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Claim by Shirley Ann CoxTHE CITY OF DUB E MEMORANDUM Masterpiece on the Mississippi BARRY LINDAHL CITY ATTORNEY To: Mayor Roy D. Buol and Members of the City Council DATE: RE: Claimant April 16, 2008 Claim Against the City of Dubuque by Shirley Ann Cox Date of Claim Shirley Ann Cox 04/11 /08 Date of Loss 03/09/08 Nature of Claim Personal Injury This is a claim in which the claimant alleges that she slipped and fell on an icy patch of sidewalk as she was walking on Pennsylvania Avenue near Ruann Drive. 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 Gus Psihoyos, City Engineer Shirley Ann Cox 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 / EMAIL balesq@cityofdubuque.org ~l~~i ~~~~ - C-~v~ ~~ ~ CLAIM AGA~~~ST THE CITY QF DUBUQUE, ~GWA This written re ort constitutes our claim a ainst the Ci of Dubuque, Iowa. You P Y g tY should comple#e this form ire 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. !t will then be referred to the appropriate department for investigation and to the City Attorney's Elffice. Once that investigation is completed, a report and recommendation will be submitted to the City Council. You wiU be provided with a copy of that report and recommendation. The final decision on aU 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: ~h 1 ~ l~ U Q. u ~ ~ ~ 2. Address: ~ ~ ~ 3 __ ~ ~ o~~r ~~ cz~ ~~ v~e , • 3. Telephone Number ~~~ 3 ~ Ss~~ -- ~ 3 L/ 7 4. Date of Incident: ~ M arc, c ~ 5. Time of Incident: 6. location ~ e nr 5~ specific): ~e~ A~ //~ ~T//~c~v i a= .y ire ,~ ~ h o u ~ Sa .~.~ e t o .e _s o ~I, R~ mt -~ -~- ~'ast S'~d 4 d /Zcsa~rn/ cldz• wheR,e. ~Ltr,uK,~/ dn. Me.c~-5 P.~,JNSy/~~,Nouc A~~ 7. Describe the a~cident or occurrence that caused injury or damage. (Give full details upon which you base your claim, I# a City employee was involved, give the employee's name.) ~- ~ ~s ~~ j ~~.~ u1Qy~ b ~ t ~ ~_ ~.~ ~ ~.~ 5,~1,~s - - (' np,JNsy / /a,J~'a~ . ~.~ ./ u vat c~ h Q 2v~~,+~~ ua,~-U ~ cz•: -~-- &. What were weather conditions Pike? 1ea~ ~ S~uc;~ ~_ C7 `~ o 9. Give name and address of any witnesses: ~T ~=: ~' '~ c t'= _ '-7 -- ~-~_--- f °T'1 t°_- G 10. Did police investigate? (lf so, give names of officers.) ~' ~ _ C7 ~~? 1~e n ~ ~ Q e l~l 0.1 -J ~ ~~ P.- ~' ~ ~ W 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. Attach estimates of damages or describe basis for ascertaining extent of damage.) ~~ 13. What other damages do you claim, if an' _- may kle,v'~` n~' al1 Mel-t Ga. 14. Have you been compensated for any part or all of your claim by any insurance company? (lf so, give name and address of insurance company and amount paid.) ~6 15. What amount do yQU claim from the City of D+~buque? 16. Why do you claim the City of Dubuque is res(ponsiblle~? .Ga1 ~KKc. ~~ fN~ff2C_'~ ..~,devuf~-eft GO~e- 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) ~'O 18. If the answer to Question 't 7 is yes, have you received any payment from that source, and if so, in what amount? Dated this I t day of ~'T 2` ~ , 20 ©~ . ~ ~ ~~ (Signature) (Print Name) nrn Inl.OS- DUBUQUE POLICE DE PARiMENi CIIi } INCIUENI CASE N0. vim- /Z tLlllEliLiT £P11FEL c'7 rSi T rt/ Tit/3U -ft,9 _ _~ PEDESTRIAN INJURY PHYSICAL AGILITY - EYEGLASSES TYPE FOUINEAR TYPE VICTIM - FIRi ~~ R/S/DU8 _ 6~J ,~ $ 27 Z 7 UNIIER ABULiIIIG PROPERLY ADDRESS YICTIM'S ADDRESS CI1Y PHONE tIU. ~-~!~~n'. ~,~fZY~I ~E/ 1r4~`1c~+ a~i~~~~~~-~r (~LTI~(/ (/~Gfk ,sz,~- ssG~. ~~~~ - OCCUPANL ApUI11ftG FRUPERiY _ NAS VICi1M FAMILIAR NIiH LOCALIUH -NOW LOCAIIUN OF INCIOENi OUSIIIE55 PIIUt1E NU. 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