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Claim by Sheri Scheffert Copyrighted October 21 , 2019 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUM MARY: Roxanne Ties Brenner for property damage, Matthew and Amanda Saylor for property damage, Sheri Scheffert for property damage SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City Attorney ATTACHMENTS: Description Type Brenner Claim Supporting Documentation Saylor Claim Supporting Documentation ScheffertClaim Supporting Documentation �� CLAIM �1GAINST TH� C1TY OF D�JB�IQUE IC}1NA .�°" ^ � �,� # a ��t� � � � This written report constitutes yaur claim against the City at Dubuque, Ir�wa. You should � complete this form in ful[ and attach any adtlitit�nal information that supparts your claim. � _ _ ; � The Claim must t�e fil�d with the City Clerk at City Nall, 50 W. 1�t�' St., Dubuque, IA 5200'i. It ; will then be referred by �he City Gouncil to the a�propriate d�partrnent far investigatian. ''i C}nce that investigatian is cornpleted, a report and recommendatior� will be submitted ta the 1 City Council. You will be �aravided with a copy of that report and recommendatian. � � THE FINAL DECISIC�N ON ALL �LAIMS IS MADE BY THE C1TY Ct�IJNCIL. NO EMPLC}YEE t7F � THE CITY C1F DUBUQUE HAS THE AUTHt�RITY TU MAK€ ANY REPRE�ENTATION TC} Yf�U � AS T{� WHETHER YC?UR CLAIM V1�ILL OR 1NIL� NC}T BE PA1D. � 1. Name of Claimant: ��^� �a�_�?�.��-� . �� 2. Address: ��J,� �P l��,��t��.�"� ' ; � �� City: �,,�,� State: .� Zip: � ` � �.��j��?r _.... �a �. Telephone l�umber; t},��j �� 4� , 4, Date of lneident; ,�� '' 5. Time af Incident: �_� �P��'"'� '7 6. Location af Incident {�e specific): ,��,�� k 7. DESCRIBE AC�IDENT QR C}CCURRENGE THAT CAUSED INJURY C}R DAMAGE. �Give � � ful� details upon which you base your claim. If a City emp�oyee was involved, give the � emp3�y��'� r�ame.� ; � .� _ � ;� � , a I � a � �� ( � ��1��hat re'w�h�canditian ike?' � ��'� ' � � c �9, G�ve name and address of any witness s;�� 10. Did pol�c� investigate? (If so, g�ve names of c�fficers.) � �� 11. Was anyone injured� {If so, give names, addresses, and extent of injuries). ; �� 3 i � i � E i i 1` ! � 1 a � � � 12. Was any damage dane to praperty? {1f sa, describe praperty and the extent c�f � damages. Attach estim�tes c�f damages or describe basis for ascertainit�g extent c�f � damage.} �.�-- � �� ` � � / j � .�� l.�.� ��'��' ��F�' ��`l�r°-�� - � � �l a t� �`�--, L��"� � � � � °; °]3. What o'ther damages do you claim, if ar�y? ��.��..�; ��1�,�� °'� r� .��2 � ;� ' � � � �� r��`� �� 14. Have yau e c m ens t far any part t�r ai1 of your claim by ar�y insurance ` company`? (1� sa, gsve name ar�d address af insurance company and amount pa�d.} �� r , , „,� - ; 15, 1Nhat amount do you claim from the City of Dubuque? � �� -' � °16. Why do yQu cla�m th� Cit �f D�buqu� is respc�nsfibl�? ii � � 17. Have you made any c�airrs against anyone else far damages as a result of this incident? ry {If yes, give name and address.� " �� ''I � '1�. If the answer ta Question �7 is yes, have you received any paymer�t from tha# source, ;; and if st�, in what amount? � � I,i � � � ' _-� � L,.��I�� , �0�. ° Dated at Dubu ue lawa this da of � � 4 ,� . � � � � ; �S�gr�ature) i � � �1 {Print �lame� � � � �1,� �'' � � � -�-� � ' �' � � r�`� � � � �"1 � u� � � �Rev. 5/18} , ,�� , ..�� c.� Cc�nfidentia! This communication and ar�y attachments may cantain information which is confidentiaf and priu�ileged by law and �s for the use of the designated recipient. �f you are not the intended rec�pient, you are hereby notified that you have received this comrr�unication in error, and that any review, disclosure, dissemination, distribution or copy�ng af its c�ntents is prahibited. Please na#ify City af Dubuque immediate�y by telephone at ("63g-589-4120 af your rece"rpt of these items and destroy the communication and any attachmen#s immediately. Further disclosure of �his information may vio�ate state and federal restrictians. Confidential infc�rmatic�n may include th� following: 1} �ocial Security Number{s) 2} Medical/Health Information 3) PersonnellDisciplinary fnfQrmation 4} Bank Account Information �} Financia! lnformati�n � 6) Credit Card Numbers If any documentati�n you desire to submit ta the City of Dubuque c�nta9ns any of the ifiems above this caver sheet must be attaehed directly to the confidentia4 informa#ian and indicate the type of informatian that is included. 1, , hereby certifiy that the attached documents include the f�[lowing prcrtecfied ir�farmation: Social Security Number{s} Bank Account Information Medicaf/Health In�ormatic�n Financial Enfarma�ian Persc�nnellDisciplinary lnformation Gredit Card Number�s} 1 understand that fihis infc�rmation may be distributed within the City arganization ar ta agents of the �ify for prc�cessing and i i�ereby authorize th� Cifiy tc� act a�cordingly taking aii precautions to protect my information frc�m �nne�essary distributi�n. � , ; � . �'� � / Signatt�re Date ki {� ...?.� :� _��.��' �� 1��1�/ '` t �1 . ��' ,i ; -�--- � �� - _ "� � � _�� ' ._.�._�.��'��.��.�. 4 e� i� � �� '�:��-��s-�•�-�� `= 1�� _ : I4 ' ... k��E?Y..�!tti.r ��c..[��.��!C�t.Y,+L-A:�.r/d..14:.�-7--1��-{�C_..�...�� i � f �� _..._._.� ��Q•}'"}!��:�1��:�4� " J-�� M t , �� r l-6�✓5,�. ; ��-�� ..��c�.��.�s ��,��s, o ____�'�' � �.��,�.�� r� ��.�� `�� J � t � � f 1 i � Copyrighted October 21 , 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: Roxanne Ties Brenner for property damage, Matthew and Amanda Saylor for property damage, Sheri Scheffert for property damage SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo � ; �3uf�uqu� � THE CITY OF a All•America City 3 � V � � NAl%:IVM1LUVIGItiY:1Jl: �� ,I �� Maste iece on the Mississi i zoo�.�o�z.2o�3 � �P pp Zoi�*2o1� �� i r l � TRACEY STECKLEIN � PARALEGAL i , ' �, N9EM0 � � � ; To: Mayor Roy D. Buol and i; Members of the City Council i i; ii Da�E: October 4, 2019 `i 'i , RE: Ciaim ,�igainst the Lity ot Dubuque �y Sheri Schefter� ;j Claimant Date of Claim Date of Loss Na#ure of Claim i 'I i Sheri Scheffert 10/04/19 10/01/19 Property Damage ',:! This is a claim in which claimant alleges that a City sewer near Rosedale and West Locust ; Street overflowed and backed up into claimant's basement at 950 W. Locust Street. '� , This claim has been referred to Public Entity Risk Services of iowa, the agent for the lowa Communities Assurance Pooi. ��; '�; cc: Michael C. Van Milligen, City Manager I,i John Klostermann, Public Works Director Sheri Scheffer� '! �� , � � � ;; � � � � � � � � � 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�� tsteckle@cityofdubuque.org � a � � �