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Claim by Christina HouselogTHE CITY OF Master-piece on the Mississippi TRACEY STECKLEIN PARALEGAL MEMI AN UM To: Mayor Roy D. Buol and Members of the City Council DATE: February 7, 2012 RE: Claim Against the City of Dubuque by Christina Houselog Claimant Date of Claim Date of Loss Nature of Claim Christina Houselog 02/03/12 01/20/12 Vehicle Damage This is a claim in which claimant alleges that a City of Dubuque snowplow truck struck claimant's parked vehicle at 2720 Broadway Street as the snowplow truck was plowing snow. 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 Christina Houselog OFFICE OF THE LIT? A' i l OI NEY DUBUQUE, IOVVA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001 -69LV I ELEHHOIAL (503) 5d3-',113 / FAX (503) 583 =10 /10 / LIJIAIL iateWo u 1tyo`idubuqu ,.oI g CLAIM AGAI S THE CITY OF DUB QUE, IOWA This written report co stitutes your against the City of Dubuque, Iowa. complete this form in full and attach any additional that supports your clai You should The Claim n st be file with the City Clerk at City U, 50 . 13th St., Dubuque, IA 52001, will the be referred by the City Council to the appropriate depart lent for vestigation. 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 HETHER YOUR CLAIM WILL OR WILL NOT BE PAID. 1. Name of Claimant: 2. Address: 3. Telephone Number: 4. Date of Incident: 5. Time of Incident: 6. Location of Incident (Be specific): o r /0 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.) .Lo (-1, G4-1 / C,',A) nel (7, 674-x 8. What ea.ther conditions like? 9. Give • arne a d address of any witnesses: Did police vestigate? (If so, give names .f officers.) 11. as anys e inj red? (if so, give names, addresses, nd exte ° 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.) fe:'ee y pQ / / rr.c./0/ ( ( (.4, /-NrI lo& 7 13. What other damages do you claim, 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.) 7,-) C2 15. What amount do you claim from the City of Dubuque? 16. Why do you claim the City of Dubuque is responsible? C c..(1 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) A) 0 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? Dated at Dubuque, Iowa this / day of C/f , 20 / (Rev. 1/00 & 7/01) (Signature) (Print Name)