Claim by Frank Vlach IIIMasterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
MEMORANDUM
To: Mayor Roy D. Buol and
Members of the City Council
DATE: September 17, 2012
RE: Claim Against the City of Dubuque by Frank Vlach, III
Claimant Date of Claim Date of Loss Nature of Claim
Frank Vlach, III 09/17/12 08/29/12 Vehicle Damage
This is a claim in which claimant alleges that as he was driving east on East 16th Street,
a City vehicle driven by a City Parking Division employee pulled out from a parking stall
and struck claimant's vehicle.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager
Tim Horsfield, Parking Systems Supervisor
Frank Vlach, Ill
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 / EMAIL tsteckle @cityofdubuque.org
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
14,
This written report constitutes your claim against the City of Dubuque, Iowa. You should
complete this form in full and attach any additional information that supports your claim.
The Claim MUM be filed with the City Clerk at City Hall, 50 W. le St, Dubuque, & 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 ill 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
THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENT TON TO YOU
AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant:
2. Address:
6to3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
j IA
5---z
6, Location of Incident (Be specific
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which y.0 base your claim. If a City employee was involved, give the
employee's name.)
mol el
el)60,-)
. What were weather conditions like?
9. Give name and address of any witnes
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
14. Have you been -comiiensated for any -art or LAI of You IT any insurance
company? (If so, give name and address of insurance company and amount paid.)
15. What a
d you claim
he City of Dubuque?
Vh do o claim City ofDLbu
plYA tk_
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes,
I dame and address.)
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
Dated at Dubuque, Iowa this day of
(Rev. 7112)
(Signature)
(Print Name)
LO
m
ni
Fri
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)-5894120 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 Nurnber(s)
2) Medical/Health Information
3) Personnel/Disciplinary Information
4) Bank Account Information
5) Financial Information
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 to the confidential information and indicate the type of
information that is included.
include the following protected information:
Social Security Number(s)
Medical/Health Information
Personnel/Disciplinary Information
hereby certify that the ttached documents
Bank Account Information
Financial Information
Credit Card Nurnber(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 infor..4 ffi from unnecessary distribution.
Date