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Claim Seifker, Florence JaneCLAIM 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: Florence Jane (Hinds) Siefker 2.Address: 1838 Central Avenue, Dubuuqe, IA 552001 3. Telephone Number: (563) 588 2652 4. Date of Incident: January 20, 2003 5. Time of Incident: App. 3:50 P.M. 6. Location of Incident (Be specific): 1667 Jackson St., Dubuque, IA 52001 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.) An uneven sidewalk with a slant of app. 3/4" - app 2' with no visible mark indicating the unevenness my right foot hit against the upper edge of the higher section and I lost my balance fell on my right side hurting my pelvic girdle and right hand 8. What were weather conditions like? fair 9. Give name and address of any witnesses: I was aware of vehicles passing and someone probably noticed but I didn't see any pedestrian 10. Did police investigate? (If so, give names of officers.) No as I was told by the neighbor next to theproperty that I could report it to City Hall. 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). I fell on right side and on falling I hit my pelvic girdle on the right side hurting both the pelvic bone as well as the ball of my right hand. 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? Pain & suffering as I am a seamstress and I have since experienced pain at my pelvic area as well as back pain since the incident. 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? $3,000.00 as I have contacted both a chriopractor and the Mercy Hospital Emergency as to the cost of treatment and the fees could be costly. 16. Why do you claim the City of Dubuque is responsible? Because the uneven spot should be visibly marked and withneon colors even if the property owner has some responsibility. It should be the City's responsibility to mark the area visibly. 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 31 day of January, 2003. /s/ Florence J. Siefker (Signature) (Print Name) (Rev. 1/00 & 7/01) / CLAIM AGAINST THE CITY OF DUBUQUEc. 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 520,01. 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: ~J_-~/~/VC~ ]"/~/V~- ~~i~,~ 2. Address: /F,~~ ~~ .~V~~ ~q~M~ /~/ 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 conditions like. ~J ~ (~ ~~' 9, Give name and address of any witnesses: J I i ~ ~ //~' 10. ~d pol]~,einvestiga,~?, (,,so, gi~?~am~sof~ffice~s -- / / / / 11. Was anyohe injured? (If so, give ~ames, addresses, and ext~nt 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? ~o...i ~.~ ~ ~-~e~-, ~ ~ 14. Have yob 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? (~fO'~ ' ~ ~ ~ liS; Why do you clai~n the~City of Dubuque is respon~le? ~ -~,~-~-.~, ~ 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, Iowa this LLi day of (Print Name) (Rev. 1/00 & 7/01) STACKIS Family CHIROPRACTIC Dr. Jeffrey A. Stackis 4855 Asbury Road Dubuque, Iowa 52002 · Phone (563) 583-9634 ~ Fax (563) 583-9684 Dear Ms. Sieflcer, Per your request I am sending you an estimate of hospital charges based on the information you provided me on the telephone. You stated that you injured your hip area as a result of a fall. The estimated hospital charges for you to be treated in our Emergency Department for this typed of injury and assuming your physician would also order a pelvis and hip xray would be: · $150.00 for the Emergency Room · $88 for the hip xray Please be aware that these charges do not include any physician fees. Mike Weigman 1838 Central Avenue Dubuque, Iowa 52001 January 31, 2003 City Clerk at City Hall 50 W. 13th Street Dubuque, Iowa 52001 Dear Sir/Madam: This refers to the incident in which I sustained injuries to the right side of my pelvic girdle and also the ball of my right due to a fall as the result of an uneven sidewalk within the vicinity of 1667 Jackson Street on January 20, 2003. To this date I still suffer from my injuries with pain sometimes to my entire hip girdle and also pain to th~ ball of my right h~nd, with the application of pressure to both areas there is pain. Presently I have no insurance coverage as I a man immigrant with legal status due to marriage to an american citizen, Daniel Joseph Sie~ker of the same address therefore I have not been able to get medical help. I, however have sought information as to the cost of medical attention from both a chiropractor and Mercy Medical Centre at best I have only been able to obtain estimates which are enclosed. I would appreciate your urgent attention to this matter as this incident has inconvenienced me grately both with my work and the responsibility of caring for my family due to pain I suffer from this fall. I do need to get medical attention but I am unable to afford it. Thm~you for your quick and favourable response and I am confident you will understand my unfortunate situation. Yours sincerelM, Florence Jane (Hinds) Sie£ker Please note: Due to my legal status I am unable to apply for and obtain state medical assistance at the moment.