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Chase ��cEf��� ����� ��- : OCT 2 � �012 sedgwicko G���'����E� October 25, 2012 City of the City Clerk City of Saint Paul 15 W. Kellogg Blvd 310 City Hall Saint Paul, MN 55102 RE: Claim No.: B221011661-0002-01 Client/Claimant: Reinhart Food Date of Loss: 05/24/2012 Description: IV WAS TRAVELING EAST ON MARYLAND AVE CONSTRUCTION FORCED FLOW OF TRAFFIC FAR RIGHT RESULTING IN IV STRIKING A TREE LIMB AND CAUSING DAMAGE TO TRAILER 1021. Dear Sir or Madam: Sedgwick is the claims administrator for the above-listed client. Please allow this correspondence to serve as subrogation notice for reimbursement of repairs made as a result of the above loss. Please see attached notice of claim form as requested as well as supporting documentation for your review. j Total Damages: $798.13 � Please make any payments payable to Sedgwick,noting our claim number on the draft and mail to the below address. I Please contact me at your earliest convenience to discuss status of payment. � Thank you. � Sincerely, ' �l lrlriei Cha.�Pi Sedgwick P: 515-327-4885 F: 515-327-4899 PO Box 14670 � Lexington,KY 40512 � PHONE 515327.4888 � FAX 515.327.4899 � FREE 866.342.3920 �22 t oo� �(��-o�aZ-� l NOTICE OF CL.AIM FORM to the City of Saint Paul, Minnesota Minnesota Staee Statute 466.OS states rhat "...every person...who claims damages from any municipality...shall cause to be presented to the governing body oj�he municipality within t 80 days afler tAe alleged toss or injury is discovered a norice stating t6e time,place,and circumstances thereof,and the amourtt of compertsation or other reliejdemanded." � Please complete this form in its entirety by clearly typing or printing your answer to each question. Ii more space is needed,attach additional sheets. Please note that you will not be contacted by telephoae to clarify answers,so provide as I much information as necessary to eaplain your claim,and the amount of compensation being requested. You will receive a written acknowledgement once your[orm is received. The process can take up to ten weeks or longer depending on the nature o[your claim. This form must be signed,and both pages completed. It something does not apply,write`N/A'. ��►�1 ��,�S�ND;,COMPLETED FORM ANA UTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY AALL, SAINT PAUL, MN 55102 First Name ��I bi� Middle Initial�Last Name ��o►�i'G Company or Business Name �g��Gl�I C�I�-- _ _—— Are You an Insurance Company? Yes o If Yes,Claim Number? �Z-��� � � �� ' ���Z' �� Sh�eet Address Q D �?0 X. ��'"��� (� ' City��t�! N 1�T�h� State �� Zip Code �D 5 l Z- Daytime Phone 15 �- '-���'S Cell Phone�) - Evening Telephone(_) - � Date of Accidend injury or Date Discovered �'ZN'7�"' �Z- Time�_am/pm Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you feei the City of Saint Paul or its employees are involved and/or responsible for your damages. �i=�i�.I������P-�v�►Z W/Jh'� T�Z�V-1.'y[u ns'c, �•4 5 7 tJ N v1.1���i-v��i� fl-V-ic. , ,°n•�h i Z�cr�o� -o�t.-�� .�ww tst T���-�riL �-J��z �t l�r�T __ ��E �. tti�� tN y1J�vP=�� V-��h-tt-l�� GiT�1�L-IN(� � t��� LtW1F� G14�75t ;U f4Wl�t �� T!t�- -r �►41�� Z. �P ease check the box{es)that most closely represent the reason for ompleting this form: I My vehicle was damaged in an accident LT�r� L1'VN�� O My vehicle was damaged during a tow , ❑My vehicle was damaged by a pothole or condition of the street 0 My vehicle was damaged by a plow ' O My vehicle was wrongfulty towed and/or ticketed ❑I was injured on City property_ i �Other type ofproperty damage–please specify �,�i� l�i WI g �{�O�XV L 1 Zd�'�fi4 �-- � ip Other ty pe of in jury–please specify , � In order to process your claim vou need to include copies of al[analicable documents. For the claims types listed below,p lease be sure to include the documents indicated or it wi11 delay the handling of' '� ` ` '� " i ; yaur claim. Documents WILL N4T be returned and become the properry of the City. You are encouraged to keep a � copy for yourself before submitting your claim form. ! Q 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 rece'spts for the repairs O 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 O Photograp}is aze always welcome to doctirnent and suppoc#your claim but will not be retumed. Page 1 of 2–Please complete and return both pages of Claim Form 7/2/2012 B221011661000201 5120120702156474 . Failure to complete and return both pages will result in delay in the handting of your claim. All CEainus-nlease comolete this section , Were there witnesses to the incident? Yes No Unlmovm (circle) Provide their names,addresses and telephone numbers: � Were the police or law enforcement called? Yes No Unlrnown (circle) i 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 landmaric,etc. Please be as detailed as possible. If necessary,attach a diagram. p� �/U�}�y�.�}�� /�t/�, ''.�-N ��� v��� � C����5 ��. � 1.�1. ��k�L �i Please indicate the amount ou are seeldng in compensation or what you would like the City to do to resolve this claim to your satisfaction.�� ��(�, l 3 Vehicie Ciaims-please compiete ttus section ❑check box if this section does not aanlv Your Vehicle: Yeaz Z DO� Make 1(r\__p�D IJ Model 3 jo Q-�.�-,�� License Plate Number I Gl 1 � (e State��Color Registered Owner ���f�� �}�y�i N t�S L, �-.G � , Driver of Vehicle {��.h D 1� �C t}-��L� Area Damaged �J P P�2 i-�9►�� Lo�N�1Z, � �Ll�tt T �1 D t D� �'� l�-t� City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name} Area�Damaged Iniurv Claims-please comnlete this section _ �(check box if this section does not a�nlv How were you injured? What part(s)of your body were injured? Have'you sought medical t�eatment? 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 I When did you miss work? (provide date(s)) Name of your Bmployer: Address Telephone 0 Check here if you are attaching more pages to tlus 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 i of your knowledge. Unsigned far►ns will not be pra�essed i Submitttng a false c[aim can result in prosecution. Date form was co�npleted 1 D'Z� `(Z Print the Name of the Person who Complete is Forrn; � � Signatnre of Person Making t6e Claim: Revised February 201 I 7/2/2012 B221011661000201 5120120702156474 . Qinhart Liability Accident Report FoodServiceo [� Vehicle Collision � General Liability P�omptly Complete and fax this report to the Safety Department fax#847-976-1679 Division Name �ivision# Division Phone# Contact Person Name TWC 508 763-428-6500 Jimmie George ddress City State Zip Code ContaCt Person Phone# 13400 Commerce Blvd Rogers MN 55374 763-428-5501 ex 540 Accident Informatfon cCident date treonwoaynea�� Time otAccident Accident Location/Address City 5/24l2012 '[1:45 AM n Maryland ave between N Cypress st 8 N Earl Police Report7 police Depariment Officer Name Report Number Ciiation Issued7 no Witness 1 Name Witness 1 Phone it Witness 2 Name Witness 2 Phone# Unknown City Empioyee' Wifiess 1 Address!City!State I Zip Code Witness 2 Address/City/State!Zip Code f2efnhart Foodservice Vehicle Information Driver Driver License Number Hire Date coayrMOm�woa�y Andy Thiele W763272394716 2/20/2012 ddress Gity State Zip one 350 Prairie Rd Monticello MN 55362 763-439-1857 Ffeet Vehicle# Year Make Mbdel olor VehiGe Type 1021 2009 Kidron 36'refer wht Front License Plate# State VeRicle IdenGfication#(VIN) Vehicle Towed? Damage Estimate 19T366 NE 1K919362494054300 no Leased VehiCle? lf Yes Owner Where can vehiGe be seen? Driver Injuretl7 if Yes Where treated? (PhysirJan or hbspital,Addross,Gky,Stata,Zip� Taken by Ambulance7 Other Vehtcles VehiGe#1 Driver Driver License Number Number of Passengers? None Address Cily State Zip Code Telephone#(Home) Year Make Model Color License Pkate� State Vehicle Identifica6on#(VIN) VehiGe Towed7 Whero can vehicle be seen? I VehiGe#2 Driver Driver License Number Number of Passengers7 I none Address City tate 2lp Code Teleplione#(Home) (CeN) Year Make Modei Color License PEate# State VehiGe IdentifiCation#(VIN) Vehicle Towed7 Where can vehiGe be seen 7 lnfured Persons Person was? In Vehicia#7 Person's Name Injury Type? NONE ere ea e (PhyHCien or Hospitel,AAMars,CMy,Slflle,tip a en y m u ance erson was 7 In Vehicle#? Person's Name Injury Typo? ere rea e (P�ysician m Hospicel,Adbass,Chy,SteM,Zi0 a en y m ance. Properfy Damage Oescripion of Property Type of Damage Property Owner dress where propery can be seen fty State Zip Ownet's Phone# Accident Description Desuibe what happenetl Driver was headin east on Ma tand Ave desi nated Truck Route in a construction zone on Ma land Ave traffic flow oin east was farced into the far ri ht lane. Because of this trailer 1421 hit a tree limb breakin it off and causin dama e to the u er front corner ri ht side of trailer 1021. 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M. �.l�, `�--I``~ i -�-� � I -�� - ' I I ��R � �� ' ' �- -� � - --- - - - - _ II . . e o s � i�I, `�R"" � �e "�" ""Z.T"' � .,'°C'� �d" .�,. '"� °'2'°' mil° � ,� � i II �..-.-_ .--� 1 I sedgwicko � � J.une 1�9,2012 J� � n� ��?�e�i �.��� � ? - G City of St Paul �r � � Department of Public Works `'� `r � 1500 City Hall Annex ��, � I SG Paul,MN 55102 �:• � �`_ �� i RE: • - "., •• ❖ Claim No.: B221011661-0002-01 � c • ❖ Glient/Claimant: Reinhart Food ❖ Date of Loss: 05/24/2d12 Description: IV WAS TRAVELING EAST ON MARYLAND AVE CONSTRUCTION FORCED FLOW OF TRAFFIC FAR RIGHT RESULTING[N IV STRIKING A TREE LIMB AND CAUSING DAMAGE TO TRAiLER 1021. Dear Sir or Madam: i i Sedgwick is the claims administrator for the above-listed client. Please allow this correspondence to serve as subrogation notice for reimbursement of repairs made as a resutt oE the above loss. I Total Damages:$798.13 Please make any payments payable to Sedgwick,noting our claim number on the draft � j and mail to the below address. � I Please contact me at yonr earliest convenience to discuss status of payment � Thank you. � � Sincerely " ' ' I . ���ZSiZ��u:. ��.�c. AU1ri.Pi Cha�Pi � Sedgwick P: 515-327-4885 ! F: 515-327-4899 i i i � � PO 8ox 14670 � lexington,KY 40512 � PHONE 5]5.327.48$8 � FA7(515.327.4899 { FREE 866.342.3920 7/2/2012 B221011661000201 5120120702156474 .