Claim by Jerrod Wernimont THE CDij-
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E MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
DATE: June 15, 2016
RE: Claim Against the City of Dubuque by Jarrod Wernimont
Claimant Date of Claim Date of Loss Nature of Claim
Jarrod Wernimont 06/14/16 05/09/16/15 Property Damage
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This is a claim in which claimant alleges that while a City Leisure Services employee
was mowing grass near the corner of Walnut Street and University Avenue, the
employee slid down the hill with the lawnmower and collided with claimant's parked
motorcycle, damaging the motorcycle.
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
Steve Fehsal, Park Division Manager
Jarrod Wernimont
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
Jun 14 2016 10:38 HP Fax page 3 I ' Ali IY 1
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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. i
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: 3 a-frac -Wee n1, rnon
2. Address: 1130q ill rpt- 157- DL&bvq ue ,. r 2
3. Telephone Number (,
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4. Date of Incident: .� -,-k , Zo!t�
5. Time of Incident: w in A� 9 aAA,t
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6. Location of9Incident (Be specific): y-
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7. Describe the 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? Jvr 4wr4-V-f-r•
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9. Give name and address of any witnesses:
10_ Did police investigate? (If so, give names of officers.)
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Jun 14 -2016 10:38 HP Fax page 4
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Jun 14 2016 10:38 HP Fax page 5
11 . Was anyone injured? (if so,Frgive 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.)
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13. What other damages do you claim, if any?
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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 the City of Dubuque?
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16. Why do you claim the City 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.)
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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 this E Y day of 20�C ? ' '
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(Print Name) > CM-
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Jun 14 2016 1038 HP Fax page 1
HE RIG INSURANCE & REAL ESTATE
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3686 Croscent Ridge. Dubuque, Iowa 52.003
1,1114.311c: �,63.556-1490 . Fak: 50,550-1550
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DISCIALME'R
*1 6e informaxion eo-ntaincd in this facsim-fk- mcssagt is lwkmidiedl for
rVOPWnts and fll-61Y C-Onjj.jjj CL)TO on, I %oti rcuei vo-i oii,; ail'-,rmunori in error. anr v
or Copy-fle of mohiNtcul, It you havv received this
I this, ir-11,6mouon is striotly I
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c0j"1117)unicat ion in errof..Please noti f\ UN 0% te1cphone wul rctimi the original inns age to us bv,
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Jun 14 2016 10:38 HP Fax Page 2
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:
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1) Social Security Number(s)
2) MedicallHealth 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 1
this cover sheet must be attached directly to the confidential information and indicate the type of
information that is included, {
I, ISTD . Vq4�rn-`rnrw4— , 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.
18ignature Date
have read the information above and do not have any confidential documentation to submit to the
City of Dubuque as part of this Claim Against the City
Signature Date