Claim by Trever Allen Copyrighted
February 18, 2019
City of Dubuque Consent Items # 2.
ITEM TITLE: Notice of Claims and Suits
SUMMARY: Trever Allen for vehicle damage, Brian and Dee Collins for
property damage, Robert Krohmer for vehicle damage, Eric
Mueller for property damage; lawsuit by Jerry Brandenburg
for personal injury.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City
Attorney
ATTACHMENTS:
Description Type
Allen Claim Supporting Documentation
Brandenburg Suit Supporting Documentation
Collins Claim Supporting Documentation
Krohmer Claim Supporting Documentation
Mueller Claim Supporting Documentation
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GLAIM AGAINST THE CITY OF DUBUQUE, IOWA `'
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This written report constitutes your claim against the City of Dubuque, lowa. You should
complete this form in full and attach ariy additional information that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50 W. 13th 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 !
TH� CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU I�
AS TO WHETHER YOUR GLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: � ��� ;�)
2. Address: � 1� l��X)���� �j
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City: State: � Zip: � !�
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3. Telephone Number: i�
4. Date of Incident: �' t��' � � �
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5. Time of Incident: 'I
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6. Location of Incident (Be specific): �C � �� �1,� � �, u
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7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. 'v ��
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full details upon which you base your claim. If a City employee was involved, give the ;
employee's name.)
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8. What we e weather conditions like? �"1'`�I�`i h_�
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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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.)
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13. What other damages do you claim, if any? _g'�,�;�,,,
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14. Have you been compensated for any part or alf of your claim by any insurance
company? (If so, give name and address of insurance company and amount paid.)
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15. What amount do you claim from the City of Dubuque�� �F�� � �� �
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16. Why do you claim the Cit of Dubuque is responsible? �i
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17. Have you made any claim against anyone else for damages as a result of this incident? �!�
(If yes, give name and address.) '�
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18. If the answer to Question 17 is yes, have you received any payment from that source, ;I
and if so, in what amount? ��
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Dated at Dubuque, lowa this _� day of -�, ��l , 20�.
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�����,� ����i� "Q���� ��� I�—el)`�� (Print Name)
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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 Dubuque immediately by telephone 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.
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Confidential information may include the following:
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1) Social Security Number(s) �i
2) Medical/Health Information I'
3) Personnel/Disciplinary Information ;
4) Bank Account Information �I
5) Financiallnformation U
6) Credit Card Numbers i
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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 G
information that is included. f
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I, ��({� 1�� l�I l�� , hereby certify that the attached documents �
include the following protected information: i�,
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Social Security Number(s) Bank Account Information �
Medical/Health Information `��� TFinancial Information !,
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�� _Personnel/Disciplinary Information Credit Card Number(s) 9
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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.
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Signature Date
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Copyrighted
February 18, 2019
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: Trever Allen for
vehicle damage; Brian and Dee Collins for property
damage; Robert Krohmer for vehicle damage; and Eric
Mueller for property damage.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur
ATTACHMENTS:
Description Type
ICAP Referrals Supporting Documentation
THB CITY QF
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Masterpiece on the Miss2ssippi
TRACEY STECKLEIN � ,
PARALEGAL �
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To: Mayor Roy D. Buol and
Members of the City Council
DaTE: February 4, 2019 i
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R�: Claim Against the City of D�abuque by Trever Allen �
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Clairnant Da#e of Claim Date of Loss Nature of Clairn i
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TreverAllen 02/01/19 01/26/19 Vehicle Damage ;
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This is a claim in which claimant alleges that his vehicle which was parked at 2928 Burden ��
Avenue was struck by a City snow plow truck. �
This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa
Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager
John Klostermann, Public Works Director '
Trever Allen �
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OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944
TE�EPHONE (563)583=4113/Fax (563)583-1040/EMai� tsteckle@cityofdubuque.org
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