Daggy, Joseph /EMCN P.�.BoX,252
Minneapoiis,MN 55440-1252
Phone 612.643.4700
Insurance C;onipanies FAX 888 992 6132
Email:Minneaoolis.Claims r emcros com
www.emcins.com
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August 29, 2014 $�Q 0� 2�1�+
CI�'Y CLEFZK
City of St Paul
City Clerk
15 W Kellogg Blvd
310 City Hall
St. Paul, MN 55102
Your Claim #: Unknown
Your Insured: Unknown
Location of Accident: Ray Street & Geranium, St. Paul, MN
Date of Accident: 8/11/2014
Our Claim #: 1085464
Our Insured: Joseph Daggy
To Whom It May Concern:
Our investigation concludes that your insured is responsible for this above-referenced
motor vehicle accident. Please consider this our notice of intent to recover.
Please notify your liability carrier of this loss for further handling. Supporting documents
will be sent under separate cover.
Please feel free to contact me with any questions or concerns.
Sincerely,
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Britt Crus n
Claims Adjuster
EMC Insurance Companies
(612) 643-4725
Employers Mutual Casualty Company Dakota Fire Insurance Company
EMC National Life Company EMC Reinsurance Company Hamilton Mutual Insurance Company ���g
EMCASCO Insurance Company EMC Risk Services.LLC Illinois EMCASCO Insurance Company �
EMC Property&Casualty Company EMC Underwriters,LLC Union Insurance Company of Providence
I-�EC�IV�D
SEP 0 2 2014
CITY CL��K
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesotu Stute Stutute 466.05 stutes diut "...erer��person...who clui�ns dumuges from um°rnunrcipulit��...shull cuuse to be presentecf to Ihe
governirtg bod�•of the municipality within 180 du��s ufter the alleged loss or i�ljury�is discovered c�notice stulir7g the tiine,plc�ce,n�zd
circumstnnces thereof,und the umount of compensnlion or other relieFden�unded.°
Please complete this form in its entirety by clearly typing 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 amount 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 depending 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
Company or Business Name EMC Insurance Companies
Are You an Insurance Company? �/No If Yes,Claim Number? 1085464
Street Address PO Box 1252
City Minneapolis State MN Zip Code 55440
Daytime Phone(�12�43_-4725 Cell Phone( ) - Evening Telephone( ) -
Date of Accident/Injury or Date Discovered 8/11/2014 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.
Citx of St Paul security officer ran red liqht at intersection of Ray Street & Geranium in
St. Paul and T-Boned our insured on 8/11/2014. St. Paul police report# 14-170068
Resultinq in property damaqes and bodily injuries.
�Pl ase 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 damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
❑ My 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
In order to process your claim vou need 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
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 and 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—please complete this section
Were there wimesses to the incident? Yes No Unl�wn (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Y1� No Unknown (circle)
If yes, what department or agency? St. PBUI PD Case#or report# 14-170068
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.
Ray Street & Geranium, St. Paul MN
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.
Vehicle Claims—nlease comnlete this section ❑ check box if this section does not applv
Your Vehicle: Year 2004 Make Chevrolet Model Cavalier
License Plate Number State Colar
Registered Owner___.lOS2ph Dagqy
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please complete this section ❑ check box if this section does not apply
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 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
Pcint the Name of the Person who Completed this Form: Britt Crusan
Signature of Person Making the Claim:
Revised February 201 I