Claim by Shannon Martin THE CITY OF
UUBUME MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and Ij
Members of the City Council
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DATE: December 1, 2015
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RE: Claim Against the City of Dubuque by Shannon Martin
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Claimant Date of Claim Date of Loss Nature of Claim
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Shannon Martin 11/30/15 10/13/15 Property Damage
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This is a claim in which claimant alleges that her basement sustained water damage
due to a watermain break on Windsor Avenue.
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
Shannon Martin
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OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA t
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944 4'
TELEPHONE (563)583-4113/FAx (563)583-1040/EMAIL tsteckle@cityofdubuque.org
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rdLec.'IGS
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA We&& t
This written report constitutes your claim against the City of Dubuque, Iowa, You i
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: In L
2. Address: -41L
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3. Telephone Number LQ 3 - 1-1 1 -® !�A
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4. Date of Incident:
5. Time of Incident: rI °)
6. Location of Incident (Be pecific):
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7. Describe the accident or occurrence that cased injury or dam e, (Give full
details upon which you base your claim. If a City employee was involved, give
the employees name.)
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8, What were weather corrdions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, gJve 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 damn e.)
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13. What other damaget do you claim, iny?
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.)
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15. What amount do you claim from t e City of Dubuque?
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16. Why do you claim the Cit of Dubuque is responsible?
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17, Have you made any claim against anyone else for damages as a result of
this incident? (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?
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r-fYa-W this - day of �� r e,41- 20 t�. � c::) M
(Signature)
(Print Name)
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