The URL can be used to link to this page

Claim by C. Dennis Gansemer 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 c�1 f� U ,J, }�I v5-k�-�-t.ar� CLAIiV� AGAINST THE C1TY OF DUBUQU�, IOWA This written report constitutes your claim against the City of Dubuque, lowa. You should � complefie this form in full and attach any additional information that supports your claim. j� '� The Claim rnus# be filed with the City Clerk at City Hall, 50 W. 13t" St., Dubuque, IA 5200'i. It ; will then be referred by the City Council to fhe appropriate department for investigation. � Once that investigation is completed, a report and recommendation w.ill be submitted to the � City CounciL You will be provided with a copy of that report and recommendation. '! � THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO ,EMPLOYEE OF ,� THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU � AS TO WNETHER YQUR CLAIM WILL OR WILL NOT BE PAID. y . � � �� 1. _Name of Claimanfi: � ; � � �� ,i 2. Address: �� '� �� -�' �i . � City: ,,`7�+�' � ;��,.�,�r� State: _ ��t°'�� Zip: 1 3. Tele hone Number: R ��',S` � �' `7 � ��'..� 4. Date of Incident: � �.. � " � �I.�: i „ 5. Time of Incident: � w �� . � . �, � � 6. Location of Incident (Be specific): ��- ,�° � t�.�' ;2��;�t.,e�" l�S`� �� ,i`� � ,�' ` '� , �, (� a� ' � � ; 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give full details upon which you base your claim. If a Ci#y employee was involved, give the � employee's name.) � � ; .et'"�rc�/2•�.- l3�°�- s � � 8. What were weather conditions like? ,,,� 0 /,�s,�.r _ _ -- J e 9. Give name an�l address. of a�y witnesses: �'1,�, 10. Did pofice investigate? (If so, give names of officers.) � � 11. Was any�ne injured? (If so, give names, addresses, and extent of injuries). � . 12. Was any damage done to property? (if so, describe property and the extent of damages. At#ach estimates of damages or describe basis for ascertaining extent of damage.) �� t � � : , � '13. What other damages do you claim, if any? �''B.�U I I 14. Have you been cornpensated for any part or all of your claim by any insurance company? (If so, give narne and a�ldress of insurance company and amount paid.) � � �� .�.� ,�� 15. What amount do you claim from the City of Dubuque . ; � � ,1 , �i 1,�. Why do you claim the City of Dubuque is responsible? ;j �1`' ° `�.� D � �.,5� � s � I� . _ _ . . �N � 17. Have you made any cla�m agains# anyor�e else for damages as a resuit of this incident? (If yes, give name and address.) - �� 18. If the answer to Question 17 is yes, have you received any paymen# from that source, and lf so9 in wh�t a�ount? _ ;;� � � C7 � � �i Dated at �ubuque, lowa this � day or��,�� , 2�� :_�`�~ � � �� =' � �-�, � ��- cr> �, � � � � � � � � ir� --� ,�� r� (�ignature) e--��' � � � � e� �� C� ,�; � � � �, r ��`�.�' ..��'�,/��:/��/�' (Prin� Name) � � � � � � � � ��" `� � �,�°'� > � (Rev. 5/18) ��„��L�'� � � _ ��t'�`�<�t.l�"Z./ . � � � Confiidential This communication and any attachments may contain information which is confidential and privileged by law and is for the use of the designatsd 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 co in of its c �'� py g ontents „ 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 !I immediately. Further disclosure of this information may violate stafie and federal �� restrictions. . � I,I i Confidential information may include the following: 'a 1) Social Security Number(s) '! 2) Medical/Health Information ` 3) PersonneUDisciplinary Information 4) Bank Account Information a 5) Financiallnformation � 6) Credit Card Numbers '� I� �i 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; , II �� , hereby certify that the attached documents include the following protected information: Social Securit Number s � Y O Bank Account Information 3 Medical/Health Information Financial Information Personnel/Disciplinary Information Credit Card Number(s) � i 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 � Qate � � 0