Claim by Susan SchetgenTHE CITY OF
DUBJE MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
DATE: September 13, 2010
RE: Claim Against the City of Dubuque by Susan Schetgen
Claimant Date of Claim Date of Loss Nature of Claim
Susan Schetgen 09/09/10 08/17/10 Personal Injury
This is a claim in which claimant alleges that as her son was pushing her in her
wheelchair on Dorgan Place, they struck a cracked area on the street and claimant fell
out of her wheelchair and was injured.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager
John Klostermann, Street & Sewer Maintenance Supervisor
Susan Schetgen
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001 -6944
TELEPHONE (563) 583 -4113 / FAx (563) 583 -1040 / EMAIL tsteckle @cityofdubuque.org
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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. 13 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: &tc ( t .
2. Address: 5 O q W 4.0 0,41
3. Telephone Number: 5o3 5J 3 0 373
4. Date of Incident: (. ti 4 /7, cQa l€
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6. Location of Incident (Be specific): rn l d d (a {AV je4 vi . 4 /i'7
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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.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries). J ' bj
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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.)
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13. What other damages do you claim, if any? o n 6 I
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14. H yo comp � nsatec ( for p art or all of your claim by any insdrance
company? (If so, give name and address of insurance company and amount paid.)
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1,5 ha amou t do you claim from the ity of Dubuque? _
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16. Wh do u clai the City of ubuquue is es onsible? �� t
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, g ye name and address.)
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18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
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q day Dated at Dubuque, Iowa this da of fn , 20 /0 .
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