Claim Lange, Thomas Jr.10/25/04
cc: MVM
Barry
Engrg
Planning
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: Thomas J. Lange
2. Address: 2659 White St. Dubuque, Iowa 52001
3. Telephone Number: 582-4306
4. Date of Incident: Oct. 24, 2004
5. Time of Incident: 9:30 AM
6. Location of Incident (Be specific): Walk under 16th St. Bridge where you come down the steep incline,
make a circle and go up to the bridge
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.) There was a path
of loose gravel crossing the black top, cause the bicycle to skid out and throw me off.
8. What were weather conditions like? Clear
9. Give name and address of any witnesses: 4 people saw it and commented on the loose gravel, but I didn't think
to get their names.
10. Did police investigate? (If so, give names of officers.) No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries). Myself.
Injured both knees and twisted back.
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.) Bicycle got banged
up.
13. What other damages do you claim, if any? None
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? I don't know any exact amount
16. Why do you claim the City of Dubuque is responsible? I feel they were wrong in building this in
such a way that the loose gravel covers the black top
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 25 day of October, 2004.
/s/ Thomas J. Lange
(Rev. 1/00 & 7/0t)