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Foth RE����`��� �fUN 2 � 2012 NO'Z'ZC� OY+' CLAIM FO�M to the Cfty of Sain� �aul, I17in�esota ,E .. -� r . (:IT; ���.��-z. 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. � / '��i.e I� ` .�_ -P � / i/1 � �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. . I'' 12/d8/2d11 t3:t8 FAX 6i2 62B 743i UIII4ERSI7Y OF I:ITfENESOTR f�001/003 ,_ ._._....�..._--- 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 I�� .�',.ti • ...... .............. ��.. .'... ..�. ....�.�.�� .��'_"__. ..._.�._.._...... ♦..._"'..... ..._._.__... ....._._........ _........... ... ............ ........._... ._""............_... .......___..... ...._.. .�,r�. . ..��'• i . 1;^�41.'�1�'f Z r'":�: :.: �. „„• oato � � ° h ,. �,r � ";:' '`i�:.� �7•���;�Post it'Fex Nvte 787i a s .� .�;1 � }s:e' .�. � , .,' .ro "`��� Prom •- [ � �JAtJ 1 3 201`l. c�^k��t ifi2-�h�� � „ r � s� A-�� Gi�I"rG/Y�!p Phoae+��� . -lL^�'�'� .,;•.�^„��.,.�•�t"� dX 9 �(�r Cr� (a� prot�<<,fictcj;�' . : . ` �`�ti�.1i1}11'�Ft�idiif�.t:i vr i,�t,.. PagC 1 019495 ill2f/�o11 io:39;ii M1 �� ��` �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 � .. . . .r 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��' � ��� `� '� :n�-t ,.,�,��p � .-.� W ;, �-j� Qear Slr nr Madam; . , � ' � � 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 � � , 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