Claim by Kimberly BradleyTHE CITY OF
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
MFMORADUM
To: Mayor Roy D. Buol and
Members of the City Council
DATE: March 13, 2014
RE: Claim Against the City of Dubuque by Kimberly Bradley
Claimant Date of Claim Date of Loss Nature of Claim
Kimberly Bradley 03/12/14 12/24/13 Personal Injury
This is a claim in which claimant alleges that she tripped on a raised portion of sidewalk
in the 1700 block of Elm Street and injured herself.
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
Gus Psihoyos, City Engineer
Kimberly Bradley
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 form in full and aftach any additional information that
supports your claim.
The claim must be filed with the City Clerk at City Hall, 50 West 13th St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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:
2. Address: -vkberi
3. Telephone Number b ,4 . � p (N2A-k5 ..1
4. Date of Incident: /
5. Time of Incident: / e -Z4, /
6. Location of Incident (Be specific):
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7. Describe the accident or1occurrence 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 pol c,1e investigate? jf sp, give names of officers.
11. Was anyone injured? (Ifso, 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.)
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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.)
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15. What amount /do you claim from the
City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
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 this day
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(Signature)
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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 and indicate the type of
information that is included.
include the followrhg prote'cted informatiofi:
Social Security Number(s)
Medical/Health Information
Personnel/Disciplinary Information
, hereby certify that the attached documents
Bank Account Information
Financial 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
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