Claim Mercy Mecical CenterCLAIM 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:Mercy Medical Center
2. Address: 250 Mercy Drive
3. Telephone Number: 589-8086 Mike Johnon Risk Management
4. Date of Incident: 12/28/00
5. Time of Incident:14:30 hrs
6. Location of Incident (Be specific): East side of PAP Building on Mercy Property
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.)
At 14:30 hrs, Keyline transit called Mercy & reported that on of their busses hit a stop sign at Mercy to the esst side of the Professioanl Arts Plaza building
8. What were weather conditions like? No issues noted
9. Give name and address of any witnesses: Keyline
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.)
stop sign was broken off, required replacement
13. What other damages do you claim, if any? as above, top sighn (p[ole fittings) all needed replacement
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? $191.20
16. Why do you claim the City of Dubuque is responsible? Keyline admitted damaging stop sign
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 18th day of Jan , 2001 .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
This written report constitutes your claim against the City
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 recommendation.
THE FINAL DECISION ON ALL CLAIMSIS 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.
2. Address: ~
3. Telephone ~,~her:
4. Date of Incident:
5. Time of Incident:
e
Location of incident. (Be specific)
DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJ%~RY 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?
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give nan~!}~ ~.~ /~ extent of
injuries.)
08:8 ~i'~ 6I I~'¢? lO
12.
Was any damage 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 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, in what amount?
Dated at Dubuque, Iowa, this /~ day of ~--~
20 ~[
(Revised January, 2000)
(Print Name)
81/17/2@81 14:18
3195579048
POR:r'FZEN CONSTRUCTION
ASTOR SI,~AT
PAC~ 8~
PAGE
000405~-IN
INVOICE DATE': 01/12/01
CUSTOMER NO: MERCY
TER~S:
DUE UPON RECEIPT
144.00
33.00
177,00