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Notice of Claims and Suits Copyrighted March 19, 2018 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Salome Farfan for personal injury, Eric Imhof for vehicle damage, and Rainbo Oil Company for property damage, Wesley Heimke for vehicle damage, Christina Wilson for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Imhof Claim Supporting Documentation Farfan Claim Supporting Documentation Heimke Claim Supporting Documentation Rainbo Oil Co. Claim Supporting Documentation Wilson Claim Supporting Documentation ��1U1�1 l-�t�a� - �, , s ��L1�� T _� CLAIM AGAINST �'HE CITY (�F I)JBUQUE, IOWA This written report constitutes your claim against the City of Dubuque, lowa. You should complete this form in full and attach any additiQnal 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 i completed, a report and recommendation will be submitted to the City Council. You will be provided with a copy of that report and recorrimendation. ' 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: �'�-1 � � 1`"L f-�� 2. Address: �� G�,�-�l��.� ��' 3. Telephone Number �� 3� ��o ' �j.�„�^Z 4. Date of Incident: (`) r.,l �/L �'�.c�u••��j Z /Z,� / �,�- � 5. Time of Incident: � 6. Location of Incident (Be specific): ��-�z� � �� n� c��- �-;,��h�- ►�-�-�.1��,�� -�� 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.) � t,��-'i"LR,. !,>, ��f► �� tf'�'M 7�Q ��P��c l�l� j�iwP �ry�� ' �-�•,,�,t..�f�-u� o�- q- s-� ;,s;i,-a�h v^� 7�—�2�..�c. �-.�n " ��-,J L Jr` /"�`✓ C � " "2. lr.lu %J 1� 'J G �l,J�. I o r �i�n�� c� c.��r SiT � !T �.s .h- ��=t�,� - �,��,��t�C� 8. What were weather conditions like? , j � /� �Q �� 9. Give name and address of any witnesses: �� 1�U�� T�dr�.�l�E " /Vt, �jtit'�-�L GrfZ- �.-�•h-i'i� 10. Did police investigate? (If so, give names of officers.) �� 11. Was anyone 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 damage.) 1�.�"�'\/f ./s J r `��-� lt�"� ��L tSU.I� S.'I`"/J'�,1'�^ �2'L.�-o V'!�. N�1 �-u�c� s-�y.� 7��y M-�-� C�� 3 c�� z��-r�v� �t� �� 7�-u�i tJ�-rM-��G �t� c�,-i� , 1 wh�st "1"�° l=��L �41S,S C��'^ �1? �l'T-lg Mti V(n!L f��2�1Y/�-�' 13. What other damages do you claim, if any? i �' r t+�-�� rT � v�_�, ��y �d�-Y-�c� � � wv� ��(�r� TLh.rM�f��'�35�n�T �=r/L �' ��5%• I r 'r�'Jj-�' IS �+��/1-Nl��✓T �/1��, t t,.ruW-t� L 1(�C l a t3�' c�r�}�� `�-7�/� l=v�� 7Z��►-T. 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.) /�`� - it�1-V'� �,S�-� i.t o�l �-)Iz,� i� S��`'4�',N�� 15. What amount do you claim from the City of Dubuque? �� 1� 16. Why do you claim the City of Dubuque is responsible? � 1�/rr��. ��-�l �c��y S��SI-/t`c,��=/J �' ►a �1(-� ��l�G �''-�� . 17. Have you made any claim against anyone else for damages as a result of this incident? (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�la.i,s �� day of ��.lSt��'��'y , 20 �� . _ -` `�' /� � _ ; _� _ ,,-, � r-�; � -, (Signa ure) - ' ' ��-� C. �/� �'�� ^ i;-; (Print Name) � � , __;'` �,� `G r�� 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 atfiachments 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) Financiallnformation 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 I information that is included. I, , hereby certify that the attached documents include the following protected information: � Social Security Number(s) Bank Account Information I � Medical/Health Information Financial Information PersonneUDisciplinary 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 Cit� Dubuque�� of this Claim Against the City I ��' � �-�� • �� ignature Date i Pam McCarron From: ERIC IMHOF <eimhof@cottinghambutler.com> Sent: Wednesday, February 28, 2018 526 PM To: Pam McCarron Subject: FW: Attachments: IMG_3575 jpg;ATTOOOOl.txt;IMG_3574jpg; ATT00002.txt;IMG_3573.jpg;ATT00003.txt; IMG_3572jpg;ATT00004.txt;IMG_3571jpg; ATT00005.txt; claim.pdf Pamela, Attached please find a claim form as well as five photographs evidencing a substance on my car caused by water dripping through the lowa Street parking ramp. I ran it through Miracle Car Wash, but the substance would not come off with a regular washing. The owner of Miracle, Doug Tonne,feels like they may be able to remove the substance with a detailing. In the interests of caution, I wanted to file this claim before moving forward,just in case the detailing causes or reveals any damage. I would expect the city to pay for such cleaning costs. Further, if there is permanent damage, I expect the city to pay for that as well. I will await a response from the city before moving forward with anything. Thank you, Eric Imhof CIC, CRM Vice President � Sales Executive Transportation Group O 563.587.5117 M 563.580.9354 F 563.587.5930 eimhof@cottinghambutler.com CONFIDENTIALITY NOTICE:This correspondence, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information or Protected Health Information (PHI).Any unauthorized review, use,disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender and destroy all original copies. Click https://www.mailcontrol.com/sr/3CnIn3ZMNNXGX2PQPOmvUtVTDJsKpCsgPuwU6Q3dnC1u0WQ2JSdnrCFp6wTcAh95R MHGzZmJt6A94h7CChK4GQ== to report this email as spam. i O M _t� _ GLAIM AGAINST THE CITY OF DUBUQI�E, IOWA C' �''��''� , This written report constitutes your claim against the City of Dubuque, lowa. You should � complete this form in full and attach any additional information that supports your claim. � I The Claim must be filed with the City Clerk at Ci#y Hall, 50 W. 13t" St., Dubuque, IA 52001. It � will then be referred by the City Council to the appropriate department for investigation. �� Once that inves#igation is completed, a report and recommendation will be submitted to the ,I� City Council. You will be provided with a copy of that report and recommendation. ,� u THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF � THE CITY QF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU � AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. ;� �--, .,.---- u 1. Name of Claimant: c`��1�� -�� i; ,, 2. Address: ��1�� a� � ��"� a `��'-�`�-f� ,�� 'i P P S �j �� 4 III 3. �'eiepi�or�� Nuer�be�: ��"�� a 4. Date of Incident: `��'�U�'�' � �� 5. Time of Incident: ``!' ° ��,��7 I'; � ;� 6. Location of Incident (Be specific): ,.�-�'i�`�.�-��2� � �� r�'�.`�. i , �r�t� ��°�r��►*°8� °� P��ie� �� '�� ;; N 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give ii full details upon which you base your claim. If a City employee was� involved, give the �'' �� _ iii employee's name.) - i� �� i� �'�i��, e��+� � 0��', ��'" ��" C�°� �..�' ! � �y �r� �T � f��t�- f�'��'i��`�:�.. ��'� ��iG� �� i�I�' `�� ✓t� ��r�-�` �� -' �y ��, i 8. What were weather conditions like? � � ��+� �,� �"�i�► 9. Give name and address of any w�tnesses: ' �f� �0. Did police investigate? (If so, give names of officers.) ��1 C.� ��- � ' � ��r IT��'�`' �-�� _..��i. e � � ��,�'°` �� ' �� -_.�� $�� 11. Was anyone injured? (If so, give names, addresses, and extent of injuri�s). � � � ��'�� ; � � � � � , � 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 �I damage.) , I��' ,� Ij 13. What other damages do you claim, if any? � 14. Have you been compensa#ed for any part or all of your claim by any insurance ' company? (If so, give name and address of insurance company and amount paid) �� i 15. What amount do you claim from the City of Dubuque? i,, q ''� ��'- �VYI�r� C.?� NI�� ("�l �'s�� I �.��1 �� fi��.��Ac�� i�...�-�� "T ` �'. °�' "� � 16. Why do you claim the Cify of Dubuque is responseble? ��c�� j �c:��..�. �-�=1�--��a�� •�' �� ° ;�t-`� �� d��.. ��f��. j 17. Have you made any claim against anyone else for damages as a result of this incident? II (If yes, give name and address.} j r�C� � � � 18. If the answer to Question 17 is yes, have you received any payment from that source, �� and if so, in what amount? � I � Dated at Dubuque, lowa this �day of ��-�1� , 20 A� . ; y / ;, � N r� I �__.�%� � �'< C�� ,c. e--�,�...-� (Signature) ; f ' b �r��. ��J�/( � ;�l d� �--,��J (Print Name) � �� , �� ,�, � r� � ' �,�� , �� ,'rvf:> � `:�k {Rev. 7/12) �,;� `�� , �._,! : ! ��:� ;�� .�"�� : �� ` c`�,�'�' � ,�- �� ; , ,� ; � � V � V � � � Confidential , This communication and any attachments may contain information which is confidential '1 and privileged by law and is for the use of the designated recipient. If you are not the i intended recipient, you are her�by 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 reaeipt of these items and destroy the communication and any attachments ;I immediately. Further disclosure of this information may violate state and federal '� restrictions. I� � Confidential information may include the following: ',I 1) Social Security Number(s) ' , 2) Medical/Health Information '' 'I 3) PersonneUDisciplinary Information 4) Bank Account Information �'I� , 5) Financiallnformation 6) Credit Card Numbers � If any documentation you desire to submit to the City of Dubuque contains any of the items above, this caver sheet must be attached directly to the confidential informatian. Please indicate below the type of information that is included. '' � I, , hereby certify that the attached documents � include the following protected infiormation: � Social Security Number(s) Bank Account Information 'I i 1�OledicaVHealth Information Financial Information �, Personnel/Disciplinary Information Credit Card Number(s) ii, { �� h 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 ia City of Dubuque as part of this Claim Against the City. ? i � � �,� �- `,� -� `�' �- �� I fs �j Signature Date ' '� ; 1 ; , � r�� CLAIM AGAINST THE CITY OF DUBUQUE, IOWA �t �.��;� ��,��k.s This written report constitutes your claim against the City of Dubuque, lowa. 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 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: �1'S ��I ��;�� -e- 2. Address: 2�5� ►��.5 �r-�;�� Q�- D�h��,a—� TA 5��3 , 3. Telephone Number: �3 -- .�� - ��7 � 4. Date of Incident: ��-r��. `i z�� 5. Time of Incident: __�. 2 `. .�o p�,� G.�r�v�c - 6. Location of Incident (Be specific): �1 b(� ~' `i�� Dc'`� �- � . ��c'+� S•�: �a�''l��`?�� GC!`Qi.lS f>.� �.Q T�iYI�' St� c"\ `�{"2 S�+ 1 � ��^sl,�r� 'T!7)�9/1 V+t�J�"l.i��-.y 7 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.) !'�S J- Gl'fI c:v6t r1 P-Ltl '�'� �tt✓iG {�,tv1 v 2�1.G lt,' �•,'� '}�'.2 S i C�. �1,� �f'�tiG- ;Z'xi.�� /u-y "lYs+/1"F !'�y h f i �c:rj,: h:�i��c:. +i-2 l�''� � �V` i t 2 i.J��(.�, 5¢�'� M v.� k�i.e-G l �v�+� `�►� t',:��h .�j *-i} iu.� �J�t2 ( U�al. �M�a'�g a c v►��,� �'°�' r��y z.- c�� a'!� �� +rc : 8. What werC weather conditions like? (�,�+�� ,��nr,�.� � H� 'S �:�,,.��,:.. �•� 9. Give name and address of any witnesses: �kv� � �� f z (S�s� 27s- Szb`l � ,�:,,,zX;�,, 10. Did police investigate? (If so, give names of officers.) ,�v 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). �J 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 �r'L'•1�' !'��J h� G.>�..t-�LI lt 'r�^t- �� .u.f l o i�l fTt.u�ct �c-�� iL'i;s �v1�;�f'�'� �nJ►�•n ,1 w'�ci 1 c�tt:�,�h:�., .}.� �,•w �..� s i�� o, �►+..e :e.� _ /�:� .}�,� �,,u,e � ,,,,c,.f,,.e„t t� ;c.c_ r��.tt ;„�:-� 6�,�n� �,k�r.� ( c�,v t-�'0��. 13. What other damages do you claim, if any? Dn� cl�;.�,� �.�� :,��,�� .� 2��NdG- �w � �0�2 ��lc.,w4�� 9 " 1-�v:v�.�� -�.t�r�a,,, �Ile,t l fv�u ii��., �r�,r�< �� q 3,�,`'� 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 qf Dubuque? _ R.��r� �.�r�-� `rl,,�-�j ��ht ( � �13,i' ) (��i t�� . 16. Why do you claim the City of Dubuque i.s responsible? o ati?fll ��it,V�LC. C.� �- �T�i=l' t��!1'✓P �I LZ I S�'IQ'✓, �- 'x C'.i'1-�1 S�2aL� f �c'.r lL�'�l Ll/'�''c�l TC`�CC _ i ��r�Sin.--�A �t ^� S��.c�( �1 " � � r '1� i!i �f'�-z �`�i ,-+7 �l�i S�:Aail n n��.�•f c �et 4a�T �n hi�� jti7 h� .re �. 17. Have you made any claim against anyone else for clamages as a result of this incident? (If yes, give narne 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 at Dubuque, lowa this ' 3 day of I`��'�� , 20�. _� ;� ��, = � ,_ -- ,�. T ,� l�� _ = "� �-,� �' (Signature) - ;-a �s.a �-... _- ,_ i ��Slt•-i t�. �e;�;��, (Print Name) � -" �_, --'- 1 c.n �'`� [L� c� ! 1�cv�: C Cio�`�-�L�" Wl:f� VJ t�1 U N� �JG$�-icV+S ., i �/c%� (Rev. 7/12) , �w� n�E- +r y �:�c� �+r� ��ic� ��:,,„ic�y,.� �- �F-�e ��`�j , -r S,e I�e�-e at�.j ��M ��s ,� ��,d � � ��"� `�(,�w� `�� _ �.�Z �' �;,�.,1� �s�' \ �3' 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. I, '�,�� - e��1 I� , hereby certify that the attached documents include the fo owing 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 pro�eGsing and I hereby authorize the City to act accordingly taking all precautions to protect my information from unnecessary distribution. � i A � � 3��3 � Ic�' 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 Claim Against the City. � �A1��'{-�'1 !"� � � , S I � 5 f �� Signature � Date , �E �- r2i 1�Sc�ry , � c ww. ��uCt a 11 v� '�1 i s �h�{�/��'✓In � � t � � , �,� "��M t`�'� �,�y �s CLAIM AGAINST THE CITY OF DU�IJQUE, IOWA ��`�"`c`�`^`� a This wrottet� report constitute� your claim against the City of bubuque, lowa. You should ' complete this form in full and attach aray additional information that supports your claim. The Claim must be filed with the City Clerk at City Hall, 50 W. 13t" St., I�ubuque, IA 5200'I. It � will then be referred by the City Council to the appropriate departrr�ent for investigatior�e. Once that investigation is completed, a report and recornmendation will be submitted to the � Gity Council. You will be provided with a copy of that report and recommendation. � T'FiE FINAL DECISION ON ALL CLAIMS IS MADE BY 1`HE CITY COUNC9L. NO EMPLOYEE OF '' THE CITY OF DU�UQUE HAS THE ALITHORITY TO MAKE ANY R�PRESENTATION TO YOU ' AS TO WHETHER YOUR CLAIIV� UVILL OR VIlILL NOT BE PAID. � 'I. Name of Claimant: ��-�� '�- ��"��`�'`�r�'��-� � Ii 2. Address. ��`� � L�.-��. � t� 3. Telephone Number: ��`� �.°��-`� � 4. Date of Incident: � �.�i "� 5. Time of Incident: ��-� ��'°°°Y`-�-� 6. Location of Incident (Be specific): ��`..� ' � � ��1.Q.1�1��..�'r�r� '� ��- �.�"�'°-.�'c..��v� i I 7. DESCRI�E A�CIDENT OR OCGURRENCE THAT CAU�ED IfVJURY OR DAMAGE. (Give �; full details upon which yau base your claim. If a City employee was involved, give the ! employee's name.) i � �:.�...�.�� ..�� .,A...�-��. ,�-�-� ,��.�►� '� � � � � �' ` � �' ��.��-r-�. C-� � � i . . _ t 8. Whafi were weather conditions like? .�� i � � � 9. Give name and address of any witnesses � � � � € '10. Did police investigate? (If so, give names of officers.) ; � � � � I 11. Was anyone injured? (If so, give names, addres�es, and extent of injuries). i ; � � i R � I � i � 4 � . 1 � � 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 af damage.) �; - --- � -��.r,.., �.�.�1Z __,. , � � � ��n f'�-�� -A-�-�- I �.,��cc.�.a� 'j 13. What other damages do you claim, if any? �..� c�...:-��t�.e..�'�r� _ � ;, �� i, 14. Have you been compensated for any part or all of your claim by any insurance company? (If so, giv� name and address of insurance company and arnount paid.) I�� i � 15. What amount do you claim from the City of Dubuque? ,� -� I � �t�`°� ,t"y� �c�.��,�,� ; ��, D��=..�'� ',� 16. Why do you claim the City of Dubuque is responsible? V r P � ,� �'_�x �,�..t.r�.�.. s �J1--�,.x.�.— � '� 17. Hade you made any claim against anyone else for damages as a result of this incident? '; (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? ' � � ; I�'� Dated at Dubuque, lowa this � day of ��-� , 20 �� . � I�/_ ,� �(5ignaturej � C I � ��'° ��-� (Print Name) ! r�;� �a I r:- , '��'� � �' �...,, � r�,`� (Rev. 7/12 ' ' °''�� °' I ) — . , ,�..E �_a ; � # 3 �. � �� ' �,�� ' �...:! : � � � ; i� 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 i � restrictions. '� �� I Confidential information may include the following: I 1) Social Security Number(s) 2) Medical/Health Information �� 3) Personnel/Disciplinary Information ii 4) Bank Account Information ' 5) Financial Information 6) Credit Card Numbers j . � If any documentation you desire to submit to the City of Dubuque contains any of the items above, i this cover sheet must be attached directly to the confidential information. Please indicate below the type of information that is included. � , hereby certify that the attached documents !, include the following protected information: ' f Social Security Nurnber(s) _Bank Account lnformation Medical/Health Information Financial Information Personnel/Disciplinary Information Credit Card Number(s) I ��ncierstand 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 Claim Against the City. � � �� _r� Signature ' ` Date� , c,.1 _ r�,� M. 1�IS��,,� CLAIM AGAINST THE CITY �F DTJBUQUE, IOWA This written report ronstitutes your claim against the City of Dubuque, lowa. You � should complete this form in full and attach �ny additic�nal 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 repork and recommendation. i � The final decision on all claims is made by the City Council. No employee of the City of Dubuque has the authority to makQ any representation to you as to whether your claim will or will not be paid. � � �7 1. Name of Claimant: f� �� c.�� i� N 2. Address: ,�';� --��'`w �t�` c,c,� �l �-�.��- i N ,, �, 3. Telephone Number /� � �'��'�� c��.�'� �--- G�� "'� �,�5`t�/�-��r j � 4. Date of Incident: l �� /�"' i��, � 5. Time of Incident: �°� �� Ni 6. Location of Incident (Be specific): � �.5�.�`',� � � �� .%�.� cdc.y�, a�-�' �-�, �1 N �� 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 errlployee's �ame.) pL,d��_ ��. i� ��r�� n � ��t'� �h-a�� ,n.��*'i�, 8. What were weather conditions like? �� ro.-��'y�, r�,a��' �'�.--� , 9. Gi��P r�mp �nd address �f an� v�itn�ss�s: 10. Did police investigate? (If so, give names of officers.) �� -- � � � � � , � V h 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). ►'Z�g�. c�Yt-� ��fi�j �1a.�� °� � �� ;�-c� �vs�s�l� �G b� ,t•G G� �� 1�� ev�.5 c�o� 12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or de�cribe basis for ascertaining extent of damage.) �-�..��- r►� �"�.�c(�-n��f 6� �.� ��' � �� t �� 13. What other damages do you claim, if any? i'I � � a '�'"�� I � � � � i ;� 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.) � '", � �'h �%� �,. �� .� �'� �,�'1� � ' _ i 15. What amount do you claim from the City of Dubuque? k �� 1. �� I �� i � 16. Why do you claim the City of Dubuque is responsible? � �' i� �" � � I li �� I 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 �°� , 20 /� �� ` �. � o s r `�``�, „�� '�"w� (Signature) `�, ` "'- . { ° � � � ..� ... �� 1 L'� � � �� 6r° `,' k �.,r ' �I� (Print Name) `� ;� � C,,,,� ct� � � � � � Confidenti�l This communicati�n 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 no#ified tha# you have received this communication in i error, and that any review, disclosure, dissemination, distribution or copying of its contents is prohibited. Please notify City of Dubuque imrnediately by telephone at (563)-589-4120 of � your receipt of' fhese items and destroy the communication and any attachr�ents W immediately. Further disclosure of this information may violate state and federal ',� restrictions. � � � Confidential information may include the following: ;j � a 1) Social Security Number(s) a 2) Medical/Health Information �i; 3) Personnel/Disciplinary Information �' 4) Bank Account Information I; 5) Financiallnformation I� 6) Credit Card Numbers li; , ' I� If any documentation you desire to submit to the City of Dubuque contains any of the items above I� this cover sheet must be attached directly to the confidential information and indicate the type of 'il � information that is included. �� ! I, �'�1�'�'�°��'��, �.c,�;t��.�r� , hereby certify that the attached documents � include the following protected information: �� 'l � Social Security Number(s) Bank Account Information � �; j; �MedicaUHealth Information Financial Information � � Persannel/Discip9inary Information Credit Gard Number(s) � � � I understand that this information may be distributed within the City organization or to agents of the a City for processing and I hereby authorize the City to act accordingly taking all precautions to protect my information from unnecessary distribution. ��—' �,c�� 'l ��3 � 1�' ;A l�° �-- 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 Claim Against the City Signature Date � i