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Claim by Susan Swanson THE CITY OF UUBUQUE MEMORANDUM Masterpiece on the Mississippi TRACEY STECKLEIN PARALEGAL To: Mayor Roy D. Buol and Members of the City Council DATE: June 27, 2016 I RE: Claim Against the City of Dubuque by Susan Swanson Claimant Date of Claim Date of Loss Nature of Claim i Susan Swanson 06/27/16 06/14/16 Vehicle Damage This is a claim in which claimant alleges that a tree limb fell from a tree during a storm onto claimant's parked vehicle while claimant was staying at the Four Mounds Bed and Breakfast. 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 Susan Swanson 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 Gv� CLAIM AGAINST THE CITY OF DUBUQUE, IOWA • L��s� 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: �U San SWGL" S C" 2. Address: _3 22UA-LA ku Dr. Z �.2 Clime _ rJ a�S 3 3. Telephone Number: 4. Date of Incident: LX k1 e, ° + O l (o 5. Time of Incident: ��'fl� �t,*n I �P �IL4 0-nd TLkn C (L 6. Location of Incident (Be specific): ),CLrl.L-,-n2, oLreo Arr a u t.S+z5 OT cirw F-6 U Sc rYl Ov,-nds -'�3 , l-0, Ptd � -S Oac D 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.) came. a �fi O�vundl I� �oAm, � I( i -0 -�n01 da�laac +) © V,-a wn an d a +rze I VV40 clear \(a r, . i;a.rk res;d ui or, 8. What were weather conditions like? C lea i but had be eii Se v erg r-co-, 1w)"A ` e-rcv, 9. Give name and address of any witnesses: C k ri s�7 e O(Svc . c-ud •NN�ecf6r f-bcLr/noLk,1cU 10. Did police investigate? (If so, give names of officer ) —Kt . & a I '�:)t.6 u 9 ue, 0f10cAr-n els cfli� ce P1 af�� 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). NO . 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.) 13. What other damages do you claim, if any? 1y O Y C, 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.) fro . W k)QVG P7o CDnf r¢n e hSivo, CouuA.�t - 15. XVhat amount do you claim from the City of Dubuque? 1$ !�$ (!I. 7 (, 16. Why do you claim the CityDubujque- is resp��gqnsible? cr7Hc c; or f1�c PttA bn —U7otc,lol kfee k"s 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? Dated at Dubuque, Iowa this _ day of JWO G 20 a'n A . � (Signature) Swanson (Print Name) cs� (Rev. 7/12) J5 �" •' r CD