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Claim by William Baum Copyrighted September 4, 2018 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: William Baum for vehicle damage; Hertz Rent-a-Car for vehicle damage; Adam Jordan for vehicle damage; Lynn McCormick/Partners Mutual Insurance for vehicle damage; Melvin Moss for vehicle damage; Jeremy Noel for property damage; Marilyn Thoma for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Claim by William Baum Supporting Documentation Claim by Hertz Rent-a-Car Supporting Documentation Claim By Adam Jordan Supporting Documentation Claim by Lynn McCormick/ Partners Mutual Insurance Supporting Documentation Claim by Melvin Moss Supporting Documentation Claim by Jeremy Noel Supporting Documentation Claim by Marilyn Thoma Supporting Documentation U��i �--�� , CLAIM AGAINST THE CITY OF DUBUQUE, IOWA ��-'��I This written�°report constitutes :your claim against the City of Dubuque, Fowa. You should 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. 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 will be submitted to the �1 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 �p 'I THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU H AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. � � � q ) � � 1: Name of Claimant: ll�✓ _ � 1� Cz:�l � e ��R.,�� ;i ;; �.-, r �� ` I 2. Address: � t .�-r-�:,`� �/°�j`l,�'�,.� � � � i _ , City. �. ..�� State: �°� �"' Zip: � �,C.��, 1 -� : � 3. Telephone Num r; .,.�� .� �� `�" �'� �.� > °` '� �� 4. Date of Incident: �� `� �-��:� � ! !I 5. Time of Inciclent: � '�' �� °l, i� , 6. Location of Incident (Be specific): :��°�1�0 �`�"'� A ��'� � �, � �� t ��... ��-��..�' � ;, 7. DESCRIBE ACCIDENT OR OCCURREMCE THAT CAUSED INJURY OR DAMAGE. (Give � full details upon which you base your claim. If a City employee was involved, give the ',I employee's name.) � d �'`�J �O�'"��_..�-�.�,�1'""�`l� 'T�'�-.�-- ��- /`'��a-e, �� -�'�,�.., ��'.,�t��2.,�- •�� f�' �-,�Cl.��P�..�� T�'2. L�--�.G'-`�� G'��—�a � L%"-��.�, �� '�;�.�--- r,.�--' � �'r a;� �- -��-�.�-�r�.�1�, 8. hat were weather conditions like? � ��,� 9. Give name and address of any witnesses: ��...,, �' `��-��r��.�� ►�� --�— 10. Did police investigate? (If so, give names of officers.) --- ��-�' -��'i �--- a ; ;S s �. ��„ '�c��.-�.t/' r�. �,�,�� 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). �� r:� � � '1:2. Was any damage done to property? {If so, describe praperfiy and fihe ex�er�t of damages. Attach es�imates �f damages or c�escribe basis for ascer�aining extent of damage.} i � � �� f � '13. Wh�t o�Eher d�mages d� you claim, if any� �� _� , _ � � � '14. Hav� you been campensated �Qr a�y part �r all of yc�ur clairn by �ny insuranee � company? �If�c�, giv� n��n� �ar�d �ddr�s� c�f in��rat�� amp�ny ar�d amuc�nt pa�d.} '� � � G� � ; 15. W�hat amoun� c#o you clairr� from the Ci y of D�ub�que? � �� '� r� � �- �` � � :� , `,'�-��; GA� � �-C� 7 16. W y� c�c� yc� claim th City of Da�buque as r�sp sibl�? „�.., - � � �..`r��.. � �' ;�e �� '� � ' 17. Have yr��u made any c1ai� against ar�yc�r�e e1s�; for d�m�g�� as a result caf this �ncid�nt? �If yes, giv� nam� ��d address.} �� '18. If tY�e answe�r to {�uestic�n 17 i� �res, h��e you received any payrnenfi from �ha� s�urce, and if so, io� wha� am�unt? : � �� . � � � �Q p Dated at C}ubuque, lowa this ��day �f `� t�,� L.t.":� ��,_�___ 20 ,� , � a _._ ��igna$ure} �� #4 Y� - � �� ,�, C�� (E'r�ir�� Narne) `�� .� �-: :.�m: � �� ; � � �� . � -� .:�," �- ` a �,,- (Rev. 511�� .:� � -�' � ��;� � � � ��.`: � � c-�-� � � � � � �rt?dl�lt��tltl'c�l f � This camrnunicat�on ar�d any attachments may contain information which is canfide�tiai � and pt-iuileged by law and is for fhe use of fih� designated recipient. If yau are no� the intended recipient, you are hereby .r�c��ified that you have received tl�is �ommunicatitin in �rror, and that any review, disc�osure, dissemina�ic�n, distribution or capying of i#s contents ° is prohibited. Ple�se na�ify City of Dubuque immedia�ely by telephane at �563}-5�9-4120 of � your receip� c�f these items and �estroy the communic�tion and any atfiachmen�s � immediately. Further disclosure of this informa�ic�n may violate stat� ar�d federal � restricfions, . �' � � Gonfider��ia1 infarmafiion may include the follow�ng: ; , ; 1) Social �ecurity Number(s) � � �� 2) Medi�a�lNealth InfQrmati�n '� 3} Per�onn�IlDisciplinary Ir�f�rmati�n � � � �`� 4} Bank Acccrunfi lnformation � :� 5} Financiallr�formation 6} Credit C�rd �umbers �; � If any docc�ment�tion you desire to s�bmit fia the Gity af Dubuque contains any of the ifems abave �; this cov�r sheet must be attached directly to the cor�fidential inform�tion and indicate the type of 'i informa#ic�n that is included. � � � � i� � I h�reb c�rCif that th� atfiached documents � , , Y Y � include th�; fallawir�� pro#ected informa�ion: � M �oc�al Security Number�s} Banl� Account (nfarmation � � �Vledical/Health Infarmation Financial Information � � Personnel/Disciplinary Infr�rmatio� Cr�dit Card Number(s} � i understand thafi this informatian may be di�fiributed within the Ci�y organiza#iori c�r to ager�ts of the City far prQcessing ar�d I hereby ��thorize the City to �ct accc�rding(y takir�g al1 precau�ions to protect my inform�t��n fr�m unneces��ry distribution. � �� Signature Dat� � p � � � �