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Claim by Anthony Rhomberg 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 � �� +CL.AIM A+GAI�TST '�H� +CIT� i.��+ I��TB�.T�U�, IQ��A �' � . This writ�en report car�stitutes yaur claim against the City of Duk�uque, lawa. Yau shauld complefie fihis form ir� full and attach �r�y additi�nai infiormafiic�n that � suppc�rts your clairn. � � � The clairn must be filed v,rith fihe �ity �C�rk afi �i�y Fiall, 5� vli�st 13`" St., � Dubuque, IA 52�Q1. It�nrill then be referred ta �he a�propriate departmen#for ? invesfiigation and to the City Attarr�ey's Q�'ice. Once that investigation is � completed, a repr�rt and recommer�datian wiN �e submitte� fio the Cifiy Council. k You will be provided wi�h a cc�py of that repor� and recommendati�n. � The final decisian on all claims is mad� by fhe City Co�ncil. No employee of the ' City c�f Du�uqu� has the aufihority t� mal�� any represen�ation tc� yc�u a� to whether your claim will or wi[1 not be �aid. 1. Name c�€Claiman#: �� j �� t?�`� �"� � � � �� I; � 2. Address: � �� ,.,� �� ""� E � �.� ; -_ ; 3. T�lep�one Number�� '� � � ��' «� ��] ; � - � 4. Date c�f Incid�nt; ��`�� l'� 5. T'ime of Incident: �� . Location �f Incider�fi (Be specific}: � � 1/' �� ,.. � �. c��' ; ��` 7. D�scribe the accident or accurrence that c�used injury ar damage. (Give full �etails �pon which yo� basa yt�ur elaim. If a City employe� was invalved, give t e P mployee' na�ne.} l� �� e.� ��.� �� -� .� 7` �. �`�� ` �� ' � � � r� �` � �`� � �� ': �. Wha�were weather conditions like? �'1�1 � � �L � �"� �. Gii�r� n me and address of ar�,y�v tness�.� �YI�� , `� �i�p �..l �.. �l �.� 1 !� � police investigat�? (If so, give name� of ofFicers.) 11. V1/as ar�yone inj�red? (lf sa, give r�ames, address�s, and e�ent of injuries}, � � � t � � � �2. ViJas any damage dane fio prc�perty? {If so, describe proper�y and the exter�t c�f damages. Attach esfiimates of darnages ar de�crik�e basis for ascertainint� E extent of damage.j � �� ,��.� ` ; � �3. What ather damages dr� yo�a claim, if any'� � 14. Nave yc�u been compensated for any part �r �11 of your claim by �ny ; insurance cornpany? {If so, give narn� and address of insurance com��ny and amaunt paid,) � � i i j I 15. What amour�t do y�u claim from the Cit� of Dubuq�ae? ; �� 16. Why dc� you claim th� City c�f Dubu ue is respc�n�ible? �� .— c� ..� � � ��. � �� . �� . �.�.�'2 1`�. �� > 17. Have you made any claim a�ainst anyone else for damages as a resul� c�f this incid�nfi? {If yes, give name and address.) � � 18: !f fihe answer fo Question 17 is yes, have yc�u received any paymen#from that source, and if sa, in what arn�unt? �.� � Qated this ��"� day c��F 20 ��d . `�`'� �� , r_. ,�.� k.��' �'<�� fT,� ,� _tl,� f ��i�� {Signature} r�M `J`� � -_� 4_ ��;� i � � �,/� �� s�� '� � C9 � � I��I C��? ,� �� `� �% .,�" {Prir�t �Jame) ~� �� `� Confidential This comr�unication and any attachrnents 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 ; 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 c�mmunication and any attachments � immediately. Further disclosure of this information may violate state and federal �i restrictions. i i , Confidential information may include the following: i 1) Social Security Number(s) I 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 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 , '�'1 � � � � 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 CTTY OF � � �ti,..! LJ '� ■ , � � � o � � 1 \ � V � I' 4 Masterpiece on tl2e Mississippi � TRACEY STECKLEIN � PARALEGAL � To: Mayor Roy D. Buol and Members of the City Council �� DATE: May 8, 2018 j , i RE: Claim Against the City of Dubuque by Anthony Rhomberg j Claimant Date of Claim Date of Loss Nature of Claim �l Anthony Rhomberg 05/07/18 04/26/18 Vehicle Damage �ii �,; This is a claim in which claimant alleges that claimant's parked vehicle was struck in the ; South Locust HyVee parking lot by a City of Dubuque fire truck which was also parked in �;; the HyVee parking lot. The parking brake of the fire truck was not completely set and the ',i truck rolled backwards into claimant's vehicle. �Il �, �,; This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa �� Communities Assurance PooL � i! i cc: Michael C. Van Milligen, City Manager j Rick Steines, Fire Chief � Anthony Rhomberg ' � h � r � I� g p a OFFICE Of THE CITY ATTORNEY DUBUQUE, IOWA j SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 � TE�EPHorvE (563)583-4113/F� (563)583-1040/EMai� tsteckle@cityofdubuque.org � � a , y