Claim by Cindy Bartolotta THE CITY
DUUB-64 w
MEMORANDUM
Masterpiece on tete Mississippi
TRACEY STECKLEIN
PARALEGAL 1
To: Mayor Roy D. Buol and
Members of the City Council
'i
DATE: July 23, 2015 ;I
RE: Claim Against the City of Dubuque by Cindy Bartolotta
�I
I,
Claimant Date of Claim Date of Loss Nature of Claim
n
i
Cindy Bartolotta 07/21/15 07/15/15 Vehicle Damage
I
i
This is a claim in which claimant alleges that the front passenger side window of her
vehicle was damaged when City of Dubuque Public Works crew members were a
trimming tall grass on Thomas Place and a piece of debris was thrown from a weed
Wacker.
i
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
cc: Michael C. Van Mllligen, City Manager
Don Vogt, Public Works Director
Cindy Bartolotta
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 p
TELEPHONE (563)583-4113/FAx (563)583-1040/EMAIL tsteckle@cityofdubuque.org
I
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA d
� K rose
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 must be filed with the City Clerk at City Hall, 50 West 13t" St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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:
� G
2. Address:
3. Telephone Numbeka )1\ UaECID-
4. Date of lncident:
F
5. Time of Incident: 1
6. Location of Incident (Be specific):
Ia Cc_
7. Describe the 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.)
i r -e—L ,,
yO.
�y
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? If so give names of officers.)
9
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
ii
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 N
extent of damage.) j
`, o", t r) cv) 1 Y
l
j
13. What other damages do you claim, if any?
�i
II
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.)
I
15. What amount do you claim from the City of Dubuque?
I
16. Why do you claim the City of Dubuque is responsible?
v
17. Have you made any claim against anyorielse for damages as a result of
this incident? (If yes, give name and address.)
� h
i
�I
18. If the answer to Question 17 is yes, have you received any payment from that h
source, and if so, in what amount?
nN Dated this day ofA , 20 r
C M
<
(Signa tu e)
ff GO
CO
W
(Print Name
I
I
I'
0
f
i
Confidential
This communication and any attachments may contain information which is confidential f
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
II
your receipt of these items and destroy the communication and any attachments
immediately. Further disclosure of this information may violate state and federal
restrictions.
it
I
Confidential information may include the following:
f
1) Social Security Number(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.
hereby certify that the attached documents
include the following protected information:
ii
Social 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
1
City for processing and I hereby authorize the City to act accordingly taking all precautions to
protect my information from unnecessary distribution.
i
I
Signature Date
have read the information above and do not have any confidential documentation to submit to the
City of Dubu ue as part of this Claim Against the City
aO�
Signature Date
i