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Claim by Kevin Lutgen Copyrighted November 19, 2018 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Kevin Lutgen for vehicle damage, Donna Pilgrim for vehicle damage, TFM, Co., for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City Attorney ATTACHMENTS: Description Type Lutgen Claim Supporting Documentation Pilgrim Claim Supporting Documentation TFM, Co. Claim Supporting Documentation . � �� i � � � � +�LAIM AGA�I��TTH� CITY QF DUBUQllE, lCJWA ��.�� This written report consti�utes your cla�m agair►st the City of Dubu�ue, lowa. Ya� should , cc�mplete this form in ful� and attac� any addi#ional information that supporEs ybur claim: � �: The Claim rnust be filed with the City Clerk afi City Hal1, 50 W. '13tn St,, Dubuque, IA 5200'1. !t wi11 then be referred by the City Gouncil to the appropriate d.epartmer�t for investigatic�n. Once that ir�vestigation is com�leted, a r'�part �nd recomrrtendatian w,ill be submitted to fihe ; City Co�ancil. Yoct will be provi�led with a capy of�Ehat r�part and recommendatian. � THE F�NAL DEC151CJN (7N ALL GLAIM� 1� MADE BY THE CITY Ct3UNCIL. NC} EMPLC?YEE O� �' 7H� CITY C)F DUBUQUE HAS THE AIJTHORITY TO MAKE ANY REI'�2�SENTAT1CtN TO Y(7U � AS TO WH�THER YOUR CLAIM 1NIL� 0�2 WIL� NOT BE PAID. . � _ � �, ,I�ame af Claimanfi: ��v ��,� �'� . �,��t � � � �, Address: �� l,C� r � � City:��,-��,��u�� tat�: �' �., Zip .��.� ° _ . —' � � 3. Telephon� I�umber: ;��-J��(� ��' `,� �� ; .,. _ �. . .,, j 4. Date of Incident: __ �� C� j� �- �, 5. Time of Incident: _�.�� _ , � ' � � �. �ocatior� o� Inciden# {Be specific): ' �,� �� c��," � �P�.r�� t.��. �.�� 7. DESCRIBE ACCIDEf�T C}R CIGCURRENCE THAT CAUSED �NJURY OR DAMAGE. '{Give � fu�1 det�ils upon wl�ich yau base your c(airn. If a City emplayee was invo�ved, c�ive the � employee's nam�.) � , ,�� rt...� � � ��'1 c��.. �C�lj C� ��- �. �r� � � �c� �i �`�"" �a �� o�, 8. What uvere weat€��r canditior�s li6t�? �� . 9. Give name ans� address c�f ar�y witness+es: 10. D�d police investigate? �lf so, give names of afficers.} � � ' � 11. 1N�s anyone injured? (If so, giv� names, address�s, an�d extent of injuries}. �� i � A 12. Was any damage done #o property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.) �� rz.�n�-- c�� _.�,�:c� �,��ac�..� c��.�►,�►.c��, ,� 13. What other damages do you claim, if any? ' ��.�� qI, 14. Have you b�en 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.) � i � �� I �i 15. What amount do you claim from the City of Dubuque? i '� ;i � � . 16. Why do you claim the City of Dubuque is responsible? � �� 1 � ,�°� 'j �t�� --r �� .� 'I _: , � 17. Have you made any claim against anyone else for damages as a resuft of this inciden't? � (If yes, give nara�e and address.) i �� i 18. If the ansvver to Question 17 is yes, have you received any paymen# from that source, and if so in what amount? � , ��. ; ;; � . � � � � n �ated ai t�ubuque, lowa this � day or��"�vvt.��f� , 2C1�• � � o (Signature) � , � � (Prin't Name) ;�� `� s� �..�,� t ; �. � � �m � � C[3 �,.� �;� �� ,,°s+� �3�"`F k � � � � � � � � I °i..> =� �'`*a � �I (Rev. 5/18) � � �.:�� f �� i � � � � � � � � � � � � �on�Idential �� This communication an�! ar�y attachmer�ts may contair� infc�rmation_ whieh is confid�ntia! � and privi�eged by law and is for the use of the designated r�cipient. !f yc�u are not the � intended recipient, you are hereby notifiecf fihat yc�u have r�ceived this communica�ian in � error, and th�t �ny review, disclasure, dissemination, distrik�ution or copyirag of i�s contents � is prof�ibited. P(eas� notify City of t�ubuque immediafiely by telephone at {563�-�89-4'120 of � your receipt of these i#ems an�l destrc►y th� communication and any attachments � immediafiely. Further discl�sure of this i�fvrmatit�n may violate state and federai � restrictiarts. . � � �; F Confidentia! informatior� rnay inc(ude the following: � 1) Sflci�1 �ecurity Number{s} � �) MedicallHealth Infc�rm�tic�n y; �) Persannel/Disciplinary lnformati4n - i� 4} Bar�k Ac�unt �nfc�rmation ; 5} Financial lnfc�rm�tian �, 6} Credit Card �Vumbers � ! If any documen�ati�n you desire fio submit fio the City af Dubuque can�ains any of the items above � t}�is cover sheet must be �ttached directly tc� the confidenfiial infarmation and indicate the type af information that ts included. i � � � 1, , hereby certify �hat the attached documents � include the fo(Ic�wing protected inform�tion: � � Social Security Number{�) Bank AccQunt lnformation � MedicallNealth informatic�n Finan�ial Infc�rmation � Pers�nnel/C�isciplinary Information Credit Card N�rnber�s) I understand that this infic�rmation may be distributed within the Ci�y organizatic�n ar to ag�nts �f the � City tor processing and ! hereby authorize the City to act accc�rdingly taking all precautians to � _-- profiect my infarmation from unrrecessary dis#ribution. � i i ...e..s... v.m.,.................. . ',. :,�-� ��` �� =-- �- _ _ si�n��-� �� Copyrighted November 19, 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: Kevin Lutgen for vehicle damage; Donna Pilgrim for vehicle damage; and TFM, Co. for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo THH CITY OF ��-✓ � � � � � 0 1\ � 1 \ � V � Masterpiece on the Mississippi � `i TRACEY STECKLEIN PARALEGAL '� , �i � To: Mayor Roy D. Buol and �� Members of the City Council ry , ;ii DaTE: November 7, 2018 ;�� , � RE: Claim Against the City of Dubuque by Kevin Lutgen � i{ Claimant Date of Claim Date ofi Loss Nature of Claim � Kevin Lutgen 11/06/18 10/28/18 Vehide Damage � ,� This is a claim in which claimant alleges that as his vehicle was parked 'on the Finley �I Hospital parking lot, a City of Dubuque police officer backed up a squad car into claimant's �, . vehicle. �i This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa � Communities Assurance PooL � j cc: Michael C. Van Milligen, City Manager � Mark Dalsing, Chief of Police ; Kevin Lutgen '� � � � � � � ;� � � � 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 i�