.
8. What were weather conditions like? Daylight, sunny, clear and dry.
9. Give name and address of any witnesses: Anita Wild, same as above, Dave Mahone and Ted STrub Phone 503 5021
10. Did police investigate? (If so, give names of officers.) Police came to residence to take a statement Case 01-48635
11. Was anyone injured? (If so, give names, addresses, and extent of injuries). I received bruises to my left leg and thigh, left elbow, and lacerations to my right knee.
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.)
My suit pants were torn at the right knee. The suit needs to be replaced. Dbq Police took a statement - Case # 01-48635
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.)
No
15. What amount do you claim from the City of Dubuque?
$430.31 The cost of a suit plus tax.
16. Why do you claim the City of Dubuque is responsible?
Because the Manhole Cover ona public sidewalk was not in position to prevent a pedestrian from falling into the hole.
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?
N/A
Dated at Dubuque, Iowa this 19th day of Decmeber , 2001.
/s/ Robert C. Wild
Note: Regarding witnesses I was walking to the Five Flags Theater to meet Gil Spece. Although Gil did not personally witness the accident, he is aware of the circumstances.
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CiTY OF DUBU-'UE, IOWA
" ' CLAIM AGAINST THE u
This wriUen repo~ eonstitute~ ~our ~laim a~ain~t the City of Dubuquo, Iowa~ ~ou ~hould
,omPlot~ thi~ ~orm in ~ull and a~a~h an~ additional information that suppo~ ~our 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:
2. 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? O~'fc4 ~,~-7'~
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 ~lamag~s.
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.) ////9
18. If the
and if so, inco what amount? ~.).//~
~ .. ~ /
~bu~lowath~s lO ~
answer to Question 17 is yes, have you receiVed any payment from that source,
day of
~)l~_CCv.~-%(~_ , 20 Ol .
(Signature)
(Print Name)
Grahsm's Style Store for Nen
890 ToNn Clock Plazs
Dubuque IA 52001
(563) 582-3760
1842
Robert Wild
ZNVOICE 3037
ROW 12/08/2001 2:29p
AC
DS
ST
1 Accessories
30,00 30.00
1 Dress Shirts
32,95 32,95
28.13
Tax ~
TOTAL 497,03
ROVD 497,03
Discover 497,03