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Claim by LaTakka Bolds Copyrig hted October 19, 2020 City of Dubuque Consent Items # 2. City Council Meeting ITEM TITLE: Notice of Claims and Suits SUMMARY: LaTakka Bolds forvehicle damage. SUGGESTED Suggested Disposition: Receive and File; Referto CityAttorney DISPOSITION: ATTACHMENTS: Description Type Claim by Latakka Bolds Supporting Documentation /*��'a�� CLAIM AGAINST THE CITY OF DUBUQUE, IOWA ✓'��,�� ..�� " � This written report constitutes your claim against the City of Dubuque, lowa. You should �� complete this form in full and attach any additional information that supports your claim. �� a ; 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. ; 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 I,� THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU �� AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. I; 1. Name of Claimant: l_S_��. �(�,�__ �d f�� I�;� �� ! � � � 2. �adress: � � ; Sta#e: �..�� Zi ' City: , 1 �, p' I � I�� c� �� ,��'� ; 3. Telephone Number: � ; 4. Date of Incident: �e��e�'"��er a � aoa� �� ;i j i 5. Time of Incident: (� � a � p-� - I 6. Location of Incident (Be specific): �� r1- s� r''��'�f ��"� �� 3 �e�e�' So�y-� �� i; I� ��blM �'V� s 1 : Q.Y�IX L,O Y�� V �, � ii i 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give � full details upon which you base your claim. If a City employee was involved, give the � employee's name.) � ,1 1� � �.✓�: �e. fG�'5��=,e�,�n�j a �i�t C�h�`�A-� Ft d Vc�V��4S ,/I�le��eet �vw.��. �t �ar -� " 8. What were weather conditions like? �� I�S ht �" C��' 9. Give name and address of any witnesses: 10. Did police investigate? (If so, give names of officers.) ��'S C�r� ��do - aa j�a31 0�� ll`�� {';ec�mctvs � � 11. Was anyone in�ured . (If so, give names, addresses, and extent of in�uroes). � �/'�j � � � 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.) � � � _ _. �� - � ,� 13. V�/hat other damages do you claim, if any? � 1 ; 14. Have you been compensated for any part or all of your claim by any insurance !i company? (If so, give name and address of insurance company and amount paid.) � �� l �; , „ 15. What amount do you claim from the City of Dubuque? '� � � �; 16. Why do you claim#he Cit of Dubu ue is responsible? � C��' 2w� �o��C� e,Or�act ftS a�S��f�. joml^�cCQ� a� �� i � 17. Have you made any claim against anyone else for damages as a result of this incident? �; (If yes, give name and address.) �� i� �; � ,� , 18. If the answer to Question 17 is yes, have yo�u received any payment from th�t source, and if so, in what amount? � � � I'i � Dated at Dubuque, lowa this day of , 2Q�. �� ,/� , ----, (Signature) �� ` � � (Print Name) � � � ��;� ca � � �� ..� � � � (Rev. 5/18) � �-� �, �� V� � � � � � � � � 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 recipient, 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 #hese items and destroy the communication and any attachments immediately. further disclosure of this information may violate state and federal restrictions. � li � Confidential information may include the following: � ; 1) Social Security Number(s) �� 2) Medical/Health lnformation � 3) Personnel/Disciplinary Information � 4) Bank Account Information � 5) F'inancial Information �� 6) Credit Card Numbers � � � �� I; If any documentation you desire to submit to the City of Dubuque contains any of the items above �f, this cover sheet must be attached directly to the confidential information and indicate the type of ! information that is included. ;' M � �I �� , hereby certify that the attached documents include the following protected information: ; i Soci�l 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. , �- � � l � �Y � � Signature Date Copyrig hted October 19, 2020 City of Dubuque Consent Items # 3. City Council Meeting ITEM TITLE: Disposition of Claims SUMMARY: CityAttorneyadvising thatthe following claims have been referred to Public Entity Risk Services of lowa, the agent forthe lowa Communities Assurance Pool: LaTakka Bolds for vehicle damage. SUGGESTED Suggested Disposition: Receive and File; Concur DISPOSITION: ATTACHMENTS: Description Type ICAP Referrals Supporting Documentation Dubuque THE CITY OF � Ail•A�erica City D V L � �mwi�.ru�i.u- , I I I ��' MRste iece on t�le Mississi i Zoo�•zoiz•zoi3 �P pp zol�*zoi9 TRACEY STECKLEIN ,� �J� PARALEGAL �v MEMO To: Mayor Roy D. Buol and Members of the City Council DATE: October 13, 2020 RE: Claim Against the City of Dubuque by LaTakka Bolds Claimant Date of Claim Date of Loss Nature of Claim LaTakka Bolds 10/13/20 09/21/20 Vehicle Damage This is a claim in which claimant alleges that her vehicle which was parked on Bluff Street near the Loras Boulevard intersection was struck by a City of Dubuque fire truck. This claim has been referred to the lowa Communities Assurance Pool. cc: Michael C. Van Milligen, City Manager Rick Steines, Fire Chief LaTakka Bolds OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 TELEPHONE (563)583-4113/FAx (563)583-1040/EMai� tsteckle@cityofdubuque.org