Claim Jagielski, LynneCLAIM 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: Lynne Jagielski
2. Address: 1890 Keyway Dr. Dubuque IA 52002
`
3. Telephone Number: 583 8154
4. Date of Incident: 1-17-04
5. Time of Incident: approx. 7:10 AM
6. Location of Incident (Be specific):
Diamond Jo Casino 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.)
Parked my car and when I got out of the car it was a sheet of ice where I got out and I fell on my hands and knees.
8. What were weather conditions like?
Icy & cold.
9. Give name and address of any witnesses:
None - I reported it to Security and a Diamond Club Employee and coat room employee... I also told several people I knew there and
an employee told me 2 other people had fallen earlier.
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
I was. I fell with my weight on my hands and knees. My hands are sore from Carpal Tunnel Surgery over a year ago and they hurt worse now along with my shoulder & back are very sore.
Security walked me to my car when I left so I wouldn't fall again.
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?
Unknown at this 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.)
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 Diamond Jo Personnel I reported the incident to said it was the City's responsibility to salt the lot.
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?
N/A
Dated at Dubuque, Iowa this 19th day of January, 2004.
/s/ Lynne Jagielski
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
JSN-19-04 HON 09:14 fii~ DUBUQUE CITY OLERK Ffl× NO, 563 589 0890 P, 02
' CLAIM,AGAINST THE CITY OF DUBUQUE;iO~~
This wrilt~n repo" constitutes your claim sgainst the City of Dubuque, Iowa. ~~~
complete this form in furl and afiach any additional information that suppo~s your claim.
The Claim must be filed w~th the Ci~ Clerk a~ 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 tha~ investigation is completed, a report and recommendation wiU ~ submlt~d to the
City Council, You will ~ provided with a copy of that repo~ and recommendation.
THE FINAL D~CISlON ON ALL CLAIMS IS MADE ~Y THE CITY COUNCIL. NO EMPLOYEE
OF THE OIT'Y OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESE~ATION TO
YOU A5 TO WH~HER YOUR CLAIM WILL OR W~LL NOT BE PAID.
Name of Claimant:
Address:. /~ go
Telephone Number:_.
4. Dale of Incident: / -/7 - d 9/
Time of Incident: /:~ ,~,o,eo ~, _.~:/o A./-'/,
'6, Location of Incident (Be specific):. ~ ;~'4 o,o o ~To
'7, DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE, (Give
full details upo~l which you base your claim, if a City employee was involved, give the
e~ployee's name,)
,~ ~'~-~7-~o~C,,~c~_.,~.,~ ._~
/J~3 ~- /~c-~3 .....
What were weather conditions like?.
9, Give name and address of any witnesses: ...... /~J~ ~-~
:10, Oid ~ollc~ in~sfigate? (Il so, give names of officers,)
' 11, Was anyone injured? (If so, glve names, addresses, and extent of injuries).
J~%N-19-04 MON 09:14 l%M DUBUQUE CITY CLERK F~%X NO, 563 589 0890 P, 03
12. Was any damage done to property? (If so~ describe property and the extent of damages.
Attach esth'nates of damages or desoribe 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?
18. Why do you claim the City of Dubuque is responsible?.
7, Have you made any claim against allyone els~ for damages as a result of this incident?
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 & 7/01)