Claim Vosberg Padget, TriciaCLAIM 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: Tricia Vosberg-Padget
2. Address: 645 Sinsinawa Avenue East Dubuque IL 61025
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3. Telephone Number: (815) 747 6395
4. Date of Incident: 10/16/06
5. Time of Incident: Approx. 4:15 P.M.
6. Location of Incident (Be specific): On the street on Rush Street in Dubuque, Iowa
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.)
There was a hole on the street that I fell in and broke my right ankle.
8. What were weather conditions like?
fine
9. Give name and address of any witnesses:
All of my children were in the van when it happened. Leah Padget, Kyra Padget, Madeline Vosber, Clare Vosberg-Padget (same address as me)
10. Did police investigate? (If so, give names of officers.)
No - informtion was given at the E.R. to nurse, but no police investigated.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, Tricia Visberg-Padget, 645 Sinsinawa Avenue, East Dubuque, IL 61025 Broken right ankle.
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.)
NA
13. What other damages do you claim, if any?
Loss of wages, medical bills, increased day care bills, fracture boot, orthopedic equip.
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.)
Not currently, the claims are being held while waiting for contact from City of Dubuque.
15. What amount do you claim from the City of Dubuque?
Undetermined at this time until all chargegs have been ocurred.
16. Why do you claim the City of Dubuque is responsible?
The hole in the street was the reason for my fall and the breaking of my ankle.
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?
NA
Dated at Dubuque, Iowa this 9 day of November, 2006 , 20 .
/s/ Tricia Vosberg-Padget
(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 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: ki u 0... VOl., b U'8' PI) c~~f-
2. Address: &'-1:5 SinsinGU..va... Me.-VltAL ws r'D~thu~W. LL (;/025"
3. Telephone Number (~/6) 11'1 -{p3CfS
4. Date of Incident: loll tD loCo
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5. Time of Incident: -,. f" pm.
6. Location of Incident (Be specific):
O(l t+u.. 5~t () VI. r<(ld In Struf In Dubuqcu ,Inl-<-c,,",
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.)
,fun l1)aS fl. hoCt.. on J--f\h Sired 'f-haJ 1: Pnl/ in and
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8. What were weather conditions like?
fine..
9. Give name and address of any witnesses:
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Leal.., Pad81_/, Jlrd Pat"Jg,l, madn/l1~ tJosJu I (liar'! VOSkh -!bdld
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10. Did police investigate? (If so, give names of officers.)
A)() -- 'VlIni-'I.n/t.hCllry wo.) Of iiIA' I Of- Hv. 'f /2. 10 /1.?!vj..<...
hill ")(I eotifJ., il1i1.f)-h'8/1~rJ
11. Wasa~y?ne inj~red? (If so, give names,~ddresses, and extent of injuries).
Yes. 1F, CUi.. liDS be~~-:d~ (Pl/~ ,~~h(;nl2oJt1_ Ai/1'.1?U.1~ {as", DUhtCr"-" /
X L lit(; zS. p'w;' ( J () <<: .
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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. What other damages do you claim, if any?
~^i~~~ ~~~'~&r~~~::~.f ~i::7;/Mrl4r@dn'{ CClA# h;lls J'
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.)
t~)~./,~i::;;:'~~''(?,; ~~A~~h~9~u~~/rJ htid u-lf1I/~' IL70/hns
15. What amount do you claim from the City of Dubuque?
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(')(1 {, if' Yl-cJ. '
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.)
A.()
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
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200&
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Dated this 9 day of 1..)0 v-<,r-tJo.i.Y
~~-Pl1ct8el--
Ignat" e)
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(Print Name)
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