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Claim by Lyla Ant/State Farm Insurance 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 � .,�, /YI i�'i�� CLAIM AGAINST THE CITY OF DUBUQUE IOWA �� G �� 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. 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 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: 5�� f� �s C�,�SI� ��- �i-,`�� 2. Address: �1� C' �� Glof7,� '��Ld��-t (��1� 3 ��1 S 3. Telephone Number: j,�,�S- �� l��l�� I 4. Date of Incident: `-� � I� �o ��" 5. Time of Incident: I • � � 'c �� 6. Location of Incident (Be specific): ��;n_r��;c��F., �v� � .,�'�,� �. ICFr��n��u ��u��f� �1�'�-- 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.) �(��l✓ d('��LIP V�C✓(�� t�f1C��t (� ��`r �✓tSL'l�-�C�+ ,S v'��i��% 8. What were weather conditions like? 1J� � 1 9. Give name and address of any witnesses: �') � : 'i0. Did police investigate? (If so, give names of officers.) u � ��-�1� �bd��'r', � 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.) , �� , 13. What other damages do you claim, if any? 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.) � � �4��.h�'1 ' �r;s � ��.��- -� .r., u �>� i u�:�� 7 �- �1�:,.�--z r" ��-�� ; 15. What amount do you claim from the City of Dubuque? � �d�.5`i 16. Why do you claim the City of Dubuque is responsible? ��Y��Y` 1 V ��t'i.t 1�`i"1�� 1. �"� l��`��L��l� � 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) ^, r1,1 � ►� 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? � � � � 5� ,JK�-�. 20�. Dated at Dubuque, lowa this day of , � � �� " �� , � �-.��ignature) ��.5;� t,�c��1-er� , ��-�� -4.:� `��5. ��S�O ��`� I�n� (Print Name) C7 w `'��- c � �_� �; :.� �� = � ' i�7 ;y� J � � f� (Rev. 7/12) `� cr,� � � �--= — (Tl A -�: -- � D � 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 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. Please indicate below the type of information that is included. I, , hereby certify that the attached documents include the following protected formation: , /' Social Security N ber(s) Bank Account Information Medical/Health for ation inanciallnformation Personnel/Dis plinar Infor ation C dit Card Number(s) I unc�erstand that this infar ation ma be distribu ed wit in the ity organization or to agents of the City for processing and I hereby a tho ize the City to act a ordingly taking all precautions to protect my information fro unnecess ry distribu ion. 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. n � / / , "'l,� � `� � � C�,� �?�1�5 �- Signature � Date ' 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 CITY QF f,;,. �T�"B � MEMORANDUM � Masterpiece an the Mississip�ai �TRACEY STECKLEIN � PARALEGAL � To: Mayor Roy D. Buol and ;� Members of the City Council � DATe: June 7, 2018 � I RE: Claim Against the City of Dubuque by State Farm, subrogating for lyla Ant �� ;� Claimant Date of Claim Date of Loss Nature of Clairn i � 'il State Farm 06/07/18 04/12/18 Vehicle Damage i Subrogating for 'I lyla Ant �� This is a claim in which State Farm alleges that a Housing vehicle rear-ended the vehicle � '� driven by lyla Ant near the intersection of Pennsylvania Avenue & JFK Road. i; ,, � � � This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa � Communities Assurance Pool. ;i y cc: Michael C. Van Milligen, City Manager � Alexis Steger, Acting Housing & Community Development Director � State Farm 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 � � G