Claim Francois, JoannCLAIM 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: Joann Francois
2. Address: 201 West 17th Apt. C12, Dubuque IA 52001-4586
3. Telephone Number: 563-583-9179
4. Date of Incident: 9/27/06
5. Time of Incident: 1:05 pm
6. Location of Incident (Be specific): Plaza 20 parking lot in front of Kmart store.
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.)
Gene Pfab was operator of bus when he hit a pole next to fire hydrant causing injury to my right knee, I was passenger on that bus.
8. What were weather conditions like? sunny and clear
9. Give name and address of any witnesses: Bus driver Gene Pfab
10. Did police investigate? (If so, give names of officers.) Yes
11. Was anyone injured? (If so, give names, addresses, and extent of injuries). Self, see above
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.)
N/A
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.)
Medical Associates wrote off $80 medical bill.
15. What amount do you claim from the City of Dubuque?
$80 reimbursement to Medical Associates
16. Why do you claim the City of Dubuque is responsible?
I was passenger on bus.
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 this 22nd day of December 2006. .
(Signature)
(Print Name)
DEC~QI-2006 FR[ 12:06 PM DBQ, CITY CLERK
FAX NO, 563 589 0890
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12. Was any damage done to property? (If sa, 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 ~ther damag~s do you claim, if any?
14. Have you besn 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 fr,om the City of Dubuque?
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,16. Wrt~.<:ou claim the City of Dl,lbuque is responsible? ~ ,~ (f-<J<J..~JAJ
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17. Have you made any claim against anyone else for damages as a' result of this Incident? .
, (lfyes; glve'name and address.) .
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18. 11 the answer to Question 17 Is. yes;' have you reCelved.any payment from that source,
and If SQ, in what amount? .... ...,". .' "
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. Dated at Dubuque, Iowa this .;2.::2-......t. day of . n ~ . 20 0 ~ .
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(Rev. 1100 & 7101)
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MrnlCAL AS~OCIAT~~
P.O. Box 5002
1605 Associates Drive. Suite IOl
Dubuque,IA 52002
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Questions?
Please contact Customer Service at
(563) 584-4885 or (866) 821-1365
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Forwarding Service Reqnested
ALL FOR AADC 522
Patient's Name: JOANN FRANCOIS
58307 0.5176 AS 0.317
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JOANN FRANCOIS 201
201 w 17TH ST APT C12
DUBUQUE~ IA 52001-4586
Identification #:
Claim Number:
Dates of Service
Group Name:
RII05454201
06288004777B
09/27/06 - 09/27/06
IA MEDICARE PLUS
Provider Name: ROBERT RUSSO
Date Paid: 10/23/06
EXPLANATION OF BENEFITS
~ifierDays/ Billed""::"" Allowed Disaii~~; '-Deni~d~r=OP."Y ',D~(fuct -pc oinSlO'the,rI"1 A,m,OU ofT, 'E;:P~'
ICoun Amount Amount Amount Amount Amount Amount. AmounM Payment Paid ..~ Cod.f....
Ii 1 80.00 .00 .00 80.00,,00 .__00,___'-'-0.0 n.._,QO ..____,~Q.. 20
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*Patient's Responsibility reflects only applicable Deductible, Copay, Coinsurance, and Denied Amounts on this claim.
**You may also be responsible for any denied amounts and/or amounts over usual and customary.
Line .Service Description ... __._..___
I OFFICE VISITS
Expl~ CQ.de_ Descri~tit:lIl
20 THIS INJURY IS COVERED BY YOUR LIABILITY CARRlER
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CITY OF DUBUQUE BUS WAS EAs'TllOUND IN THE K:MARr LOT IN FRONT OF THE STORE WHEN IT STRUCI( A CEMENT
POlE PROTECTING A FIRE HYDAANT. PRIVATE UOT. NO CHARGES FILED . PASSENGER LISTED COMPlAINED OF
SOR" KNEES ANO ANI(L!i;S. WITNESS ZACH FINCEL WAS AlSo ON THE BUS.
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