Claim by Jennifer NeyTHE CITY OF
DUB UE MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
DATE: January 14, 2011
RE: Claim Against the City of Dubuque by Jennifer Ney
Claimant Date of Claim Date of Loss Nature of Claim
Jennifer Ney 01/14/11 12/14/10 Personal Injury/
Property Damage
This is a claim in which claimant alleges that she slipped and fell on ice in the Iowa
Street Parking Ramp, injuring herself and tearing her pants.
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
Tim Horsfield, Parking Systems Supervisor
Jennifer Ney
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
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 West 13 St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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 authori y to make any representation to you as to
whether your claim will or ' not be paid.
1. Name of Claant:
2. Address:
3. Telephone Number
4. Date of Incident:
5. Time of Incident:
7. Describe the 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.) 9
9. Gi
ion of cident
at were weather con tions like?
10. Did polic
name and address of any witnesses
vestigate? (If so, give ames 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 d • you cI -'m, if any
14. Have you been compensat-d for any part or all of your claim by any
insurance company? (If so, give name and address of insurance company and
amount paid.)
17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
Why do you claim the ty of
(Print Name)
e'L 7Co\-f),(2_
buque
e c 2
onsible?
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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