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Claim by Van Meter, Inc. Copyrighted April 15, 2019 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUM MARY: Van Meter, I nc. for property damage, SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City Attorney ATTACHMENTS: Description Type Van Meter Claim Supporting Documentation �� r. � � CLAIM AGAINST THE CITY OF DUBUQUE, IOWA �.�L � �R ,a � "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. '� The Claim must be filed with the City Clerk at City Hall, 50 W. 13t" St. Dubu ue IA 520Q1. I � ,q � t `� will then be referred b the Cit Council to the a � � Y Y ppropriate. department for investigation. Once that investigation is completed, a report and recommendation will be submitted to the !; City Council. You will be provided with a copy of that report and recommendation. 'i, I 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 WHETHER.YOUR;C,LAIM VVILL OR WILL NOT BE PAID. } _ I 1. Narn� ofi Clairrran�: �'�, ��`�'�� i � � � � � 2. Add�ess. `� �+f' �i�` �1 �� ' N �� i _ CitY: .� �� ! �,t� State: �� , Zip; � � i p �� " �� l��' f 3. Tele hone Number: _ �� il �, 4. Date of Incident: � ,�" � "' I � � �, : , 5. Time of-Incident: °r�� ,°y�, � � . �� N� 6._�.-_Location of Incident (Be specific): s� ��,o�- '� ��,� 1 �� e��y� h c�c,� �a�,e�e C i � � . �.:`� C��-- �°�� ; I' � � �� 7, DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAG � E. (Give ,� fu11 details' upon which�youu base your claim. If a City employee was in�olved, give the ; e lo ee�s name. � ' �� r � � ��.,. . �� ?p Y � ): �,�(" C..l��. v'o �1�� r..c� �v�'� :�c� �' �' ��- ��c.�- ��` ��" l�,h c` �-�-,�.a� ► ��` �,� �rrn_ � � �: ��c c;�'� ��G ��.�� ~ � 'fi� �.��, ` cs��- e�t�c:.v^ ,l�� c�� ` � � � o�n.;'R,cx. �� 4. �> . �° ��,�� ' -4- he�ct �,�,,, - �, � �a c�: r� �:-� C'o 1cc " �� e ' �� =�a�,rf � �. �r�o �,� �� ,;�-P� ��-- �� '� c �c f� �-F- c�� '��. ` � 'r��c a �"�`�� ,� - - `��.� �-��.:� �t �� ; ; � �,. :�.�. � avL�: a.��:�r � I,�;�. ��-,�� : .� �:�, �n;�, �,. _- 8. hat were weather conditions:like? _ � ,.� , ,, � �,,,,cr'� � 9. Give name and address�of any witnesses: �'/�� 10. Did police investigate? (If so, give names of officers.) ` � , � �. 11. -Was"anyone injured? (If so, give names, addresses, and extent of injuries). �� - �,..��_._.�_�_.._o-.-,m.�- . �� . . v�' � �'�►�� i1�. �� ,e�l I��cc� Stet'tz�� t.�r'°d-� ��i�'h.�o �i� ��r`c�� . .�`�v-�� r�av�. �.c.� � '-C'►�e � �e��- �.b lc � �� t � ��c v� 1 e�n� �v�d' °� `�-�� -�°�� -h� bLp�.�e t��r�, c.�an�r� Cor��t ��.�- �� iwt��l ,�.�� Wr� ��r�c�� °12. 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.) �� 13. What other damages do you claim, if any? �p�� 14. Ha�� you be�r� cownpe�sa�t�d �For any p�rt or all of y�ur claien �y �ny insurance company? (If so, give name and address of insurance company and amount paid.) � 15. What amount do you claim from the City of Dubuque? /^� �} i ' � � �6F 6 � � . I 16. Why do you claim the City of Dubuque is responsible? ��-��- "°�'��- �'`��'°� ' °�-`°a-c. �e,r.,v��'.�� d � �4t.. c Y'"�. �.v^�. ��b' � - �r'In i s'.a Li G'��, a'�, .�aC.�'Gil��C �� -� `��'��'��, � �`t'� `�'C't t ��'�� a a� � t,�e�- � �'!r►,G. !; 17. Have you made any claim against anyone else for damages as a result of this incident? '� �(If yes, give name and address.) � � f� � �I. 18. If the answer to Question 17 is yes, have you received any payment from that source, �� and if so, in what amount? � �� , � � � � � � I� � � � � � � � Dafed at Dubuqu�9 I�vva thi� l_�[ day of � �� 20 Q�� _�,c, �, -- � ,� � � � ` - (Signature) � �� f °�� 'I (Print Name) �; � �=.�i.- .� �:�`�"- �:� :.�a« ��m �.� �� C� � � � �; �� ; � ,�-- ��t �'�'� s;.r,� ;� ..� (Rev. 5/18) m� �� µ; � � � .r�., � � '��'� a a"� , CTj � � � � � Confidential � � � � � aThis 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 i 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. � � ; I Confidential information may include the following: � � � � � 1) Sacial Security Nurnb�r(s) 2) Medical/Health Information 3) Personnel/Disciplinary Inform tion � 4) Bank Account Information . 5) Financiallnformation if 6) Credit Card Numbers � '�1 If any documentation you d ire to sub it to the City of Dubuque contains any of the items above ,N this cover sheet must be at ed irec ly to the confidential information and indicate the type of ; information that is included. '\ i � �� , reby certify that the attached documents include the following protected in ormation: Social Security Number(s) Bank Account Information i� ; Medical/Health Information Financial Information ' _�Persor�nel/Diaci�liroary Information (�r�,di� C�ard �Jumb�,r(s) � I understand that this information may be distributed within the City organization ar to agents of the C:itv fnr rrnrPgciny anrl I harAhy ��;thp�-,�o +h� ��y �� u�� G��u�ny��' �Q��y Q�� Ni2�,auiivila iv protect my information from unnecessary distribution. � � Signature Date � � � , Copyrighted April 15, 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: C. Dennis Gansemer for vehicle damage; Donna Sindahl for vehicle damage; Van Meter, I nc. for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo THE CITY QF .�LT� E MEMORANDUM � � Mc�sterpiece on tlte Mississippi � � TFZACEif �TECiCLEiiV � � PARALEGAL � To: Mayor Roy D. Buol and Members of the City Council � DATE: April 2, 2019 � � RE: Claim Against the City of Dubuque by Van Meter Inc. � Claimant Date of Claim Date of Loss Nature of Claim ; � Van Meter Inc. 03/29/19 03/08/19 Property Damage I� II This is a claim in which claimant alleges that the sewer line leading from claimant's !i building to the main at Kerper Boulevard was blocked. I � 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 � John Kiostermann, Public Works Director _ Keith Knockel, Van Meter Inc. 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