Claim by Adam Jordan 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
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the City of Dubuque, lowa. 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
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: � (�(� � '�i:����,r'�
2. Address: � �' �� � ;'�� C ;�" Ll ����c°�;` ���,
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4. Date of Incident: �� '��'� � J •� :�, S�1 , � U l�
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5. Time of Incident: ��J�-"'°��� � ' � �'�
6. Location of Incident (Be specific): �i����f- �� ,�! �; N�c��y� G"y� ��� � t���a �� �"�,4i� ��y"lS
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7. DESCRIB� 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.)
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8. What were weather conditions like? (� � �C�-a'� y� `��"�
9. Give name and address of any witnesses: �I�U��
10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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12. Was any damage done to property? (If so, describe property and the extent of
damages. Attach estimates of damages or describe basis for ascertaining extent of
damage.)
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13. What other damages do you claim, if any? f'J'�'� f=%�� �L�-��"cQ � l,�rl- � �a-�- •�-���.5
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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.)
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15. ,What amount do �ou claim from the Cit� of Dubuque?
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16. Why do you claim the City of Dubuq�e is responsible?
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17. Have you made any cfaim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
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18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
Dated at Dubuque, lowa this � 1 day of J('1 �� U ��'r , 20 � 0 .
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(Rev. 5/18)
Confidential
This communication and any attachments may contain information which is confidential
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 attachments
immediately. Further disclosure of this information may violate state and federal
restrictions.
Confidential information may include the following:
1) Social Security Number(s)
2) Medical/Health Information
3) Personnel/Disciplinary Information
4) Bank Account Information
5) Financial Information
�) Credit Card Numbers
If any documentation you desire to submit to the City 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.
� ,--�
I, L� �;1, �� � � �'�����- `�` , hereby certify that the attached documents
include the following protected information:
Social Security Number(s) Bank Account Information
Medical/Health Information Financial Information
Personnel/Disciplinary Information Credit Card Number(s)
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.
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Signature Date
Copyrighted
September 4, 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: Melvin Moss 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; and Marilyn Thoma for vehicle damage.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur
ATTACHMENTS:
Description Type
ICAP Referrals Staff Memo
THE CITY OE
DUB E MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
DATE: August 28, 2018
RE: Claim Against the City of Dubuque by Adam Jordan
Claimant Date of Claim Date of Loss Nature of Claim
Adam Jordan 08/24/18 08/01/18 Vehicle Damage
This is a claim in which claimant alleges that his vehicle was damaged after driving over
a pothole on Plaza Drive in front of TJ Maxx.
This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa
Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager
John Klostermann, Public Works Director
Adam Jordan
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
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