Claim Jaeger, Jane M.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:
2. Address:
`
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
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 a City employee was involved, give the employee’s name.)
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
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 , 20 .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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: Jane M. Jaeger
2. Address: 2788 Oak Crest Dr.
`
3. Telephone Number: 556 4721
4. Date of Incident: June 30, 2006
5. Time of Incident: 4:00 - 5:00 P.M. At 3:00 P.M. Michelle Jaeger called City to report street cave-in around manhole.
City did not repond until approx. 6:00 P.M.
6. Location of Incident (Be specific):
Intersection of Berkely & Oak Crest Dr.
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.)
Water/sewer line broke causing water/sewer/mud back up in my basement.
3/4 basement covered in mud. John Klostermann and Vince Connor took pictures of my
basement and evaluated situation and damage.
8. What were weather conditions like? Sunny, hot, humid 87 degrees, dry.
9. Give name and address of any witnesses:
Barb Skahill, 2794 Oak Crest Dr.
Cindy Henkel, 2766 Oak Crest - check all neighbors with same problem
10. Did police investigate? (If so, give names of officers.)
Do not know
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No one physically injuried. I suffered much mental and emotional stress.
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.)
I have an unfinished basement with concrete and tile floor. It was covered in mud/water/sewage.
No danger to floor, just had Kanndo come in and professionally clean up -
vacuumed, dried, sprayed disinfectant and steam cleaned concrete and cleaned carpet
steps. Approximate cost $800.
13. What other damages do you claim, if any?
$250 all ornaments for Christmas had to be thrown out.
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?
$1,050
16. Why do you claim the City of Dubuque is responsible?
There water/sewer line broke. Water boxes were paved over possibly
causing delay in turning water off, causing the damage.
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 11 day of July, 2006.
/s/ Jane M. Jaeger
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF DUBUQUE, IOw~;rt
This written repart canstitutes yaur claim against the City af Dubuque, lawa. Yau
shauld camplete this farm in full and attach any additianal infarmatian that
supparts yaur 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 apprapriate department for
investigatian and to. the City Attarney's Office. Once that investigatian is
campleted, a repart and recammendatian will be submitted to. the City Cauncil.
Yau will be pravided with a capy af that repart and recammendatian.
The final decisian an all claims is made by the City Cauncil. No. emplayee af the
City af Dubuque has the autharity to. make any representatian to. yau as to.
whether yaur claim will ar will nat be paid.
1. Name af Claimant: - JI/le f'll, '. Jq t' q e I'
2. Address: if, r6''6 (J<Ak C'{ t).t L\:-)
3. Telephane Number ::/ 'i r.:,-ij 7)/
4. Date af Incident: .)(AVl e... )0 3(:(:'
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5.Timea~.in~ident: . 1-/\0 /j ,(!':.: ,) Ii ;J\3'(}C1,;',,-i,e//c.:;"il"i'
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7. Describe the accident ar accurrence that caused injury ar damage. (Give full
details upan which yau base yaur claim. If a City emplayee was invalved, give
th~li.-mplayee's n~ll.1e')I!
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8.}What wer~ weayer ~orditia~~ ~ke?l
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9. iv~ name and address af any witnesges:
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10. Did pal ice investig~te? (If sa, give names af afficers.)
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11. Was anYQne injured? (If so, give na
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12. Was any damage done to property? (If so, describe property and the extent
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13. hat. oth.er da.mages do you claim, if anp_ \',/1 ..... . II 1 ..:1-
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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.) J /
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15. What amount do you claim from the City of Dubuque?
T /:030
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17. Have you made any claim against anyone else for damages as a result of
this iAldent? (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 amount? (
Dated this / ~ day of 91
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(S' ature) jJ
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(Print Name) .
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