Claim by Courtney DolanTHE CTfY OF
DUB E MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN ~!~
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
DATE:
RE:
Claimant
January 28, 2009
Claim Against the City of Dubuque by the Courtney Dolan
Date of Claim
Courtney Dolan
01 /26/09
Date of Loss
12/29/08
Nature of Claim
Personal Injury
This is a claim in which claimant alleges that she slipped and fell in the Iowa Street
Parking Ramp and injured herself.
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
Tim Horsfield, Parking Systems Supervisor
Courtney Dolan
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 / EMAIL 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. 13t" 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.
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1. Name of C
2. Address:
3. Telephone Number: ~~ ~~KU- ~~~~
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific):
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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? C.~+_°GU' ~COIGL.
9. Give name and address of any witnesses: l~-fl D ~~lA~~(1
10. Did police investigate? (If so, give names of officers.)
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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.)
S~~UCY1t-~'~D 1Y~1~~ ~Q, -' I~ U.Q. ~,YUS S 1~~ ~- S `~ ~` ~~ ~ ~
15. What amou do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for dam'~~jes~-~s a result of this incident?
(If yes, give name and address.)
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18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in yvhat amount?
Dated at Dubuque, Iowa this O~~ day of 20~~.
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'~U~-~-~,~p ~' 4~J/1 (Print Name)
(Rev. 1100 & 7/01)
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