Claim Imbus, LisaCLAIM 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: Lisa Imbus
2. Address: 2619 Central Ave.
3. Telephone Number: (563) 582 9485 or (563) 495 1053
4. Date of Incident: July 4, 2003
5. Time of Incident: 11:10 P.M.
6. Location of Incident (Be specific):
Parking Lot on left side of front entrance to Diamond Jo Casino
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.)
I was coming out of building after Air Supply concern the lighting was bad it was dark. I tripped and fell on the meridean between parked cards...my two other sisters also tripped in different spots on the same median.
8. What were weather conditions like? Humid, hot, dark
9. Give name and address of any witnesses: Cindy Donath (722 Fremont Ave., 556 1286( Christie Tuder (701 Cedar Cross Rd. Lot 25 582 9094)
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, I was sseen at Finley Emergency at approx. 11:40 p.m. 7 4 03
Lisa Imbus (2619 Central Ave. 582 9485)
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?
Medical payments
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?
Unknown at this time.
16. Why do you claim the City of Dubuque is responsible?
Because the lighting in the lot was terrible
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 7th day of July, 2003. .
/s/ Lisa Imbus
(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 Numbe~
4. Date of Incident: ~
5. Time of Incident:
'
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.) , ,
' U - . .... ~:~ ~ '-'*
9. Give nameand address of any witnesses~~~~ ~~~Zj~.
l~police investigate? (If so, give 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 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? ~_~C~-C~._~./,%~.'~ _~ ~
16. Why do you claim the City of Dubuque is responsible?._~_ ~'~__ .D
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes~g~.~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 ~-~
day of .~11'_~)/\I ' 20°~'~'
(~rint Name)
(Rev. 1/00 & 7/01)