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Claim by Douglas Spyrison Copyrighted December 18, 2017 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Douglas Spyrison for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Spyrison Claim Supporting Documentation ��v � � . CLAIM AGAINST THE CITY OF DUBUQUE, IOWA �`-'�F�1�G UJ�'�-� This written report constitutes your claim against the City of Dubuque, lowa. You sho�a�� complete this form in full and attach any additional information that supports your clairra� The Claim must be filed with the City Clerk at City Hall, 50 W. 13"' St., Dubuque, IA 5200'�. 8� will then be referred by the City Council to the appropriate department for investigafior�. ��ce that �:��tigatioe� �� complet��, a repor� ar�d rec�r�e�er�datiofl �iii be sui�r�ified to ihe City Council. You will be provided with a copy of that report and recommendation. THE FlNAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE C3F THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO l'O!J AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. 1. Name of Claimant: � ��S �,Qy r�Saa� 2. Address: �2�S �t��'� ��rr�-c� 3. Telephone Number: �63 ��'27�3 4. Dat� of Incident: rD/�/i 7 5. Time of Incident: �PM 6. Location of Incident (Be specific): �sc►►�e��' o f d1 e ha�� `e� 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (�iv� full details upon which you base your claim. If a City employee was involved, give the employee's name.) cJ'ccn,'�Q�� seu.1��'' �c.c� �/lfc7 t�e b�s�iP�' a s C�t�y pu 6/,G r.�a r�S �f'��-�� t�NE�e �I��n�! �Wa��k�l 6� � /IQi�,�a�S �ar� �[' a�. �5'e�we!' Q��b�e�e . 8. What were weather conditions like? m �� , n�� x �¢�� h��`l , 9. Give name and address of anywitnesses: �►k� ��,l��c wac�s Sf"0.ff .Pe�'�e �2�� tlsa ��r+�• W�l Leal�o ra�� I u.r�be s-. 10. Did police investigate? (If so, give names of officers.) � 11. Was anyone injured? (!f so, give names, addresses, and extent of injuries). �o -- 1 12. Was any damage done to property? (If so, describe property and the extent af damages. Attach estimates of damages or describe basis for ascertaining exterat off damage.) �t1� ��4< <Sa�,c ,�e/Sd,�,�,( �'1,�2rTzj CtS 0. 1 eSu..�� t� SP�t's ,�jt�c.�'� a,✓� Ma-w1 �a c�.�S o� Gl P�tR u,ip Q� s'�� bK.� h a�� 10 �a�m -�r�� .s. 13. What other damages do you claim, if any? �' ��ti�t��" �a5 f ey,u�`� � �e�� e se�..�er- w�,sfe ��M ,�y 1��r�e�" -�,� l�.ra.�� Sys�e� . 14. Have you been compensated for any part or all of your claim by any insuranc� company? (If so, give name and address of insurance company and amount paid.) �� 15. Wh�t amount do you claim from the City of Dubuque? 76�.3� � l+�e ,�l�.mb�-s �o�ll �o efea.r �esca.n��ary C�n�S �rcecQ e�v . 16. Why do you claim the City of Dubuque is responsible? n } ,�., Qaf� K7aS�- ��YJ�' W�-S��S -�fP.C'�t�cJ�'1��) , �.� wtS� lJo-S �faCd� ,�,'�J Pt�tf bU$'t�� y .��[�jFCt�6��_S`rr�'��`- . Q�"C at7 e�}'� * 17. Have you made any cfaim against anyone else for damages as a result of this inciden$� (If yes, giv�nanne anci address.j � 18. If the answer to Question 17 is yes, have you received any payment from that sour�� and if so, in wh�t amount? �� D�ted at Dubuque, lowa this �� day of ��cew� �' , 20/7 , � \ `�y' ��--� (Signature) "� �'� � �"S�� Prin N - � , , ( t ame) � c-� —�a � � � (ReV. 7/12) -_ ��, :, ;,-� �� — �, � __ — --i _ _' ` l-_—1,r 1� �' .� �� CD N 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 th� intended recipient, you are hereby notifed that you have received this communication on I� error, and that any review, disclosure, dissemination, distribution or copying of its conten$s is prohibited. Please notify City of Dubuque immediately by telephone at (563)-589-4120 of your re��ipt af these items a�d destroy �fie communication and any attachmen�. immediately. Further disclosure of this information may violate state and federaB restrictians. � 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 direc�y to the confidential information. Please indicate bel�w th� type af information that is included. I, l�9�� —�y�`Sa� , hereby certify that the attached docum�r��s include the follo�nnng 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 accardingly taking all precautions to protect my information from unnecessary distribution. /� /Z �� 7 , Signatur Date 1 have read the information above and do not have any confidential dacumentation to submit to the City of Dubuque as part of this Claim Against the City. /L/v`i� � S' nat e Date � I Copyrighted December 18, 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 lowa, the agent for the lowa Communities Assurance Pool: Douglas Spyrison for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referral Supporting Documentation TFiE CITY OF �T�3 E MEMORANDUM Masterpiece on the Mississippi � TRACEY STECKLEIN .�Q � PARALEGAL N` � To: Mayor Roy D. Buol and � � Members of the City Council � � DATE: December 12, 2017 I RE: Claim Against the City of Dubuque by Douglas Spyrison Claimant Date of Claim Date of Loss Nature of Claim � N Douglas Spyrison 12/11/17 10/26/17 Property Damage j� � This is a claim in which claimant alleges that a City sewer backed up into claimant's � basement on Grove Terrace as a result of City crew responding to a neighbor's sewer ;, calL � This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa Communities Assurance Pool. cc: Michael C. Van Milli en, Cit Mana er � J Y J John Klostermann, Public Works Director � Douglas Spyrison � � � � � � OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 TE�EPHONE (563)583-4113/F,vc (563)583-1040/Emai� tsteckle@cityofdubuque.org i � � �