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Claim by Paul SchiffmanBARRY A. LINDAHL, ESQ. CITY ATTORNEY MEMO To: DATE: RE: Claimant Mayor Roy D. Buol and Members of the City Council June 27, 2007 Claim against the City of Dubuque by Paul Schiffman Date of Claim Paul Schiffman 06/26/07 Date of Loss 06/14/07 Nature of Claim Personal Injury This is a claim in which the claimant alleges that the rear-end of his vehicle was damaged after he attempted to back out of his driveway at 2195 Delmonaco Drive, and struck a City of Dubuque utility trailer which was hooked up to a City dump truck. Claimant alleges that the trailer was parked half way into the entrance of his driveway. This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa Communities Assurance Pool. BAL:tIs cc: Michael C. Van Milligen, City Manager Jeanne Schneider, City Clerk John Klostermann, Street & Sewer Maintenance Supervisor Paul Schiffman 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 balesq@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 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: ~A-lt L ~L' ~'lc ~Nt ~~ 2. Address: 02l 9 S~ ~e,~/120~~0 ~2 ~u6u-~u~, -~ s ~©oi-- 3. Telephone Number 1. S'le 3> ~~3-- g/~O 4. Date of Incident: 5. Time of Incident: ~~~0(i-ncJ 6. Location of Incident (Be specific): - l1 ~ r ©e .F~o,~-- ~ ..~' Luc, `Zeno ~ - ~ o F ~y~ ~e 7. Describe the 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.) 9. Give name and address of any witnesses: `vLO ,tie. 10. Did police investigate? (ff so, give names of officers.) ~~ -~~ ~~ a ali~ ~~ ~~~ ~~ ~~~ IJt-~ o v ~v ~-e. !J~ /~ ~ ca,tiri ~ - Gtv4w/ ~ ~/l `yw _+ wrr _. K.v ..v, .r ~v v.. ... .- - ~ ..r- ..-. _ _ 8. What were weather conditions like? a ~,~ 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). '72 d 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.) U 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.) ~~- 51 ~~ ~w ~ ~` S''o a o~ ~ -~ .gym e.,u c n n0 ~~ r ~ TT s 15. W t do you claim from the City of Dubuque? ~s~ 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.) ,.r1•c-V . 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? t Dated- this ~ ~ S day of ~c,c a ~ ~ 20 ~ ~ ~E ~ y ~~+~'EG~~ (Signature) cs ~c w~ 9z ~nr co (Print Name) Q~n~~J~~ ~~ Driver Information Exchange Report Dubuque Police Department 563-589-4410 Drivers Name -Last First Middle Suffix Date of Birth U SCHIFFMAN PAUL VALENTINE 03/16/1930 N I Address 2195 DELMONACO DR City DUBUQUE State IA Z1p 52002-0000 Phone T Gender Male Dr'iver's License Number 767YY3340 Class State Endorsements Restrictions Insurance Co. Name Insurance Co. Phone # C IA NONE B AMERICAN FAMILY MUTUAL (563) 582-5898 x 001 Owner Company Name Insurance Policy # 034536870284FPPAIA Owner's Name -Last First Middle Suffix SCHIFFMAN PAUL VALENTINE Address City State Zip 2185 DELMONACO DR DUBUQUE IA 52002-0000 VIN No. 2C4GP54L25R541453 Year 2005 Make CHRY Model TOWN~COUNTRY Style VAN Vehicle Configuration License Plate # 759PZG State Year Most Damaged Area Approximate Cost to Repair or Replace IA 2007 $1,200.00 Driver's Name -Last First Middle Suffer Date of Birth U N I Address City State Zip Phone T Gender Drivers License Number Class State Endorsements Restrictions Insurance Co. Name Insurance Co Phone # NONE NONE . IOWA COMM. ASSURANCE 002 O,Nner Company Name Insurance Policy # CITY OF DUBUQUE ICP 0300 Owner's Name -Last First Middle Suffix Address City State Zip 50 WEST 13TH STREET DUBUQUE IA 52001- VIN No. UNKNOWN Year Make UTIL Model Style; Vehicle Configuration TRAILER FLATBED License Plate # 85750 State Year Most Damaged Area Approximate Cost to Repair or Replace IA 2007 $0.00 County Accident occurred within corporate limits of (city) Dubuque-31 Dubuque-2100 Literal Description "N/A" X-Coordinate Y-Coordinate ..N/A" "N/A.. If accident occurred outside of city li i " Direction Nearest City Route (Cardinal m ts show general vacinity: NIA" "N/A" of "N/A" Travel Direction "N/A" On Road, Street, or Highway: At Intersection v~ith: DELMONICO STREET ••N/,q•• Distance 200 Ft Direction 7 W Distance " " Direction " " Milepost Number - and N/A N/A of "N/A" Or Definable; intersection, bridge, or railroad crossing KEYWAY DRIVE Officer RYAN STAN Badge No. Law Enforcement Case Number Date of Accident Time of Accident , 78E 01-07-25251 06/14/2007 08:30 Hrs. Printed At: Dubuque Police Department 06N4/2007 09:15 AM Page 1 Form #: 01-07-26251