Claim by Jennifer AveryCopyrighted
August 2, 2021
City of Dubuque Consent Items # 2.
City Council Meeting
ITEM TITLE: Notice of Claims and Suits
SUMMARY: Jennifer Avery for vehicle damage; Masud Hamid for personal injury;
Mark and Diane Link for property damage.
SUGGESTED Suggested Disposition: Receive and File; Refer to City Attorney
DISPOSITION:
ATTACHMENTS:
Description
Claim by Jennifer Avery
Claim by Masud Hamid
Claim by Mark and Diane Link
Type
Staff Memo
Supporting Documentation
Supporting Documentation
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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This written report constitutes your claim against the City of Dubuque, Iowa. 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. 131h 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: ac, M 0 1 (7-c-, 4?, D 0 C (2-1
2.
Address: I —A
_ F f2.b -ZffD
City: OA 11AA ) I
LUetl. State: Ok-0 Zip:
3.
Telephone Number:
- , Ci l - q 5qCi A ) LLJ-)
4.
Date of Incident: to
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5.
Time of Incident: 14 iLO
u 0 D P OCR �J
6.
Location of Incident (Ele
specific): ('fy j+ S 7R-Ee-1 �713t%fn
I�l_ L A,
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.)
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8.
What were weather co
ditions like? F L O t
9.
Give name and address
of any witnesses:
10.
Did police investigate?
(If so, give names of officers.)
N 1 LrEy -P
f-)-Ul_.S CO
11.
Was anyone injured?
(If so, give names, addresses, and extent of injuries).
l.1V
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12. Was any damagedone
to property? (If so, describe property and the extent of
damages. Attach estimates
of damages or describe basis for ascertaining extent of
damage.)
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A g a:1 D PoLk LC Q L-;Pt)2
13. What other damages
do you claim, if any? M 1 E
14. Have you been com
ensated for any part or all of your claim by any insurance
company? (If so, give name
and address of insurance company and amount paid.)
15. What amount do you claim
from the City of Dubuque?
-A1a� 16
16. Why do you claim the
City of Dubuque is responsible?
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p-W CAA,sG3 DP�'C�/CGC
17. Have you made any claim
against anyone else for damages as a result of this incident?
(If yes, give name and address.)
PC)
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, Iowa t
is day of 20
(Signature)
C(L-i (Print Name)
=,;,J 0
Y ` J t �_7
(Rev.5118)
D ro �
MOTIORCAM TOYOTA
■
Customers for Life.
2950 Mayfield Rd - Cleveland Heights, OH 44118
(216) 321-9100 - Fax: (216) 320-6910
AVERY, JENNIFER
1228 OXFORD ROAD
CLEVE HTS, OH 44121
SERVICE DEPARTMENT HOURS
7:30 a.m. to 3,00 a.m. Mon - Thur
7:30 a.m. to 6:00 p.m. Friday
8:00 a.m. to 4:00 p.m. Saturday
216-983-4959
216-297-9599
6/28/21 j 3242394/
1 " — •
Mileage In Mileage Out
!r 1• �
Service Advisor 1 Tag #
CURTIS O.
Vehicle Identification NumFe-r-
4TIBE32K95U627706
Delivery Dale In -Service bate
20051 TOYOTA CAMRY I _ l LUNAR MIST i CVH4990
DESCRIPTION OF r PARTS•
Cell: 216-983-4959 Email: JENNIFER.AVERY@UHHOSPITALS.ORG
##1 -- 10TOZ: MISCELLANEOUS
INSTALL LEFT SIDE VIEW MIRROR ASSEMBLY
Tech: Mike Bell (MB2) 140.00
Installed 87940-AA904 :MIRROR ASSY, OUTER R 1@199.73 j 199.73.
Installed MIRRORPAINT :PAINTED MIRROR CHARGE 1@98.00 j 98.00,
Replaced Drivers power mirror
Sub Total: 437.73
-__-------------------------------------------- ---------_...__:
I
#2 * 10TOZ: MISCELLANEOUS
ADDED OPERATION
RIGHT SIDE VIEW MTRROR ON R/F SEAT NEEDS TO GO TO
BODY SHOP TO BE PAINTED. * BILL HICKEY HANDLING * i
Sub Total: .00
----------------------------------------------------------------
Please Note: CREATED 2021-06--28 03:18:OOPM TAKEN BY PRECIOUS AN
DERSON I
* Service available to 3 AM Monday-Thurs- (4)
* Toyota Master Techs on staff w/ over 100 years of * t
* experience- Motorcars rated as the top rated Auto
* Business in Cleveland Hts for 2015 * '
l I
-ERMS: STRICTLY CASH UNLESS ARRANGEMENTS ARE MADE. " 1 hereby authorize the repair
i
I
LABOR
-
rork hereinafter to be done along with the necessary material and agree That you are not
- ,
PARTS
297.73:
esponsible for loss or damage to vehicle or articles left in the vehicle in case of fire. Ihefl, or any
I
0 0!
ther cause beyond your control or for any delays caused by unava!labiiity of parts or delays in
DEDUCTIBLE
arts shipments by the supplier or transporter. I hereby gran) you or your employees permission to
---------- -- - - --- -- --- -- -
'- -
00
Aerate the vehicle herein desalbetl on streets, highways, or elsewhere for the purpose of testing
SUBLET 1
- _---- ---- - - ._. .._
I
_...... .0
mrn
ndfor inspection. An express echat's lien is hereby acknowledged on above vehicle to secure
--- _..
SHOP SUPPLIES �' �l,
G
le amount of repairs thereto:'
-
0 2'
HAZARDOUS MATERIALS
-.
IISCLAIMER OF WARRANTIES. Any warranties on the products sold hereby are those made by
_ _
3 5 0 2
le manufacturer, The seller hereby expressly disclaims all warranties either express or implied.
SALES TAX OR TAX I.D. I-
icluding any implied warranty of merchantability or fitness for a particular purpose, and the seller
SPECIAL ORDER DEPOSIT
.00
neither assumes nor authorizes any other person to assume for it any liability in connection with the
0 0:
ale of said products. Any limitation contained herein does not apply where prohibited by law.
DISCOUNTS
'
Aiscellaneous shop supplieslcharges are an integral part of the repair of your motor vehicle. These
TOTAL DUE
4 72 - 7 5;
harges are to compensate dealer for malerWs or services not olherwtse included in the parts and
abor charges for your service visit. You will be charged 15% of your labor charge for those supplies
u Free Express Wash"
rith a maximum charge of 11B-154,
4MA _ ____EST
Treat this like cash
NO RETURN ON ELLUIKIUAL UK SAht I HEMS UK 5P1=1AAL UNULKS.
1B•
Cj
Driver Information Exchange Report
DUBUQUE POLICE DEPARTMENT
(563) 589-4410
Driver's Name - Last
First
Middle
Suffix
Age
Gender
U
BUSHMAN
TIMOTHY
MICHAEL
48
MALE
N
Address City State Zip Home/Coil Phone Number
1
7825 S WESTBROOK DR DUBUQUE IA 52002-0000 (563) 589-4197
T
CDL? Driver's license Number Class State Endorsements Restrictions Insurance Co. Name Insurance Co. Phone #
NO �945ZZ1006 B �IA P 1EM IOWA COMMUNITIES ASSURANCE (563)589-4100
001
Owner Company Name Insurance Policy #
CITY OF DUBUQUE 53
Owner's Name - Last First Middle Suffix
Address City
State
Zip
Vehicle. Configuration
50 W 13TH ST DUBUQUE
IA
52001
25
VIN No.
Year
Make Modei
Style
Color
1GB6G58L6B1144132
2011
CHEVROLET-CHE
CTB451226FC
BUS
GRN
License Plate #
State
Year
Most Damaged Area
Approximate Cost to Repair or Replace
118152
IA
2021
01 - FRONT PASSENGER SIDE CORNER
$600.00
Driver's Name - Last
First
Middle
Suffix Age
Gender
iJ
AVERY
JENNIFER
ANN
61
FEMALE
N
dress City State
Zip
Home/Cell Phone Number
i
�1228OXFORD RD CLEVELAND HTS OH
44121-0000
(330) 466-2666
T
CDL?
Driver's License Number State
Endorsements
Restrictions
Insurance Co. Name Insurance Co. Phone #
NO
rpia-
RN450893 OA
I
B
ALLSTATE (800) 255-7828
002
Insurance Policy#
Owner Company Name
826094126
Owner's Name - Last
First
Middle
Suffix
AVERY
JENNIFER
ANN
Address Clty
State
Zip
Vehicle Configuration
1228 OXFORD RD CLEVELAND
HTS OH
1441210000
01
{
VIN No.
Year
Make
Model
Style
Color
�SIL
4T1 BE32K95U627706
2005
TOYOTA - TOYT
CAMRY
4DR
!I
License Piate #
State
Year
Most Damaged Area
Approximate Cost to Repair or Replace
CVH4990
10H
2O21
10 - FRONT DRIVER SIDE
$1,000.00
County
jAccident occurred within corporate limits of (city)
DUBUQUE-31
IDUBUQUE-2100
Literal Description
MAIN ST
X-Coordinate Y-Coordinate
00691849 04707638
If accident occurred outside of city
Direction
Nearest City
Route (Cardinal)
limits show general vacinity:
of
Travel Direction
On Road, Street, or Highway: At
Intersection with:
Distance
Direction
Distance Direction
Milepost
Number
and
of
Or
Definable intersection, bridge, or railroad crossing
Officer
Badge No. Law Enforcement Case Number
Date of Accident
Time of Accident
OFFICER BAILEY PAULSEN
59 2021.004334
06125/2021
12:19 Hrs.
City of Dubuque
City Council Meeting
Consent Items # 3.
Copyrighted
August 2, 2021
ITEM TITLE: Disposition of Claims
SUMMARY: City Attorney advising that the following claims have been referred to
Public Entity Risk Services of Iowa, the agent for the Iowa Communities
Assurance Pool: Jennifer Avery for vehicle damage; Mark and Diane
Link for property damage.
SUGGESTED Suggested Disposition: Receive and File; Concur
DISPOSITION:
ATTACHMENTS:
Description
I CAP Referral
Type
Supporting Documentation
THE CITY OF
DUB E N N D H a
Masterpiece on the Mississippi
JONI MEDINGER
LEGAL ADMINISTRATIVE ASSISTANT
To: Mayor Roy D. Buol and
Members of the City Council
DATE: 7/29/2021
RE: Claim Against the City of Dubuque by Jennifer Avery
Claimant Date of Claim Date of Incident Nature of Claim
Jennifer Avery 7/21/2021 6/25/2021 Vehicle Damage
This is a claim in which claimant alleges claimant's vehicle was damaged due to being
struck by a City bus.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager
Russ Stecklein, Interim Director of Dubuque Transportation Services
Jennifer Avery
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944
TELEPHONE (563) 589-4113 / FAX (563) 583-1040 / EMAIL jmedinge@cityofdubuque.org