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Claim by Jane Worm Copyrighted July 17, 2017 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: John Gansemer for vehicle damage; David MacKenzie for vehicle damage; Jane Worm for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Gansemer Claim Supporting Documentation MacKenzie Claim Supporting Documentation Worm Claim Supporting Documentation Copyrighted July 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: John Gansemer for vehicle damage; David MacKenzie for vehicle damage; Jane Worm for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Supporting Documentation i i THE CITY OF I�f DUB E MEMORANDUM Masterpiece on the Mississippi TRACEY STECKLEIN (PARALEGAL i To: Mayor Roy Da Buol and Members of the City Council I DATE: July 10, 2017 I RE: Claim Against the City of Dubuque by Jane Worm 1 '1 Claimant Date of Claim Date of Loss Nature of Claim Fl I I Jane Worm 07/10/17 06/30/17 Vehicle Damage I � This is a claim in which claimant alleges that as she was driving near the Grandview I Overpass, she drove over a large amount of debris scattered over the road, damaging I i. her vehicle, I� I This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa Communities Assurance Pool, cc: Michael Ce Van Milligen, City Manager John Klostermann, Public Works Director Jane Worm i q i 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 q p GG (n 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 13th Bt., 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. '' 11 1. Name of Claimant: J �. W t) r yv�_ 2. Address: 3 6 C) C= cAc, 141 D-f_ 3. Telephone Number 5-6 S — � — S ' 4. Date of Incident: �1 w.,2. 30, ;7- 5. Z5. Time of Incident: 6. Location of Incident (Be specific): b Uf4X - UJ!A4 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.) lL ©�n 'VrcLC i U ri GSt't — i-6- V-1 ��C o�vet - r 115 , 1 � c �r►s —Re4Vrrc 8. What were weather conditions like? Gj L," VN U 9. Give name and address of any witnesses: 10 Did police investigate? (If so, give names of officers.) �/ �\tlflu� We-� FAD ic�w1Cw�. IW I7'r't�t '� 1 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). A2 i) 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.) L� 16Ali vw is: baa u 5 o vws �r� 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 company and amount paid.) �1 c) 15. What amount do you claim from the City of Dubuque? B1, 027 , 1� �f 16. Why do you claim the City of Dubuque is responsible? `E4, 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) lM M 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? 0 4 __, c Dated this day of 1201 . C- M' 0 J M' C^ .-�.- (S i g n6Vure) Or o (Print Name) 3680 Echo Hills Drive Bellevue, IA 52031-9557 July 10, 2017 City of Dubuque City Hall W. 13`h Street Dubuque, IA 52001 To Whom It May Concern: RE: Claim Report#2017-005015 On June 30, 2017, as I was driving home on Hwys. 61/151 1 was approaching the Grandview overpass as I found the right lane of the highway filled with dark colored debris. I could not change to the left lane as there were several cars there. I tried to avoid a large mass of"something" but unfortunately, my right tires on my car were hit by this debris. I managed to get my car to the parking lot of Hardee's at the corner that intersects with Hwy. 52. 1 found my right front tire completely flat with both right tires damaged, wheel covers gone, etc. A Dubuque police office,Tom Pregler, investigated my car's damage. (He was investigating other cars with damage also.) He gave me the Claim Number/Report No. of 2017-005015. The damage occurred because of a city maintenance truck carrying road construction debris apparently dropped this asphalt/blacktop debris as they carried the debris from a construction site to the fill spot out farther on Hwy 61. So what my car hit was some large pieces of asphalt that ruined my tires. The police officer stated to me that the city workers caused this damage and I needed to report this claim to the city so I can be reimbursed for my car's repair of the damage. I am enclosing the repair bill from Riley's Subaru in the amount of$1,279.69 for which I wish to be reimbursed. I am also enclosing a photo showing the tire/wheel damage to the right front tire. If you need additional information, my phone number is 563.582.2580. 1 got my Subaru Outback vehicle back on Friday,July 7. They had to replace two wheels, two tires, two wheel covers, and one strut that was bent. I would appreciate your attention to this matter as soon as possible. Please send a reimbursement check to: Jane Worm 3680 Echo Hills Drive Bellevue, IA 52031-9557 Sincerely, Jane Worm 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 (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 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 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, —� 6--IV\ e- LO D Y-r'o- 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) 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 Gvv� LcJ 711 Q Z 1 -7 Signa re Date