Century Link (3) `1 I;M CMR CLAIMS DEPARTMENT
� � P.O. BOX 60770
I � OKLAHOMA CITY, OK 73146-0770
�/�` 1-866-887-4066
CenturyLinkTM
**�**NOTICE OF CLAIM**'�X*
Date: 06-10-2013 R E C E I VE D
CERTIFIED MAIL, RETURN RECEIPT REQUESTED �UN 141013
To: CITY OF ST PAUL
ciTV cLERK CITY CLERK
310 C[TY HALL
15 W. KELLOGG BLVD
ST PAUL, MN 55102
CERTIFIED MAIL# 9171 9690 0935 0036 8561 59
RE� Damage to Centuru Li�k Pr�►perty
C�ntary Link Claim Num: 545561
Damage/Discovery Date: 06-07-2013
Damage Location: LEXINGTON PKWY&JAMES AVE,ST. PAUL,MN
Damage County: RAMSEY
Damage Amount: UNDETERMINED
Dear Sir/Madam:
Please be advised that Ceutury Link Facilities sustained damage as a result of the negligent acts or
omissions by employees or agents of CITY OF ST PAUL .
Investigation has revealed that on or about 06-07-2013 employees or agents of CITY OF ST PAUL,
CITY OF ST. PAUL DAMAGED A 1200 PAIR BURIED CENTURY LINK CABLE DUR[NG
POWER EXCAVATION in the area of LF,XINGTON PKWY&JAMES AVE,ST.PAUL,MN.
This letter is the written presentment of Century Link's claim pursuant to Minnesota Statute 466.05 .
REQIIEST FOR GOVERNIVIENTAL 1�10TICE FORM
!f your Governmental Entity requires the cort�pletion of its own form to complete proper notice, please
forward a copy to the address listed above. Every good faith effort has been made to identify the proper
office and address to perfect our notice. Please forward to your attorney, if misdirected, to contact us.
Matters herein stated are alleged on information and belief this pleader believes to be true. If there is
insurance to cover this matter,kindly advise as to the name of the insurance company, its address and the
claim number assigned. If you have any questions, or need additional information, please contact me at
1-800-321-4158 ext 8232. \\\\\\\���,����c�,,,,�����/
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Sincerely, - �t t)E'Q�1no3 •�; –
Holly Finley = ; EXP. 11�`2h/74 ' _
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P�IOTARY —
CMR Claims DEPT Commission Expires_
C�(.�t'��� �-��r
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 municipaliry...shall cause to be presented to the
governing body of the municipaliry within 180 days after 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 may or may not be contacted by telephone to discuss your claim
circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being
requested. 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, if applicable �J����1 �.In.�� �/` r v� �Q.�.C1n S I �tt
Street Address �2-�0 W SI [.�Vl�-1'1
City b��� State �� Zip Code � �U 2
Daytime Telephone (g� ��' � � s g Evening Telephone ( )
Date of Accident/Injury or Date Discovered ���� (3 Time U I(1 l� am/pm (circle)
Please state, in detail, what occurred, 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.
Sa-�v� o S � I d ma�t IZ(�� rYa � r �11 v�*d
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Please check the box(es) that most closely represent the reason for completing this form:
❑ Vehicle was damaged in an accident � ❑ Vehicle was damaged during a tow
❑ Vehicle was damaged by a pothole or condition bf the street ❑ Vehicle was damaged by a plow
❑ Vehicle was wrongfully towed and/or ticketed C� Injured on City property
�Other type of property damage—please specify COl-��e dGUYtU-�P�
❑ Other type of injury—please specify
❑ Other type not listed—please specify
In order to process your claim ou need to includ co ies of all a licable documents. This is a general
guideline of what should be submitted with a clai form,but it is not all inclusive. You may be asked to
provide additional information depending on your laim.
O Property damage claims to a vehicle: at�east two estimates for the repairs to your vehicle, or the
actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ti�ets issued and copies of the impound lot receipts
�.Other property damage: repair estimates detailed list of damaged items
O Injury claims: medical bills, receipts
O Photographs can be provided but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to provide a completed claim form will result in delays in processing.
Notice of Claim Form, City of Saint Paul,page two
All Claims—please complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
If yes,please provide their names, addresses and telephone numbers.
Were the police or law enforcement called? Yes No Unknown (circle)
If yes, what department or agency? Case#or ort#
Where did the accident or injury take place? Provide street address,cross street, intersection, name of park
or facilit�, closest landmark, etc. Please be as detailed as�pov ible. If helpful, attach a diagram.
Please indicate the amount you are seeking in compensation from this claim or what you would like the City
to do to resolve this claim to your satisfaction. l�Yl ���-r(��
Vehicle Claims—please comqlete this section check box if this section does not apply
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 flYcheck box if this section does not apnlv
How were you injured?
What part(s) of your body were injured?
I
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 sigrting this form,you are stating that all information you have provided u true and correct to the best of your knowledge. Unsigned
forms will not be processed. Submitting a false claim can result in prosecution. ��
Print the Name of the Person who Completed this Form:
Signature of Person Making the Claim:
Date form was completed ����n« _ xe��sea,aPril2oo�