Claim by Drew Waller Copyrighted
April 19, 2021
City of Dubuque Consent Items # 2.
City Council Meeting
ITEM TITLE: Notice of Claims and Suits
SUM MARY: Kyle Fitzgerald for vehicle damage; Jenny Rouse for property damage;
Drew Waller for vehicle damage.
SUGGESTED Suggested Disposition: Receive and File; Referto CityAttorney
DISPOSITION:
ATTACHMENTS:
Description Type
Claim by Kyle Fitzgerald Supporting Documentation
Claim by Jenny Rouse Supporting Documentation
Claim by Drew Waller Supporting Documentation
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 immedlately 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: �I'
I
�
1) Social Security Number(s) C
�
2� Nfedical/Nealth Inforrraation
3) Personnel/Disciplinary Information
4) Bank Account Information I�
5) Financiallnformation i
6) Credit Card Numbers h
Il
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, Drew Waller , hereby certify that the attached
. documents include the following protected information:
Social Security Number(s) Bank Account Information
MedicaVHealth Information x Financial Information
�
Personnel/Disciplinary Information _x 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.
� M _ _ 3/4/2021
Signature Date
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 OR WILL NOT BE PAID.
1. Name of Claimant: Drew Waller
2. Address: 2595 Wilbricht Ln
City: Dubuc�ue State: IA Zip: 52001 ,
3. Telephone Number: 563-564-9098 I�
4. Date of Incident: 3/2/2021 j
I
5. Time of Incident: 4:10 pm �
6. Location of Incident (Be specific): Chavenell Rd between Metrix And Rite Hite on the ,
east bound lane . The pot hole is near the center line �
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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
empfoyee's name.) While driving home Tuesday 3/2/2021. I pulled out of AY McDonald
heading east on Chavenelle between Metrix and Rite Hite in the inside lane near the
center line I hit a pot hole that caused a piece of concrete to come up and puncture a
hole in the side wall of my tire
8. What were weather conditions like? Sunnv and warm
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.) no
11. Was anyone injured? (If so, give names, addresses, and extent of injuries). no
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.) Yes
the sidewall of my tire was punctured causing it to be unrepairable
13. What other damages do you claim, if any? $109.14Tire $83.00 disposal $3.00 and
$16.00 for install and $7.14 for tax
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.) no
15. What amount do you claim from the City of Dubuque? $109.14 ,
16. Why do you claim the City of Dubuque is responsible? This stretch of Chavenelle is �
always in bad shape . ;
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17. Have you made any claim against anyone else for damages as a result of this incident?
�;
(If yes, give name and address.) ,
1�. If th� �r�sRr✓�r;to Q���ti�� 17 is y�s, ha�� you received any.payment from that source,
and if so, in what amount? no
Dated at Dubuque, lowa this 4 day of March , 20 21
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Copyrighted
April 19, 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 for the lowa Communities
Assurance Pool: Kyle Fitzgerald for vehicle damage; Jenny Rouse for
property damage; Drew Waller for vehicle damage.
SUGGESTED Suggested Disposition: Receive and File; Concur
DISPOSITION:
ATTACHMENTS:
Description Type
ICAP Referral Supporting Documentation
THE CSTY OF
DuB E � � � o p � H a � �
Masterpiece on the Mississippi
JONI MEDINGER
LEGAL ADMINISTRATIVE ASSISTANT
To: Mayor Roy D. Buol and
Members of the City Council
DATE: 4/2/2021
RE: Claim Against the City of Dubuque by Drew Waller
Claimant Date of Claim Date of Incident Nature of Claim
Drew Waller 3/4/2021 3/2/2021 Vehicle Damage
This is a claim in which claimant alleges claimant's vehicle was damaged when they
struck a pothole on Chavenelle Road.
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
Drew Waller
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944
TE�EPHONE (563)589-4113/Fax (563)583-1040/EMai� jmedinge@cityofdubuque.org