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Claim by MacKenzie Weber 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 �� . ��-� CLAIM AGAINST THE CITY OF DUBUQUE, IOWA � , F�� 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. 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: ��_�,�� t�i�' � ��- � 2. Address: �� 1,��..i'��,,`�� . G� � �., �i '� City: � „�� State: ,� Zip: � �� 3. Telephone Number: ��.�t��'�O�� I�� 4. Date of Incident: �� ' � � 5. Time of Incident: �v �� C�„1"'� I't �� A�� , 6. Location of Incident (Be specific). � °'d��'�� '' I! I 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give i full details upon which you base your claim. If a City employee was involved, give the ' employee's name.)�� . ^�`�� a�`s4J� �� "�� r .r�. / ` �°�+'�� . L�� , _ 8. What were weather conditions like? �� 9. Give name and address of any witnesses: �f,��$.,`�� '�~`�� 10. Did police investigate? (If so, give names of officers.) . Q.,�� 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). � � i i I , � � 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.) �1� � ��.Y" i � � f � � 13. What other damages do you claim, if any? �� u' � � �� '��I �� ,; 14. Have you been compensated fior 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', u �� '��, �i 15. What amount do you claim from the City of Dubuque? I' f � � l � o � � 'i !a 16. Why do you claim the City of Dubuque is responsible?�'�`� � �� ; 'i � 17. Have you made any claim �gainst anyone else for damages as a result of this incident? ! (If yes, give name and address.) � I� � i �� '18. !f 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 thi� d�y �f I t -�-� , '9� , ��J...� �'�� (Signature) � ��( � �� .�, � V I (�rint Name) ��-�:: �, � � � � �� t� � �_ ., � (Rev. 5/18) ; � .;,� 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 !'I error, and that any review, disclosure, dissemination, distribution or copying of its contents � is prohibited. Please notify City of Dubuque immed�ately by telephone at (563)-589-4120 of '� your receipt of these items and destroy the `�.ommunication and any attachments u immediately. Further disclosure of this information may violate state and federal restrictions. � 7 � Confidential information may include the following: � � � � �i 1) Social Security Number(s) �i 2) Medical/Health Information ; 3) Personnel/Disciplinary Information i 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. ' � , I, ��''G � `�./ , hereby certify that the attached documents include the following protected information: Social Security Number(s) Bank Account Information Medical/Health Information Financial Information P�r�onr��!/Di��iplinary lnformatio� Cre�it Card Nur��er(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. F�F � ��!- � r � F � � � �. � Signature Date � HA:i�""�" �.�T`t� B OL�"� � �',��T �A�� E�Q�T ��1t7�EI��R��C>�S Itl7� L7T_T�U�Q�,ItJ'�`A��3 � p�ic� sus��tr �a c�t��a�� p�Qp�j�:��.{�� -Qr'3�� ''�: (�JC33}.�3J`�fY^�� ou oPPCtti0tl�ert not Rart M titiS�C1#�tri. N HARTAUTOBODY@AOL.COM � VE 1C4E OWMEF� ADdRESS PHq NE DATE � ,�trS �-i w�L ��(r Slt3 - S7S0 - �tKKf �D -- �9-� � y�{� �r t+j�l p ��m�: UCENSE MILEAGE &�Lp SERIftL.NI�. CQ iS#T6S7t� l {NSURANCE .4? ADJUST�Ft' PHCs � CAR LOCAT�D A : pEDUCTIBLE � � Sublet Serviae; Suhiet Sarvica; Su4iet Secrice; Cf a ��Q� Qr Paini pr Hours Parta Sym. �+�� flr Paint Or Hours Pae't� SY+n• ��H� Or Paint Or Hoota �cb 9 Bumper WIPad� � , render� FrY., _ Fender,Frt. i Bumper Rhs, ander Shitid .'j+.`/!` Fender Shield � Fender Ext. Fender Fact. i Fender MIdS. 5ide Fender Mldg. SFde ' � Fender Stripe fendtr St�ipe j Fender Midg. Fender Mid: ;I Sumper Reiaf, � � �d I , y 8umper 8rkt. Slde�EY Z,,{ Side Light AS�rtb1 u Bumper Cushian Htadiamp Headiam , �� r Valance Headlamp t�aar Headlamp [3t�, '� Svmper G�. Seafed Bearrt Sealed 9es�m i� Prt.S ste�r Patk Liqht Park Light l; Frame Cmwf . _ Cuwi �i Cross Membet� Door,fraa�t Daor,.Pro�# _ �i yVhte; Daar Hin6e Door Hin�e � Hub Ca bi��; Door Pane! Donr Panet j�, Lr.Gont Atr�rt Door Stripe Doar Stripe �' OC�qr Mid6s, 6aor Midg, ii Up.C�anR, Atrra i, r Center Pust" . Center Past '� Door Rear Dnof Re�rt , 9umPer filiet _ Daor Mtdg. _ boor Midg. _ _ ;i Griile � Griile i'enal _�<✓✓ !�� _ Grii!Qan�!f�!4d�, RacM1cer Pangi Racker Pan�i �, �� Rocker Midgo _ Rocker t�41dg, i Ffoar Floor i _ _ � DoS�e$ Dog leg : I (luaf.Panel Quar.Panel _ Air Gondenser Quar. E�ct� _ tivar. Eact.. Recharge SysC�rn . Quxr.Wheel House quar.Wheei Hous�; Name Plate 4uar, Mldg.5id� _ . Quar.Midg.5ide _ _ _ Baff�e,Up er Quar.Midg, quar.Nlid�; Losk Plate, Lr. Quar.5trip� Quar.Stripe Lock Plate. !i , : Side Cighi A�mks1 Side Light Asmbly � Hood Tp Tai1 Light Tail Ligfit Hood HitiSe: �i�i� ��CJ�i, - Hood L.oc#� BumPer lnst. Panei _ Ornamenk BumFer Abs, : Frant Seat Rad. Sup. 9umPer Cushibn Front Scat Ad!«, Rad. Core BumPer Reirst. Top Anti �resx9 Eumper BeKt. Headlinin�. Rad. Hoses Bumper Gd„ _ Top Yinyl Fan 81ade BumPer Fil#ew Tire %War�i Fan She�rud Valance Paintin � Fan Beft Lowar Pane� Aerial ,�__.,.�,�... �� Water PumP Floor Rust Pt'� Wster Pump Puiley Trunk Lid Flatt�s'y� _ Motor Mtse 7runf� Mldg, _ EPA WASTE D15POSAL C�-lARGE . � ��. �-4g�t PAR7S iPrices Subject To invoTtx) Z-f(�9,v - _ s�Rva��s R/t��s.@ ��, � windsn�eid cas i°antc PIlINT-MATRL-HDW � T� l� frame Whcei __ Mub&�rut� _ _ ,.. ,. A�tie _ SPring _ GRAND TOTAt, _ O ��' �kppraisar X _ -.,.._ e�_ua,., ng.onen P-F'aln# 1 HfR�BI'AiJTN£�}31Z�T�°IE,ASOVE REPAIR$ • KC's Downtown Auto �nvo��%e 205 Locust Street Dubuque Ia 52001 Date Invoice# 563-583-3190 ai22i2o2o 33731 Bi II To Weber Susan 580-6441 P.O. No. Terms Due Date Rep Year Model Mileage I Due on receipt 9/22/2020 k Kia � Item . Description Qty Amount 7051226 HOS/Clamp 4 5.96 MVATF. Pro Per.Trans Fluid 1 4.99 ' H1937 Power steering Hose ;1 10.99 �' 2000 Repair power steering cooler line 1.3 84.50 � Sales Tax 7.45 I � � . • � , t f �( 1� �°�' �; �� Thank you for your business. T�ta� $ll 3.89 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 CI'T'Y O� ��,.. Ali•Itaie�Ci� � �y/ � �- PWF?4LLqV1Cll'N.AH' , ��f�•i � 2Q07*2012•2013 ;� Masterpiece on the Mississippi zo1�*2019 ; � � TRACEY STECKLEIN 1 PARALEGAL ; I MEMO �� ( To: Mayor Roy D. Buol and ;� Members of the City Council ', i DAre: November 9, 2020 �' 'i RE: Claim Against the City of Dubuque by MacKenzie Weber "� ,I �i Claimant Date of Claim Date of Loss Nature of Clairn ;� ; MacKenzie Weber 11/09/20 08/23/20 Vehicle Damage i1 ij This is a claim in which claimant that her vehicle was damaged when a tree limb fell onto '; her vehicle on South Grandview Avenue near Adeline Street, and then claimant drove ';� over the limb. �,� N a This claim has been referred to the lowa Communities Assurance Pool. � � cc: Michael C. Van Milligen, City Manager � Tom Kramer, Urban Forester r Mark Dalsing, Chief of Police � MacKenzie Weber �4 � , 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 a d �