Notice of Claims and SuitsCopyrighted
May 4, 2020
City of Dubuque Consent Items # 2.
ITEM TITLE: Notice of Claims and Suits
SUMMARY: CEI ASO Syneos Health on behalf of Karl Devoto.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Refer to City
Attorney
ATTACHMENTS:
Description
CEI ASO Syneos Health (Devoto) Claim
Type
Supporting Documentation
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: SSC S c j (l eC }-� eco fh
2. Address:
Lq5-0 Sfreck \ciCA4
SLA 4e
City: lre,V cSe. State: \ A Zip: i d(S?)
3. Telephone Number:h
4. Date of Incident: 1 i 25 !'
5. Time of Incident: 1
6. Location of Incident (Be specific): t -CtS i--
e, 11`"tptvv^S r TLA 73Q3t3
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.)
i,tr i)t dr ru' r o e,r>ec:74-ton ),ir h61i)wr.L.9 ext.} (zt -Ede..
'ubtir 1 rcu-150r (Inver (eby-A Meiec) i.&)c&S e..omt n CyI- rose and eldr ftm. 6Acifp
mC ae (.c',•\;tt.(4- Lvi!�trk c ( c va.c CtuL \(x3 d(t.1 .sXccity� ft) k-rcnic k 6.11A r- drivers
8. What were weather conditions like? ; >\Th Qoa(i $ CA, -Pct vvec ii r
9. Give name and address of any witnesses: ic
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
:tic Ojt cm), co:\u(,€-S \ \s\ ,LA -,A*imp
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.)
front bumper and driver's side fender
See attached bills for total demands
13. What other damages do you claim, if any? N/A
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.)
her -
15. What amount do you claim from the City of Dubuque? $3,911.85
16. Why do you claim the City of Dubuque is responsible? _) i , (�
Oc nff:�r 'P.'1T LSS . +ec I'h (+JreLci ,Capc( v'�SCr t i; -v; rroV'Id 0 Nle. t�15 tory .
17. Have you made any claim against anyone else for damages as a result of this incident?
(If ves, give name and address.)
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
Dated al Trevose, PA this 14th day of Aril
20 20
-71 )ftj iJ"(_ \11 (Signature)
(Rev. 5/18)
,y 1
t t"U\.I\ii (Print Name)
rr
rn
0