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Claim, Roepsch, Louis S.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: Louis S. Roepsch 2. Address: 1700 Rt 20 W., East Dubuque, IL 61025 3. Telephone Number: 815 747 3380 4. Date of Incident: 7 07 01 5. Time of Incident: 14:15 6. Location of Incident (Be specific): East side of Fox Pavilion, Eagle Point Park Dubuque, Iowa 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.) While attending a birthday party, an oversize picnic table flipped over and pinned me between it and a rough support column. 8. What were weather conditions like? Clear and sunny. 9. Give name and address of any witnesses: Linda Wessels, 2243 Chippewa Dr., Dubuque IA & about 50 others. 10. Did police investigate? (If so, give names of officers.) Yes, Simon 44A 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). Louise S. Roepsch, 17000 Rt. 20 W. East Dubuque, Il 61025 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? Medical Bills, Future Bills, Pain and Suffering, Mental ???? 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.) $146.00 Unicare, Box 4050, Shaumburg, IL 60168-4050 15. What amount do you claim from the City of Dubuque? $54.00 Med, Plus Future Cost Unknown at this time. 16. Why do you claim the City of Dubuque is responsible? The City Made an unsafe environment in locating the table, which is on an incline and located by a danagerous rock piller..the construction of which is unstable. 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 12th day of June , 20 . /s/ Louis S. Roepsch (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 Dubuqup, Iowa. You,should complete this form in full and attach any additional information that supports your Cldim. The Claim must be filed with the City Clerk at City Hall, 50 W. 13u~ St., Dul~Uque, 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 EMPLOY.EE 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: /~o ~. 3. TelePhone Nu~ber~-- ~/~ - 4. Date of Incident: 5. Time~bf InCident: ' · 6. Location of Incident (Be specific): ~7. DESCRIBE,ACCIDENT OR oeCURRENCE THAT CAUSED INJURY OR DAMAGE:- (Give full details upon which .you bas--YOur, claim. If a City~hployee was invOiOed,,gi~ the 8. What were weather conditions like? . _~,/¢~ ~- g,~ ~ 9. Give name and address of any witnesses: ~/; A 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? Medical Bills, Future Bills, pain and suffering, Mental 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.) $146.00 Unicare, Box 4050, Shaumburg, Il 60168-4050 15. What amount do you claim from the City of Dubuque? $54.00 Med., Plus future cost unknown at this time 16. Why do you Claim the City of Dubuque is responsible? The city made unsafe environment in locating the table, which is on a incline and located by a dangerous rock piller, the construction of which is unstable. 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 12 day of June , 20 02. (Signature) (Print Name) (Rev. 1/00 & 7/01) Louis S. Roepsch 17000 US Highway 20 W. EAST DUBUQUE, IL, 61025-9776 815-747-3380 Lroepsch@MWCI.Net June 12, 2002 Clerk City of Dubuque Dubuque, IA 52001 Dear Sir or Madam: I am a 56-year-old male, and a life long resident of the Dubuque area. While attending a birthday party for Marge Massy at the City of Dubuque, Eagle Point Park, I was injured by City of Dubuque property. On a clear and sunny Saturday, July 7, 2001, at approximately 2 PM. We were on the East side of the Fox pavilion. Three of us were seated on the South table near the building. The table was 2 ½ feet from a rough rock support column for the pavilion. I was on the Southeast side of the table and next to me was my niece, Linda Wessels, 2243 Chippewa Dr., Dubuque, IA. My daughter, Gwen Moser was sitting on the West side of the same table. She got up from the table and proceeded to walk away. At which our side started to go down. There was no stopping it or anything to grab. It flipped over and pinned me between it and a rough stone pillar, support colunm. My spine was pressed against the protruding rock causing extruding pain. Since the column stopped me, the table the weight of the table and the weight of my niece, who was hanging on to the table, was pressing me into a fetal position. There were about 50 people there that were in the state of thinking it was funny, or some that had great concern over my predicament They proceeded to help my niece out, and then lift the table off me. My back had pain in it and to reduce the embarrassment of me to the crowd, I eventually got up. My pants had the food on it, which I was eating at the time. I went to the bathroom and returned, discovering the pain was centered on the spine and was getting worse. I took pictures of the table and rock support. I then walked up to the termis courts to talk to the park warden but as I was approaching she drove away. I wanted to get an x-ray done so we left the party and started leaving the park. The park warden was at the ticket office when we approached. She drove off just as I came up. I told the two ladies in the booth what had happened and they called her on the radio. The ladies told me it was a shift change and I was to wait here until someone else arrived. After over a half hour, I told them that I have diabetes and needed to go the bathroom. She said to go back into the park. As we were coming back out of the park we met Dubuque Police officer Simon, badge 44a. She wanted to see the table, so we went back to the pavilion. She asked about witness, and I said "all the people that are left here seen it happen". My wife then drove me to Medical Associates, were Dr. Joe Garrity examine me, they had urine test and x-rays done. He recommended pain medicine and no work for a week. That I should call again Monday for the results of the x-rays. We went home and I started taking pain medicine. I have seen Dr. Paulson at Medical Associates and described the constant pain to him. Some days when I am bent over for some time, like tying my shoes, the pain gets excruciating and it is hard to straighten up. I have had previous back operations and worry that in the future this may reappear as more serious complications. It's been about a year and the pain is still there. I cannot give a dollar amount at this time for this might be the start of a back operation or future problems. t would like to claim for medical bills, and any furore bills that might occur. Also for the pain and suffering that was caused. The Mental anxiety from the incident tends to complicates and add to an existing health problems. I feel that the City of Dubuque failed to maintain a safe environment in locating the table. Which is on an incline and located by a dangerous rock pillar. The construction of the extremely heavy table is such that the seats are laminated with air gaps making it an unstable platform. It was also not secured to the foundation. I stopped at Barry A. Lindahl office on December 27, 2001 and mention it to them that I still don't have the exact cost incurred. They said to note it on my claim. Enclosed 5 pictures. Louis S. Roepsch