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Claim by Robert Monthey Copyrighted August 5, 2019 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: David and Connie Coleforpropertydamage; Dave Hubanks for vehicle damage; Mason Kobliska for vehicle damage; Robert Montheyforvehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City Attorney ATTACHMENTS: Description Type Cole Claim Supporting Documentation Hubanks Claim Supporting Documentation Kobliska Claim Supporting Documentation Monthey Claim Supporting Documentation � �` ., � m«� "_`"\ CLAIM AGAINST THE CITY OF DUBUQUE, IOVNA � � ��`�"'r�'^`� 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 Cifiy Halt, 50 W. 13th St., Dubuque, IA 52Q0�1. It will then bE re#errEd by the Gity Council to #he appropriate department for investigation. Qnce that inv�stiga#i�rr� is completed, a repork and recommendation will be submitted to the City Council. Yau will be provided with a copy of#hat report and recommendation. THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE ClTY �4UNCIL. NO EMPLOYEE d)F THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TCl YOU ; AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. 1. Name of Claimant: � � ��,.r�" � �'�� . 2. Address: _ `�1'..S"� ��.��r G, �'�". �ity; ��e.��c� � �. State° _ �� Zip: �`�A�� 3. Telephone Number: ��"�.� � � 1 `� -.-�� 4. Date af Incident: ��n�_�'�, � �� 5. Time of Incident: �1��s� '�; �� ,�? 6. Location of Incident (Be specifiic): �.,�.��. �� ,� �, 1�� j�� ,�, �'�� " ��?� �� r��. �� :7. DESCRIBE ACCIDENT OR OCCIJRRENCE THAT CAUSED 1NJ11RY OR DAMAC;E. (Give #ull details upon which you baSe your claim. If a City employee was inyolved, give the employee's name.) '�"��'ti ��. �z��t� "j',�tor e.� � �„a��r�� l �-"? ?r�► � ��a��r�..;a�. �t �a��r�,�� ,�>��— + /�r'��►,v�'�'" r► ��mo�: �l'� �'�•�. �'��A' � • ��'J ,�� ra. ��''�J-�,�" �d"��J� ��`"h �?��aF".� 8. What were weatNfer conditians like? �°x.��,� ,�,�, ,� � ,a�a 9. Give name and address of any witnesses: r"J�� ►��r� �,� ,�°,� � ' 10. Did police ir�vestigate? (If so, give names of officers.) � �, ��„� �- ��'�� .� : �ld� � � 1��,��- ��.�✓�a�a. � .� '19. Was anyone injured? (If so, give names, addr�sses, and extent of injuries). � e��- ��,��- � ��'Y1 � !'� r�r �. ��', 12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe b�sis for ascertaining extent of damage.) ��a �"�.-�.�� y�� ' ��s- �'� �g� �.� � �� r� E � /��- . 1 r� ��'�e.��'`� /� ��, ta��_,�'= �� ,��.�rS"� �`"�� a��, 13. What other damages do you claim, if any? o,/��'�' 14. Have you been compensated for any part or all of your claim by any insurance campany? (If so, give name and addres� of insurance company and amvunt paid.) �� 15. VNhat amount do you claim from the City of Dubuque? �� 16. 1PV�y do you claim the City of Dubuque is responsible? � �' s�' �"r�' �'`��` ,�� ",�� ,�' . �� '�� ,� �¢�� >�,�� '17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, giv��e and address.) 18. If the answer to Question �17 is yes, have you received any payment from that source, and if so, in what amo�nt? � � Dated at Dubuque, lowa this �� day of �� , 20�� ° (Signature� � ✓ ' .�3�,� ,� ��'`��r�''� r,� (Print Name) �� '' ;�, � .s�:� �- C�`► � � � � � � � � � (Rev. 5/18) �' � � �..� Confidential This communication and any attachments may contain informafiion which is confidential � and privileged by law and is for the use of the designated recipient. If you are nat the intended recipient, you are hereby notified that you have received this communication in � error, and that any review, disclosure, dissemination, distribution or capying of its contents h is prohibited. Please notify City of Dubuque immediately by telephone at (563)-589-4120 of J your receipt of .these items and dcstroy the communication and any attachments ,� immediately. Further disclosure of this information may violate state and federai restrictions, � Confidential infarmation may include the following: 1) Social Seeurity Number(s) ' 2) Medical/Health Information � 3) Persannel/Disciplinary Information � 4) Bank Account Information 5) Financial Information 6) Credit eard Numbers If any documentation you desire to submit to the City of Dubuque contains any of the it�:ms above this cover sheet must be attached directly to the confidential information and indicate the type of information that is included. O, "`�.��,� �� `'ti'�- , hereby certify that the attached documents include the following protecte nformation: Social Sec�ri#y Numberts) Bank Accaunt Information �� MedicalfHealth Informatian Financial Information Personnel/Disciplinary Information Credit Card Number(s) I understand that this information may be distributed within the City organization or ta agents afi the City for processing and I hereby authorize the City to act accordingly taking all precautions to protect my information from unnecessary distribution. �� Signatu Date THE CITY OF I�T,�B LT� MEMORANDUM Masterpiece on the Misszssippi . � � TRACEY STECKLEIN � PARALEGAL 4' � Y ; To: Mayor Roy D. Buol and � Members of the City Council ' � �DATE: July 22, 2019 � � RE: Claim Against the City of Dubuque by Robert Monthey � Claimant Date of Claim Date of Loss Nature of Claim �� Rober� Monthey 07/19/19 07/10/19 Vehicle Damage . This is a claim in which claimant alleges that the drivers' side mirror of his parked vehicle '� at 1678 lowa Street was struck by a City of Dubuque truck. i! �''. This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa �: Communities Assurance Pool. '� I cc: Michael C. Van Milligen, City Manager John Klostermann, Public Works Director Robert Monthey � 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/Ennai� tsteckle@cityofdubuque.org Copyrighted August 5, 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: David and Connie Cole for property damage, Dave Hubanks for vehicle damage, Mason Kobliska for vehicle damage, Robert Monthey for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo