Claim Oglesby Mary 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: Mary C Oglesby
2. Address: 436 Clark St
3. Telephone Number: 582 7014
4. Date of Incident: 1-13-2001
5. Time of Incident: 8:45 AM
6. Location of Incident (Be specific): 17th Main, North West Corner
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.)
There was a patch of ice as I stepped onto the street my feet came from under neath me, and I went down
8. What were weather conditions like? cloundy and damp
9. Give name and address of any witnesses: All I can say is a car just passed by and a bus was leaving someone off by Hoffman's
10. Did police investigate? (If so, give names of officers.) No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries). My left wrist was broken in the fall
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.) none
13. What other damages do you claim, if any? Medical expenses and lost wages.
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? on going medical expenses and wages
16. Why do you claim the City of Dubuque is responsible? failure to have pedistrian crowwsalk free of ice
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
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 d~nages 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.
16.
What ~unount do you claim f~rom the City of _Dubuque?
Why ~O yo~clai, the City o~ 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 /y day of ~77/~,~'~
2001. ~ - J
(Revised January, 2000)