Claim by Deb LynchTHE CITY OF
DUB E M N,MORAN DUM
Masterpiece an the Mississippi
TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
DATE: August 23, 2013
RE: Claim Against the City of Dubuque by Deb Lynch
Claimant Date of Claim Date of Loss Nature of Claim
Deb Lynch 08/22/13 08/16/13 Vehicle Damage
This is a claim in which claimant alleges her parked vehicle was struck by a City of
Dubuque fire truck near the intersection of 7th Street and Central Avenue.
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
Dan Brown, Fire Chief
Deb Lynch
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
American Family Ins. 8/20/2013 3:37:00 PM PAGE 3/007 Fax Server
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 Hail, 50 W. 13th St., Dubuque, IA 52001. It
will then be referred by the City Council to the appropriate deparbnent 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 15 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): E-Tt + et11+a4-1 1114 "F'W. lisA:14% .
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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.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
American Family Ins. 8/20/2013 3:37:00 PM PAGE 4/007 Fax Server
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.)
1 What amount do you claim from the City of Dubuque?
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16 Why do you claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for damages as a result of this incident?
(if yes, give name and address.)
18. If the answer to Question 17 is yes, have you received any payrnent from that source,
and if so, in what amount?
Dated at Dubuque, Iowa this
(Rev. 7/12)
20)3
(Signature)
(Print Name)
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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. Please indicate below the
type of information that is included.
include the following rotected information:
, hereby certify that the attached documents
Social Security Number(s) Bank Account Information
MedicaVHealth Information Financial Information
/Personnel/Disciplinary 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.
Date
I have read the information above and do not have any confidential documentation to submit to the
City of Dubuque as part of this Claim Against the City.
Signature
Date
American Family Ins. 8/20/2013 3:37:00 PM PAGE 1/007 Fax Server
MERICAN FAMILY
N SU R AN, C, E
American Family Insurance Group
Scanning Center
6000 American Pkwy
Madison, WI 53783 -0001
Facsimile Cover Sheet
To:
Company:
City /State:
Phone:
Fax:
City of Clerks- IA Dubuque
563 589 0890
From:
Company: American Family Insurance Group
Phone:
Fax:
Comments: American Family insurance
Adjuster Natalie Eyre
Clm # 2I 5 03007I
phn# 1 800 692 6326 ext 62245
The information contained in this facsimile message is attorney privileged and/or confidential information intended only for the
use of the individual or entity named above. If the reader of this message is not the intended recipient, or the employee or
agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution, or copying
of this communication is strictly prohibited If you have received this communication in error please notify us immediately by
telephone using our toll free number 1 -800- 374 -1111 at the extension identified in the American Family phone number
provided above so we may arrange for the return of this material at our expense. Thank you.
Date & Time of Transmission: 8/20/2013 3:36:30 PM
Number of pages including this cover sheet: 7