Claim by Monique Hopkins 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
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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 Nall, 50 West 13th St., i(
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. !j
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 i
City of Dubuque has the authority to make any representation to you as to
whether your claim will or will not be paid.
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1. Name of Claimant:MOD I t-)-eVn()htn3
2. Address: Y)
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3. Telephone Number
4. Date of Incident:
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5. Time of Incident: � K
6. Location of Incident (Be specific):
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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.)
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8. What were weather conditions like?
9. Give name and a rens of any witnesses: I
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10. Did police in estigate? (If so, iv a of fficers.)
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111..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 ofVmate.) nVAC Yk
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13. What other damages do you claim, if any?
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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.)
No
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15. What amount do you claim from the City of Dubuque?
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16. Why do you clai he Cit of Dubuque is responsible?
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17. Have you made an claim against anyone else for damages as a result of
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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 c9 I day of 20
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(Signature)
(Print Name)
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Confidential r
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. I
Confidential information may include the following:
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1) Social Security Number(s)
2) Medical/Health Information
3) Personnelbisciplinary Information
4) Sank Account Information
5) Financial Information
6) Credit Card Numbers
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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 E
information that is included. �a
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I, Ott ti , hereby certify that the attached documents
include the follo ing protect d information:
Social Security Number(s) Bank Account Information
Medical/Health Information Financial Information
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Personnel/Disciplinary Information Credit Card Number(s) j
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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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ignature Date
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Copyrighted
August 7, 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: Lester and
Susan Bettcher for property damage, Linda Breitbach for
personal injury, Ruth Ellis for property damage, Monique
Hopkins for vehicle damage, Timothy Kelly for vehicle
damage, Mark Lansing 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; Concur
ATTACHMENTS:
Description Type
ICAP Referrals Supporting Documentation
PERS Referral - Cullen Suit Supporting Documentation
THE CITY OF
DUBUQUE MEMORANDUM
Masterpiece on the Mississippi g
TRACEY STECKLEIN 44)),
PARALEGAL
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To: Mayor Roy D. Buol and
Members of the City Council
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DATE: July 31, 2017 �a
RE: Claim Against the City of Dubuque by Monique Hopkins
Claimant Date of Claim Date of Loss Nature of Claim
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Monique Hopkins 07/27/17 07/25/17 Vehicle Damage
This is a claim in which claimant alleges that her vehicle which was parked at 24t" &
Queen Streets was damaged when struck by a City Jule bus.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa l
Communities Assurance Pool
cc: Michael C. Van Milligen, City Manager
Jodi Johnson, Transit Operations Supervisor
Russ Stecklein, Part-time Transit Operations Supervisor
Monique Hopkins
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
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