Moua, Tou C•L•G
James P. Cody
David K. Cody t The Cody Law Group, Chartered lcody@codylawgroup.com
dcody@codylawgroup.com 359 Commerce Court Robert D.Cody
Vadnais Heights, MN 55127 rcody@codylawgroup.com
Ph: 651.294.0994 • Fax: 651.292.4955
www.codylawgroup.com
June 23, ?014 ����I���
JUN �5 2014
City Clerk
310 City f Iall �s��� �r�.���'(
15 Kellogg �3oulevard �
St. Paul, MN 5510?
R�: OUC CI1�'11t: �I OU I,ee Moua
Your Driver: Daniel Christopher Michener
DOI: May 17. 2014
Our File No.: 20535
To Whom It May Concern:
I have been retained by To�i L.ee Moua to represent him in any and all matters arising out of a
motor vehicle collision which occurred on May 17, 2014. ';
I aC this time enclosing the Notice of Claim form that has bcen exec�ited bv my client relative to �
the above-entitled matter. '�
I
1 have also enclosed a courtcsy copy of the Notice of Injury of�Claim of Tou Lee Moua that was
served on the City of St. Paul.
I � s� n h sit le o contact me. ��
Thank you and should yau have any questi�ns, p ea �. do ot c a t i
Very trul o ,
;
David K. 'od��
DKC/jen � �
E:nclosures
t CML TRIAL SPECIALIST CERTIFIED BY 7HE NATIONAL BOARD OF TRIAL ADVOCACY AND THE MINNESOTA STATE BAR ASSOCIATION
fi MEMBER OF THE ACADEMY OF CERTIFIED TRIAL LAWYERS OF MINNESOTA
l
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesoto State Statute 4b6.05 states that "...eveiy person...w/to claims dnmuges fronr nny municipa(ity...shall cause to be presented to the
governing Gody of the nuuaicipnlity within 180 dnys nfter the alleged/oss or inj�u7>is�liscavered a notice stating the time,�lnce,artd
circumstances thereof,curd the an:o►au of compertsation or otlier relief demcrrtded."
Please co�nplete this form in its entirety by clearly typing or printing your answer to each question. If more space is
necded,attael�additional sheets. Please note that you will not be eontacted by telephone to clurify answers,so providc as
mueh information as necessary to explain your claim,and the amount�of compensation Ueing requested. You wili receive a
written acknowledgement once your form is received. Tlie process can take up to ten weeks or longer depending,on the
nature of yovr claim. This form must be signed,and botli pages completed. If sometl�ing 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 �QU Middle Initial � Last Name ��� VE D
Company or Business Name
�!'� ��'��
Are You an Insurance Company? Yes/(No JIf Yes, Claim Number?
Street Address ��O �'vR�+ ��- Cil�'Y C+1-ERK
` S5/OCo
City ��"• ����-- State /� � Zip Code
Daytime Phone( ) - Cell Phone(�y�� as���Evening Telephone{_� -
Date of Accidend Injury or Date Discovered J ���— �� 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.
�1 E'Lt S G� 5� -f�h Qr G�.-I--�t2 C h PCl �b��C 2� r-� 1.�'��'-I- .
�
1 se check the box es that most closel re resent the reason for com letin this form:
� ) Y P P g
My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
❑My vehicle was damaged by a pothole or condition of the street ❑,My vehicle was damaged by a plow
�My vehicle was wrongfully towed ancUor ticketed e."7� I was inj ured on City property �
❑ Other type of property damage-please specify
❑ O[her type of injury-please specify
In order to process your claim vou need to include copies of all applicable 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 far 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 bilis
and/or receipts for the repairs; detailed list of damaged items
O Injury claims: medical bills,receipts
O Photogaphs 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
railure to complete and return both pages�vill result in�lelay in the liandling of your claim.
All Claims-nlease comalete this section
Were there witnesses to the incident? es No Unknown (circle)
Provide�heir names, Addresses and telephone numbers: ���� .SQ� Ct--�'�ChF� +0��� �'�
��
Were the police or law enforcement called? Ye No Unknown (circle)
If yes,what department or agency? �-l� �R✓I Case#or report#
Where did the'accident or injuiy take place? Provide street address,cross street,intersection, name of park or facility,
closest landmark,etc. Please be as�lecail�d as possible. If necessary,attach a diagram. �k�1Z5� �-�
-�-�.� c��-#c.�cr��d n�v I i c� r�t�vr+
Please indicate the amount you are seeking in compensation or what you would like ll�e City tof�o to resolve this claim
to your satisfaction. �LQ�U/Y�lol e CIA�mA�]PS 1/1 `��E-C-�5 5 �rt" ����00_C.�`
_ __ _ _ _ _ ___-
Vehicle Claims- lease coni lete this section ❑check box if this section does not a I
Your Vehicle: Year I°f ol� Make Uv�dA� Model ✓��
License Plate Number I 12�-T State M►ti Color BI�tCIL
Registered Owner I�l h�a ►GOt1 /�U�A'
Driver of Vehicle ��vU � .M U/f'
Area Damaged ��J/�''� �
City Yehicle; Year ��D°1 Make cl Model V'�
License Plate Number State N�Color /�' 1Q C lL�
Driver of Vehicle(City Employee's Name) �•°►r��l C����s1�v io►�/' � �G �P�'
Area Damaged
In'u Claims- lease com lete this section ❑ check box if this section does not a 1
How were you injured? i,IJR h �n(U��ti ,n -t�►e YnD-�-d(� ✓2h ��L!-�
f}CG i er�t .
at pazt(s)of your body were injured? h�GC QG GZ C I'� c
Have you sought tnerlical treatment? Yes No Pianning to Seek Treatment(circle)
When did you receive treatment? ��� d� C (provide date(s))
Name of Medical Provider(s): �t �vn� � � �- �' 0 m�I'�'+ �` �'� �l QO� C rr C- '
Address •�13 M�'r �IRn .A�G � .�A�Jr lil� �vJ_. Telephone (OS�-�t�77 70 ,
Did you miss work as a result of y ur injury? �� Yes No
When did you miss work? M� �( �-J (provide date(s))
Name of your Employer. � '�" �+ �`���`� '
Address Telephone
'�Check here if you are attaclung more pages to this claim form. Number of additional pages
I
By signing t1:is forn:,you are stating that all information you have provided is true and correct to tlte best
of your k�totivledge. U�zsigned forms will not be processed.
Submittin a alse claim can result i�a prosecution. Date form was completed "' ��Q`��
g f �-
Print the Name ofthe rerson wlio Completed this rorm: ��U ��� 0�
Signature of Person Making the Claim:
Revised February 2011
NOTICE OF INJI_IRY CLAIM OF TOII LEE MOiJA
TO: City of St. Paul
Attn: City� Clc��k
iS West Kellogg Boulevard
Suite 210
St. Paul, MN .5.5102
AL�;ASE TAKF: NO'��ICF, that. E��u�suant to Minn. Stat. � -46(�.O>. I ha�c hccn rctaine�l
by Tou l..ee Moua to re�rescnt hin� in all matt�rs arisin�: out of a mc�tc�r �chicle accident ��hich
occurred on May 17, 2014, at .�r near SS; Forest Street in the Ciry of St. Paul, County of
Ramsey, State of Minnesota. That at that time �I�ou I.ee Moua was operatin� a 1999 Flonda
motor vehicle. owne�l h� tihia Kc�u '��1e�ua. �I�hat at that timn c� ��as in�ul�cd in a cuilisic�n ��ith ��
Gity of St. Paul Police �ehicic operated by Uaniel Christoph�r Michener.
"['hat at that time by rcason of the negligence and cai•elessness of Daniel Christopher
Michener and lhe Cit� c�1�St. {'aul in thc mai�a�ement. n�aintenancc. operation and contr�l of hi�
motor vel�icle a collision �iu� c��us�d und th� I'laintilt����a� injurc�i as hcreii� af�lcr allc�ed.
�l�hat as a result of the accidr:nt in question, the Plaintiff has sustained injuries to his head.
neck, back, with pain into his right hand and fin�ers and was otherwise bruised and contused in
and about his bodv. and causcd to sut�lcr {�ain and necessitatc medical care ��nd treatment.
't hat it is antici��at�u ti�at tl�c f'iaintil�l����a� hrin� .i cl�ai,;� !or pain. su;�l�e►�in�.; ancl disahilit�
including medical expense5, present and future, as well as property damage in an amount which ,
i
cannot be more accuratel�� statec� at this tiri�e ii� a reasonahle am��w�t in exeess of$50.000.00. I!
�
�� cop�' of�the ��licc rrrc�rt prc�� id�c1 h� th� ('it� of�St. I'aul ��hich is attachcd hcrctc� and �
tnarked Exhibit A sets forth the datc. tin�c and lucation ol�thc accidcnt.
"Ihat the Plaintiff� is in a position to provide and furnish f�ull information re�arding the
1
nature and extent of� th� injurirs and dama�,es ��ithin lil�te�n ( 1�) days after the demand b� the
City of St. Paul.
Dated: June 19. ?014 l�l II�; ('(>f)Y I.,�w' C;ROU('. CI 1�1R�I�F=REI)
�y��-------- --- --- -----------------
Da��id K. C'ody. /\,R.�0017590
ntt�rne�� f��r I'laintiti�
3�9 Cc�n�mcrcr C'oin•t
Vadnais I Ici�hts. MN �i 1?7
(651 ) 294-0994
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r� 3? � '' hand/arm Driver af Veh N2 initially claimed no � O1
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� �j °� N,�s transported to Regions Hospital Photos »
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