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Claim, Christenson, JoshuaCLAIM 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: Joshua Christenson 2. Address: 105 17th Street Dubuque 3. Telephone Number: 563 503 6070 4. Date of Incident: 6 14 02 5. Time of Incident: 10:30 P.M. 6. Location of Incident (Be specific): 1600 block of Main St. in front of Hoffman Schneider funeral home. 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 crossed the street near Hoffman Schneider funeral home. I fell in a pot hole and broke bone in my foot. 8. What were weather conditions like? clear and dry. 9. Give name and address of any witnesses: Heidi Walker, 2570 Asbury Rd., Dubuque Phone # 587 1988 10. Did police investigate? (If so, give names of officers.) Yes 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). I sustained a broken bone in my right foot. 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? 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.) I am not sure how much compensation I will receive from my insurance. 15. What amount do you claim from the City of Dubuque? Missed work - 2 weeks = $560 & Pain and suffering $1000 Total $1560 + Medical 16. Why do you claim the City of Dubuque is responsible? Street in poor repair resulting in personal injury 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 Dubuque, Iowa this 24th day of June , 2002. /s/ Joshua Christenson (Signature) (Print Name) (Rev. 1/00 & 7/01) CLAIM AGAINST THE CITY OF DUBUQUEi~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: 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. full details upon which you base your claim. (Give If a City employee was involved, give the 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, 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 any?_ 14. Have you company? been compensated for any part or all of your claim by any insurance (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 Dubuque, Iowa this 2 Y ~ day of LLJ ©-~ , 20oz . (Signature) (Print Name) (Rev. 1/00 & 7/01)