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Claim by Jong Cosgrove Copyrig hted December 7, 2020 City of Dubuque Consent Items # 2. City Council Meeting ITEM TITLE: Notice of Claims and Suits SUM MARY: Jong Cosgrove for vehicle damage; Leland Mobley for vehicle damage; Geraldine Skahill for property damage. SUGGESTED Suggested Disposition: Receive and File; Referto CityAttorney DISPOSITION: ATTACHMENTS: Description Type Claim by Jong Cosgrove Supporting Documentation Claim by Jong Cosgrove received 11/30 Supporting Documentation Claim by Leland Mobley Supporting Documentation Claim by Geraldine Skahill Supporting Documentation ��e�� I �i� � , � �'ol�s�e.�'��o,� 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. 13t" 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 O��ILL NOT BE PAID. �� 1. Name of Claimant: ^� � `� ' iY � . � � � 2. �►ddress: � 6� P� � . . I� � A City: '�;,�� G�'� State: ��... Zip; � � � � 3. Telephone Number: � �.�� ` � � � �� 4. Date of Incident: � `°� `� r--� r� ��. t'� �� • .� �� 5. Time of Incident: � � u ��°' � 6. Location of Incident (Be specific): �. .�i � �� 1�'� �� y 7. DESC �I IBE 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 nam�) �� v � �.S ��Ut, if I ��'�'? � � ' �� g T i ��E`� r��:��.D `�'h� � �� C� �'ir� �r �,l �� L,: �� . � �� `i� � ��',fJ�� J / � � 8. What were weather conditions like? �! �: �'i�' �l L� `f � �' �� ``� � i 9. Give name and address of any witnesses: �'�� 1�" 10. Did police investigate? (If so, give names of officers.) d I 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). � � � �`� (� iVlr�' . l�ll �i� ,� 1� , 'l� Y 'C �, I� � , � Y �. /0'� �� ', �`Y'� t� � C� � . � � � �.��t ,�� -��' c� �� ' � i� �� , .� � � �. . � � � �� , � �1� � ; �� . � : �� ,� a'� ��-� S , ,° � �� .�- �� ;� � � �� , ,,�� 1 ��.��,�.- �, . � � � � , � �� --�� N � ��, r �� w - �, �� l � � � � � � � �c�� , � , . � � �..�"� 1��'�, � �� ! .� I� -�� l,� �� "j � S � � � � ; � � � c� , � - �- ��' � � ��r� i � �� ` M � _ � � � . r � � y 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.) , � N, �_ , '�,i � � F�� %`�_ � � r �� . �L� ��' � • ,�� r°� � ��, �� (� �-�' � �Q� '�,.��{,� �,�� - �,. t�,,�. � �� Z�(��' �� h 13. What other damages do you claim, if any? �'�2 ' � I 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.) I�a �� ,, 5. ha amount do you claim from t e City of Dubuque? �°'^ ° '� I ` � �� ,� r �-� �- � e�t`�� w. � � ��- ;; 1 . �1.��`� �C�+�� -� � �' �� . � ��k�. G��` G�h �jC��. ;j(� lf�'iy�'�'/-- '';i y do you clai the City of D buque is e�pa eb e? , `� ` � ii' ` �� - ,,� �/ , " �� -✓s�v? �' ` t,d� �' C� �!� " , � 17. Have you made any claim against anyone else for damages as a result of this incident? � (If yes, give name and address.) �� ii 18. If the answer to Question 17 is yes, have you received any payment from that source, �� and if so, in what amount? ��j ii �,� m r. ;� / ' ��-�.�,�,. � � , � — �� -- d � ' � �'� 1 Dated atp��b�q��e;I�o� this � � day of Q�`�'�- , 20�. j� �� ,� � a �i � ' �` , d (Signature) o �� `�1.'�� ,�'� �"��' (Print Name) �:.�`�~� � � �= ; � �:'' � `�`� � � � E� �;;- � � �r� � � n�� (Rev. 5/18) � � � � , '� � � � � , , � � i 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 i restrictions. Confidential information may include the following: 1) Social Security Number(s) 2) Medical/Health Information � 3) PersonneliDiscipiinary Information ; 4) Bank Account Information ' 5) Financiallnformation � ti 6) Crecl�# Car� �l�rnbers � :, ,', If any documentation you desire to submit to the City of Dubuque contains any of the item� above ! this cover sheet must be attached directly to the confidential information and indicate the type of ',! information that is included. `i � �,._.-. n� � I, � `�, �'l�' , hereby certify that the attached documents include th Ilowing protected ir�formation: Social Securit Number s Bank Account Information I� Y O � Medical/Health Information Financial Information � � � Personnel/Disciplinary Information Credit Card Number(s) r � , � 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. ;� � l � � ,�� l� Signatu � Date � � � � � � d � I �� i L��' � J �I�st�.rn�S�n�P � CLAIM AGAINST THE CITY OF DUBUQUE, IOWA i� �, ��a.�.�— �� This written report constifiutes your claim against the City of Dubuque, lowa. You should ', �I complete this form in full and attach any additional information that supports your claim. , i� 1 The Claim must be filed with the City Clerk at City Hall, 50 W. 13t" 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 wi#h a copy of that report and recommendation. j; �� I; THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF 'I THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU j AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. ��i �� i 1. Name of Claimant: �� " �� 2. Address: � a � State: �1✓� �ip: � � � ', City: '' � , 3. Telephone Number: � � .) . �� r.�� '' !i 4. Date of Incident: �'� l � �c� �-� 5. Time of Incident: � � � �'e d�l r f��D . � ; 6. Location of Incident (Be specific): � �- � � � �`""` a � „ � �I � I� 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give EIi full details upon which you base your claim. If a City employee was involved, give the �; ,;. employee's name.) I� �.�„� � � �°'� � �� ' �� a �, � � � -- =� � � �� 4 a. V1ihat were weather condifiions like. � r�� w� � � � 9. Give name and address of any witnesses: � .,� � I, ,, 10. Did police investigate? (If so, give names of officers.) � a ) I �7�- ��. � � �- �l I✓' 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). � R � / 1 �., v �./ �� < � � ��`�- V"�� t.l G�t'' �✓l � i �l � i"�'L U �� 1 � �I � � � �� J � � � � F { I ;� � S� � � ..� � � ��G�� 1�� -�-� ��.r � Gc �- � � � e � i ) ^1� � � w•2 �' 1� � ''�1. � �-f � d r�-e t�- ff v� �-�- � �'" � �t. �-2. � ;l �` � � � � � , t �. �� S �l "r� I� �`"v � r .� �� 1�-` �.C-Q �. �Y � y � �` � �' � > � ; p / �- � �� . v� �-�� ,� � �� c� c� �( C�t. C.� [ G � L `� �� , � , r �-� e�c � ; s �� 5 � �� u �,� � � � !' �� ,��r�,, ��5 �, �'�- � � � � �� `�� , �U� � . ';� �� .� � � � � �� ;,,I ,, �� ; �� , ,, �� i i � i� � l � � � � u � � � i � � � 6 @ � � 0 :� 9 ill i� I�, 12. Was an dama e done to ro ert If so, describe ro ert and the extent of �' Y � p p Y� � p p Y damages. Attach estimates of damages or describe basis for ascertaining extent of � damage.) i � �li �e^Uw`� r� � " y� !f Y� � �J�'✓� � �" ��?�;: u 7 ,�. �� 7 �i e � 1 � = 7`� � �--�J� �" _ � , ;i 13. What other damages do you claim, if any? `�� ' ; , I�li 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.) ��` � ? I�Ir 15 What amo nt do you laim fro the City of Dubuqu . � (� G�, �' ►'� - ��r �-,. , �: 16. 1IVhy do you clai the City of D buque is responsible? ��] t�� r� � � �� "� V'CJ � l v � E-' �-�C=�r � � �; 17. Have you made any claim against anyone else for dama�s as a result of this incident? ; (If yes, give name and address.) I; �� ; �i 18. If the answer to Question 17 is yes, have you received any payment from that source, I' and ifi so, in what amount? li �' �� 1�� L�� f�/ ! � Dated at uqu , o� a this �day of l��"��°�'" C� , 20 �-� � ;� ,; �i i� � � � � �� -- (Signat�r�) � �� I �'� (Print Name) _�,� � � �� :.. c� � � �,� �- � � �" � � ° � � � � � (Rev. 5/18) c�i� � I, � � � � � � 5 i !� �, il r I�! Confidential " ;i 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 j error, and that any review, disclosure, dissemination, distribution or copying of its contents j 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. �� ; ;1, Confidential information may include the following: ;�� 1) Social Security Number(s) '! 2) Medical/Health Information �� 3) Personnel/Disciplinary Information `� 4) Bank Account Information 9 5) Financiallnformation 6) Credit Card Numbers � u G 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, �� , hereby certify that the attached documents �; include the �"(o lowing pr tected information: j; i; � Social Security Number(s) Bank Account Information " F Medical/Health Information Financial Information I; , Personn�l/Disciplinary Infiormation Credit Card Number(s) �I � f 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 k� protect my information from unnecessary distribution. k i, � � � l ��1�� ' Signature Date � � � �� a � � � � � � I � r Copyrig hted December 7, 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: Jong Cosgrove for vehicle damage; Leland Mobley for vehicle damage; Geraldine Skahill for property damage. SUGGESTED Suggested Disposition: Receive and File; Concur DISPOSITION: ATTACHMENTS: Description Type ICAP Referral Supporting Documentation Dubuque THE CITY OF � D All•Aeerica City UB E ,�,,..Y ��.,r 'I 1,► � � Maste iece on the Mississi i zoo�.zoiz•zoi3 rP pp zoi�*Zoi9 TRACEY STECKLEIN )��' PARALEGAL MEMO To: Mayor Roy D. Buol and Members of the City Council DATE: November 30, 2020 RE: Claim Against the City of Dubuque by Jong Cosgrove Claimant Date of Claim Date of Loss Nature of Claim Jong Cosgrove 11/23/20 11/03/20 Vehicle Damage This is a claim in which claimant alleges that as he was traveling southbound on US HWY 52-61-151 near the Main & Jones Street intersection, the driver of a City of Dubuque street cleaning truck attempted to change lanes and struck claimant's vehicle. This claim has been referred to the lowa Communities Assurance Pool. cc: Michael C. Van Milligen, City Manager John Klostermann, Public Works Director Jong Cosgrove OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 TE�EPHONE (563)583-4113/F�c (563)583-1040/EMAi� tsteckle@cityofdubuque.org