Claim by Helen ShermanBARRY A. LINDAHL, ESQ. ~~
CITY ATTORNEY
MEMO
To:
DATE:
RE:
Claimant
Mayor Roy D. Buol and
Members of the City Council
June 27, 2007
Claim against the City of Dubuque by Helen Sherman
Date of Claim
Helen Sherman
06/26/07
Date of Loss
05/28/07
Nature of Claim
Personal Injury
This is a claim in which the claimant alleges that she injured her knees and right arm,
elbow and shoulder after tripping on an uneven portion of sidewalk located on Locust
Street near 7th Street.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
BAL:tIs
cc: Michael C. Van Milligen, City Manager
Jeanne Schneider, City Clerk
Gus Psihoyos, City Engineer
Helen Sherman
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944
TELEPHONE (563) 583-4113 / FAx (563) 583-1040 / EMAIL balesq@cityofdubuque.org
__ _
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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.
.. ~ ~__ ,,...,,, ,.,.,;,.,.,~ ;~ ,,3,i~_~~ ±ha r;±,, rrltncil. No emolovee of the
.~_ _._.
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City of Dubuque has the authority to make any representation to you as to
whether your claim will or will not be paid. ^
C1~lame of Claimant:
Address: s ~O
Telephone Number,
Date of Incident: ~'~
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5 Time of Incident:
/~~7n
6'.~..oc~tion of Incident (Be specific).:
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 erraployee's name.) _ ~ ~ _ ,, ,~ .~ _~ _
~ive name and address of any witnesses:
.. ~ ,~ .
- ~
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10. Did police investigate? (If so, give names of officers.)
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C,8,1What were weather condi~t,io s uKe-!
11 Was anyone inj~re~d? (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 corrrpens~ted 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 Wha~ amount do you claim from the City of Dubuque?
,,.
~vWhy do you claim the City of Dubuque is responsible?
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 S~-~.~~ ~ , 2~~~ ~,~ ,a~~~~~~
(Signature)
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(Print Name) Q~~\{~~~~
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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.)