Sherbert RECEI�/ED
FEB 2 6 2�14
NOTICE OF CLAIM FORM to the City of Saint Paul, Minne��Y CLERI�
Minnesota State Statute 466.05 states that"...every person_..who claims damages from any municipa[iry...shall cause to be presented to the
governing body of the municipnlity within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amouni of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each questioa 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 ciaim,and the amoant 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 dces aot 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 �r'f f.,i�;'I�� Middle Initial�Last Name��j���
Company or Business Name I�/�T
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address L-�� �� . ��l��V�u L l� �L.
City ��,�I� State N►�i Zip Code ��
Dayrime Phone(��- 4�� Cell Phone(�)�-�Evening Telephone(��-��
Date of Accidend Injury or Date Discovered�"I ���`'f Time (�am/�
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 for your damages.
i �v� �J�►��a�. u;�ST on� IY1A��i�� ��� i��� � �-f��r � �Yµr��� I D�.0 JJ��s�r�
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� � '`b I�C:Cf�N ; -
1 � N�` 1,.; - �N i� N,�
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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 condifion of the street �My vehicle was damaged by a plow
My vehicle was wrongfully towed and/or ricketed ❑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 couies of all annlicable 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.
•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 pmperty 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 aze always welcome to document and support your claim but will not be returned.
Page 1 of 2-Please complete and return boW pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-nlease comalete this section
Were there witnesses to the incident? Yes No nknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes Ng� 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 detailed as possible. If necessary,attach a diagram.
l'►')/-FQ�/GA�UG �'v"�- ��/iJr- I.,��S j �i p"1— /Dnt^�T G�G�M � c'Y:S�,�+�: `�7. ^ � [7�')
Please indicate the amount ou are seekin in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � -
l 1.
Vehicle Clauns-please comnlete this section ❑check box if this section does not apply,
Your Vehicle: Year Z�Make `�'J�KS�:�?�hF.�� Model ,��Ti�
License Plate Number �S`�y 3►O State�i�Color �► LUE(�.
Registered Owner�}P�R.��'��} SN�E��
Driver of Vehicle ifi-
Area Damaged fE'�t�T S1��N�L-/'y...Tlk'-� f�ti� �l M
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims-nlease comnlete this section �check box if this section dces 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 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 pracessed.
Submitting a false claim can result uz prosecutior�. Date form was completed 2 I �J'► I �`'1
Print the Name of the Person who Comple this Form: ���A � ������f
Signature of Person Mat�ing the Claim: � -
Revised February 2011
BRAUSEN REPAIR CENTER OF ROSEVILLE
2170 NORTH DALE STREET INVOICE
ROSEVILLE, MN. 55113 45212
Phone-651-488-8800 Fax-651-488-4589
W1NW.BRAUSENAUTO.COM
INVOICE Work Completed Date : 02/24/2014 Print Date : 02/24/2014
SHERBERT, BARB 2008 Volkswagen -Jetta S -2.5L, In-Line5 (151C1)
234 W COUNTY RD B2 Lic#: SSY310 -MN Odometer In : 73013
ROSEVILLE, MN 55113 Unit#: Odometer Out: 73013
Home 651-484-2593 ---Cell 651-283-5351 Vin#: 3VWRM71K18M077440
Cust ID : 1703 Hat# : Ref# :
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STRAIGHTEN ALLOY WHEEL CHECK RF TIRE 0.00
WHE004 1.00 191.99� 191.99 MOUNT AND BALANCE 2 TIRES 40.00
205/55R16 MICHELIN PRIMACY `�" WCLUDES MOUNTING, DISPOSAL,AND BALANCING.
MXV4 AUTOFORCE TIRE PROTECTION PLAN 2 7.98
36597 2.00 141.18 282.36 AUTOFORCE TIRE PROTECTION PLAN WARRANTY.
�� ° ` TN�LUDES LIFETIME FREE TIRE REPAIR WITH BALANCING.
ALSO INCLUDES ONE YEAR FREE ROADSIDE ASSISTANCE
AND REPLACEMENT IF THE TIRE IS NOT REPAIRABLE.
I ***Discount*"*
$70.00 offparts '
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Org.Estimate a 0.00 Revisions a 0.00 Current Estimate �O.QO Labor: 47.98
Parts: 4 . 5
' Sublet: $0.00
Discount: -70.00
Sub: 452.33
Tax: 28.81
Total: 481.14
Bal Due: $481.14
(Payments-]
****"***"VISIT OUR WEBSITE***""'***
I hereby authorize the above repair work to be done along with the necessary material and hereby grant you andlor your employees permission
to operate the car or truck herein described on street, highways or elsewhere for the purpose of testing and/or inspection. An express
mechanic's lien is hereby acknowledged on above car or truck to secure the amount of repairs thereto.Warranty on parts and labor is one year
or 12,000 miles whichever comes first. Warranty work has to be performed in our shop&cannot exceed the original cost of repair.
Signature Date Time
Page 1 of 1 Copyright(c)2014 Mitchell Repair Infortnation Company,LLC invhrs 03.18.2011 JD
.
Thomas P Carlson Carlso Ss�Cla.tes L'TD Paralegals
Nigel H. Mentlez a r r o R N E Y s a r � a w Rebecca L. Hansen
Brianne T. Lawson www.carlsonassoc.com Sharlene A. Paradis
Jenifer R. Shull
1052 Centerville Circle
Vadnais Heights, Minnesota 55127
Telephone: 651-287-8640 • Facsimile: 651-287-8659 F�ECEIVED
FE� 2 7 2�14
February 26, 20�4 CITY CLERK
City of Saint Paul
Attn: Sandra Bodensteiner
200 City Hall Annex
25 West 4`" St
Saint Paul, MN 55102-1631
Re: Your Claim Number: C-130076
American Family Mutual Insu�ance Company Subrogation Claim
American Family Insured: Bella Bee Yang
Date of Loss: February 25, 2013
Amount of Claim: $14,341.55, plus undetermined expenses
Claim Number: 00-245-012241
Dear Ms. Bodensteiner:
This firm has been retained by American Family Mutual Insurance Company to pursue
the above-referenced subrogation claim. The claim is for the amount noted above, plus any
additional amounts which have not been determined. It is my understanding that the City of
Saint Paul was the owner of the vehicle involved in the above-referenced collision. Please
review your file and contact me to discuss a resolution to this claim within ten days from the date
of this letter. If I do not hear from you withiln ten days, I will assume that the City of Saint Paul
is not willing to voluntarily resolve this matter and will proceed with further legal action against
the City to obtain a judgment.
I look forward to hearing from you.
Very truly yours,
. �
Brianne T. Lawson
jrs
cc: City of Saint Paul, 15 West Kellogg Blvd., 310 City Hall, Saint Paul, MN 55102 ��