Claim by Jennifer HessTHE CITY OF
DUB
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
E MEMORANDUM
To: Mayor Roy D. Buol and
Members of the City Council
DATE: May 23, 2011
RE: Claim Against the City of Dubuque by Jennifer Hess
Claimant Date of Claim Date of Loss Nature of Claim
Jennifer Hess 05/19/11 05/17/11 Vehicle Damage
This is a claim in which claimant alleges that gravel fell from a City of Dubuque truck,
striking claimant's windshield and cracking it.
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
Don Vogt, Public Works Director
Jennifer Hess
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
G5 -18 -2011 13:43 DENLINGER INSURANCE 15635842383
CLAM 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 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 our claim will or will not be paid,
1. Name of Claimant:.�c- V) y I 4C- -
2. Address: wl if ad• or`'t 100
3. Telephone Number: 64 r - 35 ?S
4. Date of Incident: 51 I / 1 1
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5, Time of Incident: ( 4J�I ,
6. Location of Incident (Be specific) ` v r' " . A ) a,/ n"&X ; n 4t �' 4 !G A-'
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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 employees name.
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8. What were weather conditions like? 5U-VI n)
9. Give name and address of any witnesses;
10. Did police investigate? Mao, give names of officers.)
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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.)
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05 -18 -2011 13:43 DENLINGER INSURANCE 15635842383
13. What other damages do you claim, if any? "1.I "-`-
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 arnount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and
address,)
(Print Name)
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PAGE2
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?