Claim by Marving and Mary Ritt / Pekin Insurance Copyrighted
April 3, 2017
City of Dubuque Consent Items # 2.
ITEM TITLE: Notice of Claims and Suits
SUMMARY: Mark Laird for property damage; Marvin and Mary Ritt for
vehicle damage; Teamsters Local 120 for property
damage, Rachel Wedewer for vehicle damage and
personal injury; Linda Wessels for personal injury
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City
Attorney
ATTACHMENTS:
Description Type
Laird Claim Supporting Documentation
Ritt Claim Supporting Documentation
Teamsters Local 120 Claim Supporting Documentation
Wedewer Claim Supporting Documentation
Wessels Claim Supporting Documentation
CLAIM AGAINST THE CITY OF DUBUQUE IOWA
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, 60 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 B�Ef PAID.
1. Name of Claimant: �� !✓�/1� �lr �
2. Address: /,52/ 0-o r/)6
3. Telephone Number: '5�' coy
4. Date of Incident: 4�- 'p-
5.
S. Time of Incident: C
6. Location of Incident (Be specific): lies
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.)
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8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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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.)
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13. What other damages do you claim, if any?
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)1company and amount paid.)
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15. What amount do you laim fr m the City of Dubuque?
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16. Why do you Flaim the C"ty of buque " r spon ible? p���
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name 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? � g 7, ,/
Dated at que;1Ow-a-this day of I llllurcA 201
(Signature)
(Print Name)
(Rev. 7112)
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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 (663)-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) Personnel/Disciplinary Information
4) Bank Account Information
6) 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.
I, , hereby certify that the attached documents
include the following protected information:
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
City for processing and I hereby authorize the City to act accordingly taking all precautions to
protect my information from unnecessary distribution.
Signature Date
I have read the information above and do not have any confidential documentation to submit to the
City of Dubuque as part of this Claim Against the City
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Signatu� Date
Beyond the expected.'"
PEKIN'
INSURANCE
March 22, 2017
Tracey Stecklein
City Attorney's Office
Suite 330, Harbor View Place
300 Main Street
Dubuque, IA 52001-6944
Claim Number: 07-F23-748 - Marvin & Mary Ritt
Date of Loss: December 8, 2016
A supplemental payment has been made on the above loss.
We have now paid the following amounts:
$2,241.10 - Collision Payment
500.00 - Deductible
56.31 - Supplement
$2,797.41 - Subrogation Amount
Our supporting documents are enclosed.
Please make your payment payable to Farmers Automobile Insurance Association
and mail to 2505 Court St, Pekin, IL 61558 at your earliest convenience
referencing our claim number.
We need to have a response at your earliest convenience, so we know how to
proceed in this matter.
FO 4-X& V!t j&T
Bonnie Master - Subrogation Specialist
Phone 309-346-1161 ext 2197 Fax 309-346-9466
E-Mail: bmaster@pekininsurance.com
Enclosures
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Copyrighted
April 3, 2017
City of Dubuque Consent Items # 3.
ITEM TITLE: Disposition of Claims
SUMMARY: City Attorney advising that the following claims have been
referred to Public Entity Risk Services of Iowa, the agent
for the Iowa Communities Assurance Pool: Kaitlyn Birch for
personal injury and vehicle damage; Mark Laird for property
damage; Marvin and Mary Ritt for vehicle damage;
Teamsters Local 120 for property damage; Rachel
Wedewer for personal injury and vehicle damage; Linda
Wessels for personal injury.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur
ATTACHMENTS:
Description Type
ICAP Referrals Supporting Documentation
THE CTI Y OF
U E MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL f�
To: Mayor Roy D. Buol and
Members of the City Council
DATE: March 28, 2017
RE: Claim Against the City of Dubuque by Marvin & Mary Ritt, filed by Pekin
Insurance
Claimant Date of Claim Date of Loss Nature of Claim °
Marvin & Mary Ritt 03/22/17 12/08/16 Vehicle Damage
Filed By Pekin Insurance
I
This is a claim in which claimant alleges that her vehicle which was parked on 15th
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Street at the Main Street intersection was struck by a City of Dubuque Jule bus.
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
Candace Eudaley,'Transit Manager
Bonnie Master, Pekin Insurance
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 li