Claim, Nelson, Neil T.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 T. Nelson
2. Address: 2639 N. Colony Ave. Franksville, WI 53126
3. Telephone Number: 262 878 3342
4. Date of Incident: April 1, 2002
5. Time of Incident: 8:30 P.M.
6. Location of Incident (Be specific): Sidewlak/Parking Lot at the Riverboat Museum Adjacent to Diamond Joe Casino
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.)
I was walking on the cement sidewalk that was well lit. As I walked further toward the
Museum the sidewalk became asphalt and appeared to be the same level as the asphalt Parking Lot. There was no lighting and no makring to indicate that there was a curb going down to the Parking Lot.
Due to the poor lighting and both surfaces being asphalt, as I took a step I did not see difference in the levels of the curb and parking lot. I stepped on the edge of the curb and fell, breaking my ankle.
8. What were weather conditions like?
Cloudy. Cold about 40 degrees F.
9. Give name and address of any witnesses:
Incident may be on Casino Security Tape.
10. Did police investigate? (If so, give names of officers.)
No. Made a report to Casino Security who want to investigate the area.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, Neil Nelson. 2639 N. Colony Ave., Frankville
Broken Anglke. Had wife drive me to Mercy Hospital.
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?
Peronsal injury and loss of wages
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.)
Health Ins. Padi 80% ?? of Medical Bill. Disability Ins. Paid $300.00
15. What amount do you claim from the City of Dubuque? $15,000.00
16. Why do you claim the City of Dubuque is responsible?
Poor lighting and no markings on Curb causing an unsafe situation.
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 -Franvsvill, WI, Iowa this 6th day of June, 2002. , 20 .
/s/ Neil T. Nelson
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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.
3. Telephone Number: ~(~- ~'7~ -33,~z~-
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
full details upon which you base your claim. If a City employee was involved, give the
employee's name.)
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of__officers.)
11. Was anyone injured? (if so, {live names, addresses, ano extent oz 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 any?
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?
16. Why do you claim the City of Dubuque is responsible?
17. Have you made any claim against anyone else for damages as a result of this incident?
(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 what amount?
Dated at ~eTfow~ this
day of
,20 0 ~-~.
(Print Name)
(Rev. 1/00 & 7/01)
June 11, 2002
Thc City of Dubuque
City Clerk's Office
50 West 13~ Street
Dubuque, IA 52001-4864
Dear Clerk:
Enclosed please find thc claim form sent to me regarding my fall. I would appreciate it if this
could be done as expeditiously as possible. I look forward to hearing from you shortly.
Very truly yours,
N~I T. N~l~m