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N�;/ 1 5 2012
AMERICAN FAMILY (;I�T`� �,,����
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Scanning Center I 6000 American Pkwy I Madison WI 53783-0001 ( 1-800-MYAMFAM(692-6326) I amfam.com
November 13, 2012
34-PAN002
CITY CLERK
310 CITY HALL
15 KELLOGG BLVD W
SAINT PAUL MN 55102-1635
RE: Our Claim Number: 00-245-004139-1324
Our-Patiey Number: 22282698-06 -- - -
Our Insured: William E Sailer
Date of Loss: October 9, 2012
Our Company Name: American Family Mutual Insurance Company
Dear City Clerk:
Enclosed is the notice of claim form. Please set up a claim to handle this automobile accident.
American Family Insurance will be submitting a claim for subrogation for the damages sustained to our
policyholders vehicie.
A copy of the police report is also included with this form to assist in your investigation.
Sincerely,
�� �U�1�ax�
Paul A Nicholson i
Casualty Claim Desk Senior Adjuster
American Family Mutual Insurance Company
1-800-MYAMFAM (1-800-692-6326) X 62464
pnichols@amfam.com �
Fax: (866) 833-5599
www.amfam.com/claims
Enc: Notice of claim form; police report
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 to be presented to the
governing body of the municipality within/80 days afYer 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 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 w��-�.��M Middle Initial �= Last Name S�1 �,<'-+�
Company or Business Name�l!�(�I�iQ�V �'��l L`� �/V S(/,Q�/1��
Are You an Insurance Company? Yes No If Yes, Claim Number?_2yS—w'Ct c7-(
Street Address SC1� /"1�2N��c'�S�Q� ��C:�
City U�� N��-s H���j�,� State �� Zip Code �12�
Daytime Phone(��)�� -✓7�0 Cell Phone( ) - Evening Telephone( ) -
Date of Accident/Injury or Date Discovered �� � �2 Time � ��U am pm
Please state,in detail,what occurred(happened),and why you are submitting a claim. Please indicate why or how you
fe the City of Saint Paul or its employees are inv ved and/or responsible for your damages.
SL=� A77�t�t�ti n Pot,i�E R�'PD27'�
� ic i,�� =z� o, c�?y o�= c. v��r�c L�
(M P�o�/1 pT, 7fJP ��''� (�-�7 �i4�N�, �d�tid ►v!VA 7� �Cc�r2 .
�Ple se 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 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.
� 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
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 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:
Were the police or law enforcement called? Yes No Unknown (circle) � �n,�'(QS�
If yes, what department or agency? Case#or re�ort#
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park ar facility,
closest landmark, etc. Please be as detailed as possible. If necessary, att ch a diagram.
M�2Y1/J'�ID A-t� � q- P/�4�IV F /t vC-- S<< P�UZ, �(�
Please indicate the amount you are seeking in com ensation or what you wou like the Cit to do to resolve this claim
to your satisfaction. �2�'O I � 3�{ -I- .�� 0�'QUG7� �t� = �31dI�3�
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year ZOtO Make D Model US
License Plate Number 27 I7�l1 State �'1 Color (�!e/rY
Registered Owner 1N�l.L J 11{,M S,��L L=12
Driver of Vehicle S/M�C
Area Da�m�a�,e�d, F110f�C r�R 1 l/LYZ
City Vehicle: Year ��UU`� Make �'� Model SO
License Plate Number State '1�Color .D
Driver of Vehicle(City Employee's Name) �tvl0/Ii'-J �C�OWft
Area Damaged (��Y 5 S�/U!�C�2 -1�/1 t�/V7'
Iniurv Claims-please comqlete 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 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 � �2
Print the Name of the Person who Completed this Form: ��'lUL- f�j��L�v� 1 /��JC�1� �''�!L`1
Signature of Person Making the Claim: � �iu.�-1�.�,��1
Revised February 2011
(Page 2 of 2)
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