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Claim by Larry Duntan Copyrighted June 18, 2018 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Larry Dunton for property damage; Rainbo Oil Company for property damage; State Farm subrogating for Lyla Ant for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Dunton Claim Supporting Documentation Rainbo Oil Company Claim Supporting Documentation State Farm Subrogation Supporting Documentation 4, � :r�,v CLAIM AGAINST THE CITY OF DUBUQUE, IOWA G'us ��h�'yvs D��S� �b��-S 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. 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. 1. Name of Claimant: ��.r � �;�. ve, 2. Address: �,� �.-�� ,r1 b�- �, a � �__ �� j � City: � u � i,�oi, u..�?, State: �d-- `I� Zip: 4� d c� 3. Telephone Number: J� � �!� `C —��s�� 4. Date of Incident: � �,� /�v .� `.,, �,,,'� �,�... .r� 5. Time of Incident: � c�,f_� 6. Location of Incident (Be specific): �,��i:� ?,� �o v� �� l i t�,.��I C, 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.) E, l) 1 C�e— L� �...�-sL ,f` -@ �. r1, c� C� e � ,�1 �." � ,/� -�./" �� c � � J i '�c� �,t, i�, � 1� c�"��!�` I -�_ r�� c.� „ 8. What were weather conditions like? � (�� ,� 9. Give name and address of any witnesses: `� � � 1 �� ' � . /� @ � v` �1��e 2� ;,�, 10. Did police investigate? (If so, give names of officers.) Jl�' � S � i� � �V1 Q��c� Ql. V-�,,.�'` � -� � �� i� �1� �! c5� ►� � 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). � � � I 12. Was any damage done to property? (If so, describe property and the extent of darnages. Attach estimates of damages or describe basis for ascertaining extent of damage.) �v � �,�' �l �� -� (`��l'�-�'J�� 1 � � � ta.l l�J�✓` 8 U � � �� cl �� 13. What other damages o you claim, if any? �, �r"��;,� �a � � . i . � -�- !� �'P �C, � � �� R� lea �✓' l�� L,! � �w/(�c � � 7 G�iI�J'�� G�l�� ! A �l��`� � 14. Have you been compe sated for any part or all of y r claim by any insurance company? (If so, give name and address of insurance company and amount paid.) �p 15. What amount do you claim from the City of Dubuque? ��f� 16. Why d you cla' the City of Dubuque i e ponsible� � �� 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give narne 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 at Dubuque, lowa this � day of_ � �.�. �`� , 20 l � ,�� m � -'/�' (��ratur�j � � J` /' �. � ` �� l/l ^ � B� —' � � / Pf Illt Name r'�, c� � � __ � � ��; G �- � �� -S �pV + �� r� � Y" � � 1�� {�( l , i (Rev. 5/18) v =; '�•' G' �CD � � � � 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 )n"tr ro�o!'f3f Of ��'3�� 7�� '17u f�,�2��if)ji iiic^ ^,��i��iii.i'J'ilC��i3ii ai�u`j aiij� uiiai.i�f;liij 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 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. � �� , 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 the City to act accordingly taking all precautions to protect my information from unnecessary distribution. � .� �� ..� �� / Signature Date I Copyrighted June 18, 2018 City of Dubuque Consent Items # 3. ITEM TITLE: Disposition of Claims SUMMARY: Larry Dunton for property damage; State Farm subrogating for Lyla Ant for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Supporting Documentation THE CTTY OF ��TB � E MEMORANDUM � Master�aiece on the Mississippi � � TRACEY STECKLEIN � PARALEGAL To: Mayor Roy D. Buol and � Members of the City CounciJ � ;, DaTE: June 5, 2018 � � � � RE: Claim Against the City of Dubuque by Larry Dunton � � � Claimant Date of Claim Date of Loss Nature of Claim I� � Larry Dunton 06/0518 02/03/18-Present Property Damage � ;� This is a claim in which claimant alleges that a watermain break on Timberline Street � � caused numerous cracks in claimant's driveway. � � � � il 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 Manage � Denise Ihrig, Water Deparfiment Manager Gus Psihoyos, City Engineer Larry Dunton � � � � � 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,4x (563)583-1040/EMA�� tsteckle@cityofdubuque.org ' 0