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Claim by TFM, Co. 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 , , � � � �� CLAIM AGAINST THE CITY OF DUBUQUE, IOWA �. �tc6-}c.�.�-r.�,.��, ;, This written report constitutes your claim against the City of Dubuque, lowa. You shoulc! complete this form in full and attach any additional information #hat supports your clairr�. � 'I` The Claim must be filed with the City Clerk at City Hall, 5O W. 13t" St., Dubuque, IA 52001. It will then be referred by the City Council to the appropriafie department for investigation. � C�nc� that investigation is �campleted, a report and recommendation will be submitted to the � City Cauncil. You v�rill be provided with a copy of that report and recommendation. � THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY CQUNCIL. NO EMPLOYEE OF fi THE CITY OF DUBUQUE HAS THE AUTHORITY TQ MAKE ANY REPRESENTATION TO YUU ;� AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. ;' ,� 1. Name of Glaimant: 7FM Co ��I ,�' 2. Address: 2010 Kerqer Blvd ��' j' 3. Telephone Number: 563-556-8050 `� ; 4. Date of Incident: 19-20 Julv 2018 � � �� 5. Tirr�� of Incident: 6:00 PM �: � 6. Location of Incident (Be specific): 2010 Kerper— main floar in building ? � � I� ' 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give � full details upon which you base your claim. If a City employee was invol�ed, give the ' employee's name.) i1 , City sewer Ibacked up and clogged private sewer line. See Attached � i; �� i; i� 8. What uvere weather conditions like? Seasc�nal �; i� i, 9. Give narne and address of anywitnesses: See Attached �; �� 10. Did pc�lice investigate? (If so, give names of officers.) � ; NO ' i 11. Was anyone injured? (If so, give names, addresse�, and extent ofinjuri�e��. f; NO � � � � , . � 12. Was any damage done to property? (If so, describe property and the extent of � damages. Attach estimate� of damages or describe basis for ascertaining extent of � damage.) � Backed up sewage had to be cleaned up and sewer line cleaned. See Attached. 7 � u I � 13. What other damages do you claim, if any? `� ,i il ',I I; 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 amountpaid.) '�; ,� li' NQ � �i 15. What amount da you claim from the City of Dubuque? �Zso.00 'i �: 16. Why do�you claim the City of Dul�uque is�responsible? �' City sewer pumping station failed to keep main sewer line open causing grease generated fram other sources to ;i backup. I�,. 17. Have you made any claim against anyone else for damages as a result of this incident? !' (If yes, give name and address.) ',i No �I �: 18. If the answer to Question 17 is es have ou received an � � y , y y payment from that source, �, an�d if so, in vvha#amount? li �� h_. I Dat�d at DubuNue, lowa this 6th day of Au ust r.� , 20 1# . �; � � �' � ` �.'� � .�f- �.,�,,,� (Signature) ; �`�,� � � John F. Thomason (Print Name) � ._� �� _�`4" � ��' �.:.. _- �; �-� ��-s �._�- �� ' '� '�—, � �� , � ,�ti � � �� (ReV. 7/12) � �� ., �� ^� �� .E � �� i � � � � � e , �� !1 Confidential This communication and any attachments may contain information which is confidential i�� 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 the communication and any attachm�nfi� II immediately. Further disclosure of this information may violate state and federal '�� restrictions. i1 Cc�nfidential information may include the follawing: i� II 1) Social Security Number(s) i; 2) M�dical/Heal�h Infc�rmation I; 3) Persc�nneUDisciplinary Information ; 4) Bank Accclunt Inf�rmation ' 5) Financiallnformation � 6} Credit Card Numbers � � If any dacumentatian you desire to submit ta the City of Dubuque contains any of the items above, '�j this cover sheet musfi be attached directly to the confidential information. Please indicate below the ; type of infarmation that is ineluded. �I 'i'� I �, , hereby certify th�t the attached dacuments ��, include the fallowing protected information: ��; ;, n/a Social 5ecurity Number(s) n/a Bank Account Information �� !i nla MedicallHealth InformatiQn n/a Financial Informatian , i� �� n/a Persc�nnel/Disciplinary Informatian n/a Credit Card Number(s) ;i I li � I understand that this information may be distributed within the City arganization or to agent� afi the Ij Gity for processing and I hereby authorize the City to act accordingly taking all precautions to �� protect my infc►rmation from unnecessary distribution. Signature Date � I have read the infiormation abave and do not have any confidential documentation to submit to the City of Dubuque as part af this Claim Against the City. w . ,� � '� �' �'" (� � � �� . Sign 'ure Date �. , , � � Attachment ta TFM Co Claim against the City of Dubuque I� I �; i 9. Give name and address of any witnesses: �'1 Troy Kruser Tom Thompson i� P.tJ. Box 223 11168 Holy Gross Rd � Dickeyville, WI 53808 Farley, IA 52046 � li I' 1 �I{ �I �� ,; ,� � � ; i �I �1 ;; J I I I� I� I` ; 1 I; i I , I i �� ! � � � � � � � z � � � Copyrighted August 20, 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: Thomas Coyle for vehicle damage, Channing Ellison for vehicle damage; TFM Co. for property damage, Daniel and Christina True for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo � � THE CITY QF ��.T� E MEMORANDUM Mc�sterpiece an the Mississippi � TRACEY STECKL.EIN '� � �� PARALEGAL � � � � To: Mayor Roy D. Buol and ��I Members of the City Council DaTe: August 8, 2018 RE: Claim Against the City of Dubuque by TFM Co. ,i �� Claimant Date of Clairr� Date of Loss IVature of Claim � ;i TFM Co. 08/08/1� 07/19/18 Property Damage �C � . il i This is a claim in which claimant alleges that the city sewer backed up and clogged �� !; claimant's private sewer line. � � � � � �� ; This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa �; Communities Assurance PooL 'i i cc: Michael C. Van Milligen, City Manager ,� John Klostermann; Public Works Director I� TFM Co. � I� V � � � � � � OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA Su�rE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 TE�EPHorvE (563)583-4113/Fax (563)583-1040/EMai� tsteckle@cityofdubuque.org