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Claim by Kathleen Pfohl 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 �.`�`:�� , �, �, CLAIM AGAINST '�HE CITY �F l��JBiTQUE, IOWA , This written report ronstitutes your claim against the City of Dubuque, lowa. You should complete this form in full and attach �ny additional information that supports your claim. � The claim must be filed with the City Clerk at City Hall, 50 W�st 13t" St., � Dubuque, IA 52001. It will then be referred to the a�propriate 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 repor� 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 makP any representation to you as to ; whether your claim will or will not be paid. � ; � �� -�� '�� I � 1. Name of Claimant: � ' � G 2. Address: �� D`Y'`"�--ld'&�f� �� 3. Telephone Number ��" ��"� �� I 4. Date of Incident: c�— �6 1 �' ;I i� �. �; � � �� 5. Time of Incident: �!c�e�,�-�'G'( =� ��'"°1�p� � e �� 6. Location of Incident (Be specific): � a , � � 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.) � � �.�1.(�� t,��:,5 �" � � �l �'�°-� t1�l, �`ll�l,t.�� , �t�-C��- �v� �-- C�.�-�-� .�� 9 s�'�.��L v�� ,�S �Gt,6��. f�� ' �-�r�•� � ��.�a 8. What were weather conditions like? �� 1.�� 9. Give�n me and address of any witnesses: 10. Did police inve ti ate? (If so, giv� names of officers.� �� . � ��..� "7' ��6'�a a�t� ��1 �°� � � r � � � 11. Was aenyone injured? (If so, give names, ac�dresses, 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 damage.) '� �� .l��1��:� �'t�.� � `��...� �`'r�c,t� t 1��" �-t�-c� '��n c��r~ 13. What other damages do you claim, if any? �� r�-�— , � , 14. Have you been compensated for any part or all of your claim by any i insurance compar�y? (If so, give name and address ofi insurance company and � amount paid.) � � � li � � � � 15. Whaf amount do you claim from the Cit of Dubuqu�? ;� � I�- ` � p �� .�-�--� s�, k',� � n�� .�- �-S C`s�-��' � t,J�t�� - .� c =�' 16. y do you claim the City of Dub que is responsible? � �_��s.�� — �[d��. �—c��-- ��.� —�—� (� � �a �,._, l� �. �.� r..�� w �-.. � 9 �� -�.-�-�, �- �..� ��.� �-��- �L�.. �- c�,�..�� ,��rD� � � �..�~ �� a.�i�-�-c�.f�. . � 17. Have you made any claim against anyone else for damages as a result of � this incid�nt�? �,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 � day of � ;�L , 2,0�. '�,� ,, � � /�(/ I IA �� x � _:. � �� V �ii�� _.A� i d ..J�l� � 1 �� ' ...' (Sign ure) ' �_° "" �1 � ��:� � �� -� (Print Name) �`' � � � � , - � Confidential ,� This communication �nd 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 inforrnation may include the following: � !I �1) Social Security Number(s) � 2) Medical/Health Information j 3) Personnel/Disciplinary Information j 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. II �� i �, , hereby certify that the attached documents � include the following protected information: S�cial Security �Vumber(s) �ank Aceount fnforrr�afiio� � 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 n�� h�ve any confiidential documentation to submit to the City f Dubuque as part of is Claim Against the City -��.. � � �-��/� � i nature Date i h E 19 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 CTTY C7F 1� I�'LTS E MEMORANDUM Masterpiece on the Mississippi TRACEY STECKLEIN � � PARALEGAL To: Mayor Roy D. Buol and Members of the City Council � DATE: Februa 16 2018 II rY � � RE: Claim Against the City of Dubuque by Kathleen Ann Pfohl '' Claimant Date of Claim Date of Loss Nature of Claim � . Kathleen Ann Pfohl 02/16/18 02/10/18 Vehicle Damage � ; This is a claim in which claimant alleges that her vehicle which was parked in front of ; 1925 Floraview was struck by a City of Dubuque snow plow truck. ; � 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 John Klostermann, Public Works Director Kathleen Ann Pfohl 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 �'