Claim by Alec Lee Benson Copyrighted
August 7, 2017
City of Dubuque Consent Items # 2.
ITEM TITLE: Notice of Claims and Suits
SUMMARY: Alec Benson for vehicle damage, Lester& Susan Bettcher
for property damage, Linda Breitbach for personal injury,
Charles and Ruth Ellis for property damage, Timothy Kelly
for vehicle damage, Mark Lansing for vehicle damage,
Monique Hopkins for vehicle damage, Aislinn O'Brien for
vehicle damage, Lynn Pollock for vehicle damage, suit by
Chris Cullen for Civil Service veteran's points application.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City
Attorney
ATTACHMENTS:
Description Type
Benson Claim Supporting Documentation
Bettcher Claim Supporting Documentation
Breitbach Claim Supporting Documentation
Ellis Claim Supporting Documentation
Hopkins Claim Supporting Documentation
Kelly Claim Supporting Documentation
Lansing Claim Supporting Documentation
O'Brien Claim Supporting Documentation
Pollock Claim Supporting Documentation
Cullen Suit Supporting Documentation
Nod.
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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This written report constitutes your claim against the City of Dubuque, Iowa. You should �Id�'�
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 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 JWILL OR WILL NOT BE PAID.
1. Name of Claimant:
2. Address: _`1 so 1 0t,e
3. Telephone Number: (56 3)
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4. Date of Incident: L29�17
5. Time of Incident: 1 526 , S,,)6 Pp
6. Location of Incident (Be specific): 66r clork- rj(,
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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? armo,
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).
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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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C rte $�2"33,
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.)
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What amount do you claim from the City of Dubuque?
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1 Whydo you cl m the C' of Dubu ue is res onsible? j
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17. Have you made any claim against anyone else for damages as a result of this incident?
(if es, 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? 4A
Dated at Dubuque, Iowa this ] day of It 2017.
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(Signature)
Z (Print Name)
(Rev. 7/12)
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Confidential
This communication and any attachments may contain information which is confidential r
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 an review, disclosure dissemination distribution or copying eying 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.
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Confidential information may include the following:
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1) Social Security Number(s)
2) Medical/Health Information
3) Personnel/Disciplinary Information
4) Bank Account Information u
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. Please indicate below the
type of information that is included.
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I, AEC, &7_-ija , 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
prot ct my information from unnecessary distribution.
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. &&/�'O , W31117
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.
77/3/// 7—
Signature Date
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