Claim, Kennedy, DeniseCLAIM 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: Denise Kennedy
2. Address: 718 Providence St.
3. Telephone Number: 583 5384
4. Date of Incident: 8 21 02
5. Time of Incident: between 9 a.m. - 4 p.m.
6. Location of Incident (Be specific):
Bunker Hill, 2200 Bunker HIll Rd., Parking lot in front of building
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.)
I, Denise Kennedy, work at Bunker Hill Golf Course. Someone golfing hit my windshield with a golf ball breaking the windshiled. I was parked in front of building.
8. What were weather conditions like?
Hot, humid, party sunny
9. Give name and address of any witnesses:
None, one of my workers noticed it when she was coming to work - Lisa Rosenow at 3:30 P.M. Aug. 21, 2002.
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
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.)
The windshield was broke and had to be replaced (the ball hit drirvers side & spider web the whole windshield. Had to get fixed right away. It's illegal to drive that way.
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.)
No
15. What amount do you claim from the City of Dubuque?
$206.17
16. Why do you claim the City of Dubuque is responsible?
It's on their property and no one turned it in. So I feel the City Should pay part or all of the cost.
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?
DNA
Dated at Dubuque, Iowa this Aug. day of , 2002. .
/s/ Denise Kennedy
P.S. I don't feel I should have to pay this. I am a seasonal worker and cannot afford to pay this without causing financial pain. I had to use funds from other bills because I need my care for work. It's very illegal to drive like that.
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
* CLAIM AGAINST THE CITY OF DUBUQUE¢IOWA ' ~i,'~
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.
Name of Claimant: ~ ~,~4~ ~-~-~/,~ ~ ~.k_/
1.
2. Address: "~1%
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 ¢(~hditions
9. Give name and address of any witnesses: ~'~ ~ ~ C~ ~
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, ffany? ~-'~ ~ ~,~ ~ ~
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. Why do you claim the City of Dubuque is responsible? -~J~ ~L~L Wl%~ LLP
17. Have you made any claim against anyo~ 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?
Oat~edL~ at~ub ~1~, ue,.. o Iowa this ~ day of
(Signature)
(Print Name)
A-1 W[NDSH!ELD REPAIR
2915"Ridgeway '
Dubuque, IA 52001
319-583-5620
ICUSTOMER'S ORDER NO.
DEPARTMENT
258236
5805
KEEP THiS SLIP FOR REFERENCE