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Claim by Nicole and Ricardo Woods 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 f �f ��g � . D"�r Cf�*�-"" ��AIM AGAI�VST THE CITY #�F DU�UQUEa IUWA � �� l�� r�.� v :� This written r�port �onstitutes your claim against fihe City ofi ❑ubuq�e, 1owa. Yc►u should ��r��, � complete thi� form in full and attach any additional information that supports yaur claim. � 3 T�e Claim must be filed with fihe City Clerk at City Hall, 50 W. 13�" St., Dubuqu�, IA �200'1. 1t � wiH then be referred by the City Council fio the appropriate deparEment for invest�gation. � Once that investigation is completr�d, a report and recommendation will be submitted t� the a City CounciL Yo� will iae provided with a cc�py of that report and recommendation. ; � THE FINAL DE�ISItJN ON AI.L CLAIM� IS MADE BY THE GITY CCIUNCIL. Nt? EMPL{�YEE OF � ifHE CITY OF C7UBUQUE HAS THE AUTHtJFtITY Tt'� MAKE ANY REPFtESENTATl6JN TO Y4t1 � AS TQ WHETHER YC}UR CLAIM WILL UR WILL MOT BE PAID. ? � ; 1. N�me �rf Claimant: # ..�' � C 2. Addre�s: ,��.�� ,��i.��- ��,. � Cit State: �!� Zi .��' � Y� t��. �' �i � 3. Tel�phane Number: _��..� -�5�..�. - ��" �-- K�`�.�� -.�� --�,.�-�� I 4. Da#e of Incident: �''�� ,/ � �� 5. Ti�nne of In�ident. ,.�� ..�/ ! � 6� �ocation of Incident (Be specific): �� - l� r�..5'� � a r � � � 7. C}ESCRIBE ACCIClENT OR OCCURRENCE THAT CAUSEQ INJtlRY C1R DAMAGE, (Give � fufl detai�s upon wf�ich you base yaur claim. Ifi a Gifiy emplayee was i�nvolved, give the " empl+ayee's name.} � � � � � � � � `. � �� r C�.. '€ � t � _� � - _ � � ° �`� �-e.c��l�.K 8. Whafi wer� weather conditions like? �� 9. Give n�rrie and �ddress of any witnesses: _�_(�-u ��.��t�� '�.�� 0. Did police inv+�sfigat�e? �If so, �Pve names of officers.� � _ � � � � � � '�1. Was anys�ne �n�ured. {If so, g�ve nam��, addresses, and �xfent af in�ur�es}, � ' � I � � � i '12. Was any �amage done to property'? {If so, de��cribe property and the exten� of damages. Attach estimate� of darnages or des�ribe ba�is for ascertaining �xtent af � damage.} � �`/�� '� �.t`� y '�"`�' � c�' �� ; � �t��.�i�a�,r_ .� ��5 � � 13. What other damages do you claim, if any� m� _��° � � �p'$ * � � t Z t 14. Harre you been campensated for any part or all c�f your claim by any insura�n�:e � company? {If so, give name and atldress of insuran�e company and amount paid.) � � �� 95. What amount do you claim from the �ity af �ubuque? I ��l r� --e� ` .� .� . �� .� �' ` � .� � � � 16. Why dca you ciaim the City o�Dubuque is respc�r�sible? � rz t e^� '� �t�c��.�` "�� o'�.t; z,�$�',s ��t,�.�. C? �t. €.�J� �Y'Gt. C C� �°...C.� �r�`�, �,�-' �� t;�5 ��'� ; �7. Hav� ya� rnade any claim against ar�yane else for damages as a result of this incident? � {1f yes, give narne and address.j �� ;� '18, If fihe answ�r to Question �17 is yes, have you received any payment from that so+�rce, � and if�o, in what amQunt? �` �l�' 1 ii ,, L2�#�d �t �►a�ba�c�a��, lr�e�►� �h6� �� d��O a�� °�� . � � � .. n, . �� . � �Signature) .P��t�°�1�_�„��'�-�'� 1Ga`�� -�` �Prir�t Name) � � � � � � .�� y� � �.,.�,;.� c`� �' � � � � �� .� (Rev, 5118) ,�. � s � a ti � � a 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 a is prohibited. Please notify City of Dubuque irnmediately 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: �� F 1) Social Security Number(s) ti 2) Medical/Health Information I 3) PersonneUDisciplinary Information � �) Bank Account Information �� 5) Financiallnformation ,1 6) Credit Card Numbers � I. If any documentation you desire to submit to the City of Dubuque contains any of the items above �I� this cover sheet must be attached directly to the confidential information and indicate the type of ;� information that is included. ;{ �� I, �t��,�_ „1.��de�s" �- ��°c��rr�cJ �� ',�a�ar�s , hereby certify that the attached documents I�� include the following protected information: I'; � Social Security Number(s) Bank Accounfi Information � 9 Medical/Health Information Financial Inform�tion � � Personnel/Disciplinary Information Credit Card Number(s) � 1 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. , � ,� �'z�r'�z�r� Signature Date � 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 i THE CITY OF i L��CT� E MEMORANDUM Masterpiece on the Mississippi � � TRACEY STECKLEIN PARALEGAL I� I� I� To: Mayor Roy D. Buol and i Members of the City Council DATE: February 21, 2019 il Is RE: Claim Against the City of Dubuque by Nicole & Ricardo Woods ��E ; Claimant Date of Claim Date of Loss Nature of Claim � � �� IVicole & �icardo VVoods n2/2d/19 02/18/19 Personal Injury/ � Vehide Damage �1 This is a claim in which claimant alleges that as they were in their vehicle in the left lane � at a red light on Bluff Street at West 9t" Street, a Public Works employee driving a City ' vehicle attempted to turn left from the right lane on Bluff and struck claimant's vehicle. This claim has been referred to Public Entit Risk Services of lowa the a ent for the lowa � Y , 9 Communities Assurance PooL � � i cc: Michael C. Van Milligen, City Manager i John Klostermann, Public Works Director � Nicole &� Ri�ardo Woods � OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 TELEPHONE (563)583-4113/Fax (563)583-1040/EMai� tsteckle@cityofdubuque.org