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Claim by Martina SwainCity of Dubuque ITEM TITLE: SUMMARY: SUGGESTED DISPOSITION: ATTACHMENTS: Description Furlong Claim Kilburg/Dubuque Dental Claim Lindecker Claim Loewenberg Claim Swain Claim Vans Evers Claim Copyrighted November 6, 2017 Consent Items # 2. Notice of Claims and Suits Renee Furlong for property damage, Brett Kilburg d/b/a Dubuque Dental for property damage, Deanne Lindecker for vehicle damage, Chris Loewenberg for vehicle damage, Martina Swain for vehicle damage, Frank Vans Evers 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 M Ma/ CLAIM AGAINST THE CITY OF DUBUQUE, IOWA 01 c& .05106 5- T his 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 St., 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. 1. Name of Claimant: CAttrin, C'v if) 2. Address: [SO [ 0{-c3cett 6—r- 3. Telephone Number 1,90 6'62 ciO3 1 I --1 otwl 4. Date of Incident: 5. Time of Incident: 6. L9c157 Tcicljen Be specific : 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 theemDloyee'snap1e.,L. 11— 8. er eather con 0 4 ons like?9 9. Give name and address of any witnesses: 10. Did .olice investigate? (If so give na GI, 01. 1C -U cSO fl calW 11. Wan6one injured? (If so, give names, addresses, and extent of injuries). 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 da,i.:r,r)( M t 4 -e (--S1 irrtri-e J 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 claim from the City of Dubuque? 1 ns z 16; Why do you cIintIie City of Dubuque is responsible? 17. Have you made any claim against anyone else for damages as a result of this incide (If yes, give name and address.) 18. If the answer to Question 17 is yes, have you received any payment from that source d if so, in what amount? Dated this day of ( igna ure) (Print Name) C) 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. Mc Thm WQt(r , 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 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 Against the City Date t3-- 17 City of Dubuque ITEM TITLE: SUMMARY: SUGGESTED DISPOSITION: ATTACHMENTS: Description ICAP Referrals Copyrighted November 6, 2017 Consent Items # 3. Disposition of Claims 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: Renee Furlong for property damage, Brett Kilburg d/b/a Dubuque Dental for property damage, Deanne Lindecker for vehicle damage, Chris Loewenberg for vehicle damage, Martina Swain for vehicle damage. Suggested Disposition: Receive and File; Concur Type Supporting Documentation �, Masterpiece on the Mississippi TRACEY STECKLEIN PARALEGAL MEMORANDUM To: Mayor Roy D. Buol and Members of the City Council DATE: October 13, 2017 RE: Claim Against the City of Dubuque by Martina Swain Claimant Date of Claim Date of Loss Nature of Claim Martina Swain 10/13/17 10/11/17 Vehicle Damage This is a claim in which claimant alleges that the bumper on her vehicle was damaged after she drove over tree branches that had fallen from a City tree on Prescott Street. 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 Steve Fehsal, Park Division Manager Tom Kramer, Urban Forester Martina Swain 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