Claim by Rainbo Oil Company Copyrighted
June 18, 2018
City of Dubuque Consent Items # 2.
ITEM TITLE: Notice of Claims and Suits
SUMMARY: Larry Dunton for property damage; Rainbo Oil Company for
property damage; State Farm subrogating for Lyla Ant for
vehicle damage.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City
Attorney
ATTACHMENTS:
Description Type
Dunton Claim Supporting Documentation
Rainbo Oil Company Claim Supporting Documentation
State Farm Subrogation Supporting Documentation
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CLAIM AC�AINST THE CITY OF DUBl1QUE, IAWA ���"�,�
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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 s�pports your claim. �
The Claim must be filed rnrith the City Clerk at City Hall, 50 W. 13t" St., Dubuque, IA 5200'I, It 1
will then be referred by the CAty Council �o fihe appropriate department for investic�atiorn. j
Once that ir�vestigation is cornpleted, a report and recommendation will be submitted to the
City CounciL You will be provided with a copy of that report and recommendation. �I
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. N� EIVIPLOYEE OF �
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`TFiE CIl`Y OF Dl1�UQ4JE HA� THE AIJTWOf21TY 1'O IVIAKE ANY REPRESENT,4TIQN TO YOIJ i
AS TO WHETHER YOUR CLAIM WILL OR WILL NOT �E PAID. '
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1. Name of Claimant: �c+�.�.,v...� f�,,Q c�r,,vw�,.nr�.�� �
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2. Address: ��`�'� ' a�c.�aa� l� � ��i ',
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3. Telephone Number: 5 (��- �8 �,_� �.� � 'i
4. Date of Incident: �'�.,a �'���' `� �"'' � � �?
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5. Time of Incident: .��� � 1�c���:�r�.,,. `�l� l��. �,�
6. Location of Incident (Be specific): �'�,�-E� l�-arz.,..r�...o.. •z�.,.. ��
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7. DESCB2IBE ACCIDENT OR OCCURRENCE �'HAT CAUSED INJURY OR DAN9AGE. (Give !i
full details upon which yau base your claim. If a City employee was involved, give the i
�mployee's name.) I'I
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8. What were weather conditions like? :� �
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9. Give name and address of any witnesses: ��`
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'10. Did police inve�tigate? (If so, give names of officers.) ��
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'11. V1las anyone injured? (If so, give names, addresses, and extent of injuries).
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12-1Nas any damage done to property?--(If so, describe-property and-fihe extent of --- -�
darrrages. Attach estirnates of damages or describe basis for ascertaining extent of �
damage.) p
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'13. What other damage� do you claim, if any? l� ��.
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�4. Have yau been compensated for any part or all of your claim by any insurance `
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company? (If so, give name and addre�s of insurance company and amount paid.)
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15. What amount do you claim from the City of Dubuque? � I'�'
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16. Why do you claim the City of Dubuque is responsible? l 'I;
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'17. Have you made any clainn against anyone else for damages as a result of fihis incident? !i
(If yes, give name and address.) ��
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18. If the answer to Question 17 is yes, have you received any payment from that source, �
and if so, in what amount? a
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Dated at Dubuque, lowa this l?� day of .� , 20�. �',
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Confadentaal
This corrimursication arad ao�y attachments c�a��y contairo iraforrnation whOcF� is con�o�er�toal ��
and priviseged by law and is for the use of the desognated recipserat. Vf you are not fihe �
intended recipient, you are hereby no�ifed that you have received this comrnunAcation ir� ,a
error, and that any review, disciosure, dissemination, distribution or copying of its contents ,,
is prohibited. F'lease notify City of Dubuque imrr�ediately by telephone at (563)-589m4120 of
your receipfi of these items and destroy the cornmunication and any a#tachments
immediately. Further disclosure of this inforri-mation may violate state and federal
restrictions.
Confidential information may include the following:
1) Social Security Number(s)
2) Medical/Health Information
3) Personnel/Disciplir�ary Information ;�
4) Bank Account Information 'I
5) Financiallnformation „
6) Credit Card Numbers
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If any documentation you desire to submit to the City of Dubuque confiains any of the items above, !;;
this cover sheet must be attached directly to the confidential information. Please indicate below the i;
type of information that is included. ��
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I, , hereby certify that the attached documents �
include the following protected information: ��i
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Social Security Number(s) Bank Account Information ,�
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Medical/Health Information Financial Information ��
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Personnel/Disciplinary Informa#ion Credit Card Number(s) , iI
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[ un�eretar�� that th�� information �nay �e �istri�uted within the rity or��nizati�n or to ��ents �f#hs �
City for processing and I hereby authorize the City to act accardingly taking all precau�ions fio
protect my information from unnecessary distribution. �
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Signature Date
9 ha.ve read the inforrr�ation above and do not have any confidential documentation to submit ta the
City of Dubuque as part of thi� Claim Againsfi the City.
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__ _Signature �,��� Date _ �
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