Claim Prochaska, John B.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 CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: John B. Prochaska
2. Address: 430 Sidney St., East Dubuque, IL 61025
3. Telephone Number: 815 747 3463
4. Date of Incident: March 8, 2002
5. Time of Incident: 12:29 P.M.
6. Location of Incident (Be specific): Diamond Jo Left side of building near awning by valet parking Entrance. Handicap curb was blocked due to construction and van parked improperly
obstructed view.
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.)
John attempted to enter by stepping up curb because construction block cut in curb for handicap access. Pavement was damp, van blocked access to curb cut located to left of main handicap entrance.
8. What were weather conditions like?
Windy and pavement damp from something
9. Give name and address of any witnesses:
Frank Domitrovich (security supervisor) and Ed Kelly - John Vondel came to John's assistance. Susan Prochaksa saw John go done out
of her rearview mirror,
10. Did police investigate? (If so, give names of officers.)
Officer Rettenmaier stopped at hospital and called later.
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
John Prochaska broke a vertebrae in his back, chipped his sternam. He was hospitalized for a week at Mercy.
Theraphy continues at home and he wears a brace on chest. Address 430 Sidney East Dubuque, IL 61025
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.)
No
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.)
No
15. What amount do you claim from the City of Dubuque?
John is looking for medical billls paid. He does have some medicare.
16. Why do you claim the City of Dubuque is responsible?
The handicap entrance was blocked by construction and a van improperly parked. There was moisture on ground and poor visibility of other entrance.
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 at Dubuque, Iowa this 26 day of March 2002. .
/s/ Theresa Phillip's - sister
John B. Prochaska
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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: ~/7_ /~, Pr~ ~/~-~
e e. one.u er:
5. Time of Incident: /~ J ~ ~ ~ ~
6. Location of Incident (Be specific): ~ ~
~1~'~ ~.) / /
8. Wh~t w~re weather conditions
9. Give na~ and address of any witnesses:
10. ~i~ police i~vestigate. (If ~o, 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?
(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?
Dated at Dubuque, Iowa this ~ day of
(Rev. 1/00 & 7/01)
(Signatur~
(Print Name)
, 20Oo~