Claim by Kristine Blakeman THE CITY OF
LTB E MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
DATE: March 20, 2015
RE: Claim Against the City of Dubuque by Kristine Blakeman
I
Claimant Date of Claim Date of Loss Nature of Claim
q
Kristine Blakeman 03/19/15 03/14/15 Vehicle Damage u
d
This is a claim in which claimant alleges that her vehicle was damaged after driving over
a pothole on West Locust Street in front of the Dollar General Store.
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
P
John Klostermann, Street & Sewer Maintenance Supervisor II
Kristine Blakeman hh
u
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
A4V
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the City of Dubuque, Iowa. You%shoul
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. 13th 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
THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU
AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: Ala-kenna-r)
2. Address: I `7"1-,, ,�,� .` i ,, u a i o Q 1
3. Telephone Number:
4. Date of Incident: _.
5. Time of Incident: p : 3 C3 Q M
6. Location of Incident (Be specific): Ld e--s-k a - / n ron-f- O 4-1ce
( 1q , qwt )
r) lZe Way LE al-er-ing; 4- S
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.)
A, r 4 � /0 L -�O,,, � Zj-'A k7,111
8 -I h eac rd 5 0,r+7,j a" 1 S " o P :; loa ek e a® a r7 o�- o a -Y- �'o 1()Ole-
►�-�
8. Whi were weather conditions like? --=�
9. Give name and address of any witnesses: iA6L,�ek3 R l eke an
a *toa 2,11 ®Y- OLS -bck1z(AgcAe
10. Did police investigate? (If so, give names of officers.) e-0
0
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
y: q- T
my car
Nols'e— -' 1 6 eA Sa I/U
X)O Shop /s Op-eA -7-7 4ried -fo
or-e4 () r7 6t -�Sol-)a,14,y oily ploc-f- -Z
,?Se '4., /...) on, Sunday Morc�A
moo K
a id he d ryl i r I/a 4.; Me- c '0 S e- -T P7 4
-Fh e y :5o /;i de& ol cL )qcL-1 S n ap-e y Oo,41d
qe. 4- 4Ae- pae4- 4-
A
a rl Li
0;j day
7 _tu e n 4-
my
30 4M
qlh
n d (A 4- ___L VVL Nalbed
5 nod
5A e- 04 s k e,,l
A 0 ic-, --Q o b-Pcc t4s e, Q q
-ld Ate, J7
/S already Ax-PV
n Aer-two(
h e- (na.,ded
was
—L&L9 eO/,7 a4-he)te- Stl - A k-4-a-—eA
- I T—C'O-A�L4
co k
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.)
p VlP.y \i mean iyi � rh ',J OeV" o �l� -C 5
E'
13. What other damages do you claim, if any? W 'O Ile
I
i
14. Have you been compensated for any part or all of your claim by any insurance
company? (If so, give name and address of insurance company and amount paid.)
15. What amount do you claim from the City of Dubuque?
16. by do you claim the City of Dubuque is responsible?
fre c cc e- w cc s en Act ha d
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
Q
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 oft�^ 20
(Signature)
1IS6� . 1 1a.,k e j-n a (Print Name)
cn
rTj
M
(Rev. 7/12) 0 M
=—Zn