Claim Friendman, Carol A.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: Carol A. Friedman
2. Address: 17700 Bankston Park Rd. Holy Cross, IA 52053
3. Telephone Number: 319 870 2045
4. Date of Incident: January 26, 2001
5. Time of Incident: 7:20 AM
6. Location of Incident (Be specific): In front of the Deserted Iowa Inn, the older part (9th and Iowa)
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.)
Approximately 2 to 3 inches of Ice Covered by light snow causing the walkway to be very, very slippery. I slipped on the snow/ice.
8. What were weather conditions like?
Early Morning clouds.
9. Give name and address of any witnesses:
Not available at the present.
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
I was. Name and address above. My head hit the icy sidewalk causing a large sized bump (size of half a grapefruit) on the back of my head. Had to go to hospital for checkup
The hospital confirmted that I had a concussion and gave me a prescription for Pain Pills and advised me to go home and rest. I also had numerous bruises.
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?
None at Present time.
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?
Not known at present time.
16. Why do you claim the City of Dubuque is responsible?
Failrue to keep sidewalk free of a build-up of ice (of up to 2 to 3 inches).
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 14th day of February, 2001.
, 20 .
/s/ Carol A. Friedman
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
.,.HE CITY OF DUBUQUE
Thiu wr:it, ten :report constJ tul-ez~ your claim against the City of
Du.buque, Iowa. You should co~cplete this fo/-m in full and attach
The C].air.% must be filed with t:]%e City Clerk at City Hall, 50
lSth St~'eet, Dubuque, Iowa 52001-4864. it will then be
re~erre.~t by the city Council to t-he =pproprlate Department for
i~vesti<j, atio'~. Once that inv~.utigation is ~ompleted, a report and
x'eco~¥n~end~t!on ~ill be submitt~.d to the City Council. You will be
pro¥'i~e~/ wtt~% a co~y of that r~.port and recommendation.
17B~] F]iN.AL DECISION ON ALL CLAIm,S IS FiJ~DW- BY THE CITY C0~CIL.
Y~O ~=~'~ OF ~fHE CITY OF DUBUQ~ ~{AS THE A~HORITY TO ~E ~
~P~(.~I~F~'~IOt'~ TO YOU AS T0 WH]<'i~L~R YOI~ CLAIM WILL OR WILL NOT BE
e~tploy~ Wa~ involved, gi,~e the employee'~ n~.)
10.
Did 'police investigate? (If g,c, give name~ of officers.)
~a~3 an,VOo-e injured? (If [:o, give n~e, address and extent of
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1,2. N~s an'.V clan~c3e done to property? (If so, describe property
(~S~C]ui.t~e basi~ for asueruaini~%g extent of d~age.)
13.
other damages do yogi claim, if any?
you beer! compensated -~or any part or all o£ your claim by
ir~rsurance company? (If so~ give n~le ~d addres~ of
t5,
~ghr3. t a~.~ount do you claiL~ fro~ t~e City of Dubuque?
kny do yo*~ claim ~he City of DuBu~e is responsible?
....... '_~.~,~:._~_o_. I/~_~.~_~.~ ~ ~ ~ Dr g __
any claim z .~a~.n~t anyone else for damages
name and add..~ess:
answer to Questio,~ 17 is, ye~, ~,a, ve you reaeived any
frbm that source, and i~ no, in what amount?
2 D_O.[ ..... ,