Claim by Michelle HarryTHE CITY OF
DUB E
Masterpiece on the Mississippi
BARRY LINDAHL
CITY ATTORNEY
To:
DATE:
RE:
Claimant
MEMORANDUM
Mayor Roy D. Buol and
Members of the City Council
January 31, 2008
Claim Against the City of Dubuque by Michelle Harry
Date of Claim
Michelle Harry
01 /21 /08
Date of Loss
10/12/07
Nature of Claim
Personal Injury
This is a claim in which the claimant alleges that she tripped on the curb on Central
Avenue between 16th & 17th Streets, injuring her right ankle.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
BAL:tIs
cc: Michael C. Van Milligen, City Manager
Jeanne Schneider, City Clerk
John Klostermann, Street & Sewer Maintenance Supervisor
Michelle Hany
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944
TELEPHONE (563) 583-4113 / FAx (563) 583-1040 / EnnAIL balesq(~cityofdubuque.orq
UBU UE IOWA
CLAIM AGAINST THE CITY •F l ~
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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 St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. Once that investigation is
completed, a report and recommendation will be submitted to the City Cp~ginci~
You will be provided with a copy of that report and recommendation. p~ ~
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The final decision on all claims is made by the City Council. No emplo~e~'of tine
City of nubuque has the authority to make any representation to you ~ ffl~
whether your claim will or will not be paid. ~ _ C:~
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1. Name of Claimant: ~//i ~-~~ ~/~ / ~~ ~r~/ CD ~
2. Address:
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3. Telephone Number ~3 ~ 5 ~ yr`r9
4. Date of Incident: / --/~ -~ 7
5. Time of Incident: // ' S"~J
6. Location of Incident (Be specific): ,,
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7. Describe the 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.)
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9. Give name and address of any witnesses:
10. Did police invest~s9ate? (if so, give names of officers.)
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8. What were weather conditions like?
11. Was anyone iAnj,~ured? (If so, give names,,~addresses, and extent of inju/ries).
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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.)
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~. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for d~mages as a result of
this incident? (If yes," give name and address.)
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18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
Dated this / /4 day of ~ ~, ~r~ , 20 G~
(Signature)
(Print Name)
13. What other damages do you claim, if any?
14. Have you been compensated for part or all of your claim by any
insurance company? (If so, give name and address of insurance company and
amount paid.) .