Claim by Lisa HuinkerClaim Form Page 1 of 3
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Home Page :Departments :City Clerk :Claims. against the City: Claim FOrm
City Clerk ~~
First floor of Ciry Hall, 50 W. 13th Street ~~`~ ~ M
Phone: (563) 589-4120 (~, / . '
Fax: (563) 589-0890 () ` /~
Hours: 8 a.m. to 5 p.m. Monday through Friday Jr' /~(I"l ~
Email: jschneid@cityofdubuque.org Ili l n
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the Ciry of Dubuque, Iowa. You should comple
full and attach any additional information that supports your claim.
The claim must be filed with the City Clerk at Ciry Hall, 50 West 13th St., Dubuque, IA 52001. It •
referred to the appropriate department for investigation and to the City Attorney's Office. Once 1
is completed, a report and recommendation will be submitted to the Ciry Council. You will be prc
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
authority to make any representation to you as to whether your claim will or will not be paid.
Name of Claimant:
2. Address: d`7~ ~ 'h Yl ~ ~ ~ t , ~ ~ • ~ ``0 1~yh
3. Telephone Number:1 - ~~ a- ~ 5g3
4. Date of Incident: 1~ - ~ ~ - y
5. Time of Incident: ~ ~ ~ ~ ~ • ~
6. Location of Incident (Be specific):
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7. Describe the accident or occurrence that caused injury or damage. (Give full details upon whi
your claim. If a City employee was involved, give the employee's name.)
8. What were weather conditions like? ~ ~'`J~" \ ,!
9. Give name and address of any witnesses: 1'~ •~(~~ 1 ~J'~-Gf. Lr
Spa- g3or ~y(~o-Knob +h~i ~.
10. Did police investigate? (If so, give names of officers.)
http://www.cityofdubuque.org/index.cfm?pageid=155 6/27/2007
Claim Form
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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. Att
damages or describe basis for ascertaining extent of damage.)
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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? (li
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?~~ f~r1.
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17. Have you made any claim against anyone else for damages as a result of this incident? (If y
and address.)
18. If the answer to Question 17 is yes, have you received any payment from that source, and if
amount?
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Home Page :Departments : CitYClerk :Claims against the City : C~alrft Form
http://www.cityofdubuque.org/index.cfm?pageid=155 6/27/2007