Worker's Compensation Settlement AgreementTHE CITY OF
DUB E MEMORANDUM
Masterpiece on tl Mississippi
BARRY LIN� • L
CITY ATTO :NEY
To:
Mayor Roy D. Buol and
Members of the City Council
DATE: January 3, 2013
RE: Jim Melloy vs. City of Dubuque — Workers' Compensation Claim
Attorney Les Reddick, representing the City of Dubuque, is recommending approval of
an Agreement for Settlement regarding a workers' compensation claim that was filed
against the City of Dubuque by Jim Melloy. Mr. Melloy is an employee of the City of
Dubuque Transit Department and was injured while at work.
Mr. Reddick negotiated a settlement amount of $6,568.60 with Mr. Melloy's attorney,
Nick Avgerinos. This settlement is intended to reflect a reasonable amount for Mr.
Melloy's injury.
I recommend approval of this Agreement for Settlement.
BAL:tis
cc: Michael C. Van Milligen, City Manager
Cindy Steinhauser, Assistant City Manager
Randy Peck, Personnel Manager
Barbara Morck, Transit Manager
Les Reddick, Esq.
F:\ USERS \tsteckle \Lindahl\ Memos\ MayorCouncil _MelloyWkrsCompClaim_010313.doc
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 balesq @cityofdubuque.org
THE care OF
DUB
E MEMORANDUM
s rpleco ®u Miami
TRACEY STECKLEIN
PARALEGAL
MEMO
To: Kevin Firnstahl
City Clerk
DATE: January 7, 2013
RE: Jim Mellow Workers' Compensation Claim [Jim Melloy]
Kevin:
Attached for City Council approval and the City Manager's signature at the January 22,
2013 City Council meeting is the original Melloy Workers' Compensation Settlement
Agreement. I would appreciate it if you would please return the original Agreement to
me after it has been signed by the City Manager and I will forward it to Les Reddick.
Thank you.
Attachment
F: \USERS \tsteckle \Department Correspondence\ Transit \Firnstahl_ MelloySettlementAgreement _010713.doc
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
BEFORE THE IOWA WORKERS' COMPENSATION COMMISSIONER
JIM MELLOY
Claimant, : Contested Case File No.
vs. : Compliance File No.
CITY OF DUBUQUE Injury Date: 6/29/2011
Employer,
and : AGREEMENT FOR SETTLEMENT
Iowa Code Section 85.35(2)
Insurance Carrier,
Defendants.
The undersigned parties submit this Agreement for Settlement to the Workers'
Compensation Commissioner for approval. The parties agree:
1. Claimant sustained an injury arising out of and in the course of employment
with Employer on 6/29/2011 (date).
2. Jurisdiction exists because the injury occurred n Iowa OR Iowa Code section
85.71( ) applies. (Circle one.)
3. Claimant is married /single (circle one), entitled to 2 exemption(s) and gross
weekly earnings are $ 467.90 using Iowa Code section 85.36(__!_).
The rate of weekly compensation is $ 328.43 . (If the rate for PPD
differs it is $ per week.)
4. The injury caused Claimant to sustain the following disability and resulting
entitlement to compensation:
a. Temporary total disability /temporary partial disability /healing period
compensation for weeks from (date) thru
(date). Iowa Code sections 85.33, 85.34(1). (A detailed
description may be attached.) See attached claim detail.
b. Permanent partial disability for 5 % loss of whole body
(member or earning capacity) resulting in 25 weeks of compensation
under Iowa Code Section 85.34(2)(u ) payable commencing
6/27/2012 (date).
c. Other compensation or benefits consisting of
5. Benefits that accrued and were paid are shown in the attached
payment activity report (PAR), dated
Benefits that remain to be paid are
$6,568.60 (20 weeks PPD)
6. The employer /insurance carrier shall file a final electronic Subsequent
Report of Injury [SROI (FN)] and mail Claimant a PAR that contains the
information in the final SROI, including the date that weekly
compensation was last paid. Rules 876 IAC 2.6, 3.1(2), and 11.7.
7. This settlement waives a hearing, decision, and resulting statutory benefits. It
is subject to review - reopening for three years following the last date that
weekly compensation is paid. Iowa Code sections 85.26(2) and 86.14.
8. Claimant is entitled to medical care for the injury, including care in the future.
Iowa Code sections 85.26(2) and 85.27. (A detailed description may be attached.)
9. Evidence that corroborates this settlement attached. A Claimant's
Statement is attached if claimant is not r resented by an attorney.
WHEREFORE, the parties request tha ' t is Settl ,,(be approved.
e 1ct ' iI •
dC im Me rRaetitl Date Claiman
oy� Nick J. _
Employer /Insurer Date
Michael Van Milligen
orn
erin
% ;44
Date
Employer /Insurer's Attorney Date
Les V. Rdddick
ORDER
I find that substantial evidence supports the terms of the foregoing settlement,
the employee knowingly waives hearing, decision, and resulting statutory
benefits and the settlement is a reasonable and informed compromise of the
competing interests of the parties. The foregoing settlement is therefore
approved this day of , 20
Iowa Workers' Compensation Commissioner
The information provided will be open for public inspection under Iowa Code §§
22.11 and 86.45(1).
14 -0021 (7 -05)
IOWA R.
WORKFOB�
DEVELOPMENT