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Claim by Mary Peterson 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 1 8 � CLAIM AGAIIVST THE CITY C�F DUBUQUE, IOWA This writ#en r�port constitutes your claim against the City of Dubuque, lowa. You should corr�p9ete this form in full and at#ach any addi#ional ir�form�tion that supports your claim. � 'fhe Glaim must be filed with the City Clerk at City Hall, 5010V, 134h St., Dubuque, IA 52001, It � �vill ther� be referred by the City Councii to the appropriate department for investigatic�n. � Ance th�t investigation is completed, a repprt and recommendation will be subr�ritt�d to �he � City Council. You will be pravided with a �opy of that report and recommendation. ,� YFiE FIIVAL D�CISION OiV ALL CLAlMS I� lUTADE BY THE CITY C(7UNCIL. IVfJ EMPL�YEE �F � TFlE CITY OF DU�U(�UE HAS THE AtJTHORITI' Tf, IVIAKE �NY REPRES�NTATIOiV TtJ YOl9 �! �iS 1'O V4/HET'FiER YOUF2 CL/AI�lA V4/1LL OFt NVILL iVOT BE PAID. � �i � ! . , 1. Narr�e of Claimant: ��.�� ''�,�,'''"� � , �I; Z. �ddres�: � �� 'C'_°'�� -- �..' � ��.� :� � �i 3. T�a�phone Number: ��i'�°�,� �`��' �°��,"�""� ! �� 4. Da#� af Incid�nt: � � "�----� �r 5. 'firn� of Incid�nt: � �� °`" �,�� , , � 6. Loc�tian af In�ident (�e specifac):�` ��.�� t�� G'� C�-�"" ° � �� -�� 7. D�S�RI�E ,ACC9DE9VT (Jf2 OCCURREIV�� 'THAT CAUSED INJURY Oi� �AMAGE. (Give � full d��i�s �apon rrvhich ys�u base your clairn. If a �ity employ�� nras involv�d, giore �he �rtapl�y��'� narne.) '� � ., � ' `� � ` ' � . �°�°°�- "� �,. � ,,�'�� ``�. �`�� ° � � ,�' � ;.,� �, � �-� a� �'� � �� . � ��. � _. ., _ �, A � � �°��.�. ��?��n �.��.�- � �. Wh��k w�r� �nr��h�r ��nt�i't6ons 1ik�? � `� ' �. �. Giv� narne and addr�ss of�r�y wit��sses: � ' �. ��,� ��,..�..� ��. c�t�� °� °��..� � �.��. 1Q. �id polic� inve�tigat�? (If so, give nam�s of offic�rs.) � �� 11. Vl/as anyone inj�ared? (If so, give narraes, addre��es, and ext�nt of injuries). � � �." �� '�~��,� 4 s�� ,�"� � � � � � . . �� ..c�-� c��, �� v�`� �..��.�� .r...��...� _ �.�..�, �� _ ' --��.� �fi ,C.l��c� � ��Q �.�..v . �..� � .o' � �� .,�� a�..�. ��...��°+ ��..�� ,.� .-.�,11 R�--.--��- . c�..�d. �..�.��:.�.. ' �.-� �i c� `��`��..� - ��-�. . 1�..�� °� . ". � �. �X� � ! . ' ..�,� �`1.�� , -� ��.. --��:�.��..��'� � --�,�..,� �.;��, ��„�,,✓.� . ��.�o� ._��-� �.�.,��. c��.�vr.��.��`�. . .�.� . � w��.�� ;c� �1 �.. �� .� c�..�-� -� `�� -� �. -� �� ,� �� F ��.� � � �� , ; ., � � � I 6 1�, Was any damage done ta property? (If so, describe property and the extent of damages. Att�ch estimates nf damages or describe basis for ascertain�ng extent of damage.) �� ,� 13. What other damages do you claim, if any? �� ,� � a ,7 14. Have you been cc�mp�nsat�d for �n IIII com an � If so y �� °r �� ofi Y�ur claim by �ny insuranc� � p y. ( , give name and address of insurance campany ar�d arnount paid,) ;i � ; ';i F �, 15. What amount do you claim from fihe Ci#y of ubuque? � � Y��; �... -�`� �,� � �� ..� ' � 16. Why do ou ciaim he Gity�of Dubuque is r�sponsible? I; -_ t 1,� �p � `''" r� :�"a �� -� � �'��1."��:�� 1 T. Have you made any claim �gainst anyone else for damages as a r�s�lt of#his incident? I'�J (If y��, g�ve�name ared a�dress.) � � � , !� 1$. )f the araswer tc� Quesfiion 1? is yes, have ou received an � and�if so, �n what amount? y Y paymenfi from that sourCe, �fl i � ;' �. � �lafied at Dubuque, Iowa this �� da� of �� 20� , � � a � �_ . � � ��i.�ro�ie�re� _�._�� ' ��f'_k�'�� (Prir�t IV�m�) � f, :9 ,�,.� (Rev. 7/12) r--�� :� � ~�; _ j: _ _,� ,,...; . , , , _.. .. : .... ,:r -- � -� r ._} _ n a ¢i �,.�a. _y.,� 4..v��i L... ��C I�[ i y P`�'� }1«..rA� q (':�^ �,.�„A i � SEY.� � � � Ganfidential This communicatian and any a�ttachments may contain information which is confid�ntial � artd privileged by law and is far the use of the designated r�cipient. If you are not the ,� intended recipient, you are hereby nofiified that you hav� received this commwnicatian in error, and that any review, disclosure, dissemination, distribution ar �opying of its �ontents is prohibited. Please notify City of Dubuque irnmediately by telephone at (563)-589-4120 of your receipt af these items and destray the communication and any attachment� , immediately. Further disclosure of this informafiion may violate state and federa) 1 restrictions. p Con�idential rnfarmation may include the fol9owing: � !I 1) Social 5ec�rity Number(s)., _ � �) Medical/He�lth (nfiorma�tinn � � �� 3) Persannel/Disciplinary (nformation � 4) Bank Account Information � 5) Financial Information " 6) Credit Card Nurnbers ;� If any documentation you desire to submit to the City af Dubuque cor�t�ins �ny of the items above � thrs cover sheet must b� attached direcfily to the confidential information and indicate th� type of ��; information fhat is included. j 1 I� �, � , hereby certify that the attached documents A ir�clude the following pratected information: � � Social Security Number(s) Bank Account Inform�tion Medical/Health Informafiion �inancial Inforrnation n Personnel/Disciplinary Informafiion Credit Card Numb�r(s) � I und�rstand that this infiormafiian may be distribufied within the City organiz�tion or to agents of the �ity for processing ana i hereby authorize the �ity ta act accordingly taking all precautions to � protect my information from unnecessary distributian. � � Signature Date a I have read the infiorrnation �bove and do not have any confidential documentation to submit to the City nfi Dubuque as part of this Claim Against 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 OF /^�,,,, '� �'4..+r� �— � � � � 1` 1 1 � O NDUM i �� Masterpiece on tlze Mississippi i � d i; TRACEY STECKLEIN � 'I PARALEGAL i; r �I'� To: Mayor Roy D. Buol and � Members of the City Council ' DATE: May 14, 2018 � , RE: Claim Against the City of Dubuque by Mary Peterson ji �, �; Claimant Date of Claim Date of Loss Nature of Claim � Mary Peterson 05/14/18 04/24/18 Personal Injury �� This is a claim in which claimant alleges that she was injured when she fell in a City of ''' Dubuque minibus. This daim has been referred to Public Entity Risk Services of lowa, the agent for the lowa ;, Communities Assurance Pool. �i II �; cc: Michael C. Van Milligen, City Manager i� � Candace Eudaley, Transit Manager �� Jodi Johnson, Operations Supervisor G Russ Stecklein, Field Supervisor !; Mary Peterson �i I; � � G � � � � � � a ,; , � � r: a f � 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/EnnAi� tsteckle@cityofdubuque.org G � � %