Claim, Roepsch, Rebecca FCLAIM 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: Rebecca Francis Roepsch
2. Address: 7015 Badger Rd.
3. Telephone Number: (563) 557 8228
4. Date of Incident: 9-03-02
5. Time of Incident: 9:00 A.M.
6. Location of Incident (Be specific):
Columbia St., Dubuque, IA
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.)
Was unlocking the door to my van when I stepped in a pothole as twisted my ankle both ways. I fell to the ground.
8. What were weather conditions like?
Sunny
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
Yes, was called to Finley Hospital then went to Columbia St. Don't know name.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, Rebecca Roepsch, 7015 Badger, ED, Severe Sprain, with blood clotting on crutches and air splint.
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.)
NA
13. What other damages do you claim, if any?
NA
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.)
NA
15. What amount do you claim from the City of Dubuque?
medical for present adn future, loss of wages
16. Why do you claim the City of Dubuque is responsible?
damaged streets for average of 4 years
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
NA
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
NA
Dated at Dubuque, Iowa this 19 day of September , 2002.
/s/ Rebecca F. Roepsch
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
This written report constitutes your claim ould
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: ~ --
3. Telephone Number: (~'~
4. Date of Incident: ~'~ O~--~)~
5. Time of Incident: 2t ~ ~,/&/}
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?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
12. Was any damage done to property? (If so, describe property and the extent of damages.
Attach estimate/s 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? /~.?~,~7/~.~? _~/,~j~
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?
(If yes, give name and a/ddress.)
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?~,.~ J_
!
Dated at Dubuque, Iowa this
dayof
{$ignatu[e)
(Print Name)
(Rev. 1/00 & 7/01)