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Claim by Keaton Kephart Copyrighted September 16, 2019 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUM MARY: Ronald Bahr for vehicle damage, Alec Lee Benson for vehicle damage, Michael Dorr for vehicle damage, Keaton Kephartforvehicle damage, Michael and Jill Pankowfor property damage, Christy Reed for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City Attorney ATTACHMENTS: Description Type Bahr Claim Supporting Documentation Benson Claim Supporting Documentation Dorr Claim Supporting Documentation Kephart Claim Supporting Documentation PankowClaim Supporting Documentation Reed Claim Supporting Documentation Y 1��...��,` c��'� � ' �.�.,'�c.c-a-� 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. � �i 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 '� , l AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. � �, � 1. Name of Claimant: e a°�`�� . �� " °-�" I� 2. Address: .�� h �'°�" '1 �� . � �, City: ��'z� � (�r��-� State: �`� Zip: �.�c�� !i r � I 3. Telephone Number: G�r�' � :..5 ` ,/ � ;; 4. Date of Incident: � �,7` 9 ; �"ca��_ ';I � � �� '� 5. Time of Incident: _ � �� 6. Location of Incident (Be specific): ��5'�f'�� ra� ��, ��ct��.�r�v� '� ^ � �� '? � : y �'�� I��" ��n .�,�.� �o�. � I� � ' 5��'' � �i 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT C/aUSED INJURY OR DAMAGE. (Give �i full details upon which you base your claim. If a City employee was involved, give the i employee's name.) � � ��p' �ac�+V' ,�f L�� c �i ` � ��'� Q t� ��..� �Y��L'� �°�- �+�-'�s c°� ` �" ��r''��-�a � �'°-�' �.c�/�-a�' ��1++0, � fll� � �✓�s�� , L�c��c � 8. What were weather conditions like? ��;,� , �/ � 9. Give name and address of any witnesses: (m'e �i��t�� 10. Did police investigate? (If so, give names of officers.) l°�� '��j�..z�� .fi�t- �a`�e�,��-�,�,,� 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). ,�� 9 � 12. Was any damage done to property? (if so, describe property and the extent of I damages. Attach estimates of damages or describe basis for ascertaining extent of i, damage.) � 'l �s .. � �l� �� ; � � � ��,f�.a,,� �.. �� ' �+C,�a `�vv� �-1� 1��'1C ��:�.��e. 13. What other damages do you claim, if any? /�v�, % � �_ 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.) �� i � 15. What a�mount do you claim from the City of Dubuque? , ; �� ; 16. �,Why do you claim the City of Dubuque is responsible? ;I � r�f'� �•�`��`�.e r c"c�� . �''L.� ��t c�� t i !i 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give namg and address.) %�'� � �I 18. If the answer to Question 17 is yes, have you received any payment from that source, i and if so, in what amount? i I p �a#�d a# ��b�qta�, i��a thus � day of_. �.��-S� , 20�. ` i � m �.�. � �a � (Signature) :,F. .� _ . --�,� -_ �v� ��.:. _:: � ��a ��__; p pR C�`, pp . / f . / . �. �r,.," �t-j j"VA .. � o �r� °--� ��`� (Print Name) ;'� � �� v, � �r:� �-;-; . �� _� �-i.. ,�-� �-�; .. ¢4.�. `F r�,� fa (Rev. 5/18) � ; 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. Piease notify City of Dubuque immediately by telephone at (563)-589-4120 of ,l 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: Ij � 1) Social Security Number(s) ;I 2) Medical/Health Information ;� 3) Personnel/Disciplinary Information '� 4) Bank Account Information ;; 5) Financiallnformation �! 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 ,�I information that is included. i �i� � �� i� �, , hereby certify that the attached documents � include the following protected information: � Social Security Number(s) Bank Account Information � �: Medical/Health Information Financial Information �� PersonneVDiscipiinary 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 i protect my information from unnecessary distribution. � � - � �. �� -� � �-� � � � Sign ture Date � � � 1 � � , Copyrighted September 16, 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: Ronald Bahr for vehicle damage, Alec Lee Benson for vehicle damage, Michael Door for vehicle damage, Keaton Kephart for vehicle damage, Michael and Jill Pankowfor property damage, Christy Reed for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo � Dubuque ; THE CITY OF Ek All•A�eeica Citp 4 '4r.r� � � wa�wv av�c it�u� f �� °� I Maste iece on the Mississi i zoo�.zo�Z.�o�3 f rP pp zo1�*Zoi9 � ; � I �RACEY STECKLEIN � � PARALEGAL ; I MEMO �I To: Mayor Roy D. Buol and � Members of the City Council � i �ATE: September 4, 2019 RE: Claim Against the City of Dubuque by Keaton Kephart ' Ciaiman# Date of Claim Date of Loss IVature of Clair�n ;� i Keaton Kephart 08/29/19 08/21/19 Vehicle Damage i This is a claim in which claimant alleg�s that a Leisure Services employee.attempted to � back into a parking spot in the 1800 block of Washington and struck claimant's parked vehide. , . I This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa Comrnunities Assurance Pool. ; i cc: Michael C. Van Milligen, City Manager I, Marie Ware, Leisure Services Manager I Keaton Kephart � ; ; i i i � I I � P I 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 � �