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Claim by Jerry Brandenbeg Copyrighted May 21 , 2018 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Jerry Brandenburg for personal injury; Charles Northrup, Jr. for vehicle damage; Mary Peterson for personal injury; Anthony Rhomberg for vehicle damage; SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Brandenburg Claim Supporting Documentation Northrup Claim Supporting Documentation Peterson Claim Supporting Documentation Rhomberg Claim Supporting Documentation �--��.-rj�»� �� CLAIM AGAINST THE CITY OF DUBUQUE, IOWA J� �l�c�-r��, This written report constitutes your claim against the City of Dubuque, lowa. You should complete this form in full and attach any additional information that supports your claim. � i� The Claim must be filed with the City Clerk at City Hall, 50 W. 13t" 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. � a 1. Name of Claimant: �, �-� ;� � � � ;� 2. Address: � � � �'.,�� i ;; 3. Telephone Number: �f � �� `�L,►' � � � � � � �� ; 0 4. Date of Incident: � ` � � '� �� 5. Time of Incident: �,.�(`��,� �� ,��,� I'�� ry' 6. Location of Incident (Be specific): _�� Q � .�,��°��.� �� ; �� ; Ih i 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.) a �j � t� - , I, �.�5 «„ 5 ` , � a � _ � � TC� � 6�.� � �. �'� C�.� _ �.v" �C�.�- � �, � �� c,�� (:�C�L'�'�e�. ��"q�-� _ e i � . � 1 � 3. iriihai were weainer conditions iike�! °� �� y�� . � 9. Give name and address of an. witnesses: ��t ��C;��.+�.1�"' (�,,� �� l �'��; G�,v�c� � �t� YO�.i�q h�c��- �-� `�'� � 10. Did police in'iiestigate? (If so, give n mes o officers.) 6�� 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). � �.. �.:�� ., 1 �: � °� �,. ��.c� � � tt� ��_�t�,;r� �-� �, cc�r�� I�� 9 , 3 { ,q q 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 i damage.) � � � �� 13. What other damages do you claim, if any? �C,��,s��. � � �� i 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.) ''I �� 'i �� ' ' °" �, �,� � f..�.��..1{ d�l.�s�` ,� �i � i��.v�. �'.��.� �-.� �,��-c.,�. :� �� i�-h �1�� C' ��1� ��.e5 �%�,��s ..��, �� 15. Wha�amount do you claim from the City of Dubuque? �(�,�, . ,� �c��7�-�)� i ��Ss � t,� �� "- i �"►"!� l j� �� 6. Why do you claim the City of Dubuq e��re ponsible? , ��+ ` ��, ' � �a �� 1��.� �. �'..�. �� ;�� i 17. Have you made any claim against anyone else for damages as a result of this incident? � (If yes, give name and address.) �!�I � Pi �i � 18. If the answer to Question 17 is yes, have you received any payment frorr� that source, il and if so, in what amount? � � , �� ; � Dated at Dubuque, lowa this � day of l�� , 20�. ° � r ,i � � � �� R � �'l0� 3.��.-� ��yra�ure) � � � 2�`�`Y � �r"�C a��I �j�.C��j (Print IVar�e) � � �:� � �-� � °� ;-'-�� -�; � "� ,�, r �- � � :w : ..�� „�• �- ..�T, k tf:� (ReV. 7/12) f �: 1�,! � �: �� .� � � � c� � � �� I � 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 intended recipient, you are h�reby notified that you have received this communication in errar, and that any review, disclosure, dissemination, distribution or copying of its contents � is prohibited. Piease notify City of Dubuque immediately by telephone at (563)-589-4120 of � your receipt of these items and destroy the cor�munication and any attachments immediately. Further disclosure of this information may violate state and federal restrictions. Confidential inforrnation may include the following: � i 1) Social Security Number(s) � 2) Medical/Health Information � 3) Personnel/Disciplinary Information � 4) .Bank Account Information � 5) Financiallnformation � 6) Credit Card Numbers �, � , a If any documentation you desire to submit to the City of Dubuque contains any of the items above � this cover sheet must be atfached directly to the confidential information and indicate the type of �� information that is included. '' � - ,� I, , hereby certify that the attached documents ', include the following protected information: � Social Security Number(s) Bank Account Information 9 � Medical/Health Information Financial Information � Personnel/Disciplinary Information Credit Card Number(s) I understand that fhis 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 from unnecessary distribution. Signature Date 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 � '� � �� Si ature �' Date d „ � Copyrighted May 21 , 2018 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 lowa, the agent for the lowa Communities Assurance Pool: Jerry Brandenburg for personal injury; Charles C. Northrup, Jr., for vehicle damage; Mary Peterson for personal injury; Anthony Rhomberg for vehicle damage; SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo THE CITY QF �T�J�B E MEMORANDUM Nlasterpiece on the Mississippi �� I'i ,, TRACEY STECKLEIN '� PARALEGAL ;' �; � To: Nlayor Roy D. Buol and ,� Members of the City Council k ,� �j DATe: May 11, 2018 � � RE: Claim Against the City of Dubuque by Jerry Brandenburg : ; i Claimant Date of Claim Date of Loss Nature of Claim si i � Jerry Brandenburg 05/11/18 02/17/18 Personal Injury `i '�I This is a claim in which claimant alleges that as he was walking to the driveway at 3185 � Shiras Avenue, he slipped on an icy patch and injured himself. I � This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa %i Communities Assurance PooL a cc: Michael C. Van Milligen, City Manager John Klostermann, Public Works Director Jerry Brandenburg � � � y 9 � � � OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA � SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 � TE�EPHONE (563)583-4113/F,vc (563)583-1040/EMA�� tsteckle@cityofdubuque.org �, � � �