Claim by Marilyn Thona 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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complete this form in full and atEach any add�#ion�l informa#ian that supports your ciaom��`��;,`,
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T1�e Claim must be f�led w�th the C�ty Clerk at City Half, 50 W. 13t"St., Dubuque, IA 52001. it
w611 then he referred by �he C�ty Counc�i to the �ppropriate riepartment for investigation.
Once tha#inv�s#igation ts compieted, a report and recommendatiQn will be st�bmit#ed to the
Ci#y Council. You wri11 be provid�d with a copy af that report an�1 recornm�ndation.
THE FtNAL DEGI�Id3N ON AI.L CLAtMS t� MADE BY THE C1T1( Ct7UNCIL. IV0 EMPL4YEE O� ��
THE G1TY �D� DU�UQUE NAS THE AUTHORITY 7'C� MAKE/4�#Y REPRESENTATiON Tt� YQU �
A5 TO 1Ni�1�;HE�2 Y4U� Ctf��M WIL:L.fl121MiLL N{�T BE PA�lD. �
'I. Name of Claimant: �
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City: ����i State: Zlp:��:t"".aC�,,�- 1
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3. Telephor�e Number: 4.��� � �� `7,�_=���� �
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4. Date of lncsdent: � '
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5. Tim�of lncident: �
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6. L,ocafiion of Incident(Be spe�ifi�c�: �.�:+�-_f �.�� � K��"�"� `�� �
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7. DESCR[B� �l�Cia��1T 4R �CCURRE�IGE THAT CAUSED 1NJUit'a'' t3iZ DAMAGE. (Cive �
full d+�ta�is up�n rwhi+�h you base your cf�irn. if a +C�ty employee cnras ir�volve�l, g�ve th�
err��{o�ee'��a�e.�
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S�t were weathe�on i#�n� Ii#ce�
9. Give name and address�f any v�ri�nes�E�: ��?�'1'�
10. Did police investigate? (If so, gi�re nam�s of aff°rcers.)
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1'[. Was anyone �njur+�d? (tf so, g�ve nam��, addresses, and �xtent of�n�uriesj.
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.�.. ._�... ... .p w�..._�.a� �..-'-- -- r`--r—v - �-- - -. - - . - I
damages. Afitach estimates of damages or �describe 6asis� far ascertaining extenfi af
damage,)
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7 S. What ather damages do you c�aim, if any�' �
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14. Have yc�u been compensated far �ny part or a�l €�f your c4a�m hy an�t ins�rance
car�par�y? (�f so,�ive narx�e anc�address of ins�uranc�cramp�ny ancl amount paid.) �i
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�S�,Wh t�mtaunt da t�u c�a�irrm fr�m the City of Dubuque?
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16, Why do you���im th+�Cit Q Dubuque as responsible? li
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17. Elave y�u m�de an�clairrr against a�tyone else fa►r damages as a r�s�alt of this incid�n�? ��
(tf y�s,��e narne and acldress.) I
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a�. !f the answ�r to Ques�c�n 17 is yes� hav� you received any payment frar� that sou�ce, �
and if so, in wh�#amaunt'� ;,
aat�d at Qubuqaue, lt�wa this day crf ����___,_"= 20�,
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�Signatur�� �
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This carnmunication artd any attac�r�e€� � " �� ��� �s cc�r�#'i�le���al
and privile�ed by iaw and is fc�r � �f � � ��`� no� #�e
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in�encfed recipient, you are �� � ' i�
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erro�, and that any r€:�►i�,�'��i�� : , � ` . .
fiS (SI'O�tilJl'E@t,�. Please notify Gaty +�f Dubuque immediatety by telephone at{563)-589-�92€� e��
yaur receip� of these items and des#roy the communieatEan and any attachments !�
immediately. �urther discfosure af this �nformation may violate sfate and �'ederal �
tes#ric#�c�ns. ,
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Confiden#ial informafiion may include the faltowfng: �
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1) �ocfal Security Number(s) 'i
2) Medic�llHeal#h lnformati�n �
3) Persanne�lDisci�li��ry�nformatu�n
4) 8ank Accourtt tnformation
5) �inanciai In�armati�n �
6) G�edit Gard N��b�rrs
If any documentation you desire to submit to the City of Dubuque contains any of ti�e items above �
this caver sheet must be a#t��hect directfy to the ca��ider�#ia1 informat��n and ind�c�te the type of ��
informa#ion that�s included. �
__ _ _ _ _ _.
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l, � , hereby certify that the attached documents � �
include�h�fo13 ing protected infcarm�ti�n: �
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�St�ciai Security Number�s) Sank Account Infarmation i
MedicallHealth Information Financiat Information ;
�'efisc�nnetl��scipl�r�a�y��ft�rmation . Gred�t Card Number(s�
1 unders�and tha#thi� inf�armation may lae distribu#ed within the Ci#y organization�r ta �agerrts of the
City for processing �nd ! heret�y authorize the City tv act a��ordingl� taking al! precautians to
�co#�c#rny��r#�rr�a#�r� #ro���a�e�essar�+dis#�b�#�on. ;
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Srgnature ' Date
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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 OF
DUB E MEMORANDUM
Masterpiece on tlie 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 Marilyn Thoma
Claimant Date of Claim Date of Loss Nature of Claim
Marilyn Thoma 08/24/18 08/22/18 Vehicle Damage
This is a claim in which claimant alleges that her vehicle was damaged when a City of
Dubuque Transportation Services Department employee backed a City truck up into
claimant's vehicle at the intersection of Locust and 3�d Streets.
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
Russ Stecklein, Transportation Services Field Supervisor
Marilyn Thoma
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 3O0 MAIN STREET DUBUQUE, IA 52001-6944
TE�EPHOrvE (563)583-4113/Fax (563)583-1040/EMai� tsteckle@cityofdubuque.org