The URL can be used to link to this page

Claim by TransPC Solutions on Behalf of Rebecca VossMasterpiece on the Mississippi TRACEY STECKLEIN PARALEGAL MEMORANDUM To: Mayor Roy D. Buol and Members of the City Council DATE: November 23, 2010 RE: Claim Against the City of Dubuque by TransPaC Solutions on behalf of Rebecca Voss Claimant Date of Claim Date of Loss Nature of Claim TransPaC Solutions 11/22/10 01/11/10 Personal Injury on behalf of Rebecca Voss This is a claim in which claimant alleges that she slipped and fell on a large sheet of ice in the street at 761 Carriage Hill due to an improper drainage system. 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 John Klostermann, Street & Sewer Maintenance Supervisor TransPaC Solutions on behalf of Rebecca Voss 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 November 10, 2010 KEN TEKIPPE CITY OF DUBUQUE 50 WEST 13TH STREET DUBUQUE IA 52001 RE: Client Insured: Claim Number: Date of Incident: Event Number: Your Insured: Amount Due: Dear KEN TEKIPPE, Please see the attached claim form, photos of loss location and ledger of City of Dubuque. This claim involves a slip and fall on ice. Please contact me once you have a claim set up for this loss and provide person for the claim. I look forward to hearing from you in the near future. Please contact me if you have any questions. Sincerely, Clanw (*aw. Jamie E. Nicolas (800) 225 -7134 10218.68 �1 Trans PaC Solutions P.O.Box 36220 Louisville, KY 40233 -6220 FAX: (800) 723 -4869 UNITED HEARTLAND, INC AREA RESIDENTIAL CARE INC REBECCA VOSS 1/11/2010 TPCS - 1001409 - 1489988/201000000045 1001409 - 1489988/TOPENPARA/201000000045 c` payments to initiate a claim against the a claim number and adjuster /contact ni 0 In 06/23/2010 Your Claim # : 201000000045 Insured : AREA RESIDENTIAL CARE INC Policy # : 2000000251 Claimant : REBECCA VOSS Instructions: • Please include TPCS - 1001409 - 1489988 on all payments and correspondence to expedite processing. MED ASSOC CLINIC 020007125 $141.90 06/15/2010 Check Number Payment MED ASSOC CLINIC 0200006882 $97.91 06/12/2010 MED ASSOC CLINIC 020006826 $64.00 06/08/2010 MED ASSOC CLINIC 020006722 $141.90 06/07/2010 GENEX 020006614 $490.00 06/05/2010 WALGREENS 0200006667 $27.06 06/02/2010 GENEX 0200006527 $490.00 06/02%2010 GENEX 0200006528 $490.00 06/01/2010 05/07/2010 05/07/2010 WALGREENS 0200006517 $75.22 06/01/2010 05/07/2010 05/07/2010 WALGREENS 0200006517 - $70.28 06/01/2010 05/03/2010 05/03/2010 WALGREENS 0200006518 $12.82 05/21/2010 04/24/2010 04/24/2010 WALGREENS 0200006340 $15.94 05/20/2010 03/22/2010 04/16/2010 GENEX 0200006264 $490.00 05/18/2010 04/20/2010 04/20/2010 WALGREENS 0200006218 $71.96 05/18/2010 04/20/2010 04/20/2010 WALGREENS 0200006218 $49.72 05/18/2010 04/20/2010 04/20/2010 WALGREENS 0200006218 $61.62 05/14/2010 04/08/2010 04/08/2010 MED ASSOC CLINIC 0200006150 $161.00 05/14/2010 04/08/2010 04/08/2010 MED ASSOC CLINIC 0200006150 $740.00 05/14/2010 04/08/2010 04/08/2010 MED ASSOC CLINIC 0200006150 $16.80 05/14/2010 04/08/2010 04/08/2010 MED ASSOC CLINIC 0200006150 $4.06 05/07/2010 03/30/2010 03/30/2010 STONE RIVER RX 0200005998 $18.23 04/30/2010 03/24/2010 03/24/2010 MED ASSOC CLINIC 0200005824 $50.00 04/30/2010 03/24/2010 03/24/2010 MED ASSOC CLINIC 0200005824 $50.00 04/29/2010 03/16/2010 03/16/2010 MED ASSOC CLINIC 0200005766 $97.70 04/29/2010 03/10/2010 03/10/2010 MED ASSOC CLINIC 0200005767 $111.50 Statement sent to : KEN TEKIPPE CITY OF DUBUQUE Your Claim # : 201000000045 Insured : AREA RESIDENTIAL CARE INC Policy # : 2000000251 Claimant : REBECCA VOSS Instructions: • Please include TPCS - 1001409 - 1489988 on all payments and correspondence to expedite processing. ATTENTION: AMOUNT IS SUBJECT TO CHANGE, PLEASE CONTACT TRANSPAC SOLUTIONS PRIOR TO SETTLEMENT. Payment Date Service Dates Payee Check Number Payment Start Date I End Date From: Contact Information: TransPaC Solutions Examiner: Jamie E. Nicolas P.O. Box 36220 Phone: (800) 225 -7134 Louisville, Kentucky 40233 -6220 Fax: Email: My File # : TPCS- 1001409 - 1489988 Taxpayer ID : 61- 1141758 Type: INDEMNITY PAYMENTS Total Claims Paid for INDEMNITY PAYMENTS REQUEST FOR PAYMENT CASE STATEMENT FOR WORKERS' COMPENSATION Date of Loss: 1/11/2010 $10218.68 04/28/2010 03/10/2010 03/19/2010 MED ASSOC CLINIC 0200005726 $50.00 04/28/2010 03/10/2010 " 03/19/2010 MED ASSOC CLINIC 0200005726 $50.00 04/28/2010 03/10/2010 03/19/2010 MED ASSOC CLINIC 0200005726. $50.00 04/28/2010 03/10/2010 03/19/2010 MED ASSOC CLINIC 0200005726. $50.00 04/28/2010 03/10/2010 03/19/2010 MED ASSOC CLINIC 0200005726 $5 04/28/2010 03/10/2010 03/19/2010 MED ASSO CLINIC 020000572 $50.00 04/28/2010 03/05 /2010 03/05/2010 MED ASSOC CLINIC 020000572 , $50.00 04/28/2010 03/05/2040 03/05/2010 MED ASSOC CLINIC 020000572 $50.00 04/27/2010 03/30/2010 03/30/2010 WALGREENS 020000568 $21.28 04/20/2010 02/23/2010 02/23/2010 MED ASSOC CLINIC 020000555 $50.00 04/20/2010 02/23/2010 02/23/2010 MED ASSOC CLINIC 020000555 $50.00 04/15/2010 03/02/2010 03/02/2010 MED ASSOC CLINIC 020000543 $141.60 04/15/2010 02/26/2010 03/01/2010 MED ASSOC CLINIC 020000543 $50.00 04/15/2010 02/26/2010 03/01/2010 MED ASSOC CLINIC 0200000543 $50.00 04/15/2010 02/26/2010 03/01/2010 MED ASSOC CLINIC ' 020000543 $50.00 04/15/2010 02/26/2010 03/01/2010 MED ASSOC CLINIC 020000543 $50.00 04/15/2010 02/16/2010 02/24/2010 GENEX 020000540 $490.00 04/15/2010 03/08/2010 03/11/2010 GENEX 0200000540 $490.00 04/14/2010 03/16/2010 03/16/2010 WALGREENS 0200000539 $21.28 04/10/2010 03/10/2010 03/10/2010 WALGREENS 020000532 $196.10 04/01/2010 02/05/2010 02/05/2010 RAMIC DAVENPORT 0200005138 $2.26 04/01/2010 02/05/2010 02/05/2010 RAMIC DAVENPORT 0200005138 $691.38 04/01/2010 02/23/2010 02/23/2010 MED ASSOC CLINIC 0200005137 $97.70 03/30/2010 03/02/2010 03/02/2010 WALGREENS 0200005059 $21.28 03/30/2010 02/18/2010 02/18/2010 MED ASSOC CLINIC 0200005058 $97.70 03/30/2010 02/15/2010 02/19/2010 MED ASSOC CLINIC 0200005057 $50.00 03/30/2010 02/15/2010 02/19/2010 MED ASSOC CLINIC 02000005057 $50.00 Statement sent to : KEN TEKIPPE CITY OF DUBUQUE Your Claim # : 201000000045 Insured : AREA RESIDENTIAL CARE INC Policy # : 2000000251 Claimant : REBECCA VOSS Instructions: • Please include TPCS - 1001409 - 1489988 can all payments and correspondence to expedite processing. - ATTENTION: AMOUNT IS SUBJECT TO CHANGE, PLEASE CONTACT TRANSPAC SOLUTIONS PRIOR TO SETTLEMENT. Payment Date Service Dates Payee _ Check Number Payment art Date I End Date From: Contact Information: TransPaC Solutions Examiner: Jamie E. Nicolas P.O. Box 36220 Phone: (800) 225 -7134 Louisville, Kentucky 40233 -6220 Fax: Email: My File # : TPCS- 1001409 - 1489988 Taxpayer ID : 61- 1141758 REQUEST FOR PAYMENT CASE STATEMENT FOR WORKERS' COMPENSATION Date of Loss: 1/11/2010 Type: INDEMNITY PAYMENTS Total Claims Paid for INDEMNITY PAYMENTS $10218.68 03/30/2010 02/15/2010 02/19/2010 MED ASSOC CLINIC 0200005057 ,. . $50.00 03/30/2010 02/15/2010 02/19/2010 MED ASSOC CLINIC 0200005057 '. $50.00 03/30/2010 02/15/2010 02/19/2010 MED ASSOC CLINIC 0200005057 $50.00 03/30/2010 02/15/2010 02/19/2010 MED ASSOC CLINIC 0200005057 $50.00 03/27/2010 02/19/2010 02/19/2010 MED ASSOC CLINIC 0200005026'• $97.70 03/26/2010 01/29/2010 01/29/2010 MED ASSOC CLINIC 0200004976;. $141.60 03/25/2010 02/02/2010. 02/02/2010 MED ASSOC CLINIC 0200004931. $97.70 03/2512010 01/28/2010 01728/2010 MED ASSOC CLINIC 02000004934: . $50.00 03/25/2010 01/28/2010 01/28/2010 MED ASSOC CLINIC 0200004934 $50.00 03/25/2010 02/10/2010 02/10/2010 MED ASSOC CLINIC 0200004932 $50.00 03/25/2010 02/10/2010 02/10/2010 MED ASSOC CLINIC 0200004932 $50.00 03/25/2010 02/09/2010 02/09/2010 MED ASSOC CLINIC 020004933 $97.70 03/23/2010 02/23/2010 02/23/2010 WALGREENS 0200004867 $21.28 03/23/2010 02/23/2010 02/23/2010 WALGREENS 02000004867 $21.02 03/23/2010 02/18/2010 02/18/2010 WALGREENS 0200004866 $21.28 03/15/2010 01/12/2010 01/14/2010 REBECCA VOSS 0200000463 $120.50 03/04/2010 02/09/2010 02/09/2010 WALGREENS 02000004443 $32.46 03/04/2010 02/09/2010 02/09/2010 WALGREENS 0200004443 $21.28 03/04/2010 01/26/2010 01/28/2010 MED ASSOC CLINIC 02000004444 $97.70 03/04/2010 01/26/2010 01/28/2010 MED ASSOC CLINIC 02000044444 $97.70 03/04/2010 01/15/2010 01/18/2010 MED ASSOC CLINIC 0200004445 $97.70 03/04/2010 01/15/2010 01/18/2010 MED ASSOC CLINIC 0200004445 $97.70 03/03/2010 01/27/2010 01/27/2010 MED ASSOC CLINIC 0200004415 $50.00 03/03/2010 01/27/2010 01/27/2010 MED ASSOC CLINIC 0200004441 $50.00 03/03/2010 01/18/2010 01/22/2010 MED ASSOC CLINIC 02000004441 $50.00 03/03/2010 01/18/2010 01/22/2010 MED ASSOC CLINIC 0200004415 $50.00 03/03/2010 01/18/2010 01/22/2010 MED ASSOC CLINIC 0200004415 $50.00 Statement sent to : KEN TEKIPPE CITY OF DUBUQUE Your Claim # : 201000000045 . Insured : AREA RESIDENTIAL CARE INC Policy # : 2000000251 Claimant : REBECCA VOSS Instructions: • Please include TPCS- 1001409- 1489988 on all payments and correspondence to expedite processing. ATTENTION: AMOUNT IS SUBJECT TO CHANGE, CONTACT TRANSPAC SOLUTIONS PRIOR TO SETTLEMENT. Payment Date Service Dates Payee Check Number Payment art Date I End Date From: Contact Information: TransPaC Solutions Examiner: Jamie E. Nicolas P.O. Box 36220 Phone: (800) 225 -7134 Louisville, Kentucky 40233 -6220 Fax: Email: My File # : TPCS - 1001409- 1489988 Taxpayer ID : 61- 1141758 REQUEST FOR PAYMENT CASE STATEMENT FOR WORKERS' COMPENSATION Date of Loss: 1/11/2010 Type: INDEMNITY PAYMENTS Total Claims Paid for INDEMNITY PAYMENTS $10218.68 03/03/2010 01/18/2010 01/22/2010 MED ASSOC CLINIC 0200004415 $59.00 03/03/2010 01/18/2010 01/22/2010 MED ASSOC CLINIC 0200004415: $50.00 03/03/2010 01/18/2010 01/22/2010 MED ASSOC CLINIC 0200004415 $50.00 03/02/2010 02/02/2010 02/02/2010 WALGREENS . , .0200004379 $16.83 03/02/2010 02/02/2010. 02/02/2010 WALGREENS 0200004379 $26. 03/02/2010 01/28/2010 01/28/2010 WALGREENS 020000438 $12.83 03102/2010 01/28/2010 01/28/2010 WALGREENS .. 020000438 $18.97 03/02/2010 01/26/2010 01/26/2010 WALGREENS 020000437 $16.83 02/24/2010 02/15/2010 .02/21/20 REBECCA VOSS. 020000420 $87.80 02/18/2010 01/11/2010 01/13/2010 MED ASSOC CLINIC 0200004054 $155.23 02/18/2010 01/11/2010 01/13/2010 MED ASSOC CLINIC 0200004054 $97.70 02/18/2010 01/13/2010 01/13/2010 MED ASSOC CLINIC 0200004053 $50.00 02/18/2010 01/13/2010 01/13/2010 MED ASSOC CLINIC 0200004053 $140.78 02/18/2010 01/11/2010 01/11/2010 STONE RIVER RX 0200004052 $25.21 02/18/2010 01/11/2010 01/11/2010 STONE RIVER RX 0200004052 $2.37 02/18/2010 01/11/2010 01/11/2010 STONE RIVER RX 0200004052 $13.67 02/17/2010 02/08/2010 02/14/2010 REBECCA VOSS 0200003973 $100.19 02/12/2010 01/18/2010 01/18/2010 WALGREENS 0200003892 $4.82 02/12/2010 01/15/2010 01/15/2010 MED ASSOC CLINIC 0200003891 $16.83 02/10/2010 02/01/2010 02/07/2010 REBECCA VOSS 0200003857 $100.19 02/03/2010 01/25/2010 01/31/2010 REBECCA VOSS 0200003782 $137.35 01/27/2010 01/18/2010 01/24/2010 REBECCA VOSS 0200003618 $100.19 01/20/2010 01/15/2010 01/17/2010 REBECCA VOSS 0200003517 $120.50 Statement sent to : KEN TEKIPPE CITY OF DUBUQUE Your Claim # : 201000000045 Insured : AREA RESIDENTIAL CARE INC Polity # : 2000000251 Claimant : REBECCA VOSS Instructions: . • Please include TPCS - 1001409- 1489988 on all . payments and correspondence to expedite processing. ATTENTION: AMOUNT IS SUBJECT TO CHANGE, PLEASE CONTACT TRANSPAC SOLUTIONS PRIOR TO . SETTLEMENT. Payment Date Service Dates Payee Check Number Payment art Date End Date From: Contact Information: TransPaC Solutions Examiner: Jamie E. Nicolas P.O. Box 36220 Phone: (800) 225 -7134 Louisville, Kentucky 40233 -6220 Fax: Email: My File # : TPCS- 1001409 - 1489988 Taxpayer ID : 61- 1141758 Type: INDEMNITY PAYMENTS Total Claims Paid for INDEMNITY PAYMENTS REQUEST FOR PAYMENT CASE STATEMENT FOR WORKERS' COMPENSATION Date of Loss: 1/11/2010 $10218.68 Total Claims Paid $10,218.68 Recovered to Date ($0.00) Outstanding Amount $10,218.68 FootNote: If an insured's deductible or out -of- pocket expenses are listed, we are requesting payment as a courtesy to our client's insured. Client's Claim #:201000000045 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 Had, 50 West 13"' St., Dubuque, IA 52001. It wtd 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 dam will or will n paid. • •. - m 1. Nae of Claimant: "" tins C A t. irry0 CAD - CIQi d k _c uLU U ' _C 2. Address: CM) 'Jlt(U OX1 \‘aI 1OAl1I» ago Vv.\ x -10233 3. Telephone Number: R01) - - -1 • • 4. Date of Incident: 1 iiii 1 . 1i1 2.010 5. Time of•Incident: R-.1 im 6. Location of Incident (Be specific): 1 (tl CtuuU ac�-,,t 11 7. Describe the accident or occurrence that caused Injury or damage. (Give full details upon whT yfgase yogi r. claim. If a City employee was involved, give the employee's name.) b b e e C i \ l a s s S ti4(zad 6i n d Q an a_ 1.0 13 o - .: ' r s-t Y1' 110 •h]Qi, . Qh. i lilt) -Y , 4 p fv i a2 - _ • ,t it 1.11 .d a n .Ai. 'gin '8. What were weathercondttions like? �1 9. Give name and address of any witnesses: q1 t-uvvvi 10. Did poke investigate? (If so, give names of officers.) Nh4 Wry Kyvvion 11. Was anyone injured? (If so, give names, addresses, and extent of injuries.) Less- ile_heettl \(6S - lq'-1 IQ ''' 41 ,rlh \te p)r i k2l 1 Jr tl - o ri 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.) 13. What other damages do you claim, if any? NO 0 \ X Cakyvv a w I Yn 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 pald.) g m-tu Vleo Corn() (bQ n i in ;yy Via Qmcntat 9 (14 1 7_ 61, . . (to c o .o00 \/ccSS 15. What amount do you claim from the City of Dubuque? ?rA(1 VC) k O) c Ct io,Zl Cr R - U�btte�► 0_,YY7Ln 16. Why do you claim the City of Dubuque is responsible? — 611. r1. OubUc fC._ � 1 6 . ►'t� 1+ k 1.. Sid: i • • . /.1 4 ` _ 1orii n k ieV\ ko A 0AI MO �1e 1Z da f. U� j Irk r', y 1 �� 1r cick L t • � s � v� cLAc �Y cW 17. Have you made any claim against anyone for d ama g es �as e of this incident? (ff'yes givenam an }IYIt \ Y1 YES i address.) .41 1: I1.. L gsAr 18. If the answer t(D uestion 1 i s yes, hav you rece veaariy ymen frckl� tha source, an f so, in what amount? Dated this 1 b *IA day of 20k (Print Name) Un\eck 1-\-e UA3-lc*nCL who Chance) O 4- (rn Yathaa._ Cl� t . Nips :�.��;�