Claim, Ebertz, Roger P.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: Roger P. Ebertz
2. Address: 718 Loretto Ct., Dubuque IA 52003
3. Telephone Number: 563 557 1382
4. Date of Incident: June 6, 2002
5. Time of Incident:
6. Location of Incident (Be specific): On easement between 718 & 725 Loretto, near storm drain at the bottom of the yard.
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.)
Claimant stepped in hole caused by broken storm drain pipe while mowing his yard.
He twisted his ankle and fractured a bone in his leg.
8. What were weather conditions like? sunny, warm
9. Give name and address of any witnesses:
Charles McCormick, 725 Loretto Ct. 52003
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, Claimant suffered broken leg.
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?
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.)
Claim will be filed with SISCO and Blue Cross Blue Shield of MN
15. What amount do you claim from the City of Dubuque?
Not yet determined
16. Why do you claim the City of Dubuque is responsible?
Inury resulted from broken storm drain underground in easement.
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 18th day of June , 2002.
/s/ Roger P. Ebertz
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DU. BUQUE 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: -7 IF
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of lncident (Be specific): On Ea$~z,~ b~e-~h -?/~' ,~ 7~/.-~,~'~-~.~
full details upon which you base your claim. If a City employee was involved, give the
employee's name.) P___I,~,~,~ ~-ep~e~/ ~','~ hd~- ~-~scd /% br~l<o4,t sA~,'~.
8. What were weather conditions like? S
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).
le3.
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?
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.)
Claim will be filed with SISCO and BlueCross Blue Shield of MN.
15. What amount do you claim from the City of Dubuque? Not yet determined
16. Why do you claim the City of Dubuque is responsible?
Injury resulted from broken storm drain undergroung in easement.
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?
Date at Dubuque, Iowa this 18 day of June , 20 02.
Roger P. Ebertz
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)