Claim Kylmanen MackenzieCLAIM 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: Mackenzie Kylmanen
2. Address: 2506 Broadway #2
3. Telephone Number: 319 - 582 4185
4. Date of Incident: 1-15-01
5. Time of Incident: 11:45 AM
6. Location of Incident (Be specific): outside Mercy Hospital's Visito Entrance on Cith Bus Ramp
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.)
bus driver randy vaskas operationg the small bus attempted to adjust the ramp. I lost control of my three wheeled walker coming down the ramp. I attempted to break fall using my right arm
8. What were weather conditions like?
9. Give name and address of any witnesses: randy Vaskas Keyline transit
10. Did police investigate? (If so, give names of officers.) No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries). Yes, Mackenzie Kylmanen claimant, brused and spraind right arm and wrist.
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? ongoing pain and sufering
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.)
title ixx-ihs claim submitted
15. What amount do you claim from the City of Dubuque? reasonable and fair compensations for expenses, pain and suffering
16. Why do you claim the City of Dubuque is responsible? it coccured coming down city bus ramp
17. Have you made any claim against anyone else for damages as a result of this incident? No
(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 17th day of january , 2001
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST TH~. CITY OF DUBUQUE
This wr±tten report constitutes your claim against the City of
Dubuque, Iowa. You should com~tete 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 reco~unendation.
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 W~THER YOUR CLAIM WILL OR WILL NOT BE
PAID.
Telephone N-m~er:
Date o~ inCident:'
3.
4.
5.
6.
Time of Incident:
(~ive full details upo~ which you base y~r claim. If a City
~loyee was involved, ~ive the ~loyee, s n~e.)
w~ w~a:n~r =onaitions lik~
10.
11.
Did police investigate? (If so, give names of officers.)
Was enyo~e injured? (If so, ~ive na~e, address and extent of
injuries. )
12. Was any d~m-ge done to property? (If so, describe property
and the extent of damage. Attach estimates of damages or
describe basis for ascertaining extent of damage.)
13. What other damages do you cls{m~ 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 zs responsible?
17.
Have. you mad.e a.n.y claim against
result of
anyone else for damages:, as a
If yes, give name and address=
18. If the answer tO Question 17 is yes, have you received
payment from that'~oUrce. 'a~a '-if' s' o,~' i~'wh&~ am°~nt~ --- any
Dated at' DUbuqUe, Iowa. this ~ 7 day of _~c~ ~ UA ~ ex,jO'
o¢I ..... /
(Revised January, 2000)
{ s
(P~znt~ Na~e)