Absey Providing Jnsurance and Financial Servrces �,SfateFarm�
Home Offtce, Sloomington, 1L
September 26, 2013 SEP 3 0 2013
CITY CLERK
City Of St. Paul State Farm Claims
15 West Kellogg Blvd P.O.Box 52273
310 City Hall Phoenix AZ 85072-2273
St. Paul MN 55102
RE: Claim Number. 23-24L7-070
Date of Loss: September 16, 2013
Our Insured: David Absey
Policy Number: 0584845236
To Whom It May Concern:
We are submitting the Notice of Claim Form regarding the auto accident which occurred on
September 16, 2013. Our supporting documertation will be forthcoming.
You can enjoy the benefits of online registration. Benefits include chedcing the status of your
claim online and staying connected to State Farm°. Just go to statefarm.com°and select
Check the Status af a Claim to get registered. All you need to complete the process is your
State Farm claim number, your emai address, and about five minutes. If you are already
registered, thank you!
Sincerely,
�� '��
h
�iann Ile
Claim Processor Team 3
1-(866)207-6046
Fax: (800)423-0474
State Farm Mutual Automobile Insurance Company
Enclosure(s): Notice of Claim Form
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 municipality...shall cause to be presented to the
governing body of the municipality 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 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'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN��I�EIV��
First Name Middle Initial Last Name �P 3 Q ��13
Company or Business Name ��'Ol.�'� FG�rYY1 .!.1'15U.Y"(,�,V\G°t� r�TY�LER�
Are You an Insurance Company Ye No If Yes, Claim Number? a,� - a�L '� ' �'� �
Street Address �• � • a�x � �� �
City ��D�-Y�:1 X State �� Zip Code ��d'��" ���
�
Daytime Phorie (���)�1-�D�¢Cell Phone ( ) - Evening Telephone ( ) -
Date of Accident/Injury or Date Discovered �` �� ` l 3 Time 3%�� am pm 1
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 and/or responsible for your damages.
rvc � uc i e; Q � � �rr+ n� � � aD� G r
�,�,t � l rU�.1� h i V P, i i
Please check the box(es) that most closely represent tYie 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 vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim you need to include copies of all applicable documents.
For 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 Property 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; ar the actual bills
and/or receipts for the repairs; detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pa es of Claim Form ��
�o�u�e,�'�c�.-��o�, -�o b� su.b w�.► �te� �y s�b ro�a�'� d �, l���
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? Yes No Unl (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Ye No Unknown (circle)
If yes, what department or agency? s�. ��C.Lt.�,� Case#or report# �3 '�bOCP J��
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 d tail d s possible. If necess , attach a diagram.
�a�.�f 'I�r r i�'D�'i lL� � . ��� �GI.U� �N
Please indicate the amount you are seekin 'n om nsation o what you would like t�e City to do to resolve this claim
to yo r satisfaction. \ �o r QY W�, ' r q,i 1- '(.IJS 4- r �
1 V` �� ' �'--U - DGk� S ��
Vehicle Claims-please complete this section ❑ check box if this section does not apply
Your Vehicle: Year �,DO'"1 Make /�1,tYZ� Model Ti-.
License Plate Number i�t�l) - lp�/�� State Ml�f Colar
Registered Owner �(xv i d. f�b 5e�
� Driver of Vehicle
Area Damaged �r� cl.DO r � �r�
City Vehicle: Year Make Model }
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injury Claims-please complete this section �check 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): j
Address � Telephone
Did you miss wark 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 pa�es to this claim form. Number of additional pages
By signing this form,you are stating that all information 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��3
Print the Name of the Person who Completed this Form: �I GL►`�Yl �1 ���, . c�,���' � �`(Z�GN.550 r
Signature of Person Making the Claim: ✓ "'-'�-�-'�1 �.�XX-Y
Revised February 201 I