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Claim by Willian Hickson Copyrighted October 7, 2019 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUM MARY: Nick Helgerson for property damage, William Hickson for property damage, Mary Kisting for vehicle damage, LJ R Investments, LLC c/o LinsyAdamsforpropertydamage, Jayantibhai Patel for property damage, Jhony Edgordo Ramirez for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City Attorney ATTACHMENTS: Description Type Helgerson Claim Supporting Documentation Hickson Claim Supporting Documentation Kisting Claim Supporting Documentation LJR Investments, LLC Claim Supporting Documentation Patel Claim Supporting Documentation Ramirez Claim Supporting Documentation �� . CLAlllll AGAINST THE CITY OF DUBIJQUE, IC}WA .��..u.�r�..a�� tt��r � This written repart cor�stitutes yaur claim a�ainst the City of Dubuque, louva. You shc�uld ` complete this form in fu11 and attach any additional information that supports your claim. °� � � Tne Claim must be filed �nrith the City Clerk at City Hall, �ti W. '13th St., Dubuque, IA 52001, lt ' will then be referred by the City Ca�ncil to '�he appropriarte department far investigation. � C}nce that investigation is completed, a repo�t anc! re�ommendation will be submitted tc� the � City Councif, You will be provided with a copy af that report and recommendation. � �� ,� THE F'INAL DECISIC}N UN A�L CLA�MS IS MADE BY THE C1TY GQUNCIL. Nt� EM�LQYEE t�F ° TNE CITY C}F' [�UBUC,2U� HAS THE AUTHORITY TO MAKE ANY REPF�ESENTATIQN TQ YC}U � , AS TtJ WHETHER YC?UR �LAIM WILL t7R W[�L NOTBE PAID. i � 1. Nam� of Claimant: � �� 1�� L��•,�[�f� � � � � �' I �. /�►C�{�!'�SS: �� —� c' ��r�� City: Le..�i'� State: �,�� Zip: �� ; � 3. Telephc�ne Numb�r. �`��'�� 4. Date of Incident: ��°"` ��-- `" �� '� ,� 1 , � 5, Time of lncider�t: ��'� � t ��(1��j,� � +� � �� t a 6: Loca�ior� of Incident �Be specific�. �'�� Y1�� ;I � � a ?. DE�CFtIBE AGCIDENT tJR OCCURRENCE THAT CAUSED INJURY C?R DA11tIAGE. tGive � full details tapc�n whi�h yca� �a�� yc�ur ��i�. If a� �Aty era�plcaye� �nras i��>�I�reti, gke�e the � employee's na�e.� 4 �� /�` ��-- `�� `��. �`�(�`�`� �G2.�� `�'�'��— �-��i� � � 1�� !��"�� "� � �3� ��.� �� . � ��' � �� .��t��2 � ��t�'�i�� ° �. What re vtiteather conditions like? t��t�' � �' i� w � 9. Give name and address Qf a�y witr��ss�s: � � �� ,� 10. L�id police investigate? {If so, give names of officers.� ''�t�� '41�� e� d�' 1e�� 8�4:�d L:��C.�' ��- �(��e I �� j 11. Was anyt�ne injured? ��f so, c�ive names, addresses, and extent of injuries). �' �.�e ; �� i ; ; � ; 'f 2. VOtas any damage dc�ne to property? {1f so, describe praperty and the �xtent of damages. Attach estir�ate� of damages or describe basis for ascet-taining extenfi of damage.} � �-�,� �a�.� ��' ��.�' �r�� -� � ° `��` �u o�`k.� �.�� t� ��.��.� . �� -��° �h��' ��°'.��r�� r�- .�. .��°��-F��.. r��.�� 13. VgOhat ather damages do you elaim, if any? ��""�` �� '_��L��-� -g 7- � ,�a�-�` l�,�Y� 1 ,G��R E i t� t�°' 14. Have you been c�mpensated far any part or all of ycaur claim by any insurance company? (If sa, give name and address of insurance company and amount paid.) �� r�� -� j -� .� �:� ��- �� '+�� °��j�. ,�� c��- .� ��s`s }.� '!5. What amo�t da yc's'u c1ai� from the City af Dub�que? , � �� - �f��d�� r� �� . '16, V1/hy do you claim the City of Dubu�ue is respc�nsib e? ��`'. � �.'��'"tae�`°t�� .�"r�"� r` r��'�' � j �'�` °� ` .��`t l��r,� �.�" � ��'��- r��'�� : � ,� �c�� '��/� ��'�� '17. Have you r�ade any claim aga�nst any�ne else for damages as a resutt of�his nc�den �� {If yes, give name and address.} ��,�J`�"� �� fi � 98. If the answrer to Qu�s�ion 77 is yes, have you received any payrr��n# frr�m that source, and if so, in �uhat arriount? � Dated at C�ubuque, lawa this day of � ��' , 20,��,,. a (Signature} �, �� r, � --�� ' � ��,�$�� i�,�� ' `�' ' {Print Name} �- � � � �., � `.� �"� � � � c,� � � � � � � � � � ��W. �r�s� . � Itemization of Claims: � � Electrical Box Rebuild � Breaker Box/Breakers $ 184.93 � Buildmg Permit $ 21.00 �, ti Water Heater $ 1,320.00 � s � y 7 Furnace/Ductwork $ 8,630.00 � ti � Air Conditioner $ 2,960.00 j; d � i� Washer/Dryer $ 1,097.79 I ; � �I I I� Wall Reconstruction $ 200.00 �I� �� ti� Dump Trailer Rental and Cleanup Help $ 150.00 � � Miscellaneous Materials � Pumps $ 180.00 � Flashlights $ 40.00 � Faucets $ 20.00 � � � � Total $ 14,803.72 � � Copies of the major expenses are provided. Some items have not yet been purchased, such as wall construction materials. I am gathering the rest of the receipts for smaller expeses. � � � Gon�it�ential This communication and any attachments may contain informatior� r+vhich is confdentia� and priaiEeged by I�w and is for the use of the designated recipient. If you are not the in#ended recipient, you are hereby notified that you have received this �cammunication in F error, �rod that any review, disctosure, dis�seminatio�t, distribution or copying of its contents � is proh�bited. Please nc�tify City of Dubc�que imrnediately by telephone at (5fi3�-5€39-4'120 0�' � yaur receip� of these items and destroy the communicatian and any attacF�ments immediately. Further disclosure of this information may vialate state and federal k restrictions. E � � Cc�nfidential infarmation �nay include the follawing: � � �� Social Security N�mber(s) � 2) MedicallHealth Inforrnation �� 3} Personnel/Disciplinary Informatian ;i 4) Bank Account Inforrr�ation � 5) Financial lnformation � 6) Credit Card Numbers � � �; If any dc�cument�tic�n yc��a desire to submi� to the �ity of Dubuque cc�ntains any of the iterns above this cc�ver sheet must be a#tached-directly ta th� con�dential information and indicate the type of informa#ion that is �ncluded. , � � �d �'11r�� ;, � 1, ��'1 , hereby certify that the attached documents ; include the faElowing protectecf information: � � Sacial �ecurity Number�s) Bank,4c,count Informa�ion � ,� � Medica�lNealth Infcarmatic�n � Financia� Infarmation PersannellDisciplinary Infarmation Credit Card Number(s) � � I understand that this informatit�n may be distributed within the City organization or ta agent�of thre � City for processing and I hereby authorize the Cify to act accordingly takir�g afl precautic�ns to � protect my inforrnafton fram �nnecessary distrib�tion. � �',��— ,��d� � � 5ignature Date d � � � � � Copyrighted October 7, 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: Nick Helgerson for property damage; William Hickson for property damage; Mary M. Kisting for vehicle damage; LJ R I nvestments, LLC c/o LinsyAdams for property damage; Jayantibhai Patel for property damage; Jhony Edgordo Ramirez for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo ^'�° Dubuque THE CITY OF �� Ali•Anseica city �� J� NNN:Y'NLaVIC IlX3JC: , 'I I '�r Maste iece on the Mississi i Zoo�•zolz•Zo�3 rP pp zoi7��oig � � � � TRACEY STECKLEIN � PARALEGAL MEMO To: Mayor Roy D. Buol and Members of the City Council �are: September 30, 2019 ; RE: Claim Against the City of Dubuque by William Hickson �, ,;I Claiman� Da#� of Clairr� Date o�f Loss IVature of Claim II, i William Hickson 09/27/19 09/12/19 Property Damage ; This is a claim in which claomant alleges that construction being perFormed at 22nd Street � and Kaufmann Avenue caused his home at 2207 Francis Street to flood. � This claim has been referred to Public Entity Risk Services of lowa, the agenfi for the lowa Communities Assurance Pooi. � cc: Michael C. Van Milligen, City Manager Gus Psihoyos, City Engineer Deron Muehring, Civil Engineer II John Klostermann, Public Works Director William Hickson 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 e