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Claim by Shannon Katka Copyrighted May 20, 2019 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Shannon Katka for personal injury/vehicle damage, Jordan Lyons for vehicle damage, Sherrie Moriarity for vehicle damage, Linda Rauen for vehicle damage, Kimberly Sampson for vehicle damage SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City Attorney ATTACHMENTS: Description Type Claim by Shannon Ketka Supporting Documentation Claim by Jordan Lyons Supporting Documentation Claim by Sherrie Moriarity Supporting Documentation Claim by Linda Rauen Supporting Documentation Claim by Kimberly Sampson Supporting Documentation . � �" � , �� CLAIM AGAINST THE CITY OF DUBUQUE, IOIJVA ��'�� ' _ � ` . � This written report constitutes your claim,against the City of Dubuque, lowa. You should � complete this form in full and attach any additionai information that supports your claim. �� The Claim must be filed with the City Clerk at City Hall, 50 W. 13t" St., Dubuque, IA 52001. It will then be referred by the City Council to the appropriate department for investigation. i 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. � �+ THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF THE C1TY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU ;1 AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. fl _ f � ii � I) 1. IVame of �lairnanto * i �,. �,° :, ' s � �f[c, i 2. Address C� ' ,{� `'�� I� � I City: ��►��u c;�r,c�� State: _ � .� � Zip: ,,��I �� , 3. Telephone Number: ��.,� � ,2�� 2� 7,� � � 4. Date of Incident: ,�' .�-- ��j '�� , I� 11 5. Time of Incident: "��` c� /�,�. �� . �� : a � 6. Location of Incident (Be specific): �� '�� .�� '� �� `�d'�,r ,��a � '� �� „ ;; 7. DESCRIBE ACCIDENT O �� R OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give full details upon which you base your claim. If a City employee was involved, give the � �� employ�e's name,) i _ � ��`"� �. ��M � ��G� C�"1� '�1 v IPYk"r'�`t,�''ea`/�� ,r1� �1'��r �tS�!'`►°1n t'!a� - ��r� �� `�"fi �.� �r� e�fi��i � ' � � 1 8. What were weather conditions like? ��,� 9. Give name and address of any witnesses: __ ��5 �w �",�. �,,�� 10. Did police investigate? If so, ive names of officers. �'�y ��'" ��r�� J ) � �.�r�- ��`� �� ;�I� �r°�n�� f�c�. �� p��°��, 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). � _ � � �� 7 �► ��,"t��, ��Yr'4 , ,�h��C. C�.�� t�v1� �`1�'� � � ��a:e,"r �� ff i�n 1�?� �C��r '�4� �'�°Gl`�1��1 ��fh'°^ i � 9 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 I damage.) , �K��s'�., � � _ � ' a�1 � �d' �� I �� c��,. -�t � ,��I'��f,� � a � �� 7'�`�� , I �, ��I. � ��.� 13. What other damages do you claim, if any? iA!r,�;�� 1 � � � �� y� l��„� � �� -�a�r �� 14. Have you been compensated for any part or all of your claim by any insurance �� com an � If so ive name and address of insurance com an and amount aid. � p Y• � � 9� P Y p ) }� � � � �'� �� ;� "�-�--� ll�`t V t�: 15. What amount do you claim from the Cit, of Dubuque? , Ii� n�� J�,a �� I�� r�� P�� ;� � 16. Why do you claim the City of Dubuque is responsible? �^ ; � � ��- �. � � �$- N � �� " � ►�r, �, l�� + a�.��i � �t I 17e Fi�ve you rna�fe any �la�rn against anyonp else for damages as a result o##his incident? �� ; (If yes, give name and address.) 4; , �� ;� 18. If the answer to Question 17 is yes, have you received any payment from that source, � and if so, in what amount? � , ,. � , ,� .> � d�� f � 20 �1 . ' ��#�s! at D�b�que, lo�� this , � � � � (vigreature) � � �, � ��a�"1 ►�ck`��a (Print Name) + }��= � �.a � .:�"a �� ; � �� :�� .., � .q�F� ;��." � � �j' � � � � � �� . �" -.. (Rev. 5/18) @ �°� � I 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 reci ient � p' , 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: f� � 1) Social Security Number(s) � � � � � 2) Medical/Health Information 1 3) PersonneUDisciplinary Information 'H � 4) Bank Account Information � � 5) Financiallnformation !; u; 6) Credit Card Numbers ; ii �� If any documentation you desire to submit to the City of Dubuque contains any of the items above ij this cover sheet must be attached directly to the confidential information and indicate the type of ';; information that is included. � � � � � �� , �� {i I ' � � Y r��,�� , hereby certify that the attached documents � include the following protected information: � Social Security Number(s) Bank Account Information � Medical/Health Information Financial Information Personnel/Disciplinary Information Credit Card Number(s) 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. ,.�- � �� . �._..... '� v J '�r � j 6 � / Signature Dat2 Copyrighted May 20, 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: Shannon Katka for personal injury/vehicle damage, Jordan Lyons for vehicle damage, Sherrie Moriarity for vehicle damage, Linda Rauen for vehicle damage, Kimberly Sampson for vehicle damage SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Supporting Documentation THE CTTY OF ��.JB UE MEMORANDUM Mccsterpiece on the Mississippi � TRACEY STECKLEIN =''�� PARALEGAL � J � To: Mayor Roy D. Buol and � Members of the City Council � II DATE: May 7, 2019 I �i RE: Claim Against the City of Dubuque by Shannon Christopher Katka i � Clairr�ant Date of Claim Date of Loss Nature of Claim :� �i � Shannon Katka 05/06/19 05/05/19 Personal Injury/ Vehicle Damage ;� �a This is a claim in which claimant alleges that he was injured when the wheels of his II motorcycle lost traction as he encountered an oil slick turning left onto Central Avenue ,� southbound from 20th Street. N �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 Klostermann, Public Works Director � Shannon Katka � 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