Claim by Daniel Bellows and Liberty Mutual THE CM OF
LTB MEMORANDUM
Masterpiece on the Mississippi 1
TRACEY STECKLEIN
PARALEGAL
I'
To: Mayor Roy D. Buol and
Members of the City Council
i,
DATE: September 29, 2015
RE: Claim Against the City of Dubuque by Daniel Bellowsfiled by Liberty
Mutual Insurance
li
Claimant Date of Claim Date of Loss Nature of Claim
I
Daniel Bellows 09/29/15 07/21/15 Personal Injury
Filed by Liberty Mutual
Insurance
This is a claim in which claimant alleges he injured his ankle after stepping off of a curb
at 1St & Central onto uneven pavement.
�I
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
John Klostermann, Street & Sewer Maintenance Supervisor
Gus Psihoyos, City Engineer
Kathryn LaGrassa, Liberty Mutual Insurance
ly
II
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
I
MV
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA I{
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.
i
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. a
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: t LA ®b
- -I � 3 1 N. �� c�c� ��,lx- ;I� 2 3
3. Telephone Number: 581 _ Avg I
4. Date of Incident: �,A
5. Time of Incident: " w
6. Location of Incident (Be specific): C"s. 6 aLtmAt- , slll()l"h E4LCnqJS
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.) l
2dldos wos I4eav na srn4h Ezrn�s anrA sk lamed
8. What were weather conditions like?
f
I
9. Give name and address of any witnesses: ��Ss V vilc p
10. Did police investigate? (If so, give names of officers.)'
ty®.
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.)
IVA
13. What other damages do you claim, if any? Media l (CSS S and [m�
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
15. What amount d' you claim from•the City of Dubuque?
4- g31(J cl
16. Why do you claim the City of Dubuque is responsible.
i a` C� o ,ti
S10-
17. Have you made any claim against anyone else for damages as a result of this incident? �
(If yes, give name and address.)
i
ti
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�.
f
06
i I
F
l
(Signature) n
A gM24��4 Print Name
f/�Su��IC
a
(Rev. 7112) o�SvcC�c�Ce. C6tv\w oc war
'P �0 `7 e cls C Ind5tr a�
Gc1)e-d)
U F- !S N T 5-I N t�
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 f
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:
�J 'M
1) Social Security Number(s) 0 !j
2) Medical/H,ealth 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 confidentiahnformation. Please indicate below the
type of informationthat is included
hereby certify that the attached do"cements
include the"olI' wing protected information:
it
Social Security Number(s) `' Bank Account Information
Medical/Health Information Financial Information
Personnel/Disciplinary Information Credit Card Number(s)
r
M
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 I'
protect my information from unnecessary distribution.
l
1115
Signature Date �—
i
I have read the information above and do not have any confidential,documentation to submit to the
Cityof Dubuque as part of this"Claim Against the City:
i
is a10
Signature VDate
CV
Liberty Mutual Insurance CompanyLibe
Mutual-
PO BOX 9102 INSURANCE
WESTON MA 02493 a
Telephone: (800) 762-5026
Fax: (603) 334-8901
September 15,2015
Barry A. Lindahl J
City Attorney's Office
Harbor View Place,Suite 330
300 Main Street
Dubuque IA 52001
RE: Employee: Daniel Bellows
Employer: WOODWARD COMMUNICATIONS,INC
Claim Number: WC868-C20812
Date of Injury: 07/21/2015
Dear Barry A. Lindahl:
Liberty Mutual Fire Insurance Company is the Workers'Compensation Carrier for WOODWARD
COMMUNICATIONS,INC. On 07/21/2015 Daniel Bellows sustained a work related injury. Liberty
Mutual Fire Insurance Company is paying Workers'Compensation Benefits.
Our investigation reveals this injury may have been caused by your negligence. Therefore, Liberty Mutual
Fire Insurance Company is placing you on notice of a potential claim to recover the money we have paid
Daniel Bellows in Workers'Compensation Benefits.
Please notify your insurance carrier of this potential claim. If you do not have insurance,please contact me
to discuss this claim.
You can reach me at extension 47088
Sincerely,
KATHRYN R LAGRASSA
RECOVERY SPECIALIST I
(800) 762-5026 Ext. 47088
cc: City Clerk/City Clerk's Office
i
a
f
5
r
G
j
Correspondence Copy#: 276436050
EX031201 —1A
a
Liberty Mutual Insurance Company Liberty
_al.
P.O. Box 9102 INSURANCE
Weston MA 02493
i
Telephone: (800) 762-5026
Fax: (603) 334-8901
September 15, 2015
City Clerk's Office
City Hall
50 W. 13th Street
Dubuque IA 52001
RE: Employee: Daniel Bellows
Employer: WOODWARD COMMUNICATIONS,INC
Contract#: WC2-Z91-453343-015-92
Claim #: WC868-C20812
Injury: Ankle - Sprain
Date of Injury: 07/21/2015
Date of Report: 07/22/2015
Dear City Clerk's Office:
Liberty Mutual Insurance Group has a lien on any third party action which may be filed in connection with
this accident. Your claim number is unknown at this time . A completed form for claim filing is attached.
The current amount of our lien is $787.90 which is comprised of medical benefits. This is NOT a final lien
amount.
Upon receipt of this correspondence, please advise the undersigned as to the updated status of the
above-captioned claim. Please contact the undersigned for a final lien amount, or with any questions you
might have,before settling or otherwise resolving this claim. I can be reached at 800-762-5026 x47088
Sincerely,
KATHRYN R LAGRASSA
RECOVERY SPECIALIST I
(800) 762-5026
ii
I
h
q
C
bl
ti
Correspondence Copy #: 936436150
EX014301 -1A
0