Sachs NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minraesotn State Stnh�te 466.05 stntes tltnt °...ei�er��person...who clninas daniages fi�oin tui�•nu�nicip�lit��...shnll cnuse to be presented ro the
goi�erning body of the ir2u�nicipality widzin 180 days after t/2e alleged loss or inj�lry is discovered n notice stnting 1/ie tinie,place,and
circinnstnnces thereof,ai7d the cunanzt of con2perzsation or odter relief dem�ndecl.°
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 �a ral v►� Middle Initial l.r. Last Name ��`.C�1� r,r-���
Company ar Business Name �oy�
!L
Are You an Insurance Company? Yes/ io If Yes, Claim Number?
Street Address�_� l L. �y1 L��Vr� • �(�� l'�"�'�
City��• �lh.I.�� State �� Zip Code� ��
Daytime Phone((�)�9��0- I�ik3 Cell Phone(��Z)7�� ����° Evening Telephone(��� )���- ���3
C' C5 �
Date of Accident/Injury or Date Discovered / �- �L Time �.,� am 1�ir
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.
.p� G-C ' �P�
� —
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
❑ 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 Ciry. You are encouraged to keep a
copy for yourself before submitting your claim form. I
O Property damage claims to a vehicle: two esrimates 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
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
'tS�Injury claims: medical bills,receipts `` L
(�E Photographs are always welcome to document and support your claim but will not be returned.�`� ��Lv'i 65 , �,
Page 1 of 2–Please complete and return both pages of Claim Form
�v1C,���'�
�
I
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-please comulete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
�
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 p ssible. If necessary, attach a diagram.
-� �o � ,� ��P-�p��-
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.
1Z.� P �-''�,
Vehicle Claims-ulease comnlete this section LW"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 Mode]
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims-please complete this section ❑ check box if this section does not a�ply ,
How were you injured? - - i
C ��
What part(s)of your body were injured?
Q�
Have you sought medical treatmen ?. es No Planning to Seek Treatment(circle)
When did you receive treatment`� '� (provide date(s)
_ Name of Medical Provid r(s): `} � ti IL' Qp� q �/2%�
Address � • � � � -2l0 �� Telephone Jr'v ' � f'f - 2�-f-Oc�Df
— Did you miss work as a result of your in' ry? Ye No �'� 5�� � ����
When did you miss work? � (prov' e date(s))
_ Name of your Employer: ' t^i � ,n t
Address �0 � JQ . �� Telephone � 0 � 2...
�Check here if you are attaching more pages to this claim form. Number of additional pages�. �����S�
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 �
Print the Name of the Person who Comple d this Form: � �Gl,l'�� ` �\ � • C�
Signature of Person Making the Claim: � ��� 1�� � ��
Revised February 201]
Ciiy Clerk
15 West Kellogg Bivd
310 City Hall
Saint Paul,MN 55102
Re: Enclosed Notice of Claim Form h
Dear City Clerk:
I am sending this�etter to request compensation for personal injuries
f sui iered as a result of the City's failure to post proper guards and
danger signals on an excavated area of the street in my neighborhood.
On September 14,at approximately 8:20 pm,I was walking norfh with my
leashed dog on Fairview Avenue along the sidewalk. As I was crossing
Fairmount Avenue,I tripped and fell in the excavated area of the
street near the northwest corner of Fairmount Avenue and Fairview
Avenue South. The excavation had created an area of sharply uneven
pavement near the curb. I was unable to see the sharp dip in the
pavement because of the dark. Further,there was no clear marking of
the danger area:the"Road Closed"barrier was standing up on the
sidewalk and set back at least 8 feet from the danger area,rather
than standing in the street as has been the case in the other
excavated streets in the neighborhood. (See enclosed pictures.)
When I feli,I hit the cement with the right side of my face. I heard
a cracking sound in my head and felt blood coming out of my mouth. I
also hit my knees,shoulders,and hands. Fortunately I was near home
and was able quickiy to get home, holding my mouth to contain i�'ie
bleeding. My husband and children brought me straight to the
emergency room of United Hospital. At the hospital,I received
an x-ray of my left hand and a CT scan of my head. I received a
prescription for my pain and treatment for numerous cuts and bruises.
I also discovered that my upper front tooth had been chipped in the
accident. On September 27,the chipped tooth was repaired by Dr. Roberf Maley.
As you can see from the enclosed documentation, my total medical bills
resulting from the accident total$3,255.10. I also missed one
day of work (September 17) due to the accident,resulting in lost
wages in the gross amount of$48.
I believe the City of Saint Paul was negligent in failing properly to
maintain guards and danger signals marking the excavated area of the
street as required under the Saint Paul Code of Ordinances, Part II,
Title XII,Chapter 109. Therefore,the City of Saint Paul should
compensate me for the medical expenses and lost wages I suffered,in
the total amount of$3,303.10. I have enclosed the Citys Notice
of Claim Form as required by Minnesota State Statute 466.05.
�cerely, /" �
-._._ 1 �
v�.. ,
aralyn Sachs
Enclosures {Notice of Claim Form, photos,documentation of inedical
expenses}
1
TIME 3:12 PM RobeR J.Maley,D.D.S. DATE 10l29l2012
ACCOUNT HISTORY REPORT Current Account i�g:
FOR Current $78.21
2363: Nathan Sachs ��Y ���
From Sep 01,2012 To Sep 27,2012 ��Y �•�
90 Day $0.00
Contract $0.00
Balance Due $78.21
Estimated Ins $0.00
Balance Due Now $78.21
Date Name Provider T�e Descriotion Debit Credit Balance
»»»>Sum of all account activity prior to Sep 01,2012 $0.00
9J17/2012 Daralyn Sachs 1 Service D0140 Limited oral eval poblem focused $71.00 $71.00
Eet Insurance$71.00 /
9/26/2012 Daralyn Sachs Prim Ins Pmt Insurance Check: number 342564615 for $51.60 $19.40
claim from September 17,20
Daralyn Sachs Credft Adj Delta PPO-Premier Adjustmer�t: Gedit $19.40 $0.00
Account On Closing of Claim
9/27/2012 Daralyn Sachs 1 5ervice D2331 Resin-two surtaces,anterior Tooth 8 $208.00 $208.00
Surface IF
Est Insurance$166.40
Daralyn Sachs Acct Pmt MasterCard: number MasterCard $41.60 $166.40
XJ�;}OCCK;XXXXXX6420
Nathan Sachs 1 Service D0120 Periodic oral examination $48.00 $214.40
Est Insurance�48.00
Nathan Sachs 11 Service D1110 Prophylaxis-adutt(cleaning) $89.00 $303.40
Est Insurance$89.00
»?»»?>Sum of all account aetivity after Sep 27,201 ($225.19) $78.21
$190.81 $112.60 $78.21
I V�
> � z7�
�
Current Dental Terminoloav(CDn�Amencan DeMal Association(ADA). All rigMs reservetl. P�e� Of�
7210 01010000198029 O1
. � .,
� ��� Explanation of Health Care Benefits
THIS IS NOT A BILL This is an explanation of the claim we
processed based on your plan benefits in effect when the service
was performed. Please keep this form for your tax records
��1.,l���'055 ��l.�1���'11 -t.'�t� __ _ _ __ _ __ _ _ _ _
Year to Date Deductibie 431 87
of 1'1��n r�+�5c��� �----- ---_ ____ ___ _ ___ _ _ _ ____ ____:
Contact: For Customer Service Please Call
_----_ --__-----_ __ __..... _r. . . ___ . ._ ....... ___.
:;r.�nrepenc��nt��cen>ee.�i tt��61u�:ri�s��n�'�>.u�e�hripid ps�au�sian (651) 662-5004 OR TOLL FREE 1-866-870-0348
DARALYN SACHS
1851 LINCOLN AVE
ST PAUL MN 55105-1420
_ ._ _ ___ _ __ _ _.__ _. . _. __ _.___. . _ _ _._ _
Patient ID Group/Policy Date Received Date Processed Claim Number
_.. ._ __._.... _____.__ ..___.__. .. ..._.._ _. ___..______�_._____ ._�.__._._.____-----_ _.__�_. _____._ �.___._._. _ _ __ . ..__ � _.__ - ----
XZ7873064 OEP60305C THE GOODMAN GROUP 09/25/12 10/09/12 2Z69934041000
____.__ ____.. __..__._.----.___.._.__,--- -:- -------------____.,_.�.______._. . ._..---�.... .___._ _ _____ ____
___ ___..._.__ ____ . _.__
Subscriber/Member Name NATHAN SACHS
_ _ __ ____ ... _ __ ___.... ..�. ._� . � ___ __..._..___ _�_ _. __ _ __ _
Patient Name DARALYN SACHS
__-_ __, _----_._..�_..______ _ ___ _._ �.,__.._.s____ _ _. _ ___ __ ___ _ e �__ . ____,__ _ _ _ _ _
Provider EMERGENCY CARE CONSULTANTS
PA
_ _..__ _ ._._._. _. _ _...... _. __ _. _ __ __ __ _._
Patient Control Number 41b5040
_._ _____. _ ____,_. -. _�_.__ .. _ _�_.____ _e._--_ ._ ___. -._�__-- __ . __.. ._-_._
From From From From From
Dates of Service 09/14/12
_ . _ _ _ _ _ __ _______ . : _ . _.._...__ _ _. _ _
'To 09/14/12 To 'To 'To 70 '
_ _._ .,,._._.__ .._ _ _ _ _�._.____..__.__�___.. . .._.. ._ �..___.. .. _. ._....___.. .___ _ _ . _...__.__ ._.______.
Description M EDICAL
_ _..._._ _ _ .__ _._._ --�__._.___._______._... _.__..._._.. _..._.___ ___.__ ._..____.__
�.__ _,___..._�__._ .---.___ _
Charges 394.00 ' ?
___ _...._ ._._ ___��_ ________.__. �;__.. ...�._._ .._._�.._ _.s. ._.,.____...___._.__ r.----_..,.._____ .._...��.�_,:
Provider Responsibility 394.00 '
Amount � , :
_...._.� _.. _ .� . � __ .__�__�_...___..�,__ _�___ .__ _,�___._ .._� �_�_ .__.__.�-_ _..._._..__ __...___�.. .��_�___ _�_�_�_ �
Allowed Amount ' '
_ . _____._.��- --------_-----.________._...____�_.________.».__..:--___._.�___.__---_ .._..__. __.______...---
Amount Paid by Other
Insurance
__.______.__._____�_�----___..�______ .___.._ __._______.�------ -----� __�___..___ :___��_...��
Deductible Amount '
_W.V __,..__�.v______ , ._______�__�.___ .._..._�_ ___�_.�. e_�.�_ ..,_.�. �_. . ___,....._ _._._.__. _..�__. �_ .._�_ _.._.w
Copay Amount � ;
_.__ .. __._.-- ---�.___ ._ .____ _. .__�... _ �__. ___....._. __.____ �_____ __ __._�.. . _____.__ __.__ . ___.. . . .__;
Coinsurance Amount
__.___._��_ . __._ ____.__... ._. ._ __._.�_ .�._ ._ ._ ._.___., � ....� . �_��_ _. __��._�
__. �. _. . . __._� _�.__.__- --._�.
Paid Amount
_..__._...____.____- ----..____.
____�___._.__._.______:__--,--.._ _...___.�_. . _;_._._ ..._�._._...--- . .....__.� _..._____.... ......._ .., ._.___�
Patient Non-covered
Amount ' '
_.._____. __�---., .___..__.__---__.�__._,___._�._.____�.__._.._..__._,._-- -------_ _.___.... _--.___..._._.____-----�
Amount You Owe '
_._ _.____-----�_� __�.. __�__ __�__._ . __�._ ________—T__ _ ___ ._,----- ,_�.___...____�___._.
Notes ID 1 '
__ ___ _.--_._ ___ ___.._.. ___ _ ...._..__. ___. __ __. _._�. __ __... ___ _ __ __. _ _.
1 THESE CHARGES CANNOT BE PROCESSED BECAUSE INFORMATION IS Total Charges
MISSING, INVALID OR MUST BE VERIFIED BY YOUR PROVIDER. THIS $394.00
INFORMATION IS NEEDED TO DETER�1INE BENEFITS. THESE CHARGES WILL - - - -- - -
BE PROCESSED WHEN THE REQUESTED INFORMATION IS RECEIVED Total Benefit
Amount
$.00
_ _.. . .
Total Amount Paid
by OtherInsurance
$.00
Total Amount You
Owe
$.00
.__......_. _..__ �.......
UNITED HOSPITAL
3�3 N Smith Ave
St Paul , MN 55102-2344
Ph: (651) 241-8000
Guarantor Number Guarantor Name & Address
102062997 SACHS, DARALYN C
1851 LINCOLN AVE
Account Number
8�39615 SAINT PAUL, MN 55105
Detailed Bill For
Patient Name : SACHS, DARALYN C Admission Date : 09/14/2012
Account Class : Emergency Discharge Date : 09/15/2012
Attending Physician: DELISLE, CHANAH M
Charges
- -- - ------------- --- - -
Service Cost Rev. Proc . Description Qty. Amount
Date Ctr . Code Code
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
09/14/12 0250 700030 ONDANSETRON 4 MG TBDL 1 24 . 90
09/14/12 0250 700030 IBUPROFEN 100 MG/5 ML SUSP 30 31 .30
09/14/12 0320 73130 XR HAND 3 VIEWS LEFT 1 269 . 00
; 09/14/12 0351 70486 CT FACIAL BONES WO 1 637 . 00
� 09/14/12 0450 99284 HCHG ED EMERGENT LEVEL IV 1 1, 381 .40
�;r� 09/15/12 0636 700031 DIPHTHERIA-ACELLULAR PERTU 1 176 .40
09/15/12 0771 90471 HCHG IMMUN ADMIN IM/SQ ONE 1 62 .10
Total for 7 Charges 2 , 582 . 10
,�;_
Payments
Post Date Recd. From Amount
10/23/12 BLUE CROSS -466 .28
10/23/12 INSURANCE DISCOUNT -1, 347 . 86
Total for 2 Payments -1, 814 . 14
Balance 767 . 96
- - - - --- - - - -- - - - - - - - - - - - - -- - -- - --- -- - - -- - - - - - - -- - - - - - - - - - - - - - - -- - - - - - - - ---- -- ---
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