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Claim by Konstantine Batonisashrili Copyrighted May 6, 2019 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Konstantine Batonisashrili for vehicle damage; Nick Hermsen for vehicle damage; Kassandra Jacobs for vehicle damage; Carol McDonald for property damage, Aiman AI-Qady vs. City of Dubuque Housing Board of Appeals. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City Attorney ATTACHMENTS: Description Type Claim by Konstantine Batonisashrili Supporting Documentation Claim by Nick Hermsen Supporting Documentation Claim by Kassandra Jacobs Supporting Documentation Claim by Carol and Charles McDonald Supporting Documentation S uit by Ai man AI-Qady S upporti ng Documentati on �� , , l �� F 'A � 7- 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. 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 � THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. � � ��d�� r �s � 1. Name of Claimant: � � C�.T��1lS��' �� i ,, 2. Address: �� i s°�-� `' I; � �� City: �� fr�, State: ��(� Zip: � � V ,, Ii � 3. TelephoneNumber: S� � � �' ��I� ' �'� ��,' ��i � / �)/ � 4. Date of Incident: �� / �W � � � 5. Time of Incident: (� � � U � '! 1 � 6. Location of Incident (Be specific): ��-�S% � Y�I d�a�s'`� �� i�Ld��%C S�� a-1r fit.�S' �c�d��.��..� � �(�.SL � �.;,�i,�� 5��¢c� �tc7Jce�'C� 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give f full details upon which you base your claim. If a City employee was involved, give the � employee's name.) � � i � C��- � °�� C,r�,� ��w ��.�� ,r�9� � ��n .s��r� �-r-�c� �� -� � `�" rr�a� � � �� cc� a��s�t� c� ha� ��Ce .�. c��s�l�e��,l � 8. What were weather conditions like? ��J(. � ��"V1r` � V1�1 p � �, � i 9. Give name and address of any witnesses:��/ ��'C '�I'- ��O�,�e� � �1� 10. Did police investigate? (If.so, give names of officers.) 0 ��c�r�— d��, ��;� I� � 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). �� I� r-- �� I�L�� a 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.) ; � w� C�.�.� � � t�l 1�,�� i�,l�r� �-� ��r �� ' ;�a � ��- ,a�r Sd'�. �.r��% y �— s,� �ro c�� sr�r �a� � , d - ,� �, � ,� I,I ��.�S;�c� a � �t� �,�-,�� r� �r� �,� � r� � �� ,J ;� � � 13. What o er damages do you claim, if 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 amount paid.) �c� s 15. What a o nt do you claim from he Cit of Dubuque? �y � � �a � �� ,�� 5 G 16. Wh do ou claim the Cit of bu ue is res onsible? � a Y u q p 9�� , , � �.��►s;, �� c�r�- c� 1�� u J� �r b� � 9� �19� d W A p Y l�7/'� o � f'�-�.K,�GI� � r"W � ��d�� 9�!� �Oe�. �o � - 7. Have you made any claim again`st anyone else for damages as a result of this incident? (If s, give name and address.) � C�� 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? 1 � I Dated at Dubuque, lowa this �day of ,��I�r l , �0 � 'r . � �' (Signature) � �:��) � ��`��'��. I� V1��1I1�i (Print Name) {��-�'� � �: � m t h� � r- �'., a� �'` rU �" � � ��, =="� m � � � � � �,} �� (Rev. 5/18) `�' 1 `� F,; �s� �n. � 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. Confidential information may include the following: i 1) Social Security Number(s) 2) MedicaVHealth Information 3) PersonneVDisciplinary Information � 4) Bank Account Information � 5) Financiallnformation 1 6) Credit Card Numbers j 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 � information that is included. � ! I, � �;� 0 � ' , i , hereby certify that the attached documents inc ude the ollowing protected information: � I, �l.�j Social Security Number(s) I�� Bank Account Information I� ,� �I� Medical/Health Information V,�j Financial Information Personnel/�isciplinary Information Credit Card Number(s) I understand that this information may be distributed within the City organization or to agents of the City f�� processing an� I hereby a�thorizs the City to act accordingly #aking a!I precaations t� � protect my information from unnecessary distribution. �� ig re Date Copyrighted May 6, 2019 City of Dubuque Consent Items # 3. ITEM TITLE: Disposition of Claims SUMMARY: CityAttorney advising that the following claims have been referred to Public Entity Risk Services of lowa, the agent for the lowa Communities Assurance Pool: Konstantine Batonisashrili for vehicle damage, Nick Hermsen for vehicle damage, Kassandra Jacobs for vehicle damage, Carol McDonald for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo THE CITY OF DUB E MEMORANDUM Masterpiece on the Mississippi TRACEY STECKLEIN '�� PARALEGAL � To: Mayor Roy D. Buol and Members of the City Council DATE: April 25, 2019 RE: Claim Against the City of Dubuque by Konstantine Batonisashrili Claimant Date of Claim Date of Loss Nature of Claim Konstantine Batonisashrili 04/24/19 04/18/19 Vehicle Damage This is a claim in which claimant alleges that her vehicle which was parked near 1754 Bennett Street was struck by a City of Dubuque Public Works 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 Arielle Swift, Assistant Public Works Director Konstantine Batonisashrili OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET�UBUQUE, IA 52001-6944 TE�EPHotvE (563)583-4113/F,v� (563)583-1040/EMAi� tsteckle@cityofdubuque.org