Claim by Greg and Kim YokoCLAIM AGAINST THE CITY OF DUBUQUE, IOWA
cc; /A
RECE ED
11 AUG 30 PM 3: 02
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. City Cerkry ()thee
The claim must be filed with the City Clerk at City Hall, 50 West 13th St., Dubuque, IA 52001. It will theaito
the appropriate department for investigation and to the City Attorney's Office. 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: Greg and Kim Yoko
2. Address: 3660 Seville Dr., Dubuque, IA 52002
3. Telephone Number: 563 - 582 -3193
4. Date of Incident: July 28, 2011
5. Time of Incident: 7:45 p.m.
6. Location of Incident (Be specific): Sourthern Avenue, directly across
from 571 Southern Avenue.
7. Describe the 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.)
Kim was driving her bike down Southern when she approached an
unexpected area where the road had washed away. It caused her
to crash the bike and she was severely injured.
8. What were weather conditions like? Sunny
9. Give name and address of any witnesses: unknown at this time
10. Did police investigate? (If so, give names of officers.)
Yes
11. Was anyone injured? (If so, give names, addresses, and extent of injuries.)
Kim Yoko. See above for address. Two black eyes, concussion,
broken nose, 16 stitches on head and chin. 16 stitches in right hand.
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.)
Bike was damaged. Clothes were damaged.
13. What other damages do you claim, if any? possible future wage loss i f
unable to return to work
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? Unknown at this time
16. Why do you claim the City of Dubuque is responsible? Failure to warn of the
washed out area. Failure to repair in a timely manner_
Failure to close street which was dangerous
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?
N/A
Dated his X911 day of August 20 11.
/ t "
ibaAliAri
I
(Signature)
G/. -e-re, G, 70k,
(Print Name)
PROOF OF SERVICE
The undersigned certifies that the foregoing instrument was served
upon all parties to the above cause or to each of the attorneys of
record herein at their espectiv¢ addresses disclosed on the
pleadings on Wai 30 20 tI
By: U.S. Mail uu FAX
XHand Delivered Private Carrier
Signature