Claim Mills,Martha L.
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: Martha T. Mills
2. Address: 648 Beach View Drive, Iowa Citv, Iowa 52246
3. Telephone Number: 319-337-3885
4. Date of Incident: 05-30-04
5. Time of Incident: 1812 Hours
6. location of Incident (Be specific): Parkinq Lot North of Diamond Jo's, main
entrance
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.)
Upon tryinq to exit my vehicle I put my left foot on the parking lot and began to slip. I then tried bring my right foot out of the vehicle to stop
from sliding. Suddenly both of my feet slide out from under me causing me to catch myself with both of my arms and elbows on the driver's side seat.
I injured my neck and both shoulders.
8. What were weather conditions like? Rain
9. Give name and address of any witnesses: Rita J. Berg, 115 1st Street, St. Donatus, Iowa 52071
10. Did police investigate? (If so, give names of officers.)
Yes - Hardin - BIN - 59A
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Self
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.)
NIA
13. What other damages do you claim, if anY? Medical Treatment - North Liberty
Chiropractic Clinic - Dr. Tom Holub.
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? Medical Cost and $2,500.00
in Liability.
16. Why do you claim the City of Dubuque is responsible? It is your oarkinq lot, owned
by the City of Dubuque.
Also, the then layer of mire should have been cleaned
before someone was injured.
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/ Martha L. Mills
(Signature)
Martha L. Mills
(Print Name)
(Rev. 1/00 & 7/01)
-'<t
"
MARTHA L. MILLS
ATTACHMENT TO DESCRIPTION
to catch myself with both of my arms and elbowson the driver's
side seat.
I injured my neck and both shoulders.
-'- C
» ft}
CD
0
""'"
L
~
¡,,~
"'"
9?
=
,-j