Claim by William TaylorTHE CITY OF
DUB E MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
DATE: January 25, 2012
RE: Claim Against the City of Dubuque by William Taylor
Claimant Date of Claim Date of Loss Nature of Claim
William Taylor 01/24/12 01/20/12 Vehicle Damage
This is a claim in which claimant alleges that as his vehicle was parked near 912 Merz
Street, a City of Dubuque snowplow truck passed and broke off the driver's side mirror.
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
William Taylor
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 show
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 W. 13th St., Dubuque, IA 52001. It
will then be referred by the City Council to the appropriate department for investigation.
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 1S MADE BY THE CITY COUNCIL. NO EMPLOYEE OF
THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY R EPRESENTATION TO YOU
AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: itl/j / l i4k D o
2. Address: 3O i-f--)-4 1.7e l /e tt -Tt r S) eg l -0/41 — gay /Y-1
3. Telephone Number: .-63 550 z d3-3
4. Date of Incident: .1-02.0-12-
5. Time of Incident: 3 ,f) U P 14
6. Location of Incident (Be specific):
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7. DESCRIBE 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 were weather conditions like? -`! a Lv ► 1�
9. Give name and address of any witnesses: T) 2 e`'Z 5 t WO 7`
10. Did police investigate? (If so, give names of officers.)
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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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13. What other damages do you claim, if any? Non se
14. Have you been compensated for any part or all of your claim by any insurance
coo�mrpany? (If so, give name and address of insurance company and amount paid.)
15. What amount do you claim from the City of Dubuque?
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16. Why do ou claim the City ubuque is responsible?
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17. Have you made any claim against anyone else for damages as a result of this incident?
(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,
an if so, in what amount?
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Dated at Dubuque, Iowa this .2 3 day of }411 verky , 20 0
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(Rev. 1/00 & 7/01)
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