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Claim by Jordan Roberson Copyrighted April 2, 2018 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Progressive Insurance Co. /Andy Bartolotta for vehicle damage, Jordan Roberson for vehicle damage, Lloyd Haywood 3rd vs. City of Dubuque Police et. al. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Progressi� Insurance Co./Bartolotta Claim Supporting Documentation Roberson Claim Supporting Documentation Haywood vs. Dubuque Police Suit Supporting Documentation 1 x r�� c�� CLAIM AGAINST THE C1TY C?F DUBUG2l1E, IOWA � � This written repart constitutes your claim against the City of Dubuque, lawa. You should compiete this form in full and attach any additional information that supparts your clairn. � I The Claim must be filed with the City Glerk at City Hall, 50 W. 13th St., Dubuque, IA 52001. tt j , wili then be referred by the City Gouncil to the appropriate department for investigation, ; Once that investigation is completed, a repart and recommendafiion will be submitted to the ; Gity Council. You will be pravided with a copy of that report and recammendation. ' � THE FINAL DECISION C1N ALL CLAIMS IS MADE BY THE CITY COUNCIL.. NO EMPLOYEE OF j � THE CITY C7F DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU A5 TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. � � ,�,.. �„� � �� 1. Name af Claimant: ..� ��, _ � � � , i 2. Address: � ��'..� t� ��,� �j�?� --�� C�� = If 3. Telephane Number: ; fj : f 4�, Date of Incident: �� ' � II 5. Time of incident: ��.� ; !a � �� 6. L.ocatian af tncident (Be specificj: ��11 �1,l�rn�`�� ; ; , ; 7. DESCRIBE ACCIDENT QR OCCURRENCE THAT CAUSEL? INJURY tJR DAMAGE. (G'rve �I ful! detaiis upan which you base your claim. if a City employee was involved, give the employee's name.} i ��-�4 ��r��. �ik -I-�t� �v�� 1�,�- Sr�e �� ,�� ; ._ � e tinit.,.a.., ac, a� �; � - v. vv��a� w�i�`viv'�a��ici CfSilfii�ivi�a0i�rt@. '�,�r`��i,�;�tti��c P 9. Give name and address of any witnesses: ; 10. Did police investigate? (If so, give names of officers.) ; i �I�� 11. Was anyone injured? (lf so, give names, addresses, and extent of injuries). �� '12. Was any damage dane ta property? (If so, describe praperty and the extent of � damages. Attach estimates af damages or describe basis far ascertaining extent of � damage.) � � � 1�� ; � ; ; 13. What other damages do you claim, if any? ; �� 14. Have you been compensated for any part or alt +�f your claim by any insurance � � company? (If sa, give name and address of insurance company and amount paid.) � �")-�- �`�..-�'" � " � N '[5. What amount da you claim from the City of Dubuque? � � � � � � � 16. Why do you claim the City ofi Dubuque is responsible? � � . �.�'� L�c�tMa c��S ��Vv�.� �v t�� N 17. Have you made any claim against anyone else for darrrages as a result of this inciden#? � i� (If yes, give name and address.) � 'I, � � � 18. If the answer to Question 17 is yes, have you received any payment from that source, � and if so, in what amaunt? � � � � � � I ; Dated at Dubuque, lawa this �� day of____��t('j� , 20 �� . � i �.�--� �� M ;� r`` �� _�..._� � � `r``. a� � (�:ynG�u��j r`�,,- � ,�- � >- f , ��,-r�� JY�'��hS,� � C-�-�-��1� (Rrint Name) �"'� � � �:w:;�''�� - f�. � �„..� ,"T, � � . r` �- ��' ��"� (Rev. 7/12) y '"' ��' �,..,' �M 1..c' _3`.� � C� �,�.�° � � � i ; # � � Confidential This cammunication and any attachmen#s may contain information which is cpnfidential and privileged by law and is for the use of the designated recipient. If you are nat the intended recipient, you are hereby notif�ed that you have received fihis communicatian in ; error, and that any review, disclosure, dissemination, distribution or copying of its contents ; � is prohibited, Please notify City afi Dubuque immediately by telephone at (563}-589-4120 of your receipt of these items and destroy the communication and any attachments ; immediately. Further disclasure of this information may violate state and federal restrictions. i i i Confidential information may include the fallowing: � � 1) Social Seeurity Number(s) � u, 2) Medical/Health Informatiqn � � „ 3} Personnel/Disciplinary Information � � 4) Bank Account Information ; 5) �inancial Information ; � 6) Credit Card Numbers � . . . � � If any documentation you des�re to submit to the City af Dubuque cantains any of the items above � this cover sheet must be attached directly to the confidentiaf information and indicate the type of � � information that is included. � � � � N � I, �� ^� ��j ��-,� , hereby certify that the attached documents � indude fihe fallowing protected information: � � Social Security Number(s) Bank Account Information � Medical/Health Information Financial Information ` � � PersanneVDisciplinary Informafiion Credit Card Number(s) � � I understand thafi this infarmation may be distributed within the City organization or to agents of the £ „ Lity for processing and I hereby authorize the City to act accordingly taking all precautions to � protect my information from unnecessary distribution. � i � � � � � s �� - gnatur � - . Date i i I have read the information above and do nat have any confidential documentation ta submit to the City of Dubuque as part of this Claim Against the City ;`' �`" �� Signa e � ___ _ Date � ��-�.,,. � � Copyrighted April 2, 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: Progressive I nsurance Co. on behalf of Andy Bartolotta for vehicle damage, Jordan Roberson for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Supporting Documentation � � �, � TYIE CTTY OF I UB E MEMORANDUIV� Mc�ste�iece on �he Mississzppi �� i � TR��r ��r� � �� iu� �� PARALEGAL � , To: Mayor Roy D. Buol and I' Members of the City Council { DATE: March 16, 2018 i� � RE: Claim Against the City of Dubuque by Jordan Roberson � � Claiman# Date of Claim Date of Loss Nature of Claim i� 1 Jordan Roberson 03/16/18 03/06/18 Vehicle Damage i i i This is a claim in which claimant alleges that his vehicle which was parked near the � intersection of Rhorr�berg Avenue and Humbolt Street was struck by a City snow plow ' � truck. i This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa ! Communities Assurance PooL "� 4 a cc: Michael C. Van Milligen, City Manager � John Klostermann, Public Works Directorr ;, Jordan Roberson a 9 �' OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA d 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 ; � �