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Claim by Sandra Wolbers Copyrighted November 5, 2018 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Claudette Coleman for vehicle damage, Eagle Window& Door for property damage, Lori Lewis for vehicle damage, and Sandra Wolbers for personal injury. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Coleman Claim Supporting Documentation Eagle Window& Door Claim Supporting Documentation Lewis Claim Supporting Documentation Wolbers Claim Supporting Documentation �� ' 4 � 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 i 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. j 1. Name of Claimant: ,� C�. �1,cat" �� t..��.�7� � � � � �il j � . 2. Address: �.:� �`�,� '�� i��.�"'� � � � City: .,��D�t� t�`� State: �— ��j�~ Zip:-��t�� !; 3. Telephone Number: ��i�� -c��l I; � � 4. Date of Incident: y.�`'�_�a � , �� ; , I I 5. Time of Incident: � � � �� `� � • ,� '� 6. Location of Incident (Be specific): �� w` �t 'b'�� , ��,,,� ; G, l �` I I� c 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 � 4 employee's name.) � t.a.�,��-¢,..�.. ��'.��..i..n�a� ,��,�..r,� ` �" ��.�.,�� - U �...�t,�Q_��J2.� � (?�-�yCe'P�fZ��.. t�l= ''�a��a:,t�'''-a.� c2'..., _L;�_ i.x.,�,�it��`v-�-pi 8. What were weather conditions like? �,.�.f �,,- 1.�.��:,�-�.�,. 9. Give name and address of any witnesses: -°—" 10. Did police investigate? (If so, give names of officers.) �� 11. Was anyone in�r�e� (If so, give names, addresses, and extent of injuries). � ��.R:,. _��-= �`�. ��, �..✓�-.c., �. c-� j�� f� �,�. ca.n ,�:�� r 1��.�m'►t�. ��G�,�f..�C:.. �.�� C�l� I��l.-I' C�.rl�� fl�l.�i'.Jd��`,.� r�'V�„ � r;'J'...P;� �° � GLJY�.�L c,��-v�-•. �1.�."i.,�-'�' � �p"" fC� f�,.. ��L.2�•,��'.�.�`�..s �,.c..s'-.z-^ G` � � 12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascerfiaining extent of damage.) .tv�' . f�t.r-� ,�,��.,cr'1� �,�-�-� � �-�"'ynsk�. � '��.,-�-� �,.,,� ',� �� 13. What other damages do you clairn, if any? .�.,,-� �:. .� r �c:�..,-a.. ; � C'�.-�w�-�. �� c;�.::� u..�L�t��Kti�..��..s�^-°��.'�' �-��r�.-'�"�-,.-�..x.�� '�r.a.��.c��l .�.-� �� 4 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.) � ,.�-.�- . �� -��.� � � o �w ji , �; ,� 15. What amoun# do you claim frorn the City of Dubuque? ,;� C�,:,C`"'��t�::�s��ti.r�. a'Y"�°'u�di �/"��z-°-�,,�-�.�-'�►�1 �/ lC��`_' �,`�.c�`°�''�_" �,'�,� li i; 16. Why do you claim the C'ty of Dubuque is responsible? '�, '" �L.`�� .�zw__��°�.�r-,� il I � 17. Have you mad�e any claim against anyone else for damages as a result of this incident? � (If yes, give name and address.) �� ,,,�,� `,; � f; 18. If the answer to Question 17 is yes, have you received any payment from that source, y and if so, in what amount? �' � �. Dated at Dubuque, lo�nra thi� � clay of � � , 20 j�. � C� ��- � (Signature) �c�, �^�c��'� ��" � '�� (Pri nt N ame) L:� � _,� �` � �, �� _ � � T��" €fs � � � �. %=• �` �`.�s �n _._. (Rev. 5/18) � � � � � � '`� � � � � � �anfiden�ial � This comrnunica�ion and any attachments may contain infarmation which is confidential s and privileged by law and is far the use of the desi�nated recipientb tf you are not the � intended recipient, yc�u ar� her�by notified thafi yo� have receivecl this com'munication in ;: error, and that any review, disclosure, disseminatian, distr�ibutic�n or copying of its conter�ts � is prohibit�ed. Please notify City of Dubuqt�e immediafiel� by tetephor�e at {563}-5�J-4'i20 of � your receipt c�f fi�t�se it�ms and desfiroy the communication and any attac}�mer�ts �i immediafiely. F�arfi�her dis�losure of thi� infarmation may violate state and federal � restrictic�ns. ' � � � Confidential in€ormation rnay include the follawing: � � 'E) Sc�ci�1 Sec�rity Numb�r(s) � �} Medical/Health Informatian ' 3) P�rsc�nnel/Disciplinary Information � 4� Bank Accaunt lnf�rmation � 5) Financial lnformatic�n 6} Gredit Gard Numbers � �i If any dc��umentatic�n you desire t� s�bmit to the City of Qubuque cantains any of the items above p this cover sheet must be att�achec{ directly to the confidential information and ir�dica�e the type af i� infarmation that i� included. � � �� • � I, , hereby certify that the attached doec�ments � � incfude the fiollc�wing prc�tected information: # � ��{� Social Security Number�s) Bank Accc�unt Ir�formafic�n F � �Medical/He�lth Information Financial Infarmation � � PersonnellDisciplinary Informatic�n Credifi Card Numb�r(s} ' � f understand that this information may be distributed within the City organization or t� agenfi� of fihe � City for prc�cessing and 1 hereby authorize the City to aet aceordingly taking all precautians tQ protect my informatiar� from unnecessary distribution. 3 � � �; c�� -� �.., �.w�::�=:��. /�— ��-� !� � �ignature Date � 1 , Copyrighted November 5, 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: Claudette Coleman for vehicle damage, Eagle Window& Door for property damage, Lindsay Lannen for property damage, Lori Lewis for vehicle damage, Sandra Wolbers for personal injury. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Supporting Documentation THE CTTY OF � I�'�� MEMORANDUM ° J Masterpiece on t1�e Mississip�i ; a ,, � il TRACEY STECF( LEIN � � PARALEGAL ;� , I� i; � To: Mayor Roy D. Buol and h Members of the City Council � i� DaTe: October23, 2018 �I ; RE: Claim Against the City of Dubuque by Sandra Wolbers ' � i Claimant Date of Claim Date of Loss Nature of Claim '�" I; Sandra Wolbers 10/22/18 09/04/18 Personal Injury I� �; This is a claim in which claimant alleges that she tripped and injured herself in a City of �' Dubuque "Parking Ramp 2, Level 3". This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa Communities Assurance PooL �h . ��I cc: Michael C. Van Milligen, City Manager Russ Stecklein, Transportation Services Supervisor � Sandra Wolbers i; II � � 9R 9 �a ry 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 �