Claim by James Schreiner - State Farm Copyrighted
June 19, 2017
City of Dubuque Consent Items # 2.
ITEM TITLE: Notice of Claims and Suits
SUMMARY: Anderson Windows for property damage, Herbert Cook for
vehicle damage, Ron Ludwig for vehicle damage, Judie
Root for property damage, James Schreiner for personal
injury/vehicle damage, Skyler Lee Tracy for vehicle
damage.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City
Attorney
ATTACHMENTS:
Description Type
Anderson Windows Claim Supporting Documentation
Cook Claim Supporting Documentation
Ludwig Claim Supporting Documentation
Root Claim Supporting Documentation
Schreiner Claim Supporting Documentation
Tracy Claim Supporting Documentation
r�v
R
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,50 West 13"'St., Dubuque, IA 52001. It will then be referred to
the appropriate department for investigation and to the City Attorneys 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 ou as to ether your claim. 'II or will not be paid.
1. Name of Clai ant: l� T 4 r �
y � � � r
2. Address: }
3.Telephone Number: 7 7 �
4. Date of Incident: �0 �7�
5.Time of Incident: ZL .i
6. Location of Incident(Be specific): I�1I�V °�1 k— I�YJ NIJ�
;�
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.)
>(( aV&avp amru r A,�V
�
i
f.
&What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate?(If so, give names of officers.)
11.Was anyone injured? (If so, give names,addresses,and extent of inj ies.)
/J
12.Was any damage done to property?(If so,describe property and the extent of damages. Attach estimates of
damages or des1riPe basis for ascertaining exjp,nt of damage.)
4
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 in rance corrRny and amount paid.)
15.What amount do you claim from the City of Dubuque?
16.Why do you claim the City of Dubuque is responsible? anM)m I f1I11 va V
T F-
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?
Dated this day of / "t 20
L
(Print Name)
c� 1
CD
Jun/1/2017 3'35'36 PM
State Farm 692-3029 212
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
ereby notified that you have received this communication in
intended recipient, you are h
error, and that any review, disclosure, dissemination, distribution or copying of its contents
e
eprohibited. Please notify City of Dubuque immediately by telephone at (563)-589-4120 of
Is 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
5) Financial Information
5) Credit Card Numbers
s any of the items
If any documever sheet desire to directly to he confidto the City ofential ial info mationubuque knPlease indicate belowthe
this cover sheet m
type of information that Is included.
6/4 /G� �Ir�' , hereby certify that the attached documents
include the following protected information.
Social Security Number(s) Bank Account Information
Medical/Health Information rinancial information
Personnel/Disciplinary Information T _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 fro ecessary distribution.
-fm �_ 1
G ignature ''�S�Q 6 ri `-
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.
Signature Date
Copyrighted
June 19, 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: Anderson
Windows for property damage, Herbert Cook for vehicle
damage, Ron Ludwig for vehicle damage, Judie Root for
property damage, James Schreiner for personal
injury/vehicle damage, Skyler Lee Tracy for vehicle
damage.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur
ATTACHMENTS:
Description Type
ICAP Referrals Staff Memo
THE cTFY OF �
DUBUQUE MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
i
To: Mayor Roy D. Buol and
Members of the City Council
DATE: June 7, 2017
RE: Claim Against the City of Dubuque by James Schreiner, filed by State Farm
ii
Claimant Date of Claim Date of Loss Nature of Claim
James Schreiner 06/06/17 02/28/17 Personal Injury/
Vehicle Damage
This is a claim in which claimant alleges that as he was driving northbound on Sunset
Park Circle, a City of Dubuque refuse truck pulled out onto the roadway and sideswiped
claimant's vehicle.
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 i
John Klostermann, Public Works Director
Jessica Kellerhals, State Farm
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
HANSON L,ULIC & KRALL, LLC
ATTORNEYS AT LAW
November 1, 2017
Michael Vincent Conner
1075 Arrowhead Drive
Dubuque, IA 52003-0000
Public Entity Risk Services of Iowa
5701 Greendale Rd
Johnston, IA 50131-1510
City of Dubuque — City Clerk
50 W. 13th Street
Dubuque, IA 52001-4805
Re: State Farm Insured: James G. Schreiner
State Farm Claim No.: 15-0962-3G3
Public Entity Claim No.: ICP047089A1
D/O/L: February 28, 2017
Our File No.: STASUB 24204
Dear Sir or Madame:
700 Northstar East
608 Second Avenue South
Minneapolis, MN 55402
Office: 612.333.2530
Fax: 612.392.3675
Grant D. Sackett
Attorney at Law
Direct Dial: 612.392.3668
E -Mail: esacketi( lilk.corn
Cry
Our office represents State Farm Mutual Automobile Insurance Company ("State Farm") in pursuit of its
subrogation claim with regard to the above -captioned auto incident.
You are responsible for the loss because on or about February 28, 2017 at or near 3400 Sunset Park
Circle, in Dubuque, IA, Michael Vincent Conner ("Conner"), operated a City of Dubuque garbage truck,
while acting in the course and scope of his employment with the City of Dubuque and negligently merged
into a lane that was occupied by State Farm insured's vehicle, causing a collision and damages. Conner
was cited for unsafe starting of a stopped vehicle. As a result of the damages, State Farm made payment
to its insured in the amount of $13,051.90, and State Farm's insured suffered a deductible loss of $500.00,
for a total of $13,551.90. A copy of the police report is enclosed with this letter.
In addition, there may be continuing liability for any additional claim amount which may be paid by State
Farm in the future for this loss or any other subrogation claims State Farm may have regarding this
incident. Furthermore, you may have continuing liability for State Farm's ongoing PIP/No-Fault
payments. State Farm expressly reserves the right to pursue any additional subrogation claims or a
PIP/No-Fault indemnity claim(s) it may have regarding this matter. State Farm's Insured may also have
their own personal claim(s), which are not included in State Farm's subrogation claim.
On behalf of State Farm, we are seeking payment of $13,551.90. Please make payment to "Hanson Lulic
& Krall Trust Account." Our tax ID number is 41-1641289. If we do not receive payment within ten (10)
days of this letter, we may commence suit.
Sincerely,
OrowitSazicett
Grant D. Sackett
GDS/sp
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l arm 4433003 (1 1 -13)
INVESTIGATING OF'FICER'S REPORT
OF MOTOR VEHICLE ACCIDENT
MAIL REPUR55 TO Iowa Department al rrrrnsporielion, Otto of Dever Services, P O Dog 0204 Des Moines, Iowa 50303 9704
Date of Accident Tirne of Accident County
0212812017 11:21 Hrs. DUBUQUE • 31
Driver's Name - Last
U CONNER
N Address
I 1075 ARROWHEAD DR
T Date of Eirth Driver's license Number
1 1211611982 7060)06839
Male Female State Class Endorsements Restriction
0 L K
Test Results. Drug Test Given:
1
c
0
M
M
E
R
C
A
L
(M� C) IA
Alcohol Test 0 vein
Owner's Name - Last
CITY OF DUBUQUE
Address
50 W 13TH ST
License Plate No
07327
Trailer Plate No.
Sheet 1 of 4
Law Enforcement Case Numbers,
2017001563
Accident occurred within corporate Omits of (city)
DUBUQUE - 2100
First Middle
MICHAEL VINCENT
City State Zlp
DUBUQUE IA 52003-0090
CDL Citation Charge 1 Citation Charge 2
UNSAFE STARTING OF A STOPPED VEHIC
Yes No
Citation Charge 3 Citation Charge 4
4J
0
Test Result: Re•exarm Yes No reason for Re -Exam Request:
First
Middle
City State Zip
DUBUQUE IA 62001
State Year VIN: ColorYear Make Model Style
IA 2099 1HTWCAARSDJ507817 YEL 2013 1NTL 7000 SERIES PK
State Year VIN: Tow ITow # Towed To
1 1
appir cosrIo Rep,.rornepiace
$0.00
Insurance Co Phone Number Insurance Policy Number
(5630 6894120 SELF INSURED
Confi3 1 Cargo Body Type Veb. Defect Point of Initial Impact Most Damaged Area Extent of Damage Total Doc In Veh
02 I01 13 10 11 I01
Bus Use Driver Condition I Vision Obscured Contributing Circumstances Driver (up to two) 1 Driver Distractions 1 Speed Limit
01 18 19 02 25
Horizontal Alignment Vertical A1{ nmer SEQUENCE First Event Second Event Third Event Fourth Event Most Harmful Event
01 g 154 g I OF EVENTS 133 I I 33
Insurance Company home
CITY OF DUBUQUE
Initial Travel Direction Veh. Act. Veh
01 01 J 16
Special Veh, Func Emergency Stratus
01 01
Tratflc Controls
01
Carrier Name/Lessee
CITY OF DUBUQUE
Street Address
50 W 13TH ST
Number of Axles
2
Haz Mat Involvement
02 • NO
Trailer Plate: State Year
Gross Vehiclo Weight Rating
2. 10,001 LES - 26,000 LES
Haz Mat Placard
Trailer Plate: State
Year
City
DUBUQUE
U5 DOT Number
Placard Number Haz Mat Released Haz Mat Class
VIN
VIN
Converter Dolly Doty Plate. Stat Plate Yea VIN
Phone Number. (563)689-4260
P DRIVER OF UNIT 1 Transported to'
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Address
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Phone Number I D00:
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Phone Number DOE.
fransponerl10
24c1706900926WPSD41NK9 Received 311012017 4'27'05 AM [Eastern Standard Time]
MC Number
Haz Mat Name
State Zip Code
IA 52001
Underr de/Override
1 . NONE
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634135961
roan 4�L3r101ia 111.111
INVESTIGATING OFFICER'S REPORT
OF MOTOR VEHICLE ACCIDENT
611041 0 0t 4
Law Enfonxrnenl Case Numbers
MAIL REPORTS To Iowa Deuarlmeni ni 1r.insnorlanon, Unice 01 nwni n Rnu 1fl4, '}ns Mdopa lawn 303:7.9004 2017.00001663
Time of Accident County Accident occurred within corporate limits of (city)
His DUBUQUE - 31 DUBUQUE - 2100
Date of Accident
02/28/2017 11:21
- Driver's Name - Last
U SCHREINER
N Address
1 2305 CROWN POINT RD
T
2
Date of Birth
05107(1932
0215
Driver's52930 License Number
Mate Female State Class Endorsements Restriction
!q�) IA C NONE NONE () C?i
Alcohol Test 0 van: Test Results Drug Test Given,
11
Owner's Name - Last
SCHREINER
ACIdfRSS
2185 CROWN POINT RD
First""'...._......�.__._....._.__�_._ _,..._...»_..._,_.Middle'
JAMES
City
DUBUQUE
COL Cita Jan Charge 1
Yes No
License Plate No,
EEY085
Trader Plate No,
State
IA
State
Year
2017
Year
Insurance Company Name
STATE FARM
Initial 'Travel Direction Veh, Act
01 01
VIN
19XFB2F9XCE074012
V IIV'
Citation Charge 3
GERALD
State Zip
IA 52002.0000
Citation Charge 2
Citation Charge 4
Test ResultRe-exam' Yes No Reason for Re -Exam Request.
C) COD
First
JAMES
City
DUBUQUE
Color
SIL
Taw Tow #
2
Middle
GERALD
State Zip
IA 52002-0000
Year Make Model Style
2012 HOND CIV 4D
Towed To Hrn x co�no s4p.,rr or nrniae4
$3,000.00
Insurance Co Phone Number Insurance Policy Number
1563)588-1491 100 9416-817-15U
Veh Contig. Cargo Body Type Vett Defect Point of Initial Impact Most Damaged Area Extent of DamageTotal One, in Veh
01 ( 01 01 04 04 4 02
Special Veh Funo Emergency Status Bus Use Driver Condition Vision Obscured Contributing Circumstances Driver (up to two Driver Distractions Speed Limit
01 01 101 01 88 02 25
Traffic Controls Horizontal AlignmentVertical Alignment SEQUENCE First Event Second Event Third Event For Event Most Harmful Event
01 01 + Ali
OF EVENTS 33 33
Carrier Name/Lessee
C
0 Street Address
M
M
E
R
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Trailer Plate.
A
L
Number of Axles Gross Vehicle Weight Rating
Haz Mat Involvement Haz Mat Placard
Trailer Plate
Converter Dolly
State Year
Stale Year
Dally Plate. Stat
Placard Number
VIN
VIN
DRIVER OF UNIT 2
E
R I Name
S
• Address
N I
S h Name
NN1 LI
Address
JI
UT
R
E2
Name
Address
Name
Plate Yea
City
US 001 Number MC Number
Haz Mat Released
VIN
Phone Number (563) 583-9561
Haz Mat Class Flaz Mat Name
Slate
Zip Code
Underside/Override
1 - NONE
/I > 6` OS 103
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Phone Number I DOB
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°lin 4,11003111.1.1)
INVESTIGATING OFFICER'S REPORT
OF MOTOR VEHICLE ACCIDENT
MAIL KPOR IR "U teWn laepartment 01 arensportolrun, Oflice of Umar . 01*ss 00 Pok n204, Des Mentes Iowa 5020(1 9)04
Date of Accident 'Ante of Accident County Accident occurred within corpoiale limits of (city)
L 02/2872017 11:21 Hrs. DUBUQUE - 31 DUBUQUE - 2100
O Literal Description
C SUNSET PARK CIR MEASURING 374 FEET NORTH FROM SUNSET PARK CIR AND MEGGAN ST
A If accident occurred outside of N NE E SE S SW W N
T city limits show general vicinity 0 0 0 0 C.) CSC 1 CD at nearost city
Cin Road, Street or Highway: I
0 At Intersection with
N
Note. Unless accident occurred at an intersection which is completely described above, use the space below to give the exact
location front a milepost or definable intersection, bridge, or railroad crossing, using two distances and directions If neccessary of
N NE E SE S SW W N N NE E SE S SW W N
00000000 and 1,J00 00000
Milepost Definable Intersection,
Number Or bridge, or railroad crossing
ACC1DFIIN ENVIRONMENN ROADWAY CHARACTERISTICS
Lo�ahnn of First Harmful Event 01 Weather Conditions Kip to rW0) Major Contributing Cvcurnslances Environ 000 01
Manner of CrashlCollistor 06 02 Roadway 01
Light Conditions 1 Suriace Conditions 02 Type of Roadway JunctlonfFeature 01
FRA No
First Harmful Event (Crash)
33
1Name 001
N
0 Address
NM
0 Transported to,
T
V Name
R Address
5
T
Transported to
WORKZONE Yes No
RELATED? « r3)
N p If Property other than
0 R vehicles damaged explain
N 0 Owner's Last Name
V
E E Address
HR
T If Property other than
C Y vehicles damaged explain
U Owner's Last Name
LD
A M Address
RG
w
T
N
E
S
5
Last Name
Last Name
Last Name
Last Name
Last Name
Signature of Officer
HARDEN ANDREW
Name of Agency
DUBUQUE POLICE DEPARTMENT
Report Reviewed By - —
LEMBKE, JIM
Object Damaged
Object Damaged
First Name
First Name
First Name
First Name
Activity Location Type
Phone Number
Phone Number
First Name
City
First Name
City
Address
Address
Address
Address
First Name I Address
Workers Present
DOB:
Alcohol Test Given
Transported by:
DOB:
Alcohol Test Given
Transported by:
Badge Numhar
59 A
Date of Report
021202017
Dale of Review
0100112017
24c1706900928WPSD4WK9 Received 3110120174'27'05AM [Eastern Standard Time]
}haul .1 ui 4
Law EnForcernent Coro Numbers
2017-001563
Legal r---1 Pevale
Intervention? 1„._1Property?.
County' Route
31
X Coordinate'
686886.95
Y Coordinate'
4709966.62
0 Divided Highway, Provide Route
(Cardinal) Travel Direction
NB SB 00 WB
0 J 0 0
Test Results' Drug Test Given
S'esuit
Charged Yes No I
0i 0
i ! { f
Test Results: Drug Test Given Result Charged Yes No
0 0
Estimate of Damage
Middle Name Phone Number
State Zip Code
Middle Name
State' IIr Zia Code
Was owner or tenant nettled?
1 is Yes 2 is No 9 = Unknown
Estimate of Damage
Phone Number
Was owner or tenant notified?
1= Yea 2= Nog=Unknown
City State Z p Code Phone Number
City
City
City
City
State Zip Code
State Zip Code
State Zip Code
State Zip Code
Picone Number
Phone Number
Phone Number
Phone Number
Time Officer Notified of Accident Time Officer Arrived At Scene
11:24 Firs 11:24 Hrs
Ifvesngallon made at scene? T I No
Y (#j N Q
Repcit r5lven to ail Drivers? Other Teohritcal Invee'hgahng Agerry --
Y( ` NC)
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rur 11 4,1,13CO3! 1' 1 1'17
INVESTIGATING OFFICER'S REPORT
OF MOTOR VEHICLE ACCIDENT
Sheol 4 0 4
law Enforcement Case Numhors'
WA 1. 10011ri1112 1'0 luvia l IlI, crl of ,renspnrtnaer 1)1l 1 M Driv9r 5divl,es PO Hex %!04 Deb Mains; Iowa 1033.6 9?04 2017-001053
D
A
G
R
A
M
{. Meggan St
l Sunset Park Clr�
r
Meggan 51
Unit 01, a City of Dubuque garbage truck, was pulled over to the right side al the roadway facing northbound in the 3400 Blk Sunset Park Circle. Umt #2 was traveling
northbound on Sunset Park Circle passing Unit 01 Unit #1 didn't see Unit #2 and pulled out to proceed to the next residence on the street Unit 41 sideswiped Unit
N #2 No injuries reported
A
R
R
A
T
V
24c1706900929WPSD4WK9 Received 3/10/2017 4'27'05 AM [Eastern Standard Time]
HANSON L,ULIC & KRALL, LLC
ATTORNEYS AT LAW
November 1, 2017
Michael Vincent Conner
1075 Arrowhead Drive
Dubuque, IA 52003-0000
Public Entity Risk Services of Iowa
5701 Greendale Rd
Johnston, IA 50131-1510
City of Dubuque — City Clerk
50 W. 13th Street
Dubuque, IA 52001-4805
Re: State Farm Insured: James G. Schreiner
State Farm Claim No.: 15-0962-3G3
Public Entity Claim No.: ICP047089A1
D/O/L: February 28, 2017
Our File No.: STASUB 24204
Dear Sir or Madame:
700 Northstar East
608 Second Avenue South
Minneapolis, MN 55402
Office: 612.333.2530
Fax: 612.392.3675
Grant D. Sackett
Attorney at Law
Direct Dial: 612.392.3668
E -Mail: esacketi( lilk.corn
Cry
Our office represents State Farm Mutual Automobile Insurance Company ("State Farm") in pursuit of its
subrogation claim with regard to the above -captioned auto incident.
You are responsible for the loss because on or about February 28, 2017 at or near 3400 Sunset Park
Circle, in Dubuque, IA, Michael Vincent Conner ("Conner"), operated a City of Dubuque garbage truck,
while acting in the course and scope of his employment with the City of Dubuque and negligently merged
into a lane that was occupied by State Farm insured's vehicle, causing a collision and damages. Conner
was cited for unsafe starting of a stopped vehicle. As a result of the damages, State Farm made payment
to its insured in the amount of $13,051.90, and State Farm's insured suffered a deductible loss of $500.00,
for a total of $13,551.90. A copy of the police report is enclosed with this letter.
In addition, there may be continuing liability for any additional claim amount which may be paid by State
Farm in the future for this loss or any other subrogation claims State Farm may have regarding this
incident. Furthermore, you may have continuing liability for State Farm's ongoing PIP/No-Fault
payments. State Farm expressly reserves the right to pursue any additional subrogation claims or a
PIP/No-Fault indemnity claim(s) it may have regarding this matter. State Farm's Insured may also have
their own personal claim(s), which are not included in State Farm's subrogation claim.
On behalf of State Farm, we are seeking payment of $13,551.90. Please make payment to "Hanson Lulic
& Krall Trust Account." Our tax ID number is 41-1641289. If we do not receive payment within ten (10)
days of this letter, we may commence suit.
Sincerely,
OrowitSazicett
Grant D. Sackett
GDS/sp
G:\HLK\24262\Atty\Demand lir - Defendant.doc