Anderson, Kristin .A�IVCU
APR 15 2013
C:d�'Y CLERK
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
A4inn��.cuin 5'i�����Slc�n��e 4hh.0_S.c�ulr.,•�/ral "...c�rc��_v/�ersun...who clui�ns dcu��nge.c/'rom cuiy n�unic�ipnlitv....rl�all cuuse to he presei�tec!io the
�nrernin,�bnrh'u/ilu�muniri��alile�ci1/iin 1 RO dnys r�(ler dte n11e,S�ed loss or inju�l�is cli,sco��ered a nolice sln�ing flre Iin�e,plerce,and
circ�w��stcir7c�es d�ereof,aac/die amounl u(co�npen.rctlinn or other r-elieFclemanded...
Plc�se 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'.
SENll COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLFRK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �'�'`I S `�I� Middle Initial Q Last Name � �7 �e1" S �' In
Company or Business Name
nre You an Insurance Company`? Yes/� If Yes,Claim Number?
Street Acldress a7 � r� 8 t,�1la e e1 er �� N
City��D S �V�'�� � State /�/� Zip Code 5 5 � � �
Daytime Phorie(�)� 9��jQell Phone ( ) - Evening Telephone(�)�-��
1�ate of Acrident/Injury or Date Discovered�Z�,?T/a Time / �00 m pm
Please state, in detail, what occurred(happened),and why you are submitting a claim.Please indicate why or how you
fcel the City of Saint Paul or its employees are involved and/or responsible for your damages. �� �A l,c�t?�l�2 �����l
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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 vchicle was wron�fully towed and/or ticketed ❑ I was injured on City��y u5� ���/'Jr��tC�
❑ Othc;r ty�c�of property damage—please specify aa t�9< W I o�c� �
t�`Other type of injury—please specify t� ita e c?�_3�� k���oa �T_ ` ��'t�`°`^C�'P �`1
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In order to process your claim ���u need to include copies of all applicable documents.
h�or 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 returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Propc;rty 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
�lnjury claims: medical bills, receipts
�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 complete this section
Were there witnesses to the incident? es No nknown' (circle)
Provide their names, addresses and telephone numbers: P o a s n ' A�,'. `' //-� �/ �1�d�
�1 n ��� I�u y� V i 5 C��"% - ! u 1n �0�3�l ��"�- ,/���s�� a t/�:� �'It w u he�`t r�rhJe l�ti`f
Were the police or law enfiorcement called? Yes No Unknown (circle) `�51��3'� ��'�'�0°
If'yes, what department or agency? Case#or report#
Where�lid 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. /�ll��,y�C� ��h��' ��In�
�/l� C e�r 1�e ti^ n� � �
� ��- Gi ��t o�viG� �P�� r Sf' �
Plcase indicate the arnount you are seeking in compensation or what you would like the City t do to resolve this claim
to your tiatisf�action. ta9 Lf � ' ' ` ° �-2 � � ^ l'Y'P
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cz.�t�-vr� ..¢�`Fu�e �-he���� ��5° c�� -� G,ave �a ����re�s� ����` �x� l o ►v��� , ar-o-1'�ie�btilc?cQ�C��,
Vehicle Claims—ulease complete t�is section �c hec k box i f t his sec tio do e s n o t apn lv
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
Iniw v Claims please complete this section ❑ check box if this section does not applv
How were you injured? � ` �� ���
tC S D �
What part(s)of your body were injured?
Have you sought medica]treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? / ' (provide date(s))
Namc of Medical Provider(s): � I�I�u s i c �`� il,c�a� , � o j fn s r ti r�,'o��"�llf�,
nddre1ti � t --�Telephone ' �G�_�) 7I.a5�—�l 9D0
Did you miss work as a result of our injury? �'es ��� �
Wh�n did you miss work? (provide date(s))
Name of your Employe�° �-��l-►v��nl
ncldress Telephone
0 Check here if you are attaching more pages to this claim form. Number of additional pages
By signing tltis form,you are stating that all information you have provided is true and correct to the best
��f 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 Ferson who Completed this Form: r i S�'i v� �� � �t C� eti" S�V�
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Signature of Person Making the Claim:� �-��'1''✓ � ��"� C'�.C���d..�� —
Rcvisal�cbruary 201 I
Transaction Totals by Date Report Page 1 of 1
Report Settings .
Account: ANDERSON,KRISTIN D[1187459] ���''$�����t"�'
�'i`ii,t9E'.ft1 HC�:Oi1ililfiCj
Patient: ANDERSON,KRISTIN D[30323974] ��,;k,�;y, 41-����i���
Submission lnformation �17�)3J��d;',u�nua:;�utl�
User: [2272] ���=•. c �� ;:,�� :_,.•:uC��
Time: Mon Apr 8,2013 1:52 PM
;� Transactlon Information
Service Date From Service Date To Total Amount
� Charges � 01/15/2013 01/1512013 402.00
Tx# Procedure Sdrvice Provider Date Amount
593 99213-OFFICE VISIT EST.LEVEL3(99213)15MIN R�inschmidt,Jamie Lyn[... 01/15l2013 186.00
(Match Pmt)596 PAY101-PMT-INSURANCE I 01f24/2013 0.00
(Match Pmq 604 PAY101-PMT-INSURANCE 02/05/2013 0.00
(Match Fmt)609 PAY120-PMT-ONLifVE PAYMENT u^3Y24/2013 i 1.55
(Match Adj)597 ADJ110.CONTRACTUAL ALLOWANCE 01/24/2013 114.45
594 73562-RADEX KNE 3 VIEWS Xr,Rv[35394] 01/15/2013 108.00
(Match Pmt)599 PAY101-PMT-INSURANCE 02l04/2013 0.00
(Match Adj)600 AOJ110-CONTRACTUAL ALLOWANCE 02/04l2013 69.47
595 73562-RADEX KNE 3 V1EWS Xr,Rv[35394� Q1l15/2013 108.00
(Match Pmt)599 PAY101-PMT-INSURANCE 02/04/2013 1.29
(Match Adj)601 ADJ110-CONTRACTUAL ALLOWANCE 02/04/2013 69.47
Payments Matched to charges 72.84
Adjustments Matched to charges 253.39
Note:This report contains only those payments and adjustments which are matched to the charges listed in the Charges section.
Professional Billing 4/8/2013 1:52:20 PM
DEPARTMENT OF PARKS AND RECREATION
SENIOR CITIZEN PROGRAMMING
CITY OF SAINT PAUL 400 City Hall Anncx
25 West 4°'Street Telephone: 651-266-6400
Mayor Christopher B.Coleman Facsimile: 651-292-7311
Saint Paul,Minnesota 55102
www.stpaul.gov/parks
i
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Gy�:�pn,enca
January 11, 2013
Kristen D Anderson
2008 Wheeler St. N.
Roseville, MN 55113
Dear Kristin,
I am sorry to hear that you are still having difficulty with your knee. Enclosed with this letter is
a notice of claim form and the accident report form that I filed with our Department's safety and
security section. �j,. � � 3 — �'6��, S
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The person who is in charge of the Alliance Bank building is Shawn Wiski. She can be reached
at 651-221-0999. The mailing address is SNSC, 55 E. 5`h Street, St. Paul, MN 55101. I don't
know what sort of forms they may have.
Sincere�,
�i
Mary E. Li ngston, ogram Coordinator
Recreation for Adults 50+
651-266-6447
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