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Claim by Dorothy Ernzen Copyrighted April 16, 2018 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suites SUMMARY: Dorothy Ernzen for personal injury, USAA General Indemnity Company for property damage SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Dorothy Ernzen Claim Supporting Documentation USAA (David Thimmesh Tyler Sytie) Supporting Documentation � ��i� _ I ,� �; . �� Y�� -1`V�C��S � CLAIM AGAINST �'HE CITY �F I��JBUQUE, IOWA � . This written report constitutes your claim �gainst the City of Dubuque, lowa. You � should complete this form in full and attach �ny additi�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 II 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 mak� any representation to you as to �� whether your claim will or will not be pai . � � . ; '� 1. Name of Claimant: y ;� 2. Address: � C� � i � � � � � 3. Telephone Number � ��`' �� ;� i ��/ � 4. Date of Incident: / �"" �"� �. � ;, � � � ,, c� �, � 5. Time of Incident: � � � %� � 6. L c tion of Incident (Be specific): �� °� � � � �� f � �� 7. Describe the accident or occurrence that caused injury or damage. (Give full �I{ details upon which you base your claim. If a City employee was involved, give � th employee' nam .) ,� � � .,, r � �° � � � � � 8. hat were weather conditions like? � 9. Give name and address of an witnesses: � '"�,��---�-�--� y � � � 10. Did police investigate? (If so, give names of officers.) � � �� „ i N 1 j i � 1 � , � , � 11. W�s artyone�njured? {1 so, give names, ress�s, and exfient of injuries). � � �i .� ;i I ;� 12. Was any darr�age dor�e to pr�perty? (If so, describe property and the extent p of damages. Attach esfiimates of damages ar d��crik�� basis f�r asc�rt�ining ' � extent c�f damage.) � �� ; �:� � 1�. W�at �ther damage dc� you laim, if any? � � , �1t � r 14. Nave ya� been campensated far any par� or all �f your claim by any = ir�surance company? (If s�, give n�rne and address ot insurarace cc�mpany and ; amount paid.} ; � �..�'° c; ;; 15. What arn n t� you claim from the Cit� ofi I�t�buque? � ��a�� ; 16. Wh do c�u im th �ifiy of Du �aque is r sponsibl�? �i � � � � � 17. H�ve yc�u made any claim agair►st anyone else for damages as a resulfi c�f � this �r�cid�r�t? (If yes, give �am� �nd �ddr�ss.) � „� . � 18. if the answer to Questic�n 'C 7 is yes, have you received ar�y payment from that sc�urce, and if so, in what �mount? � � � � Dated this day of � � 20 ��, � �� t �. � r� r � a.� 7 � x .4�y. (Signature} � M1•a � �i '� � � �� i � t'.'c�'J �� ''�- �3 � {Print Nam�;} � � � � Ca►nfiden��1 ` This cornmunica�ic�� r�d �ny at�achmenfis may cor�tain �nformation wl�ich is confidential ant� priv�leged by law and is fior the use of the desi�nated recip�ent. If you are not th� ir�tended recipient, you �re hereby notified �hat you have received this cflmmur�ication in errc�r, and thafi any revie�r, dis�losure, dissemi�ation, distribution or copyin� c�f its contents � i� prohibited. Please notify City c�f Dubuque imme�ia�tely by tel��one a� (563}-58�-4"120 of � your r�ceipt of these i�ems ar�d destroy fihe commur�icatior� and any attachtnents � imr�nediately. F�rther dis+cic�sure af fhis informatic�n m�y vic�[ate state and federal � restrictions. ; Confidential infarrnation may include the fallowing: � 1) Sc�eial Security Number(s) 2) MedicallHealth Information 3) Perse►nnellDisciplinary 1r�fQrmation � 4} Bank Accat�r�t Informatior� � 5) Financiallnfc�rmatior� 6) Credit Card Numbers ;� , � If any dacurnenta#ic�n you desire to s�bmit tc� fihe City raf C}u}auque contains any of the items abc�ve � this c�ver sheet m��t be attached directly t� the cc�nfidential inform�tion �nd ir�dicate the type of E� ir�farma�ic�n tha� is included. � � �; ;I I, , hereby cer�ify th�t the atfiached documents � include the following prfltec��d infc�rmatior�: � � Sacial Security Number{s} � Bank Accaunt Information �, MedicallNealth Inf�rmation Financial Information � '� Persc�nnellDisciplinary Information Credit Card Number(s) � 1 understand that this inf�rmation may be dis#ributed within t�e City organization ar ta agents �f the �ity for prac�ssing and I hereby �uthorize the Gity to ac� aecardingly �aking all precauti�ns t� protect my Enform�tic�n frcam unnecessary distribution. Signature Date � � I have read the informatian above and dc� not have any confid�r�tial docurn�ntation tc� submit to the � City of Dubuque as par� of this Cl�im Agains�the City � � �" �� Signature Date � 5 � Copyrighted April 16, 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: SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Supporting Documentation THE CITY OF � �'UB �� E MEMORANDUM � Mastespiece on the Mississippi � TRACEY STECKLEIN � PARALEGAL To: Mayor Roy D. Buol and Members of the City Council � DATE: April 11, 2018 � � RE: Claim Against the City of Dubuque by Dorothy Ernzen � , Claimant Date of Claim Date of Loss Nature of.Claim I. H �� Dorothy Ernzen 04/09/18 04/04/18 Personal Injury ;'I This i� a claim in which claimant alleges that she was injured while attempting to exit a li City of Dubuque Jule bus when the doors on the bus were closed to quickly and struck both of her arms. � 1 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 ; Russ Stecklein, Transportation Services Field Supervisor j Dorothy Ernzen ;� G � � � � OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA N SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 �i TE�EPHONE (563)583-4113/Fax (563)583-1040/EMai� tsteckle@cityofdubuque.org � i� �