Loading...
Claim by Barbara LombardiTHE CITY OF DUB E MEMORANDUM Masterpiece on the Mississippi TRACEY STECKLEIN PARALEGAL *P. To: Mayor Roy D. Buol and Members of the City Council DATE: September 15, 2014 RE: Claim Against the City of Dubuque by Barbara Lombardi Claimant Date of Claim Date of Loss Nature of Claim Barbara Lombardi 09/12/14 08/13/14 Personal Injury This is a claim in which claimant alleges that she was injured while walking through a construction zone area on 14th Street between White and Jackson Streets. Claimant attempted to brace herself on two blocks of cement which were located by a "Sidewalk Closed" sign, and the blocks fell onto her leg. 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 John Klostermann, Street & Sewer Maintenance Supervisor Barbara Lombardi 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 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: ..1q,/1- MPuiblic.001,5 I� ce/ Address: ` 3 q U L4 i k(+ 5 411 j b ip• (�`Z©0 3. Telephone Num 51 6 3 b�<J 47- 4! P � 4. Date of Incident: c7/ � � — � 5. Time of Incident: J O n / 0 , Yvl, 6. Lo ton of Inci ent (Be specific : a sh S H' b Q Z' I--, L 1 (�M' r _. c' z2 (,AAA--1 1 tel. �1. (0,61-11k, l )11"1 � ,�- v'14 -K , a o,✓� u 7. Describe the Accident or occurrence th t caused incur or damage. (Give full details upon which you base your claim. f a City employee was involved, give the employee's name.) 8. What vere weather conditions ike? ct,° (9761A.A. f U- 13 @ r- 9. 9. Give name and address of any witnesses: �/ ca /1)2- 10. I)2 10. Did ce investigate? (If so, give names of officers.) V t -44 `3 CO `i . ,1/d .'t' -1--16967C I 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). , r C c 12. Was any damage done to property? (If s•, desbribe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.) tbi lot 13. What othe damages do you claim, if any? c -v (I1t 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 f)5 15. What amount do you claim from the City of Dubuque? 16. by do you laim the City of Dubuque is responsible? —r-- 17. ave you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) (4,4j c 18. If the answer to Question 17 is yes, have you received any payment from that source,andjf so, in what amount? Dated this/Ji'iiayof Signature) ,20J w42/. City Clerk's Office 50 W. 13th. St. Dubuque, IA 52001 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 lnformation 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. I, , hereby certify that the attached documents include the following protected information: Social Security Number(s) Bank Account Information Medical/Health Information Financial Information Personnel/Disciplinary 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 I have read the information above and do not have any confi e tial d cumentation to submit to the City of Dubuq e as part of this Claim Against the City a+ Date