Claim by Mary LucasTHE CITY OF
DUB E MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN ,~,-`
PARALEGAL ~`-
To: Mayor Roy D. Buol and
Members of the City Council
DATE: January 26, 2009
RE: Claim Against the City of Dubuque by the Mary Lucas
Claimant Date of Claim Date of Loss Nature of Claim
Mary Lucas 01/23/09 12/15/08 Personal Injury/
Property Damage
This is a claim in which claimant alleges that she tripped on a frozen ice piece on 16tH
Street between Central Avenue and White Street, falling and injuring herself, and
breaking her glasses.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
BAL:tIs
cc: Michael C. Van Milligen, City Manager
John Klostermann, Street & Sewer Maintenance Supervisor
Mary Lucas
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944
TELEPHONE (563) 583-4113 / FAx (563) 583-1040 / EnnAIL tsteckle@cityofdubuque.org
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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 WILt~ 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): , ',~~,-~, r~
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.) l
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i. What were weather cend~tiens like . ~~~ '~'~
9. Give name and address of any witnesses: i~~~~,•
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 d you clai from the City of Dubuque? r_
16. Why,do you claim thg pity of Dubuque~is responsible? ~ ~ ;'~.
17. Have you made any claim against anyone else for damages as a result of this incident?
(lf 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 ~ y~ .day of ~ ~ 20 ~ ,C•
i~;~~~J?~ (Signature)
(Rev. 1 /00 & 7/01)
Print Name)
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