Claim Swift, ConnieCLAIM 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: Connie Swift
2. Address: 38568 Pumpkin Ridge Rd., Guttenberg, IA 52052
3. Telephone Number: 563 252 1850
4. Date of Incident: Nov. 26, 2002
5. Time of Incident: 1930 hrs.
6. Location of Incident (Be specific):
Chamber of Commerce parking lot next to Capri parking lot - corner of Main and 3rd (between meter P-714 & P 713)
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.)
The parking lot was poorly lit - I didn't see the curb separating the two parking lots and tripped. I received severe abrasions on my nose, right check and above my eyebrow.
8. What were weather conditions like? clear/dry
9. Give name and address of any witnesses: Dave Bures (my husband) found me lying on the pavenment when I yelled for him.
10. Did police investigate? (If so, give names of officers.) Yes
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Connie Swift (see above)
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?
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? $282.00
16. Why do you claim the City of Dubuque is responsible? accident occured on City property - caused by poor lighting
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 19 day of March, 2003.
/s/ Connie Swift
(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.
3. Telephone Number: ~ ~ ~ ~ - i ~O
4. Dateoflncident: ~OQ, ~) ~0~
7.~ESCRIB[ ACCIOENT OR OCCURRENCE T[AT CAgSED I~J~RY OR ~A~A~E, (~ive
full details upon which you base your claim. If a City ~mployee was involv~: give the
~loyee's na~e.)
8. What-~re'weather conditions hke? ~/~6 ~r-// c~r)/
9. Give name and address of any witnesses: ~ r~.
10: D,i(~ police investigate? (If so,~ive 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 dama'ges.
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 s(~, 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 responsibYe~
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
_0
/ ~ day of
, 2005.
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)