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Claim by TFM, Co. 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 � �� CLAIM AGA#NST TNE CITY OF DUBUQUE, IOWA � ��'�'"` �� This written rep�rt constitutes your claim against the Gity of Dubuque, lawa. You should ' comple�e this forrn in fult and atta�h any additiona! inform�tion that supports yaur c[aim. � � � The Clairn must be �il€:d with the Ci�r Clerk at Ci�y Hall, 50 W. �13th St., Dubuque, IA 52001. It a will then be referred by the City Cc�uncil to the apprc�pri�te d�partment for investigation. � t}nce tha� ir�vesti�a�tion is completed, a report and recc�mmendation will be �ubmitted to the � Gi#y Council. You will be provided with a capy of tha� rept�rt and recammendatior�. � � THE FINAL DEGISIC}N QN ALL C�AIMS IS MADE BY THE CITY CC}UNGIL. NO EMPL�}YEE OF � THE CITY OF C}UBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATIC71d TQ YOU � AS TO WHETHER YC}UR GLAIM WI�L OR W��L NOT BE PA�C}. '� 4, I, 'I. Name �f Claimant: TFM Ca � 2. Addres�: .��'�� .�� ,��..�. ' ; k � 3. Telephc�ne Number: 56�-5;�6-8050 " 4. Date Qf lncider�t: 5 October 20'18 �; i� i , 5. Time of Incident: 6:00 PM i 6. Locatic�n of Incident {Be specific}: 20'[4 Kerger-- main floor ir� building ;; �; r „ 7. I}ESCRIB� ACCIDENT C?R QCCURRENCE THAT CAU�ED INJURY t3R DAMAGE. (Give � full details upon which you base yc►ur claim. lf a City employee was invalved, give the � employee's name.) � , City s�wer backed up and c�ogc�ed private sewer Iine. See Attached ' � � � - � � � 1� � �. �1Vh��e��r�:��th�►�.c��a.�� leke�" �ea��! 9. Give name and address of any witnesses: See A ��che� � � 10. Did pc�lice investigate? (If so, give names of officers.) � e Nt� ; '1`I. Was an one in'ur�d? If so iv� names addresses and extent ofin'uries . � Y J { � 9 � a J } Nt? � � � € � � 12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.) Backed up sewage had to be cleaned up and sewer line cleaned. See Attached. 73. �hat other damages c�o you claim, i�any? 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 amountpaid.) NO �5. V1lhat amount do ya�u �lairn frc�m tF�e Cify of D►ubuque7 " $145.00 16. Why do you claim the City of Dubuque is responsible? City sewer pumping station failed to keep main sewer line open causing grease generated from other sources to backup. 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) NO 18. If the an�wer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? Dated at Dubuque, lowa this 5th day of November , 20 1�. � � _ (Signature) � John F. Thom�son (Print Name) �� :�' — ,� ,`=�- �` ��, rt-� � ' ��x f� �°_ ,� ��_�� ;-�� tn' �� ,.- �.,. (Rev. 7/12) � �` � E�'"' f..r._4 �- .. \.....: �� C� {.g,_"� C�nfidential This communicatian and any attachments may cvntain inforrnatic�n which is con#idential ar�d privileged by law and is for the use af the designated recipient. If you are not the intended recipient, yc�u are hereby notified that you have received this camrnunication in error, and tha# any review, disclosure, dissemina�it�n, disfiribufiion or copying of its cont�nts is prahibited. Please notify City of �ubuque immediately by telephone a� {5fi3}-589-4120 of yca�ar r�we6�p�# s�� h��+� �t��s �r�d �gs�� th� cc��ra�r��atian and any a�tachments immedtate9y. Furfher disclasure caf this information may violate state and feder�l restrictions. Confiidential information may include the follawing: 1) Sc�ci�l Securi#�r Number{s) 2} MedicallHealth Information _._ ___3-)--P�r-sa�n�Ildi�ciplin�ry-lr�f�a�-rr�atac�r� q�} Bank Account lnformation 5} Financiai Information 6} Credit C�rd Numbers If any documentafiic�n you desire to submit to the City �f Dub�que contains any of the items above, this cover sheet must be attached directly to the cc�nfidential information. Please indicate bel�w fhe type af infiarmation that is included. I, -�� '��`�� , hereby certify that the at�ached dacum�nts include the fofl�wing pro�ected informatior�: n/a Social Security Number{s} n/a Bank Aceount lnformatian n/a MedicallHealth Intarmatic�n nla Financial Infc�rmatiort n/a P�rsonr�ei/Disciplinaty Informafiiern n/� �redi� Card Number(s} 1 understand that #his informatic�n m�y k�e distributed within the City ar��nizat�s�n e�r t� �g�r�t� c�f the City for pracessir�g and � hereby authorize the City to act accardingly taEcing all precautians to protecf my informatic�n from unnecess�ry distributir�n, _ �,a,�`�� I � i a ure Date I have read the inforrrration above and d� not have any c�nfiidential d�cumentation ta submit to #he City c�f Dubuque as part of this Claim Against fihe City. Signa#ure Date � i Attachment to TFM Co Claim against the City of Dubuque ' 9. Give name and address of any witnesses: I Troy Kruser Tom Thompson �� P.O. Box 223 11168 Holy Cross Rd �' i�ick�yviii�, �ifi 5380� Far�i�y, if� 526�6 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 � � THE CITY OF �� 1` � 1 \ � V � Mastexpiece an the Mississippi i � �� TRACEY STECKLEIN ' PARALEGAL i To: Mayor Roy D. Buol and Members of the City Council � ; D,�Te: November 8, 2018 1 RE: Claim Against the City of Dubuque by TFM Co. , Claimant Date of Claim Date of Loss Nature of Claim ��: II TFM Co. 11/08/18 10/05/18 Property Damage � � This is a claim in which claimant alleges that a city sewer backed up and dogged �i �� claimant's private sewer line at 2010 Kerper �oulevard. This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa , Cammunifiies Assurance Pool. � cc: IVlichael C.Van Milligen, City Manager John Klostermann, Public Works Director � John F. Thompson, TFM Co. � � � � , � 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