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Claim by Black Hills Energy Copyrig hted November 16, 2020 City of Dubuque Consent Items # 2. City Council Meeting ITEM TITLE: Notice of Claims and Suits SUM MARY: Black Hills Energy for property damage; Mackenzie Weber for vehicle damage; Michael J. Vondal forvehicle damage. SUGGESTED Suggested Disposition: Receive and File; Referto CityAttorney DISPOSITION: ATTACHMENTS: Description Type Claim by Black Hills Energy Supporting Documentation Claim by Mackenzie Weber Supporting Documentation Claim by Michael J. Vondal Staff Memo \ � �� .K1��,� CLAIM AGAINST THE CITY OF DUBUQUE, IOWA This written report constitutes your claim against the City of Dubuque, lowa. 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. 13'" St., Dubuque, IA 52001. It will then be referred by the City Counci{ 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: ��,a,c.k' �� LG.1" F�l.t�r� �..�r 2. Address: ��' �a x �o��/ City: ��k-p raL C� State: S � Zip:S��' ��/ 3. Telephone Number: ��' $�lcb - SSS� 4. Date of Incident: � �s� ' Z O�.Q 5. Time of Incident: � • 3 �'1 �M 6. Location of Incident (Be specific): ��/ � ,�Y,/l �c �'� �' �" �� 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 employse's name.) C �� c Cx3a�-k'S LJ"�S �•.s rry �! C��i.fi r"t�"�0 4c�..,c ---t- G. o,vf .ri» ___— �;.-4' �Q s s�.ry�� L�+�..,P e,p�.►-e� -s� .� �'? � o�'rt o�r-Y .oc-a �- 8. What were weather conditions like? ��y'' � 9. Give name and address of any witnesses: 10. Did police investigate? (If so, give names of officers.) .�1/c� 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). /�c7 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.) oNc,� �-,�u � ,� G.rrs L..�,� 13. What other damages do you claim, if any? �c��'� 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.) uo 15. What amount do you ciaim from the City of Dubuque? � � •�, �►?�/ . 2!0 16. Why do you claim the City of Dubuque is responsible? / ,r- �/G�V' �,v' .�rr>1`r'�'1�f�6�/ts�:►.�'��i�s/' 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 yes, have you received any payment from that source, and if so, in what amount? Dated at Dubuque, lowa this�day of �� t,te�,�rer , 20 Z-�? �� Si nature ( 9 ) ��' �� L-�c,. (Print Name) r� ,:� �� t1�� •-� � �G.� V - /''''�+ i� � � l . ( F"'.'1 -- CD � J ;�; �: � r�'l 9 (Rev. 5/18) :�; � � � �.., "�' j I' _'z '� C� �~l � q CD � 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) Financiallnformation 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. !, �eS�. ��..- L-f-� _ , hereby certify that the attached documents include the following protected nformation� Social Security Number(s) Bank Account Information Medical/Health Information Financial Information Personnel/Disciplinary 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. �� Sig Date � .— Biack Hilis Energy PO Box 6001 � Rapid City, SD 57709-6001 � �t�r� �Y Phone: 888-890-5554 R61dy October 27, 2020 Dear City Of Dubuque, As of the date of this letter,you have not paid the amount billed to you for company property damages. Immediate actian is required to avoid legal activity, if you do not pay the outstanding amount listed below,we will proceed with referring this to aur legal department, and you may be liable far any associated legal fees. Notice date: 10l27/2020 Due date: IMMEQIATEI�Y Account number:9532 9360 69 � Service Address: � Last paymeni date: �6/04/202q � Last paymen#amount: $1,088.87 Outstandina amount: $3,601.26 To avoid legal activity, please submit the payment immediately at blackhilisenergy.cQm/pav or cali us at 888-890-5554. Sincere►y, Black Hilis Energy Customer Service � i � � � € � [ � --------------------------------------------< Detach and mail the bottom portion with your payment.>------------------------------------------------------- _ _ _ = Fo sax eoo� RAPID CITY SD 57709-6001 ** p p S T D U E N O T 1 C E ** ' s��s�y Ready �• +�4 Account Number Rue Date Amount Due �� 4� " � 9532 9360 69 IMMEQIATELY $3,601.26 CITY OF DUBUQUE � � ` .; �� 925 KERPER CT DUBUQtJE IA 52001-2405 � BLACK HILLS ENERGY PO BOX 6001 RAPID CITY, SD 57709-6001 ' 95329360b900Q0036Q126QQQ�03bQ12683032815220605 3rd_pariy2 Copyrig hted November 16, 2020 City of Dubuque Consent Items # 3. City Council Meeting ITEM TITLE: Disposition of Claims SUMMARY: CityAttorneyadvising thatthe following claims have been referred to Public Entity Risk Services of lowa, the agent forthe lowa Communities Assurance Pool: Black Hills Energy for property damage, MacKenzie Weber for Vehicle Damage, Michael J. Vondal for Vehicle Damage. SUGGESTED Suggested Disposition: Receive and File; Concur DISPOSITION: ATTACHMENTS: Description Type I CAP Referral Staff Memo � Dubuque THE CITY C7F � �Ae'„ Ail•A.eeica City � �rr� � � wc�xbwv.cavicuaxxn: - ,'�� '•r Maste iece on the Missassi i 2oo�.zo�z.zo�3 ; �"p pp zo17*zoi� �; � TRACEY STECKLEIN i PARALEGAL I MEMO i To: Mayor Roy D. Buol and ;� Members of the City Council � II „ DATE: November 4, 2020 i�i RE: Claim Against the City of Dubuque by Black Hills Energy ,� Claimant Date of Claim Date of Loss Nature of Claim I'I �V Black Hills Energy 11/04/20 08/06/20 Property Damage '�� I� This is a claim in which claimant alleges that Public Works staff were digging for curb � replacement and hit a gas service line going to 3871 Andrea Street. � I� This claim has been referred to the lowa Communities Assurance Pool. � cc: Michael C. Van Milligen, City Manager � John Klostermann, Public Works Director � Jeff Welty, �lack Fiills Energy � � � � � 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 �