Claim Day, Kelly LeeCLAIM 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: Kelly Lee Day
2. Address: 2631 1/2 Washington Street
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3. Telephone Number: 588 1194
4. Date of Incident: 6/06 - 7/06
5. Time of Incident: 6:20-6:30 P.M.
6. Location of Incident (Be specific): 400 Block of E. 15th Street
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.)
I was stepping down off of the sidewalk - curb and there was a defect in the curb and I fell down on my knee (right).
8. What were weather conditions like? Dry
9. Give name and address of any witnesses: None
10. Did police investigate? (If so, give names of officers.)
Officer Schlosser
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Myself (I have to Dr. Perotti on June 21st 06 at 10:45 A.M. - I also
went to the Finley Emergency and Dr. Haas.
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.)
None (Myself)
13. What other damages do you claim, if any?
None other than right knee.
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.)
Yes, I have health insurance through John Deere. They might pay my medical bills.
15. What amount do you claim from the City of Dubuque?
Reimbursed for medical bills and pain and suffering.
16. Why do you claim the City of Dubuque is responsible?
It is there property.
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 20th day of June, 2006.
/s/ Kelly Lee Day .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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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 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 West 13th St.,
Dubuque, IA 52001. It will then be referred to 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: ~ / IV jl?~ rL );,y
2. Address: {l 0/3/ k~ l{l}c;/lINIIDl 61,
3. Telephone Number \ 5&.?: //(;4-
4. Date of Incident: ~~)(~" 0'1/ u(?
5. Time of Incident: (J;'-~~ ./,3<\f'm
6. LocatJon of Incident (Be specific):
LICO L'Vcck Gf-~ ,f"" /Sill ,<::;hfi?f
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.)
" ' '(!Lif h
8. ~!tt were weather conditions like?
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9. Give name and address of any witnesses:
/1!()/"7e'j
10~ QW police i~~~, a~e? (If so, give names of officers.)
Oftrcc'.r c...A..' l.DY-.T
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.)
AI?Jne- - (;'JJySfc"IP)
13. What ot.her damages d~U c1aim~? k
I'J6fJe offer .0'1 -n 'fee
14. Have you been compensated for any part or all of your claim by any
insurance company? (If so, ive name and address of insurance company and
amount paid.) {.,
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c
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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.)
1l/0
.
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
Dated this ,pO day of \...}U..i12.J
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(Signature)
. iii I ~ Ace /J('lY
(Print am
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