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Claim by Daniel Jacobs Copyrighted J une 3, 2019 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUM MARY: Daniel Jacobs for vehicle damage, Patrick Konzen for property damage, Garry Redman for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City Attorney ATTACHMENTS: Description Type Claim by Daniel Jacobs Supporting Documentation Claim by Patrick Konzen Supporting Documentation Claim by Garry Redman Supporting Documentation ! 1`,�� -� �� _ CLAIM AGAI�iST THE �ITY OF DUBUQ,UE, IC}IPVA � ��.�� -_ _ _ � This written rept�rt cc�r�stitutes your claim against the Gity of Du6uque, Ic�wa. You sht�uld - camplete this form in full and attach any addit�onal it�forinatian that supports your claim. The Glaim must be filed with the City Clerk at City Ha11, 50 W. �13�" St., Dubuque, IA 52001. It � wi[I then be referred by the City Council to the appropriate department for investigation. � Clnce that investigation is completed, a report and recommendation wil[ �e submitted to the �ity Cauncil. You will be provided wit� a ct�py of that report and recommendation. ' THE F1NAL DECISIC?N CJN ALL C�AIMS IS MADE BY THE CITY COUNCII�. Nfl EMPlC}YEE {JF THE �ITY OF QUBIJQUE HAS THE AUTHt'�RITY TCy MAKE ANY REPRESENTATION TU YtJU � � AS T{� WHETHER YC}UR CLAIM WILL {7R WI�L NflT BE PAID. { :� 'I. Name of Claimant: �aniei�acobs � � 2. Address: 712 Mill Creek Rd �� Clty: Bellevue St1��: lawa �� 52031 �. Telephone Number: t��)��-�22� � 4. Date of[ncident: `�l$��fl�g ' { ,� i 5. �T�me of Incident: �:`��pm � � 6. Location of Incident{Be specific}: ��versity Ave, L7ubuque, �a � �, 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY t�R DAMAGE. {Give � full details upon which you base your claim. If a City employee was involved, give the � employee's name.} � Tire feil off af city bus and struck parked vehicle awned by Danie6 Jacobs. � R � � � _ � 8. What were weather conditior�s like? �� 9. �ive name and address af any witnesses: '10. Did potice investigate'� (If so, give names of officers.) t?fficer l�aren Smith with Dubuque Caunty Sheriff, report#20�9-002522 � � '1'1. Was anyane injured:� (If so, give names, addresses, and extent of injuries). ; � No � 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.) Damage to Daniel Jacob's 2015 Nissan Murano. Driver's side front bumper and fender are damaged. � __ 13. What other 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.) `� � Yes, damages paid by Westfield Insurance. PO Box 5005, Westfield Center, OH 44251. Paid $9637.25 �j 15. What amount do you claim from the City of Dubuque? ' $9637.25 d 16. Why do you claim the City of Dubuque is responsible? � �� Vehicle was legally parked when damaged,city owned bus was responsible for the damage. li u 17. Have you made any claim against anyone else for damages as a result of this incident? �I (If yes, give name and address.) � No i 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 15th day of May , 2019 , � �t�`� � . (Signature) p Anne Bay (Print Name) n '� ��i�tl �� a�`� � �� tre� ��,�' `� �� -�..',, �� , -- �.J a-�- �t� � � y t.S�+��`� � � PTl � � �� ,f � �. ��,� �� r� � �``� (Rev. 5118) �` � °� � ��`�-, �Q��.C��.� � � '� �' � � � � Copyrighted J une 3, 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: Daniel Jacobs for vehicle damage, Patrick Konzen for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo � d a 9 � THE CITY OF ' '1 .--- � DUB�C , _ �E MEMORANDUM � Masteapiece on the Mississippi j i � TRACEY STECKLEIN ��,�� s� PARALEGAL � � � �l To: Mayor Roy D. Buol and � Members of the City Council i; �; �, DATE: May 21, 2019 ;; I' RE: Claim Against the City of Dubuque by Daniel Jacobs �'�y. � Claimant Date of Claim Date of Loss Nature of Claim �I � Daniel Jacobs 05/20/19 04/08/19 Vehicle Damage I� �� This is a claim in which claimant alleges that claimant's vehicle was damaged when a f; City of Dubuque bus traveling on University Avenue near Nowata Street lost its back tire, il which struck claimant's vehicle. � Please note that a claim for the same damage was also filed April 11, 2019 by Kassandra ! Jacobs, daughter of claimant Daniel Jacobs. 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 �tecklein, Transportation Services Field Operations Supervisor � Daniel 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/F� (563)583-1040/EMai� tsteckle@cityofdubuque.org CLAIM AGAINST THE CITY OF DUBUQUE, IOWA This written report constitutes your claim against the City of Dubuque, Iowa. 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. 1. Name of Claimant: Daniel Jacobs 2. Address: 712 Mill Creek Rd City: Bellevue 3. Telephone Number: (563)495-0229 4. Date of Incident: 4/8/2019 State: Iowa zip: 52031 5. Time of Incident: 1 45pm 6. Location of Incident (Be specific): University Ave, Dubuque, IA 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, give the employee's name.) Tire fell off of city bus and struck parked vehicle owned by Daniel Jacobs. 8. What were weather conditions like? Gear 9. Give name and address of any witnesses: 10. Did police investigate? (If so, give names of officers.) Officer Karen Smith with Dubuque County Sheriff, report #2019-002522 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). No ItY 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.) Damage to Darnel Jacob's 2015 Nissan Murano. Driver's side front bumper and fender are damaged 13. What other 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.) Yes, damages pald by Westfield Insurance, PO Box 5005, Westfield Center. OH 44251 Paid $9637.25 15. What amount do you claim from the City of Dubuque? t 110 63-7, a S- �� G(�c e 0 ur l iv% ttci woo ded , AMA 16. Why do you claim the City of Dubuque is responsible? Weide wet iepty parf.a4 when aanr}ea. or' c41.4 Cul vas rases f ax daauge 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 answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? Dated at Dubuque, Iowa this 15th day of May , 2019 . Anne Bay Adnan, sup `i Ws's lc(4 C(gtr, K \;Q 1 Gr t:S\ tAA *r -D-4 0a10 Ky4556og (Rev. 5/18) do on o' 0o 5✓, 9 (Signature) (Print Name) ao%` lcs n �1 e r-. CCD c'u � n >_ 0 CZ m m