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Claim by Hope Ehlinger Copyrighted March 4, 2019 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUM MARY: Hope Ehlinger for vehicle damage,Audrey Gottschalk for vehicle damage, Zachary Hallman for vehicle damage, Andres Liza for property damage, Kalyn Nowacki for vehicle damage, Conor Shoellhorn for vehicle damage, Nicole and Ricardo Woods for personal injury/vehicle damage, SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City Attorney ATTACHMENTS: Description Type Ehlinger Claim Supporting Documentation Gottschalk Claim Supporting Documentation Hallman Claim Supporting Documentation Leza Claim Supporting Documentation Nowacki Claim Supporting Documentation Shoellhorn Claim Supporting Documentation Woods Claim Supporting Documentation �� , �`�,S i CLA1M AGAlNST i'HE C1TY OF DUBUQUE, IOWA `J• ��nS-�r-�.c,.�.� This written report consfiitutes your claim,against the City of Dubuque, lowa. You should � complete this form in full and attach any additional information fihat supports your claim. ; , The Claim must be filed with the City Clerk at City Hall, 50 W. 13t" St., Dubuque, IA 52001. It ' wiil then be referred by the City Council to the appropriate department for investigation. Once that investigation is completed, a repo�t and recommendation w.ill be submitted to �he � City Gouncil. You will be provided with a copy of that report and recommendation. ' �� THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE C1TY COUNCIL: NO EMPLOYEE OF I� THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. _ , i u 1. Name of Claimant: .� 1 �'�� , '� 2. Address: �� .�' ; G n � •� . ,I City: ��,i' State: �.��i� Zip: �� I � � ;� p �C��- � g� � s��'`� �a ; 3. Tele hone Number: � I; 4. Date of Incident: _ � I �' � � ; n �° 5. Time of Incident: u a � � � ; � , � u 6. Location o# Incident (Be specific): �'� �( V ��0 ,:�� - � .� I� � V � � �� _ � � 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT C�4USED INJURY OR DAMAGE. ° Give I fufl details upon which yo�a base your claim. If a City employee was involved, give the employee's name.) �1�' � y��l-� `�1�� , -� �(1�� ' i , � " a � 8. What were weather conditions like? _ ��`.� a 9. Give name an�! address of any witnesses: w � ��('�.�� } �j�� j��'Pi � 10. Di�! olice investi ate? If so �� p g ( , give names of officers.) � �� 1'I. Was anyone injured? (If so, give names, addresses, and extent of injuries). '', I� � i 6 € a . � 12. Was any damage done to property? (Ifi so, describe property and the extent of �� damages. Attach estimates of damages or describe basis for ascertaining extent of '� damage.) � � � � . � � .. � . '� � d c•� �.�'. .. u , � ' . a '.. . . f. r ��-��,! �`� �'1��,�,7•�� l/ �'9�! �;�",��,��rs �� 1 �� ` ��V16�Q� � �� '��Y��a - � 13. W a other damages do you claim, if any? ' � �, i � �� 14. Have you b�en 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.) � � ` ,,. I 15. W t � o nt do you claim from the City of Dubuque? ��1;� � " p J i 6. Why do ou claim the City of Dubuqa�e is responsible? ��, � � �� '� �� `lr��1�� 1 � - y ��d� �°0� � �y�v��ro I�e�4�(�11�1 V��:t��..s �U��c, � ��I, 4 17. Have you made any claim agains# anyone else for damages as a result of this incident? � (I#yes, give name and address.) � f . . . . . . . - . . � .. � . 4 18. If the answer to Question 17 is yes, have you received any payment from that source, i and if so, in what amount? ` h f a ' � � � �iated at �ubuque, iowa this dav ot , 2�i ' - - - � � ,.. ----� � '� (Signature) � , � ; i' (Print f�ame) ' � � �-�� -�- C; �' ��¥ �, �i, �'oa � .� �; '"� E•�� cr' C�t.t �� @V. rJ�'�8� ,_'' � �� I Qf a �i' Confidential This communication and any atfiachments 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)-5�9-4120 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 Ir�formation i 4) Bank Account Information � 5) Financiallnformation j 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 dir ectl to the c onfide , Y ntial information an ' . d indic ate the t e of information Yp that is in i. cluded. ; , �, � � �` I! ° , hereby certify that the attached documents r include the following pro�ected information: � Social Security Number(s) Bank Account Information II� Medical/Health Information Financial Information � 9 Personnel/Disciplinary Information r�rA�;+ r�r� n�,imh„r��, � � ...u�..� �vuii�uci�a� I understand that this information may be distributed within the City organization or to agenfis of the City for processing and I hereby authorize the City to act accordingly takin.g all precautions to protect my information from unnecessary distribution. 4. r �-�,� - I 1 � Signature �ate � i