Claim Burrows, LoriCLAIM 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: Lori Burrows
2 Address: 1750 Rosemont
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3. Telephone Number: 556 1254
4. Date of Incident: 9 12 04
5. Time of Incident: 2030
6. Location of Incident (Be specific): S. Grandview Ave. sidewalk between the two streets
that goes down into Plymouth Ct.
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.)
My husband and I were out for a walk and I stepped on the edge of the sidewalk and went into a hole along
the sidewalk and fell onto the grass.
8. What were weather conditions like?
Normal
9. Give name and address of any witnesses:
David Burrows, 1750 Rosemont, Dubuque IA
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Lori Burrows, 1750 Rosemont, Dubuque, IA fracture of tibula on R 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?
See astricks below - I have lost 148 hours of reg. pay @ 24.12 hr = 3569.76; I lost all my charge pay (usual pay for me)
$1.00 hour x 32 days 8 hr/day $192.00 total of $3601.76 lost wages @ this time 10/26/04
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.)
Not at this time. My insurance company is Health Choices
15. What amount do you claim from the City of Dubuque?
Medical Bills and out of pocket expenses for housework (Merry Maids $130.)) - hired help - extra medical supplies - Jobst Relief Knee Highs $27.11
16. Why do you claim the City of Dubuque is responsible?
Poor repair of the grassy areas along the edge of the sidewalk. I reported it to City Engineer office after the incident and still not repaired.
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 20 day of September, 2004.
/s/ Lori Burrows
* I am unable to drive until at least after 10/26/04. I have to hire someone to drive me anywhere I got. I am unable to do my full job at work and am having to use my limited vacation time to have a paycheck which I can
not live without. I have had to hire Merry Maids for 2 weeks - total of $130.00. My driver took me to 3 doctor visits also. Mileage for my driver 560 miles - to and from work x 20 days - 7 miles each way. (Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF DUBUQUEj'IOWA D~
This written report constitutes your claim against the City of Dubuque, Iowa. You s~
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:
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7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
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10. Did police investigate? (If so, give names of officers.)
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12. Was any damagé 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 insura~~
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17. Have you made any claim against anyone else for damages as a result of this incident?
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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 :;!
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Merry Maids Service Agreement .
Entry: Service Type: Cleaning Day: Appt. TIme: R . é) 0 A yY\
TIme: ~, A. ,dvertiS8 mentType: . Appt. Date: 9 / .:2t / O£f
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Name 1 (Jh.hJWJ~ Address J7c)/)/ ~o;)r¡;~T
ResidencéPhoneNo. 5c;t,-/~S1, , BusineSSPhor'IeNo. Ex!,
Directions
Weekly SaIe$ Total
Tax
Biweekly Sales Total
Service h£ Tax
Fee: Sales Total
Tax
Special Sales Total
Tax
Window Sales Total
Foe Tax
1 Window
Living Room clean, dust & vacuum
1 Dining Room clean, dust & vacuum
1 Kitchen clean a liances count
StudY clean dust & vacuum
J Family Room C dust & vacuum
Rae, Room clean dust & vacuum
M, Bath
J M. Bedroom clean dust & vacuum
Bedrooms clean du t & vacuum
Bedrooms clean dust & vacuum
Bedrooms clean dust & vacuum
Utility Room
1 HanS@
1 Bathrooms
L Foyer
Total
First Sales
TIme_Tax
Total
Total
cabinets table & chairs swee & wash floor
& wash floor
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1845 Washington reet 8 Dubuque, IA 52001
Tel: 563-583-9144