Claim, Danielson,Timothy - DaveCLAIM 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: Timothy Danielson (1 yr. old infant)
2. Address: 1485 Lucy Dr. Dubuque IA 52002
`
3. Telephone Number: (563) 582 8707
4. Date of Incident: July 18, 2004
5. Time of Incident: approx. 2:40 p.m.
6. Location of Incident (Be specific):
Eagle Point Park approximately 3/4 of the way around park about 100 feet from the old concession
stand parallel to playset
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 Dave was walking through the park and carrying infant son, Timothy. He tripped over a pothole that was not clearly visible. Dave fell to the
ground with son in arms and son Timothy hit the pavement head first.
8. What were weather conditions like? Warm, sunny day, shady area
9. Give name and address of any witnesses:
Melvin Kohler, 3867 Hillcrest Rd., Dubuque, IA 52002, Dawn Danielson, 1485 Lucy Dr. Dubuque, IA 52002
10. Did police investigate? (If so, give names of officers.) Yes. A. Hardin
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, Timothy Danielson, 1485 Lucy Dr., Dubuque IA - Head injury; Scap from top and head down to top of left eye. Dave Danielson, 1485 Lucy Dr.
Dubuque, IA scap knees, elbow, twisted ankle.
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?
personal injury
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?
$637.30
16. Why do you claim the City of Dubuque is responsible?
The City is responsible for the park and public walkway where there was a hazard rut/pothole not clearly visible which caused personal injury.
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 19th day of August, 2004.
/s/ Dave Danielson .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
de, JVJ {I f1
.',' ~
" ' CLAIM AGAINST THE CITY OF DUBUQUE,.IOWA Æ ~
This writlen report constitutes your claim against the City of Dubuque, Iowa. Y 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 submitled 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: TIIYìo1-VtI D~i'1I~J";o/ì (1 ~(. old IrlûlCt)
2. Address: I~ Or J)u¡)U&US J7l 5dc::cG-
3. Telephone Number: (§OS) $.).<-~ 707
Ju~ \3 IdooLf
aø>rr>i(YIa;f.d~ ;)40 pfYì
6. Location of Incident(Be specific): fOj /Q 101m tart. aFrVbY/~ 31i of-
(ov abol/T foo.íèd- Avm --1te o\c1 I '. arJk I i1J ð~çl+
OIlo\'\<1 rb ¡,v\«e... púrJ¿it1Cj is Ioc~kd
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If a City employee was involved, give the
employee's name.) I
while. i)a WI.. iAJa~< we, (Icr ") t+,rDUSh tk2 fdrlL ~ (?JrY(j infi't"f Son
'T,(Y)oi-h'1' -i-t. +rïff<c1 ave, Ct rc+hol~ -t'Ì"'Bi-Wè-\. Y)ai- c~ar~ v"~11k:, Ot¡,;e..
1/ Jv 'íDV"o( w¡+h Son In CUM$ ç, .5on Tlrno+l-> h+ -J.hz ûve 4
eet. c{ II ,f-
8. What were weather conditions like? War rY1 5u n n 'êJ c{C<¡j- -I, ~~ n HI ¡)..-
9. Give name and address of any witnesses: me.!Vln tohlff 381.:,1 I-J¡I)ües+ ~(~
Q;6U~uG :2A ';2xJz. OWùn Q Aìe I":cr, 14~ S- LvC¡ Or ßf3,vQJJ-G .:v<- ~Od.
10. Did police investigate? (If so, give names of officers.)
'::Ii') A, \-k~""
4. Date of Incident:
5. Time of Incident:
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
\f~' < ,r,lO+\-c; \)0. Y\ ¡e\~ \4ß,Ç wc"1Or O",.">v':¿ v-G 'XA - f1> f< c\ ¡~v('1- SC(Ccf {.rr~
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'\)v'6vQAJt s:p. - ~Ocf' \U1Qu> ,Z\\-xJwo +w,s-kd c""k\L-
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?
(JtL í5.cn?9 ; ~ ' "j
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?
$ fc31, 3'
16. Why do you claim the City of Dubuque is responsible? +W ~ IS rlZ,Çf of\S 'Dk
<~ ," +he fàík: ~ fvl.> U C w2\ t:.w ~ whQre -fv-ef,,- w?3ì Q hOt<? iZB.
'('\)+-/ ~\e nO+- ckQr~ v¡çlblz. which l&;yd çe(Ç~~ ì^j'^"1
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
he
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 Dub~ue;'10wa this
\q~
day of
()\/~ us:+
1\,,"'^v>-{~~,~ tt"",
(Signature)
DetvQ D1()I'e,l~
(Print Name)
, 20.Q;L.
1,-
(Rev. 1/00 & 7/01)
DUBUQUE FIRE EMS
'(800)786-4911 Ext 230
Call Number:
Date Of Call:
Call Time:
From Location:
To Location:
30-04-0002250
07/18/2004
02:58 PM
1500 RHOMBERG AVE
MERCY HEALTH CENTER - IOWA
NONE
Patient Name:
TIMOTHY DANIELSON
Reason(s) 959,01
For 919,0
Transport
#BWNKMRY
TIMOTHY DANIELSON
1485 LUCY DR
DUBUQUE, IA 52002
Insurance: MEDICAL ASSOCIATES H 352720729
DESCRIPTION OF CHARGES
ALS EMERGENCY RES NO SPEC SRVS
MILEAGE RESIDENT
HCPC
A0427
A0425
QUANTITY
1,0
4,0
UNIT PRICE
400,00
6,00
AMOUNT
400,00
24,00
Total Charges
424,00
This collection agency is licensed by the:
Office of the Administrator of the Division of Banking
p,O, Box 7876, Madison, Wisconsin 53707
Total Credits
TOTAL AMOUNT DUE =>
0,00
$424.00
,-------------------------------------------------------------------------------------------------------------------------------------------------,
^DETACH ALONG ABOVE LINE AND RETURN STUB WITH YOUR PAYMENT^
'*
Our billing office has submitled a claim to your insurance carrier
provided insurance information is accurate. Please check the
information & report errors to the billing office.
Patient Name: DANIELSON, TIMOTHY R
Patient Number: 709
Call Number: 30-04-0002250
Billing Date: 07/27/2004
DUBUQUE FIRE EMS
c/o LlFEOUEST BILLING OFFICE
N2930 STATE ROAD 22
WAUTOMA, WI 54982-5267
Total Amount Due:
$424,00
Amount Enclosed:
$
Federal Tax ID: 42-6004596