Thao ����c��E�
FEB 2 � 20�3
NOTICE OF CLAI�I�'�'��to the City of Saint Paul, Minnesota
Minneso�a 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 ncunicipaliry within 180 days after the alleged loss or injury is discovered a notice stating the tinte,place>and
circurrestances thereof,and the amount of compensation or other relief dernanded."
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 Middle Initial Last Name
CompanyorBusinessName i"��tirCfSi►'Q l�i�lC-� 1nSv�anc� Cv• �{�S/D 5vv Thqa
Are You an Insurance Company? es/ o If Yes, Claim Number? �2- ��S D �Sv
Street Address �� 3 �k S�/2 �2�I
City ��5 �[,a2�5 State C�i Zip Code Cl�
Daytime Phone(�) �gg- `(Zl Cell Phone( ) - Evening Telephone( ) -
Date of Accidenb Injury or Date Discovered 10�2?� �Y Time ���� am/�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.
G��Y �n�.�nQ �.t- �j (�r 'r( '�'�vclC �il�� ¢'U ��f i 4(� ��n�—�Frin�
�uG {JkV C4vSi� ACC� i�
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 G �M h G� C r► ���� 5���Sfi�ti�v�
In order to process your claim vou need to include copies of all auplicable 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 WII.L 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
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—nlease comnlete this section
Were there witnesses to the incident? Yes No nknow (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? es No Unknown (circle)
If yes, what department ar 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.
uu'1rC�Wu�� �r�t� l���v(a�l Sfi•
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
toyoursatisfaction. � (�f 9d0 � 0�
Vehicle Claims—please comnlete this section � ❑check box if this section does not arn�tv
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
Iniurv Claims—please complete this section ❑check box if this section does not annlv
How were you injured? ,�a�� a��i ddnfi
What part(s)of your body were injured? t� ho�/ QGK
Have you sought medical treatment? No Planning to Seek Treatment(circle)
When did you receive treatment? S'� MPc�?c.a� l�olcll _(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: i
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�����3
Print the Name of the Person who Completed this Form: �0�?�'� �'�� � � ���°S r PS 5�+�'f 2 f P)
Signature of Person Making the Claim: � �
Revised February 201 I
������.���,��.
P.O.Box 512929
Los Angeles,CA 90051-0929
Phone:(888)489-4214
Fax:(888j 781-6947
2/19/2013 9:08:00 AM
SHARI MOORE/CITY CLERK
15 WEST KELLOGG BLVD.,310 CITY HALL
SAINT PAUL,MN 55102
RE: Date Of Loss: 10-27-12
Our Insured: THAO,MOSES
Our Claim Number: 12-1150150
Your Insured: CITY OF ST.PAUL
Your Claim Number:
Dear SHARI MOOREICTTY CLERK,
To date, Progressive Direct Insurance Co has paid $19,900.00 for Personal Injury Protection
("PIP") benefits resulting from a loss, which occurred on or about 10-27-12. Progressive Direct
Insurance Co is entitled to rights of recovery. We request 15 WEST KELLOGG BL�7D., 310
CTTY HALL to notice,aclaiowledge,protect and preserve these rights.
Our rights of recovery include, but are not limited to, indemniry or contribution created by the
payment of claims or benefits to insureds or qualified third parties under automobile accident
reparations statuses or common law.
For your reference,PIP benefits already paid,include:
Partv Name PIP Total
THAO,JOU $19,900.00
Please refer any inquires regarding our rights to recover to the attention of the InsPIP Team at
(888) 489-4214. Payment may be sent to Subrogation Payment Processing Center 24344
Network Place Chicago, II,60673-1243.
Sincerely,
InsPIP Team
Progressive Direct lnsurance Co
PIP41.D (Rev.7/1110)
Medical Payments/PIP-Print Preview Page 1 of 4
Medical Payments Details
Named Insured: Moses Thao Sr
Injured Party: Jou Thao
Claim Nurnber: 1 2-1 1 501 50
Date Of Loss: 10-27-12
Total Billed: $94,073.15
Total Paid: $19,900.00
Amount Amount Date Invoice Payment
Frovider- E.xposur.e Seruice.Dates �-.-.---.BiUed..To.Be-Faid-.S�cuice-Type.- - . __ _Received. Lien.-Number.--Stat.WS.-----.
I
MAI SPINE CENTER PA i
(
PIP MED 01-31-13/01- $308.04 $0.00 02-12-13
31-13
MAI SPINE CENTER PA ;
PIPMED 01-23-13/01- $999.62 $0.00 02-OS-13 �
29-13
MAI SPINE CENTER PA
PIP MED 01-14-13/01- $810.92 $0.00 01-21-13 ;
16-13
i
MAI SPINE CENTER PA
PIP MED 01-08-13l01- $195.84 $0.00 01-18-13 i
08-13 �
MIDWEST SPINE INSTITUTE LLC I
PIP MEO 01-21-13/01- $198.95 $0.00 02-01-13 ;
21-13 i
MA1 SPINE CENTER P A �
PIP MED 12-27-12/01- $442.68 $0.00 01-12-13 '
04-13 �
HEALTHEAST ST.JOHN'S HOSP I
l
PIP MED 11-01-12/11- $21,406.54 $0.00 01-11-13 i
02-12
HEALTHEAST ST JOHN S HOSP
PIP MED 11-01-12/11- $21,406.54 $17,708.50 01-07-13 8466866 01-13-13 i
01-12
I
MAI SPINE CENTER P A
PIP MED 12-17-12/12- $195.84 $0.00 01-07-13 �
17-12
UNTED MEDICAL IMAqNG
PIP MED 11-28-12/11- $3,468.00 $0.00 01-07-13
28-12
MAI SPINE CENTER PA �
PIP MED 12-10-12/12- $740.52 $0.00 01-07-13 I
12-12
MAI SPINE CENTER PA
PIP MED 12-03-12/12- $493.68 $0.00 01-07-13
04-12
MAI SPINE CENTER PA
PIP MED 11-26-12/11- $883.32 $0.00 01-07-13
28-12
MAI SPINE CENTER PA
PIP MED 11-21-12/11- $150.84 $0.00 01-07-13
21-12
MAI SPINE CENTER PA
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Medical Payments/PIP-Print Preview Page 2 of 4
PIP MED 11-20-12/11- $240.84 $0.00''; 01-07-13 i
20-12
MAI SPINE CENTER PA
PIP MED 11-16-12/11- $251.68 $0.00 01-07-13 ;
19-12
MAI SPINE CENTER PA �
PIP MED 11-08-12/11- $913.92 $0.00, 01-07-13
13-12
M A 1 SPINE CENTER PA
PIP MED 11-19-12/11- ' $244.80 $O.00 I 01-07-13 �
26-12 ;
MA1 SPINE CENTER PA
PIP MED 12-21-12/12- $390.68 $0.00' 01-07-13
21-12
MA1 SPINE CENTER PA ;
PIP MED 12-18-12/12- $740.52 $OAO 01-07-13 !
20-12
MAI SPINE CENTER PA ':
PIPMED 11-16-12/11- ' $242•00 $0.00I 01-07-13
16-12
i
UNITED MEDICAL IMAGING
PIP MED 11-12-12/11- ' $907.80 $0.00 01-07-13
12-12 �
UNITED MEDICAL IMAGING �
;
PIP MED 11-08-12/11- $907.80 $0.00; 01-07-13
08-12 I '
HEALTHEAST ST JOHN S HOSP '
PIP MED 11-01-12/11- ' $585.00 $585.00' 01-07-13 8466855 01-11-13 ;
01-12 '
ST PAUL RADIOLOGY PA
PIP MED 11-01-12/11- ' $788.00 $788.00 01-07-13 8466852 01-11-13 �
01-12 I
�
ST PAUL RADIOLOGY PA �
PIP MED 11-01-12/11- $261.00 $0.00; 01-07-13
01-12
i
ST PAUL RADIOLOGY PA
PIP MED 11-01-12/11- ' $124.00 $0.00'; 01-07-13 �
01-12 � I
ST PAUL RADIOLOGY PA
PIP MED 11-01-12/11- $261.00 $261.00 01-07-13 8466839 01-11-13
01-12
ST PAUL RADIOLOGY PA
PIP MED 11-01-12!11- $124.00 $124.00 01-07-13 8466838 01-11-13
01-12
ST PAUL RADIOLOGY PA
PIP MED 11-01-12/11- $151.00 $151.00 01-07-13 8466832 01-11-13
01-12
VOYAGEUR RADIOLOGY LLC
PIP MED 11-12-12/11- $382.50 $282•50 01-07-13 8466830 01-11-13
12-12
ST PAUL RADIOLOGY PA
PIP MED 11-01-12/11- $261.00 $0.00 12-20-12
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Medical Payments/PIP-Print Preview Page 3 of 4
01-12 "!
MA1 SPINE CENTER PA
PIP MED 12-18-12/12- $740.52 $0.00' 12-27-12
20-12
MAI SPINE CENTER PA
PIP MED 12-21-12/12- $390.68 $0.00 12-31-12 ,
21-12 '
;
MAI SPINE CENTER PA ' �
PIP MED 12-10-12/12- $740.52 $0.00' 12-21-12
12-12
MAI SPINE CENTER P A I
i
PIP MED 12-17-12/12- , $195.84 $0.00; 12-27-12 �
17-12 ;
�
MAI SPINE CENTER PA i
PIP MED 12-03-12/12- $493.68 $0.00 12-15-12
04-12 i , I
ST PAUL RADIOLOGY PA ' '
PIP MED 11-01-12/11- $124.00 $0.00' 12-10-12 �
01-12 �
M A I SPINE CENTER PA � �
PIP MED 11-19-12/11- $244.80 $0.00' 12-03-12 i
26-12 i
I
MA1 SPINE CENTER PA ', �
PIP MED 11-26-12/11- $883.32 $0.00 12-08-12 �
28-12 I
UNITED MEDICAL IMAGING I
PIP MED 11-28-12/11- $3,468.00 $0.00' 11-30-12
28-12
HEALTHEAST ST JOHN S HOSP
PIP MED 11-01-12/11- $585.00 $0.00 i 11-12-12
01-12
MAI SPINE CENTER PA ' j
PIP MED 11-21-12/11- $150.84 $0.00 11-27-12 ;
21-12 �
MAI SPINE CENTER PA '
PIP MED 11-20-12/11- $240.84 $0.00' 11-27-12
20-12 ; I
MAI SPINE CENTER PA � �
PIPMED 11-16-12/11- ' $251.68 $0.00: 11-27-12 �
19-12
MAI SPINE CENTER PA
PIP MED 11-08-12/11- $913.92 $0.00 11-20-12
13-12
MAI SPINE CENTER PA
PIP MED 11-16-12/11- $242.00 $0.00 1�-2�-�2
16-12
ST PAUL RADIOLOGY PA
PIPMED 11-01-12/11- $261.00 $0.00 1�-��-�2
01-12
UNITED MEDICAL IMAGING
PIP MED 11-12-12/11- $907.80 $0.00 11-1�-�2
12-12
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Medical Payments/PIP-Print Preview Page 4 of 4
ST PAUL RADIOLOGY PA ;
�
PIP MED 11-01-12/11- $788.00 $0.00' 11-17-12 i
01-12 �
VOYAGEUR RADIOLOGY LLC '
PIP MED 11-12-12/11- $382.50 $0.00' 11-17-12 +
12-12 i
UNITED MEDICAL IMAGING ' '
PIPMED 11-08-12/11- ; $907.80 $0.00; 11-16-12 �
OS-12 i '
I
ST PAUL RADIOLOGY PA i
: I
PIPMED 11-01-12/11- $151.00 $0.00! 11-17-12
01-12
HEALTHEAST ST JOHN S HOSP ;
PIP MED 11-01-12/11- f$21,406.54 $0.00� 11-12-12
01-12
ST PAUL RADIOLOGY PA
PIP MED 11-01-12/11- $124.00 $0'.00 11-12-12
01-12
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