Adair WEST BEND�" THE SILVER LINING'"
February ]9, 2014 �C��� V ED
F�B 2 4 2�)4
CITY CERK C�N CLER�
15 WEST KELLOGG BLVD
310 CITY HALL
ST PAUL MN 55102
Claim No.: AE88012
Insured: BEN ADAIR
Date of Loss: 02/17/2014
Dear City Clerk,
I have provided a notice of claim form on behalf of our insured, Ben Adair.
Please contact me with any questions.
Sincerely,
KARRIE OUELLETTE, AIC
CLAIM REPRESENTATIVE
(262)365-2881 or(800)236-5010 Extension 2881
Fax: (262)335-7000
KOuellette@WBMI.com �
wB-iz�i�os-io�
I900 S. I8th Avenue � West Bend WI 53095 � thesilverlining.com
RECEIVED
� ��B 2�'f 2�14
NOTICE OF CLAIM FORM to the City of Saint Paul, Minn�b�E� CLERK
Minnesota State Stat�ue 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipaliry within 180 days afzer 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 Name 4G0.1''n � Middle Initial Last Name �C,.���1 C."�'+'�,
Company or Business Name (ti?QS--k� ��-�nc� �Y1Sc�►'a-;r�C�
Are You an Insurance Company? Yes No If Yes,Claim Number? �E fR�01�,
Street Address '�c� C3OX 19°I S—
City LvCS4' a�V1GL State �� Zip Code s30`i�
Daytime Phone (,$(v"��-�L Cell Phone( ) - Evening Telephone( ) -
Date of Accident/Injury or Date Discovered �`1 � l�-1 Time I 1 3U am/prr
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 far your damages. N r. Ac1 ai; pruc,c cd t n o�
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,,�lease checl�t�e b�o (es)that most closely represent the reason for completing this form:
l��veliicle was aamaged in an accident ❑ My vehicle was damaged during a tow
j❑� y 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
In order to process your claim vou need to include copies of all apnlicable 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 propeRy 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 $500.00; or the actual bills
and/or receipts for the repairs;detailed list of damaged items
� O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
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►s cdn.�p�+cc�-
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please complete this section
Were there witnesses to the incident? Yes � Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Ye No Unknown (circle)
If yes, what department or agency? .��•1Pt n-�'1��►'►u t�D Case#or report# I`���l7y�
c:.t� o-E S�t� P�u 1 P 1� 1�{ -0 3 i — �38
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram. (vi�C-�St�c�7on G f
� n��*-+,�+-euc� c;�h d C��e,�;t,l r��cl S� �aSLtc�n 1kc.t a v��s fv�N
Please indicate the amount you are seeking in compensat}'on or what xou would like the City to do to resolve this claim
to your satisfaction. Y��('cYxd�l:2�C� CP"f' �1"�O '�'1►'!'�Q �
Vehicle Claims—please comqlete this section ❑ check box if this section does not apply
Your Vehicle: Year o`LOO Make �Y1-h�C�L Model V'�b�
License Plate Number �D�[p�, _ State�nJ Color g�Gt��' .
Registered Owner ,�'1 dcc.� r
Driver of Vehicle �$��1 I�D�GU Ir
Area Damaged n�S ►^ Gi 1� t('o2� �� SiC�,�
City Vehicle: Year��Make SY1Cu� r'J�au� Model
License Plate Number U h k State Color
Driver of Vehicle(City Employee's Name) VI�'A!Y1 I G� i'1'1 V�I R yj$
Area Damaged �j�Q,��
Iniurv Claims please complete this section �heck box if this section does not anplv
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 all 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. Date form was completed a � i q�1�
Print the Name of the Person who Com lete this Form: KG(�t'1� v CA����'f
Signature of Person Making the Claim:
Revised February 20ll