Claim by Robert Johnsen Copyrighted
July 16, 2018
City of Dubuque Consent Items # 2.
ITEM TITLE: Notice of Claims and Suits
SUMMARY: Kimberly Erickson for vehicle damage, Robert Johnsen for
vehicle damage, Anthony King for vehicle damage, Justin
Mills for vehicle damage, Jane Marie Walsh for property
damage.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City
Attorney
ATTACHMENTS:
Description Type
Erickson Claim Supporting Documentation
Johnsen Claim Supporting Documentation
King Claim Supporting Documentation
Mills Claim Supporting Documentation
Walsh Claim Supporting Documentation
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA .� � f1C' �«' ,
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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 supports your claim.
The Claim must be filed with the City Clerk at City 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 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: Robert Johnsen
2. Address: 145 W 23rd St
City: Dubuque State: IA Zip: 50021
3. Telephone Number: 563-599-8684
4. Date of Incident: 7/11/2018
5. Time of Incident: 8 AM
Grandview Ave, Clark Dr,
6. Location of Incident (Be specific): Dubuque, IA 52001
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 n
CV collided with IV rear wwhile IV was stopped, CV was attempting to swing out for a right hand turn
ind made impact with I D
8. What were weather conditions like? clear
9. Give name and address of any witnesses: none
10. Did police investigate? (If so, give names of officers.)
yes 2018-005707 Dubuque Police Department, Officer Andrew Harden badge 59A
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
no
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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.)
Yes, Rear end of Hyundai Elantra
13. What other damages do you claim, if any?
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.)
Nationwide, TBD
15. What amount do you claim from the City of Dubuque?
TBD
16. Why do you claim the City of Dubuque is responsible?
Truck 100% at fault
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
no
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 �� day of July � 20 201,8
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.1oe Kotz (Print Name)
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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 �he comm�nication and any attachm�nts
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
information that is included.
�, ,1oe Kotz , hereby certify that the attached documents
include the following 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 processing and I hereby authorize the City to act accordingly taking all precautions to
protect my information from unnecessary distribution.
7/12/2018
Signature Date
I
THH CTTY OF
�T� E MEMORANDUM '
Mc�sterpieee orr. the Mississippi
TRACEY STECKLEIN
PARALEGAL •
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To: Mayor Roy D. Buol and I
Members of the City Council
DATE: July 12, 2018
RE: Claim Against the City of Dubuque by Robert Johnsen, filed by Joe Kotz of
Nationwide Insurance Co.
Claimant �
Date of ClaAm Date of Loss Na#ure of Claom i
Robert Johnsen 07/12/18 07/11/18 Vehicle Damage �
This is a claim in which claimant alleges that a Public Works employee struck claimant's
vehicle at the intersection of Clarke Drive and North Grandview Avenue while attempting �
to make a right-hand turn.
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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
Robert Johnsen �
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OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
Su�rE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944
TE�EPHONE (563)583-4113/Fax (563)583-1040/EMai� tsteckle@cityofdubuque.org
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Copyrighted
July 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: Kimberly
Erickson for vehicle damage, Robert Johnsen for vehicle
damage, Anthony King for vehicle damage, Justin Mills for
vehicle damage, Jane Marie Walsh for vehicle damage.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur
ATTACHMENTS:
Description Type
ICAP Referrals Staff Memo