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Claim by Linda Rauen 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 }� • } � p 0 G�AIM AGAINST 1`HE GITY OF DUBUQUE, IOWA �� ' :� � , � This written report constitutes your cfaim against the City of C�ubuque, lowa. Yau shc�uld � complete this fc�rm in full and attach any additianal infarmation that suppor#s your ctaim. � ; � The Glaim must be filed with the City Clerk at City Half, 50 W. '13t'' St., Dubuque, IA 520a'�. It w'[II then be referre�i by the City Council to the appropriate department for inve�tigation. y {�nce that investigatian is completed, a report and recommendation will be submitted to the f! City Cauncil. You will be provided with a capy of that repart and recammendation. � � THE FINAL DE�ISI4N QN AL� CLAIMS IS MADE BY THE CITY COUNCI�. NQ EMPLC}YEE t�F � THE CITY QF DUSUQUE HAS THE AUTHt�RITY TO MAKE ANY REPRESENTATION Tt� Yt�U � A� T{� WHETHER YC}UR CLAIM WI�L OR WI�� NC}T BE PAID. . �s 1. Name af Claimant: _,,�,{�� . d�.-�G�C,��`'� , �/ �. � �c��i� �t.�t�'�S �t3a� td � 2. F�ddre�s: � C e�ty: ��t��f� st�t�• ,�'t�c� z�p: � �� 3. Telephone Number: ��.� - L�..�(��`��( % � _��' �'�r ��l`� ; 4. C}ate af Incident: � ,; i ` d�l'wt. i� 5. Time of Incident: �t�• �� ,. 6. Location af Incident {Be specific): �. t� f r �,'�` �,�'� � r, .��e,��C t ��►�� c�.a�,�e�� -�t� 3��.i ��s a.h�. ��s� �-a -�-h�; ��r�s �c��c� � 7. DESCRIBE ACGIDENT OR OCCURRENCE THAT CAUSED INJURY t,�R DAMAGE. �Give � full detai�s upan w�ich yau base your claim. If a City emplc�yee was inval�ed, give the � employee's name.} � } , � m�n, �c�s c.u.��, c�r�s� c�t�� . so�- r � -�� r� �� rn�� r� � �' � � „ � �t1��' �l �"�1� b t�"� T 9� �ft?�t�' �' � d� �S's�,��. � � �. What were weather conditians like? �`� ��!1��"� - �SGt�►nv 9. Cive name and address of any witnesses: '10, did police investi�ate? (If so, give names of offiicers.) �� '�1. Was anyone injurect? �If so, give names, addresses, and exter�t c�f injuries}. , � �� 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.) �eS _ oIs �' 'wax LT 19 000,�,��es owa�� o�'bw� o, e as �h� I�. � �' 0. a VGr 0 u. h u f 'f s S, � � I; � 13. What other damages do you claim, if any? �One � � �I 14. Have you been compensated for any part or all of your claim by any insurance ,; company? (If so, give name and address of insurance company and amount paid.) ! �D I'a� ',i 15. What amount do you claim from the City of Dubu ue? �I Q�- u�� '� k�� 6 c�� o o ,' � Pre-es�'s -1'�. �(08�. S7 j� �� 16. Why do you claim the City of Dubuque is responsible? �i e( 'e ' � w r c 'f lo e oc s�b-c.�n-�ra�.�o� -�r C�� .U�.bc��c�.e � ;� 17. Have you made any claim against anyone else for damages as a result of this incident? � (If yes, give name and address.) �� o �;I �i 18. If the answer to Question 17 is yes, have you received any payment from that source, � and if so, in what amount? il (1 i � Dated at Dubuque, lowa this � day of , 20�. �i � � ° � (Signature) �1 I�� ,• I�,GI.u..F In (Print Name) C7 � ' �`� � � ��- �F� �`"� �`� � �. E�> � �" mE'� ,-�`.. .`J ,�,,,,�`� (Rev. 5/18) � `�' � � � � � C.a �� a Gonfidential � This communicaticrn and any attachments may cont�in information onrhich is confidential and privi�e�ed by faw and is for the use of the designated recipiertt. If you are not the intended recipient, you are hereby notified that yc�u have received this communicatian in errar, and that any review, t�isclosure, dissem€nation, distribution c�r capyin� of its contents is prohibited. Please notify City vf Dubuque immediately by telephone at (563)-589-4120 of � yc�ur receipt of these items and destroy the communicat�on and any ai�achments � immediately. Further disclosure af this information may violate state and federal � restrictians. q ;, � Confidential informa�ion may inc�ude the fallowing: � Y 1} Sacia�l Security Number(s) �� 2) Medical/Health Information 3} Perstznn�l/Discip0i�a�r �nfor��tion � 4} Bank Accaunt lnformation 5} Financlallnformatian B} Credit Card Numbers � 3 '� i lf any documet�tatian you desEre ta submit to the City of Dubuque cc�ntains a�y af the items above I? this cover sheet must be attached directly ta the confidential information and indi��te the type of � information that is included. il h � ?I N I, , hereby certify that the atta�hed docume�ts � include the fiallowir�g prc�#ected information: � , Saeial Security Number(s} Bank Account Infarmation �' MedicallHealth Information Financial dnfarmation � F'ersor�nel/DiscipEir�ary Infarmation Credit Card Number(s} � I understand that this infarmatian may be distributed within the City organization or to agents af the � City for prt�cessing and 1 hereby authori�e the City to act accordingly taking all precau�ic�ns to prc�tect my inft�rrr�atian from unnecessary distributio�. i `� ' . /,��ce�� —� �— �c��` Signature Date 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 CITY QF �Z.B E MEMORANDUM Mc�sterpiece on �he Mississippi � � � TRACEY STECKLEIN - � PARALEGAL To: Mayor Roy D. Buol and Members of the City Council DATE: May 8, 2019 '� RE: Claim Against the City of Dubuque by Linda Rauen � Claimant Date of Claim Date of Loss Nature of Clairr� Linda Rauen 05/07/19 04/24/19 Vehicle Damage � ; This is a claim in which claimant alleges that as a City employee was moving grass on Asbury Road, a rock flew from the lawn mower and struck and damaged the passenger � side front door of her vehicle. � l 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 !� � Linda Rauen � j i� ,9 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