Vondelinde (4) �
Subrogation Department
P O Box 2100
F I N A N C I A L Bloomington,IL 61702-2100
Fax:(866)255-7961
OS/03/2013 RECE�vED
MAY �'� 2013
C�TY CLERK
City of St. Paul, MN
Attn: City Clerk
15 West Kellogg Blvd, 310 City Hall
St. Paul MN 55102
NOTICE OF RECOVERY INTEREST
RE: Your File: Unknown
Your Driver Brian Cook
Our Claim No.: 201-1126839
Our Insured: Tyler Vondelinde
D/L: 12/12/2012
PIP Payment Amount: (Pending)
Dear Sir/madam:
Our investigation of the above captioned incident indicates that your insured's negligence was
the cause of injuries to our insured or passenger/s.
We have made payments for the treatment received as a result of the above accident. This letter
is to place you on notice of our recovery interest. Our documentation
will be fowarded once treatment is concluded
If you have any questions you may contact m at (866) 551-8806. My office hours are
8:00 a.m. to 4:30 p.m. Monday through Friday.
Sincerely,
CO TRY Mutual Insurance Company, Bloomington, IL
/;�- —� � �
� ��' C-� _
Joe Roe
Subrogation Specialist
Fax: (866) 255-7961
State law requires us ta notify you:
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is
guilty of a crime. ' :
For automobile claims, disregard the following notice.
If this is a homeowner claim, please read the following.
Notice to homeowner claimant:
Section 65a.29, Subd.l l of the Minnesota statutes requires us to provide you with a statement
that sets out the minimum number and amount of claims during an experience period that may
result in the nonrenewal of your homeowner policy.
• Your homeowners insurance policy is subject to nonrenewal if you have two or more
losses during a 36-month period. The following types of losses are not counted:
1. Losses caused by natural causes including, but not limited to, lightning, wind or hail; or
2. Loss for which no payment was made by us; or
3. Losses for which we recover 80% or more of the payment through subrogation.
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota Sta�e Sta�uic 466.05 sta�es thut "...eve�y pe�son...who clnims da�nages fi•om am�muiiicipalit}�...sliall cause to Ge presented to the
guvc nein,�body qf the mimicipality w�ithin 180�t�it�s«fter tlie u(leged loss or injuiy is discovered a notice stuting the time,p/nce,und
circ�nnstanees thereof,antl the crmotrnt of compensatrori or otlter relief tlen:arttled.°
Pleasc 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
writtcn 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 � Y� � _' r Middle Inilial � Last Name ��I? �.'- ( � i''!� :
Company or Business Name-- -� ;_7+:� l'�-!� r 'r' � r� _: :� r. ', � ?
�� �� � �
Are You an Insurance Company?��es/No If Yes, Claim Number? ��,c,�7 . "� � �c�L�:i ��.� �
�1 �
Street Address / /j {'l ��� ��.. �O:i,� � . ��. �c5 j� � J�U4�
City ���C.'?�?'�"� % t'�o� f!� l'�. State ��-- Zip Code ���
Daytime Phone (��;L- � Cell Phone ( ) - Evening Telephone( ) -
� -r � -,„ , ��
Date o{�Accident/Injuiy or Date Discovered ,�' �.-';��."��: -- .� �_ Time �(._ �6 am�m
Please stace, 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/a�re involved and/or responsible for your damages. �7�-f t ,,�r:- J:?-i .
1n1,;��l�1 D^T� %'�O"-ff�� /l�r �n�/L l ['9 fl i'r_'ri' !L� y C�'� �N�' ��� ' �n1�=f< —�a"-ff. �O�l�� �
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�^�.� i� rtr ��� /���' Lv1�;.� j�0/! , yU�if r�hiV°(i' iC q�� {;�.-�� '�Ot �'o ; �li �� f0
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�' i: �i{� /' I C: /i=-r p-t' l,J�/'/ �li!�'� �T t-=f/� �A'i /�.�-� � j h ,< <.(c� ; �r. � r -r�f
/'rn a� n i� / 'W�;�'n�'' O /1 � ��
I. �
Please check the box(es) that most closely represent[helreason for completing lhis form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or conditio�l of the sp�eet �.My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed anci/ur ticketed ❑ I was injured on City property
❑ Other type of property damage-please specify
�� Other type of injury-please specify Du� d v � u2r �v� ;,nd�atp�,� i h f��� c orl;s � ci�.. �'4 �l�, h,"�=�
7n�,-� , �-s>� ., .;'� ; ;:/c:��„�. uh_d� /^ef-2i/,e°�.. 6:0,�� ;
In order to process your claim you need to include copies of ail 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. Doc�unents W1LL NOT be returned and become the proper[y of lhe City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle: two estimates I�or 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;de[ailed list of damaged items
0 Injury claims: medical bills,receipts -4 �/ �!! �o r w,��� `'�`"� �r�`�"�'r°'''ri� �--�
O Photographs are always welcome to doc�unent and support your claim but will not be returned. �onC-I y.<� 1 =�-
Page 1 of 2-Please complete and return both pages of Claim Form
� ,
�C�i- � � ;�� �J �
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please complete this section
Were Chere witnesses to lhe incident? Yes No Unknown (circle) � c..� ,y �,
Provide their names, addresses and celephone numbers: � �4 c� C-> �� Y �{?�r�-� '" ��!-' � I �� ' '�-S� �
�
Were Che police or law enforcemenl called? (Ye No Unknown (circle) �
If yes, what department or agency? c���,:" d r� �--�-. !���' � Case#or reporC# ��Z�2 y'����C _
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, at�ach a diagram. ���=,^�-'�� �-- (�/l�. �� �'_
��- .: — =� ^ / ,� ��, _ '�:� r ��'T {'rr ,.r ; � �J
Please indicate the amount you are seeking in com ensatiou or what you would like the City to do ro resolve this claim
to your satisfaction. r=� ��' i s {o r ?'��'�r c� � ��r_f h� � r��c Cf'�,/�� ��n�y"_ �'L � i r �f;� 1
,
�'-r'�h / P 'r '� i. y cr -¢�'� iS fi �C�
Vehicle Claims—please complete this section ❑ check box if this section does not apply
Your Vehicle: Year ;''' Make %�����:=� Model �; �2 �; ^ '
License Plate Number `-�=f�" `'�� State `�_Color �: �U°lr
Registered Owner i,�1� � i/0 h�� i r�/c=
Driver of Vehicle i�� ��=r '✓Unc�G i� h���'
Area Damaged �r�• n t �/!c(�
City Vehicle: Year / Y`,`G� Make Ta�-.� Model �' J� �,�/�-+ s� 1
License Plate Number `i/S'I y� State �'I'I��Color �i'1 F=1�.c'✓�1 r�,
Driver of Vehicle (City Employee's Name) ,C�r�a� �Tah n C.v o ls'
Area Damaged r�- ���� � r ��
��- �urv Claims—please complete this section ❑ check box if this section does not applv
9 � How were you injured?
�"�:4''' i
c��^ � % � What part(s)of your body were injured?
� , .--
/?"r`�"�"� Have you sought medical treatment? Yes No Planniug to Seek Treatment(circle)
� When did you receive treatment? (provide date(s))
�_ �^�%� '-�'�Name of Medical Provider(s): I
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 Ito this claim form. Number of additional pages
By signing this forni,you are stating that all infornzation you have provided is true and correct to tlze best
of your kfaowledge. Urzsigned forf�zs will fzot be processed.
.Submitting a false claim can result in prosecution. Date form was cornpleted ��� �� ����
Print the Name of the Person who Completed t is Form: �=��-� /\ (��
Signature of Person Making the Claim: �- V Gvu 1�'t✓ �i/L�i n� % 4 �
Revised February 201 l
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PAGE 213"RCVD AT 1f22l2013 9:47:25 AM[Central Standard Tlme]'SVR:CIAPP22612*DNIS:98205600'CSID:RIsk Solutions(A1)`DURATION(mm-ss):01-09