Claim, Kelley, Neil E.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: Neil E. Kelley
2. Address: 526 W. 5th St.
3. Telephone Number: 563 583 2735
4. Date of Incident: Approx. between Apr 1 2002 and May 15, 2002
5. Time of Incident: Unknown
6. Location of Incident (Be specific): 1360 Dell St., Dubuque IA
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.)
McClain Fencing destroyed part of our porch roof, sidewalk and our wall when they (McClain Fencing) took their equipment in and did work for City Park.
8. What were weather conditions like? Unknown
9. Give name and address of any witnesses: None to my knowledge except for the
workers.
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
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.)
The porch on the house had just been replaced and had been re-inspected by the City. Now the roof has been damaged, the cement broken and wall is falling due to
all this work.
13. What other damages do you claim, if any?
None
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?
$20,000.00
16. Why do you claim the City of Dubuque is responsible?
City of Dubuque hired McClain Fencing to do the work and they tell us they don't know of the insurance covering
McClain Fencing.
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 28th day of May , 2002.
/s/ Neil E. Kelley
(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 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:
2. Address:
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific):
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
~!~l~;[n~Ull details upon which you base your claim. If a City employee was involved, give the
plovee's name.)
y '[ ..............
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names pf officers.)
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. ~ ~t~damage~ do~o~m, ~ - ~" /~/~
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.)
15. What amount do you claim from the City of Dubuque? JJ~, ~ O'/g:::/~'
16. Why do you claim the City of Dubuq~e is respenSible? (3. ;-JL'-/, ,, ~ ~-~l~ t~, ~.
,. --~ , -~ - , .... ~ ~ , .. - ,. _ ~
17. Have you maa~any ~laim against anyone e~se Tor aamages as a result ~this inciaent?
(If yes, give name and address.)
18. if the answer to Question 17 is yes, have you received any payment from that source,
and if so, in wh~t amount?
Dated at Dubuque, Iowa this ~ 0~ day of
,20
(Print Name)
(Rev. 1/00 & 7/01)