Claim by Kevin CiesielskiTHE CITY OF
DUB UE MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
)<)i
To: Mayor Roy D. Buol and
Members of the City Council
DATE: May 9, 2011
RE: Claim Against the City of Dubuque by Kevin Ciesielski
Claimant Date of Claim Date of Loss Nature of Claim
Kevin Ciesielski 05/04/11 04/30/11 Vehicle Damage
This is a claim in which claimant alleges the tire on his vehicle was sliced by the sharp
edge of a newly constructed curb while claimant was attempting to park at a meter near
the intersection of 1 & Main Streets.
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
Kevin Ciesielski
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
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA 11 MAY —14 PM 2: 314
This written report constitutes your claim against the City of Dubuque, Iowa. You should comp) i�tc#��n�f�ulOf fi
attach any additional information that supports your claim. `"''"`77
Dubuque, IA
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 Attorney's 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: 61// ti CIEs f EL S �C 1
2. Address: 8605 ic)
3. Telephone Number: 563 5C30 /302
4. Date of Incident: OM/30 he /1
5. Time of Incident: ^- /0- *dd ,frl
6. Location of Incident (Be specific): � a t Pv,��wq lieb ' W )l o
� ('
, 7411 t- j; 0, 1 a r 15f 9t /1101'0
)/ J
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.) /
I/tiA �7a r 1 47 i l2 f e ;um/ COP1Cr'e c / oi1;0 or
r tAVIo v1�S �KF and S //�ce� SItG� Or rrpo- f �<iSS7itGL/
+1 i.e. Gau�r f A a cio f4t. 2+ wns Arai ✓'ept ;fAih. and ims fry /4 u�.
8. What were weather conditions like? C./ e��r'
9. Give name and address of any witnesses: ! „ ea n et e
10. Did police investigate? (If so, give names of officers.)
No
foo
S)1AbitGILO , Zl{ 52003
11. Was anyone injured? (If so, give names, addresses, and extent of injuries.)
l.' MVO
RE FR/ED
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.)
— Fir A/a5 4ctwt<�irC' I y cJr1#1 Ve/ ///. 6I+L ✓/er„,,• y
War /anry 0 ✓t I i 14 - r f' CI? C- evwcNI Cosy AA 4 6,3�.
13. What other damages do you claim, if any? Ai oete_
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.)
15. What amount do you claim from the City of Dubuque? # 3-2
16. Why do you claim the City of Dubuque is responsible? /lam Curb re/ et
ex-ktmds at-, --o frr, - nhg- CIA v and is lkv S harp
CYCFi-i hq 4 447arc� 7-P 4 - I l i re S of a hYo+tc faeii ar
c‹ ,
17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and
address.)
n
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
n�a
Dated this 3rd day of Ma y 20 ! L
(Signature) /1
isEtimi E C /E5 /ELSk /
(Print Name)
Savings Made Simple
SAM'S CLUB
CLUB MANAGER JON WHITVER
( 563 ) 687 - 0576
Fax and Pull 1 ( 563 ) 587 - 0584
04/30/11 12:15 2450 4973 042 647
W MEMBER 101- * * * * ** *7363
THANK YOU,
PREFERRED MED LEGAL CONSULTING
TMA ITEMS FOLLOW
ORDER NUMBER 0048570067966
5 TIRE INSTALL 15.00 T
957779 P205/65R15 28.29 T
TMA ITEMS COMPLETE
SUBTOTAL 43.29
TAX 1 7.000 % 3.03
TOTAL 46.32
SAMS DISCOVER P CREDIT 46.32
ACCOUNT * 3728
APPROVAL 11 000538
CHANGE DUE 0.00
x ITEMS SOLD 2
NR dI IIII ' I IiiiiiIIIIY iuiiiii 1 lll
c
THANK YOU
Show Mom how much you care with
flowers, Jewelry, and housewares.
04/30/11 12:16:21
* ** MEMBER COPY * **
WE VALUE YOUR OPINION
WE WANT TO KNOW ABOUT YOUR SHOPPING
EXPERIENCE TODAY AT SAM'S CLUB
Please complete a survey about today's club visit at:
htto://www.survey.samsclub.com
IN RETURN FOR YOUR TIME YOU COULD RECEIVE
ONE OF FIVE $1,000 SAMS CLUB SHOPPING CARDS
You must be 18 or older and a legal resident of the
United States to enter. No purchase necessary to win.
To enter without purchase and for official rules visit:
www.entry.survey.samsclub.com
Sweepstakes period ends on the date shown in the
official rules. Survey must be taken within TWO weeks
of today.
Esta encuesta tambiin se encuentra en espaFtol en la
pigina de Internet.
DATE
04 -30 -2011
NAME
CIESIELSKI, KEVIN
8605 WILDLIFE RDG
DUBUQUE, IA 52003
PHONE #
(563)588 -1302
YEAR
1999
MAKE
FORD
MODEL
TAURUS
COLOR
Dark Green
LICENSE
872 RJF
ODOMETER
137751
MEMBER ARRIVAL TIME
2011 -04 -30 12:17 PM
SERVICE COMPLETED TIME
2011 -04 -30 12.41 PM
Service Description
Service
TIRE INSTALL PACKAGE Whitewall - IN
- Tire Pressure - Dry Rear - CHECKED, 30 - Tire Pressure - Pass Rear - CHECKED, 30
- Tire Pressure - Dry Front - CHECKED, 30 - Tire Pressure - Pass Front - CHECKED, 30
- Valve Stem - Pass Front - COMPLETE - Balance Accepted - Pass Front - COMPLETE
- New Tire - Pass Front - COMPLETE - DOT: BFURF7I 1141 1
- Dispose Tire Accepted - Pass Front - COMPLETE - SAMS Battery Check - TESTED GOOD
LUG TORQUE
Pass Front 100 FT -LB
ADJUSTED TIRE MILEAGE
'PMABnDBBTTH I
Dry Front - 4 /32 Dry Rear - 10/32 Pass Front - 9 /32 Pass Rear - 11/32
15.00
Merchandise Description
Quantity
Unit Price
Merchandise
P205/65RI5 92T PRO
Discount for above item
1
75.38
75.38
- 47.09
—
Total (Excluding Tax)
43.29
Muiibc' C„""°L"L'
Technician Comments
DISCLAIMER
1 hereby authorize the stated repair work to he done along with
the necessary material, and hereby grant Sam's Club permission
to operate the vehicle herein described on streets, highways or
elsewhere for the purpose of testing and/or inspection. An
express mechanic's lien is hereby acknowledged on above
vehicle to secure the amount of repairs thereto.
SAM'S CLUB IS NOT RESPONSIBLE FOR LOSS OR
DAMAGE TO VEHICLES OR ARTICLES LEFT IN
VEI -IIC LES IN CASE OF FIRE, THEFT OR ANY
OTHER CAUSE BEYOND SAM'S CLUB CONTROL.
04 -30 -2011
MEMBER SIGNATURE DATE
1
See cashier for michelin registration card or visit
www.michelin.com to reels }er vour tires
CLUB# 4973
4400 ASBURY RD
DUBUQUE, IA 52002 -0000 US
(563)587 -0576
LIC#
HAVE YOUR LUG NUTS RETORQUED AFTER THE FIRST 50 MILES.
1111
111
1
1
485700 67966
11
BATTERY TECHNICIAN: ADAM 647
COMMON TECHNICIAN: ADAM 647
QUALITY CONTROL TECH: KEVIN 82
SALES ASSOCIATE: KEVIN 82
TIRE ADJ ASSOCIATE: RYAN 5
TIRE TECHNICIAN: ADAM 647