Claim Brehm, Clarence M.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: Clarence M. Brehm
2. Address: 2186 Suzanne Dr.
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3. Telephone Number: 583 4091
4. Date of Incident: 1 13 05
5. Time of Incident: 4:00 P.M.
6. Location of Incident (Be specific):
2180 St. Celia
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 was walking ont he sidewalk and fell backwards on the ice.
8. What were weather conditions like?
Clear
9. Give name and address of any witnesses:
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, Clarence M. Brehm, 2186 Suzanne Drive, fell on ice, hit back of head and ribs.
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?
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?
None
16. Why do you claim the City of Dubuque is responsible?
They aren't - property owner is responsible.
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 22nd day of January, 2005. , 20 .
/s/ Clarence M. Brehm
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF DUBUQUE,"IOWA' !~[,:. t"ir.J .
This written report constitutes your claim against the City of Dubuque, Iowa. ~ou 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.
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.)
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8. What were weather conditions like? 0 /ea ;.
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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12. Was any damage done to property? (If so, describe property and the extent of damages.
tl.ttach estimates of damages or describe basis for ascertaining extent of damage.)
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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.)
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15. What amount do you claim from the City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) ~/ ()
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 ,~07 )J J day of
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(Signature)
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(Print Name)
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(Rev. 1/00 & 7/01)
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