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Claim by Jerome Ehlers Copyrighted November4, 2019 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Jerome Ehlers for property damage, John Koenig for property damage, George Langas for personal injury, Julie Rupert for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City Attorney ATTACHMENTS: Description Type Ehlers Claim Supporting Documentation Koenig Claim Supporting Documentation Langas Claim Supporting Documentation Rupert Claim Supporting Documentation . � � � �� j� - �� CLAIM AGAINST THE CITY OF DUBUQUE, IOWA ��'�' �� /�.�T �I This written report constitutes your claim against the City of Dubuque, lowa. You should i complete this form in full and attach any additional information that supports your claim. ;� � The Clalm rnust be filed with the City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52001. It I,� 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 s,ubmitted 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 i THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU ; AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. � !I I 1. Name of Claimant: � � j� �., �_„ �-� ,� , 2. Address: � � � ��,��"�'��,�.�t`['" ��s � '�'��.� �I City: �r �� Stateo .��,,� Zip: �` , � ��- � 3. Telephone Number: ; �� '�..� -�/�� j� � � � i 4. Date of Incident: �r,� � C��.��'�' ,� �� !I 5. Time of Incident: � 6. Location of Incident (Be specific): �� , � �- '� rt� �j,�^��r� � � 11 II �� 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give y full details upon which you base your claim. If a City employee was involved, give the ;'. �m�l�y��'� �a��.� n I� r � � _ � � � � ti �-��- �r� � �� ` � �� f��o �f��—� � �� 8. V1/hat were weather conditions like? �/�� 9. Give narne and address of any witnesses: ��,�,� � 10. Did poloce investigate? (If so, give names of officers.) � � � 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). � /V�� ' � � �� ! � �� I I � M , ;j 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 ;I damage.) ! ;� � � � � ;� � h II � �,� I � 13. What other damages do you claim, if any? ,� � 9,��'�. � � { � � " 14. Have you been compensated for any part or all of your claim by any insurance i; company? (If so, give name and address of insurance company and amount paid.) �� ;� ��i i 5. Viiha�t amounf do you ciaim from tne Lity of 6ubuque5 I�� 7�� .'� ; , �i� 16. Why do you claim the City of Dubuque is respon�ible? ; � �� " � � i �� ,� 17. Have you made any claim against anyone else for damages as a result of this incident? �`'� (If yes, give name and address.) � li �, 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 � Dated a# �ab�as�u�, I�wa this � da� of , � ��.�'�—� ��.� j �� (Signature) � �^ � � �J��"�►�'t c� `"�'o � � ��-'� (Print Name) i� � ,s_�� R.� �--, ...�.� �--� `�- _� � � � � C�- �� -�� (Rev. 5/18) � r�, � � � �. :� — � � , � �, � � a � � �u G � a 9 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 l 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 vlolate stafie and federal � restrictions. �+ 9 ,� �1 Confidential information may include the following: ;i �i �i 1) Social Security Number(s) � 2) MedicaVHealth Information '� 3) Personnel/Disciplinary Information � 4) Bank Account Information 'a 5) Financiallnformation � � � ; 6j Credit Card Numbers ;, � ��, �i ,; If any documentation you desire to submit to the City of Dubuque contains any of the items above \ '�i this cover sheet musfi be attached directly to the confidential information and indicate the type of >i information that is included. � ;� ;i i� ,_.,...�.-� ] I� �, _ ��`��'_:. �h,�� , hereby certify that the attached documents ,I include the following protected information: � Social Security Number(s) Bank Account Information �'; ',; �,^Je�ie�!lHga{th ��arrr�a#i�r F��a�eiai ir�v�<<�aii��i ° �i 1 Personnel/Discipiinary Informatian Credit Card Number(s) ''I 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. � � � � �� S' � ignat e Date � � � � � � � a s � 'a � � a Copyrighted November4, 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 forthe IowaCommunitiesAssurance Pool: Jerome Ehlers for property damage, John Koenig for property damage, George Langas for personal injury, Julie Rupert for vehicle damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo �THE CITY OF � � TT�.TT� E MEMOI� ANDUM � �Master�zece an tlze Mississzjapi ;I i �! �, � TRACEY STECKLEIN � PARALEGAL d � To: Mayor Roy D. Buol and � � Members of the City Council � ,,� Darg: � October 25, 2019 ;i RE: Claim Against the City of Dubuque by Jerome Ehlers �I C�air�ant Date of Claim Date of Loss iVature of Claim � I, Jerome Ehlers 10/25/19 07/02/19 Property Damage ,��,� This is a claim in which claimant alleges that a Ci#y sewer line backed up into claimant's '; lower level of her home at 3115 Brunswick Street. !' This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa I;''� f Communities Assurance Pool. i cc: Michael C. Van Milligen, City Manager i Denise Ihrig, Water Department Manager u Arielle Swift, Assistant Public Works Director ii Jerome Ehlers � � � � � a � , 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/EMai� tsteckle@cityofdubuque.org � �