Dupre Providing lnsurance and Financial Servrces ��ateFarm�
Home Offrce, Bloomingbn, !C
March 13, 2014 RECEIVED
City Clerk State Farm C�aims MAR 18 2014
15 W Kellogg Blvd P.O.Box 52273
310 City Hall PhoenixAZ85072-2273 CITY CLERK
Saint Paul MN 55102
RE: Claim Number: 23-28F5-612
Date of Loss: January 14, 2014
Our Insured: Brad Dupre
Amount of Loss: $ To be determined
Vehicle Involved: 2013 Ford Crown Victoria
License Number: 1373 Minnesota
Driver: Mary Alberg
To Whom It May Concern:
Our records indicate you are the owner of the vehicle involved in an accident with our insured
on January 14, 2014. If you did not own the car at that time, please provide us the name and
address of the current owner.
If you were the owner of the vehicle involved at the time of the accident, forward this letter to
your insurance carrier and notify us of your insurance information. If you do not have insurance,
please contact us immediately. Your response is requested within 15 days from the date of
this letter.
Sincerely,
Jim Tracy, CPCU, AIC, AIS
Claim Representative
(866) 207-6046, Team 22
Fax: (800) 423-0474
State Farm Mutual Automobile Insurance Company
State Farm�insurance policies, applications, forms and required notices are wriften in
English. This document has been translated for your convenience. In the event of any
difference in interpretation, the English language version contro/s.
Praviding lnsurance and Financial Services „7�ate�arm�
Nome Office, Bloomington, lL
13 de marzo de 2014
City Clerk State Farm Claims
15 W Kellogg Blvd P.O. Box 52273
310 City Hall Phoenix AZ 85072-2273
Saint Paul MN 55102
Asunto: Numero de Reclamacion: 23-28F5-612
Fecha de la Perdida: 14 de enero de 2014
Nuestro Asegurado: Brad Dupre
Cantidad de la Perdida: $**AMOUNT OF LOSS**
Vehiculo Involucrado: 2013 Ford Crown Victoria
Numero de Licencia de Conducir:
Conductor: City Clerk
Estimado(a) City Clerk:
Nuestros datos indican que usted es el propietario del vehiculo que estuvo involucrado en un
accidente con nuestro asegurado el 14 de enero de 2014. Si en ese momento, usted no era el
propietario del automovil, por favor proporcionenos el nombre y la direccion del propietario
actual.
Si en el momento del accidente, usted si era el propietario del vehiculo involucrado, envie esta
carta a su compania de seguros y proporcionenos la informacion de su seguro. Si usted no
tiene seguro, por favor pongase en contacto con nosotros inmediatamente. Se solicita su
respuesta dentro de 15 dias a partir de la fecha de esta carta.
Atentamente,
Jim Tracy, CPCU, AIC, AIS
Claim Representative
(866) 207-6046, Team 22
State Farm Mutual Automobile Insurance Company
Las polizas, formularios y notificaciones de State Farm°est�n escritos en ingles. Este
documento ha sido traducido para su conveniencia. En e/caso que surja un conflicto de
interpretacion, la version del idioma ingles dominara.
Ma r, 12. 2014 8: 24pM No. 7128 P. 1
I`TFihl�b'�,20�A 1�;00 P'��������
N(aTTC� p�' C�.A�M FO�tM to th� City af S��nt Paul, lVZtnnesota MAR 18 2014
�t.fln�erolo Stala S'!a[utR 4G6 dJ atutes dhar" .avery�er,roR .wfu�elatnrs duMages from any,rt�nic(pulity.,s5alr c�r�s��a be p�a�onra� �
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clrcumsfance�s tharcof,a►ud 11,s araounl ojcn��n.safion or o�ar liCllsf damQpded." ,
Please coMUlc[e t 1&torl�t in 11�5 Cn�rEh'bY C[�Arh��tYP�aL Or pr�tttlng yOttl'anSrWCT to e$c�qurst5pn. '(f InorB Space is
neeQcd,atiach adclitiana!sheets. Alexse nu[e th�kpou wll]notbe contuctcd hy telaphoqe�c1�rlCy�nswera,so prov aa es
mut1�lolormatlou ws neeessary to e�cplAia your el�im,and the amoant of�nmpensatlon 6eing reque6ted. YoU wW Ceck9ve n
wri+ten arknowledgemo�t ance your Porm Rg ree�eiaed. The procesg e�n i�ke up M kn►veeks nrlanger dr,��adlns ou the
nature of your Clatrn. �'ll#�s{o�mu9t be sl��or3�and both p�as cnmpleted. Yt somethin�docs not 4pply,write`N1A'�
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Firs[Namc �Ar'1 Middle Inidaf_,�.aet Name_ ��8_� - -
G(�xr►pany or�3'u6tness Name��e ,�r A�r � �r1�V!���1 GQ, _
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Day�me Yhono�':•�� Q�} C:ell P���'"'�' E'�enui8 Tel�phone{,_�"'-' '
Data of Acaiden�/lnaury or J]ate bisoovered tiQ I ������ - 'hm� � ���'�
P1c�se stale,�u detaii,what��urzcd(fsappened)�and wh�y�u��b��g a clatm.P�ease�ndicate why ar hor+v you
feel�he�ty of S�nt paul oi ats�mploy�ts Tn;mval'ved unc�/or rdsponsible for your dnmag�s.
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Ylc�se chccl�thc box{cs)that��o�t closelY r�Preseut th,e reas�.n far complct7ng ttne form'
�My veh�cic was d�maged ln a.n acciJent C)My veh�cle wss dacnaged dunng a taw
❑lvjy vehicle wes damog�d by a ppthole or coadit,on of thd stre�t ❑My vrh�clo was damaged bY g plow
C]Tv�y veh,e2e was wrongfully to�ved andJor ticketcd C��1va9 ittlie�'GC�Dn Gltj'�,TD,p�riy
GJ Ol�er typG of pro�Crty dstmage�pZsase spEa�fy _. .�,_.., -
Q Other type of�nituy--plcase spec�fy, . --�.
In order t�p��a�ss ypur claim vo� aeed ta i�clu�„co��es ox�11�upliC�le doeum�.nts.
P'or tbC claims typ�s lista�bel,ow,Pleasc he surc to includc tt�e dootiunents uici�catad ot rt wi;i delsy�h ed to k�p a
yoar c]aun. Documents W .1V T�ie zetuiz�ed gnd become t[�C p�npert5'of the C�ty. �'ou�enGOUrag
copy�'or yo�salf b�dT�submiti�.n�your claun�'onn.
Q Pcoperty damsge cla�ms ta a vsh�ale_tw�estu�te�for thg rcpairs co yauX ve�icle�f 4}ae damsge e�ccegds
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1'a�e 1 of 2-'PleASe co�p�etc an�retl�rn�iotl►pages o£C'leim Form
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Ma r. 12. 2014 8:25AM No. 7128 P, 2
riHlf-l'Jf-2FJ14 �e�91 F'�d6/06
'F$S�.�txe to coniplc�rc and retni-n bbth pages wlil result in delay in tho hnudlia�u#�otir clait�.
All Clalma-p�easo eomplete this settfou
Were tbcxc�Messas to the mciclent? 'Y'es No Q� (o�rele)
Pro�dc thCir namcg,addresses and telcphont nutnbers, _ .,,.. _ —
'W'ere th�pal�cc rn law enforcement called? � No Unl�awn (circle
If yes,what deperhnent or s.�ency7 +• � � ^P D Casa#�ar re�ort# 1 O ��Cr
'I7►rhere did the aceidcnti or m�ury take place? prov�de street adclrea�,aross s�eet,intersection,n&nne of park or faeilxty,
closest 1an���to.�p��e be as detailed as possi6le, Yt'�,eec,qs�y,attach a dia.�rram, _ - _
_ __.�_______.
Flcnsc�dicate the amount you are seelut��m campensa.tion ux whet yotE would like tl�e G`ity to do to resalve th+s claim
(q ypur sattsfactcon T� D •
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T.�cense Pl�ts Number 13 73-_� �tate�1�G�lvr �
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chca b x if ttus sec �n does nac fl t
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�Tame ofM�:ciical Pro�vtdcr(s): - "� TelepnonC --
Address "�`.� No
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�r�e ofyour�mpioyer:„^ �r- - Te[c,�hone ~
A,ddress
1��he4k here if�ou are�lta�hing nuore pt�g thfs clairr�fnrm. unabar of�dditional pages
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uf yosrr kno�vler[ge. rTrrsxgnad forms wt!!not be rncessed.
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1c140T100211WPSDLHI7 Receivetl 3f12f2014 8.26;16 AM�C�n6�al Da�ight Time�
Risk Solut�ons (A2) 2/18/2014 11 :09:32 AM PAGE 2/002 Fax Server
464843162
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