Claim Boekholder, AmyCLAIM AGAINST THE CITY OF DUBUQUE, IOWA
CC: MVM, Barry, Tim H.
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: Amy Boekholder
2. Address: 812 3rd Ave SE Dyersville IA 52040
3. Telephone Number: 563-875-2442(home) 563-557-4265(work)
4. Date of Incident: 10-29-04
5. Time of Incident: 6:45am
6. Location of Incident (Be specific): Top of Locust St Ramp going
down the metal stairs in SW corner
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 slipped on the stairs going down them. My
feet when right out from under me. My shoes (tennis shoes) went
flying and I landed directly on my rear end, hitting my arm and leg.
8. What were weather conditions like? It was damp out - rainy
9. Give name and address of any witnesses: -none- pretty early in the
am. I did tell a co-worked as soon as I got into the building.
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, I (Amy) went to the Dr. in Dyersville and found out that
I broke my coccyx (tailbone). I also have back and next
pain resulting from the fall.
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 damage to property - just my body.
13. What other damages do you claim, if any?
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.)
A claim has been filed with my HMO. I am unaware
of any amounts other than my $20 co-pay.
15. What amount do you claim from the City of Dubuque? I would like my medical expenses
covered plus I would like to be compensated for my pain and suffering.
16. Why do you claim the City of Dubuque is responsible? The metal steps were
wet which made them slippery - perhaps they need new treading on
them.
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 4 day of November, 2004.
Amy Boekholder
(Rev. 1/00 & 7/01)