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Claim by Conor Shoellhorn 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 �� t� 1�'� t � CLAtM AGAINST THE CITY OF DU�UC�UE, IOWA ��'��t��""�r�`�'� �� This wri#ten report constitutes yc�ur claim a�ainst the City c�f Dubuque, lowa. You should complete this form in full and attach any additional informatic►n that supports y4ur claim. The C1aim mu�t be filed with the City Clerk at Gity Hall, 50 W. �13�" St., Dubuqu�e, IA 52001. It wi11 ther� be r�f�rred by the Gity Council to the appropriate department for investigatic�n. ()nce that inuestigation is cornpleted, a report and recornmendatian will be submitted to #he Gity Council. You will be prcrvicled with a copy of that r�epart and recommendatian. THE �'1NAL [3EClSlt?N tJN ALL CLAIM� IS MADE BY THE GITY GOUNCIL. NO EMPLQYEE C}F THE ClTY OF DUBUQUE NAS THE AUTHtJRITY TQ MA}�� ANY R�PRES�NTATION Tt� YOU � A5 TO WHETHER YQl1R CLAIM WILL t�R WI�L NC}T BE PA[D. � �,} 1 ,� �f. Nam� c�fi Glaiman#: � �� t��(��'� 'i /.��,�Z�> �� , � 2. Addres�; �1��? ��'d� ��. �� ityn ��t�,��,�.��;�; Stafe� �1�- �ip; '�c�--C.�C� " �` _ ,� � � 3. Telephc�ne Number: �� ( � '� " _�� ,i (3I 4. Date of Ir�cident: � " �� ` �� v � � �. Time �f lncident: � - �� `t i � 6. Locafiion c�f Inciden�E {Be specific): �� ;. �-c�e,ti;� � � ,.��.�S�C" ��, �� '' .�— � � � �; � �� '� TM� � � 7. DESGRiBE AGCID�NT �JR UCCURRENCE THAT CAUSED INJURY ClR DAMAGE. �Giv� ;� full de�ails upon which y�u base y�ur claim. If a �ity �mplayee was ia�volved, give �he � employee's name.� �1� .� ��1��.�r��,__� -T"�.�t��; ��ti�..�� ', ��..��?. �v�-� �� -- y�� .�.� �--r��.�.�-�- ��1�_��s�t��;�—�,. `�t�'t�..��— � � �(�� t�..,� ,��.�-� l� "•�� .� �- ��-�,��.� � � y j( ;- �}� }, . . . \ .'�l°l�� '��1! P '� 4�'4��' .. ��.4��Y�;Q.1'" \=4,4„s7� �� '�- �;� " � �, $. 4N'hat were weath�r conditions 19ke? ��-�_�� C��'��. ,.,� d`�C�� , � 1�. �� 9. Give name and addr�ss of any witnesses: � _ �. 10. �id palice investigate? {Ifi so, give names of afficers.� �� `�-�c,�..�' '��. �_ � �-�-. � r �� , 11. Was anyone �r�jured? (If so, give names, addresses, and extent of injuries}. �r�� ., � S ' � 12. Was any damage dc�ne tr� prc��erty� {If so, describe property antf the extent of damages. Attach estimates r�f damages or describe basis for ascertaining extent of damage,} � � �'-�,��' r�t�-`�~��e-�s � �t t,t��. �,�- r�,� �'�c.e.�-, �t�rw c��- ��e��,�r � � L � {w� 1 t '�� `��. �t,1.r'rti S�`�f't�r '�'� �,�� r � Y} � �{�.� ' t ��C 3 . t`T��. /.�1'2G� �. !'��r�r-I�� 'SY"�n � ��:��:�...�� `� ...� ,_ f �. 13. What other damages do you claim, if any? ` I _ � '14. Mave yc�u been cc�mpensat�ci for any par# or all of yaur claim by any insura'nce � corr�pa�y? ��o, give name and �ddress nf insuran�e company and amount paid.} � � ��r � � � � 15. What amour�t do you ctairn from the City ofi Dubuque? � � � `� �� c�� , -- �" �' ' � 16e Why dc� you ��aim the Gi�y of €�ubuque is responsibl�� ki +� ��-�.�:�'.�*- �Sn.-�j �..��s � �"1 i�-- t�,�. ' ��-�--- r,? �t) " °�. t�.,��.�.t �p�'w.-�� -„'� ^ �i � �� ,� .fc'..i�.G1�:��,�t,c.��. r ;r�(=�a�� ,� cy�.��. - � �,.,;��r '-�e. �`-t��r•�r-. 't7. Have yt�u rnade any ciaim against anyane e(se ft�r damages as a re�ult of this Bncid�nt? (If yes, give name and address.} � " ��, � � 48. If fih� answer to Questic�n �f7 is yes, have you re��ived any payment frc�m that saurce, 'I �r�d if sc�, in uvhat amcrunt? ' � � � �: C3ated a�t ��ab�qt�e, lawa th�� :�-�. day o# �-�. ��'u �,�'�, 20�. �''� � '�' .��--,�'`��-�---- �a r . ��71��t�r�� :�,�~ ��a�e.��..��-�-�. {Print Narne) �� ;' �' � C� ' ��_ c� �� .5�.� {' `�` �-�_� �' �,�j` „� c� � � � �� ; (Rev. 5!'I�j �� 3 6 � Copyrighted March 4, 2019 City of Dubuque Consent Items # 3. ITEM TITLE: Disposition of Claims SUMMARY: CityAttorney advising that the following claims have been referred to Public Entity Risk Services of lowa, the agent for the lowa Communities Assurance Pool:Audrey Gottschalk for vehicle damage, Andres Leza 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; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo _ __ _ � ,, � _ � . � Cc�nfidential This commurtication and any att�chmenfis may contain infc�rmation wl�ich is confiderttial � artci privileged I�y law and is far the use nf the designated recipient. if you are not the in#ended recipienfi, you are hereby notified that you have received this communication in � error, and that any review, disclasure, disseminatian, dis�ribution c�r copying c�f its contents ;� is prc�hibiteci. Please nQ�ify Gity c�f Dubuque immedfately by telephone at {�63)-589-4�20 of your receipt vf these items artd destroy the communicatic�n and any attachments � immecfiately. Further disclosure of this information may violate s�ate and federal j restrictions. � � a C�nfiden�ial inf�rrnation m�y include the following; ,� ,� 1) Socia[ Securit�r Number�s} � �} MedicallHe�lth infarma�ion ;1 3} PersonneflDisciplinary fnfc�rmatian � 4} Bank Account Ir�fflrmation 5} Financial Informatian � 6� Credit Gard Numbers � � if any documentatior� yr�u desire to submit tc� the Ci#y af Dubuque cc�nt�ins any o€the items above `; this cc�ver sheet must be attaehe� directly to the confidential inf�rmati�n and indicate the type of ',i information that is included. E� ,. � 1, ��-�'" ��'f'�- , hereby cerfiify that the attached documents � include the fio(Icawin ratected information: '3 9 � ii Social Security Number{s) Bank Account Informati�n '' � � MedicaliNealth Information Financial Information � ��F'ersonne(/Disciplinary Informati�n Credit Card Number{s) '� � i undersfiand that this inf�rmation may be distributed within the City �rganizatian or to agents �f the � City for processing an� 1 h�r�by a��h�rize the �it,1 t� �cf �cccr�ing€y taking all pr�c�utions to � pro#ect my information from unnecessary distributic�n. � � � - ��--- ,�`�--�. ��1��'�� ' ign�tur Date � � � � � THE CITY OF U�✓ � � � � 0 1\ � 1 \ � V � Masterpiece an the Mississippi ', TRACEY STECKLEIN '� � � PARALEGAL � I To: Mayor Roy D. Buol and Members of the City Council DATE: February 21, 2019 � �� RE: Claim Against the City of Dubuque by Conor Shoellhorn �; ii Claimant Date of Claim Date of Loss Rlature of Claim �' � �onor Shoelihorn � O�I21I19 02/16/19 Vehicle Damage � ,� � This is a claim in which claimant alleges that his vehicle which was parked at 1401 Wingate Drive was struck by a City of Dubuque Jule bus. �� This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa I Communities Assurance PooL i cc: Michael C. Van Milligen, City Manager � Russ Stecklein, Field Operations Supervisor � �� Conor Shoellhorn � '� � 11 i � � 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