The URL can be used to link to this page

Claim by Evelyn Maddux (Jennifer)~.,-, ~~~~ j ~-~Ylw'~ ~ C7~ G 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. 13t" 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. R ~ W 4 ~ ~ 1. Name of Claimant: Evelyn Maddux c/o Jennifer Maddux (mother) 2. Address: 210 Alta Vista St.i 3. Telephone Number: ~ ~~ ~ ~ J~ ~__ ~ f 4. Date of Incident: ~7f' f' "7 ~ 0 ~ 5. Time of Incident: AY McDonald Park 6. Location of Incident (Be specific): ~~t', ~ t; ~ C e1 ll~ c~ ~Gj, 4' ~ ~ 1, ~ ve r 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.) ~v~ (~in ~atie 3) ao1- 1~er e~ ~~.~~`- ~u1~~ 5-f-~c.k i~v-1 rc~~nc~ ~~~t~~- 1111 ~~ r ~ ~ SSG s ~~fCl^ uSlti JGC' ~~UI~c~ SGi~j~r' ~ & cinf~iE'vr t~1~ c~ .1 v-~~' ~~1''2~.. ~,~. Y^ CGile '~ 1 ~ T '~ 5 ~ f irG c~= parAwlk. .t CS ~ w~.h~ wc~. v¢r'~ 8. What were weather condi ons like? w~"'c ~O` `-~~'~ ~~ bkt also c ~~-~,dnf r2.k _{,,r rr ~ • -~1:~,,y eti~ e~^ ~G ~ ~ ~ c,4~ ~ l ly ~~ ` J K~ se.~, i Vl U w- „x ~;ti~ ce., t~;-ti-ra,2 ~~t: ~ ks n~o ~ ~ .~ 9. Give name and add ess of any tnesses: ~e~ bek.a~, 1< i ~ ~1 i ~ LVer~Z i r'ui i I~ ~iinq (~,~- ;,~3b~ ~r~~wcolt 2HH4'i NQ l~Qii.1J C~~i+'1 10. Did police investigate? (If so, give na es of of~icers~r i1O , 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.) ~J ~Iv~ ~U G ~S~ 13. What other damages do you claim, if any? f1 c~ bill ~ ~ a~~~~-~~ ~~5 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.) n o-~- v .e ~-- . L~J i ~ I -1-=b r ut.~ a r~ _ ~.-~-- -I-v C i -1--~, a s i~' c~~ S i -~ . 15. What amount do you claim from the City of Dubuque? t~ ~;-{- c, c b+e,~ - .~'y y~Y'~~~11 cc,,~~ -~V-~l ~%~~ ~i ~ ~ C~o c.. c ~'1 A, i^c~.Q. S . 16. Why do you claim the City of Dubuqu is resporYsible"? ,, :J i t (S ~~ e ~ r r~ a r I~ b ~ M .P ~ '~.L" ~ 1~ ~, 3 ~.,cnr - o ~ ~: ~ ~ ~ o ~- tv~ I s u S-~ ~ -~ ~ TA~,~ way 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? 20 ~~ Dated at Dubuque, Iowa this ~ day of ~. Signature) (Rev. 1 /00 & 7/01) Print Name) C~ r }~~ T+ 1 ~~ ~ -- ( ~ _ - ~~. ~ ~_ ~ TI , N ~ m c~ ra, o»5u?b~~o Mk7~c,At A1SUl;lA(t_S 16U_S~~Associates Drive, Suite 1U1 P.O. Boy 5002 Dubuque. IA 52002 Electronic Service Requested 5-DIGIT 52DD1 26D D•3584 AV D•335 ~rllltrlllllll~~illllll~I~Il~lllll~~ll~lllu~llllllll~illlll~ll PATRICK MADDUX Z 2~1^ ALTA VISTA ST DUBUQUE, IA 52001-4338 2UVYUN'_~t{76 My clink is a new online tool giving members easy access to claims and benefits information. Now available at www.mahey'yaylthcare.yc~~om y{ Questions? Please contact Customer Service at (563) 584-4885 or (86f-) 821-1365 ,Patient's Name: EVELYN MADDUX Identification #: Rl 106457705 Claim Numbc~ : 092300850105 Dates of Service: O7/17/09 - 07/17/09 Croup Nume: CLARKE COLLEGE Provider Name: DUBUQUE FIRE EMS .EXPLANATION OF BENEFITS Date Paid: 08/24/09 •• r w c N w Line ' 17:;ysi ~ Billcu- -- ~ - Allo,ved _ ~ - Qisaiiuw ~ Dcuied- - j -Cufaa) ~ )3cuuit ~ ~'oins ©tt-er Ins Amount Exryl. I Coul t Amc,('O 00 Ams~~ OO Amount00' Amount Amount Amount Amount Payment Paid Code _ .00 .00 500.00 --_ .00 .00 -- .OU O] 2~ - ~ -- .50.00 _ 50.00 _ AO __-- AO _ _ .00 SO.U_ 0 .00 .00 .00 O1 *Patieut's Responsibility reflects only applicable Deductible, Copay, Coinsurance, and Denied Amounts on this claim **You may also be responsible for any denied amounts and/or amounts over usual and customary. Line Account Information I $500.00 has been applied to 1~4EIv1BER DEDUCTIBLE; LEAVING $250.00 I $SU0.00 has been applied to F_AIvIILY DEDUCT1Bl.E; LEAVING $992.35 1 $500.00 has been applied to MEMBER OUT OF POC'IiET; LEAVING $1.850.OU 1 $SOO.UO has been applied to FAM(I,Y OUT OF POChET; LEAVING $4,017.35 2 $50.00 has been applied io MEP,~IBER DEDUCTIBLE; LEAVING $200.00 2 $50.00 has been applied to FAMILY' DEDUCTIBLE; LEAVING $942.31 2 $10.00 has been applied to MEMBER OUT OF POCKET; LEAVING $1,800.00 2 $50.00 has been applied to FAMILY OUT OF POCKET; LEAVING $3,967.35 Line Service Description___ 1 A0429 AMBULANCE 2 A0425 AMBULANCE Expl. Codc__ Descrifttion O1 DEDUC 1'IBLE AMOUNT'