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Claim by Jacqueline Clasen Copyrighted J une 7, 2021 City of Dubuque Consent Items # 2. City Council Meeting ITEM TITLE: Notice of Claims and Suits SUM MARY: Jacqueline Clasen for personal injury; Steve Haferbecker for property damage; Mediacom/PRG for property damage. SUGGESTED Suggested Disposition: Receive and File; Referto CityAttorney DISPOSITION: ATTACHMENTS: Description Type Claim by Jacqueline Clasen Supporting Documentation Claim by Steve Haferbecker Supporting Documentation Claim by Mediacom/PRG Supporting Documentation �� CLAIM AGAINST THE CITY OF DUBUQUE, IOWA ��I�n 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. ,� 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 i 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 �;� THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU IC AS TO WHETHER YOUR CLAIM WILL OR 1IVILL NOT BE PAID. a ��f 1. Name of Claimant: , C�.��.�,'i1.�1 ��' ��a'`^l � � 2. Address: ��1 �� Cv..� �.,,,.'�-� I, r City: �"�C�,�...�a�'1..�.'� State: � � Zip: ,�� ,� � i � 3. Telephone Number: �� "- �--�� °` �� ;� i, aa 4. Date ofi Incident: ,�,�� i .� �1 r � ��i 5. Time of Incident: (gC�)„(�}��. I �� f�.,�Y'1 _ �.. _ � 6. Location of Incident (Be specific): ' � � � � � �� , �, I � � � �- � � � � t�r�,� 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give i full details upon which you base your claim. If a City employee was involved, give the � employee's name.} c�� -n c��r � c�r�r� ��-� ��- ��:��.�� G �'�,�,� �e.c� � 1 C�.r, �� c��.�~�C� 1��- '�e� C`x�C� �\�..1� � �c�.\.°�_ 1r�ts�__�t.e.'r C:�["�t��'► 8. What were weather conditions like? '", �,G� 9: Give name and address of any witnesses: �� . . � C� �rC�� `�'�,Q�� ,�� C��.- ��.�c� �r`1�, t��, �� u ic� �� d� Lm��IC�. 10. Did police Pnvestigate? (If so, give names of o icersl.) �� Y� �'1�� Y\P C�� `��'��1 a �� `��\ �Y" '�1G�a�"+�-(�. 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). 1 ��Ca� �c��,r�Qc� ��, ��,t a I��- �i�� c��c� 1�-�, �,1 r.�c.,�J. � �i_ ,S�,y�.�� ` � �- �� I`�Z ��.-��` -�� c��,� �� c�� t' �'7�� i J�c ��S' bJ�1��. � 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.) � � �� a ';; �� 13. What other damages do you claim, if any? �-�`=' ' u i� � ;i 14. Have you been compensated #or any part or all of your claim by any insurance � company? (1f so, give name and address of insurance company and amount paid.) �!� i �� G n � 15o What amount do you claim from the City of Dubuque? N ,i � �i 16o Whyfdo y u claim the City of Dubuque is responsible? !, � � �'� � i, , ��; 17. Have you made any claim against anyone else for damages as a result of this incident? � (If\�, giv� name and adclress.) � �a � I 18. If the answer to Question 17 is yes, have you received any payment from that source, � and if so, in what amount? � � c li � a� Dated at Dubuque, lowa this C�� day of ��1c�1 , 20 21 . (Signature) � \ r.,� V �' .� e � (Print Name) ,.$ _�� w:... � ;=� -. � ��`�- �''.� '��. c�; ��`�*� ��3 F,��5 �'"``.. a !F F �� ! »:� :� (Rev. 5/18) � �, � �-�� ;�`�.t .� � Confidential �� This communication and any attachments may contain information which is confidential and privileged by law and is for fihe 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 these items and destroy the communication and any attachments �. immediately. further disclosure of this information may violate state and federal ; restrictions. � � � Confidential information may include the following: � �� 1) Social Security Number(s) � 2) Medical/Health Information �; 3} P�rso�nel/Disciplinary Information ; 4) Bank Account Information ! 5) Financial9nforr�ation 6) Credit Card Numbers �� If any documentation you desire to submit to the City of Dubuque contains any of the items above ' this cover sheet must be attached directly ta the confidential information and indicate the type of information that is included. � � � � � i, � �C��"s�,�,�'�.,h,+t� �. �'.,��9��1�'1 , hereby certify that the attached documents � include the following protected information: Social Security Number(s) _�Bank Account Information �.� Medical/I�ealth Information �„`Financial Information Personnel/Disciplinary Information Credit Card Number(s) I understand that this information may be distributed within the City organiz�tion or to agent� of the City for processing and I hereby authorize the City to act accordingly taking all precautions to protect my �nformation from unnecessary distribution. . Si natu e Da e Copyrighted J une 7, 2021 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 for the lowa Communities Assurance Pool: Jacqueline Clasen for personal injury; Steve Haferbecker for property damage; Mediacom/PRG for property damage. SUGGESTED Suggested Disposition: Receive and File; Concur DISPOSITION: ATTACHMENTS: Description Type ICAP Referral Supporting Documentation THE CiTY OF DuB E � � � 0 � � K a Q � Masterpiece on the Mississippi JONI MEDINGER LEGAL ADMINISTRATIVE ASSISTANT To: Mayor Roy D. Buol and Members of the City Council DATE: 5/25/2021 RE: Claim Against the City of Dubuque by Jacqueline Clausen Claimant Date of Claim Date of Incident Nature of Claim Jacqueline Clausen 5/20/2021 2/23/2021 Personal Injury This is a claim in which claimant alleges claimant injured her left knee and left elbow after stepping on a patch of ice causing her to fall. 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 Russ Stecklein, Interim Director of Dubuque Transportation Services Jacqueline Clausen OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 TE�EPHONE (563)589-4113/Fax (563)583-1040/EMai� jmedinge@cityofdubuque.org