Claim by Clyde Kay Copyrig hted
April 5, 2021
City of Dubuque Consent Items # 2.
City Council Meeting
ITEM TITLE: Notice of Claims and Suits
SUM MARY: Clyde Kay for vehicle damage, Jaylin I nc. for property damage.
SUGGESTED Suggested Disposition: Receive and File; Referto CityAttorney
DISPOSITION:
ATTACHMENTS:
Description Type
Claim by Clyde Kay Supporting Documentation
Claim by Jaylin Inc. Supporting Documentation
�'9W�
�����
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA J KJos�-�a�m��
P�, �w,��- 'I
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 I
City Council. You will be provided with a copy of that report and recommendation.
,
1
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 ��� )�� ,
1. Name of Claimant: i
2. Address: D �� ���( �1�� . '�
City: �w� State: �� Zip: �� � � i
1
�� 3--�'���-�-9�./ �
3. Telephone Number: I
4. Date of Incident: �-� '"' ,��"! �-- � i
i
5. Time of Incident: ��'E i
,
il
( p ) �1�� ����� �
6. Location of Incident Be s ecific : ',;
,�
,�
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.)
J �
� � J�' /��� 6�✓'ts' I'1/��'!�l��
b
8. 1�h�#��a�r� a�,��ath�r �Qr��s��oras Isk�? ����
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
�/ � f��. 1l1��,�C ��1�/� �
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
��
i
�
�
�
u
12. Was any damage done to property? (If so, describe property and the extent of I�
damages. Attach estimates of damages or describe basis for ascertaining extent of �'
damage.) �
����� ����� ������ ,'�I
�
�1
,� �I
13. What other damages do you claim, if any? .�'C��d � !
�)
i
��
14. Have you been compensated for 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� � I
��
-- - . „
15. What amount do you claim from the City of Dubuque? ;
��� D �� r
1
;,
16. Why do you claim the Cit of Dub que is responsible? ''
��� � i �r� i
I�
i
17. Have you made any claim against an one else for damages as a result of this incident? 'j
(If yes, give name and address.) � I;
:�
���
18. If the answer to Question 17 is yes, have you received any payment from that source, �
and if so, in what amount? � �
,��� '�
�
n
Dated at Dubuque, lowa this day of � , 2p��
�
�
�_(Signature)
� (Print Name) , n..,�
�� W.Mb
��`�" �� :.�:r
�-� �:� ;�-��: �
� �^�;� 4°�� r°�; �
� c.r� a_ ..
� �� � �� �
(Rev. 5/18) A t�' �+�� R�°
.. � �� �',
{� ���
r�,�
�
� .
�--��
Z�_�� � �--'4'�'Yy� . +C3-z.iSvS �?2:.3 � �V ��3§i���3 �3.J. �.
I-� � � ����-r'""� ��i-��'i :!
�.9ti.�[��. �:�`'�,' ,_�j'�7 � � �' � �vi�v�,iti,�� 3L1YYN �,GUUL . ,�.'
s -- 5�3 �83-578�
r^.,: � _,�.,T ,; ���� �' {�8�i3�7�7'-422�
��,n���;'
� _ ,. _
y . .
,� �� ��,�:>.
�-�,x �
N ANI� {•' , G'"/.C_.:'.. '. ��
DATE � �� �
�.�.... �
'1'��R �� �—j� 1�1BLAG� � �
�
,
�'iAKE �G+�w"1 ADVIS�R i'�
#�',OD�L / ) L����-i/(' TECHt�!1ClAP� '�`'`"_ �
. �
I�ES+CRlPT10N lJ.B�R PARTS TOTAL � I
�
s
� 5?�� 3ac��� �i
- - �
I
;
;
�j
�i
,,.
�
� il
�
�
�
,�
�
�l
. � �
�
�
_ �
�
��
.
. � �
SUB TflTAt �`?�• S� �
TAX �
z���� �d 3.�f3 �
�
�
Copyrig hted
April 5, 2021
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: Clyde Kay for vehicle damage, Jaylin I nc. for property
damage.
SUGGESTED Suggested Disposition: Receive and File; Concur
DISPOSITION:
ATTACHMENTS:
Description Type
ICAP Referral Supporting Documentation
THE CTTY OF
DUB E MEMORANDUM
Masterpiece on the Mississzppi
� ONI MEDINGER
LEGAL ADMINISTRATIVE ASSISTANT
To: Mayor Roy D. Buol and
Members of the City Council
DATE: 3/25/2021
RE: Claim Against the City of Dubuque by Clyde Kay
Claimant Date of Claim Date of Incident Nature of Claim
Clyde Kay 3/8/2021 2/12/2021 Vehicle Damage
This is a claim in which claimant alleges claimant's vehicle was struck by a City snow
plow.
This claim has been referred to Public Entity Risk Services of lowa, the agent for the lowa
Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager
John Klostermann, Public Works Director
Clyde Kay
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 3OO MAIN STREET DUBUQUE, IA 52001-6944
TE�EPHONE (563)589-4113/Fax (563)583-1040/EMai� jmedinge@cityofdubuque.org