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Fladwood 1 RECEIVED INJURY LAW . JUN032013 CITY CLERK �� � � �-�" ., � May 30, 2013 Via Facsimile (651)266-8886 and U.S. Mail Sandra Bodensteiner City of St. Paul 15 West Kellogg Blvd � 310 City Hall Sta Paul, MN 55102 Re.: My Client: Delmer Fladwood Date of Loss: O1/04/2013 Dear Ms. Bodensteiner: j ; Please be advised that our firm has been retained to represent Delmer Fladwood for injuries he sustained when he was struck by a falling tree that was being taken down by the City of St. Paul on O1/04/2013. I am enclosing the completed Notice of Claim form. Please cease all communication with my client. If any information is needed you may go through my office instead. Please forward to my attention all future correspondence. In addition, please provide for me the following items: 1. color photographs you may have 2. any discoverable statements taken by you or your representatives I appreciate your anticipated cooperation. If you have any questions, please contact me. Very truly yours, TSR Injury Law I i— Erik D. Willer EDW:ecd Direct Dial: 952-832-3592 erik e,TSRInjur,yLaw.com Enclosure Terry,Slane&Ruohonen,PLLC � 7760 France Avenue South Suite 820 Bloomington, MN 55435 � �952.832.5800 f952.835.8900 TSRINJURYLAW.COM 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 gaverning body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place.and circunutances thereof,and the amount of corry�ensation 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 Tlus form must be signed,and both pages completed. If sometlung does not apply,write`N/A'. SEND COMPLETED FORM AND OT�IER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name 0 e l me� Middle Initial ' Last Name �/GIGI W��l Company or Business Name I V� Are You an Insurance Company? Yes/� If Yes,Claim Number? Street Address U �� 1�►M�U �� # � City �� . P�,(� State M I V Zip Code� Daytime Phone(.�)D�-��Z Cell Phone(_) - Evening Telephone(_� - Date of Accidend Injury or Date Discovered �'�W�J Time 2-�� am/� Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate hy or how you feel th Cit�of Saint P�u]or its employees are involved and/or responsible for your damages. � — �,,,� � c x Please check the box(es)that most closely represent th�reason for completing this form: ❑ My vehicle was damaged in an accident O 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-pleas�s�ec�fy n . �Other type of injury-please specify � � '�-�"'t tcr+�.�- rrz.cTMi�.����1 In order to process your claim ou ne to include co ies of all a licable documents. For the claims types listed below,please be sure to in lude the documents indicated or it will delay the handling of your claim. Documents WII.L NOT be returned and come the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. i 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 Clauns—ulease complete this section Were there witnesses to the incident? es No Unknown (�ircle) Provide their names,addresses and telephone numbers: � ���K� Were the police or law enforcement call �n � No Unknown (circle) If yes, what department or agency? �J�.LJ Case#or report# Where did the accident or injury take place? Provide street address,cross street,intersection,nam of park or facility, clo st 1 dm k,etc. Please be as detailed as possible. If necessary,attach a diagram. C"��� r��I)�� vi .� � � 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. �.;r�,�,��,� . � �� b; �� ��.��� Vehicle Claims—nlease complete this sectaon ❑check box if this section does not annlv 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 In'ur Ctaims— lease com le e this s tion ❑check box if this section does not a 1 How were you injured��' What part(s)of your body were injured? Have you sought medical treatment? e No lanning to Seek Treatment(circle) ! When did you receive treatment? (provide date(s)) '� Name of Medical Provider(s): j � Address Telephone Did you miss work as a result of your injury? es 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 i By signing this fornz,you are stating that all in�rmation you have provided is true and correct to the best of your knowledge. Unsigned forms will not be rocessed. Submitting a false claim can result in prosecution. Date form was completed Print the Name of the Person who Completed this Form: Signature of Person Making the Clai • � Revised February 2011