Claim by Tanya Anglin,
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the City of Dubuque, Iowa. 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.
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
AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: 7i1j71t Ar1
2. Address: 6713o kla6htnil-Dy-1
City: itg State: _IA Zip: i3b0 I
3. Telephone Number:
(6/03) 3b4-1- -7540
4. Date of Incident: 1 q [WO
5. Time of Incident:
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6. Location of Incident (Be specific): diothtnct the
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7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If a City employee was involved, give the
employee's name.)
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9. Give name and address of any witnesses:
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10. Did police investigate? (If so, give names of officers.)
11. Was anyone Injured? give nam
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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.)
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13. What other damages do you claim, if any?
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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.)
15. hat a ount do you claim fro the�City Qf Dubu ? LAV'4 (Pc n
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16. Whry
do you claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) ino
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
Dated at Dubuque, Iowa this " I day of ..I1 , 20 aP
V3rst
CtPuPet
(Rev. 5/18)
(Signature)
(Print Name)
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. 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 violate state and federal
restrictions.
Confidential information may include the following:
1) Social Security Number(s)
2) Medical/Health Information
3) Personnel/Disciplinary Information
4) Bank Account Information
5) Financial Information
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
information that is included.
include the folio protected information:
9
Social Security Number(s)
Medical/Health Information
Personnel/Disciplinary Information
, hereby certify that the attached documents
Bank Account Information
Financial 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
protect my information from unnecessary distribution.
J21,11
Signature
Date
Copyrighted
April 20, 2020
City of Dubuque Consent Items # 3.
ITEM TITLE: Disposition of Claims
SUMMARY: City Attorney advising that the following claims have been
referred to Public Entity Risk Services of Iowa, the agent
for the Iowa Communities Assurance Pool: Tanya Anglin
for personal injury and Brien Mohlis for vehicle damage.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Concur
ATTACHMENTS:
Description Type
I CAP Referrals Staff Memo
THE CITY OF
UB F
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
MEMO
To: Mayor Roy D. Buol and
Members of the City Council
Dubuque
**
All -America City
NVII NAL(1 CIPAid'�
I 1
I
2007*2012*2013
2017*2019
DATE: April 13, 2020
RE: Claim Against the City of Dubuque by Tanya Anglin
Claimant Date of Claim Date of Loss Nature of Claim
Tanya Anglin 04/13/20 02/19/20 Personal Injury
This is a claim in which claimant alleges that she was injured after slipping on an icy alley
located between Locust and Main Streets, near 8th Street.
This claim has been referred to the Iowa Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager
John Klostermann, Public Works Director
Tanya Anglin
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944
TELEPHONE (563) 583-4113 / FAx (563) 583-1040 / EMAIL tsteckle@cityofdubuque.org