Claim by Jennifer SwansonDUBWE MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
DATE: February 5, 2013
RE: Claim Against the City of Dubuque by Jennifer Swanson
Claimant Date of Claim Date of Loss Nature of Claim
Jennifer Swanson 02/14/13 01/30/13 Vehicle Damage
This is a claim in which claimant alleges that a City of Dubuque refuse truck slid on
snow and struck claimant's parked 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
Don Vogt, Public Works Director
Jennifer Swanson
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 farm 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.
I. Name of Claimant:
2 Address: • 15
3. .Telephone .Number: 565 -"
4. Date. of Incident:
5. Time of Incident:
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Location of incident (Be specific) : cin -t
c 9;
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?
9. Give name.and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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.)
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 you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is respon ible?
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17. Have you made any claim against anyone else for `damages as a result of this incident?
(If yes, ive name and address.)
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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 at day of
20 ).
(Signature)
(Print Name)
3130/1700'd
50:11.£i0Z/1£/10
Confidential
This communication and an 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 :Iiereby 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 Informati &n
3) Personnel /Disciplinary Information
4) . Bank: Account Informatio
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 attac ed directly to the confidential information and indicate the. type of
information that is included:
I,
include the following protected i formation:
Social Security Nu ber(s) Bank Account Information
Medical /Health Inf rmation Financial Information
Personnel/Discipli ary Info ation Credit Card [umber(s)
I understand that this inforrnati n ,: y be distributed within the City organization or to agents of the
City for processing and I herd: authorize the City to act accordingly taking all precautions to
protect my information from ecessaryydistribution,..
hereby ify that the attached documents
Signature
300 /ZOO 'd
(XVd)
Date
PO: II £IOZ /1£/•10•