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Claim by Anthony King 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 i � l�"' a - , �.�j�� . CLAIM AGAINST THE CITY OF DUBUQUE, IOWA �EIS�I.�'� ��t�iG�S �alt��.. This written report constitutes your claim against the City of Dubuque, lowa. You should complete this form in fufl and attach any additional information that supports your claim. The Claim must be filed wifih 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 w.ill 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: �6 ,. ��. - ; 2. Address: � �� a �,. .w.---_ . ._... �� City: _ State: °�... Z�p; . � 3. Telephorae Number: �� 4. Date of Incident: `� G � ` � � � �� 5. Time of Incident: �? — �� •� � _ � , 6. Location of Incident (Be specific): c `� � �(� .� � rt �.. � W �- 1 � � �� t"� ._ �..�� -C�.�,� 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.) � � �_ ,, � � _ _.� `� (� �� '" � � 0�(„1� , , �� r 8. What were weather conditions like? � � �� 9. Give name and address of any witnesses: � �.: �� ` '10. Did police investigate? (If so, give names of officers.) _ � �� — 11. Was anyone injured? (If so, give naines, addresses, and extent of injuries). �C l� 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.� •- _._ 13. What other damages do you claim, if any? � ��j��_ -�� 14. Have you been compensated for any part or all of your claim by any insurance cornpany? (If so, give name and address of insurance company and amount paid.) � � -- 15. W at am nt do y�o�claim from the City of Dubu ue? � � �t vy,` . 16. Why do you claim the City of Dubuque is responsible? �`' l � � �� ' � �, : r,��..-a�: � R � ��, �.. 17. ave you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) �� 18. !f the answer to Question 17 is yes, have you received any payment from that source, and if sa, in what amount? � �::_� � y-�.� � �� _ _ Dated at Dubuque, lowa this day of . , 20 �� ' � �.�- � �'1 f � � � �� ( .�_. �.�_ � � � ,, (Signature) � , ^ ...... ' __ : � �� , .� c_. �. � (Print Name) �:� c� I°'�� ;_f -�_.� f?�j t �y �.::� "s�� .:� L!7 � 4�._ {:� � tT`� (Rev. 5/18) � . ,. . � c� r'�' � 1 � , � 1 k Cc�n�'idential � ; This cammunication and any at�achments may cc►nt�in infarmation which is confiden�9ai � , and privileged by law and is for the use of the desi�nated rec6pient. 1f you are not the � in�end�d recipient, yr�u are hereby notifi�d that you have reeeived this cam'munieafiion in error, arid that any review, disclosure, dissemi�ation, di�trik�utior� crr copying ofi its con#�nts i is }arohibi�ed. Ple�se nm#ify City of Dubuque imm+�diately b� fielephone at {563}-589-4'�20 of ; �s�t�e� rA�+eip� c�� t9��a� �#�rr�� ! u��trc��r �h� ��;��r��a�� a�� y ��ta��t� � immediately. Further disclosure of #hi� informatior� may vic�late state and federal restrictions. . i E � � i Ct�nfidential information may incit�de the fc�liowing: � 1} Social Security Numb�r(s} � 2} MedicaUNeal�h Infc�rmation � 3} P�rsonneUDisccplinary infarmation 4) Ban1�Acc�unt Infarma�lon 5} Fir�ancial Information i 6) Credit Card Numbers , If any doc�mentation you desire tc� submit fi� the City of Dubuque eontains �ny of fihe ifiems abc�ve this �over sheet must be attached directly t� the confidential ir�formatian and indicat� fihe type of informatit�n that is included. 1, , hereby certify that the at�ached document� include the fc�llov�ring prat�cted infc�rmation: Sc��ial Security Number(�} Bartk Account Informat�o� Medical/Health Infflrmat�on Financial Infc�rmatian Perst�nnellDisciplinary Inform�tian Credit Card Numb�r{s) I under�tand th�# t�is inf�rmatior� may be distribufied within the City arganization or�c� agents of the City for processir�g and 1 hereby authorize the C�ty ta act accordingly t�king all precauti�ns ta prc�tecf my �ri� rmation from unn�cessary distributic�n. � ,, ��f _....,. � ;� ,. � � � : c:�:�� „�.. �`''�` ��,� .. �� Signature Date THE CITY OF � ��.J� E l�IEMORANDUM � Mc�sterpiece on the Mississippi � I TRACEY STECKLEIN �P j PARALEGAL I � ? To: Mayor Roy D. Buol and � Members of the City Council I�I� � DAt�: July 2, 2018 �I� i" RE: Claim Against the City of Dubuque by An#hony Kong ;; �� ,, Claimant Date of Claim Date of Loss Nature of Claim �; Anthony King 07/02/18 07/01/18 Vehicle Damage j ; This is a daim in which daimant alleges that a tree fell onto claimant's vehicle which was � parked in front ofi 1228 Jackson Street. � , � � This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa �� Cornmunities Assurance PooL � cc: Michael C. Van Milligen, City Manager - � , � Steve Fehsal, Park Division Manager Tom Kramer, Urban Forester � Anthony King � � � � � a � � � � d � � � � � F OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA � SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 r TE�EPHONE (563)583-4113/Fax (563)583-1040/EMai� tsteckle@cityofdubuque.org � . � � � 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