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Claim by Doug Winner Copyrighted September 17, 2018 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Kelly Casperson for vehicle damage, Jerald Kinsella for property damage, Gerald Klein for property damage, Abby McGrane-Ralston for vehicle damage, David Prince for vehicle damage, Steve Ruden for property damage, Daniel Scott for property damage, Sisters of the Presentation for property damage, Brock Tyner for vehicle damage, Morgan Weaver for vehicle damage, Doug Winner for vehicle damage, Suit by Michael and Jacqueline Wood for vehicle damage/personal injury. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Casperson Claim Supporting Documentation Kinsella Claim Supporting Documentation Klein Claim Supporting Documentation McGrane-Ralston Claim Supporting Documentation Prince Claim Supporting Documentation Ruden Claim Supporting Documentation ScottClaim Supporting Documentation Sisters of the Presentation Claim Supporting Documentation Tyner Claim Supporting Documentation Weaver Claim Supporting Documentation Winner Claim Supporting Documentation Wood Lawsuit Supporting Documentation M�tM CLAIM AGAINST THE CITY OF DUBUQUE, IOWA . � �''��' , a—�'1��s_�`. �� v'r��:_`.> 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. e. 1. Name of Claimant: ,�f�)�✓�; ��e� l�l � Y � L' /1 �' L/ / 2. Address: / /�'C�' �.�Ct a�t`�/t�^ �,� ��--� Cit J��! �, :� � y: i State: ,L��, Zip: � �c�=�c i 3. Telephone Number: =� � L� �� C% 4. Date of Incident: ✓ � �� °�� 5. Time of Incident: ��:� r,� �. j � � e [ i �'� � �. ? � l_ � �'�� V� �:� t �� `� C �' �"� 6. Location of Incident (Be specific): �� C��r' 'J�� -l�� ' �� _� �c �� /-��l�Y 7. DESCRIBE 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.) , �� c` / � :� �'�,a i� %��✓�� a: /�� 8. What were weather conditions like? ��I� Ci�'" ��c �`�� / �J z� �:.:�.�-��,��' 9. Give name and address of any witnesses: J�4��1�� L-,��tc�c s��.4.�.t<<-�� 10. Did police investigate? (If so, give names of officers.) t ,�.i � i�� E�`C' ��'� L � � L: �� , . 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). - 1� �� -'" � ; � ' i � . � � '�2. Was any damage dc�ne to property? (1f so, describe properfiy and the exter�� of ! damages. Attach esfimate� of dama�es or describe basls for ascertaining ex#ent of damage.) �,Dt �- �� . � "��'�-�--�� ` � �� Ca.�°` l � ��o. � � '�� ti � �� .� � � ' '13. Vglf�at ather d�mages do you claim, if any? �q�;� �'�:�� ' � � ; '14. H�ve yr�u been campensated for any par� +ar all of your cl�im by any insurance cc�mpan�r? (If so, give name and address of i�searan�� compar�y ar�d amot�nt paid.} � � ' ; r; 15. W�afi �mou�fi ya�t cl m fro #he City c�f Dubuq ? � � �� r--- - ��. �. �.� �`� �� 4 ;� 16, Wh dt� ou claim th� C�t of Du u e�� is res �ns'rble j�� Y Y � P � � , � � � �� c°��',� t��-��c� . � � '�7. Have you rr�ade �ny claim again�t any4ne e1�� for damac�es as a resuit of this inciden�? . � {�f yes, give name and address.} �� '18. If the answer fia (�uestion 17 is yes, have you received any paymer�t firom that source, � and if so, in what amount�' � � , , ��ed afi �u#�uque, �c��va this __� day caf � , ZO � � � ,o�.� ��._�,� � � � � �--�_ �nature} � � � ' � � � � � � (Prir�� Nam�} � -�' � �. � aa c"� r,;,;�, t� � (Rev. 5118) �� r I �--�� .�..��.,, �.,��-•-- �:L�t..,.�-%'�.:�.�,..�� 1,..,.� `_ ��.� I � c� L� � �.-.-- �� `� �?�;� �� 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 Dubuq�e irnmediately by teleph�ne 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 6) 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, , 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. —� � � ��d , � � � Signature Date �