Sanchez, Santa (Xcel Energy)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? 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.
________________________________________________________________________________________________________
The Claims Center, LLC. on behalf of Xcel Energy, Inc. Santana Sanchez
The Claims Center, LLC. on behalf of Xcel Energy, Inc.
No, TPA 2MN195846
No
The Claims Center, LLC. PO BOX 47604Minneapolis MN 55447
866-233-0353 reference# 2MN195846
10/25/2023 Xcel Energy's gas service line wasdamaged by St Paul Regional Waterduring water utilities excavation work. For further info contact TCC ref# 2MN195846
unknown
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(_)
246 Charles Avenue. ST PAUL, MN
____
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
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NOC letter, photos &CFD
Santana Sanchez
Third Party Claims Administrator - The Claims Center, LLC.
12/21/2023 reference# 2MN195846
Xcel Energy gas line
3300 Fernbrook Lane North, Suite 180 Plymouth, MN 55447
PO Box 47604 Minneapolis, MN 55447
866-233-0353
Fax: 866-233-9627
12/21/2023
City Clerk
15 Kellogg Blvd. W.
#310 City Hall
Saint Paul, MN 55102
Dear: CITY OF ST PAUL
The Claims Center, LLC 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 ST PAUL
Regional Water Service. 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 10/25/2023 at the location of 1246 Charles Ave. in St Paul, MN.
If you need additional information or have any questions please send an email or call 866-233-
0353 ext. 1535. Please include our reference number 2MN195846 when responding to this
letter.
Thank you,
Public Relations
The Claims Center, LLC
PO Box 47604
Minneapolis, MN 55447
Fax: 866-233-9627
Santana.sanchez@theclaimscenter.com
Work Authorization Number:
110624238
Notification Date:
12/20/2023
Claims Center
P.O. Box 47604
Plymouth, MN 55447
Upon Receipt
Payment Due Date:
PLEASE MAKE CHECK PAYABLE TO
Xcel Energy
Claims Center
PO BOX 47604
PLYMOUTH, MN 55447
ST PAUL Regional Water Service
OVERNIGHT DELIVERY ADDRESS
1900 Rice St
Xcel Energy
Saint Paul MN 55113
Claims Center
3300 Fernbrook Lane North Suite 240
Plymouth, MN. 55447
CLAIM FOR DAMAGES TO XCEL ENERGY PROPERTY
F O R I N Q U I R I E S C A L L 8 6 6 - 2 3 3 - 0 3 5 3 O R F A X 8 6 6 - 2 3 3 - 9 6 2 7
DAMAGES TO XCEL ENERGY FACILITIES
Location:
1246 Charles Ave
Date of Loss:
10/25/2023
Description:
Gas service damage
BREAKDOWN OF DAMAGES
AMOUNT
Labor:
$9,647.61
Material:
$115.91
$873.09
Vehicle:
Contract Labor and
Miscellaneous Total:
$0.00
Damage Investigation and
Billing:
Lost Product:
$1,063.66
$0.00
TOTAL
PLEASE DO NOT PAY WITH YOUR XCEL ENERGY BILL
OR TO ANY OTHER XCEL ENERGY LOCATION
$11,700.27
Work Authorization Number:
110624238
TOTAL AMOUNT DUE
Amount Remitted
Notification Date:
12/20/2023
$11,700.27
Please visit https://theclaimscenter.com/payments to make a payment
through our Credit Card Payment Vendor.
Xcel Energy
ST PAUL Regional Water Service
Claims Center
1900 Rice St
PO BOX 47604
Saint Paul MN 55113
PLYMOUTH, MN 55447