Claim by Cynthia ThomasMasterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
MEMORANDUM
To: Mayor Roy D. Buol and
Members of the City Council
DATE: October 8, 2012
RE: Claim Against the City of Dubuque by Cynthia Thomas, filed by Attorney
Dan McClean
Claimant Date of Claim Date of Loss Nature of Claim
Cynthia Thomas 10/05/12 06/30/12 Personal Injury
This is a claim in which claimant alleges that she was injured while riding the slide at
Flora Pool.
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
Marie Ware, Leisure Services Manager
Dan McClean, Esq.
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 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 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:
2. Address:
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific):
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.)
8. What were weather conditions like?
9. Give name,and address of any witnesses:
10. Dfd police investigate? (If so, give names oT officers.
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?
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 y9u claim from the City of Dubuque?
buque is responsible?
16. Vh
\,1
do you claim the of
of
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes,Ove name and address.)
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 12" day of ' , 20 i a
(Signature)
(Print Name)
(Rev. 7/12)
MCCCLEAN, HEAVENS VORWALD
LAW OFFICES
Dan McClean
Courtney Vorwald
401 First Avenue East
Dyersville, IA 52040
Ph. 563 - 875 -6002
FAX 563 - 875 -7534
McCleanLaw @Iowatelecom.net
October 4, 2012
City Clerk
City of Dubuque
50 W. 13th Street
Dubuque, IA 52001
Re: City of Dubuque vs. Thomas
Dear City Clerk:
Alan Heavens
120 N. Main St., Box 116
Elkader, IA 52043
Ph. 563 - 245 -3890
FAX 563 - 245 -3889
Aheavens @windstream.net
Enclosed you will find the written report for claim against the City of Dubuque. This
claim involves the Flora Swimming Pool.
I am representing Cynthia Thomas regarding this matter. You may forward all future
correspondence directly to my office in Dyersville.
If you have any questions, please feel free to contact me.
Thank you.
DM: tl
Encl.
Sincerely,
Dan McClean
Confidential
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.
1
include the following protected information:
t Social Security Numbers) Bank Account Information
Medical /Health Information Financial Information
Personnel /Disciplinary 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.
, hereby certify that the attached documents