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Claim by Ethel Schneider Copyrighted December 2, 2019 City of Dubuque Consent Items # 2. ITEM TITLE: Notice of Claims and Suits SUMMARY: Michael Lenstraforvehicle damage and Ethel Schneider for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Referto City Attorney ATTACHMENTS: Description Type ClaimAgainstthe City - Michael Lenstra Supporting Documentation ClaimAgainstthe City - Ethel Schneider Supporting Documentation �� AIM AGAINST THE CITY C3F GUBUQUE, l(JIPVA ��,� This written repor# constitutes your claim against the City of Dubuque, lowa. You should comp(ete this fc�rm in fuli and attach any additional informatior� that supparts yc�ur c�aim. � E The Claim must be filed with the City Cferk at City Hall, 50 W. 13�h St., Qc�buque, IA 52001. It � wi11 �hen be referred by the City Cou�ncil �cr #he apprQpriate depar#men# far inuestigatian. � C}�� th�# ir�v��iga�ior� is �orrl�let�d, � r��e�r� �r�ci recammendation will be su�mitted to the � City Couneil. You will k�e provided with a eopy of�hat report �nd recommendatian. A THE FINAL DEGISI{3N G1N ALL C�AIMS IS MADE BY THE CITY CQUNCI�. NC7 EMPI.QYEE UF � THE CITY C?F DUBUt�UE HAS THE AUTHt}R1TY TC} MAKE ANY R.EPRESENTATION TC� YC?U � Aa TO WHETHER YQUR CLAIM WILL t�R WILL. NC}T BE PAID. � ��'�� d�� 1��"�' � 1. Name af Claimant: ' i � 6 � 2. Address: ��C� ��fi��i ��°��', —�- � � City: _ �� !�� State: .�r�� Zip: �.�� 3. Telephane Number: ; A, �,� � �. Date of Incident: ��''�e<`��` Ix ��1� � � 5. Time of Incident: � �p �� i� » , � 6. Location of Inciden# {Be spe�ific}: ��c�� 4'�'��,�,� �''.��`��?�: e� � A � � � 7. DESCRIBE ACGIDENT OR C?CCURRENCE THAT CAUSED INJURY OR DAMAGE, Give � � fuil details upon whic� you ba�e your ctaim. If a City employee was involved, giv� the � emplayee's name.} ��X,�`"" �l�� 't� �` �S �d� � c,° � � � � �+-" � � ��° � �; �' �' .d� J � v�':�� ,,��,� �°� �r �` 3 ��a��' �' �d,��'�� '�� e��"� ��,�i �r��'�' ��'�',�� :��''e�� ,�h ��"��i �" ��"i �"�a�to� � a 8. What were wea#her onditions like? .�u�1� ,. �� r�a $ � 9. Give name and address of any wi�r�esses: l��1'�"o s � vaa r� ��, ��'��,��.�� '10. Did polic� inv�:stigate? (If sa, give nam�s of officers.) � � '1'1. Was anyone ir�jured? �tf so, give nam+�s, addresses, and extent of injuries�. � � � s 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.) �e� - �1��on�� a��a �a�� J'�•�e�i, r,�t�J' �� = ,��°�� , � �� G /�� ' e�r �l��'e 6� f"� ��d;,, ��'/��i(r t' Gl�dl f.�,�''�� 13. What other damages do you claim, if any? �°�,�� r 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.) � � ( /G��., � � 15. What amount do you claim from the City of Dubuque? 'I �� 9� ' � 16. Why do you claim the City of Dubuque is responsible? � ! �✓�T� /��"','��r�l�°`�4s/ u��J� ��.�.�� /f1�j�� e��r.��'��/� �0?� C��'s°7r �Bd�`�� /j�s��4',��,+� � 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) � 18. If the answer to Question 17 is es, have ou received any payment from that source, Y Y and if so, in what amount? � � � Dated at Dubuque, lowa this �� day of ,��,�r�� , 20�. a �� ..�k'��'Z��r..�..�.�.�._.�.._..� (Sig natu re) � .� _-� �, �� !� �, ��-��>��'w (Print Name) �.�?`= � `�.� y'� �1 �.... , . . {� T � f�+,. ��' 6V A �'T! t_a ;z- CD �' � � � � �@ �� -�=+, ;-, ti..�" (Rev. 5/18) n �, Conficler�tial This cvmmunicati�n and any attachments may confiain information which is confidential an�d privileged by law and is for the use af tE�e designafied recip�ient. If you are not the int�nded recipient, you are hereby notified that you have received this communication in error, and that any review„ disctosure, dissernination, distribution or �opying of its cantents is prohibited. Please notify City of Dub�uque immediately by telephane at (563}-5�9-4120 crf yc�a�r r��pt rs� #he�e �#+�� an� dl��trc�g� �'�� €�mrnur�6�a��€��ro �r�d ��ay �##��hrn��t� � immediately. Further disclosure �f this information may violate state and federal � � restrictions. � a ¢ � Confidential infarmatic�n rnay include the follawang: ;; 1� Social Security Number{s� ; �} MedicallHealth Infiormation ,� �) Personnel/Qisciplinary Infarmation � 4) Bank Account Informati�n �� 5) Financiallnformatic�r� 6) Credit Card �1�arr�k�ers ' i If any documentation yc�u desire to submit t� the City of Dub�aque contains any �f the items above ° this cover sheet must be attached directly tc� �he confidential informatior� and indicate the type of information that is included. � �' � � I, �=�� c"��,��r��"" , hereby certify that the attached doeuments � include the fol�owing prc�tected ir�fc�rmation: � '� Sacial Security �lurnber{s} �'°'" Bank Accaunt Information �'"" Medical/HeaCth Ir�fc�rmation � Financial Informatian `�'" PersonnellDisciplinary Informatic�n � Credit Garc# Number(s} � I understand that this infc�rrnation may be distributed within tne City organizatian or to agent� of tl�e � Gity for pr�cessing and I hereby authorize the City to act accordingly takir�g all precautions to protect my information from unnecessary distribution. ' � ��r�.�--r ��r��,�� ignature Date � Copyrighted December 2, 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: Nancy Fett for vehicle damage; Michael Lenstra for vehicle damage; Ethel Schneider for property damage. SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur ATTACHMENTS: Description Type ICAP Referrals Staff Memo Dubuque THE CITY OF 811•A�eriea Ciiy ��../ � wmc�rw.a�cirar�xs I '� II�o' '� Masterpiece on the Mississippi 2ai�*zoia � � J ,� ,I TRACEY STECKLEIN ��,. PARALEGAL I� MEMO I'� � '� To: Mayor Roy D. Buol and !' � Members of the City Council ij '�I i DATE: November 25, 2019 1 ''J RE: Claim Against the City of Dubuque by Ethel Schneider I � Claimant Date of C9aim Date of Loss Nature of Claim ; Ethel Schneider 11/22/19 11/01/19 Property Damage 'I ; � This is a claim in which claimant alleges that City of Dubuque Fire Department personnel � responded to and forced entry into 710 Duggan Drive. � � This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa i Communities Assurance PooL � cc: Michael C. Van Milligen, City Manager � John Klostermann, Public Works Director I Ethel Schneider � I � ; �; ; � � � I � OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 I� TE�EPHotvE (563)583-4113/Fax (563)583-1040/EMai� tsteckle@cityofdubuque.org � � B i �