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Claim, Weland, KrisCLAIM 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: Kris Weland 2. Address: 2480 Elm St., Dubuque IA 52001 3. Telephone Number: 563 582 7535 4. Date of Incident: August 6, 2002 5. Time of Incident: 1:00 or 1:30 6. Location of Incident (Be specific): Comiskey Park - at the playground equipment - on the slide 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.) Kris was playing on the equipment, he went down the slide, he said there were wood chips on the bottom of the slide which caused him to fall and he landed on his wrist. 8. What were weather conditions like? It was sunny for a while 9. Give name and address of any witnesses: Danielle & Brandon Swift, and Jeff Clancy (don't know addresses) 10. Did police investigate? (If so, give names of officers.) Yes, an officer came to the hopsital to fill out a report. I don't know his name though. 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). Yes, Kris received a broken wrist. 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.) No 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.) Flexsteel Health Plan; Attn: Barb McCoy, P.O. Box 389 15. What amount do you claim from the City of Dubuque? Approximately $4700.00 to date. 16. Why do you claim the City of Dubuque is responsible? The insurance company claims the City of Dubuque is reponsible. 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? Dated at Dubuque, Iowa this 18th day of September, 2002. . /s/ Peggy Weland / Rick Weland (Signature) (Print Name) (Rev. 1/00 & 7/01) 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 WILL NOT BE PAID. 1. Name of Claimant: ~'~% 2. Address: 3. Telephone Number: 4. Date of Incident: 5. Time of Incident: I : CIO __O ~- ~ ', 3 CID' ~ * 6. Location of lncident (Be specific): (",~c~\ ~,'~, 0fKT~k - +¼e 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.) _ oD4' o vepor4~ ~ do~4 IC~o~ %~e ~&~e ~ou~' 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 do you claim from the City of Dubuque? ~,~>~'-~[~ ~¥~ ,-3(hca. otb 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 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, Iowathis 1 ~R-¼ dayof (Rev. 1/00 & 7/01)