Bergstrom (2) GOLDSTEIN & SUTOR P��� ��=������� �
, ATTORNEYS AT LAW ��;��I �/� ZO�3
CITY CL��K
October 30, 2013 Will Sutor
Direct Dial: 612-977-1048
will@goldsteinsutor.com
City Clerk
310 City Hall
15 Kellogg Blvd.West
Saint Paul, MN 55102
- i
Re: Notice of Claim
Our Client: John Bergstrom
Date of Accident: 07/12/13
Our File No.: 13-1774
Dear City of St. Paul,
Please be advised the undersigned represents John Bergstrom regarding claims arising out of the
above-captioned accident that occurred near the intersection of West 7th Street and Delaware
Avenue in St. Paul, Minnesota. John Bergstrom was the driver of the vehicle that was rear-ended
by Andrew Justin whom was employed by the City of St. Paul. John Bergstrom has sustained
injuries as a result of this accident.
John Bergstrom is asserting a bodily injury claim against the City of St. Paul for the negligence of its
employee in causing this accident. If the vehicle your employee was driving was covered by
automobile liability insurance at the time of this accident, please forward this information to the
insurer and ask them to contact me as soon as possible.
Enclosed please find the applicable Notice of Claim Form completed by John Bergstrom on July 24,
2013.
Thank you for your cooperation.
Very truly,
�� �•
Will Sutor
Attorney
WKS:Iec
cc: John Bergstrom
2550 Blaisdell Avenue South I Minneapolis, Minnesota 55404 I Office 612.977.1040 I Fax 612.977.1043 I www.goldsteinsutor.com
��c�e����
[�pv �4 2013 NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
��'�`� C L�fr�a State Statute 466.05 states thnt".,.every person...who claims damages from any municipality...shadl cause to be presented to the
governing body of the munlcipality witfzin 181J days after dhe allegerl loss or injury is discovered a notice stating the time,place,and
circumstances ihereof,and the amount of compensation or other relief demanded."
Please complete tlus form in its entirety by clearly typing or printing your answer to each questton. If more space is
needed,attach additional sheets. Please note that you wiil not loe contacted by telepbone to clarify answers,so provide as
mach information as necessary to ea�plain your claim,and the amount of compensation being requested. You wiIl receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on tbe
nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'.
SEND CUMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL,MN 55102
First Name �� /, i� MiddIe Initi�l�Last Name ��/� �'S /���
Company or Business Name
Are You an Insurance Company? Yes/� If Yes,Claim Number7
Street Address 6 c�6.5 �,�.�(��'(l7��� �/Q�/�
City���/�� �I�d 1�� �G'T'5; State /�/�/✓tS'0 �f� Zip Code J` o �
Daytime Phone(�����,�Cell Phone(_) - Evening Telephone(b�1)�S..� �7
Date of Aecident/Injury or Date Discovered�v������o /.� Time -��/pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.,
��j:��� F � cc,=�v,�.� �.� � i f� c��Z y oF f T; p�-v[. r�1�a��,�. r.�� L
, � L.i� s " .c�'��,+� � r ^� • b " f� T�R� s ! v c
� �. ree�,Q o� �9Y C.42 r-���7�i �''�vcJ r"=oRr� ,��-r rorA�.�a �rv CaR An��
�, > E � � ` Ep os �1 a/✓ �Gv
W ' 'e T'h e r' uck �a S' I ✓en! A .i /YI s �i�'�S 7i.✓
/1-,11 %S �A�.�6C1A /�T �f y'-/ N 7JAL� S7' s'i P v��',ir1.U�'s�+?A
Please check the box(es)that most closely represent the reason for completing ttus form:
�My vebicle was damaged in an accident ❑My vehicle was damaged during a tow
❑My vehicle was damaged by a pothole or condirion of the street t7 My vehicle was damaged by a plow
❑My vehicle was wrongfully towed and/or ticketed ❑I was injured on City property
❑Other type of property damage—please specify
❑Other type of injury—please specify
In order to process your claim vou need to include conies of all annlicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WII,L NOT be returned and become the property of the City. You are encouraged to keep a
copy for yaurself before submitting your claim form.
O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds
$500.00;or the actual bills and/or receipts for the repairs
O Towing claims:legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims:two repair estimates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims:medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be retutned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—alease comnlete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers: �?/�r� �S .4 r�vC Tt i� r/r eRE: y�� Tc/�
�J/e ti'o i �"'o /19�V�� � C`AN '7 /��,ir�em��� �i�s n/.4,+.�e .
Were the police or law enforcement called? es No Unknown 4c�rcle),
If yes,what department or agency? ,S�`i Pn��- l�� Case#or report# ��3/`7�'41�y.3
Where did the accident or injury take place? Provide street adcu-ess,cross street,intersection,name of park or facility,
closest landmark etc. Please�be as detailed as possible. If necessary,attach a diagram. ��T�R s��T rr�! /
h(�s? 7T� fJN� tiO�C�L.As S%/�EE'T e, GUe e `o e ' � L.�rr��/f.
Please indicate the amount you are seeking in compensarion or what you would like e City to do to resolye this claim
to your satisfaction. � /3 ..3/7 7E> /DL�/S �A/�i �Qe�l7'�4� �.31. 3t.� l�'�/" r.�(�x v'__---
F�on� �'u Z y I-s-�
_' n /3
Velucle Claims—elease complete this section ❑check box if tlus section does not anvlv
Your Vehicle: Year s�Zoa� Make �u r c'�_Model L�
License Plate Number oZ�.I/ /�L State�,_Color SA ,�s'►'o N e�
Registered Owner J'o%�A! i4N3 /YI�t o�( �FR G 5�?�'Z o m
Driver of Vehicle o
Area Damaged �i9le o Ir C'�R .�NtD �F F� Si bc e�R
City Vehicle: Year oo/ Make f''o R?> Model S
License Plate Number �v���' State f1'�(_Color c' ` r.c.'
Driver of Vehicle(City EmpIoyee's Name) N ' a �S � U '""�
AreaDamaged tJ/�1K1�1�i.�.f/✓ �iRurk �pA�ARS o h� Re��t1FoRC�'��
Claims— lease com lete this section ❑check b x if this section dces not a 1
How were you iniured� C�,Q V i c`�L S°PR A f R/A'J.4 R v •�s:°11► L cj�,� L3.�6-c' K S j RA/N
What part(s)of your body were injured? /I/�� C�( - %�h ip L�s�i A� /��'�a'✓R`l°'i on� o� �
af e � e 7, e J�i s•c::s ii✓ Lv c�3� a e k • o a o�� s�j�t,�i,v
Have you sought medical treatment? es No Planning to Seek Treamient(circle)
When did you receive treaiment? ��� d. �lJa4 y " � (provide date(s))
Name of Medical Provider(s):�Ni T'L�D �osPi7�� /�l�1� �4 L1,ji�lA C i�t/>� n/es7'�'i �,tuL�, i11�1� bSt•:1�lI
Address.�3 3 �1 S�YI i l� Atl� S i.fAv��m�t!. 3°Si��e. Telephone
Did you miss work as a result of your injury? Yes �No
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
1S[Check here if you are attaching more pages to this claim form. Number of additional pages 9
By signing this fornt,you are stating that aU info�ntation you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecu�io�. Date form was completed ��L x �y�. r� o I-�
Print the Name of the Person who Completed this Form: �1 r���t�. �� q G S' 1 c7 A'!
Signature of Person Making the Claim:
Revised February 2011
GOLDSTEIN & SUTORP��� ����5���'�
, ATTORNEYS AT LAW !�°OV O4 20�3
CITY CLE�K
October 30, 2013 Will Sutor
Direct Dial: 612-977-1048
will@goldsteinsutor.com
City Clerk
310 City Hall
15 Kellogg Blvd. West
Saint Paul, MN 55102
Re: Notice of Cfaim
Our Client: Marion Bergstrom
Date of Accident: 07/12/13
Our File No.: 13-1775
Dear City of St. Paul,
Please be advised the undersigned represents Marion Bergstrom regarding claims arising out of the
above-captioned accident that occurred near the intersection of West 7�h Street and Delaware
Avenue in St. Paul, Minnesota. Marion Bergstrom was the front seat passenger of the vehicle that
was rear-ended by Andrew Justin whom was employed by the City of St. Paul. Marion Bergstrom
has sustained injuries as a result of this accident.
Marion Bergstrom is asserting a bodily injury claim against the City of St. Paul for the negligence of
its employee in causing this accident. If the vehicle your employee was driving was covered by
automobile liability insurance at the time of this accident, please forward this information to the
insurer and ask them to contact me as soon as possible.
Enclosed please find the applicable Notice of Claim Form completed by Marion Bergstrom's
husband, John Bergstrom, on July 24, 2013.
Thank you for your cooperation.
Very truly,
�� �.
Will Sutor
Attorney
WKS:Iec
cc: Marion Bergstrom
2550 Blaisdell Avenue South I Minneapolis, Minnesota 55404 I Office 612977.1040 I Fax 612.977.1043 I www.goldsteinsutor.com
R�CEI�'�1� RECEIV�I�
t,;OV 04 2019 (�OV 04 2013
CITY CL�R�OTICE OF CLAIM FORM to the City of Saint Paul, Mi��t��,���
Minnesota Srate Statute 466.05 states that"...every person...w{:o claims damages from any�municipality...shall cause ro be presented to the
governiRg body of the municipality withrn 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additionai sheets. Ptease note that you will not be contacted by telephone to clarify answers,so pmvide as
much information as neces,sary to explain your claim,and the amount of compensation being reqaested. You wilt receive a
written acknowiedgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL,SAINT PAUL,MN 55102
First Name��/��� Middle Initial � Last Name 1J�f��7.5 �/��/1�
Company or Business Name
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address ��'��" BL,� �K,E�.� i�K �"�'�1 i� .
cicy 1� �''R o �E ��%S : sc�te 1��ti�ti�r'S o?"fl Zip Code..SySo 7 '7
Daytime Phone(� ..13-�.�Cell Phone(� - Evening Telephone(6S�)�- /l7y
Date of Accident/Injury or Date Discovered .I U�y rvZ,� 010,�.J Time o� % 3 �/pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved andlor respo ible for your damages,
�' u.` �'b " �e. . .AUL L E6t��� in�n/�
z� C � i, U � " aR :s��" vc. �. e"k
�v ' l� �+c r-e 7'a T�L E� cv Qs i A/���1 7"�
� ' o u, o G�%�i.s• 'd R�
�vas� • a a � �" MCS � � :'N.
L� �E' < N.
' — ,
P�le�check the box(es)that most closely represent th�e reason for completing this form:
�"My vehicle was damaged in an accident O My vehicle was damaged during a tow
0 My vehicle was damaged by a pothole or condirion of the street ❑My vehicle was damaged by a plow
D My vehicle was wrongfully towed and/or ticketed ❑I was injured on City property
❑Other type of property damage—please specify
❑Other type of injury—please specify
In order to process your claim vou need to include coaies of all analicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WII.L NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds
$500.00;or the actual bills and/or receipts for the repairs
O Towing claims:legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims:two repair estimates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims:medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and retarn both pages of Claim Form
Failure to complete and return both pages will resutt in delay in the handling of your claim.
All Claims-ulease comnlete this section
Were there wimesses to the incident? Yes No Unlrnown (circ�e)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what department or agency?.S''T' ��q u l. Case#or report# �.3 I�j'�'f�.�
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest landmark,etc. Ple e be as detailed as possible. Tf necessary,attach a diagram. %1�I`��/QSE�Ti�/�/
�es� . TT�i ,�N��Jc�t'�iLc.3' tsiRe�`�t WP �t,'e�e. �Toih/9 7c �� C�dj'u5 l�cR
�u���-
Please indicate the amount you aze seeking in compensation or what you woald like the City to do to resolve this claim
to your satisfaction. /� C-b �itl '�'�� 'j c€ i `L�c� 6
-- r�s �b c�' _,�-� ��e�_�- - -----
Velucle Isims- lease com lete this seetion ❑check box if this secrion does not a 1
Your Vehicle: Year Da F� Make i� r/1 Model 'u '"
License Plate Number �2�// �/[. State�i✓ Color S'�/�'� s i oi✓�,
Registered Owner /fI/��R/o N �►�.D .�c Nni [3�R G S 7"Ro/y'1
Driver of Vehicle ,�o N�!
AreaDamaged_/Q��k O� C'Al2 An1� �eFT side l2ec�R
City Ve2ucle: Year '�vQ,/ Make /CDR D Model S'
License Plate Number f'ob 6�q State�N .Color cn1'T ��y�
Driver of Vehicle(City Employee's Name) �1/�/.��Th/►!ES .I US'T;`.J
Area Damaged u N/C�1 o c�n1� �I?v c/< ,�a P EA R s ,io ,�� �e�rJ�a�c�FD
I ' Claims- lease com lete this section �check box if this secrion does not a 1
How were.you iniured? �"/j� Sc+FT 7�'/�5'.��'t c�' /�'i y / �r k �1�S c�6-/rrG•9�=� . i 7 /�
: v.s : n/' � iks eud,�c e s:
What part(s of your body were injured? nl�c�Jc � 6 iz u;.r�e ,G h ck R�t�� Le s:
Have you sought medical treatment? es No Planning to Seek Treatment(circle)
When did you receive treatment? +J��v� !� i fi! (provide date(s))
Name of Medieal Provider(s): A �/ c`�. N(c' i�o �iq�/t S�� �V�.• �d;e c T �S`°�: f',�4vL,
Address ���,���,,��s�t�Tii r'' />� Telephone 6,���?�/-/�o�
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s)3
Name of your Emgloyer:
Address Telephone
19�Check here�f you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stating that all i�f'orntation you have provided is true and eorrect to the best
of your knowledge. Unsigned forms will not b�processed
Submitting a false claim can result in prosecution. Date form was completed `.�i�1 � �'� �o��
Print the Name of the Person who Complet this Form: 76�,[Lr �S' �i�0/19
Siguature of Person Maldng the Claim: �' -�= -���'�
Revised Febmary 201 I