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Claim by Lori Lewis Copyrighted November 5, 2018 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Claudette Coleman for vehicle damage, Eagle Window& Door for property damage, Lori Lewis for vehicle damage, and Sandra Wolbers for personal injury. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Coleman Claim Supporting Documentation Eagle Window& Door Claim Supporting Documentation Lewis Claim Supporting Documentation Wolbers Claim Supporting Documentation �� . CLAIM ACANN�T THE CITY OF DUBUQUE, IOWA ��'�� F This written report cons�itutes your claim against #he Cit� of Dubuque, lowa. You should I � complete this fcarm in full �nd attach any additional infarm�tion that supports your claim. The Gtaim must be fil�d with the City Clerk at City Hall, 5� W. 13t'' St., Dubut�ue, IA 520�'1. It � will then be referred by the City Cauncil to the ap�propriate department fc�r inve�tigation. � �nce that inv�stigation is completed, a repart and recomrnendation will be submitted ta the City Cocancil. You will be provided wi�h a copy of that report and recammendation. THE FINA� DE�ISION C�N A�� L.Al1U1S IS NIADE �Y TH� CITY C@UN�IL. NC} �MPLOYEE C}� THE CITY �F DUBUQUE HAS THE AUTH4RITY TQ MAFCE ANY F�EPRESENTATION TC? YOU i AS Tt}WHETN�Ft Y()UR CLAIM WILL t�R WILL NQT BE PAI[�. '1. Name af Glaimant: �,� �� `�'� J�� I E �� `�'��'`��'� �� 2e Ac�dr��s: �� , � � r City: �; �.�v�'�.. _ State: `'`�� Zip: � � �� . '�e��F�c�r�� N�rm��er: ��,G� J�� ,.�� -, �._._ _ � 4. Date c�f Incident: �� 5. Time of Incodent: � � � y� �. Location c�f Incident (Be specific): � r� �. �� -'�� "�.�� ` ��: .�:�.� , � � � 7. DESCRIBE ACCI�ENT OR OCCURRENCE THAT CA�lSED INJURY QR DAMAGE, �Giv� � f�ll detail� upc�n which yau ba.�e your c�aim. If a �ity employe� was involved, give the ' employe�'� name.) � `- � �� - �� J� � ! � �� .. � �-�� 9 8. What w�re wea�her c€�nditions like? ��,,�i � 9. Giv� r��rr�e and addres� Qf any witnesses: ' 1 Q, Did polic� ir�vestig�te? {If so, give n�rr��s of offic�rs.} 1� � '1'1. Was anyone injured? (If so, give names, addresses, and extent of injuries}. � o- � I � � B5 9 e � 12. Was any damage done #o property? (If �o, de�cribe proper�y and the ext�n# of � damag�s, Aftach estimates of damages or describe basis far asce�rtaining extent of damag�.) � � �� c a � € � '13. Wh�t other damag�s do you claim, if any? �� G 9 ' � � 14. Hav� you been compensated fQr any part c�r all of your claim by any insurance . �; cc�mpany? (If so, give name and address of insurance company and amount paid.) a 1� �;, �� , '15. What amount do yau claim from the City t�f Dubuque? �� d,� � � ��' ' 1G. Why do you ciaim the City ofi Dubuqa�e is re�ponsik�le? � , �� ,� �a �,� ' � � � � �� 17. Have you macle any claien against anyone els� f�r damages as � res�lt of this incid�r►t? �' (if yes, give narne and addres�.} � k 18. 1� the answer �o Questiar� 17 is yes, have you r�ceiv�d any paym�nt from th�t source, and if so, in wh��amaunt? E � ; Da�ed �t Dubuque, lowa this � da�r af , 20��. ; I � (Sig�ature� I �� ' � {Print Name) _ .� �� _�� i ��' �-� -� !�'� � � �� ,. � {Rev. 5118) � �� °�. � � � � � � � � 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) Personn�l/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 the City to act accordingly taking all precautions to protect my information from unnecessary distribution. Signature Date Copyrighted November 5, 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: Claudette Coleman for vehicle damage, Eagle Window& Door for property damage, Lindsay Lannen for property damage, Lori Lewis for vehicle damage, Sandra Wolbers for personal injury. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Supporting Documentation � V THE CITY OF �,�. V .V Lt � � � 0 1\ � l \ � V � � Masterp2ece on tlze Miss2ssippi � TRACEY STECKLEIN PARALEGAL � � To: Mayor Roy D. Buol and �,� Members of the City Council ' DATE: October 23, 2018 '� � i RE: Claim Against the City ofi Dubuque by Lori Lewis ' i� Clairr�ant Date of Claom Date of Loss RJature of Claim ;� Lori Lewis 10/22/18 10/09/18 Vehicle Damage I �� This is a claim in which claimant alleges that a curing compound was inadvertently I�� oversprayed on claimant's vehicle during curb installation at 1000 White Street. This claim has been referred to Public Entit Risk Services of lowa the a ent for the low y , g a , Communities Assurance PooL �� J cc: Michael C. Van Milligen, City Manager � Gus Psihoyos, City Engineer Lori Lewis 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