Claim by Area Residential Care THE CITY OF
DUBUME MEMORANDUM
Masterpiece on tine Mississippi
TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
DATE: October 23, 2014
RE: Claim Against the City of Dubuque by Area Residential Care
Claimant Date of Claim Date of Loss Nature of Claim
Area Residential Care 10/20/14 07/17/14 Property Damage
c
This is a claim in which claimant alleges that a City of Dubuque bus struck and
damaged the canopy on claimant's property.
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
Candace Eudaley, Transit Manager
Karl Stieglitz, Area Residential Care
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
My
rQ n��Ik
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 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: JJ 4 ,.1,I16P
3. Telephone Number:
4. Date of Incident:
et a
5. Time of Incident: lL� ✓✓1 p ��� /�`���
6. Location of Incident(Be specific):
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.)
,5�� a4t-� 6;4e-.,
8. What were weather conditions like? d
9. Give name and address of any witnesses:
10. Did police investig te? (Ifs give names of officers.)
11. Was anyoneA i/nju d? (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.)-
&xe -
13. What other damages do yo cialm, 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. What amount Ifo you claim from the City of Dubuque?
16. Why do yo clai the City of ubuque is responsi ?
17. Have you m e any claim against anyone else for damages as a result of this incident?
(if yes, give name and address.) A/19
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 / ® day of _ 20
- JI (Signature)
(Print Name)
E7 .r
(Rev. 7/12) coo
o m
N
r_ ITI
C;).
j= M
CD cn
c.n
August 2007
VEHICLE ACCIDENT REPORT FORM
All work-related accidents require the following notification/action steps:
1. All accidents that occur on public or private property must be reported to the police department. This
report will document/verify the information needed for insurance purposes.
2. Driver of agency vehicle must contact his/her immediate supervisor to report accident as soon as possible,
and no later than within 24 hours. Immediate supervisor will require the staff person to detail an account of
the accident.Using this account, immediate supervisor will then contact Facility Operations Director and
Finance Director to facilitate maintenance and insurance action.
3. For accidents that occur on private property that the police do not file a report with the Iowa Department
of Transportation,the driver of the ager y vehicle is responsible for obtaining the following information:
Date/Time accident occurred: /� /-1 ea
Location of accident(include addre so ¢¢ent' buildings so exact area can b identified;e.g.,parkin It at South Locust,Hy Yee store)
Area Residential Care vehicle involved: _Yes No If yes,complete parts a,b,&c. If no,complete a&b only.
a. From the other vehicle operator's drivers license:
First name: f Middle initial: Last name: l �
Driver's license#and issuing state:
Date of birth:
Current address:
City: State: Zip Code:
b. Other information:
Insurance company name: Phone number:
Insurance agent name:
Insurance agent address: Phone number:
Policy number:
Type of vehicle. aj.c"— Year: Make: Model: Style:
License plate# and state: zo
Home phone number: Work phone number:
Witnesses names and phone#:
Occupants of other vehicles:
c. Area Residential Care employee inrmation:
Name of employee driving vehicle:
Agency vehicle license plate#: gency y chicle VIN#:
Other employees and individuals involved:
Did anyone need medical attention? Yes No If yes,who?
4. Finance Director will meet with employee within 72 hour period to formally document the accident report
to State of Iowa(IDOT)and Area Residential Care insurance carriers.
5. USE BACK OF FORM FOR A WRITTEN DESCRIPTION OF THE ACC
i
�� �� �-
c" �
VY � I��
��
����
� F� ����� � �i
� � ��
��- ���
� ',�
4
I
��
��
� � ��� ii
�� '�
��
���,
l'i
_.� �,
. .
11
i
��
��
4
z
s
�I
0