Claim by Sarah RyanTHE CITY OF
DUB E MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
DATE: September 13, 2011
RE: Claim Against the City of Dubuque by Sarah Ryan
Claimant Date of Claim Date of Loss Nature of Claim
Sarah Ryan 09/13/11 09/02/11 Property Damage
This is a claim in which claimant alleges that during refuse collection, a Public Works
employee struck and damaged claimant's refuse can and mailbox with a refuse truck.
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
Paul Schultz, Resource Management Coordinator
Sarah Ryan
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
2011 -09 -13 09:34 Finley 4th FL Rehab
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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.
Tho 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 wilt be provided with a copy of that report end
recommendation,
The final decision on all claims is made by the City Council. No employed 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: • • l .I,t f `l- •
2. Address: !SCI Cl
3, Telephone Number: J -6sq
4. Date of Incident: iz/ii
5. Time of Incident: %t I° (1x',+rnit -le. i,t i(")' (i fi(Y\
6. Location of Incident (Bo specific): ■ •( wYCt
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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 employee's name.)
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8. What wore weather conditions like? (Ica
9. Give name and address of any witnesses:
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10. Did police investigate? (If so, give names of officors.)
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11. Was anyone Injured? (If so, give names, addresses, and extent of injuries.)
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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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2011 -09-13 09:33 Finley 4th FL Rehab
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13. What other damagos do you claim. if any?
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14. Havo 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.)
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15. What amount do you claim from the City of Dubuque ?i
16. Why do you Claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone olse for damagos as a result of this Incidont? (If yes, give name and
address.)
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18. If the answer to Question 17 is yes, have you received any payment from that source, and If so, in what amount?
Datod this t day of Se
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2011 -09 -13 09:34
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CITY OF DUBUQUE Date c •) tt
50 W. 13th St.
Dubuque, IA 52001
Vehicle Physical Damage / Vehicle Liability Claim Report
Department Contact u �� � L� ;4•V-1 -- Phone # t.�
Loss Location l C( ! \-L.4 c ,
Date of Loss (i
Accident Facts L ` (:? 1 : t , ;.� c 1 .,'V\ . �. r� (')
/ (; •v(kK.. f f: :�� . < . ■ : L:; r L �.
ICAP Certificate #003
;
Time of Loss \ `_)
Citv Vehicle Other Vehicle
❑ Yes ❑ No ❑ Pending Driver Charged ❑ Yes ❑ No ❑ Pending
ICAP Insurance Carrier
Year /Make /Model
VIN#
Vehicle Number not applicable
Vehicle Location
Name of Driver
Driver License # _
Citv of Dubuque Owner
Is Vehicle Driveable?
Was the City of Dubuque's vehicle used with permission? ❑ "Yes ❑ No ❑ Not Applicable
Accident Witnesses and Phone # l ! ,� . >~ 4•. ,, ).: 5
Police Department S'v C Report #
Non -City Driver Address and Phone # \'1.) , �. ( ` t. ; , r
Attach if Available
Report completed by_ V'
Submit two written estimates on City vehicle.
NOTE: State report required WITHIN A 72 HOUR PERIOD if total
damages equal $1,000 or more or there is bodily injury.
Mail or Frank O'Connor, O'Connor & Associates Phone 563- 557 -7440
Fax to: 305 Locust St, Dubuque, IA 52001
Fax 563 - 583 -9142
Form sent to: ❑ Legal Department ❑ Finance Department ❑ O'Connor & Associates
Last Revised: January 2005