Zangs NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.OS 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 e�lain your claim,and the amount of compensation being requested. You will receive a
written aclaiowledgement 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
First Name �u�V'Ct-�'ICCG Middle Initial�Last Name �A
Company or Business Name
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address ��7i� �. �Cl uJ`�'(^0 P vl¢ �.✓
City �G� � V`� �Ll v� State � ` �� Zip Code �^���P
Daytime Phone(�'�l)��l V Cell Phone(�!�! ) '���3�rv Evening Telephone�i'S! ��� Q T��
Date of Accident/Injury or Date Discovered � v�Q �� Z�t 'Z Time : 3� am/�/
Please state,in detail, what occurred(happened),and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
S E E.. A-r`t-Rc N �.�
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 o condition of the stree ❑ My vehicle was damaged by a plow
❑My vehicle was wrongfully towed and/or tic ei�-- ❑ I was injured on City property
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim vou need to include conies of all aanlicable 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 WIL.L NOT be returned and become the property of the City. You aze encouraged to keep a
copy for yourself before submitting your claim form.
Ql'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
$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
fd Photographs are always welcome to document and support your claim but will not be retumed.
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—alease comvlete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Prpvide their names, addresses and telephone numbers: _ 1��►-�ZiL�.N V w� �� Sq�t.r- t w
`fkL s�t' vdt�� c�Q, �.►w GS� ► ?? (o- SS2�o
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 facilit,Y,
closest landm/�ark,etc. Please be as detailed as possible. If necessary,attach a diagram. � s��'� � b�� T�l r
'G l +'�-E. 1�[' �r L c�C�G. S \ , S p u`f� �� 1 �t'T f c.C s�r C"��G''+ti � W i�� �a J'f��t.i t'�t c.J r �.J;(S��c u�4C�l�
l
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. a r c� s �b w:.� ` r� a c�a �� -�' � a s a 'E l.�c ��G��c Q
� � ►1 Z l ,a � ,�i �. k�.�-Ea e� ��E � als�"
Velucle Claims—please comnlete this section ❑check box if this section does not a�nlv
Your Vehicle: Year�O�Make �A'Z-0� Model M �V v a v� ,
License Plate Number R.1� Z 5 a�L State��1 Color S ►�,V�R
Registered Owner �- i S c` 'F r�:ccs¢
Driver of Vehicle cl a „� o
Area Damaged D'► S v�. �o�K ¢ ct�S '�` f'rc�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please complete this section �check box if this section dces not applv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
'�Check here if you are attaching more pages to this claim form. Number of additional pages�.
By signing this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed V��y «. 2 0 l�
Print the Name of the Person who Complet this F rm: ����'�K CQ-- �- �o` �1 S
Signature of Person Making the Claim:
Revised February 2011
2
ATTACHMENT : Description of the Accident for the Claim of Lawrence Zangs
Against the City of St Paul for Vehicle Damages Cause by Loose Water Utility Valve
Cover Plate in Street.
On June 13, 2012, at approximately 7:30 PM, my son was driving our 2003 Mazda
van south bound on Arcade St near the intersection of Larpenteur Ave. A vehicle,
just ahead of him drove over a cast iron cover to a water shut off that was located in
Arcade just south of the intersection with Larpenteur. That vehicle dislodged the
cover causing it to flip upright. My son was unable to avoid this raised cover,which
collided with the underside of our van breaking the oil pan,the oil sump pipe and
perforating one of the flexible exhaust connections at the rear of the engine block.
With the oil pan broken, oil leaked out and the vehicle was no longer drivable. We
had the vehicle towed to our mechanic. His assessment of the damaged confirmed
what we were able to see at the time of incident.
Cost to repair damage to our vehicle totaled $858.27 (copy of receipts attached).
This amount includes towing,work performed by our mechanic to replace the oil
pan/sump pipe. It also includes work on exhaust system,that was performed by a
separate technician.
We are submitting this claim for damages,which we believe were caused by an
improperly secured and maintained water utility valve cover. '
3
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TYPE OF TOW TOWED PER ORDER OF REASON fOR TOW TOWING CHARGE
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❑FLAT BED/RAMP ❑ LOCAL POLICE ❑AbafldOn2d ❑TOw ZOf1B MILEAGE
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❑ ❑ DEALER ❑ Flat Tire ❑Snow Removal ❑ Fire Lane
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STORAGE FROM REMARKS SPECIAL EQUIPMENT
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TAX ' '
CONDITION OF VEHICLE: i-M�NOR 2-MODERATE 3-EXTqEME "�"
TOTAL � <:-
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KEYS LEFT � + DAMAGE RELEASE: METHOD OF PAYMENT
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Y N ' " 2 r'� '� ��"'�� �""7 �9 C�C� ❑CHECK ❑DRIVER LIC.#
�7, ,�g � �q , fiberglass — steering — damage
,_$�'; � � ; ; caused by faulty tires — personal
RADIO ��' _� , � � '10' property �eft in vehicle. Towing �� � � EXP.DATE
` _.. J ��' �••••---� '.-...: company wrU not be h�ld responsible CFEDIT
Y N - �� after vehicle hag been�ropped. cnao n
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CITY T9TE,ZIP� t„,..
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2ND AUTHORIZED NAME PHONE
MATERIAL:ALL PAHTS NEW UNLESS SPECIfIED:U-USED,R-REBUILT,RC-RECON�ITIONE��
1 � 1 ■� 1 1' 1
RECEIVED(DATE&TIM� q M CUSTOMER'S ORDER N0. PROMISED(DATE&TIM� A.M.
I `I � ��- —_ � � ; I P.M. P.M.
, Y� YEAR•MAKE• ODEL SERIAL#NW
,�t� (,.%� i��C, Z � C� �`��� � � MOTOR# ,
tt,��� �-` G. �,^ e�' LI NSE NO., ODOMETER WRITTEN BY
��h ���
� yr� � ���l � � �LUBE �OIL CHANGE �FLUSH TRANS. �FLUSH DIFF. „__�WASH �POLISH
r CHARGE FOR HAZARDOUS OR OTHER WASTE REMOVAL*
,, � ,'r ;� :
_ �
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i
TOiAL PARTS METHOD OF PA MENT: � Daily' to age fee after repair work has been �pgOR ONLY ;C G
� � �, � ❑CHECK �HARGE complBte and customer has been notified. No
charg�s�s all accrue or be due and paya6le for a PARTS . � I��
❑C H� period of working days from date of notification.
ACGESSORIES
LABOR GUARANTEED ITEM(S) GAS,OIL&�REASE
❑FLAT RATE ❑HOURLY
' ❑BOTH MISC.MERCHANDISE
GUARANTEE EFfECTIVE UNTIL , 'i
Estimated cost$ Estimate Charge Basis for Charge .�� 3FlB�P�RS"�� � [;:{'}I
❑RETAIN PARTS TIME STORAGE FEE �
PLEASE READ CAREFULLY,CHECK ONE OF THE STATEMENTS BELOW,AND SIGN; ❑DESTROY PARTS MILEAGE �
I UNDERSTAND THAT,UNDER STATE LAW,I AM ENTITLED TO A WRITTEN ESTIMATE, AUTHORIZED BY T�
INCLUDING A COMPLETION DATE,IF MY FINAL BILL WILL EXCEED�100.($50 in MD) roTAi.► �
— I REQUESTA�NRITTEN ESTIMATE, THE FINAL BILL MAY NOT EXCEED THIS Youareentitl?dbylawtothereturnofalipaRsreplaced,ezceptthoseforwhichthereisacorecharge,unless
ESTIMATE WITNOUT MY WRITTEN APPROVAL. you agree otherwise by initialing the followin�:_I tlo noi desire the return of any of the parts ihat are
replaced during the au(horized repairs.
— I DO NOT REQUEST A WRITTEN ESTIMATE,AS LONG AS TNE REPAIR COSTS DO NOT EXCEED Estimate good for 30 tlays.Not responsibie for damage caused by iheft,fire,or acts oi nalure,I authonze
$ , THE SHOP MAY NOT EXCEED THIS AMOUNT WITHOUT MY WRITf EN OR ORAL APPROVAL �ehi�e°�o meap��a�ot�es�m4 mspecn�,ndedelivery at myZesk.An etlpress meclhanicstlieo isrhtereby
_ ���N��REQ�EST A WR�"�EN EST��ATE. acknowledged on the above vehicle ro secure the amount of fhe repairs thereto.if l cancel repairs prior to their
completion for any reason,a tear-down and reassembly(ee oi$ wiil he applied.
*Checked lines apply(Preparer must check at least one): StGNED
—This charge represents costs and profits to the motor vehicle repair facility for miscellaneous shop supplies or waste disposal. w.a�ms
—This amount includes a charge of$ ,which is required under law. DATE o9�e�o
7
MetLife Auto&Home�
Freeport Field Claim Office
Mail Processing Center
P.O.Box 410250
Charlotte, NC 28241
(800)854-6011
M4'1'Llft'
June 14, 2012
Lisa Freese
1124 E Hawthorne Ave
Saint Paul, MN 55106
Our Customer: Lawrence Zangs
Our Claim Number: FRE32734 DR
Da�e of Lcss: Jur�e 13, 2012
Dear Lisa Freese:
A loss, which occurred on June 13, 2012, has been reported to us. Please be advised that I have been
assigned to handle your claim.
I understand that incurring a loss can be a trying experience, but I hope to make the process simple and
expedient so as to resolve your claim promptly. As your adjuster, I encourage you to contact me at any
point with any questians or concerns about your claim. My telephone number is (800) 854-6011,
extension 7198.
A coverage disclosure page, outlining the coverages available to you under your policy, has been =
attached for your reference. -
�
In the event your vehicle is at a location where it is incurring storage fees, please contact us immediately =
so that we may assist you in moving your vehicle to a storage-free facility to avoid out-of-pocket =
expenses.
If your automobile has sustained damage and the attached coverage disclosure page shows you have
comprehensive and/or collision coverage, we will cover the reasonable costs of repairing your vehicle to —
its pre-accident condition no matter where you have the repairs done. You have the legal right to choose
aily repair shop to repair your vehicle. If you have not had the opportunity to choose a repair facility, we =
will be glad to recommend one that provides quality repairs and offers a MetLife Auto & Home °
Guarantee of those repairs for as long as you own your vehicle.
To best serve you, certain aspects of your claim may be assigned to a specially trained representative =
who will work with the both of us to facilitate the resolution of your claim. If at any point you have =
questions about the progress of your claim,please contact me in any of the manners noted below. °
Our ultimate goal is to deliver superior service throughout the handling of your claim. We realize you
have a choice when selecting an insurance company and thank you for choosing Metropolitan Casualty =
Insurance Company.
� _
MetLife Auto 8 Home is a brand of Metropolitan Property and Casualty Insurance Company and its Affiliates,Wanvick,RI �
MPL ACKNEW Printed in U.S.A 0698
�
Sincerely,
Greg Underwood, AIC
Metropolitan Casualty Insurance Company
Senior Claim Adjuster
(800) 854-6011 Ext. 7198
Fax: (866) 947-0184
Email: Metlifeimaging@Metlife.com
MINNESOTA LAW REQUIRES US TO NOTIFY YOU OF THE FOLLOWING: A person who files a
claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
Minnesota law gives you the right to choose a repair shop to fix your vehicle. Your policy will cover the
reasonable costs of repairing ycur vehicle to its pre=accider�t-conditio�no matter where you have repairs
made. Have you selected a repair shop or would you like a referral?
Claim Number: FRE32734 DR
Please refer to the following to determine which coverages are available to you, under your policy.**
Liability Limits:
$100,000/$300,000 Bodily Injury per person/per occurrence
r ert Dama e
$
50 000 P o
� Y g
P
$100,000/$300,000 Uninsured Bodily Injury per person/per occunence
No Coverage Uninsured Property Damage
Medical Payment Limits:
No Coverage Medical Payments
Personal Injury Protection Coverage:
Yes PIP Coverage
Physical Damage Limits:
No Coverage Collision Deductible
No Coverage Comprehensive Deductible
No CoveragelNo Coverage Rental Coverage per day/per occurrence
**Policy Endorsements may modify coverage.
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