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A T T C+ R N E Y S A T L A W ���' Q � LO�Z
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• Patrick J. McGuigan
patm@kellyandlemmons.com
August 27, 2012
City Clerk
310 City Hall
15 W. Kellogg Boulevard
St. Paul, Minnesota 55102
Re: Notice of Claim Form
1541 E. Cottage Avenue, St. Paul, MN 55106
Estate of Betty Mae Drake
Dear Friends:
Our office represents William J. Drake who is the personal representative of his mother's
estate currently pending in Ramsey County, Court File No. PR 12-439. In that regard we are
enclosing herewith and serving upon you a Notice of Claim Form arising out of a sewer back up
which occurred in the home on May 27 of this year. After you have had a chance to review the
enclosed, should you have any questions or require any further explanation, please advise.
Otherwise, I would appreciate knowing when we could expect a reply. Thanking you for your
attention to this matter and awaiting word from you now, I remain,
Yours very truly,
KELLY&LEMMON5,P.A.
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PJM:sIh Patr'c . cG 'gan
Enclosures �� _ !
cc: William J. Drake (w/encs.)
176 SNELLING AVENUE NORTH,SUITE 200 • SAINT PAUL,MINNESOTA 55104
TELEPHONE 651-646-6325 • FACSIMILE 651-646-8584
www.kellyandlemmons.com
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 ta 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 nmount 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 acknowledgement 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 William Middle Initial J- Last Name Drake
Company or Business Name Personal Representative of Estate of Betty Mae Drake
Are You an Insurance Company? Yes/No If Yes,Claim Number?
Street Address 2076 Park Row
City NOrth St. Paul State MN Zip Code 55109
Daytime Phone( ) - Cell Phone(651)238-0093 Evening Telephone(651 200 -3187
Date of Accidend Injury or Date Discovered May 27, 2012 Time am/pm
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.
I am the personal representative of my mother's estate. My mother's home at
1541 E Cottage Avenue, St Paul, Minnesota 55106, experienced damage when the sewer
backed up on May 27, 2012 Roto Rooter Services were called and ultimatPlv it was
determined that we needed to excavate the street in front of the house to rebair a
blocka e in the sewer which was caused bv a build-up of resin found bv Roto Rooter.
The insurance company has paid for property damage suffered in the home but would not
pay for the repair of the sewer line which caused the problem.
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
�Other type of property damage-please specify Sewer back-up caused by resin blocked sewer connection.
❑ Other type of injury-please specify
In order to process your claim vou 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. I
O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds i
$500.00; or the actual bills and/or receipts for the repairs
O Towin claims: le ible copies of any ticket issued and a copy of the impound lot receipt
g g
� 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-please complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers: Personnel from Roto Rooter, in particular ,7osh
Lillquist, Sewer Solutions Specialist, 612-369-7978, �osh.lillciuist@rrsc.com
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. In street (point of sewer
connection) at 1541 Cottage Avenue E. , St. Paul, MN 55106.
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. 57.592.65 (Roto Rooter excavation $6,500.00; Roto Rooter initial
billing $592.65; insurance deductible ($500.00)
E'ehicle Claims-please complete this section N/A ❑ check box if this section does not apply
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims-please complete this section N�A ❑ check box if this section does not apply
How were you injured?
What part(s) of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatrnent(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
m 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 8-2�-2012
William J. Drake, Personal Representative,
Print the Name of the Person who Completed this Form: Estate of Betty Mae Drake
,
Signature of Person Making the Claim: �'�u���� ��f �--
/
Revised February 2011 '
NOTICE OF CLAIM FORM
1NDEX OF ATTACHMENTS
1541 E. Cottage Avenue
St. Paul, MN 55106
1. Correspondence and settlement from Country Financial.
2. Photos and statement from Josh Lillquist from Roto Rooter dated June 4, 2012.
3. May 31, 2012 invoice from Roto Rooter and Video Inspection Report.
4. Excavation proposal and proof of payment.
5. Holes and Depressions & Property Information dated August 15, 2012.
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Drake Edward & Betty
1541 Cottage Ave E
Saint Paul,N1N 5 5 2 06-2203
RE: Date of Loss: 5/27/2012
Claim Number: 176-0014554
Insured Name: DRAI�EDWARD&BETTY
Policy No.: AK6509916
NOTICE OF PARTIAL
DENIAL OF COVERAGE
Dear Mr. and Mrs. Drake,
Enciosed is a draft in the amount of$3,117.53 and a copy ofi the estimate to repair the damaged items.
As was previously discussed we will have partial coverage for your claim and the following language is
taken directly from your policy as it reiates to this cfaim.
The Home Insurance Palicy issued ta you provides:
Perils Insured Against-
Sections 2 through 6
"Wen insure covered praperty against loss caused by fhe fallowing peri{s as indicated in
the Declarations except as excluded under EXCLUSIONS—SECTIONS 2 through 6.
16.Accidental �ischarge Or Overflow
a. This peril means accidental discharge or
overflow of water or steam from within a
plumbing, heating, air conditioning or
automatic fire protective sprinkler system
or from within a household appliance.
b This peril does not include loss:
(1►To the system or appliance from
which the water or steam escaped
Your policy also contains the following exclusions:
Exciusions-
Sections 2 through 6
A. "We"do not insure for loss ca�sed directly or
indirectly by any of the following. Such loss is
excluded regardless of any other cause or event
contributing concurrently or in any sequence to
the loss. These exclusions apply whether or not
the loss event resuits in widespread damage or
affects a substantial area or the loss arises from
natural, man-made, or externai forces, or occurs
as a resuft of any combination of these.
19.Any of the following:
a.Wear and tear, rrzarring, deterioration;
b. Mechanical breakdown, latent defect,
inherent vice, or any quality in property
that causes it to damage or destroy
itself;
With the above mentioned in mind there is no cove�age for the actual repair/replacement or clean out of
the sewer line. Should you have any additional information you wish us to consider, please let us know
and we will reconsider our position an this matter.
This enumeration of defenses and exclusions under the palicy is not meant ta be, nar should it be
construed as a waiver of any otherterms, provisions, conditions, definitions or exclusions, which may now
or thereafter apply to the insurance afforded under this policy.
If you have any further questions or concems, please feel free to cantact me at the number betow.
Sincerely,
COUNTRY Mutual Insurance Company
f
Dave Essen
Claims Rep-Field
dave.essen@countryfinancial.com
(612) 345-Q025
Minnesota law requires that our company advise you that if you wish to take this matter up with the Minnesota
Department of Commerce, you may contact them at 85 7"'Place East, Suite 500, St_ Paul, MN 55101, or at
651-296-2488 or 800-657-3602.
�
State law requires us to notify you:
A person who fifes a claim with intent to defraud or helps commit a fraud against an
insurer is guilty of a crime.
For automobile claims, disregard the following notice.
If this is a homeowner claim, please read the following.
Notice to homeowner claimant:
Section 65a.29, Subd.11 of the Minnesota statutes requires us to provide you with a
statement that sets out the minimum number and amount of claims during an
experience period that may result in the nonrenewal of your homeowner policy.
• Your homeowners insurance poficy is subject to nonrenewaf if yau
have two or more losses during a 36-month period_ The fallawing types af losses are
not counted:
1. Losses caused by natural causes including, but not Iimited to, lightning,
wind or hail; or
2. Loss for which no payment was made by us; or
3. Losses for which we recover 80% or more of the payment through
subrogation.
• � Country Financial
FINANCIAL
P_O.Box 64042
St.Paul,MN 55164-0042
insured: Betty and Edward Drake
PropeiTy: 1541 Cottage Ave E
St Paui ,MN 5�106
Claun Rep.: Da��e Essen Business: (612)345-0025
Business: PO Box 64042 Fax: (651) 631-4660
St Paul,MN 55164 E-mail: dave.essen@countryfinancial.com
Estimator: Dave Essen Business= (612)345-0025
Business: PO Box 64042 E-mail: dave.essen@countryfinancial.
St Paul,MN 55164 com
Claim Number: 176-0014554 Policy Number: Type of Loss:
Date of Loss: 5/27/2012 Date Received: 6/1 112012
Date Inspected: 6/12/2012 Date Entered: 6/11/2012 1_54 PM
Price List: MNMN7X MAY12
Restoration/Seivice/Remodel
Estimate: l 76-0014554
This estimate of repairs reflects the extent of�own covered damage to your property_You may have the repairs made by a
contractor of your cboice.However,any repair charges that increase the repair cost above our estimate will be your
responsibiliry unless agreed to in advance by us_COUNTRY Financiai does not gnarantee the worl:manship of any contractor or
vendor. Contractors and vendors are selected and hired by yon_
Please note:If you have purchased replacement cost coverage(see your policy declarati�ns page),you have one year from the
date of loss to make repairs noted on this estimate and to request payment for the difference between the actual repair costs and
the amount we have already paid.However,any replacement cost exceeding our estimate wiil be your responsibiliry unless
otherwise agreed to by us_
.
• Country Financial
FINANCIAL
P.O.BOX 640=42
St_Paul,MN 55164-0042
176-0014554
Main Level
�-�-,
- � Rooml Height: 8'
1064.00 SF VJalls 1029_00 SF Ceiling
""" 2093.00 SF VJalls&Ceiling 1029.00 SF Floor
1 11433 SY Flooring 133.00 LF Floor Peri�neter
133.00 LF Ceil.Perimeter
DFSCRIPTION QUANTITY LINIT COST RCV DEPREC. ACV
1. Haul debris-per pickup truck load- 1_00 EA 122.96 122_96 (0_00} 122.96
including dump fees
1fie following two line items are for the labor and material to clean the basment
2. Water extraction from hard surface 1,029_00 SF 0_69 7}O.Ot (0_00} 71Q.Q1
floor-Cat 3 water
3. Apply anti-microbial agent 1,029_OOSF Q19 I95.Si {0.00) 195.51
A search of E-bay showed pricing on the titlles shown in the photos or similar to range from$3 to$15 resuiting in an$8.00 average
4. Specialty Items(Bid Item) 315_00 EA 8_00 2,520_Of} (0.00} 2,SZ0.00
TotaLs• Rooml 3,548.48 0.00 3,548.48
Total• Main Level 3,548.48 OA4 3,548.48
Line Item Totals: 176-flQ14554 3,548.48 0.00 3,548.48
Grand Total Areas:
1,064.00 SF VJalis 1,029.00 SF Ceiling 2,�93.00 �F Walls and CeiFing
1,029.00 SF Floor 11433 SY Flooring t 33.00 LF Floor Perimeter
0_00 SF Long Wall 0_00 SF Sbart Wall 133_00 LF Ceil_Peruneter
1,029.00 Floor Area 1,073J8 Tota[Area 1,fl64_00 TnteriorWall Area
1,221_00 Exterior Wall Area 135_b7 Exterior Perimeter of
w��
0_00 Surface Area 0_00 Number of Squares 0_00 Total Perimeter Length
OAO Total Ridge Lenbath 0.00 Total Hip Length
]76-0014554 8/7l2012 Page: 2
i
/
.
�� Country Financial
F�NpNCIAI
P.O.Box 64042
St_Paul,MN 55154-0042
Summary for Dwelling
3,548.48
Line item Total
Cleaning 5ales Tax @ 7.625� 69.05
Replacement Cost Valne $3,61753
(500_00)
Less Deductible
$3,117.53
Net Claim
Dave Essen
�
8/7/2012 Page: 3
176-0(1145�4
�
• Country Financial
FINANCfAt
P.O.Box 64042
St.Paul,MN 55164-0042
Recap by Room
Estirnate: 176-0014554
Area:Main Level
Rooml 3,548.48 lOQ.00%
area Subtotal: Main Level 3,�48.45 100.00%
Subtotal of Areas 3,548.48 100.0U%
To� 3,548.48 100.00°Io
176-0014554 8/7l2012 Page:4
� Countrv Financial
FINANCIAL
P.O.Box 64042
5t_Paul,MN 55164-0042
Recap by Category
Items Total °Io
GENER�I,DEMOLITION 122.96 3.40%
SPECIALTY ITEMS 2,520.00 69.66%
WATER EXTRACTION&REMFDIATION 90552 25.03%
Subtotat 3,S�t8.48 98.09%
Cleaning Sales Tax @ 7.62�% 69.05 1.91%
Total 3,617.53 100.00%
176-0�i 4554 8/7/2012 Page:5
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