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Claim by Justin Mills 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 P"� V� l--i.. a-� �� CLAIM AGAINST THE CITY OF DUBUQUE, IOWA �-�. This written report constitutes your claim against the City of Dubuque, lowa. You shauld 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. 13th 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 MAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO Y�U AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. 1. Name of Claimant: � v�� -� 2. Address: � � t � � �Ah dG S �t�"' I� �-- ;� ~` �ov� City: 1J J v �� C State: �� Zip: S 3. Telephone Number: � b 3 " �g� ' �S/-� 4. Date of Incident: c� �3 2� " �Qlt� 5. Time of Incident: f ��S /��• 6. Location of Incident(Be specific): ��DO ' �y00 �Lii►vtNG��c �.�. %r►7�'�C /��!� fit H c 7�i-��a/%k� f�W�r��s f�}! /�'tc. �m►,rl.� 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.) �i�i�v�r►S e�/ro,Y • ,3v rrr��i �r ��.vt«e`/t %N �L!'j� �w+RR� `i i� era u-s.r'� � �fl rlj• �L�pCh ��NC�G �� .a✓t� QN/l �J'�Gal p✓T �jw a.,� /t/� �lyG�- • 8. Whatwereweatherconditionslike? ,.Sur�ti7_i �7� 9. Give narne and address of any witnesses: /V� 10. Did police investigate? (If so, give names of officers.) ca N D � �_ ��: -- �,- - -- , �., �. 11. Was anyone injured? (If so, give names, addresses, and extent of injuries).; (T� � , -�- /'!/O 0 h r� �•ti/e�S ��► j��c � - '_ -� t�T�: �-, ,- " L_ �r ---- �) i 12. Was any damage done to property? (If so, describe property and the extent of damages. Attach esfiimates of damages or describe basis for ascertaining extent of damage.) Y�.S� b�Otw� QYf tlT 1��VG . �qHns�L T1° r1•�t (�t/CS C�M�7�Nt�ts� /M�a�� IJ �G�+Y«✓1� �RT �j��L , �Ot r�p�tl�/s.��l � Kitf�( TD /1V�L�stC�hs/�,�I1 r��, P�'C. 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.) ✓�Ca , 15. What amount do you claim from the City of Dubuque?�r��` �a 16. Why do you claim the Cit of Dubuque is responsible? , � / ��t��/S[ 1�A� !„� 1 r' �o��L, 51�+r�� t ee.r! Yt�w,�•, /�aw��r/�� Ca vt�� [t�«!!e. / 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.} ,�t? . 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? �/� r'� ,rs.a.. t Dated at Dubuque, lowa this � day of J�r�_, 20 �� , �� ! ��.�� (Signature) � /� �V S T��t1 (�• !��C.C. S (Print Name) �j c� —��' C �% (Rev, 5118) � �: �, �i co � �'� _� r.� �Tl -U «J � � �J -.�. � � (.j' � �( Cl) \� iJ � THE CTTY(3F � L� � � � �.T MEMORANDUM ,, Ntasterpiece a�n fihe MiSsi�sippi � u ti TRACEY STECKLEIN ? PARALEGAL � � � To: Mayor Roy D. Buol and Members of the City Council � DATE: July 5, 2018 � i RE: Claim Against the City of Dubuque by Justin Mills ; �; Claimant Date of Claim Date of Loss Nature of Claim � � Justin Mills 07/05/18 06/29/18 Vehicle Damage � �,' This is a claim in which claimant alleges that while he was driving in the 4300-4400 ; �: Chavenelle block of Chavenelle Road, he drove over a pothole/loose concrete and damaged claimant's back left tire. ;; �� This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa h � Communities Assurance Pool. � �� cc: Michael C. Van Milligen, City Manager � John Klostermann, Public Works Director u Justin Mills ' y � � � � � � � � � � � � OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA I� 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 � � a � 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