Claim by Nationwide Agribusiness Insurance / Mary Althaus THE CU�4QbE
DUB MEMORANDUM
Masterpiece on the Mississippi
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TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
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DATE: September 9, 2016
RE: Claim Against the City of Dubuque by Nationwide Agribusiness Insurance
Co. on behalf of Mary Althaus I
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Claimant Date of Claim Date of Loss Nature of Claim
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Nationwide Agribusiness 09/08/16 07/20/16 Vehicle Damage
Insurance Co. on behalf l
Of Mary Althaus
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This is a claim in which claimant alleges that while she was driving on W. Locust Street, {
a manhole cover popped up and claimant was unable to avoid hitting the hole and
sustained damage to her vehicle.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa 1
Communities Assurance Pool
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cc: Michael C. Van Milligen, City Manager
John Klostermann, Public Works Director
Nationwide Agribusiness Insurance Co.
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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
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: Nationwide Agribusiness Insurance Company a/s/o Mary Althaus
2. Address: Nationwide: 1100 Locust St, Dept 2019, Des Moines, IA 50391-2019
3. Telephone Number: 515-508-3025
4. Date of Incident: 7/20/2016
5. Time of Incident: 11:45 AM
6. Location of Incident (Be specific): West Locust near Rosedale, Dubuque, IA 52001
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.)
Our insured was traveling on West Locust when a manhole cover popped up-she was unable to avoid hitting the hole,
and her vehicle sustained damage as a result.
8. What were weather conditions like? Dark, Raining
9. Give name and address of any witnesses: Mary Althaus- 16715 Cordillera Dr, Peosta, IA 52068
10. Did police investigate? (If so, give names of officers.)
No - not called
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
N/A
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.)
Total: $2,570.57 ($2,070.57 paid by Nationwide; $500 paid by Althaus); There was damage to the rocker,
frame, rear suspension, fuel system, and quarter panel. See photos and estimate for further information.
13. What other damages do you claim, if any? N/A
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.)
$2,070.57 paid by Nationwide.
15. What amount do you claim from the City of Dubuque?
$2,570.57
16. Why do you claim the City of Dubuque is responsible?
Failure to maintain propt-fty
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
N/A
Dated at Dubuque, Iowa this 2nd day Of September 2016
(Signature)
Ashley Klocke of Nationwide Agribusiness Insurance Company (Print Name)
(Rev. 7/12)
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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:
1) Social Security Number(s)
2) Medical/Health 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 confidential information. Please indicate below the
type of information that is included.
1, Ashley Klocke hereby certify that the attached documents
include the following protected information:
Social Security Number(s) Bank Account Information
Medical/Health Information x 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.
alLu'_ u uk 9/2/2016
Signature U Date
I 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.
9/2/2016
Signature UDate