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Claim by Robert Johnsen/Nationwide Agribusiness Copyrighted August 20, 2018 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Thomas Coyle for vehicle damage; Robert Duster for property damage; Channing Ellison for vehicle damage; Robert Johnsen/Nationwide for vehicle damage; TFM, Co. for property damage; Daniel and Christina True for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Coyle Claim Supporting Documentation Duster Claim Supporting Documentation Ellison Claim Supporting Documentation Johnsen Claim (additional submission) Supporting Documentation TFM, Co. Claim Supporting Documentation True Claim Supporting Documentation L_� V � M� ('1�, CLAIM AGAINST THE CITY OF DUBUQUE, IOWA �� `�+��`'�� This written report constitutes your claim agains the City of pubuque, lowa. You should �I complete this farm in full and attach any addition I information that supports your claim. � h I�� The Claim must be filed with the City Clerk at Git Hall, 5p W. 13t St., Dubuque, IA 52001. It � will then be referred by the City Cauncil ta the appropriate department for investigatian. ' Once that investigation is completed, a report an recommendation will be submitted to the ,� City C�uncil. You will be provided with a copy of that report and recommendation. I� THE �INAL DEGISIQN ON ALL CLAIMS IS MADE Y TH� CITY COUNCIL. NO EMPLOYEE QF �I� THE CITY OF DUBUQUE HAS TME AUTHORITY Q MAKE ANY REPRESENTATION TQ YOU 'll AS TO WHETHER YOUR CLAIM WILL QR WILL N T BE PAID. ,,I , � � 1. Name of �laimant: �l � � �. �'},�� 2. Address: �� . � � � �� Cit +��. � o�"��y State: Zip: c, � �� 3. Telephone Number: �� l � � 4. pate af Incident: � 1 ',; _ , i 5. Time af Incident: ° , '!i , ,� 6. Location of Incident (Be specific): ' ��P'1 1 ;; � � i ; 7. �ESCRIBE ACCIDENT OR OCGURRENCE TH T CAUSED INJURY OR DAMAGE. (Give '�� full details upon which yau base your claim. If a City employee was involved, give the !, emplayee's narne.) !,I , � � „ � � . � _. , �, ,i _ , �� .� b' 8. What were weather canditions like? �...� 9. Give name and address of any witnesses: 1Q. Did police inVestigate? (If so, give names of officers.) , �� 11. Was anyane injured? (If sa, give names, addresses, and extent of injuries). � � a � . � B � �� 12. Was any damage dane to property? (If so, describe property and the extent of dama�es. Attach estimates of damages ar escribe basis for ascertaining extent of !� damage,) - � , � � ; ; ; �r- �-- ��-- ��- ; 13. What other damages do you claim, if any? I'1 `-�---� ;I '� ;; 14. Mave yau been campensated for any par Qr all of your claim by any insurance '� cqmpany? (If so, give name and address af ins�rance company and amount �aid.) ' 'j �1 ' 1 _ � � � , 1 . What amount a ou claim from the Cit of D bu ue? � � � Y Y � ,: �: 16. Why do you claim t�e Gity f Dubuque is res 4,nsible? � � � r e u f h i i n ' e n � 1 7. F i a v e u m a d e a n c l a i m a a i n s t a n n e e l s f o r d a m a e s a s a s I t o t s c i d t. o a Y Y 9 Y 9 i; (If yes, give name and address.) � � IC I� � 18. If the answer to Question 17 is yes, have y u received any payment from that source, i' and if so, in what amount? " I;: '; � Qat�d at Dubuque, lowa this �;, day of , 20�. ;, � � N � � (Signature) � � 1 r �(�/� �b�;:a � �� '� °� �� (Print Name) `=� � �,� �� 6 `�1� � �� ,.J 1.�� 11��,i'�Q� ' � �' � �� ,� �� ., +� .; �::.� �, �`-�" � �� .�� L� � �� '�$ � (Rev. S/18) ''� � � �' �� ' �s � � 0 � � p 4 y 1 ��"�� c�� yaur�� 8/8/2018 ;� City Clerk I City Hall 5Q W. 13t" Street j Rubuque, lA 520Q1 a 'I Date qf loss: p7/11/2p18 � ��,I My claim no.: 528013-GH � Your claim: unknown I,� Qur insured: Robert L Johnsen � To Whom It May Concern: ('; �i � The intent of this letter is to submit a claim for damages sustained to our insured's uehicle. Enclosed are '; our supporfing documents. 'i (a) The name and address of the claimant; Nationwide Agribusiness Insurance Company a/s/o Robert L. Johnsen, 11Q0 Locust St. Dept. 'i 2019, Des Moines, IA 50391-2019 II II� Contact Person: Selisia ML Schwarz, Claims Specialist II ;�, Phone: 515-508-4154 I Email: schwas18@nationwide.com ;� i (b) A concise statement af the factual basis of the claim, including the date, time, place, and circumstances of the act, omission, or event complained of; �fl �i On July 11, 2018, our insured driver, Robert Johnsen, was stopped at the intersection due to a ''� posted stop sign. Mr, Johnsen was in a stopped position,when your driver, Corey M. Leach,failed � fo pull from a parked positipn safely. Mr. Leach struck the rear af Mr. Johnsen's stopped vehicle ; causing damages. The loss occurred on Grandview Avenue north near Clarke Drive in Dubuque � IA. (c)A concise statement of the nature and the extent of the injury claimed to have been suffered; � The insured's vehicie sustained property damage to the rear bumper, rear lamps,trunk lid, quarter I panel, rear body, and rear door. � We are seeking reimbursement for the amount paid for these damages. 1 � (e) A statement af the amount of monetary damages that is being requested. Collision: $3717.84 Deductible: $250.00 TOTAL: $3967.84 (f) Insurance Carrier Information: �' Nationwide Agribusiness Insurance Company � Policy: PPGM Q019284939 � � After reviewing the enclosed documents, please contact me to make payment arrangements and include � . � � , � my claim number on any payment or correspondence. - � � i. cerely, e sia Schwarz � Legal Subrogation � �lationwide Agribusiness Insurance Company i 1100 Locust St, Dept 2019 � Des Moines, IA 50391-2019 1 (515) 508-4154 � � (855) 219-9254 [fax] schwas18 an.nationwide.com , i I a � ,; Enclasures: Police Report; Estimate; Check Listing; and Vehicle Damage Photos '; I ; I ; il � _ � � - � � � �; � � B �I � � 3 f � i; � ! � � � Z � � Tr:�cey L.Stecklein � Pe1C�I4g<tl ' � �U�711�UE TbiE CITY OF � 5uit�33O�. W�u•bnr Vi�w Flaev � � � � �� w � 3Ot)iUlaiti Strcr:C �"��' � { Duhu�ue,faw<t 52()UI•6�)zW � � , i { � (5�'i3)583-�I 13 t�f'tic� � IVrClSI'��l�l�u'C�pYT ��li�!�'IlSat9at�7�1i ; t543jSg�-IQ40 f��x " ! [st�ck:le(r�cicyotifubwr�ue.c>r:; xoo�•zn�x•2ora I I I I w uly 12, 2018 i ''. i . III Rabert Johnsen ,'� 145 W. 23�d Street � � � pubuque, IA 52pQ1 � � � , � RE: Claim Against t�e City of Dubuque f i � pear Mr. Johnsen: ! 'j � The ciaim �led on your behalf against the C'tty f Dub�uque by Jc�� Kt�tz af Nati�nwid� I � Insurance Company on July 12, 2p18, allegin your v�hicle was struck by a City of ; Qubuque Pubtic Work� v�hicle, has been r�ferr� ta Public �ntity Risk �eruices of lowa, ; '; the agent far the lowa CQmmunities /�ssuran�e Qol. !,j ;,i, If you should have any �uestions regardir�g thfs atter, yau may cali th�m at (888) 520�- i' 4p?4 (tall-free), or yau may writ� to them afi: � � � Claims . f Public Entity Risk Services of lowa 5701 Greendale Raad � ' � Johnston, lawa 50131 � n _ � V ry sincerely, � � � .�� T acey �tecklein P ralegal Enciosur� cc: John Klastermann, Public Works Director Amy 11�liner, Claims Manager, �'ublic �ntity Risk Seruices Tim English, C7'Conn�r& English (nsuranc Agency � � � � � i � � . � I � � � THE CTTY(�F ,;.✓ I � I .��.JB � M E M C.� �. A N � U :M ' � lkfasterpiece on ey�e Mi�sissi�pf � ' � i TRac �v S -r � c �c �. � irw � PARAL� GAL � � � Ta: Mayor R4y p. Buol and i I�emb�rs af Che Gity GQur�cil � � �� a UATE: July 12, 2018 ; 'i � _ R�: Cl�im Against the Gity of Dubuque by Robert Johnsen, fil�d by Jve Kotz ofi ; Natianwide �insurance Co, � �� i '1 Cla�,�imant Date af Claim a#e of Loss FJature af C�aim ; !; , ' !i � Rabert Johnsen �7/1�/18 q7/11/18 vehicle Damag� N � ' i This is a cla(m in which claimant aileges that a Public Warks employee struck claimant's � j vehicle� at the intersectiQn af Glarke prive and N rth �r�ndvi�w Avenue while attemptin� ( � to make a right-hand turn. ; j � � � r �i This claim has been r�ferred to Public Entity Risk Services of lawa, the agent for the law� I � Commun�ties Assurance pool. � I cG: Michael C. Van Milligen, Gity Mana�er � � John Klost�rmann, Publia Works Director , I Robert Johnsen i � i u , � � � 'I i, i � . � , ' � � � I � � � � i � � � , QFFfCE OF THE CITY ATTQRhfE DUBUC2UE, ICJWA � s SUITE 33�, HARBQR Vf�VV PLAGE, 300�V1�1�N$ REET C.71��3IJt�U�, IA 52001-6�J44 � T��prtoN� (563)583-4113/F�x (563)5d3-1 Q4q/E��Aa� tsteckle a�cityofdubuque,org � I � i Trsi�:c,y �,.Steckletn nub�u��+� �►��,-��Y a� II �i1fi1��'il� �....'"""' Suite:i3Q f-I�irh��rVie.�v{71,�e.c A�� 3()t)M+yin Strr:et � GJub�ic�� li��a 5"�UI)I-(a9�i�} _ (s�>3)�a�-ai�3 �,�r�;�� ,rYtng�er�aiece on �Ite Mississi��i I ��)a��-i t��t��7 e�.� � . � tsteckle�i cityo#ciubi�que.ar•� zoo�•2n�z•znaa � I � uly 12, 2Q18 ! �l �I; '�; Amy Miner, Claims Man�c,�er i Public Entity Ri�k S��rvices � � � 57Q1 Greendale Road 'i Johnstan, lowa 5U131 ; '� q �,; RE: Claim Aga�rtst the City ofi Duk�uque by Robert Johnsen, filed by Joe wC�t� c�f � ;; Natip�twide insurance Company I � s ,'' Qear Amy, , v, i i I �`; Encio�ed is a cl�im filed on July 12,.2p18 against the City of Dubuque by Robert Johnsen, � �i Glaimant ailege� that a Public Works empl yee struck claimant's ve�icle at the i� intersectian of Clarke Drive and North Grandvi w Avenue whil� afitem�tfng t� r�ake a ��: right-h�nd turn. i' if you hav� ar�y questions regarding this ciairn, please call John Klo�termann, Pwblic � Works Director at (563) 589-�25Q. I� � 4 ery sincer�ly, � � �^ � � i racey Ste lein j aralegal ' � Enclas re � u cc: John Klostermann, Public Works Directar I�obert Johnsen � Tirn Engiish, Q'Gonnar& English Insuran e Agency � �