Claim by Kimberly Sampson 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
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CLA1l�l AGAIN�T TNE CtTY (JF DUBUQUE, [OINA
This wr�tten repor� constitutes your claim against the City of Dubuque, lowa. You should
complete this form in full and attach any addifiional information that supports your claim. �
The Claim must be filed with the City Clerk at City Hall, 50 W, 13th St., Dubut�ue, IA 520�'I. It 'i
�r��� ���n be referred by the �ity Council to the apprapriate department for investigation. �
Once tha# investigation is completed, a repart and recammendation witl be submitted to the �
City Counc�l. You wiil be prc�vided with a copy of that report and recammendation. �
THE FtNAL DECISIQ(V ON A�L CLAIMS IS MADE BY THE C1TY Ct7UNCIL. NtJ EMPLQYEE UF I
THE CITY CJF QUBUQUE HAS THE AUTHARfTY TO MAKE ANY REPRESENTATIC3N TfJ YC}U ''�
.AS TO WHETHER YC}UR CLAIM W1LL t�R WILL NC}T BE PAID, �
1. Name of Claimant: ��`�t�-�,�,�-�,; � „�
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2. Address: � �� �� ,,�.. �j;.�,,� � �, i
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�ity: _ f�`�c� �,�fr���� State� ���
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3. Teleph�ne Number: �`�, �� ��c��-���,�c �
4, C}ate of Incident; � �� ,�� �c�
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5. Time pf tneident: _---1C� r��, !�
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6. Location of lncident {Be specific): t�r��„�,,,� ��...�� ��. �.. � ��1
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7, DE5CF�IBE ACCIDENT OR C7CCURRENCE THAT CAUSED tNJUf�Y {�R DAMAGE. (Give
fiull detaiis upon which you base your claim. If a Gity employee was invc�lued, give the
employee's name.)
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�t-t�..1_� �^,c ;t �S i r!t �:� '_ _„ ��rt.` '7--,.��P �,�L.-�Cl-s—c t.�,
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8. What were weather conditions like? rfi1,�,-,,.
9, Give name and address of any witnesses:
'10. Qid pc�tice investigate? (Ifi so, give names of officers.)
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�1'!. Was anyc�r�e inju�ed? {If so, give names, addresses, and extent af injuries},
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fi2. Was any damage dane to property? (tf sa, describe property anci the extent of
damages. Attach estimates of damages or describe basis for ascertaining extent of
damage.}
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13. What ather damages do you claim, if any? _ �,.� �- �
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'(4. Have you been compensated for any part or all of your cfaim by any insurance �I
company? (If so, give name and address of insurane� company and amount paid.} '
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15. What amount do yau claim from the City af Dubuque? I
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16. Why do you claim the City af Dubuque is responsible? i
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17, Have you made any claim against anyone etse for damages as a result of fihis incident?
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(If yes, give name and address.)
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18. If the answer ts� Question 17.is yes, have you received any payment from that saurce,
and if so, in what amount?
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Dated at Dubuque, lowa this �`�O day of A�, 1 , 20�,
��r� Ut� f'`�e��r�.�'� �cy�v� 1.�7��i�eLtJ.` � (a tm � (Signature) �7 �
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�tr�.��;c� �..� e�rc� (Print Name) � ��? �., t:.,�
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(Rev. 5/'18}
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
'i'HE CITY OF
�.B E MEMORANDUM u
Masterpiece on the Mississippi
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TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
DaTe: � May 6, 2019 �
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RE: Claim Against the City of Dubuque by Kimberly Sampson !
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Claimant Date of Claim Date of Loss Nature of Claim i
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Kimberly Sampson 05/06/19 04/29/19 Vehicle Damage ;I
This is a claim in which claimant alleges that her vehicle which was parked on James l
Street was struck by a City of Dubuque Jule bus. �
This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa
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Communities Assurance PooL
cc: Michael C. Van Milligen, City Manager
Russ Stecklein, Transportation Services Field Operations Supervisor
Kimberly Sampson �
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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