Claim Avenarius, Debra AnnCLAIM 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: Debra Ann Avenarius
2. Address: 2264 Prince St., Dub, IA 52001
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3. Telephone Number: 563 582 7617 599 4071
4. Date of Incident: Nov. 12, 2003
5. Time of Incident: 5:00 P.M.
6. Location of Incident (Be specific): Diamond Jo Parking Lot
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.)
Tripped over Curb onto Sidewalk
8. What were weather conditions like?
Clear - Dark out
9. Give name and address of any witnesses:
Becky Berkley 557 7096
165 West 23rd
Dub, IA 52001
10. Did police investigate? (If so, give names of officers.)
No, Medic - Adam Maas - Diamond Jo
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Debra Avenarius, Broken Ankle in two places.
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?
Loss of work time.
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.)
Gallagher Benefit - P.O. Box 5227 - Lisle, Ill 00532 5227 has paid a percent of claim to Finley Hospital and Dr. Tim Quagliano.
15. What amount do you claim from the City of Dubuque?
Unknown at this time - surgery may be required
16. Why do you claim the City of Dubuque is responsible? Frank Domitrovich 583 7005 Ext. 111 told me Diamond Jo is not
the owner of the parking lot...City is.
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 5th day of January, 2004. .
/s/ Debra A. Avenarius
(Signature)
Talked to Monica Ackley
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUE¢IOWA
a ainst the Cit of Dubu ue Iowa~Sl'~'-~~-
This written report constitutes your claim g ' y q , ou 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. 13m 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.
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3. Telephone Number:
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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
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8. What were weather conditions like? ~_~ ~/~/~
9. Give name and address of any witnesses:
10. D. id police investigate? (If so, glove 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? ~ ~/z~/ ~/.~?~c ~__
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.)
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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
(Print Name)
(Rev. 1/00 & 7101)