Claim, Reinholt, JoanCLAIM 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: Joan Reinholt
2. Address: 261 Valeria St.
3. Telephone Number: 563 588 1899
4. Date of Incident: August 18, 2001
5. Time of Incident: 8:30 P.M.
6. Location of Incident (Be specific): By Town Clock in middle where trees are planted.
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.)
Was walking back to car, was a lot of people and fell to ground by Town Clock fell on creib (?) where tree was planted.
8. What were weather conditions like? Hot
9. Give name and address of any witnesses: Do have several witnesses
10. Did police investigate? (If so, give names of officers.) No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Joan Reinholt, 261 Valeria St. - still in pain
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?
No
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.)
No
15. What amount do you claim from the City of Dubuque?
Not sure yet, still in pain.
16. Why do you claim the City of Dubuque is responsible?
they should have some marking to tell people that a curb is there. Can't see when place is packed.
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?
No
Dated at Dubuque, Iowa this 3rd day of March , 2002.
/s/ Joan M. Reinholt
(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 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 CLAI~_.WILLOR WILL NOT BE PAID.
2. Address:~/ ~~
3. Telephone Number:
4. Date of Incident: ~~ /~ ~/
5. Time of lncident: ~'~ ~ -
6. Location of Incident (Be specific): .~ ~2~
full dotail~ upon which ~ou be~o your olalm. If a Ci~ omplo~o~ ~ invol~od, ~N~ th~
e~pl~ee'~ n~e.)~
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did..~e investigate? (If so, give names of officers.)
11. Was anyone injured? .(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 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.)
15. What amount do you claim from the City of Dubuque~./~_? _~?//~.~_~/~_~-'-~
16. Why do you claim the City of Dubuque is responsible?~.~Z~// _///~ _ .~_~,?_~-~/_~J~/
· -/_-- - /.
(If yes, give name and address~
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?./?C~
Dated at Dubuque, Iowa this
day of ~,~'~.~
(S~.q~at ~ure~)~
(Priht Name)
(Rev. 1/00 & 7/01)