Claim by Ron Smith & Sons Construction THE CPPY OF
DUBtJQtJE MEMORANDUM
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TRACEY STECKLEIN I
PARALEGAL
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To: Mayor Roy D. Buol andI
Members of the City Council
DATE: February 16, 2016
RE: Claim Against the City of Dubuque by Ron Smith & Sons Construction h
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Claimant Date of Claim Date of Loss Nature of Claim
Ron Smith 02/12/16 02/02/16 Vehicle Damage
& Sons Construction
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This is a claim in which claimant alleges that a City of Dubuque snowplow truck struck
claimant's parked vehicle on Cottonwood Court.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa ?.
Communities Assurance Pool.
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cc: Michael C. Van Milligen, City Manager
John Klostermann, Street & Sewer Maintenance Supervisor
Ron Smith & Sons Construction
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
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA pub 11c, �M5
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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.
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1. Name of Claimant: Tob LYRI& -4 ',Vh M6
2. Address: il beere-
3. Telephone Number: 9
4. Date of Incident: C�0
5. Time of Incident:
6. Location of Incident (Be specific)
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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.)
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8. What were weather conditions like?
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9. Give name and address of any witnesses: qoyi 1,3mA /2 /2- 7f_AO
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10. Did police investigate? (if so, give names of officers
11. Was anyone injured? (if so, give 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
damage.)
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13. What other damages do you claim, if any? f r S
14. Have you been compensated for any part or all of your claim by any insurance I
company? (if so, give name and address of insurance company and amount paid.)
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15. What amount do you clairp from he City f Dubuque?
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16. Why do you claim he City of Dubuque is res onsiblO
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, dive name and address..)
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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 � r � , 20
(Signature)
(Print Name)
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(Rev. 7112) 0 I
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