Claim Arends, MicheleCLAIM 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: Michele Arents
2. Address: 405 N. Ellen St.
Cedar Falls, Ia 50613
3. Telephone Number: 319-277-8488
4. Date of Incident: Oct. 8 2004
5. Time of Incident: Between 8-8:30pm
6. Location of Incident (Be specific): East Diamond Jo Casino Parking Lot
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.) Was walking from car to Diamond Jo Casino, crossed
medium cobblestones were not even height with
cement curb caught my shoe heel on curb and fell down
8. What were weather conditions like? clear, normal
9. Give name and address of any witnesses:
Mark Arends 405 N. Ellen St. Cedar Falls IA 50613
10. Did police Investigate? (If so, give names of officers.) No
11. Was anyone injured? (If so, give names, addresses, and extent of Injuries).
Yes myself, sprained left 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?
No
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? $229.70
16. Why do you claim the City of Dubuque is responsible?
Cobble stone blocks were not level with
curb top causing me to catch my heel on
curb and resulting in a fall and injurying my ankle
17. Have you made any claim against a one else for damages as a result 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 Cedar Falls, Iowa this 31 day of October, 2004.
Diamond Jo Sec Guard
Erik took accident
report and provided as
much medical attention
as he could.
(Rev. 1/00 & 7/01)