Claim by Sunnycrest ManorTHE CITY OF
DUB UE MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
)406
To: Mayor Roy D. Buol and
Members of the City Council
DATE: October 25, 2010
RE: Claim Against the City of Dubuque by Sunnycrest Manor
Claimant Date of Claim Date of Loss Nature of Claim
Sunnycrest Manor 10/22/10 08/31/10 Property Damage
This is a claim in which claimant alleges that City ambulance staff struck the electric
sliding doors with a gurney at the entrance to Sunnycrest, knocking the doors off track.
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
Dan Brown, Fire Chief
Sunnycrest Manor
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001 -6944
TELEPHONE (563) 583 -4113 / FAx (563) 583 -1040 / EMAIL tsteckle @cityofdubuque.org
Home is where the heart is
10/21/10
City of Dubuque
City Hall
13 & Central
Dubuque, Iowa 52001
Attn: City Clerk
To Whom It May Concern,
Board of Trustees, Dubuque County Hospital
Sunnycrest Manor
2375 Roosevelt St. Ph. (563)583 -1781
Dubuque, IA 52001 Fax (563)583 -1705
Enclosed with this letter is a claim in the amount of $411.11 filed on behalf of the Dubuque County
Hospital Board of Trustees /Sunnycrest Manor for damages to the front door of Sunnycrest Manor from
an incident that occurred on 8/31/10.
On 8/31/10 at approximately 11am, a city ambulance crew responding to an emergency call at
Sunnycrest, accidently hit the electric sliding doors at the front entrance of Sunnycrest with a gurney,
jamming the doors off the track.
A copy of the county incident report, witness statement and repair bill from Automatic Door Group,
Inc. are included with the letter. The Board of Trustees is seeking reimbursement for the $411.11
repair costs that have been paid by the Board.
If any further information is required from the Board of Trustees, please contact Cathy Hedley,
Administrator of Sunnycrest Manor (563)583 -1781.
Sincerely,
L , ' Cathy edley, Admiriiktrator
Sunnycrest Manor
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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 West 13 St., Dubuque, IA 52001. It will then be referred to
the appropriate department for investigation and to the City Attorneys Office. 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: DNbbC rt,e 14D5p1
Z� ?� eUS t° V Q /
2. Address: eV/if
3. Telephone Number: QP 3 59 - /V/
4. Date of Incident:
5. Time of Incident: 1��
6. Location of Incident (Be specific): SsNNNycrLod �l't, er - J'YO Fti'11
7. Describe the 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.)
6j Ay►, le.ry IA- nLe- 1 TD PtV th1 -1I--4 Gq f
- P NV 5 Ai h 3 i/eGbe � d
ct,I ehAillnce 6 hN GlfiS1� ltl i 1//'h� i k IJ
y
8. What were weather conditions like? A//4
9. Give name and address of any witnesses: - 27/14 /hi/ r L?�
10. Did police investigate? (If so, give names of officers.)
A/0
11. Was anyone injured? (If so, give names, addresses, and extent of injuries.)
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.)
�QS ° rktivi eh �YRh (�� 7/�- �(�`YI / L � � SId/h dlS7�r�j
`l $ lam- it /i- �16J41
13. What other damages do you claim, if any?
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.)
0
15. What amount do you claim from the City of Dubuque? 4 /4 / < 1/
si r h fr/rs - ,St
16. Why do you claim the City of Dubuque is responsible?
atmw Me- del M 7 Me-
17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and
address.)
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
Dated this /5 day of GL7' 1CL-tk , 20 /U.
g z a t (Signatur
0.4-h y le
(Print Name)
474.
DIm'N /514- D
Voice:
Fax:
515 - 264 -0782
515 - 299 -9714
Sold To:
SUNNYCREST MANOR
2375 ROOSEVELT
DUBUQUE, IA 52001
Customer ID
SUNNYCREST MANOR
Sales Rep ID
Quantity
1.00
2.004204109746
1.00
2.50
110.00
Item
4204100092
LABOR - REPAIRS IA
TRUCKMILESIA
Check/Credit Memo No
AUTOMATIC DOOR GROUP INC
1501 NE BROADWAY AVE STE 14
DES MOINES, IA 50313
BEST WAY
Customer PO
Shipping Method
Ship to:
SUNNYCREST MANOR
2375 ROOSEVELT
DUBUQUE, IA 52001
Description
REPLACED BOTH TOP GUIDE WHEELS;
LSO REPLACED LOWER GUIDE BLOCK
THAT WAS WORN THEN ADJUSTED S.O.
PANEL. TECH: MIKE
CHRIS CALLED 8/31 10:45AM
563- 583 -1781 FIRE DEPT HIT MAIN
tNTRANCE DOOR AND IT IS OFF
TRACK, CANT GET IT BACK ON,
SECURITY ISSUE, NEED ASAP TICKET
72168
(CARRIAGE WHEELS; A /SLIDE
GUIDE BLOCK DOM
LABOR - REPAIRS IA
TRUCK MILES IA (PARTIAL TRIP)
u S
l—n 2
Ship Date
Unit Price
Subtotal
Sales Tax
Freight
Total Invoice Amount
Payment /Credit Applied
TOTAL
Payment Terms
Net 30 Days
67.55
15.00
70.00
0.70
Invoice
Invoice Number:
071186
Invoice Date:
Sep 23, 2010
Page:
1
T
Due Date
10/23/10
Extension
1
135.10
15.00
175.00
77.00
402.10
9.01
411.11
411.11
Number:
DUBUQUE COUNTY INCIDENT REPORT
Please utilize this report for incidents involving any property, automobile or accident
Date Report Filed: \ 0 ke^ Department: S V1/4,'MVILk:51) 1\01 64\-0
Date of Incident: \ \
Time of Incident: 9^ f/ /gni
A
Is the incident location or propeitrownedTand/or maintain the County? ) Yes No
If not please explainseaoriforxpport.:_:„
Describe any property irT iypilLth FIZA1 n
c? us.AA_ . . :
Describe any iIvJ in the incident;
Facts oft1M
. - a. A 411 Aka
1 .1 A PA !! • P PP inci • IP • A ala s
j_IllgVPRPIMOMIDISIIllMPIR- a
Yes No.
Wereqllerra n
ny Injues7.-
Address:,
Report Completed by: tANk 5 A soRAr
. .
•
Narnd:4of injured Party, if, anJ
- Please
Telephone Numbdt:
Return to: Jan Hess, Courthouse, 720 Central, Dubuque IA 52001
Phone: 319-589-4441 Fax: 319-589-7884
Zip
-3333. 3 3 3- 3333: 3 3.-.333-3.33i3-333-33
Name of any Law Entorcernentlkgentrtharinvestigated'thenncident,rif any
Witness Naffie:
Telephone: 6'8 3 - )1.. Employee
. -
3:3
Witness NamefLZL.-:,;--tf_4: -:::-='::=';Employee Yes No
Telephone: -S S'
Employee(s) Involved.
Department:
Witness iName:= \
Witneei.Adar'gsFS 4%45 oo4+,
611 71:44
' -
EM
Wits
eyeA
..1sT
"•"• --
\f \_v
an (1 cou.
Witness Signature:
Date: 9////0
Information requested in Section 1 should be filled in by the employee
;LA
• _
• .••• •••••••
INCIDENT INVESTIGATION
WITNESS STATEMENT
Section 1 ---
.1 Eocaff57
Incident Report No.
. , • L... • :" ,
Incident DafeW
Time: ij
Statemerit=Dat
•
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Information in Sectierra..snqUldrbe:prOvided 4 b`y: the own words
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•.:=7, '91 al' ... :•4 . 3 ." -.: : :: 4 .. : : 441 . ? :1:501 ! 4•7•11. 7 '1 4 ,;• ." , F ,:z.- : • ' . ,: ':: • -.5i1 ,- - , 'i , rl'i!',".?. al 0 .. , Likr...3 1
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To the Witness: Briefly explain in your own worcls the Your commeSits are
Important to fitMckdetekmiqe the cause of the incudent Thankyou —
"7.7124_.
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