Claim by Gary SieverdingTHE CITY OF
DUi1JE MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
DATE: May 28, 2014
RE: Claim Against the City of Dubuque by Gary Sieverding
Claimant Date of Claim Date of Loss Nature of Claim
Gary Sieverding 05/23/14 02/26/14 Vehicle Damage
This is a claim in which claimant alleges that his two vehicles sustained water and ice
damage while parked in his driveway at 3245 Kaufmann Avenue due to a watermain
break on Asbury Road.
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
Bob Green, Water Department Manager
Gary Sieverding
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
�r c1
Q obi
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 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:(N �� EK..6 -�
2. Address: /�45 `uf\A���
3. Telephone Number: ail �51e
4. Date of Incident:
5. Time of Incident:
5_- ,C'30k, '
6. Location of Incident (Be specific): 1-\40\ '4L i ,2 -J
1 -Ii CA As We K6(/'e 4I pe 14,/,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.)
\j KAPA f DO. t\-- V-ta C1-
' -
S'‘ ) L G i)(\6.\:Au(' \M\N ,% (6 \k_L \'.—C 16
8. What were weather condi "ons like? ? •ctTiR
9. Give name and address of any witnesses: QOL(l,., Pkmol
10. Did police investigate? (If so, give names of officers.)
[do CRN r),".(�1z��
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.
Lkak—
�i,� 1\ nii1 C-1)0)
`‘,1\ Kte \
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. WhatTy�t,do claim from the City of Dubuque?
7
16 Why do you claim t e City of DulNque+is responsible?
17. Have you made any claim against anyone else for damages as a result of this incident?
Wm, give name and address.)
L
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 ,r }i\ day of +V\G, , 20
Cf -a e 611-7
(Rev. 7/12)
(Signature)
(Print Name)
0
C -
n
0- --- N
C tD W
a mc
E2.3 r
n O
N
m
m
0