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Lumen Technologies JNR NOTICE OF CLAIM 1MN80777..NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states that “…every person…who claims damages from any municipality…shall cause to be presented to the governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time, place, and circumstances thereof, and the amount of compensation or other relief demanded.” Please complete this form in its entirety by clearly typing or printing your answers to each question. If you have additional documentation you may add those documents to your submission. You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards of four (4) weeks. This form must be signed, dated with all applicable sections completed. Submission is to the Saint Paul City Clerk’s Office. You may email, fax (651-266-8574) or mail the form. Mailing address is “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102” Individuals: First Name ____________________________ Last Name _____________________________________________ Please Indicate Your Pronouns: She/ Her/Hers ______ He/Him/His ______ They/ Them/Theirs _______ Company or Business Name: ______________________________________________________________________________ Is this claim being made by an Insurance Company? ____ If yes, what is your Claim/File Number?: _____________________ Is this claim being made by an Attorney? _________ If yes, what is your File Number? _______________________________ If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________ Street Address: _________________________________________________________________________________________ City: ____________________________________________ State _______________________ Zip Code __________________ Daytime/Work Phone _______________________________ Cell Phone ____________________________________________ Date of Incident or Date Discovered (Must complete) _____________________________Time _________________________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _____________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? ______________________________ ______________________________________________________________________________________________________ Please check the reason that most closely describes the reason for your submitting a claim. Please note the documents that will need to be provided with your completed form. Photographs will be accepted. All documents submitted become the property of the City of Saint Paul and shall not be returned. ___ Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid. ___ Automobile damage from a street defect or pothole : please provide two estimates for repairs or actual bill that has been pai d. ___Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or actual bill that has been paid. ___Snow Emergency: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or actual bill that has been paid. ___Property damage: please provide two estimates for repairs or actual bill that has been paid. ___You were injured during a motor vehicle accident: please pr ovide police report number, details about injury. ___You were injured in the City of Saint Paul: please provide police report number, witnesses and details about injury. This section must be completed for all claims. Is there a police report for this incident? Yes No If yes, please provide the police report case number ____________________ Revised December 2021 Lumen Technologies C/O JNR Adjustment Company, Inc. Lumen Technologies C/O JNR Adjustment Company, Inc. No No PO Box 27070 Minneapolis MN 55427 800-279-2567 07/01/2020 Unknown Lumen's 50-pair buried cable was damaged during landscaping/ agriculture by Phalen Beach. For further information contact Lumen's third party claims administrator JNR Adjustment, include JNR reference# 1MN80777. Lumen's 50-pair buried cable was damaged during landscaping/ agriculture by Phalen Beach. x No Notice of Claim Form, page two. Failure to complete and return both pages will result in delays. If yes, what law enforcement agency responded? _______________________________________________________ Where did the incident take place? Please provide a street address, intersection or name of City park or facility. ________________________________________________________________________________________________________ What would you like to see happen to resolve this claim to your satisfaction? _________________________________________ ________________________________________________________________________________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers. ______________________________ ________________________________________________________________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year ________ Make _________________ Model ____________________ Color ________________ License Plate # _____________________ State vehicle is registered in ________________________ Registered owner of vehicle ______________________________ Driver ______________________________________ Area(s) damaged ___________________________________________________________________________________ If a City vehicle was involved: License Plate # _______________________________ Color _______________________________ Was there City insignia on the vehicle? Yes No Driver’s Name _____________________________________________ Other property damaged: ___________________________________________________________________________________ For injury claims of any type. What part of your body was injured? __________________________________________________________________________ Did you go to the emergency room or urgent care? Yes No Where? _________________________________________________ Was medical treatment received? Yes No Where? ______________________________________________________________ First day of medical treatment? _____________ Are you still receiving medical treatment? Yes No Did you miss any work as result of this incident? Yes No Employer(s) _______________________________________________ How much time have you missed from work?___________________________________________________________________ If you are submitting other documents, please state what you are attaching and how many pages. ______________________ _______________________________________________________________________________________________________ By signing this form, you agree that all information provided is true and correct to the best of your knowledge. Please NOTE that submitting a false or misleading claim can and will result in prosecution under Minnesota Statutes. Name of Person completing form: ________________________________________________ Relationship of person signing to Party making the claim: _________________________________________________________ Date document is being signed ________________________ Signature of Person submitting this form: _______________________________________________________________________ Revised December 2021 N/A 1400 PHALEN DR in ST. PAUL, MN n/a N/A Paid in full N/A Lumen's 50-pair buried cable Notice of claim for damages (1 page), demand (2 pages) Hailey Sosa - JNR Adjustment Company, Inc. Third Party Claims Administrator 5/24/2022 P.O. Box 27070, Minneapolis, Minnesota 55427-0070 3300 Fernbrook Lane N, Ste. 225, Plymouth, MN 55447 800-279-2567 ~ 763-519-2710 ~ Fax 763-744-1480 05/24/2022 City Clerk 15 Kellogg Blvd. W. #310 City Hall Saint Paul, MN 55102 Dear: City of St. Paul JNR Adjustment Company, Inc. is a third party claims administrator for Lumen Technologies, which has assigned our firm to investigate and resolve claims for damages to Lumen Technologies facilities. This letter should serve as official notice of tort claim submitted with the PHALEN BEACH HOUSE. If additional information is required to affect official notice of claim, please respond to include any necessary forms, or specific procedure mandated by statute. Enclosed is a demand for property damage. These damages were discovered or repaired on or about 07/01/2020 at the location of 1400 PHALEN DR in ST. PAUL, MN. If you need additional information or have any questions please call 800-279-2567 ext. 2481. Please include our reference number 1MN80777 when responding to this letter. Thank you, Public Relations JNR Adjustment Co. PO Box 27070 Minneapolis, MN 55427 Fax: 763-744-1480 Hailey.sosa@jnrcollects.com PREVIOUS - PAYMENTS + CURRENT + LATE = NEW AMOUNT PAYMENT BALANCE CHARGES CHARGE BALANCE DUE DUE DATE 0.00 0.00 2220.40 0.00 2220.40 2220.40 UPON RECEIPT NEW AMOUNT PAYMENT BALANCE DUE DUE DATE AMOUNT ENCLOSED:________________ 2220.40 2220.40 UPON RECEIPT P.O. BOX 2348 1400 PHALEN DR SEATTLE, WA 98111 2348 ST PAUL, MN 55106-0000 92849152MN/BF672724A4944441222202160000022204002T600/ ACCOUNT NO: MN BF672724 INVOICE NO: A494444- INVOICE DATE: 12-22-2021 849152 11906008 RETURN PAYMENT TO: CENTURYLINK PHALEN BEACH HOUSE CONTINUED ON NEXT PAGE... ACH TRANSFER INFORMATION - US Bank ACH Routing #102000021 - Account #103674281664 Send in CTX, EDI820, or CCD+ format with remit Return this portion with your payment - please write the invoice # on your check. ---------------------- Detail of Current Charges --------------------- Labor Hours: 6.00 Labor Hours 97.96/HR 587.76 Material Costs: 1.00 REPAIR KIT - 50 PAIR 142.74/EA 142.74 P.O. BOX 9541 MONROE, LA 71211 ---------------------------------------------------------------------- To pay via check by phone, please call 1-844-208-3636 Know What's Below, Always CALL BEFORE YOU DIG!!! Call 811 or visit call811.com for more information. DATE OF DAMAGE: 07/01/20 LOCATION : 1400 PHALEN DR, ST. PAUL MN Damage Claim #: 0672724 Claim ID: 7394735 Mail correspondence to: CENTURYLINK/DAMAGE CLAIMS PAGE 1 OF 2 MN ACCOUNT NO: MN BF672724 INVOICE NO: A494444- INVOICE DATE: 12-22-2021 DAMAGE DETAIL : 50 PAIR BURIED CABLE - AGRICULTURE MISCELLANEOUS COSTS $ 1,489.90 MATERIAL 142.74 LABOR - REGULAR HOURS 587.76 TOTAL CURRENT CHARGES $ 2,220.40 IF YOU HAVE ANY QUESTIONS, PLEASE CALL (844) 208-3636 2021-07-21-092538 CUPS 1,252.00 DIRECT ADMINISTRATIVE COST 237.90 ---------------------------------------------------------------------- SUMMARY OF CURRENT CHARGES CHARGES PAGE 2 OF 2 MN ACCOUNT NO: MN BF672724 INVOICE NO: A494444- INVOICE DATE: 12-22-2021 Miscellaneous Costs: