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Xcel EnergyNOTICE 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? Choose an item. 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 paid. ☐ 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 provide 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 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. ________________________________________________________________________________________________________ JNR Adjustment Company, Inc. on behalf of Xcel Energy, Inc. JNR Adjustment Company, Inc. on behalf of Xcel Energy, Inc. No, TPA 2MN151696 No Xcel Energy JNR Adjustment Company, Inc. PO BOX 27070Minneapolis MN 55447 800-279-2567 reference# 2MN151696 12/17/2022 Xcel Energy's overhead wires were damaged by a City of St Paul plow truck that snagged triplex wires with their dump box. unknown x (_) 221 MARYLAND AVE, ST PAUL, MN ____ N/A Notice of Claim Form, page two. Failure to complete and return both pages will result in delays. 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: ________________________________________________ Signature of Person submitting this form: _______________________________________________________________________ Relationship of person signing to Party making the claim: ___________________ Date document is being signed _____________ Revised December 2021 see attached Claim For Damages unknown N/A N/A NOC letter &CFD Hailey Sosa - JNR TPA - JNR Adjustment Co. Inc. 8/30/2023 reference# 2MN151696 Unknown 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 08/30/2023 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 Xcel Energy Inc, which has assigned our firm to investigate and resolve claims for damages to Xcel Energy Inc facilities. This letter should serve as official notice of tort claim submitted with the CITY OF SAINT PAUL. 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 12/17/2022 at the location of 221 MARYLAND AVE in SAINT PAUL, MN. If you need additional information or have any questions please call 800-279-2567 ext. 2481. Please include our reference number 2MN151696 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 Claim Number: Notification Date: Payment Due Date: JNR Adjustment PO Box 27070 Minneapolis, MN 55427 $2,393.98 $150.30 Credit Card Number:Three digit security number on back of card: Name on Card:Expiration Date: Amount to be charged to your card: $Signature: Xcel Energy City of Saint Paul c/o: JNR Adjustment Company, Inc. PO Box 27070 Minneapolis, MN 55427 0 August 30, 2023 $318.51 FOR INQUIRIES CALL NATIONALLY AT: 800-279-2567 OR FAX 763-744-1480 D A M A G E S T O X C E L E N E R G Y P R O P E R T Y 108843530 Saint Paul, MN 55102 Xcel Energy c/o: JNR Adjustment Company, Inc PO Box 27070 September 29, 2023 PLEASE MAKE CHECK PAYABLE TO: 25 W 4th St, Suite 200 City of Saint Paul 108843530 Return this portion with your payment - Please include our project number on your check $3,149.06 Material: $286.27 Minneapolis, MN 55427 CLAIM FOR DAMAGES TO XCEL ENERGY PROPERTY Contract Labor / Other: Labor: B R E A K D O W N O F D A M A G E S Equipment: Overhead Wires 221 Maryland Ave, Saint Paul, MN 55117 AMOUNT Date of Damage: Damage Location: 12/17/2022 Saint Paul, MN 55102 Please complete information below if you wish to pay by credit card 25 W 4th St, Suite 200 $3,149.06 Damage Description: Amount Due Amount Remitted Total August 30, 2023Notification Date: Claim Number: