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Claim by Kathy Jansen Copyrighted September 3, 2019 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUM MARY: Kyle and Shelby Christina for property damage, Kathy Jansen for vehicle damage, Gail Miller for property damage, Suit by Timothy McKenzie vs. City of Dubuque et al. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City Attorney ATTACHMENTS: Description Type Christina Claim Supporting Documentation Jansen Claim Supporting Documentation Miller Claim Supporting Documentation McKenzie vs. City of Dubuque Suit Supporting Documentation _ � 1�� , ��- C�AIM AGAINST THE CITY OF DUBUQUE, IC3WA �� '�� tr ��c�� This written repc�rt cc�nstitutes yaur claim against the City of Dubuque, lowa. You s�ould ; complete this fc�rm in full and attach any additional informatior� that supports your claim. � � a The Claim rnust be filed with the City Clerk at Gity Hall, 5t1 W. '13t" St., Dubuque, IA 5200'1. It � will ther� be referred by the City Cauncil to the appropriate department for investigation. j flnce that investigation is comp�eted, a reporE and recommendati�n will be submitted to the � City CounciL You wi11 be provided with a capy of that report and recommendation. � � THE F1NAL DEG1S10N flN AI�L CLAIMS IS MADE BY THE CITY CC}UNC1�. N4 EMPLQYEE C}F � THE C1TY C7F Dll�l]QUE HA� THE AUTHORITY TO MAKE ANY REPRESENTATION TQ YOU ; AS T{7 WHETNER Y4UFt G�AIM WI�L t}R WIL� NflT BE PAtD. � � � 1. Name c�f Claimant: �+�,��a ,�..�t�.,n��.o� ' � 2. Address: � `��,.� T/�`�-�'�dre �b�� .�'T� a F City: �.��. State: ..��`.�� Zip: . .'��,C�/ ! � �„ � 3. Telephone Number: ��--� �. �C�� ,: �' � 4. Date af Incident: �� ° /� � , � � 5. Time af Incident: ��,��x, � � a 6, Location of Incident �Be specific): � �i.� r��,��_�a� �/� � �i � 7. DESCRIBE ACCIDENT C}R OCCURRENCE THAT CAUSED INJURY {�R �AMAGE, (Giv� � fuAl d��ols up�r� wt��ch �o� �ase y��r �lairr�. �� a �i�y empioyee was invc�lve�, g�ve the � employee's name.} � � � � � � �� . ��. �� '� � �� .�° # � �.�- ��` /��. r�� r�� -�� r�-�� 1'�,�s�� t�rt �r.+-p" �- r�C.�, a ^� �Ca�� Y�;r s�et �t� +�. tw^rC�a a! �,-�+^��t'l n 8, What were weafiher canditions �ike? ��►a n 1 ,'e�+�r-�9 �'!/ 9. �ive name and address of any wi#nesses: �ar�� t�n.��r, � f� ,��.,.� n�t��7�.� 1Q. Did police investigate? �1f so, give names af afficers,) � f i '�f�Q,`� �C, ��i��' 18� .�c� U'tC's� �1"`��,dl ..�7� �1�'�.L4 T�� f°�tf Pf C Gs..� �,� 1?�1�i�f1�'......5 i �.e�t, � ��c.--4 ��-�,�. . C��a s��t��C,�� 11. Was anyone injure�!? {If s�, give names, addresses, and extent ot' injc�ries}. i � � "� C.�� '� , , �,�a�,��, 1��a�� n -�4�� -��e��-f t�.1�� `�� `F�� - s��-��.s , ��r�,� �1�y r��,. c � � r�� 1 �,�,q -t � ►�- p .� � � $ , � � 12. Was any damage done tca property? (If so, describe property and th� extent of � darnages. Attach estim�tes of damages c�r describe l�asis far asce�taining extent of ¢ dama�e.) � � �,�1;e�� i�.�,� t��s br-�k�� , °�r��.�� .��. �' r��..�.�. d�,-�� '�... �'��n s�.�a�e c� � �"'T�"�... �i��F+ j ��,�¢r-t. ��S6� t—i� Glv1 f� ��#"��'S � 1 t�:"#�r,� . ,�—�' �Gt:,.S, � (��.� ;�t�"" ..,�-�„� �' +��..t�.e�, 1�» � 13. What other dama�es do you claim, if any? ��.. bc�.-� �-� i�- ��r� � e � � � �� av�s �-�' � �i t� �l�� 1 �. �""f` r� 111�� ',��Pe� � f��a-E�. �� ,�� f�� . � �1`�,a l.t�c�� '�,�'a- i�- ° '—� , � 1�. Have you �een compensated far any part ar all of your �laim by any insurance � cQmpany? (1f so, give name and address af insurance company and arnount paid.} a � � ;; ;� 15. What amcaur�t do yau�claim from the �ity af Dubuque? � �.��,r�5 ,'�.1�' n e.�� re. P'�...p I�.r.+�� s �.,� �� A��,.�ec� � � 16. Why r�o ynu claim the City af Dubuque is responsible? 'i .��''�s ��i�� t�+',��K�� -r-t-� €�n r� � ��'..��ar~��c�1 1-� c.��- ��'�'�� a�c��r��a �'��'�''� ! , �-�'� t�-,� �l�;�. tv ��-t �, c�.. �o-� a r c��c�P l�,�, �s,„ k�t�� r s p��F�h J �.� . ', , 17. h#ave you rt�ade any claim against ar�yane else fc�r damages as a result at this incident? ;� (If yes, give name`and address.} j � �� c� ; � 1�. tf the answer to Questian 17 is yes, have you received any payment from that so�rce, � and if sa, �n what amt�unt'? � � � h � Dated at t�ub�q�a+�, l�vva thas .� day of ,t�r.��' , 24�� - ,,,,,..,,. {�ignature} � � � �. r1 '� ,—.�.. _.:. � .� �Print �lame} � '$7 c� � ;� � �� s j � � � (� �.f �� _. � � �� ; � , � � f�I� � � � � �Rev, 5118} :; =,-. �' ' � .� �a �- ;.; r ' �.ra �� Gonfidefl�ial � This communicatian and any attachments may canta�n information which is cor�fidential � and privileged by law and is for the use of the designated recipient. lf yau are not the � intended recipienf, you are hereby notified that you have received this communicatian in � error, and that any review, discl+�sure, dissemination, distribution or copying af its c�ntents is prr�hibited. Please notify Ci�y of Dubuque immediateiy by telephone at {563}-�89-4120 of � your receipt of these iterns and destroy the communication and any attachments ; imrnediately. Further disclosure af this infc�rmation may violate sfate and federal � restrictions, � Canfident�a! infarmatian may include the follc�wing: '; �j 1} 5ociaf Security Number�s) � 2} MedfcailHealth Information '� 3} PersanneC/Riseiplinary Information - x 4} Bank Account Enfarmatiar� � 5} Financiallnfarmation � 6} Credit Gard Numbers � � n; If any docurnentation you desire to submit ta the City of Dubuque contains any of the i�ems above j this cover sheet must be attaehed directly ta the canfrdential informatian and indicate the type �f � informatian that is included. ' ;, �� I, . , hereby certify that the attached documents � include fihe following protecfied ir�formation: � � Social �ecurity Number(s} Bank Accaunt Information � MedicallHealth Informatic�n Financial Informatian � �; Personnei/Discipiirroary In�ormation Credit Card Number{s} � 1 understand that this information may be distributed within the City arganization or to agents of the City for processing and I hereby authorize the City to act accordingly taking al] precautions ta prc�tect my informatian from urrnecessary distribution. ; � � �� ' �� S�igna�ur Date i i � E j � i Copyrighted September 3, 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: Kyle and Shelby Christina for property damage, Kathy Jansen for vehicle damage, and Gail M. Miller for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo Dubuque � THE CITY OF All•A�eeica eity � V � � rvni�swu.cnm�u�x-sxi: � �' ��' � I I Masterpiece on the Mississippi 2017*2019 � � 1 � TRACEY STECKLEIN �� PARALEGAL � 1 � MEMO ' � To: Mayor Roy D. Buoi and � Members of the City Council � , ,� i DATE: August 26, 2019 �, R�: Claim Against the City of Dubuque by Kathy Jansen � � Clairr�ar�t Date of Clairn Date of Loss IVa#ure of Claim � Kathy Jansen 08/26/19 08/24/19 Vehicle Damage I , i This is a claim in which claimant alleges that the windshield of her parked vehicle in front '� of 2755 Hickory Hill was damaged after being struck by a City tree limb on August 24, � 2019. ;� '1 This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa h Communities Assurance Pool. ;� � �� cc: Michael C. Van Milligen, City Manager �� Steve Fehsal, Park Division Manager �� Kathy Jansen � � '� �� 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/EMa,i� tsteckle@cityofdubuque.org � �� 0