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CenturyLink �1�� CMR CLAIMS DEPARTMENT P.O. BOX 60770 �i 1� OKLAHOMA CITY OK 73146-0770 1-866-887-4066 CenturyLinkTM *x*xxNOTICE OF CLAIM*X*** Date: 01-08-2014 CFRTIFIED MAIL, RETURN RECEIPT REQUESTED I,� CIT�' OF ST PAUL �� CI Tl' CLERK >>o c�TV HaLL J�N 1� 2014 1� W. KELLOGG BLVD ST PAUL, MN 55102 �+�� i CERTIFIED MAIL# 9171 9690 0935 0035 8303 65 ??�: r)nr��;�c ±a�f':n:L� ;,:c:�•.n: �er:.- Centur� Link Claim 1�1um: 552920 Damage/Discovery Date: 09-26-2013 Damage Location: COTTAGE AVE& FARRINGTON ST,ST.PAUL,MN Damage County: RAMSEY Damage Amount: UNDETERM[NED Dear Sir/Madam: Please be advised that Century Lank Facilities sustained damage as a result of the negligent acts or omissions by employees o��agEnts of CITY OF ST PAIJL . lr_�estigation has revealed that on or about 09-26-2013 empioyees or agents of CITY OF ST' AAUL, C(TY OF ST. PAUL DAMAGED A 1200 PAIR BURIED CENTIJRY LINK CABLE DURING f'OWER EXCAVATION in [he area of COTTAGE AVF,& FARR[;�IGTON ST, ST. PAliL, MN. ��his letter is the written presentment of Century Link's claim pursuant to Minnesota Statute 466.05 . RI�:Q��EST FOR GOVERNMENTAL NOTICE FORM If vour Governmental Entity requires the complerion of its own form to complete proper notice, please forward a copy to the address listed above. Every good faith effort has been ma�e to identify the proper office and address to perfect our notice. Please fon�,�ard r� y�ur a±±orne„ if^::sdirected, to wr�act us. Matters herein stated are alleged on information and belief this pleader believes to be true. If there is insuraiice to cover this matter,kindly advise as to the name of the insurance company, its address and the 1�800 32r1 4158s�ignged.�f you have any questions, or need additional information, please contact me�a��G�,��'�. ..� .G . . .... ✓ �., . �. ..•��Tq• F % . � �'l-`•• N Sincerely, _ '� ��n6011463 •: _ Holly Fin1eY =. u3 :: FyP 11/28/14 � _ ,/ � A _:��` � � ��•� • i,��.1G ..'�� : .� � , . � OK'-P� `�� / � \ /�� , t J �- '� n u i�+"`�\\\ � ) /' ' �� `-' NOTARY�__ � CMR Claims DEPT Commission Expires Cl,�n �: �z�2� NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota .1lrrinesnru State Stntute 466.05 states that"...every person...who claims damages from any municipaliry...shall cause to be presented to the Qo�rniiii,�bod��of die municipality 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." Pfease 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 l�C�l(�'�"��L( � (�� i�-� �i��l'1�S �� Street Address �� S�Vlr 4(,a.�l City �F—� State �� Zip Code �3(��- Daytime Telephone (�� ) 32) "4�� Evening Telephone ( ) Date of Accident/Injury or Date Discovered �'2�p�2��3 Time U�� 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 em loyees are involved and/or responsible. <�-�, oF s�. �RU,( a.m,�aed a i2oo ra�.� i��ed Ct -h�vu ta V� 1(ZI� t�l.1/�`v�Q C�ow.e12 c.�V�-h�n . n c r c��p �� , � �n14 r��v c:i ERK Please check the box(es) that most closely represept 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 and/or ticketed ❑ Injured on City property �Other type of property damage—please specify C�,V�Ie G((�l.1VlCL4jG ❑ Other type of injury—please specify ❑ Other type not listed—please specify In order to process your claim vou need to include copies of all applicable documents. This is a general guideline of what should be submitted with a claim 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: at 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 :�II Claims—nlease comnlete this section «�ere there ��itnesses to the incident? Yes No nknown (circle) If��. please provide their names, addresses and telephone numbers: ��ere the police or law enforcement called? Yes No U k w (circle) If�e�. ��hat department or agency? Case#or report# �l�here did the accident or injury take place? Provide street address, cross street, intersection, name of park or facilih. closest landmark, etc. Please be as detailed as possible. If helpful, attach a diagram. 1'� �U0_ � I�VII'�17�Y1 S�l' 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. �)YIC�-Q.,��1(�1�1/�PG� Gl,-�' �.l S 11(Yl.l . Vehicle Claims—please complete this seetion �check box if this section does not apply 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 Injurv Claims—please eomplete this section ��check box if this section does not applv How were you injured? What part(s) of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment (circle) «�hen did }ou 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 fornz,you are stating that al[information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a false claim ean result in prosecution. � Print the Name of the Person who Complet d this F m: Signature of Person Making the Claim: Date form was completed � • O•U V I_I xe��5ed April 200� i �