Claim McCarthy, AngelaCLAIM 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: Angela McCarthy
2. Address: 1098 Rush St., Dubuque
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3. Telephone Number: 583 7253
4. Date of Incident: 2/26/04
5. Time of Incident: Approximately 8:15 a.m.
6. Location of Incident (Be specific): Iowa Street Parking Ramp, behind my spot #390
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.)
I parked my vehicle, got out, walked around back of my van, slipped on ice and fell. I fell onto my hands/wrists and knees.
8. What were weather conditions like?
Cold, icy ramp
9. Give name and address of any witnesses:
My supervisor say my hand/write approximately 5 minutes after incident - Bob Shaw 557 8251
10. Did police investigate? (If so, give names of officers.)
I filed a report with them and notified parking office.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, me, saw my family physician - xrays tken
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?
I lost 2 hours of overtime work due to having to go to doctor's office and hospital
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.)
Barnstead International Health Plan (SISCO) P.O. Box 389, Dubuque IA 52004-0389
15. What amount do you claim from the City of Dubuque?
Reimbursement for Dr. Bagby's services, Finley's services, and time away from work.
16. Why do you claim the City of Dubuque is responsible?
The parking spot was not salted / de-iced and that is what resulted in my fall.
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 28th day of April, 2002.
/s/ Angela McCarthy
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF DUBUQUE, IOW~ J t/-'~~
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.
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6. ~ocation of Incident (Be specific): ~ ~~ F~ ['CtIMf)
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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? Cò[J I ìc.y (Q1MP , .
9. Give name and address of any witnesses: ¡~ 'KII ßVlÌìSö.í 'Sw.J V<4j L\t;I J /4JVI5t
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10. Did police investigate? (If so, give names Qf officers.) . .o"r, ~ 4 f)- /¡' 6Vtc. òÞœ
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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1. Name of Claimant:
2. Address:
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
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.)
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13. What other damages do you claim, if any? ~ {Os+- ~, k.~ crP ðVel'17y...¿
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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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15. What amount do you claim from the City of Dubuque? ~~.{~io-W
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16. Why do you claim the City of Dubuque is responsible? ~ r./t;,^:j Sfb+
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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.) ~ \
'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
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(Rev. 1/00 & 7/01)