Claim Ehlinger, LouiseCLAIM 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: Louise Ehlinger
2. Address: 865 Council Hill Drive
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3. Telephone Number: 563 583 4045
4. Date of Incident: September 15, 2005
5. Time of Incident: 12:30 P.M.
6. Location of Incident (Be specific): the Corner of 8th Street and Locust, located directlynext to the Knights of Columbus
Parking Lot.
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 park in the KC lot and work at McKesson. On this day the sidewalk from the
post at the beginning of the parking lot over to the stop light had the sidewalk torn up to replace. There was a yellow caution tape around this
area. In order to get around the construction I cut between the fire hydrant and 8th Street.
In doing this I hit my right knee full force onthe part of the fire hydrant where the base is
connected. For a few minutes I was seeing stars because of the pain. After work
I went to the police station to file my complaint.
8. What were weather conditions like? Fine
9. Give name and address of any witnesses: None
10. Did police investigate? (If so, give names of officers.)
Yes, Officer Lrenzen & Officerf Latham, Case # 05-42133
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, myself
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?
Not sure at this point I am still under doctor's care.
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?
No sure at this point I am still under doctor's care.
16. Why do you claim the City of Dubuque is responsible?
Because of a turn up sidewalk, I was required to take an unsafe detour to be able to stop within the cross walk to cross teh street.
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 7 day of August, 2006.
/s/ Louise Ehlinger
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
.
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA (/ J
.
This written report eonstitutesyour 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.
i. Name of Claimant: de o...J.l.AU & ~ / .
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3. Telephone Number: ~5'~3- Sg3 -- 10 fS'"
4. Date of Incident: ~.1.QAJ IS} d.Dn:)
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6. Location of Incident(Be specific): 'm 0!M\Rh 1 ~ 'lit ../lfurt Cl ~~+--
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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 employee was involved, give the
e\r'ployee's name.) .L '(',.( IJ
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8. What were weather conditions like? '~.11l'\1 ~
9. Give name and address of any witnesses: ~L
10. Did poliGe invest' ate? (If so, giv names of 0 icers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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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.)
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13. Wh~t other damages do you claim, if any? '-(0.. A t ~ a::.h lj. W ~ i ...j)
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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.)
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15. What amount do you claim from the City of Dubuque? M.f)4..lJ.AJ/.-.o..1- ;t:Ul'lj) ~
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16. Why do you claim the City of Dubuque is responsible?~k~N n-l:ll\. 4 (L fill J./\ 11.{l-
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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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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 7
dayof ~
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(fi ~J\ ~U ~ ~ril )
(Signature)
t-iJU,'Se.. EhLir\~Q..R.
(Print Name)
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(Rev. 1/00 & 7/01)
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