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Claim by Aaron ShiversTHE CITY OF DUB11JE MEMORANDUM Masterpiece on the Mississippi TRACEY STECKLEIN PARALEGAL To: Mayor Roy D. Buol and Members of the City Council DATE: August 7, 2011 RE: Claim Against the City of Dubuque by Aaron Shivers Claimant Date of Claim Date of Loss Nature of Claim Aaron Shivers 08/04/11 07/17/11 Vehicle Damage This is a claim in which claimant alleges that as he was driving through the Hotel Julien parking lot, a police officer backed a police squad car out of a parking spot and struck claimant's vehicle. 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 Mark Dalsing Chief of Police Aaron Shivers 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 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 13th St., Dubuque, IA 52001. It will then be referred to the appropriate department for investigation and to the City Attomey'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: 5t j V f At/_ A A�jRc J T1 2. Address: (0 30 aOTh , v c • (AO Ao/ )e 3. Telephone Number: 3 7Cf c1,2 a3 ©S 4. Date of Incident: J%<237/ 5. Time of Incident: Gs-CCt.A/)U 1- l� pet I A J 6. Location of Incident (Be specific): 1 i� Out])iAt ,� A C) L& de c) 't" () 4Jie✓1 -nil In 7 r`K poIrk)oj Jo-) 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.) 13Au e3 O, afbv c) 5C 0 vtAt U f (tar) I0 - , Cr P s+ butt4 Goo ckove 4Ayitir c.,10 Mar LAP ,r, l roe. ku,ri. 8. What were weather conditions like? vwn,3 1 erc 9. Give name and address of any witnesses: ' c,�- �tt�St' c ' c 31(g (Noiwb ion ') 7 h,iIdesfi Cow 4of a atbv .off 10. Did police investigate? (If so, give names of officers.) \1 : 1,)r'w, h'e I)ey 11. Was anyone injured? (If so, give names, addresses, and extent of injuries.) cw � nsHu c,rm btA,E Jnr Seek U%cnt,0 Dub ,At 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.) \lei 6sec, c54,(.ie. i 5 den-k- pr/b.50i5er (, (itcf ck f 13. What other damages do you daim, 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.) NO 15. What amount do you daim from the City of Dubuque? ti k ,• eMt l' eft tl /1Qd1 Ct*" ik CaSe 6 ya -i c ► vre )LA-i '`� �G V" r (i i�, i\'q Cf5 c"t��(1 16. Why do you daim the City of Dubuque is responsible? 1 Cbe 1�kaJn I 1(.90 'iI 61 C DA) ()toife& c&p l n ku me ;� � i�� o.licxu ryvver. S . . 17. Have you made any daim against anyone else for damages as a result of this incident? (If yes, give name and address.) tvc) 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 day of 114115\) (Signature) LYh'w3 (Print Name) 20 � . 0 C Cr C ;, _0 CD Cr) A 0 0