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Claim by Adrian Appelman Copyrighted April 1 , 2019 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUM MARY: Adrian Appelman for property damage, Wade Duncan for vehicle damage, C. Dennis Gansemer for vehicle damage, Donna Sindahl for vehicle damage. Francis J. Ward for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City Attorney ATTACHMENTS: Description Type Appelman Claim Supporting Documentation Duncan Claim Supporting Documentation Gansemer Claim Supporting Documentation Sindahl Claim Supporting Documentation Ward Claim Supporting Documentation � � � ��i� �� CLA9M AGAINST THE CITY OF DUBUQUE, IOWA � 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. 1 3 � The Claim must be filed with the City Clerk at City Hall, 50 W. 13t" St., Dubuque, IA 52001. It �I� will then be refierred b_y the Cit_y Council to the appropriate department for investigation. � Once that investigation is completed, a repor� and recommendation w.ill be submitted to the � City Council. You will be provided with a copy of that report and recommendation. � THE FI�IAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL.: NO ,EMPLOYEE OF ! THE CITY OF DUBUQUE HAS THE Ak1THORITY TO MAKE ANY REPRESENTATION TO YOU �, AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. �j 4 1. Nam� of Claimant: �c�r-ic�� c�c�' , �� ' �t� . . _ i y � 2. Address: � � �rh,,� J ��""j ;, Cit Ltl��.�� r State: �� Zip; ��.-- . y: � e G� --- 3. Telephone Number: ,,j��- !�g(�� '�d� � 4. Date of Incident: t/ �`�/� `� I 5. Time of Incident: ir-5'}� �� %`�'. (� a �� c�rv� , 6. Location of Incident (Be specific): �, . �� t� 3 L�'� ��` ��°. `�� i� +^ 9 �� 7. DESCRIBE ACCID�NT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. '(Give fu11 details upon which you base your claim. If a City employee was involved, give the employee's name.) a � l V V ��'l.�:� � 1/lE� '�,� �'I 7�A� %.a �S� 1oLf�Y� +3 N V 1�ls/ � � T f �� A.0°� �� °�'ilmL.�i�"•P "�A� � t I�l��a.> � 8. What were weather conditions like? c��R�d� 9. Give narne an�f address of any witnesses: 1e��- _ 10. Did police investigate? (If so, give names of officers.) �t� 11. Was anyone injur�d? (If so, give names, addresses, and extent of injuries). �� 1.2. 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.) / �.�`,*X+!IV�� _�._°fM��.+..:�A✓� �� 'b"Y�,\ ��.a � . � . � � . ' . � . . . � D 13. What other damages do you claim, if any? _ �.lF� : 14. Have you b�en compensated for any part or all of yo�r claim b� any' insurance company? (If so, give name and address of insurance company and amount paid.) l�� 15. What amount do you claim from the City of Dubuque? '�'� ��'� f.�� 16. Why do you claim the City of Dubuque is responsible? �f�ir S:�<�' �:a C'r��v �� _ � 17. Have you made any claim agains# anyone else for damages as a result of this incident? (If yes, give name and address.) : �� 18. If the answer to Question 17 is yes, have you receiv�d any payment from that snurce, and if so, in'what amount? 1�.�,� � � Datea ai �u�uque, iowa this � day ot /�� , 2G� �- (Signature) " P �''�� 'l Print Name ( ) � � �:: � c�` c�-; � � .� � � �� - � �. (�2ev. 5/18) �� :� :� �, �`� .� � s -�.:� 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: '!) Social Securit� Number(s) 2) �Jl��i�al/i-�e«!th lnforaraticn 3) Personnel/Disciplinary Information �, 4) Bank Account Information 5) Financial Information 6) Credit Card Numbers ',,� �� If any documentation you desire to submit to the City of Dubuque contains any of the items above ii this cover sheet must be attached directly to the confidential information and indicate the type of '' information that is included. ,� , � � � � I� I, , hereby certify that the attached documents � include the following protected information: � Social Security Number(s) Bank Account Information �� 'I � Medical/Health Information Financial Information y � ;i Personnel/Disciplinary Information Credit Card Number(s) � � I understand #hat this inforrr�ation may be distri�utec� withir� the �ity organizaiaon or to �g�nts af th� City for processing and I hereby authorize the City to act accordingly taking all precautions to protect my inforrnation from unnecessary distribution. ` ° � � /'� Signature Date � Copyrighted April 1 , 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:Adrian Appelman for property damage, Wade Duncan for vehicle damage, Francis J. Ward for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo 9 THE CITY OF I�'� E MEMORANDUM M�sterpiece on the Mississippi TRACEY STECKLEIN "'�� PARALEGAL �'v � To: Mayor Roy D. Buol and Members of the City Council DATE: March 15, 2019 RE: Claim Against the City of Dubuque by Adrian Appelman � � Claimant Date of Claim Date of Loss Nature of Claim H � Adrian Appelman 03/15/19 01/29/19 Property Damage � H , This is a claim in which claimant alleges that a Public Works employee driving a City snow �� plow truck plowed snow into claimant's fence, damaging the fence. � This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa � Communities Assurance Pool. � �, cc: Michael C. Van Milligen, City Manager il John Klostermann, Public Works Director � Adrian Appelman � OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 � TE�EPHotvE (563)583-4113/F,vc (563)583-1040/EMai� tsteckle@cityofdubuque.org