Barrett (4) RECEIVED
SEP 04 2013
NOTICE OF�LT�I to the City o�S�ain'�`P`a�hl, Minnesota
Minnesota State Staiute 466.05 states that "...even�person...who claims damages from am�municipalin•...shal/cause to Ge presented to the
goven:ing bodp of the municrpalin�within 180 days cr�ter the alleged loss a•rnjun�is discovered a notice stating the time,place.and
circumstunces thereof,crnd die umounr 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 esplain your claim,and the amount of compensation being requested. You will receive a
written acirnowledgement 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 DUCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name SCO( � Middle Initial�Last Name Q��. �.-�
Company or Business Name
Are You an Insurance Company? Yes,� If Yes,Claim Number?
� Street Address 6 Y 8� ��}E PrS f�-1�1T �-(L.LS �Q I � E.
City / I ?� +� �-A��S State 1h 1�J Zip Code 5S�3c�
Daytime Phone(��-8s9yCe11 Phone - Evenin�Telephone( -
Date of Accident/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 andlor responsible for your damages.
�- O T" T7"
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 dama�ed by a pothole or condition Of the street ❑ My vehicle was damaged by a plow
� My vehicle was wron=fully towed and/or ticketed j ❑ I was injured on City propeny
0 Other type of property damage-please specify �
❑ Other type of injury-please specify C��E w �.�5 1 - S o IZE Lo w�� Q��G
In order to process your claim vou need to include copies of all applicable documents.
For the claims types listed below,piease be sure to include the documents indicated or it will delay the handling of
your claim. Documents WII.L NOT be returned and become the property of the City. Yon are encouraged to keep a
copy for yourself before submitting your claim form. ,
O Property dama�e 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 damaQe 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 alwavs welcome to document and support,your claim but will not be returned.
Page 1 of 2-Please complete and return both pages Of Claim FOt'tll
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease comnlete this section
Were there wimesses to the incident? Yes No nknow (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? � No Unknown (circle)
If yes,what department or aaency? S�F �E P���T Case#or report#.� �yo 0 9�S
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 dia�ram.
S E�-- �PO�t C� �.�f'fl F�-r
Please indicate the amount you are seeking in compensation or what you woul like the City to do to resolve this claim '
to your satisfaction. NT L M NTS 1 �u�� �5 �N �N �
DFavc��6�� .�Soo. o o -t— . l
Vehicle Claims ulease comulete this section D check box if this section does not annlv
Your Vehicle: Year Make Model
License Plate Number State Color
Re�istered Owner
Driver of Vehicle f.-
—�-r--r— � � � c i ��. �
Area Damaged �-� +-� �--_- � —_
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Dama�ed
In'urv Clai s— lease com lete this section ❑ check box if this section does not a ]v
H���were vou iniured� � I C A�rL �.�f'��— �N fl�!.� M ( +t.l �
What part(s)of your body were injured? L_O W� '� (�AC� �' �1 fo �-4-T W�-� ��
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? Z„ L [ � (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? es No
When di�you miss worl.� 2—2 ' I� � Z " —l�, 2 'S—�3 , Z —b �!3(provide date(s))
Name of yaur Employer:
Address Telephone
Check here if you are attaching more pages to this claim form. Number of additional pages�.
By signing this forna,you are stating that all inforination 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 7 �Z "r ��
Print the Name of the Person who Completed this Form: 5 C° � � �����'�
Signature of Person Making the Claim: ���` �3
Revised February Z011
To: City of St. Paut City Clerk
15 West Kellogg Blvd
310 City Hall
Saint Paui, MN 55102
From: Scott Barrett
6487 Pheasant Hills Drive
Lino Lakes, MN 55038
651-307-8594
City Clerk,
It has been 7 months since the accident and this is the first correspondence I have received from The
City of St. Paul. My claims representative has been trying to get the proper documentation to process
the claim with no results until now. I have been waiting to seek further medical assessment and
treatment because I did not want to spend more money out of pocket until I was sure my medical bills
would be covered.Since it has taken 7 months just to get a response from your office my confidence
was not high on being re-reimbursed for my medical bills.
My lower back has been sore since the accident and my right wrist has acute soreness a few times a day.
1 will now have my doctor access the injuries and will be in contact through my insurance agent and/or
lawyer.
Prompt processing of my rental reimbursement would be appreciated.
Scott Barrett
651-307-8594
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Case#: 13400905
Report Date: 2/6/2013
Accident Narrative,continued:
REAR END DAMAGE.
OCCUPANTS OF VEHICLE 2 WERE TAKEN TO REGIONS HOSPITAL FOR POSSIBLE INJURIES. NO OTHER
INJURIES REPORTED. CLEAR/DRY ROADS. NO WITNESSES ON SCENE.
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NONE ROBB J RAMACHER 390
� nterpris� Rental Agreement D556705 - 1908
DUPLICATE
2740 MAIN ST NW STE 102 escription Rate Amount
COON RAPIDS MN 55d48-t273
17 DAYS @ 37.99 645.83
h1NREGrEE 3�•29
hiNRENTL 40.04
SALES -AX`r: 7. 12 46.02
Biii To:
- WOpO1S�00W2l��2 1�190899MJ19
SCOTT BARRETT
6487 PHEASANT HILLS DRIVE
LINO LAKES MN 55038
�- .
Date Qtut Oate In _ _
2/05/13 2i21!13
Renter
SCOTT BARRcTT
OTAL CHARGES 764. 18
AdditionalDriver ESS AMOUNT RECEIVED 76G• �g
Name
NONE �
AMOUNTDUE- - • • • - • - • • • • • - '�
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Color License Na. Claim �`/Poliay #/P.O. # gi����g Inquiries Call Fed Tax ID # �
SILVER 792JC1' 133604804 763-323-1134 26-4548555 ��■
Model Unit � Insured
12 B15C�. iGDMK5 BARRETT SCOTT
Date of Loss Type of Loss
2i01/ 13 IMSURED
Type of Car Repair Shop , .
CHEVROL�T H"cRIT�GE AUT
DUPLICATE COPY
PLEASE DISREGARD IF
ALREADY PAID
� i ■ ■ ■ ■ ■ ■ i ■ ■ • ■ ■ ■ ■ ■ ■ ■ ■ ! ■ • ■ ■ ■ ■ ■ ■ E
Please Return This Portion with Remittance AMOUNT DUE• • • - � � � � � ' ' ' - ' , .00
Remit ta: Paid by:
ENTERPRISE LEASING COMPANY SCOTT BARRETT
ATTN: ACCTS RECEIVABLE 6487 PHEASANT HILLS DRIVE
2775 BLUE WATERS RD�N 55121-1439 LINO LAKES MN 55Q38
EAGAPI
999999 er# D5567059reement /amounoto c'�g08
02/25
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