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Smith, Monique
��u������"�� :�It}TICE QI' C'LAI�� �'t��',41 to thc. (.:it;�-+�t Ss�in� P��ut, Nl�nn�sota SEP �9 20��+ r fa+�r r t,.��� '�r ererr JrP �_.tff ti rdt 17"`..,ni r t� sr t ti t r iaa.�r ct sk,c �r a���q int,rzt�t;ra�it} �,trraa cr.rease t�br�rrr,ce+rtatlPC 3Yve �j�� i ���i!� .,.rtcn,t.�,,5�.,�'S-;��f a m nxzsi�:�.I�tt�c�rf$ut7�`*Y�ef tv a7� f✓s�_�Ic��.?s_aa r.r irr,re+ t�..a,�S:.vveff�rYitOhtY�SfG�tP�'i,g t�te ttnte,�sfe1_i�.rs�zd 1 \ ��r«rrrr t.mrrs fia�r� r .,r,ItJ: n��wtt ey ,x,���...,:tt t w-.�tli,rr U.j famw7a`Prl„ I'lea�e�axom�+lrte rlh�s 1`oe��t1 in ifa eia4tr�is•b}c�eartv t}�@in��r pi�irating ytiur a�!�trer�v eaci��u+�st�cr�t, IC�mure sp;aee ix ��cr}ed,�.xc�t�tr sa�l�1"rl�d��xsal�1�eeis. PIe��R note 1h:s1 rou witl�ot b�c��nl�zct�d by tcl�plcaate tn cimri�`s:�nsrve�cs,s+�petrv9de us �vcl7 inYE��°inw#iat��s rxe�e��i9rv to ecp9:�a�p�,u#�elaim,:and t}sr��tnenunt nf e�r�t�ee�saiie�n taeinp reyu��tet1_ Y�xc fci(t�rrceyti°e� �srirter��el;xwm�led�en�€�t onre S�o�u forz��is��rcc°ii�ed. "1�he�rc�cesc can fa�xt up lo ten�tcek�s+rr I�n�et da�p�nd�ng c�n the zi:�tf�re c�fy�our c�t.�irn, '#'tri�f�rrrf uzz€��t hc•xi�a�e��:�rtJ boih�ages r�rti��te�t�ci_ If sn�nelhfng da�C�tza!a���r1y,cr�ii�`tiirl'. 5�4�� +C'OMFLE;TETI F?aRM a�N� �TFI�R Ti+�CI:;�t�l"�i�t°51'C}: t,'1TY CI,ERK, i5`Ub�E'�'C' E��.LLC3�t'� Bi,�'I�,3t1) CITY' IiALi.,SAtN'T YAC�L,1t✓IN 5:+��2 I<`et�s� �l.�mc � '� '� � r' r.. �` C. ���vy"�s('°�.� i�4idclt�;Iftiti.�9 � �,,+xt.dam�:."�^t��;�s� 1 �'c�ni�anti c�rt3u�;iri�,��:�mc i',�����v:�.�:�Yr. ,����s�{ �a�,.� �g^��,�, ;:.�,i.�. _�b"��<`����.� 1�":�1�"��rc� ����r�'t� � .?��`i'c�u�3ttltraurancc:'c>ntpan�' lc�,s?��o 111�,5.�:'Iairti�-;umfsir:' '��_��� .'.�?_`�'�`� �,,, _.�__�__.__ _. �- , , ����.:�a�,��� `t'� _��_s��.�k...___�___.__ __.._ __ _ — ___ _____ _. c'it�- ..._..�{f,.,,;�;��, t �-� _ . ___ _ _ S�.fe t^�-4_ I..iP 't�de `x`��!Z"T _ _ � � :�; ���.� I��S>tin�c 4�k�cr�tc;�'�t�t„, }1_���- Ca� ,�<c;l(E'lina��;f t • ���uiris�a*�i'�:l�p(tc>ac( f - [�at:;ol.�ci:itl�.�nk Jnjus}^c>� (I�t�1)i,cr,��rui �?������,�� lirn� �_L.t am�*rn` _. __ 1 y, f�l�xvc�.�tat�.i�i<3ct.�il,�vluat�r4:;zirce<i t�,.a}�E7er���E);anci�sl�� s�+�r��re s�xtr�rxittinu cr clain5.�'Iea�e ia�itis:ate rti•h}<c�r h��w�c:ta � f�u[tii�.C:it�}�rt q�i��t I'�u9 x,it��.nipl�����;��.�rs im�,le�c{�r��r,i i����E}a���l>(� '��zr��u��c�aena�c�. _ -a : ������i��`�te��__�, �� '� ,��- _.. �� S`�--�___� _.--.______�__,__._.__._.__.__ ._ _ _ __ __ _ __ _ __ _ _ _ � t'1�,�,ti •lru�3�ilr�,h«�i ��h:�4 rns�,t 4�}����1� oc;�31���€�nE tlr�r��v�rsn�«r�:c�n�,a��,°�i�3�+ilxa�f�rm �� �� �I��z��chiclu tias c(an»t ut]t}arr<<�i�l�nt �'v1t t��3i'rcle wa��I�����ai durr_n�a Yr�w I� C3�(ti�ciii�He�ia�dasna�ul 1,i a�crt}ic?!c<>r;tintiit�c,n,:>+,titc�ircet t�\.i}'c'�hi�le tieas.i�ma�txl Ity a�,(aw ! L:7 4-i�, c-ehi�:Ic°rtax esrc>n�;lia}1}'tcw�c�ci<izz<!ur ts�k�t�c! �I 1 uas iajure<I cm C'iti���vpi;�lu ! p t�tlxLr tr�ic;t�#'E�rc����;r2�a[�rnttr!c (�Ic:,�sc Spz:,c�#;t� I �,t��i�r ta�ic f�f tniur.-�pleeasi�;�.7<�:if��r wt'.... �::�'�,t' `�q��.,'�fia€§ �,4.��?_��?4�. :�!-i'�i�._t'�'�� C'—�,'��'i�+">`�--;� � fz�vrcier iv�c°7ce;�:��E�r�laii�i�e�p necd tc�iezcfude eupies�tfi�ll np[�lienble doeumenf�f � I�`raz ihu cl�tin�c ty�+c�li;+t�:c!truk�>�4.�ilc.aaxc he�ur�:f�>incE�}ii�ti��>cl�rcurt�czttw inslicatc�3 nr i€ti�il€;��:1�� th�h�ndtint;of �csttr ci�im. 1)t��un�r.�it�t��Il.3:`�t)'l R}c rc�tmne�3 anzt bcc�rw�c tC�c�ni�yxria c�f tl��;'�t�-. 1'cw are�:t5�;nuraa�c:d fc,kacp�s c.aFc 1'or 1��>sir��[I'bel�r��eibmitting��aur c.taim f'r.rnn. - _ O 1'rt>p��tv cl.in��t�e cl:inns fcs a E:;ttir.l�:tuir esiintat��t�3 the 9���airs t�,irrttrvchi�l�ifthe dacnapc c�c�.:eeii, �it){t.E}[1;F;ra il�c auG:tal 1�i11s c�r�t3-i;�r'r�:�:�i�a[s li+r tli;:tc�a�t�sg t U [c�sk-irtr�:;lasr��.�c: l�,€.�il>iU��+�i��v of:�t€�>tic:},c:i i�;Gu�ci�in�3 a cca�+c caf th€:irtt�acaunit ltrl rc:c;s;'r�E C7 t 7€�f�z prn��rt�.�iaxtta���laitta:�:ttsc����air ert�ssan[�:5 if'tlae d:�at�;a�u e�ceccic„��5t}Ct.f7U;t>r tl�e actual hiEls anti ua'r�;cei�rt*i`t�r t1Ye rei!air:�:tiataileif 3ist ctf damas?eYl iYerns ' CJ tngtca�� �lain�s.rri.:aic<il krait�,a �c;i�rt:+ C�k'4tote�nra�33tw�i-�al��a}�gi:�:Ei4lrtrc t�s,tra��s�r�;:nt«ctrcl,u��par�t ts7itr ct.inr�nat trill smY h�rs:ltEm�.r�. I���� t ai`;—t'Irsi�cr cr�n��?i�-ic aE�c�i�etura h��t�t panos�f<`t�im]+orm PCN:3tl01A201A0948200135T I}CN:3Q4142�t14�91821}01357001 R�ceived DateiTime:91t8f2Q14 9:51;OQ AM Page 4 of 5 ' 1�`�ii��re t�r�°erm�atete��tu1 retrt��n hoila�r��t3s»ili r���d!in d�1;��in tE�e handiin�4:R1't'��tar�.Icaim. ;tll C'Isiims—�rle:�sc�cor��leic i[3iv seciicc❑ ,,,a.:� '+l'�t�th4retieit��cscc�f�>tl�wis��icicrtt? 'f'�s i :r�� l"nknn~c�n feircle) �'�c�tiitic tlt�:ar n.iancv,zcc��3re:ssG�aa�tl iulvpitzaatc��rxrr����r4`_.."" _ _ Gt �e.the�e3lace c�r l.s��;nf�re:c.m�:nt�alt�tl" 1 u+`s �du !'ttkn�x+ri icirc ic;i ,`�;��}'���i.z� {f�°��,���liat sl��arimerrt�zr�g���:' _....._—__.__ _.,..'�. _C;�s��srr��p�€rt� _..._...�.._ 44'tterr dz�i t};e�;:cr�lent crr injur�•i.i�:e�>tzc�;'.' I'r+,��isl�:streat acl�iress,.:rc���ntrect,intersecti,-an,ttaati�:nf'Park rrr faczli�Y, c1t�;�a;!iandmark.�#� 1'l,:as.F+c a�J�:t��ile�3 a�j+�,�sil�l�. al rz�c�^ssaq•i.�.�tt�s�:h a�ic3tr:�tn. . ._ __ `�r�: w�l�°k ��$�:`k��� _ _ �_ ._ I''9��z:e i��dac:Ets t3�c ain«unC���c�are sLikins�iri��nn�r€trsaiion a�r uh:�t yoix staulci tik�thc t;ifti to cic�tcr resr�lve this claim ?�>�a?iat sati:�ia�vtic�a, -? � _ _�����o�.��__._---.___�——__________.____._ _�__ ±'i��tic•Ic�(`l;�ini� ��tca�,t�rt3m�lctc�ilii�sr�c•ii��n E3'�I��:c}.'�o+�ii,!�issectit�ndu�:sn��ta,��1} _ _ K _ ���.rtx>��tticl�: 1��ar I�Ja�,� 1-1,�c��� _ __ _... __.. . �_..._n P :��rn��;E'I:rt��`:�mb�r `;t.rtc= t rslor hc:ttt:lcr:c�h:�FSnc:r _ — __ I}ril.t c�:[�"el�tc3�, _ - ______._.__.�. _,..______�__ _.�__...___. � --� ___._..___________._,._,... ��e.�3 L>c�zr'�<i�„ex� �"'ft:t 11ii.1�; '�'car� � Nf�k�= 1�i;�cicl _ _ . _ I.,iu:n��F'lah_'�untl�;;s� �itatz �'��I��r _ — _.._ __.._ _..._. _ __.. _ .. �___ 2�rat'yr rit`ti clu .�.��"',it��}ati��Ir�t��4 '�'an�c;'t �:t�.t I?�xtta(Evi� _ In,�ur� ('lairnti pleastWc�3iltalet�thiv sec#itan _ _...C3 ul��t'k l�o.y if t�is seCitcrtt tioes not a I� --- a�� raz,r�}��i�nj4�rc�c1'� ��'� ti�"������,� t.���'�'"��a°�„��� �� a f, �����1�°€„ �t.,� ��,�� qu� �,� ������-����.____`_'_=�.�.�� t -�-t1�I--���`1 t __ 1��}taf�,.i.ti�,4}€sC�cjurhr�dtv.er����frcd`? _..,___m____ ,.�... ___.. -- I��it��°�±�r;�i ws�����tt meJi�q�1 trcati�r:;��d•) �'�4 \t� _ �"•1�nnir+�F?ts=�4cck�.Cr�ni�ri�t tc'rr�le} .. Tt�ih..tt tixl vcru te:�iti°�ttcatrrten[� tpscrvid��afe�s}} �'rkm�;a��f`�lu3a�:.�l!'��c'}3tz3eftsr; ___.--- - _____ __ ___ ., .__.u._ __._.._ � �_ r'�Ictr�±� __ ����pFrtm�__._ . . _._ ... _ �__�� � �.,......... C�ic{tfr+a�ni�£ic��rl.€aw a r��ulr c t����r u�jun`' 1w+ `-iz� ��'h��3�ic-1 erou mi�4s ti�-r,r};�� `provide�ia�e{si) \��ru,c�f,p�v�t�f:inE,Eztv,�.. _ _ __ _. _ . . _.._ _.,. _�.. � _ ;�r��i�i:�s _ _. .._�..,.. _� __..__.. ______ _ 1�[ep3�onu �'{°l�er€�hrre if s�c�u�re aeracl��ai;;tnc�rc�a��s tu tlai�rtaitn t'c�rn3. Nuaai}�er r�t�i�friitir�nal���k�s �. /31•si�;�nin�tfri,�f%�rrax,}�rru rtre s�ttrtin�;tlx�r rr11 i�:jtrrrntriirttr t't�tt htrve�r��ti�itle�l ic true txtttf cnrreet t��t3tr.tles�t r�f r�t��er knn���fert�r. G r�ci,��re�',f'nrtns ri?itl t:«L!ie proc�ss�ct. S►cd�milrite,�a�a/se elrritri cmr�c�sa�ltitz�r�ixa>z����%�r��. 1:)at�tirrm+��p�;�:-�,nrpic�f��l ..`����`���`��-�,w p.._.�..._._ Y �4 � 1'ri�i tlrN'tirme otihe l'c.rson��6�a('c�m}�I�tt:c!thi5 Ifraem ��"'v'r��"sr ;.�`� ����'4 �.� Si„an�i+��cs c�P�'eriear± �lakins?ttre t'Ixirn: ,��k t�;�P;,,+f,�'{,�J ��°`XrL�v �'1 i:te� 1 �.... _ta. � P�N:3�014201AQ8i$2001357 DCN:3tt41d2(it4t}91$2QU13�7�i41 R��eived D�telYime:9J18J2014�9t:51rOD+a(�1 Page 5 Qf 5 Risk Solutions (A2? 8/26/2014 9:44 :47 AM PAGE 2/002 Fax Server ���-��,�,,,. �'` '�.r�..,'�'�/�� 489910332 �� ----- ---- - ° - . . . . S�P �9 �b�� ,.� Kcident Report 9414 7266 9904 2010 1720 17 Page 1 0�' � � CL Cp� Ci` � � � � • ' � ��,�„•.� �� -"'"�",lflifE0F811ANQ0!'��'P�II�' . � S 191 S 1007 N �+i�a:.��N,1• � �}3?9���. vi�ce ��'�"��oP' •���-�t p `���[trD�ti���i� � ryt� �_.___� a .�+w+�. •w.w-w..on ..iro o ��.wJ �.'7���rA.� �:•����•�����„�`y�o1ru a:� rtwi I'1011 A uninr�c � . N Y tl2 00 00 Y �, •� i w�;�-.'�,'��������� .:_'� 7 21 2014 1621 'jn' nartccvnw �w+cwrrxwanurww NpLp°NQb°�1°" �M dtnn.� a __B� �y" Q�n� 2 �„ l0 FOREST ST . . ��� u� u � cwnr�n � .nnw �vc��ror. � wwn�n WrRI{AffTCOM4�(61fWWk 62 �,� ST PAUL +_ 10 E MARYLAND AVE F' -4 L�' :.I� � pll•ll'Tlb� OWV��If�MYMIMI�.t w •:'741[ QAV�••.A)I�M.Idi11IH dF/11lItlVYyMON i ••_ •:ii�n [Mtl•:••OIf��M �4 O1 V732231073312 MN D 04 •; O1 X224275239408 MN D O1 � HCTI NIMiRLW- GRVFITI :M�lpIY1.Y4L�i.W�1 C�.KNM�1M 4.�IA! TIMOTkY JAME5 NIEDERMAYER 10 14 70 ' ROBERT JOSEPH SWEENEY 12 03 98 w�n. unru ava `,a wM►� arnoc� �� O1 1897 NRZLEWOOD ST Y O1 ; 5300 AYBEE CTRC N; O1 0� „�.�y on.n.n a. .a,.w,� a O1 MAPLEWOOD 55109 651-230-909� � SQHITE BEAR LAKE 55110 612-812-6�68 Oi ww° u} .- car Wttn rw u�a .�ri ' � n. wvi v�r��vi •.we uc* wan un.m � O1 �M �9 09 04 OS N !� M �4 04 09 OS N O1 Nuo �'/�[ v� rvsf. roNn. IMrsvwr wMUUtsrn.n a►w�crll irua M1.a a+c �nc rowMr tau<ro+� �wwwtA�u�nw wrry�f� "� 98 i�" 98 N o,�,�, "t� 98 �f" 98 N a���,� sav �o..t.�...a _ �.., ';,,x.,.,,,' '•r, ' ,a,,• Q1 ST PAUL REGiONAL WATER SERVS N SWEEtJEY ROBERT JOSEPH N O1 .t�n. .ro.a .a,.� �.�+��, — � ���� 02 1900 N RICE ST N 5300 AYDEE CIRC N OI vfx�lfl �.)1�1L.fJ wA�ti�PF[C/' .tlh�'nl�./Y YNAW pYCT �E�U11' 16 ST PAUL MN 55113 `17' 05 �WFITE BEAR LAKE MN 55110 "'t7 05 01 0�0�0[ Wp N'n0 fM G4M �WR �G0._ CJ�a OwIK OB FORD SRW 201 9LU PORD TSE �00 BF.0 Q4 Ow:M+' M11• �rrBG `WK: �aar�i��a wn 'RARI Tt0 �tWIO6 . . ML�[. OZ 938544 MN 6 O1 O1 � ' 756GKH MN 5 O1 v �� O1 � 03 � �w.+c[ snr.wan rau,ri�v+i n �.w•wu� � CITY OF ST PAUL • FROP 6 CASUALTY INS C SBPHH�68551-209062 i }Ci�no �w• nwm� nrccno.� �.u�.uw. IfaCC1UENTPNOWEDACOYMFRCW.M070RYEMIC4E�SCXOOI&1l.ORMUD3TMT6ltS `�'Mn �wr unen� REMEYeER 70110T1/�tNE STATE PATROI(npu WA unOK MS 1n./U�ne fUA517} m�aonvwornw.�w�cwuw�wur potww�� ' mr�c�:r+a[i.+�a�✓rauw..wr m�r.�ec� �wAW.«m�►w �Nr n. nuux•i aa �.r� uw �wa iK� ..im mrwr mw�oet 1 y n� ��� �r..n�[• � . o"», ,y Ory uwG�w% �MVnwY �.1� . Q�� _\ � �— O� W Y�J �IY MMf� I ' .. QOI�� � _.,. � , � _ _••_..• —_. .—_ (wi��MO'1ft�Y✓<O�P[�'�w9�4 RWJOrrQLnUMM���4dn111a�lauw�.wN�11 1DYYGIO/11t/flRft�lUOM�tiML�M � .L. I K�^' Li � t•y MWUTC ? IrtKL '�. OL :� w� LL .... ?' �03� A 4� UNIT I DRIVER MAS HEADING S/8•ON FORESi ST AT fr aI _- I �TFIE INTERSECSION OF FOREST SS AND E lfARYI.AND AVE '}', .w�. I _ �r�ww � N DRIVER TNO(1GNT UNIt 2 wAS TURNiNG L6ET HEADING O1 OS r✓ � B E/8 ON E MAAYLAND FROM FORESS ST WHEN UNIT 2 * m• °1OiO0a ��! , t�t SUDDENLY SYOPPED CAIVER REAR ENDED UNIT 2 ��••• N A � OS ' �}NCM2� �����~��x �4� UNIT 2 ORIVfR SiAS FACING'S/H ON FORESS S4 ; � (� � � AT7EHP'fING TO NAKE A LEFT TURN HfADING E/B ON E � � �. 98 �, � +i }• t1AFY[.ANO AVE FROlt FOREST ST DRIVER DIDN'T SEE � �`� � � � �� ONCOHING.SRAFFIC AND SUDDENLY STOPP6D DRIVER WAS� w+•�••� �r : - - - - - 52 SYPUCK FROM BEHIND BY UNIT 1 O1 'tY `—� j D(iSVER OF UNIT 1 NAS ISSUED`A CITATION FOR + Mu�W' ""'�"' e�� DAIVING AFR'6R SVSPENSION (CITATION 09 � � m pi 1620900237Z65) r•^ .n.,+ nr�r no�c ��� :. 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