Claim Erickson, ShawnCLAIM 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: Shawn Erickson
2. Address: 1665 Bies Dr. #5
3. Telephone Number: 563 543 6403
4. Date of Incident: Friday June 21st 2002
5. Time of Incident: 4:00 P.M.
6. Location of Incident (Be specific): At the corner of Pennsylvania and Sylvan
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 making a right hand turn from Pennsylvania onto Sylvan, the back tire of my motorcycle bounced off the
pothole in the road, cuasing my motorcycle to slide out from underneath me.
8. What were weather conditions like? conditions were good.
9. Give name and address of any witnesses: James Elliott, 2488 Birchwood, Asbury, IA
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, Shawn Erickson, 1665 Bies Dr., #5, Dubuque IA
Injuries consist of scraped shouilder and forearm.
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?
Damage was done to my 1991 Suzuki GS 500E. The front brake lever was broken off as well as scratches to the
muffler and engine ???? See photos.
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? $500 to $800
16. Why do you claim the City of Dubuque is responsible?
The City of Dubuque is responsible for failure to maintain the upkeep of the road.
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 day of , 20 .
/s/ Shawn M. Erickson (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:
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?
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 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. Whydo you claim the Cityof Dubuque is responsible? -7~/~ d?~/ ~ ~,~--
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
day of , 20__
(Rev. 1/00 & 7/01)
¥! 'enbnqnG
(Signature)
(Print Name)