Claim Jungblut, StacyCLAIM 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: Stacy Jungblut
2. Address: 710 S. Grandview, Dubuque, IA 52003
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3. Telephone Number: 556 5091
4. Date of Incident: Thursday, April 20, 2006
5. Time of Incident: Approximately 5:30 P.M.
6. Location of Incident (Be specific): 1440/1460 S. Grandview
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.)
We were walking along S. Grandview, Emma was in her stroller, when we struck an uneven patch of sidewalk. The stroller came to an abrupt stop flipping forward causing Emma to hit sidewalk
with her (R) hand and side of her face.
8. What were weather conditions like? Sunny & Warm
9. Give name and address of any witnesses: Linda Erickson, 1520 Kehl Ct., Apt. 10, Dubuque, IA 52003
10. Did police investigate? (If so, give names of officers.)
Mp
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, Emma Jungblut, 710 S. Grandview, Dubuque, IA 52003. Emma Sustained a Buckle fracture of her right wrist and a hailine fracture at the base of her secondfinger. Scratched right cheek.
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?
None
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, Emma's Doctor visits and xrays will be billed to our insurnace but we have not had any of these bills compensated as of today (4-26-06)
15. What amount do you claim from the City of Dubuque?
Ongoing; Doctor Visits, x-rays, radiologist fees, orthopedist fees, cast
16. Why do you claim the City of Dubuque is responsible? We were walking on City property, the sidewalk. I spoke with Kelly in Engineering and she recommended that we file a claim.
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 26 day of April, 2006.
/s/ Stacy Jungblut
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF DUBUQUE, IowA ~ / <., U .~
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.
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14. Have you been compensated for any part or all of your claim by any insurance
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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? '\leu wct ~<.u \JVtL~6-
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17. Have you made any claim against anyone else for damages as a result of this incident?
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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 amount?
Dated at Dubuque, Iowa this ~ day of ~ \'h\ \; , 20JlVl
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(Rev. 1/00 & 7/01)