Claim Heiderscheit, JulieCLAIM 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: Julie Heiderscheit
2. Address: 758 Highland Court - Holy Cross, IA 52053
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3. Telephone Number: (563) 870 4625
4. Date of Incident: 11/24/03
5. Time of Incident: 7:58 A.M.
6. Location of Incident (Be specific):
8th Street Parking Ramp. Top Floor North side of corner of 8th and Iowa - Dubuque, Iowa.
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.)
(See attached polic incident report). Improper ramp maintenance for ice buildup.
8. What were weather conditions like?
Light dusting of snow with patches of ice.
9. Give name and address of any witnesses:
Kitty George, Chris Lambert (at time of fall). Kate Hefel, Tami Roher, Linda Brant after fall, all work for Cottingham and Butler / Sisco - 300 Security Bldg., Dubuque
10. Did police investigate? (If so, give names of officers.)
Yes, Officer Edward A. Baker 06
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, Julie Heiderscheit, 758 Highland Court, Holy Cross, IA. Broken Fibula at ankle level. Broken ankle in two places requiring surgery. 15 screws and a plat. 3 Days in hospital. 3 weeks off work.
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.)
My glasses are scratched - sock and pants had to be cut off.
13. What other damages do you claim, if any?
Lost wages for my husband - mileagle etc. modification to clothing
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.)
Not at this time I received a questionnaire from them and I am uncertain if they will cover it.
15. What amount do you claim from the City of Dubuque? Unknown medical if not paid by insurance; compensation for lost time; expenses and inconvenience to my husbands,
kids and co-workers.
16. Why do you claim the City of Dubuque is responsible?
Failure to adequately maintain safe parking.
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 16th day of December, 2003.
/s/ Julie Heiderscheit
(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 Number.~'~?')~ <~ .~-'-~.~L.~_~--~
4. Date of lncident: [~/ ~_~L-~,~,(~
5. Time of Incident:
Location of Incident (Be specific):
6.
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
empl(~yee's namp.) .
8. What were weather conditions like?
9. Give name and address of any witnesses: ~l'~ ~, ~ ~ p~,'~
10. Did police investigate? (If so, give names.pt o~cers.)
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, ifany? I~ c~,5,,S
14. Have you been compensated for any paA 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?
16. Why do you claim the City of Dubuque is responsible?
17. Have you made any Claim against anyone else for damages as a result of this incident?
(If yes, giv~e 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 ~~ ~d~
/"~- v {Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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