Foth RE����`���
�fUN 2 � 2012
NO'Z'ZC� OY+' CLAIM FO�M to the Cfty of Sain� �aul, I17in�esota
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Ml��aesola S1nfe Slalute 466.OS stafes�hnl"...every petson...who cla!»u daruages jrorn mq�1,►�rntcipaTfry...sl+alJ cause!0 6e presentett 10 rlie
gover•nhig Gody of liic�stn+fcfpaJ�ty wtthln 180 days afler Ihe atleged loss or tt�jury ts dlsaovei+ed a notice s�nllug ll�e lline,place,�r1d
clrcunrslances lbereoj�nd�he o�nount of compensattal or o�her reAejde��a►xted,"
Ple�sa complete ft►is form fu its eutii•oEy by cleArly typi�tg or prii►ting you�•aus}ve�•to eacl�questiou, Yf moro spnee is
needed,atfnch adciSfton�t sheets. Please note fLat 7�ou wlll not be coiztt�cted by felephone to clnrify m►stivors,so provtde as
mi�ch informntio�i as necessary to explain yoto•c!»im,s�nd the antoitnt af compc�tsntton being�•equested. You wlil receiva�
�ti�ritte�t actcnosti�leclgenio»t oiiea yo�u•form is i�eceived. The process can tnke up to tett t��celcs m�loiiger depending ou tlie
nature of y�om�cleim, Tliis form must ba signed,and Uoflt pnges completed. Xf so�netliing does noE applp,K�rlte°N!A',,
SEN�? CONII'T1�T�D T�'ORIYX AND �TI���t.DOCCTIV��TS TO: CITX CI.�RI�,
15 Vt'�ST I�LLOGG BX.,'YD, 3�0 CIT'Y HAT.L, SA�NT PAUL, 1l�N 55102
I�irst Name,�(�� Middle Tnifial Last Name �) �/-�-
Company or Busiaess N�+me
1Ue Yoti an I�zsuranee Campsny? Yes I� If Yes,Claim NumUer?
Staeet Address,� /Dii ��/�• .St
City .S�. ��a u..� State /�.'�� Zip Code -�-r/3O
Dayt'sme Phone�� �� "�B3`�Cell Phone(_) - Bvening Telephone(____) •
Date of Accidend I��ju�y ar Date Diseo�c�ered 1� Z•!J Time m prn
Please state,it�detail,�vhat occurred{liappaned),and�vhy you are submitting a ciaim.�'tease indicate titi�hy or lio�v you
fecl the City of Saint Paul or its employees are involved ai�d/or xesponsible for your damages.
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�lease oheck the box(es)that most closely represent the reason for completing this�oi�n: � �
❑My vehicle wAS du�nagecl in an accident O�4y vehiale tivas damaged during a to�v
C!1�Zy vehicle tivas damaged by a potltole or condition of the sh•eet !7 Tvty z�ehiale�vas dnmaged by a plo»r
❑My veliicle was wro�3gfully to�ved ancUor ticketed D I�vas injured oti City property
�Other type of proi�e�ty ciatinage—�lease speaify --�pl� ��j'Yl� �-/��h �/e`1/C�-�
Othee type of injury--please specify
I��ordea•to pY•ocess yonr claim�u ueed to iuclude cQpies of all n�plicable docnmenfs.
For the claims rypes listed belo�v,please be sure to include the documents indicated or it will delay the handling of
.
_ ___ y ouur olaiti�.—Daa�ni��t�-W�.LL NOT b�returned and-becomc the xro er of ttse Ci 'SP'ou mro-encour�ged-to- eep a _-.._ _... _.
.P p h' tY�._..
copy for yo��rself Uefore submifting your elaim fartn.
O Property datnage clai���s to a vehicle,two estimates for tlte repairs to your vehicic if the daniage exceeds
$500.00;or tl�e actnal b'slls and/or reeeipts for the repairs
O To�ving claims:legiUle copies of any ticket issued and a copy of the impound Iat receipt
O Olher property damage claims:hvo repair est'smates if ttie'damage exaeeds$500.00;or fhe achial bills
anct/oc•receipts£or the repairs;detailed list of damaged items
O I�ijt�ry elnims;medieal bills,receipts
O Photograpl�s are ahvays welcome to dacwt�eiit and support your claim but�vill uot be reriuried.
P�ge 1 of 2—Please complete And retnx•n Uotl���ges of ClRiun�orm
Ttiis claim form is being raturned without having been set up as a claim for tiie�'ollowing
reasons;
�Failui•e to��rovide a written desaription as to what happened and rvhy a claim form �
was being submitted(pAge one).
17`I�Ailuee to provide the proper and required docuitientation(page one).
. Failare to provide a date of accident or iujury(page one). �
V� Paih�ra to indicate the amount of compensation being sauglit(page two},
� Failure to provide information about the vehicle involved(page two),
F�ilure to provide infoi7natioli aboi�t the it�jury claimed(page two).
,�ailure to sign the claim form(pagc two).
V`Failura to print the nan�e of the person�vho completed the elaim forni(page ttivo).
.
Otl�ex•� ��SL `�f?_ GL. C'i�.LU-d/+�1.
PleRSC return the coxnpleted claim#'oa7n to;
Office of the City Clark
City of Saint Paul
15 Z�.Kellogg Blvd,
310 Cify I�all
Saint paul,A�FN 5S 102 ,
Yf you do not return the completed claim form with the Appropriate documentation or'
info�tinatioft con�pleted,then a claim�le will NOT be established and an investigation
WILL NOT ba done. T�i other woxds,NO�CJRTHBR ACTION wilt ba taken untii the
iufonnation reguested is provided by you. .
Please remembei•that it is a crime to subznit a claim for�n or to pursue can�ensation ��
falselyor under false circumstazices.
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12/d8/2d11 t3:t8 FAX 6i2 62B 743i UIII4ERSI7Y OF I:ITfENESOTR f�001/003
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wbrkn►e lo: d56e5640
RAYMi}Nri AUrd B�C�Y,�IVC. federalfD: �►�-oe�szs�
1�75 PI�RC��Uri�R R'f�,SAiNI'pAUl, hiN S5],04
3�h0�1�:(651}�88-058�
�AX: (651)�{a8-47�3�1
pr�����n�ry Estintate
Cuetcsmer�M�4iS0AN,pAT
�rr�u�n�y:STEVE SUNDERtAPiD
�n5ured: MEIitGAt�l,PA7 Pollty b�t
�Saim s: t��Y�b� �p�7`�`�y•A 0-- n 4
'�'�P6 of loss:
Date nf i.osst ng1'�to RCpnir: 0
Polrlt OE Tmpad;
awnon
Inspoatlon LoWt�an: I�a�rattco Campanyt
D1ENI(?AN,PA'C 4b1YI�lONb AUT�O BODY,ING.
1100 JC-SS16 ST�2EE� ' 1�75 PiLf�C�BUTU:R FTG
51'PAUL,MN 55130 5AlNT p�ul,Mtv 55104
t651)771-10�4��np Rep�71r Fadllty
(651)90@•45AU austness
VEHICI.�
��S��e; qp`yG� Y(�: iFAlP57UXVG3030� t�ineage ln:
Year: 1�h1 6•3.01.•F� Uoer�so: MlktaUe out:
t4akat �ORn ��ff�na' Vehtde Out:
Productton bate: State:
Moda1: 1'AURUS Gt Ja��;
C,olor: Int: Cand�dan:
Cloth SeaiG LUgpaga/ROOf R��Sc PowCrWindOws
9 WheE)DIsC 82kCS OvCYddve Rear OefOgger
plr r�,ndluoning consolC/Storago ��i„�n,p„�@ S�sts
AM Rad1n Drlver A���fl Pes50n418r Alr qac�
Pp�ver Mtenna SearchlScek
putolltatic Tnfios►nisslon auai i�irYOr9 Stt�
Qpcty S1dA Moldings FM Rsdlo POVref Hrakes
pow�r h�lrror� 711t WiSeel
pucket S��s �u1!Wt�aes aovecs �tnted Givn
dear Coat natnt
Iatemtitttent wia�� Do�ver Steer�nfl
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PagC 1
019495
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�� ��` �a Gallaghe�r Bassett Services Inc.
;:�.s f:� ,
March 5, 2012
Carof Foth
'f 100 Jessie St
St. Paul, MN 55130
RE: Claim No: Od4063-067945-AD-09
Our Client: US Foods, Inc.
Date of Loss: 11/17/11
Dear Sir or Madam:
Please be advised that Galtagher Bassett is the third-party claims administrafor
for US Food Service, and f am handlin� the above referenced claim.
This office previously ter�dered your property damage cfaim to the City of St.
Paul, to which we received the enclosed form. I apologize for any inconvenience
and appreciate your patience. I can be reached at the undersigned, should you
wish to discuss further.
Sincerely,
C���x--�----- -�
Tamaira Bell �
Claims Representative ;
Gallagher Bassett Services, Inc ;
Direct: 630.317.1633 '
Fax: 866.401.9691
Email: tamaira_bell@gbtpa.com
Gailagher Bnssett Services,lnc.
P.O.I3ox 5520
Oakbrook Terrace,lL 60181
(630}932-3400 Phonc
(630)932-4223 Fax
�i:
�y��������. Ga1laglze-� Basset� Se�vices Znc.
jtf,��i7 �
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2012 J�i�� !3 ..I'�i ,I��03
i.i� : � � �;.i.��, {�;.,��,
December 5, 2011 ftl+t-t�,�t tt�F:SUU�tcr:5 o�F-zt:�
City of St. Aaul
Safety& lnspaci[ons
375 JacEcson St
Suite 220
Sa€ni Paul, MN 55101
R�: Our Ciaim No: 404063•067A4ii�Ap-01 •
Our CEient: U.S. Foodsorvice, lnc. �
Date of Loss: 1�I/17/19 ' �
Accidont l.acafion: Maryland Ave W Truck Route �
Ctaim�nt: Caral Foth cr, ''' `"� �
1100 Jassie S! '�°�' � ��
St. Pau1, MN 65130 �� ' ��=
Ph:651.771.�034 �"..r��' � ���
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W ;, �-j�
Qear Slr nr Madam; . , � ' �
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F'lease be aciviseci that GallaghQr Bassett is ihe third-party claims administrator for US
f-ood Service, and I am handffnc�fhe above referencsd claEm. Our Investigatlon indlcates
the above referenced party suffered properiy damay�,whlch is alleged to ba the result
of tree branch that fell from a trae and anto the claimanYs windshleld. Therefore,we are
p[acing your company on notice of lhis claim,We request that you submit th{s notice to
your insurance carrter.
I have included with it�is letter coples of tho claimant's ostimate, as it pertains to the �
above re€arenced malter. We are requesf;ng wr}tten acknowladgement within ten (15) '
days of recoipt of thls lettar, �
Should you have any questions, I may be reachod direct at: 630.317,1633: I
Sinc�ely, � . • ,��F.`s`�.
i
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,
amairG-a�Q I �,
_._ - _ _. __
__ _ .. --
__. __ _..._ __ _. ;..
Ciaims Represeniative _ \., s �; � , .
Gaflagher Bassef# Servicds, Inc �... ��_ •. =••� � �� t? • �° �
Dlrect: 630,317.'f633 � •��'�`i� �
F�tx: 866.�(01.�J69� r> . ...c:;�'� '
�mall: tamalra_ball@gbtpa.com ,i?\�'} 1 3 'II�F..
, . �. .;�r:r
�' • , Dalinghcr Aaucfi Sen�ic�s,Sno.
� . .. �• P.O.Dax 5520
Oal;brook Tcrrnce,Il.6fl131
(630)932-34(�A I'hone
(G30)932•��2231'ar