Claim Kearney, Mary V.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: Mary V. Kearney
2. Address: 3329 Brook Meadow Ct.
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3. Telephone Number: 563 557 7991
4. Date of Incident: 12/27/05
5. Time of Incident: 12:55 P.M.
6. Location of Incident (Be specific): Iowa Street Parking Ramp - walking down incline's sidewalk by Iowa Street entrance - hit ice and hit pole railing.
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.)
Was walking from car down the sidewalk incline, hit ice, left leg extended
forward, back flung backwards, jolted forward and hit the pole railing. Could not move right away due to the sudden
movement of slipping. Had pain in lower back and left knee.
8. What were weather conditions like? Wet & Icy
9. Give name and address of any witnesses: Cathy Haislet, 4986 North Range Ct., Dubuque, IA 52002; Stormy Kieler, 28283 400th St. Bellevue, IA 52031
10. Did police investigate? (If so, give names of officers.)
Officer Lindecker- called Dispatch 589 4415
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Mary Kearney - extended left knee and cracked back then flew forward into a pole railing. Back hurt and knee pain, thought it would go away, but it has not.
Major tingling in back of knee and down leg which I have not ever had problems with before this time. Hoped pain would go away, but has not subsided.
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.)
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?
Medical Care Compensation
16. Why do you claim the City of Dubuque is responsible?
Because two people had incidents in the Iowa Street ramp in the same location that day, and I have never had knee or back pain before.
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 5th day of January, 2006.
/s/ Mary V. Kearney
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Jan, 5, 2006 10:49AM CITY OF D3Q LEGAL DEP-
No,6223 p, 3/4
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.131h 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 recomme,ndation.
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. NameofClalmant:~~' ~~
2. Address: 33 d-- q ,J?jrClO K- vY\..e c.....Aou.. ) 0.
3. Telephone Number: ':SlC] 3~ 557 - 7 C; '7 (
4. Date of Incident: / .;) / OJ 7 :I 0 5
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7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If a City empJoyee was involved,: give the
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9. Give name and address ofanywitnesses: c..rl~ ~Ie.-t- 'f1l(lo '(\o(~ ~e U .
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10. id 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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Jan, 5, 2006 10:49AM
CITY OF DBQ ~EGA~ DEFT
10,6223 p, 4/4
12. Was any damage ~one to property? (If so; describe property and the extent of damages.
Attach estimates of damages or describe basis for ascertaining extent of damage.)
13. What other damages do you claim, if any?
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14. Have you been compensated for any part or an of your claim by any insurance
company? (If so, give name and address of Insurance company and amount paid.)
VLo
15. What amount do you claim from the City of Dubuque? Jv\.o oLt eJ C~
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16, Why do you claim the City of Dubuque Is responslble?.]i'k ,~, -J....>T\ ' ~
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,17. Have you made anyclalrn agamst anyone else for damages as a result of this in'cident?
, <If yes, give name and address.) , ,
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18. If the answer to. Question 17 is yes, have you received any payment from that source,
and if so, in'what amolint?
Dated at Dubuque; Iowa this
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(Rev. 1/00 & 7/01)