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Carelli RECEIVED MAR 19 2014 NOTIC� OF CLAIM TORM to the City of Saint Paul, n�t��ERK Mr�rnesuta Strr�e Stuurte 466.05 stntes d�at "...every pe�son...who e•lainrs dumages.�'rom nny mu�ricipality....rlra//cnu.se tn he�n-e.se�rterl tn[he go��enting hudy of the municipnliry witllin 180 den�s njter ihe n!leRed loss or injurv is discovered n notice stnti�tg d�e time,pince,and circumsta�tces tlrereof,anc!the mnotrnt of compensntr��n or olher relief dernnnded." Please complete this form in its entirety by clearly typinfi 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 amo�nt 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 dependin�;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 / Middle Initial Last Name( �,1�� l � Company or Business Name Are You an Insurance Company? Yes/No If Yes, Claim Number? Street Address�� C�J�� 1 �-X. �� y City � ��}t ��• � State `�L I�l Zip Code �� V� Da time Phone 5� �3��e11 Phone ( ) - Evening Telephone (��--Qq� � �� y (�)� Date of Accident/ lnjury or Date Discovered ��-I ��l l � � Time am/pm 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. C`j �� -� \ r �� . i 5 �-�--, � , -c L�v' � n ��'_G'c � d �l `(1C� Y'C�� ' - . � . 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 �M❑ y vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow y 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 ]n 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 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; or the actual bills and/or receipts for the repairs �'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 suppoR your claim but will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form Failure to complete and return both pages will result in delay in the handling of your claim. Ali Claims-nlease comnlete this section Were there witnesses to the incident`? Yes No Unknown (circle) 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 facility, closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. Please indicate the amount you are seel:ing in compensation or what you would like the City to do to resolve this claim to your satisfaction. Vehide Claims- lease com lete this ection ❑ check ox if this section does not a 1 Your Vehicle: Year ,��o Make �_- Model ��C3—th � u 1 7` License Plate Numb � �%�State olor - � O` Registered Owner � Driver of Vehicle � l.�-� �J \ °�—S Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Injury Claims-please comelete this section ❑ check box if this section does not a�plv 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 attachin�more pages to this claim form. Number of additional pages I3y signing this form,yocc are stating tltat all information you have provided is true and correct to the best of your knowledge. Unsigned forms witl not be processed. Sr�bmitting a false claim can reseelt in prosecrition. Date form was completed �f � �1 � Print the Name of the Pers�n who _ leted s l�'orm: �l £-- ' '�� =N . -_ __. C_ Signature of'Person Making flie Claim: - - > Revi�ed February 201 I ; � � 62090021532� � � �. ; � � � � _ �� o t � .� Q�' �}. � � � N � �� y O _- � w U O � z� Y � � � �� n c '►� �� •� ,: $ '� ,,.�:� � c m O v�i�r y � �j�'. Z � 'C �� m � _ �' c c �a � � � oo o c � ` � o �N in❑ c� ❑ . E E E � ❑ .c o U p, � � V �M � �".. � � � "'a�� m C ,7 � •i �.�.. ad., v �' d p� N 3 � m_ V � �� N � � �� ..� � o t .o � � � d m� 'a �. � ��r U m in �n io N � �' c-- C �"' o �.�N c � .,�, o m � � C o o a W � �O m �•,.., >> � m o ❑ g o � ��" � Z � �� 'sm a o z c n c� no �y � � �� ❑ � ❑ ^i ❑ -p ❑ ❑ 0 � ado � ie � O " _ � ° � �� ...._t j tmi� $ C ' m� � �� , � � L � y C V � _s:4��. � �� V�_ . � C a � y p � '� . � � Ye; .: . �� ....1- �� ' p ❑ � V�.� � � f6;�..�.. �a � i 'J p d �t1 � � � ❑ C � � � C � �>� � - U � �� ;...� d O m C �� N °*-... Q -�p � Gi U p >� N'�►_.. L - � � � +.�::;�� U ❑ �r� r` w � a�i � o p~ O � �� ` -g m � o � = Z �� Y � - /�� _ . o `. � � �i j ° o o fn � � V• i0 � " ,� l'"�`.,�� :i� ❑ ❑ � V t�i.�'�o y M m_. �-:-"°' �,,a ._ ^� �'�' � Y �_� R __�' � �/� N � �I G. � � � �O � � G C m�" i . C d m., � � �a � � p� 3 � ,�,�`"� A 0 y N � w � ��.� � � «� � d o= � � O_ � � rt � y � � � � �YO N , O Q O ti../ � t., . v� �O J U d. y O � � y �� Z p ��.i. . . � � � � � C Z c�i E d � � S' C H�:"N ly .y.-, �N � fn � m (� j �� C ,O�J fq `^y� -p �. � � � m � 'O J _ � _.N -p �t�. y � � m � C �O f�6 � d d y Z 7 � � � Q E � N � a� •-+,� �v, o y � O � ��n m ,�, -c ,�s_, 'o > y m � �s o N Z m� m m � ..��° t. = o � N � �, Z � = w �� =o � � � � � � c�a� v �' O m � c�o °� o 0 0 ~ � _ � v � o z LL a G o >�:,� a ❑ � z z z ❑ ❑ � ❑ ❑ - Dr. Key Carelli RECE�VEp 280 Ravoux St #804 Saint Paul, MN 55103-2343 APR �� zQ,4 keycarelli _qmail.com C�TY 651-200-4392 Home CLERK 612-998-9197 Cell 651-338-2780 Office April 6, 2014 Sandra Bodensteiner City of Saint Paul Office of Human Resources 25 West Fourth St 200 City Hall Annex Saint Paul, MN 55102-1631 651-266-6500 RE: File Number C-140152 Dear Ms. Bodensteiner: I received the letter stating that you have completed the investigation of my claim, and denied it. I wanted to give you a clear picture as to what happened. I was out of state at the time of the incident. Mr. Arthur Sykes was authorized to use the 2002 Pontiac Grand Prix. On February 17, 2014 it snowed throughout the day and evening. When Mr. Sykes was moving e car from in front of his h e as he is on a Night Plow Route on Marshall Avenue he�stoppe police officer. The police were in the area looking for a suspect. As he was new to the Saint Paul area, Mr. Sykes asked the officer where he could safely park the vehicle so that it would not be ticketed or towed. The officer told him that he would be fine around the corner from his house (where he was stopped). That was on the East side of Avon Street. The next morning the car was gone. Mr. Sykes called me to tell me about the car. I called the impound lot on Tuesday February 18, 2014 to inquire how Mr. Sykes could pick up the car. They informed me that I would need to give him a notarized statement authorizing him to pick up the vehicle. I was out of state caring for my mother who had emergency surgery and was unable to do this. I should not be charged for the tow as the officer clearly stated where the vehicle could safely be parked. If the officer had given him the correct place to park the car would not have been towed. The above statement is true and correct. � � I I /j L Mr. Arthur Sykes Date . K �arelli Date , OFF[CE OF HL-MAN KESOURCES Ange(u S..�'ale.rry',Director RISK M��NAGEMENT CITI� OF SAINT PAUL ?00 Cin Hall Annes Telephone: 651-266-6500 Christoplzer B.Co/enran,hlai-or 2�4�est�o:rr�h Streel Fuesimife: 651-266-8886 SaintPauf�1N .S�102-l63/ i� April 4, 2014 Key Carelli 280 Ravoux Street#804 Saint Paul, MN 55103 RE: Claim Number C-140152 Dear Mr. Carelli: I have eompleted my investigation of your claim filed with the City of Saint Paul. Your vehicle was properEy tagged and tawed in accordance with the snow emergency rules and regulations of the City of Saint Paul. No refund is owed. Sincerely, � � --: �� ;,��;:�-��s � � �.� , rf� � �� ' ., — .._ _ � < �-_ , ,�,,�,„ C_�� "� GL� � ,/ /� �--�'-� U' Sandra Bodensteiner Claims Manager SB Ar�-,4DA-EEO Employer OF1�'ICE OF HUMA?v RESOURCt=S ' -IngeluS. .\'ale=m'. f)irector RISK MANAGE�9GNT CITY 0�' SAINT PAUL ?00 Ciry Hnll A�tnex Telepha�e: 6�l-266-650� ('hrrslopher H.C'n/enimi.,bin}�or ?J Fi'est Fourih S'trcet f ucsimile: 6J!-?66-8886 Sairvt Pa�d:41.-N �51(1?-1631 �wr March 27, 2014 Mr. Key Carelii 280 Ravoux Street, Apt# 804 Saint Paul, MN 55103 RE: File Number C-140152 • Dear Mr. Carelli: I received your claim filed with the City of Saint Paul and have begun my investigation. Please refer to the above file number in any correspondence with me. I will notify you of my decision on your claim when I have completed my investigation. Sincerely, , � � ! , i ��/ , % / ,.,�,fi'��'�.-G� �-r'j c:��'�- '� �2� v Sandra Bodensteiner Claims Manager SB ��-,�nn-r:e-.o e�„�to>��