Claim Hoffman, Diane
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes' your claim against the City of Dubuque, lows. You should
complete this form in full and sttach any additional Information that supports your claim.
The Claim must be flied 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 Councfl. You wilt 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.
Diane Hoffman
1. Name of Claimant:
144 State Street Dubuque Iowa, 52003
4. Date of Incident:
5. Time of Incident:
3:00 AM
400 E 3rd Street Ice Harbor Dubuque Iowa
6. Location of Incident (Be specific):
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If 8 City employee was Involved, give the
employee's name.) F II' "ddl f t t .
e In ml e 0 s ree very Ice snow slush covered road.
8. What were weather conditions like?
Winter weather
Edward Kelley pictures were taken
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 nameJ, addresses, and extent of inJuries).
Diane Hoffman
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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.)
Paying Workers compensation benefits.
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.)
Zurich is pursuing subrogation. Diane Hoffman is not pursuing a claim.
15. What amount do you claim from the City of Dubuque?
Pending
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16. Why do you claim the City of Dubuque is responsible?
We submit final claim when we claim is closed.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) n/a . :
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, In ~hat amount?
Dated at Dubuque, Iowa this
11th
day of
April
, 20~.
.DcA a. 17'J1.JJ.h
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(Signature)
Scott D. Mullin
(Print Name)
(Rev. 1/00 & 7/01)