Claim Hoeffllin, Linda C.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: Linda C. Hoefflin
2. Address: 1662 Settler's Reserve Way, Westlake, OH 44145
`
3. Telephone Number: 440 835 0181
4. Date of Incident: December 28, 2003
5. Time of Incident: Approx. 3:45 P.M.
6. Location of Incident (Be specific): 86 Main Street, Dubuque, IA
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.)
Carol and I were going to my Backyard Shop. We got out of Carol's car, and started across the street, cracks and pothole in street, the heel of
my shoe caught on hole (cracks very deep) causing me to fall forward onto street landing on my face...
and ____ arm (left wrist and left leg).
8. What were weather conditions like?
Clear
9. Give name and address of any witnesses:
Carol Kaune, 835 Harlan St., Dubuque (52001; Karen Langas, 86 Main St., Dubuque, 52001
10. Did police investigate? (If so, give names of officers.)
Yes, don't know Officers' names but there is a report on file - Taken to ER at Finley Hospital.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes; Linda ("Lynn") C. Hoeffllin, 1662 Settlers Reserve Way, Westlake, Ohio 44145 - injury to face, mouth, tooth, both knees, left wrist,
and scrapes and cuts; chipped front tooth, left know - bruised and sitill painful.
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, only myself; Bracelet fell off my larm - locking catch is broken; Noticed several scratches on my watch & diamond (left arm/hand) that were not there previously.
13. What other damages do you claim, if any?
Watch repair (face) possibly and will have ring and bracelet evaluated; bracelet repair necessary on locking clasp.
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?
All medical expenses incurred and anything related to the accident until the doctors release me. I am seeing my dentist, med. dr. and orthopedic dr.
16. Why do you claim the City of Dubuque is responsible?
Your street needs repairs, and is in poor shape, and caused me serious pain and injury (front tooth chipped as well), and the City is responsible.
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 day of , 20 .
/s Linda C. Hoefflin
(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, NameofClaimant: ~j /'43~ C,
2. Address: /~ ~~ ~V~
3. Telephone Number: ~y~,~ ~,~ D/~/
4. Date of Incident: ~~ ~
5. Time of Incident: .~p~X,
6. Location of Incident (Be specific): ~ ~
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
l
8. What were weather conditions like?
9. Give name and address of any witnesses: ~[
10. D~ police investigate? (If so, give names of officersl)
~!~ ~a'+ Kn~o ~?c~~ n~ b~~
J ~.' ~s anyone Jnjure~? (Ii so, give names, a~resses, an~ 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, it~ 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? ~[ mO~O__b~ G_AL~nS~_~.B ~-
16. Why do you claim the CitY of Dubuque is responsible? ~13~ ~-~ ~6¢~
17. Rave ~ou 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
day of , 20
~ (Signature)
(Print Name)
(Rev. 1/00&7/01) -~- uo¢~ ~c~ ¢o..C-n c~:~ %c~o,c~ ~ z~.e_PF,~ o~ ,=l~o?~;
January 18, 2004
City of Dubuque
50 West 13th Street
Dubuque, IA 52001
RE: Accident - December 28, 2003
Attention: City Clerk
Enclosed is the claim form your office mailed to me to complete.
I have also enclosed the bill I received this week from the EMS.
If you have any questions you may contact me at (440) 835-0181 (home) or (440) 871-
8900 x273 (work).
Sincerely,
Enclosures