Claim by James Meyer THE CTTY OF
DUBUQUE MEMORANDUM
Masterpiece on the Mississippi
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TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
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DATE: March 21, 2015
RE: Claim Against the City of Dubuque by James Meyer
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Claimant Date of Claim Date of Loss Nature of Claim
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James Meyer 03/19/15 03/18/15 Property Damage
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This is a claim in which claimant alleges that a watermain break caused water damage I
at claimant's residence at 670 Edith Street.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa u
Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager
Bob Green, Water Department Manager
John Klostermann, Street & Sewer Maintenance Supervisor
James Meyer
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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
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA L�
This written report constitutes your claim against the City of Dubuque, Iowa. You should
complete.this form in full and attach any'additonai information that supports your claim. p
The Claim must be filed with,the City Clerk a#City Hall, $0 W 13, St., Dubuque, IA 52001. It q
will then. be`referred by the City Council to the appropriate department for investigation. V
Once that investigation is completed, a report and recommendation will besubmitted 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, j
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IName of Claimant:
2. ,-, Address: }>
3 Telephone Number:.' ;' S ?- t5 3a r
4Date of Incitlent -/ g. lam'
S T�me'of Incident � t
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6 Location'20,11 ncident;(Be specific]
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TDESCRIBE ACCIDENT OR OCCURRENCE.THAT`CAUSED INJURY Old;DAMAGE: (Give,
full cletailsupon which`you base"your=claim:; If,'a Gity=empCoyee;was involved,'give the
employee"s-name;] -
S + l qtr t� ✓s
wereiiveather�conJdifions like? ,t h triv
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9:" Giveratrie andaddress of an �inrltnesses:
10 Did puce investigate? (If so, give names of officers:]
11 - Was agyone injured? (If so, give names, addresses,and extent of injuries].
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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.) )
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13. What other damages do you claim, if any? )x
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.)
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15. What amount do you claim from the City of Dubuque?
16. Why da you claim the City of Dubuque is responsible?
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17 Have you made any claim against anyone'else for damages as a result of this incident?
(If yes,give;narrie'and address.)
1�8 If the answer.to Questeon 17 is yes; have you �recoived any payments from Ghat source,
and if so,,m inrhat amount?
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Dated at Dubuque;Iowathis -day of 20
(Signature)
(Print Name)
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(Rev. 7%12)
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