Claim Hood, Robert C. Jr.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. 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 Carl Hood Jr
2. Address: 2000 University Ave Dbq
3. Telephone Number: 583 3297 #425
4. Date of Incident: Jan. 8, 2001
5. Time of Incident: C. 12:20 P.M.
6. Location of Incident (Be specific): By a parking meter on Main 2 doors N of Yen Ching Rest.
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.)
While stepping off the curb I slipped on alarge thick patch of ice went off the sidewalk and landed on the edge of the curb breaking my elbow in several places.
8. What were weather conditions like? Cold & windy
9. Give name and address of any witnesses: Melissa Milam, Box 188 Apple River IL 61001, David Poust, Box 476 Orion, IL 61273
10. Did police investigate? (If so, give names of officers.) Yes a report was made at the Emergency Room.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, Robert Carl Hood - a broken elbow treated at Finley ER and Surgery at Mercy on 1/17/01
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?
Medical Costs for the treatment of the injury
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, I have no insurance. I am currently unemployed and a student.
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
The ice was not cleared properly by the parking meter.
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?
No
Dated at Dubuque, Iowa this day of , 20 .
/s/ Robert Carl Hood, Jr. (Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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
West 13th Street, Dubuque, Iowa S2001-4864. 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 CLAIMS IS MADE BY THE CITY COUNCIL.
NO EMPLOYEE OF T~E CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY
REPRESENTATION TO YOU AS TO WH~T-~ YOUR CLAIM WILL OR WILL NOT BE
PAID.
Address: Zo0o5
3. Telephone Number: ~,~- ~$~gQ
6. LoCa~0~ 0f incident. (Be sp~CifiC}-~ .~% ,~
7. DESczIBE-aCcID~ OR OCC~CE ~T ~US~ IN~Y OR D~E.
(Give f~l details upon.which y~ base,your cla~.
-mployee ~s involved, give the ~loyee, s n~e.)
8. ~at were weather conditions like~ ~ n-~J
9. Give n~e ~d address of
11. Was anyone injured~ (If so, ~ive ~e, address ~d ~x~ent of
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 d-m~ges do you claim, if any?
~ - ena~-st~d
1%. Have'you peen comp 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.
17.
Why do you claim the City of Dubuque is responsible?
Have¥ you ~madel any--claim against anyone else for damages as a
result of this incident? ~
If yes, give name and address:
18. iifthe answer to Question 17 is yes, have you received any
paym~":fr~tHat-~6u~c~'~a~~ ~'i~:~a~ am°~nt~
day of
(Signature)
(Print Name)
(Revised January, 2000)