Claim by Avery ButlerMasterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
MFMORANDUM
To: Mayor Roy D. Buol and
Members of the City Council
DATE: October 22, 2013
RE: Claim Against the City of Dubuque by Avery Butler
Claimant Date of Claim Date of Loss Nature of Claim
Avery Butler 10/21/13 10/18/13 Property Damage
This is a claim in which claimant alleges that his bicycle was damaged while secured to
a City of Dubuque bus bicycle rack. The bus and bicycle rack were struck by an
oncoming 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
Jodi Johnson, Transit Manager
Avery Butler
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
report constitutes your claim against the City of Dubuque, Iowa. You should
This written rep supports your claim.
complete this form in full and attach any additional information that supp IA 52001. It
Claim must be filed with the City Clerk at City appropriate 50ia W. 13th
departm Dubuque, IA 5 investigation.
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The the City Council to the pp p
Once then be referred tiga i by Y
investigation ation is completed, a report and recommendation rcommendat ontted tot the
Once that in g provided with a copy of that report
City Council. You will be p
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY
REPRESENTATION UNCIL. EMPLOYEE YOU
THE CITY OF DUBUQUE HAS M WILL OR WILL NOT BE PAID.
AS TO WHETHER YOUR CLAIM
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
you base your claim. If a City employee was involved, give the
full details upon which y
employee's name.)
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).
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?
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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 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 payment from that source,
and if so, in what amount?
Dated at Dubuque, Iowa this day of , 20
(Signatur'e)
(Print Name)
(Rev. 7/12)
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