Claim by Jade Wiegel Copyrighted
April 17, 2017
City of Dubuque Consent Items # 2.
ITEM TITLE: Notice of Claims and Suits
SUMMARY: Lindsy Nadermann for property damage; Gene Allen
Ninneman for property damage; Jade Wiegel for vehicle
damage
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City
Attorney
ATTACHMENTS:
Description Type
Nadermann Claim Supporting Documentation
Ninneman Claim Supporting Documentation
Wiegel Claim Supporting Documentation
MOA
ULAIM AURA' b I I ht L;I I Y Vl- UUbUQUt:1 IVVVA
This written report constitutes your claim against the city of vubuque, 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, b0 W. 1P 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 15 MADE BY THE CITY COUNCIL. NO EMPLOYEE OF
THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY KEPRESENTATION TO YOU
AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant:
2. Address:
J. Telephone Number:
4. Date of Incident: IL4
5. Time ofincidlent:
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6. Location of Incident(Be Specific}: '
7.
pecff-
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
tutl details upon which you base your claim. it a City employee was involved, give the
employee's name.)
-V MY
8. What were weather conditions Re?
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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).
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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? ----_.
14. Have you been compensated for any part or all of year 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 do you claim the city of Dubuque is respond le?
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17. Hage you made any claim against anyone else for damages as a result of this incident?
(if yes, give name and address.)
18. it 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 AO rs 20a-
.
a m �
(Signature)
�- (print Name)
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(Rev. 77112)
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toonnuenual
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 notifiedthat 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
your receipt of these items and destroy the communication and any attachments
immediately. Further disclosure of this information may violate state and fedam- I
restrictions.
Confidential information may include the following,
1) Social Security Number(s)
2) Medical/Health Information
3) Personnel/Disciplinary Information
4) bank Account information
b) Financial information
6) Credit Card Numbers
If any documentation you desire to submit to the Uty of Dubuque contains any of the items above,
this cover sheet must be attached directly to the Gontidential information. Please indicate below the
type of information that is included.
1, hereby certify that the attached documents
include the followinVprbtected information*
Social Security Number(s) -Bank Account Information
Medical/Health Information Financial Information
Personhel/Disciptinary 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 tram unnecessary distribution.
411b
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P91fature
I have read the information above and do not have any confidential documentation to submit to the
City of Dubuque as part of this Maim Against the City.
fnatureB&
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Copyrighted
April 17, 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: Lindsy
Nadermann for property damage; Gene Ninneman for
property damage; Jade Wiegel for vehicle damage
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur
ATTACHMENTS:
Description Type
ICAP Referrals Supporting Documentation
THE CITY OF
7 E MEMORANDUM NT T
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
y Y
Members of the City Council
DATE: April 10, 2017
RE: Claim Against the City of Dubuque by Jade Wiegel u
Claimant Date of Claim Date of Loss Nature of Claim
Jade Wiegel 04/10/17 04/04/17 Vehicle Damage
This is a claim in which claimant alleges that the driver's side rear wheel and tire were
damaged when she drove over a pothole on Yale Court.
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This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool
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cc: Michael C. Van Milligen, City Manager
John Klostermann, Public Works Director
Jade Wiegel j
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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