Claim Brandenberg, RoseCLAIM 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: Rose Brandenburg
2. Address: 1900 Washington #3, Dubuque, Iowa 52001
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3. Telephone Number: (563) 556 3547
4. Date of Incident: Friday, July 2, 2004
5. Time of Incident: (?) Approximately 12:15 P.M.
6. Location of Incident (Be specific):
9th Main St., the main bus stop downtown.
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.)
Wayne (Bus Driver) ...When upon stepping onto the Wheel Chair lift, at the same time he started closing
the lift and caught my leg, cutting and bruising it.
8. What were weather conditions like?
Sunny, fair day.
9. Give name and address of any witnesses:
A few people on the bus, showed the bus driver what he had done.
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 injured only. Rose Brandenburg.
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 damages to property, just a human leg. I have diabetes and the injury has caused a major problem, the pain is bad.
13. What other damages do you claim, if any? (None) Except the pain and damage to my leg.
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.)
I haven't been compensated but i do have insurance. I have to have a surgery and whirlpool also.
15. What amount do you claim from the City of Dubuque? $10,000 for pain and suffering and future doctor appointments.
16. Why do you claim the City of Dubuque is responsible?
Because the bus driver shut the lift on my leg. And now it 's a hole and infected badly. It will have to be cut and sewn by a surgeon.
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 31 day of July, 2004.
/s/ Rose Brandenburg
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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. CLAIM AGAINST THE CITY OF DUBUaUEj'IOWA -~/.F~6:
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This written report constitutes your claim against the City of Dubuque, Iowa. Võú 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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7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
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10. Did polifi ~vestigate? (If so, give names of officers.)
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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14. Have you been compensated for any part or all of your claim by any insurance
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15. What amount do you claim from the City of Dubuque? Ó .
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17. Have ou made any claim against anyone else for damages as a result of
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18. If the answer to Question 17 is yes, have you received any payment from that source,
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Dated at Dubuque, Iowa this 31 "t day of
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(Rev. 1/00 & 7/01)
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