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Claim by William Brown Copyrighted December 3, 2018 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: William Brown for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Brown Claim Supporting Documentation ��i� ,�, 9 ` �� G'�.. � - CLA1M AG,rAlN�T T�E CITY �F C}�E�UQUE, IOWA ��.. �1�- ��' � > � { This written repc�rf constitu�es your claim against the City of Dubuque, Ic�wa. You should � compl��e this form in tull and attach any additional inforrnation that suppc�rts your claim: � � The Claim mu�t be filed with th� City Clerk at City H�11, 50 W. "13t�' St., Dubuque, tA 5200'1. 1� � will then be refierred by the City Courtci[ to,the appropriate d�partment for inv�stiga#ion. � C?nce that ir�v�stigatior� is campleted, a report and rect�mmendation will be s�tbmifified ta the � �ity Council. You will be pravided with a copy of that r�pc►rt and re�ammendation. � � THE FINAL DE�I�IQN ON ALL C�A1MS IS MADE BY TNE CITY CIJUNGI�. C��t EMF'LC}YEE OF � THE CITY OF' DUBUQUE HAS THE AUTHORITY TC3 MAKE A�IY REPR�SE�ITATIC?P� T� YOU � AS T� WHETHER YUUR CLAIM WI�� t�R WILL N4T BE PA1D. � �� 1: Name c�f Cl�imant. ��c�..c,..��{� �i?�`�.t �--t i i� �, 2. Address: � � � ��t`�...�C...ce.. �`�-�-" ll � __ " !i City: t,.�C.-t��.,c C�� State: '� �'��1.Ql�a. �ip; .��(�c�� , � ; 3. Telephone f�umbei�: �,,.��... �-�c�a-t��,�� C��,.�-`-� ��a�tcCL �..a��a r,� �� , z 4. Date of lncidenf. t�C,cC� ��, '?-e�� ; i � � 5. Time of Incid�nt: ��t�''�.t�t� f�t°`� ��-c"��,•.,�C� ��k` �.t--c��t C.�' ,i � , '� � �. L.c�c�tic�n ��F Ir�cident �Be s�ecific): ��'� 0��. �.�t:�.� �� `� � � � n 7. DESCRIBE AC�IDENT OR £}C�URRENCE THAT CAU�ED 1NJURY OR C?AMAGE. {Gi�re ' full d�#ail� upon v�rhich yau base your claim. If � City emplc�yee wa� ir�vcalved, give t�e � emplayee's name.) � � � ��. ut...� t �S C�� ' �I�� . � � C��i� � � , ��, �� k�tr� �, °c� i i 1�'1 `t' �6�,t�G.�- F1�t � ��.ic,�� (✓�Cr�d�� a 8. What were vve�#her conditio�s 1�ke? �,��. ��`� � � 9. Give narne and �iddress of any wi#nesses: �tc�e�,i.,,� _ _ ____ � '�0. Did p�rlice investigate? �lf so, give �ames o� e�f�ic�r�.) ,�3 s,sd.r . �""'Y� lr �\Y�t/� *,,',,� � \ J'��..{1... ��til �� i�P'\��. �,� �ti�'.+ ��vy�C��r �i 9. Vllas ar�yon� inju�ed? (lf so, c�ive names, addresses, and extent of injuries). � �� i � 12. Was any damage don� tt� proper�y? {�f sa, describe property �rzd the ex�ent of dama�+es. Afitach estit�r�ates c�f damages or describe ba�is for ascer�E�ining exfent of damag�.} , �� 9`��.�G c,s..�; l �t�t5a�.i i L�. A.�. 7erlft�i 1�.,.t,�:`:�"G `"� � ' � �. ,�:.1�= �'S��_�� r rh° �-c`�l.,l�� 13. WF�at other d�mages do you �laim, if�ny? ��=- � '14. Have yc�u bee� comp�nsa��d for any part or aIl of your claim by any insura�c� � �o�n�an�'� �If�ca, giv� nat�e �nd ac[dr�� of insur�r�� r��np�ny� ��d �m��rat paid.} !j � � � r� �..� � � 'Ea. What arnou�t dta you claim fre�m fhe City of Qc�buque'� � -� T�...�c 1 � �� 76. Why do you claim �h� �ity �f�}u�uque is responsible?' � `j�. �tst��L� ��4 ��Jr � ;�1 t . '17, Have yc�c� r�ade any clair� again�� a�yc�ne else for d�mage� as a re��lt of this ir�cident? � {If yes, give nam� ar�d address.} � ��,i� � : � � '18. 1f the answer to Question 17 is yes, �ave yae� received ar�y paymer�t from fihat source, � and if��, ir� what amount? . � �� , Dated at Duk�uque, towa fihis �� day e��_ t�i�v��t�- ��:fi�. , 20'� t��,,��-�- � � {�ignature� '�..�.� � �.�_ � fi�.t. e�Cz.��.�...�.��, (Prin� N�me) _ .r ., � � �:-'`�� .:.�� - �. f .. ��~: � �;� � f� � �, .: r� �, � �� - �--,. � �=. {Reu. 5118} ;=`' -�; .�� ' "�' �.� Confider�tial � F This communicatian and any a#tachments may contain information whic� is confidential 1 and privileged by 1aw and is for fihe use of the designa�ed re�ipient. If yc�u are not fhe ; intended r�cipient, yc�u ar� hereby ncrtified that you have received this communication in errar, �nd fhat arty review, disclosure, dissemination, distributior� or copying ca�its con��nts � is prohibited. P(ease na�i#y City of Dubuque immed�afiely by telephone at {563)-589-4'120 of your receipt of these items �nd destroy #he cc�mmunicatic�n and any attachments �; immediatety. Further discic�sure of this Et�form�tion rraay violat� state and feder�l � restrictions. � � � Ganfidentia! information may ir�clude the foll�wing. � � � � � �I} Social Se�urity Number(s} ; 2) Medic�I/H�alth Ir�formafiic�n ;_ 3) Per�or�nellDisciplirr�ry lnform�tion � � � � � I 4� Bank Accaunt lnformati�n � 5} Fin�nciaf �n��rmatian � � � 6) Credit Card Numbers �' ? �i � If any documentation you desire to st�bmit to #he �ity of Dubuque contains any of the items abave j this cc�ver sheet.musfi be att�ched directly t� the confider�tial information and indicate the type of n inform�tion that is included. ; �7 1, , hereby cer�`tfy thafi the attached dc�cuments '! � i�clude the following protected infc�rmafiic�r�. ; ;: Sacial Security C�umber{�} Bank Accaunt Infarrnatit�n r � Medical/Hea1�h fnform�atian Financial Infarmatian � ,� , PersonnellDisciplinary Informatic�n Credit Card Number(s} � � 1 understand that this informatior� may be distributed within fihe Gity organizatian or to agents c�f the � . Gity far processing and [ hereby ��atharize the City tc� act accardingly taking all precautiarss to ' protect my informatior� frcrm unr�ecessary distributic�rt. i � � .�� - �`�-�- ��- �� `�' � s��atu�� t� � $ � � , ; � � � � � � � Copyrighted December 3, 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: William Brown for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo THE CTTY OF ��CT� �� E MEMORANDUM Mr�sterpiece on the Mississippi � 'I TRACEY STECKLEIN PARALEGAL � � � To: Mayor Roy D. Buol and � Members of the City Council j� � DATE: November 19, 2018 ,; �i. RE: Claim Against the City of Dubuque by William Brown ir li Claimant Date of Claim Date of Loss Nature of Clairn � William Brown 11/19/18 08/14/18 Vehicle Damage This is a claim in which claimant alleges that as a City Public Works employee was � mowing grass at 610 Wilbur Street, a rock and debris were discharged from the mower, � striking and damaging the vehicle and puncturing a window. , This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa 1 Communities Assurance Pool. , cc: Michael C. Van Milligen, City Manager j; John Klostermann, Public Works Director � William Brown � OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SuITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 TE�EPHONE (563)583-4113/F,vc (563)583-1040/EMai� tsteckle@cityofdubuque.org Tracey L. Stecklein Paralegal Suite 330, Harbor View Place 300 Main Street Dubuque, Iowa 5 200 1-6944 (563) 583-4113 office (563)583-1040 fax tsteckle@cityofdubuque.org William Brown 950 Spruce Street Dubuque, IA 52001 Dubuque THE CITY OF hiked All -America City 11 11 I. 2007 • 2012 • 2013 DU5tJE Masterpiece on the Mississippi February 12, 2019 RE: Your November 19, 2018 Claim Against the City of Dubuque Dear Mr. Brown: Brenda Snyder, Claims Representative for Public Entity Risk Services of Iowa, the agent for the Iowa Communities Assurance Pool, has been assigned to your claim. Ms. Snyder is unable to contact you because you failed to list a contact number on your completed claim form. If you wish to have this claim investigated, please contact Ms. Snyder at (515) 727.1595. If she does not hear from you by February 20, 2019, your claim will be closed. Very sincerely, Tracey Stelein Paralegal cc: Brenda Snyder, Public Entity Risk Services Claims Representative John Klostermann, Public Works Director F:\Users\tsteckle\Claims\Brown William \Brown ContactPERs 021219.docx