Claim by Premier Dry Cleaning_Cathy Ludwig%.:/VV ~~..~
CINCINNATI ~ COMPANIES
THE CINCINNATI INSURANCE COMPANY THE CINCINNATI INDEMNITY COMPANY
THE CINCINNATI CASUALTY COMPANY THE CINCINNATI LIFE INSURANCE COMPANY
Regina L. Pint
Field Claims Specialist
P.O. Box 1213
Dubuque, IA 52004-1213
Ph :563-556-2084
Fx :888-843-0518
March 24, 2008
City Clerk G
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50 W. 13~' St. ~
C~7`c m
Dubuque, IA 52001 ~ ~-~
RE: Claim # :831066 ~ =~-`~
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Insured :Premier Linen & Drycleaing ~
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Loss Date : 1/11/08 ('~ =~ -~
Damages $ 647.03 > ~~_
Injured Employee: Cathy Ludwig C~D~ '~
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Location of accident: Washington Park, Dubuque, IA
Dear Sir or Madam:
We are placing you on notice of our subrogation claim concerning the above referenced incident. Our investigation
concluded that the City of Dubuque is negligent for the injuries sustained by our insured employee, Cathy Ludwig. It
is understood that Cathy reported to have slipped on the ice covering the sidewalks, while walking to the Post Office
on the above referenced date of loss. It is also understood that Cathy was working at the time of the accident,
therefore, the medical expense were paid under Premier Linen & Drycleaning's workers compensation policy.
Since we have made a settlement with our insured under the terms of this policy, our insured has assigned this claim
against you for $647.03 and includes our insured's $500.00 deductible.
Enclosed is documentation supporting our claim for damages, along with a completed claims form. Payment is to be
forwarded to my attention at the address listed above. Payment is to be payable to: The Cincinnati Insurance
Company.
If you have any questions or concerns in regard to this matter, please give me a call. Thank you.
Sincerely,
THE CINCINNATI INSURANCE COMPANIES
r ~'%T
Regina Pint
FIELD CLAIMS SPECIALIST
Maim Form
Page 1 of 3
Home Page :Departments :City Clerk : Cla~ms_again_st the City: Claim FOlrrn
City Clerk
First floor of City Hall, 50 W. 13th Street
Phone: (563) 589-4120
Fax: (563) 589-0890
Hours: 8 a.m. to 5 p.m. Monday through Friday
Email: jschned@c.tyofd.ubu.qu.~..Qrg
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the City of Dubuque, Iowa. You should comple
full and attach any additional information that supports your claim.
The claim must be filed with the City Clerk at City Hall, 50 West 13~' St., Dubuque, IA 52001. It
referred to the appropriate department for investigation and to the City Attorney's Office. Once i
is completed, a report and recommendation will be submitted to the City Council. You will be prc
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
authority to make any representation to you as to whether your//claim will or will not be paid./j
1. Name of Claimant: ~r~/~ ~~ ~~~ ~ ~ •U~v~~~t~r~~//?c:a' '~ C -l ~
2. Address: `y ~i-' I
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3. Telephone Number: ,~L~ ~ '"Q~~~ ~ ~ ~~~,~ ~ V
4. Date of Incident: ~ - f ~ ' ~ ~~7
5. Time of Incident: ~U 3 v
6. Location of Incident (Be specific): li~ ~~~ S /,) l.l~'~~1~ Y/.~~ , IJ~~L/~L14 LlE' //~
7. Describe the accident or occurrence that caused injury or damage. (Give full details upon whi
your claim. If a City employee was involved, give the employee's name.) 1
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8. What were weather conditions like? _~~~'L~j(~1~~ {V [.,Z/?c./ c,~C~Qi/"
9. Give name and address of any witnesses: ~ l.J (J l l ~ f% ~ ~,'~j ('f~,~s
10. Did police investigate? (If so, give names of officers.)
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http://www.cityofdubuque.org/index.cfm?pageid=155 3/24/2008
Claim Form
11. Was anyone injured? (If so, give names, addresses, and extent of injuries.)
12. Was any damage done to property? (If so, describe property and the extent of damages. Att
damages or describe basis for ascertaining extent of damage.)
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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? (It
and address of insurance company and amount paid.) .
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16. Why do you claim the City of Dubuque is responsible? ~~ ~t:/ ~~sm~ ~~
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17. Have you made any claim against anyone else for damages as a result of this incident? (If y
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
amount?
(Signature
~P~ ,'n_~ ~; n f _ ~lll C t n Ylc~ t 'n S(1,(~,ftC'~
Dated this ~ day of / I ~C~1.~'.j7 . 20~
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(Print Name)
Home Page :Departments : C~ Clerk :Claims against the City : C~811f71 FOf 1'Yl
Page 2 of 3
http:!/www.cityofdubuque.org/index.cfm?pageid=155 3/24/2008
15. What amount do you claim from the City of Dubuque ! ~ ~ • " -~