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Claim by Giese Sheet Metal Co. Copyrighted August 6, 2018 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Teresa Davis for vehicle damage; Giese Sheet Metal Co., Inc., for property damage; Justin Smith for property damage; True Fitness/Life for property damage; Stanley Wasmund for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Davis Claim Supporting Documentation Giese Sheet Metal Claim Supporting Documentation Smith Claim Supporting Documentation True Fitness/ David Claim Supporting Documentation Wasmund Claim Supporting Documentation CLAlMJ AGAINST THE CITY OF D�IBUQUE, IC7WA � This written report constitutes :your claim against the City of Dubuque, lowa. You should � complete fihis form in fuli and attach any,additional information that supports your claim. The Claim must be filed with the City Clerk at City Hali, 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: - �`��.�; �� °��-�� c� i t°�,C., � � � 2. Address: � �c��a ��.,�_��' �r' �� 9 �i 'i � p: � �.c�� f � , City: ��.��i �..- , , State. � � Zi � , > � ; . �� 3. Telephone Number: � `�,�� "�"��•�C� `�.� , 4. Date of Incident: �� t� g :�� b i� , ��- �'._�.,��-�� ! _ I�; � �� : �;� . � � � I� 5. Time of Incident: �� i�.�� - �� 'Y1 �; :i�... , .:�. .��. � ... �.� ��.'. -: .� . . �.' .:.-:. :.:� .' , . , , n R .:, .. . i 6. Location of Incident (Be specific): ��-i��4�.�. �� ' � � � �� , ; . � � . _ �, �, . , e ��.� �� .�,�� .�r �� a�.1 �g � �-- �� C �' ,h 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give J full de#ails upon which you base your claim. If a City employee was involved, give the � employee's name.) � � ��°�. ` `• '� ` °;p ;`'-8�5.-�. ��4� p.'*, ",5 9,l � �s ,� � K � �-t _ (, ,y u .... C� a� �.4, ` '`� � �J � �._.:v�,Jbd .M �.. �f � r� d_ !s��.%l e� � �_a ' � � � U �R. CT�✓+�� '\-'a3 �"I��,J1�_ j ��S�'t�...� 8. What were weafher conditions like? �i�� i 9. Give name and address of any wi#nesses: _��,��,�;,.�� - t��..�� . . � ..'� � ��.#rs✓ i�'`� l't'�`...7�,��,_'o.��!'1,�,.,'� . 10. Did police investigate? (If so, give nara�es of o#ficers.) ��°� �`��`'� ` � '��. Was anyone ir�jured? (if so, c�ive names, ad�lresses, and ext�nt of injuries). �C� . C M � � 12. Was any damage done #o property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.) � r I -C� R- � v� '� V�r'1�\t`� "�cLa��`� a� r Ch.;�t'1 � i �K..'�h.�� `�lc�.sL.�l.v.:� , , 13. What other damages do you claim, if any? ��-- �(��-��c�,-;�,� ""�?�� 9 > �^�'l ! a `C1 ii � '14. Have you been compensated for any part or all of your claim by any insurance j company? (If so, give name and address of insurance com�aany and amount paid.) ; � � � j �� j , �i 15. What amount do you claim from t�e City of ��apuc��ae? '� `�'��.�C�s l� 'Z !I �� 16. Why do you claim the Cityp of Dubuque is responsible? � _ _ � �' �i 1r� , ',s��c� ° � c.�. � �1 �jL�.��^�V�. i � 17. Have you made any claim against anyone else for damages as a result of this incident? i (If yes, give name and address.) ` �, �� { , � 18. If the answer to Question 17 is yes, have you received any payment from that source, ;; and if so, in what amount? : '� 'i fi � Dated at Dubuque, lowa this �'�'"�� day of �� , 20 �"� . � d � �� (Signature) ' .. � ��.-�Va.rE- I�'1 v� S (Print Name) �,") � J3�=�;" c.._ __ c� �.� �.�" C�—`� � �i~'? � . , � C�} r*,7 r°� -�.� � G,s.� �„ �.� . (Rev. 5/18) `�=� �" � � :,,� � �"� � � � . . � � � �C � � �...� � s � � R , i � Confidential ' This communication and any attachments may contain information which is confidential and privileged by law and is for the use o# the designated recipient. If you are not the � intended recipient, you are hereby notified that you have received this com'munication in error, and that any review, disclosure, dissemination, distribution or copying of its contents j is prohibited. Please notify City of Dubuque immediately by telephone at (563)-589-4120 of � your receipt of these items and destroy the communication and any attachments � immediately. Further disclosure of this information may violate state and federal I� restrictions. '� Confidential information may include the following: !, ; i 1) Social Security Number(s) 2) Medical/Health Information j 3) Personnel/Disciplinary Information 4) Bank Account Information � 5) Financiallnformation 'ii C`j� ('_roruJl± v^u�u �.Ll��P'� ;� ji H �� if �ny d�curne��a�ion you desire to submit fo the �ity 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. �� 4`�`C� i�V�� .� . I� � � _ �°" ' , hereby certify tha# the attached documents I,'� includ the following rotected information: ii i+ �i Social Security Number(s) Bank Account Information �i � ,� � �� r: �. iv9e�ai�alin�ai�r� i�livr�rid�i�n � Financiai information �I� � �l 7 Personnel/Disciplinary Informatic�n �r?�it ra�-� (�ar-,-,t��(�) � ,' 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. � � � �� , - � - � . A � �� -� � � Si a ure Date � a k � � � Copyrighted August 6, 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: Teresa Rainbo Oil Company for property damage; True Fitness/Life for property damage; Stanley Wasmund for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo