Claim Fuerstenberg, James PCLAIM 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: James Pl. Fuerstenberg
2. Address: 760 Summer Dr.
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3. Telephone Number: 582 3051
4. Date of Incident: June 25, 2003
5. Time of Incident: Approx. 11:30 a.m.
6. Location of Incident (Be specific):
Approx. 100 yards beyond 770 Mt. Carmel Rd. (going down Mt. Carmel Road)
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.)
While biking downMt. Carmel Road with Clete Schmitt in front of me, my front tire got caught in a 2 inch wide, 5 inch deep, 13 foot long separation in the street. (I measured it the next day)... As I was falling down I put my hand out against
the guard rail and tore my rotator cuff.
8. What were weather conditions like?
Good - sunny & 75 degrees
9. Give name and address of any witnesses:
Clere Schmitt, 1230 Altura Dr.
10. Did police investigate? (If so, give names of officers.)
Yes, the next day - After going to Mercy hospital for x-rays the day of the accident, I was talking with my neighbor, Dwayne Prine, (a police officer) that night telling him what had happened.
He said usually the police investigate accidents that happen on city streets. The next day an offer - I don't remember his name, called my house
and asked if I would cover over to Mt. Carmel Rd. & show him exactly where the accident happened. I did. He took a photo of the street and I wrote
down my account of the accident.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, me. July 15 2003 MRI showed a tear in rotator cuff. I had arthroscopy surgery on 10-27-03.
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.)
Just my bike.
13. What other damages do you claim, if any?
Just my out of pocket money that my insurance company did not pay, e.i. $348.00
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?
$348.00
16. Why do you claim the City of Dubuque is responsible?
The seperation in the road made bike travel unsafe. The investigating officer said it was pretty bad also.
The city repaired the separation before July 4, 2003 so must have thought it to be unsafe also.
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 June , 2004.
/s/ /s/ James P. Fuerstenberg
582-3051
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF DUBUQUE, íöWA L
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: JQ..me3 P. Fu'ef'ste/lbert!
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2. Address: 7tto Sttmmer Yr.
3. Telephone Number: Sf?";¿ - 3 oS J
4. Date of Incident: Jtll7 e ;;25 ;2003
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6. Location of Incident (Be specific): .4~. I()o'!f:¡lif~vf 770/lllT&/;~Ifd.
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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
empl9yee's name.) . > ¿7 .-H- .
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9. Give name and address of any witnesses: cøz;; ;:; r:hÆ /:2 3 0 IÎ~ :/)Jl-. ~
10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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12. Was any damage done to property? (If so, describe property and the extent of damages.
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13. What other damages do you claim, if any? ~ ~ ¿- ~ ~ ~.R/I¿ ¡I/
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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.)
15. What amount do you claim from the City of Dubuque? ~ 3 i J: ¡Yo
16. Why do you claim the City of Dubuque is responsible? -;1ht ~~ #. z:?i ~
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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.)
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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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James P Fueísfenie('(¡
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(Rev. 1/00 & 7/01)
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