Claim by Mary OldhamSterpkcc. on the Mis isS7.pp77
TRACEY STECKLEIN
PARALEGAL
ME AN UM
To: Mayor Roy D. Buol and
Members of the City Council
DATE: January 25, 2013
RE: Claim Against the City of Dubuque by Mary Oldham
Claimant Date of Claim Date of Loss
Mary Oldham 01/22/13 01/14/13 Personal Injury
Nature of Claim
This is a claim in which claimant alleges that she was injured after tripping over a raised
portion of sidewalk near the corner of 7th & Iowa Streets.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager
Gus Psihoyos, City Engineer
Mary Oldham
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001 -6944
TELEPHONE (563) 583 -4113 / FAx (563) 583 -1040 / EMAIL tsteckle @cityofdubuque.org
22 San 2013 10:01PM TERRY 3. SCHMITT, DDS, PC 553- 588 -8570 p.1
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the City of Dubuque, Iowa. You should
complte this form In full and attach any additional information that supports your claim.
the Claim must be filed with the Ci Its 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.
ItHE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF
ltHE 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: x 2i F Oki7A_
e (�'/
Address: ??7 r� ei[%
3. Telephone Number:
1.. Date of Incident:
5. Tire of Incident:
J w /t/ 20 /3
Location of Incident (Be specify):
d' ZO' 7C6/1
7i. DESCRIBE ACCIDENT OR OCCURRENCE
II details upon which you base your claim.
mployee's name.)
MO eV') efn
-/; / 'd kmy (7a_r -it9
L. What were weather conditions lake? Bleak - 5.4 m y
�. Gi�re name and address f any Witnesses: 5,&i- ,, Ale/1'3,7 , /&I //e2&17/2
THAT CAUSED INJURY OR DAMAGE. (Give
If a City employee was involved, give the
Gras leak/4
,636-71-• A 4Ja..rn rs
O. Did police investigate? (If so, give names of officers.) •
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1. Was anyone injured? (If so, gve names, addresses, and extent of injuries).
— / 7 ea/5 Were: ...�. Gi � "! f/7 le
h it' -5/7a /14p/ rn
22 Jan 2013 10:01AM TERRY J. SCHMITT, DDS, PC 553-588-8670 p2
1 . Was any damage done to poperty? (If so, describe property and the extent of
12
amages. Attach estimates of damages or describe basis for ascertaining extent of
amage.)
• &I 0 1:
iiikhat other damages do you ciSim, if any? ine6Z/Cez, e5..//5
114. Have you been compensated for any part or all of your claim by any insurance
dompapy? (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?
470667 -/--n 7
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.)
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8. If the answer to Question 17 1$ yes, have you received any payment from that source,
,
and if So, in what amount?
i -----
,
Dated lat Dubuque, Iowa this day of 37-1111't r-V , 20 .
((ey. 7/12)
In!
It
(Signature)
(Print Name)
22 Jan 2013 10:01AM TERRY J. SCHMITT, DDS, PC 583- 588 -8670
Confidential
"Oils communication and any attachments may contain information which is confidential
and privileged by law and is for the use of the designated recipient. if you are not the
i tendd recipient, you are hereby,; notified that you have received this communication in
rror, and that any review, disclosure, dissemination, distribution or copying of its contents
is prohibited. Please notify City ofDubuque immediately by telephone at (563)-589-4120 of
your receipt of these items and destroy the communication and any attachments
immediately. Further disclosure° of this information may violate state and federal
restrictions.
P.3
confidential information may include tie following:
1) ocial Security Nuber(s)
2) M m
edical /Health Information
3) ;personnel /Disciplinary Information
4) rank Account Information
5) ;Financial Information
6) Credit Card Numbers
I any documentation you desire to submit to the City of Dubuque contains any of the items above
this cover sheet must be attached directly to the confidential information and indicate the type of
information that is included.
I / 7 4 2 leLhetrn
includ the fdllowing protected information:
_Social Security Number(0)
Medical /Health lnformation
, hereby certify that the attached documents
Bank Account Information
Financial Information
Personnel/Disciplinary Information Credit Card Number(s)
I underistand that this information maybe distributed within the City organization or to agents of the
City fo,r processing and I hereby authorize the City to act accordingly taking all precautions to
protect my information from unnecessary distribution.
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Date