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Gernert RECEIVED ' NOTIC� OF CLAIM r�RM to the City of Saint Paul, Min��a��14 Miruresotci Stnte Stalute 466.05.stntes t6�a! "...ei�ery perso��...��lrn clnirr�.r cluma�e.+./i•on�miv rnunic-ipnlih�....rl1aR cnu�tr�he�i•eMiff��i IR�` �o��erning bocly u/'llre nrt�nicipnlilV u�ithift 1<ti0 dui�s nfier tfie crlle�ed loss or injury i.r disroverecl a notice stnting!he tinie,place.a��d ci�rum�7a�rces tlreren/;nnd tl�e nrr�ount�`cnrnpenscitiun or uther relief demnnded." Please complete this form in its entirety hy dearly typing or printing your answer to each question. If more space is needed,attach additional sheets. Ple�se 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. 'Che 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 DOCUM�NTS TO: CITY CLERK, 15 WEST K�LLOGG BLVU, 310 CITY HALL, SAINT PAUL, MN 55102 First Name��^� Middle Initial�Last Name �eRN�2"z' Company or Business Name Are You an Insurance Company? Yes No If Yes, Claim Number? StreetAddress �ZIZ� �g��'� �J�-. � City r'1ra lcr L'+rznv�. State r�1J ZipCode �� Daytime Phone (°7�3)Z1� -8G�7`# Cell Phone ('?le3)�t5- c�-7� Evening Telephone (7L 3)z1 B- �t�7� Date of Accident/Injury or Date Discovered �rV 5�. z�l� Time '7�0� <<_ /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. �� ' a :r-�� . ' � t�: 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 clamaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow ! �My vehicle was wrongfully towed and/or tic]<eted ❑ I was injured on City property 0 Other type of Property damage—please specify ❑ Other type of injury—please specify In order to process your claim y^�� npPd to include copies 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. 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 estimaces if the damage exceeds $500.00; or the actual bills and/or receipts for the repairs; detailed]ist 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 Failure to complete�nd return both pages will result in deldy in the handling of your claim. • All Claims-alease comnlete this section � Were there witnesses to the incident? Yes� No Unknown (circle) Provide their names, ad esses and telephone numbers: ��a i 1 �tt�, pL�-. IZ<_c�V e2� ("�+SS�s 7!j- 9 33 -�.ti�°� �.57 -z5['7- �''76:3 Were the police or law enforcement called? �Yes � No Unknown (circle) If yes, what department or agency? �� '�• A`�� Case#or� �-3 '��"'-`�� p�l«<. P��-r, Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility, � closest landmark, etc. Please be �s de ailed as possible. If necessary, attach a diagram. K}1`1 �rz� �Z1�3 ��ra2�es �v'e , ��, �4�� Please indicate the amount you are seeking in compgnsation or what you�would like the City to do to resolve this claim to your satisfaction. =t-� .�,.��i cl� . � �3��.L" c Vehicle Claims- lease com lete this section check box if this section does not a �l - Your Vehicle: Year Make Model License Plate Number State Color Registered Owner � Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged In'ur Claims- lease com lete this section check box if this section does not a 1 How were you injured'? What part(s) oi'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 o:your Employcr: Address Telephone �Check here if you are attaching more pages to this claim form. Number of additional pages 1� I3y signing this form,yoic are stating tltat all informatio�a yoct lzave provided is true and correct to the best of your knowledge. U►zsig�ied forms will fiot be processed. Submitting a false claim can resiilt ifi prosecution. Date f'orm was completed 3! � /1� Print the Name of the Person who Completed t is orm: �N z"h�� e�e r- Signature of Person Making the Claim: � � �� Revitied February 201 1 � / ��.— �o�/ _�� Z L 1 `� `7 `E1� �k .M :�- r'1 y I 9°�2 � �1 C ��2 � v/�,.1 \�.�5 I �-`-�1e..s ��,� r,7 pQ�s e�,-s � I��- r1 �T�z I �� 1f�2\e'S ��J� _ �i, \1tJ � � .�— -� C`� ��e� � 1 1 �1-t�►e� ��-G�. 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N�� T�= �, 1 ''- ��1"'t � 1 � � S;. �� 1 ^ w � .y�� -�..,� C � T dp � �^t �LQ i� ( . � � �_ �� 's � /-\`Jc� l � ��r T— � �Lh-� �i7'� �� "� 't � � ✓ � '--rJ �+' � /� G f}1�-� � �r� l �� ` �� ` '�"' �� .C� J` \ � � .0 -�'-t —� � l� ` /�fj'� /'T l� C �:�-s �� I A-� 1�✓y`-" f . - � �� .�u��2"� i �1 ��N 11 ^� 1�,.,r,� JY J.^'� 'z 2 !N L'S��.2�G_._ L t C�i�i-[-S�''� y l /�;.i�l �G. e;2 �� nf� U1/�� N�,��..��.v �i��'�c=t� /.�� ./.�/� � <-.�.�-� o �� } G��+ ,— TG.� c�� ,�a[ l,�-i co.��1{-t--� � � ) �� o� . �-n�.-�,e�,A--��d.•� e4/�� c�.� ,�9-�" /.1-fl� �(Co �r �. - � . � --�-�...�, ��-�. .— J l-..� '� e��;1 /�-�- �-�,� r� � -�� , � �� -�-�.-2_ LJ r-1 i�C ,-- ,,� �'�:1,^'�,4--rl O,..F , -� �,( .t l� � . .-,�. - �� :, �� , �.z�. W .��, .� �.:� � � � RAMSEY COUNTY ' NOTICE OF CLAIM Minnesota State Statute 466.05 NOTICE OF CLAIM. . . (E)very person . . . who claims damages from any municipality. . . shall cause to be presented to the governing body of the municrpality within 180 days after the alleged loss or injury is discovered a notice stating the time, place and circumstances thereof, and the amount of compensafion or other relief demanded. Minnesota State Statute 658.55 APPLICATION FOR BENEF/TS. . . A plan of reparation security may prescribe a period of not/ess than six months after the date of accident within which. . . any other person entitled to claim basic economic loss benefits. . . must notify the . . . obligor or its agent of the accident and the possibility of a claim for economic loss benefits. (Ramsey County requires by its policy that notice be presented within 6 months as prescribed by statute) Please mail completed form to: Claims/Ramsey County Attorney's Office 121 Seventh Place East, Suite 4500 St. Pa�!I, !�/I�! 5510�-5�J01 Phone: 651-266-3350 1. Describe in detail the incident or situation which is the basis for your claim against Ramsey County: �C�--c,� --r� FtT,l��r�c.yT 2. Date and Time the incident occurred: �+'�t_�' .7 `Lt:�_3 '1�.a-> �\�i 3. Location where the incident occurred: _ �2 i 3 �-�2�es' � �P c. . S-;'_�� 4. Names and address of any witness to this incident: t liSSy GWn�.eC a� {�L� � L�e.,e 5. Descr�be your damages or injury (include documentation that supports your claim, e.g. repair estimate, receipt, etc) ��rr=cz �;�.�v QL� 2��<< � - -f-:�a.... Ptc Your Name: �,.i-�,o,..� - ��,e� Daytime phone number: '7�3--Zr 8-- �'��7`F (Print) Address: �Zf� �`��, �vc . �. Soc. Sec. No.: 2� - `�z -�3� Z r'��-lr �eo.�c l`11�! Ss3�`t -f r __',, � Date: � 1-� -1� Signature: ,..J � - By signing this form, you are stat g that al!of the information provided is true and correct to the best of your knowledge. Minnesota State Statute 60A.955 states `A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime." Unsigned forms wil/not be processed. 07/2011 .tvlSEY CpG Of�FICE OF THE RAMSEY COUNTY ATTORNEY �,�-Kt^�4� �� y a .� John J. Choi, County Attorney o ;"' `y 'y � ;.o� ��' 121 Seventh Place East, Suite 4500 • St. Paul, Minnesota 55101-5001 �- �`kinneao�'• Telephone(651) 266-3222 • Fax(651) 266-3032 Civil Division February 18, 2014 Anthony Gernert 12120 69th Ave N Maple Grove, MN 55369 RE: Claim Number: LM 6Q867 � Dear Mr. Gernert, This lett�r acknowledges receipt of the Notice of Claim that you filed with Ramsey County. The claim form was signed and dated January 6, and received in our office on January 9, 2014. Your claim has been assigned the claim number above. You contacted law enforcement to report your vehicle stolen by calling 9-1-1. The call came into the Ramsey County Emergency Communication Center (RCECC), who dispatched St. Paul Police Qepartment staff. It is my understanding that St Paul took the information, and filed a report on this matter, case number 13238561, which has a date of November 5, 2013. I am uncertain which law enforcement agency r�ecovered your vehicle and had your vehicle towed, but was told by staff at the (RCECC) that the recovering entity called in the actual plate number to see if it was stolen. The plate number given did not bring back information classifying your vehicle as stolen because the database had a different plate number on record for your vehicle. In your situation, the County did not make an error—we ran the information given, ana informea -- fihe recovering entity that we did not see the plate listed as stolen, which was correct information. Therefore, we must respectfully deny your claim. Sincerely, � �,,,;� ��`�� G'-�-�' ��` Deb Somdahl �j� Claims Administrator 651-266-3042 � �� -� 3 �z 3 � . \�-� r �� .��' � �' � _______ �_�_�____.____-__ __ ._____ � __,___ __ � _. � T S;.� j � <<I��,� �..�-�� l �'< -4 T" � �i -z��, - �� 3 � L.. ___ ___ ----�_._._._._.._.___ .__._______..._ ,, ..� _f __,; , _ � 7 c ==_ _, �, ,;, �;"� — _ �..� > �� f'J_ � •� \ ,�` � ,.., ' _ � ,�� f� ,- -� � � .Rt ,� ' f , , .r�� --�. " >, : - x � ��I + _,._ _.�- PO Box 4U25 Saint P�ui, MN 55104 Phone: 651-247-9783 Fax: 651-641-1818 Email: plcrecovety�yahoo.com Carole Ruth Vanvlkenburg-Gernert Anthony Eugene Gemert 12120 69th Ave N Maple Grove MN 55369 Registered Owners: Carole Ruth Vanvlkenburg-Gernert&Anthony Eugene Gernert Title: HJ298A004 On November 19, 2013 your vehicle: Year: 1992 Make: GMC Model: Safari VIN: 1GKEL19W3N6518646 Plate: 2CN548 (MN)was impounded by PLC Recovery the vehicle is being held at our storage lot. As of this date 11/22J13 the charges against the vehicle are $325.00 (includes an Impound Fee of$200.00 and an Administrative Charge of$25.00). This amount will increase by $25.00 per day (Storage Charge) until the vehicle is claimed and/or the bill is satisfied. Under Minnesota Statue Number 1686.051 Subdivision One and Two, PLC Recovery will hold this vehicle for 45 days at which time the vehicle will be disposed of at Public Sale or Salvage Yard. Under Minnesota Statue Number 1686.087, PLC Recovery has a deficiency claim against the registered owner of this vehicle for costs of services provided in towing, storage, and inspection of this vehicle. Storage will not exceed the cost of 45 days under Minnesota Statue Number 1686.051 Subdivision One and Two. Failure to claim the vehicle in the time allowed by Statue will be deemed a waiver of all right,title and interest in this vehicle and will consent to disposal or sale of this vehicle and force us to exercise our right thru court. Please contact our office at 651- 247-9783 to resolve this matter and avoid civil trials and costly expenses. Release conditions are as follows: 1) Registered Owner must be present 2) Valid Driver's License 3) Proof of Insurance 4) Proof of Ownership 5) Cash Only Please contact our office 651-247-9783 with any questions. Thank you! 1 � i . I i i I � � � • PLC RECOVERY P.O. Box 4025 St. Paul, MN 55104 Towing, Jumpstarts & Lockouts 651-247-9783 DATE # NAME PHONE ADDRESS CITY STATE ZIP LIC. PLATE N0. YEAR/MAKE/MODEL REASON FOR CALL ❑ ACCIDENT ❑IMPOUND ❑ BREAKDOWN ❑POLICE ❑ ABANDONED TYPE OF TOW ❑ SLING HOIST ❑ FLAT BED ❑ WHEEL LIFT , STORAGE __TO DAYS @$ HOOK UP CHARGE � MILES @ ❑ LOCKOUT p IMPOUND ❑ TIRE CHANGE O WINCH OUT ❑ STORAGE ❑ D.O.T. ADMIN TAX TOTAL Not responsible for loss or damage to vehicle in case Thank OU of fire,theft or any other cause beyond our control. y Signature X Date