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Claim by Kassandra Jacobs 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 M ��M �-�.� CLAIM A AI T T CI F D I , r�� G N S H E T Y O U B U Q U E, O W A ._ (�Q.n�i� This written report constitutes your claim against the City of Dubuque, lowa. You should complete this form in full and attach any additionai information that supports your claim. The Claim must be filed with the City Clerk at City Hall, 50 W. 13�' 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. 1. Name of Claimant: �c'�S S'��;V'Ol. \,1�''�V�i S 2. Address: �� 1�11, �� ti'�x;�;�- y�Gjl - � City: ��/�'-�l�U VV� State: Zip: �� 1 3. Telephone Number: �� ? " �-�'�, CJ ^ l� O �� 4. Date of Incident: `—}' � �J � �� S. Time of Incident: �� ' �� 6. Location of Incident(Be specific): 1� l�V'�9��(�- ��(�..�� G� \7�,i v� ,�'S �� /1 �1-�'� �1,� 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, �ive the employee's name.) �C�,i ti�1��C�. ��1�1 G��l �a�.r�i�l'l��1��" ��''t �1 l� �� 1��'�;4��I C�� r�Gt,� 1n v� ��;�-�s��/��" c�,�;L�i�� L�,�cr�c�c�i�l�-�. 1�vt,fi 1'1��- ��:;�c.�, �r�,�P ui�,� ��tifi.u� �;�� 1�v�S y o S� �. � �e� c�,inc,l �-1�v� �c��- �n v� v �,t�� c;� � � ,�� -�1 � � 8. What were weather conditions like? U1�� 'l�' 6 � � y � `� ` ,. 9. Give name and address of any witnesses: ��?'4/��,� t;�,�,��0�'�,��, �I �1��(,��IL1� 10. Did police investigate? (If so, give names of officers.) 'v , � �'�� c� ��.�,� : � � �`1 C�'��' �'0�,�� .iti'l 5 Ir'�� I� , �' �1 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). � ,� G� � V�(`�I� L� 1� � ` � V ` 1 � , L (?�, I C� ��`t�� J V�`� ��f1 C�,� �Cl�i P�''v`1��'�l - 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.) �if� V� � `� S j �l� ��'� �'G��f � . ' �` `I' � ; ��r '�� %`t �-� G�;�n� �;�'� C:''o,�r t �T� � ,� ', v'�� i'� ,(�;'��,Cti�:'�� 13. What other damages do you claim, if any? �� 1/1�G�,� C�� ;.�l��'C� , �.a/LG� � 1 , ��C � � �� '� �v�t�c�� 1�.- c�c�v�.L ��1� . 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.) ��J , 15. Wha a ount do you claim from the City of Dubuque? C�1,► �l� -� o'�' � � i ��C.-- 16. Why do you claim the City of Dubu ue is responsib e? � c��,ot,in��-�.�� °� ' 1 � '�� 1 . 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) �� = 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? Dated at Dubuque, lowa this 1 � day of � tQ 1� � 1 , 20 ti� . " -� G�l�� (Signature) �, - Cit,�S 1/1 �� C�`� n � (Print Name) _ - �_, �� -- �;� n�, ,4�- t.� ....._ r--, - ci, ; , �? �`- � �'. ;_ ._ _ �; t, `Y (Rev. 5/18) - n -�a r, .-: �=- �; � t;� �_, cn �'a rn 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 inc{ude the following: 1) Social Security Number(s) 2) Medical/Health Information 3) Personnel/Disciplinary Information 4) Bank Account Information 5) Financia! Information 6) Credit Card Numbers 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, , hereby certify that the attached documents include the following protected information: Social Security Number(s) Bank Account information Medical/Health Information Financial Information Personnel/Disciplinary Information Credit Card Number(s) 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. � � � �� `� � � i nature 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 �zJB E MEMORANDUM Masterpiece on the Mississippi TRACEY STECKLEIN PARALEGAL To: Mayor Roy D. Buol and Members of the City Council � DATE: April 12, 2019 � RE: Claim A ainst the Cit of Dubu ue b Kassandra Jacobs � 9 Y q Y � � Claimant Date of Claim Date of Loss Nature of Claim � � Kassandra Jacobs 04/11/19 04/08/19 Vehicle Damage � �� This is a claim in which claimant alleges that her vehicle was damaged when a City of d Dubuque bus traveling on University Avenue near Nowata Street lost its back tire, which � struck claimant's vehicle. y i� 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 ° Russ Stecklein, Transportation Services Field Operations Supervisor Kassandra Jacobs 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