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Claim by Charles Northrup Jr. 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 Nl Vw� �� CLAIM AGAINST THE CITY OF DUBUQUE, IOWA �)�.��1 � �,��,� I This written report constitutes your claim against the City of Dubuque, lowa. You should I 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 j 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: �^�e � -� '� 2. Address: �� g S0. (or�iC}�<�eEv !'�u� , 3. Telephone Number: ��,3 ��'l�,2 ?�� 4. Date of Incident: �/'�� 1� o� l�, ,'?Q�� ' 5. Time of Incident: f.�i(V�(.�pcv� � 6. Location of Incident (Be specific): ti iv S � 7`r � � �� o�� 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.) h`� J /'1C �/�Ocv �GB� Z�fi� Cl2�<Kf�' �G�fvNr�v9' �� /a� b�i�Y� ��N��C �-�- n .. T� l✓t� I�GI/�G�/,c-r f��f '/ _ �ct�i�S /¢- �/�!'' J�/�-t'' �,P '�d� 5<� `'_� 8. What were weather conditions like? .�i��u>t,��° 9. Give name and address of any witnesses: �a�_ 10. Did police investigate? (If so, give names of officers.) l 1�� 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.) � ,/� � � � �o��G-ri�� /� /`"GLw�r�'F.�L'�5�� /U�� A`i►�c-t��i^e, �21D.�� ? 13. What other damages do you claim, if any? �p�t°� I � I �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 l 15. What amount do you claim from the City of Dubuque? / ��? 16. hy do you a,,�m the City Qf,Ia' que i responsible? * � ` �° G��. `S� �Gp�.t �CX ✓�-G� � � 'T ��Q�l'��L I� C'��-�� /'�'c�Y-�,�c� ��; . 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) 9�0 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, lowa this � day of ��( , 20�. � � � (Signature) l�P � /� � (Print Name) � t"t q r -�- � �; — _ _ _. -- ; __ - �a ' - �Tj (Rev. 7/12) ��• �.T. ;F._; p= � �l� � 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 hereby notified that you have received this communication in error, and that any review, disclosure, dissemination, distribution or copying of its contents is prohibited. Please notify City of Dubuque immediately by telephone at (563)-589-4120 of 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) Financiallnformation 6) Credit Card Numbers If any documentation you desire to submit to the City of Dubuque contains any of the items above this cover sheet must be attached 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 Medical/Health Information Financial Information Personnel/Disciplinary Information 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 ihe City to act accordingly taking a!I 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 Dubuque as part of th' Claim Ag inst the City � �� Signature Date 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 C>F �'LT� � E MEMORANDUM Masterpiece an the Mississippi �li TRACEY STECKLEIN � � PARALEGAL I � To: Mayor Roy D. Buol and ! IV�embers of the City Council ', � DATE: May 8, 2018 ;i RE: Claim Against the City of Dubuque by Charles C. Northrup, Jr. �� i .� Claimant Date of Claim Dat�e of Loss Nature of Claim � ,� Charles C. Northrup, Jr. 05/07/18 04/14/1� Vehicle Damage , This is a claim in which claimant alleges that the tire on claimant's vehicle which was � parked on Dunning Street near the intersection of South Grandview Avenue was � punctured by a City of Dubuque snow plow truck. This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa Communities Assurance PooL � cc: Michael C. Van Milligen, City Manager I� John Klostermann, Public Works Director �'� Charles C. Northrup, Jr. ,,I ji ,� h � � '� � � OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA ' SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 `� TE�EPHONE (563)583-4113/Fax (563)583-1040/EMai� tsteckle@cityofdubuque.org ; I