Claim by Greg BornerTHE CITY OF
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
MF,MORANDLM
To: Mayor Roy D. Buol and
Members of the City Council
DATE: June 18, 2014
RE: Claim Against the City of Dubuque by Greg Borner
Claimant Date of Claim Date of Loss Nature of Claim
Greg Borner 06/18/14 01/10/14 Property Damage
This is a claim in which claimant alleges that a City water main break caused water
damage to claimant's basement, driveway, sidewalk, and backyard.
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
Greg Borner
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 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 NYL DCISION ALL THECLAIMS AUTIS MADE BY THE CITY COUNCIL. NO HORITY TO MAKE ANY REPRESENTATION TO YOU
PLOYEE OF
THE CITY OF DUBUQUE HAS
AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: C�l'c-l. 1Y \i)ef
2. Address: aq 05 Rk oat -6 Swe - b ubuchut, I
3. Telephone Number: 5103-
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4. Date of Incident: an, to
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5. Time of Incident: e - �� •'�^ • a
6. Location of Incident (Be specific): aln\C\OS6 * ' \v9 I
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
ve
full details upon which you base your claim. If a Cityemployee was involved, give
employee's name.)
C> (`iwc1 \N c X p\cc cen6 ODS'- Rusk
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,,. What were weather conditions like
Cob , 00 pCeCkp\-\--aVDr1
9. Give name and address of any
witnesses: ��
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\--e-\\&10. Did police investigate? (If so, give namofficers.)
11. Was anyone injured? (If so, 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.)
WOS 0 u -V o de ' rAoiev\iQL ra s\c
IstvAQ) 'e1deo\ entlfe. L wag\' o -s
13. What other damages do you claim, if any? --
Of OM( eAe
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
oot�and amount paid.) kr6
•Vack \Nts\ MAtwir\ \f\S lqa)
15. t amount do you claim from the City of Dubuque?
1Q., Why dp you, t‘-\--\ N')e \Mat c\Tde
he City of Dub que is r s on iblle 00(e C\ auf ,
\C)61/461A'i'i6 • tefe‘ as a result of this incident?
17. Havt you made any claim against anyone else for damage
(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 \1 day ofk_me, 20 \ i
(Rev. 7/12)
(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.
I, JC ner , hereby certify that the attached documents
include the foliowing protected information:
Social Security Number(s)
Medical/Health Information
Personnel/Disciplinary Information
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.
Signature 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.
Lo- 0- IL\
Date