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Caulfield � � B ENNEROTTE & AS S O C IATES, PA , Helpin�y�ou ... ruhen hel� is nc�ec�erl n�ost.�``� �� January 19, 2012 , TOM BENNEROTTE �°N°RT°BINt RECEII/EG Joxrr scoTT City Clerk Atcomeys at Law City of St. Paul JAN 2 � 20�2 310 City Hall tAlso admicced in Wisconsin 15 W. Kellogg Blvd. �I�(���RK St. Paul, MN 55102 RE: My Client: Jennifer Caulfield Place of Injury: 1953 Rome Avenue, St. Paul, MN 55116 Date of Injury: 11/24/11 Our File No.: 15612 Dear City Clerk: Please be advised our office has been retained to represent Jennifer Caulfield in the above-referenced trip-and-fall incident at 1953 Rome Avenue, St. Paul, MN 55105 on November 24, 2011. Enclosed please find a Notice of Claim Form. Please turn this notice of claim into your insurance company. Please advise me of the adjuster's name and the claim number, or if any information as captioned above is incorrect. Please do not contact my client directly. Please forward the following information as it becomes available to you: 1. A copy of all records you receive including, but not limited to, medical reports, wage records,police reports and any other records received; 2. Any statements in your file of my client, or any parties or witnesses in this accident; 3. A certified copy of the declaration page; and 4. Documentation of property damage, including estimates, photographs, valuations, and payments made. Pursuant to Minnesota Statute 72A.201, Subd. 11, an insurer must disclose the coverage and limits of an insurance policy within 30 days after the information is requested in writing by a claimant. Please consider this as a written request for your policy limits. The information requested above is deemed continuing, so that any information received by you subsequent to this letter should be forwarded to me. Thank you in advance for your cooperation and assistance. 3340 Sherman Court,Suite 100.Eagan,MN 55121 PH: 651-203-5990 . FAX: 651-288-0860 .www.bennerotte.com Current Medical Providers United Hospital 333 North Smith Avenue St. Paul, MN 55102 St. John's Hospital 1575 Beam Avenue Maplewood, MN 55109 Summit Orthopedics, Ltd. 1560 Beam Avenue, Suite D Maplewood, MN 55109 Prior Medical Providers Aspen Medical Center 1020 Bandana Blvd. West St. Paul, MN 55108 Yours truly, � Conor E. Tobin, Esq. CET/baa Enclosures cc: Jennifer Caulfield 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 answer to each question. If more space is needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a written aclu►owledgement once your form is received. The process can take up to ten weeks or longer depending on the � nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'. ; SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 ,' �' � (�A�.� -��l�p First Name��11 Middle Initial Last Name N I � ��-t;ErvEQ Company or Business Name�_ Are You an Insurance Company? Yes l� If Yes,Claim Number? JAN 2 3 2012 Street Address O ' CITY CL�RK i City.�' ��-l�l State��� Zip Code� Daytime Phone(.2t��)��- '��Cell Phone(��.�J'�'-�Evening Telephone( ) - Date of Accident/Injury or Date Discovered (���� �,� Time��am� � Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you � feel the Cit of Saint Paul or its employees are involved and/or respons'ble for your damages. I �• t l G' � e �( ; ` 7 �,'S e i D� t C � i .Q Please check the box(es)that most closely represent the reason for completing this form: � ❑ My vehicle was damaged in an accident ❑My vehicle was damaged during a tow ❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow ❑ My vehicle was wrongfully towed and/or ticketed �I was injured on City property i, ❑ Other type of property damage—please specify ❑ Other type of injury—please specify I In order to process your claim you need to include copies of all applicable documents. ' For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds $500.00; or the actual bills and/or receipts for the repairs O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt O Other property damage claims:two repair estimates if the damage exceeds$500.00;or the actual bills and/or receipts for the repairs;detailed list of damaged items O Injury claims: medical bills,receipts O Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—nlease complete this section Were there witnesses to the incident? Yes No Unknown (cir e) Provide their names,addresses and tele ho umbers: � 1 c - Were the police or law enforcement called? Yes No Unknown (circle) If yes,what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. 1�(�� t�iv�P- ���a?--�-�-t - ��`�N► �� (( ln Please indicate the amount you are seeking in com ensation or what you would like the City to do to resolve this claim to your satisfaction.��Q-�_�wi�v�e� Vehicle Claims—nlease connulete this section �;check box if th?s section does not apgly ; Your Vehicle: Year Make Model '� License Plate Number State Color Registered Owner Driver of Vehicle , Area Damaged City Vehicle: Year Make Model I License Plate Number State Color �I Driver of Vehicle(City Employee's Name) ' Area Damaged In'ur Claims— lease com lete this section ❑check box if this section does not a 1 How were you injured? - e - What part(s)of your b were injur ' . - frn i °� � Have you sought medical treatment? es No , Planning to Seek Treatment(circle) � When did you receive treatment? L- ��` - (provide date(s)) l�IGNI�� Name of Medical Provider(s): � Address 3 � �^Telephone ` ' — Did you miss work as a result of your injury? Ye No When did you miss work? (provide date(s)) Name of your Employer: S i a 11 ZCiY\-f� Address Telephone , �Check here if you are attaching more pages to this claim form. Number of additi9 tnal��pages�. ��;e t�a�e �.�i-cc�uP c�►�u�+ we l�c�ue -�c �. Ma�� w�1,i b� 1vr�t"►�cv,M��V� By signing this fornz,you are stating that all information you have provided is true and correct to the"best I of your knowledge. Unsigned forms will not be proeessed. ', Submitting a false claim can result in prosecution. Date form was completed �"• �� �`b r�' Print the Name of the Person who Completed this Form: �eG� A. /��/U����s— �� ��''' Signature of Person Making the Claim: Revised February 2011 .. 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'' • Page 1 of 1 ' � � JENNIFER�CAULFIELD � ALLINA HOSAITALS�CLINICS S PO BOX 9125 � 1817 SARGENT AVE MINNEAPOLIS MN 55480-9125 � SAlNT PAUI.MN 55105 � 0 0 UO�OOD��072�9},�2g[l0{123p499D9 02 HOSPITAL STATEMENT ACCOUNT NUMBER PA7IENT NAME HOSPITAL NAME 7 09128 ENNI E L C ULFIEL Uni ed Hos ital ; Date ' - ' Description : : , _;: . ; , ChargeslPayments ... SERVlCES FROM 11/24/2011 to 11/25/207 9 at if you requ(re an itemization of charges,please call(612)262-9000 or(800J 869-5077. 11/24/11 Room and 8oard $2,580.00 11/25/11 Pharmacy $1,242.85 11/24/11 MedicaUSurgicai Supplies $11.30 11/25/11 Laboratory General $593.80 11/24/11 Radiology-XR $1,008.60 11/25/11 Physical Therapy $231.10 11/25/11 Occupafional Therapy $224.30 19124/11 Emergency Room $2,767.70 TOTA�CEiARG�S $8,853.65 12/27/11 insurance Payment -5,196.46 12/27/11 Insurance Discount -1,158.20 ; BALANCE: $2,304.99 �I � �� 4� �� S 0 PLEASE NOTE:If you have requested thts itemized statement,the balance Iisted as patient responsibility may still be pending with your insurance company. ' T ankny �,�Cho ing Alima Hos�itafs&Clinics � �r� ^�,� <" �.- r� >� .- �,. �, - - -- . ..__ .,,..._y �. ,. .... . a � - - . ' $ 04 99 , .. � ,r: ; t .�M1� �� -; �- �' ' • . .�, -��- � 2,3 k -.� � � � .. , ��� � � � ���g � �� ��; ` , , . m "�`�' "�;,'�+�',�"��������"�. ��c���'"E ��fa:. r x� � . .-w r �:,. .:: --�; f :; �,: ..�_.,.....,�» . ....��,...,..,..r„-�.�.�..,.a,,, .,_.,_......>_,�.�._... �.,_,,,:,...«�..z„Y.......,,. ,,._,. , n ..... Go to�Ilrn�com/PayNospitalBtit`; � � � � �� � ' ' ' FOR BILLING INQUIRIHS: 612-262-9000 or�.-800-859-5077(if you fo�seCute�aycnecit�vichyour ' � " " ' are outside#he Twin Cities areay. °� • .,• , , .�. � v� cxet�►t ca�dc bat�tc account .• , � � �� �r � -�� EMAIL ADDRESS: Contact.Center@allina.com 4� Atlina Hospitals&Clinics:2325 Chicago Ave�Minneapolis,MN 55407 �