Century Link (2) F��C�I�!�� CIY1,�-� l b305g�
MAY 13 2013 C�1Y1�: �� 1153
NOTICE OF CLAIM FOR�toYt��f�f Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipality within 180 days after the aUeged loss or injury is discovered a notice staring 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 Middle Initial Last Name
Company or Business Name l�U 1.� �•�,�� G'M•�F� u��(,� �T�"
Are You an Insurance Company? Yes N� If Yes,Claim Number? 1 Yt't� ����$(
Street Address �?.�D `1� 5���,n
City ��i State d�•- Zip Code �, (4�
Daytime Phone(�)�-��Cell Phone( ) - Evening Telephone( ) -
Date of Accidend Injury or Date Discovered � ������ Time am/pm
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.
e S+
2 u �
Please check the box(es)that most closely represent tt�e 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
C7 My vehicle was wrongfully towed and/or ticketed I w inju�red oq City p operty
�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 apulicable 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 retarned 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 andlor 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$500.00; or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please comvlete this section
Were there witnesses to the incident? Yes No nknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No know (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.
133U -Na�qe� �CV2 t�J � S�. �ol.ul
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. `� (���$a.y'1
Vehicle Claims—Alease comqlete this section �,check box if this section does not apvlv
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 comnlete this section �check box if this section does not apnlv
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 page�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 ����°
Print the Name of the Person who Complete this orm: � �`
Signature of Person Making the Claim:
Revised February 2011
OQWEST CORPORATION DBA CENTDRYLINK QC PACiS 1 OF 2
OACCOUNT NO: 1�II�T BF491153 INVOICB NO: A259479-
OINVOICE DATE: 04-01-2013
0
0 PREVIOUS - PAYMENTS + CURRENT + LATE = NEW AMOUNT PAYMENT
0 $ALANCE CHARGES , CHARGE BALANCE DUE DUE DATE
.00 .00 18,889.47 .00 18,889.47 18,
0
DAMP,GE DFsTAIL : 1240 PAIR IINDffitGROUND CABLE - WATER EXCAVATION
DATE OF DAMAGE: 05/26/10 CABL£ LOCAT$ WAS ACCURATE
LOCATION : 1330 HAUGB AVE W, ST PAIIL MN
Damage Claim No: 0491153
Mail correspondence to:
CenturyLink Claims '
615 N. CLASSEN
OKLAHOMA CITY, OIC 73106
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Contact your homeowner/business/auto lia.bility insurance for coverage.
To pay via check by phone, please call 8003214158
---------------------- Detail of Current Charges ---------------------
Labor Hours:
41.OU Overtime Hours
45.00 Regular Hours
34.00 Supervisor Group 1 xoura
Material Costs:
2.00 EA BOND, CABL£ 3M 1.34
1.00 EA CLOSURE3, XAGA 1650D4 140.96
24.00 EA PISCE OUT 22-24 GAIIGE 25 PAIR 133.68
OCONTINUED ON NEXT PAGE. . .
0 Return this portion with your payme�t - please write the invoice # on your check.
OACCOUNT NO: MN BF491153 INVOICE NO: A259479-
OINVOICS DATE: 04-01-2013 I 717080 11902195
0 NEW AMOi7NT PAYMENT
0 BAI,ANCE DUE DUE DATE AMOUNT ENCLOSED:
16,689.47 18,889.47 UPON RSCEIPT
0 '
0 RETURN PAYMBNT TO: I
0
0 CENTURYLINK ST PAUL WATER DEPARTMENT
0 P.O. BOX 2348 15 W KELLOQG BLVD
0 SEATTLE, WA 98111 2348 ST PAUL, MN 55110-0000
Q
0
0
92717080[�T/BF491153A2594790401201320000188894703USWC/
OQWEST CORPORATION DHA CENTURYLINR QC PAGB 2 OF 2
OACCOIINT NO: [�T BF491153 INVOICE NO: A259479-
OINVOICE DATE: 04-01-2013
0
Miscellaneous Costs:
ADMIDTISTRATIVE LABOR COST 150.00
DIRECT ADMINISTRATIVE COST , 1,705.60
CONTRACTOR/ RWMOM0904 1,389.21
CITY OF ST PAUL PERMIT 189.00
Special Tool Houra:
15.00 Hours TRAILER W/ENGINE
Vehicle Hours:
17.00 Houra LIGHT VEHICLE
6.00 Hours MEDIUM TRUCR W/$QIIIP
73.00 Houre MSDIUM TRIICR W/$QIIIP
17.00 Hours MSDIUM TRIICR �
----------------------------------------------------------------------
0 SUNIIKARY OF CURRBNT CHARGFS
� CHARGES
0
OENGR - SUPl3RVISOR GRP 1 $ 1,199.42
OLIGHT TRUCK 322.32
OMEDIUM TRUCR 478.72
OMEDIUM TRUCR WITH EQUIPMENT 5,216.37
OMISCELLANEOUS COSTS 3,433 .81
OMATERIAL 275.98
OLABOR - OVERTIME HOURS 3,953.56
OLABOR - REGUI�AR HOURS 2,892.84
OSPECIAL TOOLS - TRAILSR WITH ENGINE 1,116.45
0 TOTAL CORRENT CHARG�S $ 16,889.47
0 IF YOU HAVE ANY QUESTIONS, PLEASB CALL (800) 321-4158
0
0
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D:ire: �5-2K-20I0
C �l�`I'li+I�p M�IL,RETIIRN RF,CFiPT REf�i1_F_.,�TCD
.ro: c:n'v c�r� sr i�nu�_,
C'I'I'Y CI.ERK
310 C1`['Y NAt.I.
IS W.i4ELLE)t�C; [iLV7)
S'I'}'A U 1_,. (�9 N 5 5 I 1?2
CFRTiF(FD MAEL# 91 7108'1i33 i935 831 l �)7S1
RI:: i)an�a�e tn(;��t�est Prc�pe��ty
�west C:laim iVum: 491153
Dam;��e/Discove►y D��tc: Ui-26-2(i[l)
l.)auia�;c Locatinn: 1330 HALJCE A�'E W,ST PAUL,MN
Dama�;e County:
�7�magc Anaau��t: lJNDF;T�:R.MIN�,D
L}car 5ir!M�idam:
Please lic advised that Qwest facilities sustained dam�:;e as � r�su{t of the. negligent acts or
ornissi�»�s by employees i>r agents af(:l"l'Y t1F ST PAL1L.
lm�estigation has �•evealed that on or ahout CIS-26-201f1 employees or a�;ents of C["CY OF ST i'AUL,
C:1"I'Y (?P 5T PAUI� 1�UATGR DL1'`I' UAMnGF.,D A QVVF_.ST ]20{� PAiR UND�:RCrRO[1ND
CAE3l.E Vdl fH A UIRF:C"�'fONAI, E�ORE Dl.1RING WAT'LR i3XCAVA'1'lON in the area of I:i30
l IAUGE AV£ W,S'1'C'AUI.,, MN.
This lettee is the written pr�scntn�ent c�f Qwest`S CIi11111 E7UI'5U8.t1[f0 MIIlt1050�$S(1tUlC�I6O,OS ,
REQUI;S"�' FOR GOVERNMF..NTAL N(b'T1CC FORM
lP your �,overn+nent�l Entit�� rcquir�s the completion of its o�vn form to contplete proper r�oEice, please
for��'acd a ci>�>y ta thc address listed alx�ve. Every good faith efii�rt has heen made tci identity the prop�r office
�nd address tc� perfect our notice. Plcase ['onvard to your attorney, if misdirected, to contact us. Matters
herein stated are a)leged on inforrnaucm anc! belief this pfeader be[ieves tn be truc. If lhere is insurance to
cover this iliatter. kindly advise as to the name qf the insurarice comhany, its a.ddress�nd the claim nutnber
assi��ned. II'you have any questions,or need addi�ior�al information,please contact me at I-804-321-�4�'�������'�4,�
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Sinccrely, _ �Xp.1�RgftO
Destin�-Wilsnn �,�'•. '�`r�
... ' � l `' !`�n rt. �%.�j.-.. AC161.\G,�'��:
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f. � NOTARY ,,� `
C�9R Claitrls bEF'T Ct►mmission Fxpires __
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■ Com�ete Rems 1,2,and 3.Atso�mplete a SPgnsaure
It�m 4!f Resirkctec!D�ivery is desirad. • �Agerit
■ F'r�st.yciur name end address on ihe reverse ❑Addr�seo
so thst we can rehun the�to
■ Attach thfs card to the baok of them i{pleca, �e�tbY��� � ' ��°���ry
or on the frant'rf space permfts:
1. Article Addressed ta: �"� D. ts d�Jivery ' :�.i�ff�ri�t,' i? (7 Yes
�f !/i�� t�,r�s,�A�a�t��v a� ,,. ': � ❑No
" 481153 _ i � � �rt
CITY OF 57 PAUL � t3 ,
CiTY CLERK [ ,I€.#�Fr (,�i l�� �` j
31Q CITY HALL i �'''�� � � .I �
15 W.KELLQGG BLVD ` r�� �' ��'�
ST PAUL,�lIN 35i02 �' "'
3. se►vice Typ��4�, � �,;11� i
C]Certified M�H--_C��r�"ass Mall
O R�istored ❑Retutn Recelpt f�Merchandls�
O triswed M�il ❑C.�.D. ,
4. Restricted De��veN?(���) ❑Yes
2. arrrie�e hlumner .
(n�rrsterr�am•senr�oe�irae� ' 91' �7},0`8 �],3 3 3 9 3 5 tl�1�1' ' 9?51 �
PS Form 3811,Fetiru�ry 200d ' ooeimesqc Retum�ecetpi io2ss�o2-M•�s�w
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