Claim by Monical HalversonTHE CITY OF
Masterpiece on the Mississippi
TRACEY STECKLEIN f
P
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
August 16, 2012
Claim Against the City of Dubuque by Monica Halverson
Monica Halverson
08/15/12
07/26/12
Vehicle Damage
This is a claim in which claimant alleges that a City of Dubuque refuse truck struck and
damaged the driver's side mirror of 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
Paul Schultz, Resource Management Coordinator
Monica Halverson
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
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 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
AUTHORITY ®Y TO MAKE ANY EMPLOYEE OF TO YOU
THE CITY OF DUBUQUE HAS T HE
AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
Name of Claimant:
2. Address:
3. Telephone Numb(
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific):
7. • OCCURRENCE _
DESCRIBE full details upon which you :., employee a involved, �..
• �. • claim.
employee's name.)
8. What were weather conditions like? All
9. Give name and address of any witnesses:
10. Did police investigate? (if so, give names of officers.)
f�
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.)
13. What other damages do you claim, if any? No L
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 amount do you claim from the City of Dubuque?
This communication and any attachments may contain information which is confidential
and privileged by law and is for the use of the designated recipient. If you are not the
intended recipient, you are hereby notified that you have received this communication in
error, and that any review, disclosure, dissemination, distribution or copying of its contents
is prohibited. Please notify City of Dubuque immediately by telephone at (563)- 589 -4120 of
your receipt of these items and destroy the communication and any attachments
immediately. Further disclosure of this information may violate state and federal
restrictions.
Confidential information may include the following:
1) Social Security Number(s)
2) Medical /Health Information
3) Personnel /Disciplinary Information
4) Bank Account Information
5) Financial Information
6) Credit Card Numbers
If any documentation you desire to submit to the City of Dubuque contains any of the items above
this cover sheet must be attached directly to the confidential information and indicate the type of
information that is included.
include the following rotected information:
Social Security Number(s)
Medical /Health Information
Personnel /Disciplinary Information
hereby certify that the attached documents
Bank Account Information
Financial Information
Credit Card Number(s)
I understand that this information may be distributed within the City organization or to agents of the
City for processing and I hereby authorize the City to act accordingly taking all precautions to
protect my information from unnecessary distribution.
ignature
c./
Date