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Claim by Alex Helbing Copyrighted March 5, 2018 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Alex Helbing for vehicle damage, Kathleen Pfohl for vehicle damage, TFM, Co./Tom Thompson for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Claim by Alex Helbing Supporting Documentation Claim by Kathleen Pfohl Supporting Documentation Claim by TFM, Co. Supporting Documentation � '��� � p , � � ��_• ����� � �v�� - � CLAIM AGAINST TWE CITY OF DU�UQUE, IOWA ���c� This written report constitutes your claim against the City of Dubuque, lowa. You should �omple#e #his form in full and attach any additional infrarmation that supports your claim. . I'� The Claim must be filed with the Cafiy Clerk at City Hall, 50 W. 13r" St., Dubuque, lA 520A°I. It j will then be referred by the City Coun�il to the appropriate depar�ment for investigation. '�, Once that investigation is completed, a repork and r�commendation will be submitt�d to the ; City Counail. You will be provided with a copy of that repart and recommendation. 'I ; THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY+COUNCIL. NO EMPLOY�E C)�' �� THE CITY fJF DUBUQUE MAS THE AUTHORITY TO MIAKE AIdY REPRESENTATION T4 YQU I� AS TO WHETHER YC)UR CLAIM WIL.L t�R WILL NOT BE PAID. !I �';i 1. Name of Claimant: � �' � i i �7 , 2. Address: L- � �,� ��� '�; p �,��� ��� �� � � '� 8, Tele hone Number: 'i 4. Date of Incident: � ���, ��� � � � i 5. Time of Inaident: ,��°� '� �`i� � � " i G. Location of Incident(Be specific): �... �°'Tv ��.,�.�Si c�� , , i �. �..�e...�, ��' �� � � 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give � full details upon which yora base yaur claim. If a City emp►loyee was invoMved, give th�e � emplayee's name.) � ;, C� � � �`;� ��.— ���:�� � �1 �+o -� ;' _ _ �.�., �.-1�--� `�� o���-�-��� , 8. What vuere weather conditions Ni�Ce? ���� 3� �� � 9. Give name and address of any witness�s. � 10. DId police invesfiipate�' (If�o, aivs names of officers.i � �� 11. Was anyone injured? (If so, give names, addresses, and exfient af injuries). � � � � � � � 9{ 9 T 4 y s 0 f u d t � 12. !lVas any da�r�ge dane to pra�ae�fiy? {If �so, d�scribe propert�r and �he e�ent of � t�amages. At�a�h estimates of d�mages or +d+�scribe ba�os for �sc�rta�nir�g exfient c�f damage.) ; i �����' �� �a��� ���� �� � ��� �� ��� � u � �S �-. G�e�� �` � '��� NI � 1�. Wha�o#�e�r darn�c�+�s dc�y+��a ���im, if any'� � � �14a Have you bee� comp�r��at�d fiar any p�rt sar a!1 of your ci�im by �ny Nnsurar��e "'� c�m�ar�y'� {If so, give n�me �r�d addr��s c�f i�nsura�nc� �ornpany and amaurt� p��d.} � �� W '� a a 75. �hat�rnc�u�dc�you cl���ra�r�m�he G�ty af�ubuq��'� � a . . .. . . . . i 16. Why do yvt� �I�irn th� City o�f��bc�que is responsible? v� �.C,�1�-.. ���1�... � �- ���� � �-� � , � 77. H�ve you �ad� any claimi �gainst anyane ��se for dama��s as� res�zit+�f tt�is in+�id��t��' � {I#yt�s�give nar�ne an�l at�dress.} ` �� i i! 1�, If the answ�r tc� Questi+�n 1? �� yes, have you r�ce�ved any payment fram that sc��rce, ; and �f so, �n what�rnoe�nt? � G � ,�- �1 �� D�t�d �t D�buque, lowa�his ��d�y t�f �-�'��`� t , 2�1� . � � {Signatur�) � � �+a {Print�lame) � � �� � � � ��'�� � ..�� . �� c� �—� � �. �� f`;3 x'.�,. I , r �� - wt , ���V 9 I�C"��} ' • :��x „_�� � (� '��; ,_:�.;: i �� � � ' � � � t�"�''�- #, � � `w' °� 3 �*:� � � � � E i � � � �c�nfid�ntl�f � '�his �omr»e�r�ic�tion and any �fita�chments may cant�ir� infc�rmation whi�h is conf�dentiai � a�d priv�t�g�d by taw and �� fc�r th�� t��e of the desi�nated recipient. !f you are nc�t th� a intended r��Ep�ent, yuu ar� hereby nvt��i�d that yc�u have receiv�d this cQmmunicaticrn in � errc�r, a�d t�at any review, c�i��lc►sur�, d�ssemination, di�tribution or ce�pying c�f ets c+�ntents � is proh�bi���l. Please notifiy +�ity a��` Dubuqu� immediately by tele�shone at {���}-589-4'120 af ! your rec�ipt of t1��se ��ems �nd destray th� cc�mrr�un��c�tion and any �tt�achrn�n�s C immec�i�fiely. ��arther dis+closur� c�f th�� inforrnatiar� m�y violate �tate and f�der�l z resfiricti+�n�. � � 1 t �r�nfidenti�l inform�tion may inc�c��t� the�Follc,wing: � f I,. 1) �ocial �ecurlty�l�mb�:r{s) � 2} Medic��ll�ea��1� �nfQrmataon � � 3) Per�c��nei/Disciplinary Infiarm�tic�� � 4} E�artk Account 1nfc�rmation �} Fin�nci�l �r►fc�rmation �} Cr�dit Card Numb�rs I ;; , If�ny dac�menta�ic�n yQu d�sire tc� �ubmit�o th� Ci#y of C�ub�que �onf�ins ar�y t�f#he item� alac�ve, � this cav�r sh�et must be attacF��d directly��the cc�nfidenti�l ir�farmation, Ple�se indic���belt�w th� tYpe c�fi infr�rma�it�n that is incl�aded. � 1, , h�r�by cerkiirCyy th�t th� �tt�ch�d de�eurrter�ts � inc6ude��re fc�llowir�g pt`��ec��d infr�rm�tian, a Sa�i�l Securifiy Nt�rr�b�r{�� �B�nk Acccxunt lnform�tiort � � IV4edi�t/Heal�h 6nft�r�natic�n Fin�nci�l Information � � i PersannelOD��ciplinary In�arm�#iQ�n �r�dit C�rd Numk�er{�) � � 9 t�r�d�r����d fi'���tni� ir���i���i�rt ��y b� di��ribi���d v�ri�h�i� �h� �i�`y c�����;z€�iiv� ur te��t�+��t�tr��i� ; City for �ra�essir�g an� � her$f�y ���hc�ri�� th� City tc� act a��ordin�ly takinc� �I� pr�cautions �� � p��ect my irtforma#ic�n frr�m unrre��s��ry disfrilaut�on, � � � � Si�natur� C��t� � i have read �he mformat�an abov� �nc� d� rrot have ar�y con�dent'al dc�cumentat�ar� �c� suk�m�t to the Gity of Dut�uque a� part of fihis Cla�m A�ain�t#he City. � ���� � � �ignature Da�� � , Copyrighted March 5, 2018 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: Alex Helbing for vehicle damage, Kathleen Pfohl for vehicle damage, and TFM, Co. for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo THE CITY OF �UB �� CTE MEMORANDUM Masterpiece on the Mississippi TRACEY STECKLEIN � PARALEGAL � � To: Mayor Roy D. Buol and ' Members of the City Council DATE: February 27, 2018 I RE: Claim Against the City of Dubuque by Alex Helbing �� Claimant Date of Claim Date of Loss Nature of Claim II Alex Helbing 02/27/18 02/14/18 Vehicle Damage hl ! This is a claim in which claimant alleges that a city bus struck claimant's vehicle which t; was parked near Hill and 9t" Streets. � I; �i This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa ; Communities Assurance PooL � ,; cc: Michael C. Van Milligen, City Manager a Russ Stecklein, Transportation Services Field Supervisor � Alex Helbing ; � � � �, � � � OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA � SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 � TE�EPHONE (563)583-4113/FAx (563)583-1040/Emai� tsteckle@cityofdubuque.org � � p �