Robbins, Adam �
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September 26, 2014
City of St. Paul State Farm Claims
Attention: City Clerk P.O.Box 2371
310 City Hall Bloomington IL 61702-2371
15 Kellogg Blvd.W
Saint Paul, MN 55102-1691
Certified Mail - Return Receipt Requested
RE: Claim Number. 23-515Z-259
Our Insured: Adam A Robbins
Date of Loss: August 25, 2014
Your Insured: City of St. Paul
Your Insured Driver: n/a
Loss Location: , St. Paul, MN
Sir/ Madame:
It is our understanding that you are self insured. Our investigation indicates you are responsible
for this claim. Therefore, we are seeking recovery from you. This letter is to notify you of our
subrogation claim and request your cooperation in settling this matter.
To assist you in your review, here is a breakdown of the amounts State Farm�paid by Cause of �
Loss:
041/045- Uninsured Motorist BI $n/a
042- Uninsured Motorist PD $n/a
300 senes/400- Comp/Collision $229.27 ,
501 - Rental/Loss of Use $n/a I
600-050- Med Pay/PIP $n/a
Other $n/a
Salvage Recovery $n/a
Amount State Farm Paid $229.27
Insured Deductible $0.00
Total Claim Amount $229.27
Based on the assessment of liability befinreen the parties, State Farm Mutual Automobile
Insurance Company is seeking 100% of the Total Claim Amount listed above. The amour�t
payable to State Farm Mutual Automobile Insurance Company for this loss is $229.27.
Please remit payment of this claim and include our claim number on the payment. If you have
any questions or need additional information, please call me at the number listed below. If I am
not available, any other member of my team may assist you. Thank you for your cooperation.
In order to assist you in evaluating and processing the subrogation claim we are asserting, we
may provide nonpublie personal information about our customer. We are sharing this
information to effect, administer, or enforce a transaction authorized by the consumer. However,
. •
23-515Z-259
Page 2
September 26, 2014
you are neither authorized nor permitted to: (1) use the customer information we provided for
any purpose other than to evaluate and process the subrogation claim, or(2)disclose or share
the customer information we provide for any purpose other than to evaluate and process the
subrogation claim.
Sincerely,
����
Whitney Hi I
Claim Specialist
(877)457-8276 Ext. 6156927716
Fax: (866)231-9276
State Farm Mutual Automobile Insurance Company
Enclosure
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NOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota ` �� °° ry
Minnesota State Statutt 466.05 states that"...every person...who clnims damages from any municipaliry...shnU cause to be presented to the
governing body of the municipaliry within/80 days after the alkged loss or injury is discovered a notice stating the dme,place,and
circumstances thereof,and the amount of compensation or other relief derrwnded."
Please complete this form ia its entirety by dearly typing or printing your answer to each questioa. If more space is
needed,attach additional sheets. Plesse note Wat you�y or mey not be coatacted by telep6o�to discuss your claim
circumstances,so provide as much informstion as oecessary W explain your claim,and the amount of compensatbn being
requested. T6is form mast be sigoed,and boW pages completed. If something dces not apply,write'N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO:
CITY CLERK,15 WFST KELLOGG BLVD,310 CITY HALL,SAIlVT PAUL,MN 55102
First Name �o�M Middle Initial � Last Name �Uhl�i n S
Company or Business Name,if applicable �tn�-e �Q�( 1.nSIn.Cc�UI ('►_.�S `0 ��a� � . QO�,I�1 V15
Street Address �•�J. Qvk 2�3�1
City ���'�lXl'1��d-rt�'t State I L. Zip Code L " 31(
Daytime Telephone(��) y�1� gZ�l% X �DC Evening Telephone(��J �{� -�CZ.1l� x �0
Date of Accidenb Injury or Date Discovered ��.ZS,�??.(?I y Time t;l,v��• am/pm(circle)
Please state,in detail,what occurred,and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees aze involved and/or responsible.
(�r i/1Su�-cd vPki� was t�c�ric��1 a•✓�c� v,..•-�t>c.��.�n�erl 'Th� ci+�-�
1`� t � - �� �; a s S� cz.. r
� G•, �" U�m � �t t�Jl 4'�� 'l
Please check the box(es)that most closely represent the reason for completing this form:
❑Vehicle was damaged in an accident ❑Vehicle was damaged during a tow
❑Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow
❑ Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property
C�Other type of propeRy damage-please specify �� c+f -1� �1 c�ss I �a�o��_SF�Cv►csz-
❑Other type of injury-please specify
❑ Other type not listed-please specify
In order to process your claim vou need to include coaies of all aunlicable documents. This is a general
guideline of what should be submitted with a claim form,but it is not all inclusive. You may be asked to
provide additional information depending on your claim.
O Property damage claims to a vehicle: at least two esrimates for the repaus to your vehicle,or the
actual bills and/or receipts for the repaus
O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts
O Other property damage:repair esdmates,detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs can be provided but will not be returned.
Page 1 of 2-Please complete and return both pages of Claim Form
Failure to provide a oompleted claim form wlll resutt in delays in prooessing. ,
I
. � �
Notice of Claim Form,City of Saint Paul,page two
All Claims-nlease comalete this section
Were there witnesses to the incident? Yes No �� (circle)
If yes,please provide their names,addresses and telephone numbers:
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Were the police or law enforcement called? Yes No �'[T, c�s� (circle)
If yes,what department or agency? •-� L� Case#or report# �n�G�--
Where did the accident or injury take place? Provide street address,cross street,intersection,name of pazk
or facility,closest landmazk,etc. Please be as detailed as possible. If helpful,attach a diagram.
►�11<�cl � O� �nst�.`rC.c��.S u lc�c.e_ c�-F em u 1 cx�w. �.rr1�
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Please indicate the amount you are seeking in compensation from this claim or what you would like the City
to do to resolve this claim to your satisfaction. �2`��t .2'I
Vehicle Claims-please complete this section ❑ check box if this secrion dces not annlv
Your Vehicle: Yeaz l�tctG Make Sa��v� Model .Sz��'n �-(1�Cz-
License Plate Number��. - State,�pl Color tNG1�
Registered Owner�a:.,..� � � Rc�b����
Driver of Vehicle ' J � j���r
Area Damaged � i�nrl 1-i 1�1 G l�S S
City Vehicle: Year�_Make ti I c�- Model n �U-
License Plate Number ���-- State Color__T
Driver of Vehicle(City Employee's Name) r�a—
Area Damaged v� �a—
Iniurv Claims-please complete this section �check box if this section dces not aaalv
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
L°f Check here tf you are attaching more pages to this claim form. Number of additional pages 2�
By sigaing tkis form,you are smtixg that all information you have provided is due and correct m des best of your lcnowl�dge. Unsigned
forms will not be processed. Sub�nilting a false cJaur+cart rssult 1s prosecution.
Print the Name of the Person who Completed this Form: �?!�i a ►-��-�-�•-�r' S�v-�- ���s�
Signature of Person Making the Claim: crr, o.�s�o �ob b►�►s
Ac��^'� R��_b i'�l s
Date form was completed cl��Zl-e �2.¢�i� Revisod April 2007 `'
RBZ00070
StateFarm State Farm Mutual Automobile Insurance Company
�� Auto Payments by Participant/COL
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Route To: Whitney Hill
BASIC CLAIM INFORMATION
Claim Number: 23-515Z-259
Date of Loss: 08-25-2014
Policy Number: 3747-977-23F
Named Insured: ROBBINS,ADAM A
Named Insured(s)/ 340 -COMP
C denotes consolidated payment
E denotes EFT payment
P previously converted payment from CAT/CMR
Payment Issued Payable Pay Auth Rsn
Number Date Payee COL Cd Status Amount ID Cd
105289020K E 09-04-2014 LYNX SERVICES, L.L.C. 342 1 Paid $229.27 ECSAPY
Total: $229.27
Date: 09-26-2014 Page 1
FOR INTERNAL�TATE FARM USE ONLY
Contains CONFIDENTIAL information which m not be disclosed without express wr'itten authorization.