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� NOTICE OF CLAIM FORM to the City of Saint Paul, Min esota
� Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be present�tf tb'T)teC E I VE C
� governing body of the 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." MAR 14 2014
�}- Please complete this form in its entirety by clearly typing or printing your answer to each question. If more sp��-� C L E R H
r1 needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so pro e
o much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
r' written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
� C nature of your claim. This form must be signed,and both pages completed. If something dces not apply,write`N/A'.
G� C
� � SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
� t� 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
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�_ � First Name ��v �a f�1 Middle Initial � Last Name ������������\ �
� /�/ /�.
� �,, Company or Business Name ! " /' `
p�,i � Are You an Insurance Company? Yes No If Yes,Claim Number?, ��� �> j ��
• �- ''_ Street Address ��� L�S� ����'��� �S � �, �e e t
� � City J� U�. "\ •S(���� �C �a � I State �v \1 v Zip Code ������
G � Daytime Phone�'� L��o'�Qell Phon .,��'7��'S�'�v ning Telephone(�— -
� � Date of Accidend Injury or Date Discovered Q�6 0 7`�� Time�am/pm
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Please state,in detail, what occurred(happened),and why you are submitting a claim.Please indicate why or how you
c � feel the City of Saint Paul or its employees are involved and/ r responsible for your damages. A �lu C�te r ✓n�i'n
� —°' v o c� E �,� -t f I o e v�'!e ' E E S
3�, WOI�e� � ' Fur o.c� 4 00 tcv Q 2�000
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ecaUSe t h��p pe �e (s�av Ze t� �o� � yQ�e� Z"y ,
3 � Please check the box(es)tha`t most closely represent the reason or com etmgtthis forni:
L ❑ My vehicle was damaged in an accident ❑ My v e h i c l e w as damaged during a tow
� � ❑My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
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�3 � ❑ y vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
� � �ther type of property damage—please specify N O U S E F�,00 O E,� 81' C I T Y iuv A�+E R f1111�Z N
� � ❑ O t her type o f injury—p l e a s e s p e c i f y
� S In order to process your claim vou need to�'include copies of all anplicable documents.
�
� For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
S O
r � your claim. Documents WII.L 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; ar 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 an�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—ulease comnlete this section
Were there witnesses to the incident? Yes No Unknown (ci cle)
Provide their names, addresses and telephone mbers: MD� C�� I rl l'1L �tJ C I��j v1S1't� , SQ IJ'C�1 S 9I�h t
Po_��o�i c� a v�c� -F �►re S�to[f--F.
Were the police or law enforcement called? Yes No Unknown (circle)
If yes, what department or agency? P 0 LI c t f F S S Q Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersect'on,name of park or fa ility,
closest landmazk,etc. Please be as detailed as possible. If necessary, attach a dia ram. - t �� s�
<SQ,S�.. Pa�l — MY HOt1SE .P�PC QRot�E �JNpc�Z STRr�S �N �RONT
Please indicate the a unt you are se��eacing in compensation or what you would like the City to do to resolve thi claim
to your satisf ction. �b (��0 -- o rE �dC& V Y 11�I CG �tier heq�e Y l�NQS Inev v , r� -Fr�"Le✓
PQf5QY1o1� it?v�nS C �n1v� �l1 C/SZ 7 I�YIOtP t►nC01�1U1�1�('-G' C S't
Vehicle Claims— ease com lete t ' ection check box if this section does not a 1
Your Vehicle: Year e Model
Licen Plate Nu r State Color
Registe Ow
Driver of h' e
Area Dama
City Vehicle: Year Make Model
Licens late N ber State Color
Driv of Vehicle ity Employee's Name)
Ar Damaged
Iniurv Claims—nlease comnlete this section LY check box if this section does not apvlv
How w re you m�ured?
What part of your bod ere injured?
Have you soug t me ical treatment? Yes No Planning to Seek Treatment(circle)
When did you re ve treatment? (provide date(s))
Name of Medic vider(s):
Address Telephone
Did you mi work as a iesult of your injury? Yes No
When did ou miss work?� (provide date(s))
Name o our Employer: _
Addre 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 0�,,,%'��` 1�"
Print the Name of the Person who Completed this Form; i✓V�� D ���'� ��S k
Signature of Person Making the Claim:�-���IMM
Revised February 20ll
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Mutual Insurance Com an
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16 E Hwy 61 ♦ PO Box 308 ♦ Esko, MN 55733
March 11, 2014
Brian Ducklinsky
568 E Annapolis Street
South Saint Paul, MN 55075
RE: Clairn No: DH05564
DOL: 03/07/14
Policy No: 197725
Dear Brian, Corrine and Lorraine,
The inspection of your loss was completed on March 10, 2014. A claim was filed for damage to
the dwelling unfinished basement due to water.
Based on the inspection of the Ioss, the city of Saint Paul had damage to an underground water
main line. The water line broke, causing water to travel back towards your home, seeping
through the foundation walls and floors and entering through two windows. As a result, the
unfinished basement had over three feet of standing water, dirt and debris.
Please review page 9 and 10 of 23 of your DH3 policy. SECTION 1- GENERAL EXCLUSION.
Number 3 and 13 a, b and c. We do not pay for loss resulting directly or indirectly from:
3. concurrent causation if one or more of the exclusions apply to the loss regardless of
other causes or event that contribute to or aggravate the loss whether such causes or
events act to produce the loss before, at the same time as or after the excluded causes
or events.
13. water damage. This means loss caused by:
a. floor, surFace water, waves, tidal water, overFlow of a body of water or spray from
any of these whether wind driven or not;
b. water which backs up through sewers, drains or sump pumps; or
c. water below the surface of the ground including water which exerts pressure on,
or seeps or leaks through or into a building, sidewalk, driveway, foundation,
swimming pool or other structure. We pay for direct loss by fire, explosion, and
theft which may result.
Page 2, Ducklinsky
Based upon the above exclusion(s), no payment can be made for your loss. Coverage for this
loss is denied.
Please contact me with questions or concerns you may have.
Sincerely,
Leah Bushard
Claims Adjuster
RAM Mutual Insurance Company
Enc.
cc: Strong Agency, Inc.
www.rammutual.com (218) 879-3321 generalnrammutual.com
General Fax: (218) 879-7097 ♦ Claims Fax: (218)879-1644 ♦ Auto Underwriting Fax: (218)878-2948
Personal Lines Underwriting Fax: (218)879-3404 ♦ Commercial Lines Underwriting Fax: (218)879-0904
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