Lunde NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipaliry within 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 additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement 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 Iv`ame 't��►'��'�� r��c��`�� Middle Initial Last Name �-i.�°���-- R E C E I V E D
Company or Business Name ��� NQV 2:) �013
Are You an Insurance Company? Yes/No If Yes, Claim Number? (`IT�I�ERK
Street Address
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City �� (,�+��( State ✓��" Zip Code S�� � ���j, �,�
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�e Yhone(� �S�-C� ��`}Cell Phone((9 S j )_�3Cz 3`sh�;. Evening Telephone�` ) - �,Mc S��
Date of Accidend Injury or Date Discovered ���?> � ! 3 Time am/pm E��i Cs�>"a�U
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Please state,in detail, what occurred(happened),and wk�y you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employges�e involved and/or responsible for your damages.
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Please check the box(es)that most closely represent the reason for completing this form:
❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
❑My vehicle was damaged by a pothole or condition of the street ❑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 C'c�\C u SS t U�1 � �l; (��k.)/ ��7.�n� /
In order to process your claim vou need to inctude couies of all annGcable 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 WILL 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 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—nlease comnlete this section
Were there wimesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephon mbers`•
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Were the police or law enforcement called? Yes No Unlrnown (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 or facility,
closest landmark,etc. Please be as etailed as possible. If necessary, attach a diagram.
t-4��r i c�1c� �P��Z�� S�i �l.(Z.
� Please indicate the amount you are seeking in compens tion or what you would like the City to do to resolve this claim
to your satisfaction. ��C��e �-e' ��� �� S ���`fS d" b ���S ',l� �.
� � {�� a (r'cxCr �- MCte N�p,'��f
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Vehicle CI s— lease com lete this section �check box if this section does not a 1
Your Vehicle: Make Model
Li nse Plate Number State Color
Regi red Owner
Driver Vehicle
Area Dam ed
City Vehicle: Year Make Model
License Plate ber State Color
Driver of Vehicle ity Employee's Name)
Area Damaged
� I 'ur Claims— lease com lete this section ��� �e ❑check box if this section does not a 1
% How were you injured? ' �S
What part(s)of your body were injured? C=�'�-��SS�� ` � � �� '�'
Have you sought medical treatment? es No Planning to Seek Treatment(circle)
When did you receive treatment? � � a��\���`'� (provide date(s))
Name of Medical Provider(s): ''
Address G� `� Tel
Did you miss�srk as a result of your injury? Yes No S'.��C��
When did you miss work? � �(provide date(s))
Name of your Employer:
Address Telephone
—�,k- �Check here if you are attaching more pages to this claim form. Number of additional pages ��
�`J
By signing this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed
Submittin a false claim can result in proseculion. Date form was completed �! ��` �> ���`
S
Print the Name of the Person who Compl this Fo • i��� �� `� G�"`-'
Signature of Persoo Making the Claim:
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Revised February 2011
S��nopsis of Nils Lunde's Accident at St. Paul Highland Pool August 13, 2013
Three 1�-year old boys, including Nils Lunde and his friend Luke Moses-Thomsen
and Charlie Sutmeyer, were sliding down the water slide. They were not always
follo«�ing the rule of waiting until the person in front had gotten out of the slide to
go. According to Luke, the lifeguard noticed this and knew and did not tell them
to stop. The lifeguard would chuckle and roll her eyes. Luke thinks she was
blonde with long hair but he does not know her name.
One time Charlie went down, then Nils went right after Charlie. Charlie and Nils
stopped inside the slide about half-way down. Luke did not know they had
stopped. He waited and figured they were almost out; then he went. Luke heard
them, realized they were still in the slide, and he yelled that he couldn't stop, so
GO. Luke tried to stop himself but could not. Nils and Charlie were right next to
each other, but Charlie had moved. Luke hit Nils in the back and Nils hit his head
on the top of the slide and he said "Ow." The seriousness of the injury was not
apparent until a couple days later when Nils became very ill and had to be taken to
the emergency room. The ER doctor confirmed that Nils had suffered a
concussion when he hit his head on the slide.
Nils was not able to start school on time and is still not able to attend school full �
time, complete school assignments or participate in sports. It may take him months
to recover fully.
We are submitting this claim because it occurred on City property and because the
lifeguard did not enforce the rules. The damages we are seeking are the total of
our out-of-pocket expenses for medical care as well as other expenses such as a
tutor, which has now become necessary.
. �
�.,,.�
Kennedy Eye Association -
i790 Lexington Avenue
Roseville, MN 55113
Phone 651-488-6771 � �
Fax 651-488-5576 �/� �
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From: "Dr.Les Alsterlund"<dr.les@comcast.neb
Subjeci: Invoice from Dr.Les Alsterlund,Optometry,LLC
Date: November 4,2013 11:18:12 PM CST
To: <marthaOmarthasfiora�studio.com>
1 Attachmeni,502 KB
Dear Martha:
Your invoice for Nils's evaluation is attached. Please remit payment at
your earliest convenience.
Thank you for your business-we appreciate it very much.
Sincerely, �
Dr.Les Alsterlund,Optometry,lLC
612-724-5125 �
Dr.Les Alsterkx�d.Optometry,LLC ���O�a�
3319 E 25th Street �
Mmneapolis,MN 55406
Date ta2312ot3
i�voice# 355
- _ __ ----__ _ ----
Bill To - Patient
_ -- ----------- _.._._: --___------- -- ----
Martha and Daniel lunde Nds Lunde
2008 Princeton Avenue 2008 Princeton Avenue
St.Paul,MN 55105 St.Paul,MN 55105
P.O.# _-_ _ _ _
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Terms Due Date 11/1�t2oi3
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b51-389-9295 Balance Due 5249.90 ��
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If this date does not work for you please call Kym to find a mutually agreed upon date.
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STATEWENT� ACCOUNT NUMBER PLEASE PAY
s8ss2�o 2�1371 THIS AMOUNT � � � �-53
C�11�C�Ten_� Statement Date: 10-30-2013
Patient Name: Nils Gabler Lunde
Hospitals Clinics Children's Hospitais and Clinics of Minnesota Account Number. 12547152 .
of Minneso� Hospital Patient Finan�ial Services
2910 Centre Pointe Drive Start Date of Service: 09-27-2013
Roseville, MN 55113 End Date of Service: 09-27-2013
Balance Due: $433.00
Payment Due Date: 11-24-2013
Dear ROBERT DANIEL LUNDE:
Your insurance company has processed this claim.The balance due is your responsibility. Please send
payment in full.
Hospital charges: $433.00
Insurance payments: $0.00
Patient payments: $0.00
Adjustments: S0.00
Total balance due: $433.00 !
If you are unable to make payment and would like to discuss financial assistance, an uninsured discount, or
have other questions, please contact us.
�Cu�anar�re�ac�e R��es are aeraiialble Mond�y�FR�,8=0�Akl�8�Pl�lr�
Sa�eirt9aq/81U0/�1�01�12�t10 Pf4A at�651)85�2200 to assist you with questionsn oonoerr►sr ac to provide y�ou wi�h
arn�e�re�e�be�_Yaaa cx�rn�SO ernal yayr�ons to _ _a'g-Pl�se inc�ide y�our�c�our�dt
�eaar�a�er�moat�esn eart�_l6ioe also dFer the option to P0Y Y'o�r�it��9s�Gree at de�:�",lrawre►_d�eero_aro�
payhospitalbill.
If you continue to have concerns that have not been addressed,you may contact the Minnesota Attorney
General's Office, at 651-296-3353 or 1-800-657-3787.
Thank you for your prompt payment,
Children s Hospitals and Clinics of Minnesota
Hospital Patient Financial Services
piora�o�P s 1�'��°IdC 3s-�s��-��o�-�sa�nro�-� �a-�:���
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Staur�Dalte a�Seavi�c�e: 09-2�-20'93 �Ntls G�Lunde ��-2�-2�� i;
En[9 Da�ee a�S�rtvioe= 0�-27-2013 — ,,�y--:: — �!!■ _ � � �'�.
Paitier�Na�ee: t�s�r Lunde — �- — _ —' �'
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R��fl�.��6�'�13 �:s��e of Seavime_ ���-�9�
��Uue' $100.00
Payment Due Date: 10-07-2013
Dear MARTHA GABLER LUNDE:
Your insurance company has processed this claim. The balance due is your responsibility. Please send
payment in full.
Hospital charges: �824.48
Insurance payments: $468.81
Patient payments: $0.00
Adjustments: $255.67
Total balance due: $100.00
If you are unable to make payment and would like to discuss financial assistance, an uninsured discount, or
have other questions, please contact us.
Our Customer Service Representatives are available Monday through Friday, 8:00 AM to 8:00 PM, and
Saturday 8:00 AM to 12:00 PM at(651) 855-2200 to assist you with questions, concerns, or to provide you with
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Roseville, MN 55113
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2008 PRINCETON AVE P.O. Box 860261
SAINT PAUL. MN 55105-1527 MINNEAPOLIS, MN 55486-0261
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