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CenturyLink (2) `,,;"" CMR CLAIMS DEPARTMENT � � P.O. BOX 60770 �i 1� OKLAHOMACITY OK 73146-0770 1-866-887-4066 CenturyLinkTM ****XNOTICE OF CLAIM***** Date: 02-13-2014 CERTIFIED MAIL, RETURN RECEIPT REQUESTED R�C E I VE D To: CITY OF ST PAUL CITY CLERK FEB 18 2�14 310 C1TY 1-iALL is w. KFL�o��BLVO CITY CLERK ST PAUL, MN 55102 CERTIFIED MAIL# 9171 9690 0935 0036 8355 OS RE: nama�e to('fnturv Link}'roperty C'entury Link Claim Num: 560052 Damage/Discovery Date: 02-11-2014 Damage Location: 18TH & HENRY,ST. PAUL,MN Damage County: RAMSEY Damage Amount: U1�TDETERMINED Dear Sir/Madam: Please be advised that Century Link Facilities sustained damage as a result of the negligent acts c�r omissions by employees or agents of CITY OF ST PAUL . Investigation has revealed that on oi•about 02-11-2014 employees or agents of CITY OF ST PAUI., C1TY OF ST. PAUL DAMAGED A CENTURY LINK BURTF,D CABLE DURING HIGHWAY/STREET EXCAVATION in the area of 18TH&HENRY, ST. PAUL,MN. This letter is the written presentment of Century Link's claim pursuant to Minnesota Statute 466.05 . REQUEST FOR GOVERNMENI AL NiOTICE FORM If your Governmental Entity requires the completion of its own forn� to complete_proper notice, please forward a copy to the address listed above. Every g�od faith effort has been made to identify the proper c,f;ce and a�'dress to perfect c:;: n�*.i:°. Please forward te yo�ir attorney; if misdirected, te contact us. Matters herein stated are alleged on information and belief this pleader believes to be hue. If there is insurance to cover this matter,kindly advise as to the name of the insurance company, its addre`�atttiMlM�+�n�,�� claim number assigned. If you have any questions, or need additional information, please eQl�\��tG�`�.,��i 1-800-321-4l S8 ext 8232. .�� ::•�CTA�q y..,.'L�% � _ = �06011463 ' - _ � EXP. 11/28/14 ; _ ; N '. � � �•. Sincerely, .y •., A ,- Q'\ � � �'�. •••..�/$LIG;:�' ��: Hollv Finley � O ,��1j, oF......K�P,r\\`��. . �,�� „\�� _ �-, ,� - ; :. �� . • , �. � NOTARY CMR Claims DEPT Commission Expires Ct�n�-= �c��2 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." Piease 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 BL?VD,310 CITY HALL,SAINT PAUL,MN 55102 First Name Middle Initial Last Name Company or Business Name, if applicable L��a �t V� �..�� 1�- S �� l��S Street Address� ��-� � ��' �f�� Cit VF--i� State �� Zip Code� �� Y Daytime Telephone ( ) ��' f f �� Evening Telephone ( ) Date of Accident/Injury or Date Discovered �� —I Time 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. E � �� r�� - ��;�'ED ['rD 1 Q �U�4 Please check the box(es) that most closely represent the reason for completing this form: �+�TY C�'ERK ❑ 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 ❑ I�jured on City roperty��, ,j�Qther type of property damage—please specify +�� ❑ Other type of injury—please specify ❑ Other type not listed—please specify In order to process your claim you need to include�copies of all annlicable 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 All Claims—please comnlete this section _----- - Were there witnesses to the incident? Yes No '_,�.�_U i�kncown, (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 or acil��y, closest a d�k�, etc. Please be as detailed as possible. If helpful, attach a diagram. .,� Please indicate the amount you are seeking in compensa,t,}'on rom this claim or,what you would like the City to do to resolve this claim to your satisfaction. �,��(.t�' ��1 �t°(� Vehicle Claims—please complete this section ��heck 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 Iniurv Claims—please complete 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) 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 fornt,you are stating that all information you have provided is true and correct to the best of your knowledge. Unsigned fornzs wil[ not be processed. Submitting a false claim can result in prosecution. g � ��# �? �'�; !�) Print the Name of the Person who Complet�d this For�: �"L��•' -�1—: �� , �1 Signature of Person Making the Claim: �� ' � y � y � � �`r � +{ Date form was completed �l�� i �` Revised April 2007