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Claim by Jodi WiegelCity of Dubuque ITEM TITLE: SUMMARY: SUGGESTED DISPOSITION: ATTACHMENTS: Description Elliott Claim Goin Claim Manternach Claim Merz Claim Reisdorf Claim Skrocki Claim Stewart Claim Wiegel Claim Copyrighted October 2, 2017 Consent Items # 2. Notice of Claims and Suits Michael and Vi Elliott for property damage, Heidi Goin for property damage, Sue Manternach for vehicle damage, Kelly Jean Merz for personal injury, Joseph Reisdorf for personal injury, Aaron and Ashley Skrocki for property damage, Sydney Stewart for Toss of property, Jade Wiegel for vehicle damage. Suggested Disposition: Receive and File; Refer to City Attorney Type Supporting Documentation Supporting Documentation Supporting Documentation Supporting Documentation Supporting Documentation Supporting Documentation Supporting Documentation Supporting Documentation CLAIM AGAINST THE CITY OF DUBUQUE, IOWA This written report constitutes your claim against the City of Dubuque, Iowa. You s o 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 WILL OR WILL NOT BE PAID. 1. Name of Claimant: 2. Address: Address:( S ilmts etik&k .55\pkt, i#0,1 513tf 3. Telephone Number: 102 4M-- COW 4. Date of Incident: CI 3 5. Time of Incident: 7 ;2b Pin 6. Location of Incident (Be specific): ----\\17-Kc—rOt .c" /" C4' PAA -Q414 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.) sorKbr Aar\ CoA.Clvit (Xd_dt Vjolcd , .L/Kiru 41-k Cat eaLt9 CaleidetJas' 8. What were weather conditions like? rbIA_Sk 9. Give name and address of any witnesses: eitic 10. Did police investigate? (If so, give names of officers.) 11. Ircti ICkUOgrivkm L(Q Was anyone injured? (If so, give names, addresses, and extent of injuries). 1 `tkiz- +kr con cide 01,A 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.) N\ 3r(-4- ey4A skit. ok or 44_ Cif v CIS ;0{-e, &-A‘ p;rc coVir-arLa ?OV 1,1 a4\ c«'664t)4 (Tor 4-)01 001V V% 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.) 15. What amount do you clal odt q.1kci) S he it o Dubuque?„ .,5Go 1 Le 16. Why do you cjaim the City o Dubuque is responsible? ThLur\CAaeAkr C A irk kot 17. Have you made any claim against anyone else for damages as a result of this incident? es, give name and address.) 6 18. If 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 (Rev. 7112) , 20 (Signature) (Print Name) (r) rrl 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. Please indicate below the type of information that is included. JCL uki k LOC , hereby certify that the attached documents include the followint 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 protect my information from unnecessary distribution. Pit —/ Da e 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. Dat CIPOPI Copyrighted October 2, 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: Heidi Goin for property damage, Sue Manternach for vehicle damage, Kelly Merz for personal injury, Joseph Reisdorf for personal injury, Sydney Stewart for property loss, Jade Wiegel for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo THE CITY OF DUB E MEMORANDUM Masterpiece on the Mississippi TRACEY STECKLEIN PARALEGAL To: Mayor Roy D. Buol and Members of the City Council DATE: September 22, 2017 RE: Claim Against the City of Dubuque by Jade Wiegel Claimant Date of Claim Date of Loss Nature of Claim Jade Wiegel 09/21/17 09/13/17 Vehicle Damage This is a claim in which claimant alleges that as he was traveling north near 280 JFK, he struck a piece of loose concrete which struck and damaged the side of his 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 John Klostermann, Public Works Director Jade Wiegel OFHCE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 TELEPHONE (563) 583-41131 FAx (563) 583-1040 / EMAIL tsteckle@eityofdubuque.org