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Hauschild Providing lnsurance and Finencia!Services �StateFarm� Home Offrce, 8loomington, !t August 13, 2013 RECEIVED State Farm Claims ciry c�er�c P.O. Box 2371 AUG 191013 310 City Hall Bloomington IL 61702-2371 15 Kellogg Blvd.,west CITY CLERK Saint Paul MN 55102 CERTIFIED MAIL - RETURN RECEIPT REQUESTED RE: Claim Number. 23-17F5-646 Our Insured: Taylor Hauschild Date of Loss: March 12, 2013 Your Insured: St. Paul Police Dept Your Insured Driver: John O Lacska Your Claim Number: Your Policy Number. Loss Location: Linwood Ave St Paul, MN To Whom It May Concern: We have been informed you are the liability carrier for the party involved in this loss with our insured. Our investigation indicates your insured is responsible for this claim. Therefore, we are seeking recovery from you. This letter is to notify you of our subrogation claim and request your cooperation in settling this matter. To assist you in your review, here is a breakdown of the amounts State Farm°paid by Cause of Loss: 041/045- Uninsured Motorist BI $ 042- Uninsured Motorist PD $ 300 series/400- Comp/Collision $2,734.29 501 - Rental/Loss of Use $ 600/050- Med Pay/ PIP $ Other $ Salvage Recovery $ Amount State Farm Paid $2,734.29 Insured Deductible $500.00 Total Claim Amount $3,234.29 Based on the assessment of liability befinreen the parties, State Farm Mutual Automobile Insurance Company is seeking 100% of the Total Claim Amount listed above. The amount payable to State Farm Mutual Automobile Insurance Company forthis loss is $3,234.29. Please remit payment of this claim, or contact us to discuss settlement. Include our claim number on the payment. Thank you for your cooperation. 23-17F5-646 Page 2 August 13, 2013 If you have any questions or need additional information, please call me at the number listed below. If I am not available, any other member of my team may assist you. In order to assist you in evaluating and processing the subrogation claim we are asserting, we may provide nonpublic personal information about our customer. We are sharing this information to effect, administer, or enforce a transaction authorized by the consumer. However, you are neither authorized nor permitted to: (1) use the customer information we provided for any purpose other than to evaluate and process the subrogation claim, or(2)disclose or share the customer information we provide for any purpose other than to evaluate and process the subrogation claim. Sincerely, y� n Y�� ��� Natalia Ryan Claim Representative (877)457-8276 Ext. 60 Fax: (866)231-9276 State Farm Mutual Automobile Insurance Company Enclosure(s) � � 3- 1 �7 �' s�- � . � � � NOTICE OF CLAIM FC)RM 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 6e presented to the governing body of the municipaliry wirhin I80 days after the ullr.ged loss or injury is discovered a noiice stnting the time,place,and circun�.stanr,es thereof,aul tke nneount of com��e+isation or other relief tlemanded." Please complete this form in its entirety by cleariy typing or printing your answer W each question. If more space is needed,attach additional sheets. Piease note that you may or may not be coatacted by telephone to discuss your claim circumstances,so provide as much information as necessary to explain your ciaim,and the amouut of compertsation being requested. This form must be signed,and both pages completed. Tf something does not apply,write�N/A'. SEND COMPI,ETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD,310 CITY HALL,SAINT PAUL,MN 55102 First Name � Middle Initial LaSt Name �a �L ���� �(�. Company or Business Name,if applicable IJ � Street Address�� ��1 i�1d��)�l� �-t'u�.C�� City`�, ��LL.� State /� � Zip Code,�,�!US Daytime Telephone(��)�0 `�U^�U [ 9 Evening Telephone(___i) Date of Accidend Injury or Date Discovered � '� �l "o�U I � Time �• U v �/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. , �n � r _ Please eck the box(es)that most ciosely represent the reason for completing this form: ehicle was damaged in an accic3ent �Vehicle was damaged during a tow ❑ Vehicle was damaged by a pothole or condition of the street O Vehicle was damaged by a plow Cl Vehicle was wrongfully towed and/or ticketed � Injured on City property ❑ Other type of.property damage—please specify_ � ❑ Other type of injury—please specify ❑ Other type not listed—please specify`_ In order to process your claim You need to inelude copies of all apalicable documents. This is a general guideline of what should be submitted with a claim form,but it is not all inctusive. You may be asked to provide additional information depending on your claim. O Property damage claims to a vehicle: at least 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 tickets issued and copies of the impound lot receipts O Other propeRy damage: repair estimates,detailed list of damaged items O Injury claims: medical bil.ls,receipts O Photographs can be provided but wil.l not be returned. Page 1 of 2—Please complete and return both pages of Claim Form Failure to provide a completed claim form will resutt in delays in prceessing. � � a3�, � r--s� �� Notice of Claim Form,City of Saint Paut,page two All Claims-please camalete this sectian Were there witnesses to the incident? Yes No Unknow (circle) Lf yes>please provide their names,addresses and telephone numbers: Were the police or law enforcement called? Yes No Unlaiown (circle If yes,what department or agency? � P Case#or report# I (� � 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 helpful,attach a diagram. cl�-_�___L►n �J tk)l� Q'Y�Q. Please indicate the amonnt you are seeking in com ensation from this claim or what you would like the City to do to resolve this claim to your satisfaction ���,�i 4• a q Vehicle Ciaims-please comp(ete this section ❑ check box if this section does nat appiv Your Vehicle: Year ��L`j Make !v e � Model � �-'q- License Plate Number 3 a 5 �� State Color b 1�, Registered Owner��,pG�l�,� 'U'� � ' Driver of Vehicle � Area Damaged -��-} '�' �_ City Vehicle: Year�_Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Iniury Claims-please complete this section c eck box if this section does not apply 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 C�'Check here if yau are attaching more pages to this claim form. Number of additional pages By signing this fornt,you nre stttti+tg ihat aU infornwtion you have provided is t�ue and correct to the best of your kaowtedge. Unsigned forms will not be processed. Submilling a false daim can resuU in prosecutio Print the Name of the Person who Completed this Form• � Signature of Person Making the Claim: �� � �� Date form was completed g ")3��� Revised Apri12007 r ' 23-17F5-6�46 Page 3 June 06, 2�13 AUTHORIZATION TO RELEASE INFQRMATION PURSUANT TO MINN. STAT. 72A.502 Claim Number: 23-17F5-646 Name: Taylvr Hauschild Date of E.oss: March 12, 2013 s—� Si nature: � 9 Date: � ' I� � ��� , , � :-�, � } . � � � �<� *"��.��`�, � ' a� ' :�. g� � ,. � ���� s;� •:> h�: > � � ��;` � , �� ' � ; Q;,�� �k� `� �s�^�"` , ; Z���� '� .. .. . � - ,� »...' "L•' i I �' �' � � ,��cw ��: �, r. � �,� �a`i� "-.,, e6 IEi�II �� t $ k" � � �.� ' � �'gr����:� , .. a�,. � �,�� �, a� � � �f � ` h', �'' Y ?4"� M � - N� n �� - _ _.._.,.,,� / i' .. � ' � t� _ � .� �. � . . . Y�" �,� -,., :.., �� . ;�,�r � vw a w . w �, : t�. � .. L. � - '�r ��' . . � t ���� a m .ar �� a + �� �.R "�.lk* . ' M-A �� s .-.._�':. ����... . . ���� _ �, _ � � � �� � ���:�,, � � �y � o�p. �� <..4 �'. � .�� � _ _. ... —., .f: �t � t i � '� ��. � � i':'v.- . . 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RBZ0006Z S��J'Jn State Farm Mutual Automobile Insurance Company � Auto Payments by COL Route To: Demetria King BASIC CLAIM INFORMATION Claim Number: 23-17F5-646 Date of Loss: 03-12-2013 Policy Number: 1305-128-23D Named Insured: HAUSCHILD,TAYLOR 400 -COLL C denotes consolidated payment E denotes EFT payment P previously converted payment from CAT/CMR Payment Payable Pay Rsn Number Issued Date Participant COL Cd Status Amount Auth ID Cd 105628287K E 04-24-2013 Named Insured(s) 400 1 Paid $2,734.29 ECSAPY Total: $2,734.29 Date: 08-13-2013 Page 1 FOR INTERNAL STATE FARM USE ONLY Contains CONFIDENTIAL information whicFi may not be disc�osed without express written authorization.