Holenko ��C�����a y
' . G�� 0 i 2�1�Z
NOTICE OF CLAIM FORM to the City���i��b�'aul, 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 municipaliry 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 acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your c►aim. 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 Susann Middle Initial M� Last Name Holenko
Company or Business Name
Are You an Insurance Company? No If Yes,Claim Number?
Street Address 1939 Wordsworth Avenue
City St.Paul State M� Zip Code SS ll 6
Daytime Phone( 612 ) 373 - 8386 Cell Phone(651 ) 274-0199 Evening Telephone(651 )690 -9848
Date of Accident/Injury or Date Discovered 6/10/12 Time 930 p.m.
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. On the evening of 7une 10,
2012 at approximately 9:30 p.m.,a diseased and weakened boulevard tree split during a storm. A portion of the tree broke away
from the trunk of the tree and landed on the roof of mv home causing damaQe to mv chimnev roof �utters fascia and window
wraps. The City arrived the next morning after I contacted the Forestry Department and removed the tree from my roof. They
have since marked a second diseased and weakened tree for removal to avoid the possibility of a branch breaking off in another
storm and landine on the roof of mv home. I ask that you reimburse my deductible as the diseased tree was on CitYproperty and
the City was responsible for its removal due to its diseased and weakened state. The tree was in obvious distress and the trunk had
numerous splits in it.
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
C�l�ther type of property damage—please specify Damage to roof of my home
❑ Other type of injury—please specify
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
OC�ther property damage claims: two repair estimates if the damage exceeds$500.00;or the actual bills
andlor 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—ulease comnlete this section
Were there witnesses to the incident? Yes �ic Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes � 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.
1939 Wordsworth Avenue on the corner of Wordsworth and Prior Avenues
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. I would ask that the City reimburse the$1,000 deductible incurred for the damage to the roof and gutters
of my home which occurred when a diseased and weakened boulevard tree fell onto the roof of my home in a storm on June 10,2012.
Vehicle Claims—nlease comnlete this section ❑ check box if this section does not annlv
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
Iniury Claims—please comulete this section ❑ check box if this section does 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 fornt,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 �L�o��
Print the Name of the Person who Completed thi orm: �',t ��V1 Yl� ��D IG��
,�
/
Signature of Person Making the Claim: ,�' �
Revised February 2011
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SUMMIT ADJUSTING SERVICE
1687 Woodlane Dr., Ste 207
Woodbury,MN 55125
Insured: Susan Holenko Home: (651)690-9848
Home: 1939 Wordsworth
St Paul,MN 55116
Claim Rep.: kyle G. Schrieffer Business: (952)835-5350
Estimator: Holman D.Hood Business: (320)491-7611
Reference: Business: (952)835-5350
Company: Western National Insurance
Business: 5350 West 78th Str
Edina,MN 55439-3]O 1
Contractor: Business:
Company:
Business:
Claim Number: 000300570520 Policy Number: O1H027464 Type of Loss: Wind and Hail
Date Contacted: 6/11/2012
Date of Loss: 6/10/2012 Date Received: 6/11/2012
Date Inspected: 6/21/2012 Date Entered: 6/28/2012 11:08 AM
Date Est.Completed: 7/1/2012 9:52 AM
Price List: MNMNSB JiJN12
Restoration/Service/Remodel
Estimate: S24887HOLENKO
This is a repair estimate.The insurance policy may contain provisions that will reduce any payment that might be made.
Receipt of a copy of this estimate is not to be interpreted as an acceptance of liability.All estimate figures are subject to
company review and approval.This is not an authorization for repair.Authorization to repair or guarantee of payment must
come the owner of the property.No adjuster or appraiser has the authority to authorize or guarantee payment.The insure re
assumes no responsibility for the quality of repairs that might be made.A copy of this document does not constitute
settlement of this claim.The included figures are subject to the insurance company approval.
Sales tax is included in unit prices except where noted.
SUMMIT ADJUSTING SERVICE
1687 Woodlane Dr.,Ste 207
Woodbury,MN 55125
S24887HOLENKO
Main Level
�r-�.—.,- � .:�
T; .-- ----_--------- House
�' 6 1147.02 Surface Area 11.47 Number of Squares
� � 143.20 Total Perimeter Length 47.67 Total Ridge Length
1 ��
1 ---------�-------------
DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV
1. Remove Laminated-comp. 11.50 SQ
shingle rfg.-w/felt
2. Laminated-comp. shingle rfg.- 12.50 SQ
w/felt
Includes all accessories,dmtl,vmtl,vents,ridgcap,disposal etc.
3. R&R Additional charge for steep 11.50 SQ
roof-7/12 to 9/12 slope
Totals: House
�—u�—�
,, T Garage
I,; I
i � `` 589.35 Surface Area 5.89 Number of Squares
�� Y 97.34 Total Perimeter Length 22.67 Total Ridge Length
�
I� 1
DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV
5. Remove 3 tab-25 yr.- 5.90 SQ
composition shingle roofing-incl.
felt
6. 3 tab-25 yr.-composition shingle 6.50 SQ
roofing-incl. felt
Totals: Garage
Total: Main Level
Exterior/General
DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV
524887HOLENKO 7/1/2012 Page:2
SUMMIT ADJUSTING SERVICE
1687 Woodlane Dr.,Ste 207
Woodbury,MN 55125
CONTINiJED-Exterior/General
DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV
7. Masonry-Minimum charge 1.00 EA
Repair one brick on North side from tree branch damage
8. R&R Wrap wood window frame& 5.00 EA
trim with aluminum sheet-Large
9. R&R Wrap wood window frame& 1.00 EA
trim with aluminum sheet-XLarge
10. R&R Gutter/downspout- 30.00 LF
aluminum-up to 5"
11. R&R Wrap custom fascia with 56.00 LF
aluminum(PER LF)
13. Comb and straighten a/c 1.00 EA
condenser fins-with trip charge
16. Clean with pressure/chemical 1,232.00 SF
spray
Debris from storm on house siding
18. R&R Window screen, 1 -9 SF 2.00 EA
Totals: Exterior/General
Garage
Exterior/General
DESCRiPTION QUANTITY UNIT COST RCV DEPREC. ACV
14. Clean with pressure/chemical 65.00 SF
spray
Overhead garage door
l 5. Paint overhead door-Large- 1 1.00 EA
coat(per side)
Totals: Exterior/General
524887HOLENKO 7/1/2012 Page:3
SUMMIT ADJUSTING SERVICE
1687 Woodlane Dr., Ste 207
Woodbury,MN 55125
Total: Garage
Line Item Totals: 524887HOLENKO
Grand Total Areas:
0.00 SF Walls 0.00 SF Ceiling 0.00 SF Walls and Ceiling
0.00 SF Floor 0.00 SY Flooring 0.00 LF Floor Perimeter
0.00 SF Long Wall 0.00 SF Short Wall 0.00 LF Ceil.Perimeter
0.00 Floor Area 0.00 Total Area 0.00 Interior Wall Area
337.37 Exterior Wall Area 0.00 Exterior Perimeter of
Walls
1,736.37 Surface Area 17.36 Number of Squares 240.54 Total Perimeter Length
70.33 Total Ridge Length 0.00 Total Hip Length
524887HOLENKO 7/1/2012 Page:4
S24887HOLENKO 7/1/2012 Page: S
i
S24887HOLENKO 7/1/2012 Page:6
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