CenturyLink `„�"' CMR CLAIMS DEPARTMENT
� I P.O. BOX 60770
�I 1� OKLAHOMACITY OK 73146-0770
1-866-887-4066
CenturyLink�M
'�*x*XNOTICE OF CLAIM*x*XX (��C�'����
Date: ]0-31-2013 ��y �4 2��3
CERTIFIED MAIL, RETURN RECEIPT REQUESTED ��TY �L���
To: CITY OF ST PAUL
CITY CLERK
310 CITY HALL
15 W. KELLOGG BLVD
ST PAUL, MN 55102
CERTIFIF,D MAIL# 9171 9690 0935 0036 8595 70
r i:: I3an►age to Czrrtury Link Pr::�,c�:-3
Century Link Claim Num: 555114
Damage/Discovery Date: 10-29-2013
Damage Location: FOREST ST&5TH ST E,ST.PAUL,MN
Damage County: RAMSEY
Damage Amount: UNDETERMINED
Dear Sir'Madam:
Please be adviseci that Century Link Facilities sustained damage as a result of the negligent acts er
�missions by employees or agents c�f CITY OF ST PAUL .
Investigation has revealed that on or about 10-29-2013 employees or agents of CITY OF ST PAUL.
C1TY OF ST. PAUL WATF,R DEPT DAMAGED A CENTURY LINK FIBER OPTIC CABLE
DURING WATER EXCAVATION in the area of FOREST ST& STH ST E, ST. PAUL, MN.
This letter is the written presentment of Century Link's claim pursuant to Minnesota Statute 466.05 .
RFQi1EST FOR GOVERNMENTAL NOTICE FORM
]f}�our Gove►�nmental Entity requires the completion of its own form to complete proper notice, please
forward a copy to the address listed above. Every good faith effort has been made to identify the proper
office and address to perfect our notice. Please forward to your attorney, if misdirected. to c�ntact us.
Matters herein stated are alleged on information and belief this pleader believes to be true. If there is
insurance to cover this matter,kindly advise as to the name of the insurance company, its address and the
elaim number assigned. lf you have any questions, or need additional information, please contac\\����iiui�������
1-800-321-4158 ext 8232. .\`���`���E GIVF��i,'�.
`�`�:.�pTA/�y•.�iS' ''�
#060��463 —
Sincerely, _ _
Holly Finley i =: EXP. 11128114 = —
N�., P��\G ::�0���
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NOTAR�'
CMR Claims DEPT Commission Expires
RECEIVED ����. �'�-�`� �'
NaV 0 4 2013
CITY CLE�TICE OF CLAIM FORM to the City of Saint Paul, Minnesota i
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to the I
governing body of the municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the time,ptace,and I
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 additional sheets. Please note that you may or may not be contacted by telephone to discuss your claim
circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being
requested. 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
Company or Business Name, if applicable (,�`��� t V� L� ����- �I 1� ���S I �'�
Street Address �� W ���� �a n _ .
City ��� State �C`� Zip Code ���G�
Daytime Telephone (�W) ���� �� � Evening Telephone ( )
Date of Accident/Injury or Date Discovered ����-���� Time 1)1�� am/pm (circle)
Please state, in detail, what occurred, 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.
I
G l \� r
Please check the box(es) that most closely represent the reason for completing this form:
❑ Vehicle was damaged in an accident � Vehicle was damaged during a tow
❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow
❑ Vehicle was wrongfully towed andlor ticketed ❑ Injured on City property
�Other type of property damage—please specify
❑ Other type of injury—please specify
❑ Other type not listed—please specify C
In order to process your claim you need to includie copies of all applicable documents. This is a general
guideline of what should be submitted with a clai�form,but it is not all inclusive. You may be asked to
provide additional information depending on your�claim.
O Property damage claims to a vehicle: a�least two estimates for the repairs to your vehicle, or the
actual bills and/or receipts for the repairs
O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts
O Other property damage: repair estimates, detailed list of damaged items
O Injury claims: medical bills, receipts
O Photographs can be provided but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to provide a completed claim form will result in delays in processing.
Notice of Claim Form, City of Saint Paul,page two
All Claims—nlease complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
If yes, please provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown � (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address, cross street, intersection, name of park
o�facility, closest landmark, etc. Please be as detailed as possible. If helpful, attach a diagram.
-�1��eS-E- ��Cl��e�—�, �"� s-t�ree-�- �-cc�+
Please indicate the amount you are seeking in compensation from this claim or what you would like the City
to do to resolve this claim to your satisfaction. l��-P_'���CY� I 1�1�� �" ��.1_S fi1 I�VI�,
Vehicle Claims—please comnlete this section �check box if this section does not applv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Iniury Claims—please complete this section ,CV,check box if this section does not auplv
How were you injured?
What part(s) of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment (circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address 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
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stating that aU information 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 prosecution. �
Print the Name of the Person who Complete this For :
Signature of Person Making the Claim: r
Date form was completed �t� '�� I o �°3 Revised April 2007