Claim, Sawvell, EricCLAIM 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: Eric Sawvell
2. Address: 20 W. 18th St. Dubuque, IA 52001
3. Telephone Number: 563 583 9537
4. Date of Incident: July 13, 2002
5. Time of Incident: 330 P.M.
6. Location of Incident (Be specific): Eagle Point Park - section of park on left going South before the old concession stand officer Papentient has everything in his report he took on 7/13
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.)
Eric was at Eagle Point Park, he was playing frizzbee with some friends. Went to catch it ran into a restrooms sign that is in middle of a grassy area. Sign is lower to ground than othersa.
8. What were weather conditions like? Clear day.
9. Give name and address of any witnesses: Aaron Klauer, Brett Birkett & Nic Romaine
10. Did police investigate? (If so, give names of officers.)
Officer Pappentient
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Eric Sawvell, 20 W. 18th DBQ, cut to side of head requiring 10 stitches
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.)
NONE
13. What other damages do you claim, if any?
NONE
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.)
My insurance from DIsco paid 80% even after I said City should pay.
15. What amount do you claim from the City of Dubuque?
Sign is too low in middle of a grassy area corners of sign are too sharp.
16. Why do you claim the City of Dubuque is responsible?
17. Have you made any claim against anyone else for damages as a result of this incident?0(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 30 day of August , 2002.
/s/ Vickie Sawavell, parent
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
c.^ M ^G^,.ST T.E C.V OF DUBUQUE, OW^
This written report constitutes your claim against the City of Dubuque, Iowa. You shou~l~
coh~plete 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: ~---~'; c_
2. Address: ~0 ~ ~
3. Telephone Number: ~G~-~g~-
4.
5. Time of Incident: ~ ~ ~ ~ ~
6. Location of InCident (Be specific): ~
7.~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~na~.) __~ . ,
9. Give name and address of any witnesses.~~ ,
10. Did police investigate? (If so, give na.mes 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
14. Have you been compensated for any part or all of your claim by any insurance
com. pany? (If so, give rtame and address of insurance company and a~mou_nt paid.)
15. What amount dO you claim from the City of Dubuque? ~_~
16. Why do you claim the City of Dubuque is responsible? ~ ~'3~
17. Have you made any claim against anyone else for damages as a result of this incident?
address.
(If yes, give name and ~
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
(Signature)
(Rev. 1/00 & 7/01)