Lemmer RECEIVED
SEP 13 2013
NOTICE OF CLAIM FORM to the City of Saint Paal,Minneso�I TY C L E F��
MinnGSOta State Staaue 466 OS atates d►at"...evcry peraon...who cTaims daniageaJrom miy municipaTity...aholl caus�e to be presented to the
Sm'��8�Y of tht manfctpality wtthin 180 daya aJter the alkgtd 7ass or i�f ury ts dracovered a nodce smting the ttnu.Place,and
ci►cnn�stances deeraof,and t1u amo�nt of compurawtroR or other nlitf demanded•,
Plea�e rnmplete 16ia form in iffi e�Y by ckarly typinC or P��C 7our answer to e�ch qaeation. If more spoce is
needed,attad�ndditionnl sheets. Plenqe note tl�at yon wil not be contacted by tekpho�to daliiy answers,so provide as
mac6 mformation as neoessary to expla�►yoar claim,and We anwunt of compe�sation being reqaeeted. Yoa vn71 r�eive a
wrttten acknowledgement once yonr iorm is recared. T6e prnceas can tate ap to tea wee�s or longer depending on tLe
nature of yonr daim. 17ds form maat be signed,and both pages completed. Ii somet6Pmg dces not aPP�Y�write`N/A'.
SEND COMPLETED FORM AND OTI�R DOCUMENTS T4: CITY CLERK,
15 WEST KELLOC'�G BLYD,310 CITY HALL,SAINT PAUL,MN 55102
First Name Middle Initial I�st Name
CompanyorBusinessName PRob�tSSIV1 NRt��C�ct� �ins tQ �����Q//�'�Lj�f �.LI{���
Are You an Insurance Company es No ff Yes,Claim Nwnber? �o�:�� �e
Street Address 2 Z q
c�ty s i� �A �PCoae�a05�"o9Z9
Daytime Phone(�)u�o-013' Ctll P'hone( } } fivemng Telephone(_� -
Date of Aocidend Injury or Date Discovered ZQ'� T� ��00 P�
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel�{{ity of Saint Paul or_jts�l�y�c�involved and/or responsible for your darnages.
-�k.l�(�(a n
Please check the box(es)that most closely represent the reason f�ccmapleting this form:
O My vehicle was damaged in an acc;,ident ❑My velricle was damaged during a tow
O My velricle was damaged by a pothok or condition of the street ❑My velricle was damaged by a plow
O My vehicle was wrongfully towed andlor ticketed � p I R'���tt�on�it.Y PmP�
�Other type of pmperty damage—please speafy // �K1�r�,�;.�T�- d��f K b�'
���of�;,�-�s� �I� cl�ury tahat
In order to prooess your claim von need to inclnde wuies of all auolicable docamenta
For the claims types listed below,please be sure to include the docwnents indicated or it will delay the handling of
your claim. Documents WII.I-NOT be returned and become tbe property of the City. You are encouraged to keep a
copy for yourself before submiriing your claim f�m.
O Pmperty damage claims to a vetricle:two estimates for the repaic's to your vehicie if the damage exceetis
$500.00;or the actual b�1ls and/ar receipts for the repairs
O Towing claims:legible copies of any ticket issued and a oopy of the impound lot receipt
O Other property damage claims:two repair estimates if the damage eaceeds$500.00;or the actual bills
andlor receipts for the repairs;detailed 1i.st of dannaged items
O Injury claims:�cal bills,receipts
O P'hotographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please oomplete a�d return both�of Claim Form
Failure to camplete and e�eturn both pages will result in clelay in the bandling of yonr clsim.
All Claims—�leaae wm�lexe tlris sedion
Were there wibnesses to the incident� ����mbers:No Unlmown (cincle
Provide the�r names,addresses and
�
Were the pc�lice or law enforcement called? Y No Unknown (circle)
If yes,what departrnent or agency? Case#or report#
Where did the accident or injury take plaoe? Provide street address,cross street,intersection,name of park or farility,
closest landmark,etc. Please be as detailed as p ble. ff ecessary,attach a diagram.
��eslrt�'�r�t�� 7Ylo�t�tYr�
Please indicate the ampunt you are seelring in compensation ar what you would like the Qity to do to resolve this claim
to your satisfaction. �'30 0 00.o 0
Vehicle CI ms—ul�se oom�lete th�s seclian �chack boa if this saction does not au�lv
Your Vehicle: Year Make Model
License Plate Nnmber State Color
Registered Owner
Driver of Velucle
Area Iramaged
City Velricle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area D�noaged
IJn iurv Clsi�ns �lease comvl�e this se�tion check box if this section does not a�lv
How were you injured?
What part(s)of your body were injured?
Have you sought me�lical treatment? Yes No Planning to Seek Treatment(circle}
vide date(s)}
When did you reveive treatment? �°
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury7 Yes No
When did you miss work? (provide dake(s))
Name of your Employa:
Address Telephone
❑Check h�e if you are attaching more Ps�Ses to this cla�m form. Number of sidditional pages
Bj,signing this forns,you are sl+arti�tg that all in�'or�+atioR you have provided is true mid conect t+v tlie best
of your kr�ow�edge. U�signed forms wil!r�ot be processe�d
Sub�g a false claim can result i�proseculio�. Dste form�s completed C(, ' � �Z,���
Print the Name of the Perea�who Completed this F rm: �` �'� _�"'° ������
Signature�Peison Maldng the Cla�m
Rev�sed Peb�ue�y 2011
Description of Loss:
Our named insured's 1996 Saturn SL2 was traveling on Kent Ave approaching the intersection
of Thomas Ave. As our insured entered the intersection, unable to see a stop sign as it was
being obstructed by a tree branch, our insured struck a 1996 Chevrolet Tahoe. We are seeking
reimbursement from the City of St Paul for payments made for the injuries of the driver of the
Chevrolet Tahoe.
���������A
Payment Address Document Address
24344 Network Place P.O. Box 512929
Chicago, IL 60673-1243 Los Angeles,Ca 90051
Phone:(877)818-0139
Fax:(888)781-6947
9/4/2013 3:26:00 PM
Certified Mail 91 7108 2133 3934 2468 4103 Retum Receipt Requested
CITY OF ST PAUL
CITY CLERK OFFICE
310 CITY HALL
15 WEST KELLOGG BLVD
ST PAUL,MN 55102
Your Client: CITY OF ST PAUL
Your Claim Number: N/A
Our Insured: LEMMER, NATHAN
Our Claim Number:1a4035840
Amount Subject to Reimbursement:30,000.00
Amount of Insured's Deductible: N/A
Please take this as formal notice of our subrogation rights relative to the above-captioned
claim. We have completed our investigation into the facts of the above-captioned loss and find
that your insured was the proximate cause of the accident.
Location of Loss: E ON THOMAS AVE AT KENT AVE in St Paul
Date and Time of Loss:09-01-10 @ 11:00 AM
Description of Loss: Our named insured's 1996 Saturn SL2 was traveling on Kent Ave
approaching the intersection of Thomas Ave. As our insured entered the intersection, unable to
see a stop sign as it was being obstructed by a tree branch, our insured strudc a 1996 Chevrolet
Tahoe.We are seeking reimbursement from the City of St Paul for payments made for the
injuries of the driver of the Chevrolet Tahoe.
Please make your draft payable to Progressive Preferred Insurance Co as subrogee of
"LEMMER, NATHAN", in the amount stated above and mail it to the attention of the
undersigned at your earliest oonvenience. All supporting documentation is endosed. I have
diaried my file ahead fifteen (15) days. Thank you for your anticipated, prompt attention to this
matter.
�
Richard Berlan
Subrogation Representative
Progressive Preferred Insurance Co
Tel. 877-818-0139 Ext 37571
Fax. 888-781-6947
Email: Richard_W_Berlan@progressive.com
(&h) &f - PASSPORT&b&D, &T August 26, 2013, 08 :42:17
CMSD2320 /CMSM2320 P A C M A N AvG 26 13 - 8 :42
OPID: A088515 CLAIM PAYMENT HISTORY TERMID: ?01I
INSD: LEMMER, NATHAN J POL: 21327693 -7
DOZ : SEP O1 10 MN-MN LIT-BRN-A CLM: 104035840 ACTIVE REP: T POTHEN
SEL DRAFT Z/COV PAY TO TYPE* AMOUNT DATE CD*CZR
320479052 PIP MED REGIONS HOSPITAL L 178.00 OCT 29 10 I Y
320450115 PIP MED ST PAUL FIRE AND SAFE L 1, 527.00 OCT 21 10 I Y
DC912701 LAST PAGE *
COMMAND: CLMPOLI
(&h) &f - PASSPORT&b&D, &T August 26, 2013, 08:42: 05
CMSD2320 /CMSM2320 P A C M A N AUG 26 13 - 8:41
OPID: A088515 CLAIM PAYMENT HISTORY TERMID: ?01I
INSD: LEMMER, NATHAN J POL: 21327693 -7
DOL : SEP O1 10 MN-MN LIT-BRN-A CLM: 104035840 ACTIVE REP: T POTHEN
SEL DRAFT LICOV PAY TO TYPE* AMOUNT DATE CD*CLR
478438539 RBI HAUER, FARGIONE, LOVE A 550.00 JUN 13 13 I Y
478440131 RBI DEMETRIUS LARKINS AND L 30, 000.00 JUN 10 13 I Y
47820d603 RBI JACKIE YOUNG********* A 203.00 MAY 21 13 I Y
477858655 RBI IAM CENTRAL MEDICAI� R A 46.58 APR 22 13 I Y
477858364 RBI RKO REPORTING, INC. * A 343. 50 APR 23 13 I Y
477391473 RBI HEALTH PARTNERS****** A 112.56 MAR 11 13 I Y
477174293 RBI NORTH MEMORIAL HEALTH A 77.73 FEB 13 13 I Y
477174178 RBI THE MINNEAPOLIS CZINI A 22.35 FEB 19 13 I Y
477050962 RBI REGIONS HOSPITAL **** A 73.56 FEB 07 13 I Y
477050958 RBI CM INFORMATION SPECIA A 22. 79 FEB 03 13 I Y
477Q50840 RBI HEALTHPORT*********** A 44.33 FEB 04 13 I Y
477050066 RBI NORTH MEMORIAL AMBULA A 24.86 FEB 07 13 I Y
320517310 PIP MED REGIONS HOSPITAL L 474.00 OCT 29 10 I Y
320479052 PIP MED REGIONS HOSPITAZ L 178.00 OCT 29 10 I Y
DC912665 FIRST PAGE *
COMMAND: CLMPOLI
08�2812013 14;4� FXx 8�12343d59 PRO�RESSIVE R�Q02lOOd
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aucceestns aad sesi�ae,and all o�'her pe�an�and ar�aniz�tiaa�alao are or u�i�pit be Iiabl�,�arm
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laeg; loss ar impsart� o�'esrro�og c�l��'Y; cx�'qainal rr�iit�iti�a�, in'�a`ag`�; aasi�
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pha�e�s of n1y ei.eams and that t �can nat�yi�g dt�x�s�rrtat�ona or s��z►�►te s�de�rY
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