Claim by Jeffrey HerbstTHE CITY OF
D
LB
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
M FMORA1\ DUM
To: Mayor Roy D. Buol and
Members of the City Council
DATE: February 12, 2014
RE: Claim Against the City of Dubuque by Jeffrey M. Herbst
Claimant Date of Claim Date of Loss Nature of Claim
Jeffrey Herbst 02/10/14 02/05/14 Vehicle Damage
This is a claim in which claimant alleges that a City of Dubuque snow plow truck 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
John Klostermann, Street & Sewer Maintenance Supervisor
Jeffrey Herbst
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
h!('
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA /C
This written report constitutes your claim against the City of Dubuque, Iowa. shoul
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: g 1
2. Address:
3. Telephone Number: (
oi
0
(
4. Date of Incident: 0 2&, 4
5. Time of Incident: \[)/
6. Location of Incident (Be specific): -17,2 LE /\„,
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
(-(1
)
VA/1 k Ii rylit 1
erpployee's name.)
f
((is‘
8. What were weather conditions like?
,
9. Give name and address of any witnesses: ,J (A,4 « 4 7- 1
1,14,VC,'Art.
10. Did police i yeAtigate? (If so, give names of 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.)
\
yeA - s
11(.1A k:s
LA-L. -49 F-6) r- He:,
S e'LL.• L (wt.
IA, IA (:,t- r LLflL
13. What other damages do you claim, if any? 1j LtUL
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.)
\I)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
) .A..i co Li tr;
\T-)
0 if
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes,Igirve 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
(Print Name)