Claim by Cheryl HayesTHE CITY OF
DUB E MEMORANDUM
Masterpiece on the Mississippi
l~
BARRY LINDAHL -~
CITY ATTORNEY
To: Mayor Roy D. Buol and
Members of the City Council
DATE:
RE:
Claimant
September 26, 2007
Claim Against the City of Dubuque by Cheryl J. Hayes
Date of Claim
Cheryl J. Hayes
09/19/07
Date of Loss
09/13/07
Nature of Claim
Personal Injury
This is a claim in which the claimant alleges that as she was walking near the corner of
Stn & Bluff Streets, she stepped into a hole of a drain cover, causing her to fall and injure
herself.
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
John Klostermann, Street & Sewer Maintenance Supervisor
Cheryl J. Hayes
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 3OO 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 (~ y
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This written report constitutes your claim against the City of Dubuque, Iowa. You ~~~~,ti (.c/
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: 1.~ ~I' ~ 1 ~
2. Address: ~ ~ ~- E~rQ ~ ~~~~
3. Telephone Number~~~~ ~ ~ ~~ t~
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4. Date of Incident: ~. ~ ~ ~ ~~ 1
5. Time of Incident: a ~~ f,,~ 1. ~~~ s ~ ~'
6. Location of Incident (Be specific): ^ ~ `^ ~
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.) t~~ ~ ~~ ~ /~ 6 i~
2
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8. Wh~a~ were weather conditions '~e?
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9. Give name and address of any witnesses ~~ >/P
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10. Did police investigate? (If so, give names of officers.,
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11. W`as anyone inju/r?e/d? (If so, ~/ive names, addressesy andl`extent ofries).
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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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3. What othe
you claim, if an
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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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?
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D ted this / day of ~ l~, ~ 20 07 ~ ~~ ~ ~
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