Claim by James Schreiner - State Farm Copyrighted
June 19, 2017
City of Dubuque Consent Items # 2.
ITEM TITLE: Notice of Claims and Suits
SUMMARY: Anderson Windows for property damage, Herbert Cook for
vehicle damage, Ron Ludwig for vehicle damage, Judie
Root for property damage, James Schreiner for personal
injury/vehicle damage, Skyler Lee Tracy for vehicle
damage.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City
Attorney
ATTACHMENTS:
Description Type
Anderson Windows Claim Supporting Documentation
Cook Claim Supporting Documentation
Ludwig Claim Supporting Documentation
Root Claim Supporting Documentation
Schreiner Claim Supporting Documentation
Tracy Claim Supporting Documentation
r�v
R
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 13"'St., Dubuque, IA 52001. It will then be referred to
the appropriate department for investigation and to the City Attorneys 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 ou as to ether your claim. 'II or will not be paid.
1. Name of Clai ant: l� T 4 r �
y � � � r
2. Address: }
3.Telephone Number: 7 7 �
4. Date of Incident: �0 �7�
5.Time of Incident: ZL .i
6. Location of Incident(Be specific): I�1I�V °�1 k— I�YJ NIJ�
;�
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.)
>(( aV&avp amru r A,�V
�
i
f.
&What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate?(If so, give names of officers.)
11.Was anyone injured? (If so, give names,addresses,and extent of inj ies.)
/J
12.Was any damage done to property?(If so,describe property and the extent of damages. Attach estimates of
damages or des1riPe basis for ascertaining exjp,nt of damage.)
4
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 in rance corrRny 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? anM)m I f1I11 va V
T F-
17_ Have you made any claim against anyone else for damages as a result of this incident?(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 this day of / "t 20
L
(Print Name)
c� 1
CD
Jun/1/2017 3'35'36 PM
State Farm 692-3029 212
Confidential
This communication and any attachments may contain information which is confidential
and privileged by law and Is for the use of the designated recipient. If you are not the
ereby notified that you have received this communication in
intended recipient, you are h
error, and that any review, disclosure, dissemination, distribution or copying of its contents
e
eprohibited. Please notify City of Dubuque immediately by telephone at (563)-589-4120 of
Is your receipt of these items and destroy the communication and any attachments
immediately. Further disclosure of this information may violate state and federal
restrictions.
Confidential information may include the following:
1) Social Security Number(s)
2) Medical/Health Information
3) Personnel/Disciplinary Information
4) Bank Account Information
5) Financial Information
5) Credit Card Numbers
s any of the items
If any documever sheet desire to directly to he confidto the City ofential ial info mationubuque knPlease indicate belowthe
this cover sheet m
type of information that Is included.
6/4 /G� �Ir�' , hereby certify that the attached documents
include the following protected information.
Social Security Number(s) Bank Account Information
Medical/Health Information rinancial information
Personnel/Disciplinary Information T _Credit Card Number(s)
I understand that this information may be distributed within the City organization or to agents of the
City for processing and I hereby authorize the City to act accordingly taking all precautions to
protect my information fro ecessary distribution.
-fm �_ 1
G ignature ''�S�Q 6 ri `-
I have read the information above and do not have any confidential documentation to submit to the
City of Dubuque as part of this Claim Against the City.
Signature Date
Copyrighted
June 19, 2017
City of Dubuque Consent Items # 3.
ITEM TITLE: Disposition of Claims
SUMMARY: City Attorney advising that the following claims have been
referred to Public Entity Risk Services of Iowa, the agent
for the Iowa Communities Assurance Pool: Anderson
Windows for property damage, Herbert Cook for vehicle
damage, Ron Ludwig for vehicle damage, Judie Root for
property damage, James Schreiner for personal
injury/vehicle damage, Skyler Lee Tracy for vehicle
damage.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur
ATTACHMENTS:
Description Type
ICAP Referrals Staff Memo
THE cTFY OF �
DUBUQUE MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
i
To: Mayor Roy D. Buol and
Members of the City Council
DATE: June 7, 2017
RE: Claim Against the City of Dubuque by James Schreiner, filed by State Farm
ii
Claimant Date of Claim Date of Loss Nature of Claim
James Schreiner 06/06/17 02/28/17 Personal Injury/
Vehicle Damage
This is a claim in which claimant alleges that as he was driving northbound on Sunset
Park Circle, a City of Dubuque refuse truck pulled out onto the roadway and sideswiped
claimant's vehicle.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager i
John Klostermann, Public Works Director
Jessica Kellerhals, State Farm
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 tsteckle@cityofdubuque.org
HANSON L,ULIC & KRALL, LLC
ATTORNEYS AT LAW
November 1, 2017
Michael Vincent Conner
1075 Arrowhead Drive
Dubuque, IA 52003-0000
Public Entity Risk Services of Iowa
5701 Greendale Rd
Johnston, IA 50131-1510
City of Dubuque — City Clerk
50 W. 13th Street
Dubuque, IA 52001-4805
Re: State Farm Insured: James G. Schreiner
State Farm Claim No.: 15-0962-3G3
Public Entity Claim No.: ICP047089A1
D/O/L: February 28, 2017
Our File No.: STASUB 24204
Dear Sir or Madame:
700 Northstar East
608 Second Avenue South
Minneapolis, MN 55402
Office: 612.333.2530
Fax: 612.392.3675
Grant D. Sackett
Attorney at Law
Direct Dial: 612.392.3668
E -Mail: esacketi( lilk.corn
Cry
Our office represents State Farm Mutual Automobile Insurance Company ("State Farm") in pursuit of its
subrogation claim with regard to the above -captioned auto incident.
You are responsible for the loss because on or about February 28, 2017 at or near 3400 Sunset Park
Circle, in Dubuque, IA, Michael Vincent Conner ("Conner"), operated a City of Dubuque garbage truck,
while acting in the course and scope of his employment with the City of Dubuque and negligently merged
into a lane that was occupied by State Farm insured's vehicle, causing a collision and damages. Conner
was cited for unsafe starting of a stopped vehicle. As a result of the damages, State Farm made payment
to its insured in the amount of $13,051.90, and State Farm's insured suffered a deductible loss of $500.00,
for a total of $13,551.90. A copy of the police report is enclosed with this letter.
In addition, there may be continuing liability for any additional claim amount which may be paid by State
Farm in the future for this loss or any other subrogation claims State Farm may have regarding this
incident. Furthermore, you may have continuing liability for State Farm's ongoing PIP/No-Fault
payments. State Farm expressly reserves the right to pursue any additional subrogation claims or a
PIP/No-Fault indemnity claim(s) it may have regarding this matter. State Farm's Insured may also have
their own personal claim(s), which are not included in State Farm's subrogation claim.
On behalf of State Farm, we are seeking payment of $13,551.90. Please make payment to "Hanson Lulic
& Krall Trust Account." Our tax ID number is 41-1641289. If we do not receive payment within ten (10)
days of this letter, we may commence suit.
Sincerely,
OrowitSazicett
Grant D. Sackett
GDS/sp
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634135961
INVESTIGATING OFFICER'S REP
Sheer 1 er 4
Term 44=03fir 13) OF MOTOR VEHICLE ACCIDENT
MAIL REPORTS TO Iowa Department Cl frenspodation, °nice or Dover Sevides, P 0 Oar 9204, Des Moines, lows 50059204
Law Enforcement Case Numbers: '
't
2817.001553
Date of Accident
02/28/2017
Time of Accident
11:21
County
DUBUQUE
Accident occurred within corporate Smits of (city)
Hrs.
• 31
DUBUQUE . 2100
U
N
I
T
"I
Driver's Name - Last
CONNER
First
MICHAEL
Middle
VINCENT
Address
1075 ARROWHEAD DR
City
DUBUQUE
State
IA
Zip
52003-0000
Date of Birth
Drivers license Number
CDL
Yes No
Cite
UNSAFE
ion Charge 1
STARTING OF A STOPPED VEHIC
Citation
Charge 2
Male Female
(1) 0
State
IA
Class
ES
Endorsements
L
Restriction
K
®C)
Citation
Charge 3
Citation
Charge 4
Alcohol Test Given:
Test Results,
Drug Test Given:
1
Test Result
Re•exarre Yes No
r^
Reason for Re -Exam Request:
Owner's Name - Last
CITY OF DUBUQUE
First
Middle
Address
30 W 13TH ST
City
DUBUQUE
State
IA
Zip
52001
License Plate No
87327
State
IA
Year
2099
VIN:
1HTWCAARSDJ3O7817
Color
YEL
Year
2013
Make
1NTL
Model
7000 SERIES
Style
PK
Trailer Plate No.
State
Year
VIN:
Tow
I
Tow
Towed To
Appi cm Gust lo9eparenepace
$0.00
Insurance Company Name
CITY OF DUBUQUE
Insurance Co Phone Number
(563) 589.4120
Insurance Policy Number
SELF INSURED
Initial Travel Direction
01
Veh. Act.
01
Veh. Config.
16
Cargo Body Type
02
Veh.
01
Defect
Point of Initial Impact
10
Most Damaged Area
10
Extent of Damage
1
Total Occ In Veh.
01
Spectral Veh. Fungi
01
Emergency Status
01
Bus Use
Driver Condition
01
Vision
18
Obscured
Contributing Circumstances Driver (up to two)
19
Driver Distrac'one
02
Speed Limit
25
Traffic Controls
01
Horizontal Alignment
01
Vertical Alignment
04
SEQUENCE
OF EVENTS
First Event
33
Second Event
Third Event
Fourth Event
Most Harmful Event
33
c
0
M
IV!
E
R
C
I
A
Carrier Name/Lessee
CITY OF DUBUQUE
Street Address
50 W 13TH ST
1 Clly
DUBUQUE
State
IA
Zip Code
52001
Number of Aides
2
l'Haz
Gross Vehicle Weight Rating
2.10,001 LBS • 26,000 LISS
US DOT Number
MC Number
Underride/Override
1 . NONE
Mat Involvement
02•NO
Haz Mat Placard
Placard Number
Has, Mat Released
Has Mat Class
Haz Mat Name
Trailer Plate:
State
Year
VIN
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24c1700900926WPSD4WK9 Received 311012017 427:05 AM [Eastern Standard Time]
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634135961
INVESTIGATING OFFICER'S REPOR
Sheer 2 et 4
rnnn 4e3rloiOlt1.r31 OF MOTOR VEHICLE ACCIDENT
MAI. REPORTS TO Iowa Thwart rent of iranepdrfalion, (MIce or LYivre Spnr n, a rl ratio 1904, Dee Manes fawn 3630 50020'I
Lew Enforcement Case Numbers
2017.001553
Date of Accident
Time of Accident
County
Accident occurred within carpornte limits of (city)
02/28/2017
11:21 Hrs.
DUBUQUE - 31
DUBUQUE - 2100
LI
N
I
T
2
Driver's Nan e - Last
SCHREINER
First
JAMES
Middle
GERALD
Address
21E5 CROWN POINT RD
CitY
DUBUQUE
State
IA
Zip.
52002-0000
Date of Birth
Driver's License Number
COL
Yes Na
Citation
Charge 1
Citation
Charge 2
Male
`rj) 0
State
IA
Class
C
Endorsements
NONE
Restriction
NONE
C) U
Citation
Charge 0
Citation
Charge 4
Alcohol Test Given:
1
Test Results'
Drug Test Given:
1
Test Result:
Re•nuem: Yes No
r..
Reason for Re -Exam Request:
Owner's Name - Last
SCHREINER
First
JAMES
Middle
GERALD
Address
2155 CROWN POINT RD
City
DUBUQUE
Slate
IA
Zip
52002.0000
License Plate No.
EEY085
State
IA
Year
2017
VIN
19XFB2F9XCE074012
Color
OIL
Year
2012
Make
HONE)
Model
GM
Style
4D
Trailer Plate No.
State
Year
VIN•
Tow
2
Tow #
Towed To
appro. coal°
$3,000.00
Repay or Prnhee
Insurance Company Name
STATE FARM -
Irsurance Co. Phone Number
1563) 588-1491
Insurance Policy Number
109 9416-B17-1560
Initial Travel Direction
01
Veh. Act
01
Veh Confrg.
01
Cargo Body Type
01
Veh Defect
01
point of Initial Impact
04
Most Damaged Area
04
Extent of Damage
4
Total Occ. in Veh.
02
Special Veh. Fuss
01
Emergency Status
01
Bus Use
Driver Condition
01
Vision Obscu ed
01
Contributing Crcumstances
88
Driver (up to two)
Dnver Distractions
02
Speed Limit
25
Traffic Controls
01
Horizontal Align ment
01
Vertical Alignment
04
SEQUENCE
OF EVENTS
First Event
33
Second Event
Third Event
Fourth Event
Most Harmful
33
Event
UQMEWff0-<'-1
Carrier NameiLessee
Street Address
City
Slate
Zip Code
Number of Axles
Gross Vehicle Weight Rating
US DOT Number
MC Number
Underride/Override
1-NONE
Hex Mat Involvement
Her Mat Placard
Placard Number
Hee Mat Released
Haz Mat Class
Haz
Mat Name
Trailer Plate:
State
Year
VIN
Trailer Plate
State
Year
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24c1706900927WPSD4WK9 Received 3/10/2017 4.27.05 AM [Eastern Standard Time]
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634135961
°lin 4,11003111.1.1)
INVESTIGATING OFFICER'S REPORT
OF MOTOR VEHICLE ACCIDENT
MAIL KPOR IR "U teWn laepartment 01 arensportolrun, Oflice of Umar . 01*ss 00 Pok n204, Des Mentes Iowa 5020(1 9)04
Date of Accident 'Ante of Accident County Accident occurred within corpoiale limits of (city)
L 02/2872017 11:21 Hrs. DUBUQUE - 31 DUBUQUE - 2100
O Literal Description
C SUNSET PARK CIR MEASURING 374 FEET NORTH FROM SUNSET PARK CIR AND MEGGAN ST
A If accident occurred outside of N NE E SE S SW W N
T city limits show general vicinity 0 0 0 0 C.) CSC 1 CD at nearost city
Cin Road, Street or Highway: I
0 At Intersection with
N
Note. Unless accident occurred at an intersection which is completely described above, use the space below to give the exact
location front a milepost or definable intersection, bridge, or railroad crossing, using two distances and directions If neccessary of
N NE E SE S SW W N N NE E SE S SW W N
00000000 and 1,J00 00000
Milepost Definable Intersection,
Number Or bridge, or railroad crossing
ACC1DFIIN ENVIRONMENN ROADWAY CHARACTERISTICS
Lo�ahnn of First Harmful Event 01 Weather Conditions Kip to rW0) Major Contributing Cvcurnslances Environ 000 01
Manner of CrashlCollistor 06 02 Roadway 01
Light Conditions 1 Suriace Conditions 02 Type of Roadway JunctlonfFeature 01
FRA No
First Harmful Event (Crash)
33
1Name 001
N
0 Address
NM
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5
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WORKZONE Yes No
RELATED? « r3)
N p If Property other than
0 R vehicles damaged explain
N 0 Owner's Last Name
V
E E Address
HR
T If Property other than
C Y vehicles damaged explain
U Owner's Last Name
LD
A M Address
RG
w
T
N
E
S
5
Last Name
Last Name
Last Name
Last Name
Last Name
Signature of Officer
HARDEN ANDREW
Name of Agency
DUBUQUE POLICE DEPARTMENT
Report Reviewed By - —
LEMBKE, JIM
Object Damaged
Object Damaged
First Name
First Name
First Name
First Name
Activity Location Type
Phone Number
Phone Number
First Name
City
First Name
City
Address
Address
Address
Address
First Name I Address
Workers Present
DOB:
Alcohol Test Given
Transported by:
DOB:
Alcohol Test Given
Transported by:
Badge Numhar
59 A
Date of Report
021202017
Dale of Review
0100112017
24c1706900928WPSD4WK9 Received 3110120174'27'05AM [Eastern Standard Time]
}haul .1 ui 4
Law EnForcernent Coro Numbers
2017-001563
Legal r---1 Pevale
Intervention? 1„._1Property?.
County' Route
31
X Coordinate'
686886.95
Y Coordinate'
4709966.62
0 Divided Highway, Provide Route
(Cardinal) Travel Direction
NB SB 00 WB
0 J 0 0
Test Results' Drug Test Given
S'esuit
Charged Yes No I
0i 0
i ! { f
Test Results: Drug Test Given Result Charged Yes No
0 0
Estimate of Damage
Middle Name Phone Number
State Zip Code
Middle Name
State' IIr Zia Code
Was owner or tenant nettled?
1 is Yes 2 is No 9 = Unknown
Estimate of Damage
Phone Number
Was owner or tenant notified?
1= Yea 2= Nog=Unknown
City State Z p Code Phone Number
City
City
City
City
State Zip Code
State Zip Code
State Zip Code
State Zip Code
Picone Number
Phone Number
Phone Number
Phone Number
Time Officer Notified of Accident Time Officer Arrived At Scene
11:24 Firs 11:24 Hrs
Ifvesngallon made at scene? T I No
Y (#j N Q
Repcit r5lven to ail Drivers? Other Teohritcal Invee'hgahng Agerry --
Y( ` NC)
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634135961
rur 11 4,1,13CO3! 1' 1 1'17
INVESTIGATING OFFICER'S REPORT
OF MOTOR VEHICLE ACCIDENT
Sheol 4 0 4
law Enforcement Case Numhors'
WA 1. 10011ri1112 1'0 luvia l IlI, crl of ,renspnrtnaer 1)1l 1 M Driv9r 5divl,es PO Hex %!04 Deb Mains; Iowa 1033.6 9?04 2017-001053
D
A
G
R
A
M
{. Meggan St
l Sunset Park Clr�
r
Meggan 51
Unit 01, a City of Dubuque garbage truck, was pulled over to the right side al the roadway facing northbound in the 3400 Blk Sunset Park Circle. Umt #2 was traveling
northbound on Sunset Park Circle passing Unit 01 Unit #1 didn't see Unit #2 and pulled out to proceed to the next residence on the street Unit 41 sideswiped Unit
N #2 No injuries reported
A
R
R
A
T
V
24c1706900929WPSD4WK9 Received 3/10/2017 4'27'05 AM [Eastern Standard Time]
HANSON L,ULIC & KRALL, LLC
ATTORNEYS AT LAW
November 1, 2017
Michael Vincent Conner
1075 Arrowhead Drive
Dubuque, IA 52003-0000
Public Entity Risk Services of Iowa
5701 Greendale Rd
Johnston, IA 50131-1510
City of Dubuque — City Clerk
50 W. 13th Street
Dubuque, IA 52001-4805
Re: State Farm Insured: James G. Schreiner
State Farm Claim No.: 15-0962-3G3
Public Entity Claim No.: ICP047089A1
D/O/L: February 28, 2017
Our File No.: STASUB 24204
Dear Sir or Madame:
700 Northstar East
608 Second Avenue South
Minneapolis, MN 55402
Office: 612.333.2530
Fax: 612.392.3675
Grant D. Sackett
Attorney at Law
Direct Dial: 612.392.3668
E -Mail: esacketi( lilk.corn
Cry
Our office represents State Farm Mutual Automobile Insurance Company ("State Farm") in pursuit of its
subrogation claim with regard to the above -captioned auto incident.
You are responsible for the loss because on or about February 28, 2017 at or near 3400 Sunset Park
Circle, in Dubuque, IA, Michael Vincent Conner ("Conner"), operated a City of Dubuque garbage truck,
while acting in the course and scope of his employment with the City of Dubuque and negligently merged
into a lane that was occupied by State Farm insured's vehicle, causing a collision and damages. Conner
was cited for unsafe starting of a stopped vehicle. As a result of the damages, State Farm made payment
to its insured in the amount of $13,051.90, and State Farm's insured suffered a deductible loss of $500.00,
for a total of $13,551.90. A copy of the police report is enclosed with this letter.
In addition, there may be continuing liability for any additional claim amount which may be paid by State
Farm in the future for this loss or any other subrogation claims State Farm may have regarding this
incident. Furthermore, you may have continuing liability for State Farm's ongoing PIP/No-Fault
payments. State Farm expressly reserves the right to pursue any additional subrogation claims or a
PIP/No-Fault indemnity claim(s) it may have regarding this matter. State Farm's Insured may also have
their own personal claim(s), which are not included in State Farm's subrogation claim.
On behalf of State Farm, we are seeking payment of $13,551.90. Please make payment to "Hanson Lulic
& Krall Trust Account." Our tax ID number is 41-1641289. If we do not receive payment within ten (10)
days of this letter, we may commence suit.
Sincerely,
OrowitSazicett
Grant D. Sackett
GDS/sp
G:\HLK\24262\Atty\Demand lir - Defendant.doc