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Nicholls � �� f _ 1 F�,_: ;�, ;� ��:�. OCT 02 2013 . �� C�C C� OF CLAIM rORM to the City�o�f Sa��,�'�}�1, Minnesota Minnesotu State Statu�46�.rtntes tlrn� "...everv pers�nt...wlrn clnrms dn��ruges./'ron�nriv m��nicipnli_ry...sh�!!l ccruse to be��re.sented to tlre go��erning borfy of the mu�ricipnlity x�ithiii I80 derys after dre ulle��ed loss nr injury is dis�•overed u notice stntin,S�[he�nr�e,pince,a�rd circrrmstunces tlierenf,n�td d�e amnunt o(compensatirnt or ather relief denrancled." 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 tl�at you will not be contacted by telephone to clarify answers,so provide�s much information as necessary to explain your claim,and the amount of compensation being rec�uested. You will receive a written acknowledgement once your form is received. The process can take up to ten weeks or lonfier depending on the nature oC your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUM�NTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name��A� � "/ Middle Initial�Last Name �' IG f�.l I ` 5 Company or Business Name Are You an Insurance Company? Yes/ 1c lf Yes, Claim Number? Street Address � � S L i' �"Z � ` � ' ��' � s�.� � � , City ��'" ' ��^''( State M,1�� Zip Code Daytime Phone (�S�) �� 31Ce11 Phone ( ) - Evening 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 Cit of Saint��ul r i`ts�em lo �ee,,�s,�a,��e i volv d and�/,�r�r�s onsib e fo� (�ur dama es. �c� •��'-�-A��nrc ,.` �o,��!�' ��'� /"►�'J�SO ��"y`t`t-I`_` b �,�, � �.�,' G!-r t O S � �� Y �ox;.A(V� - 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 dam�iged 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 vou 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; or 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 supPoR 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? Yes No nknown (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called'? Yes 10� Unknown (circle) If yes, what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street, intersection, name of p�rk or t�icility, closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. L?.e �' f L�',,;�- Please indicate the amount you are seel:ing in com nsation or what you would like the City o do to resolve this claim to your satisfaction.�;Lt; � (% e ��(,��;' ____�� /`p � e��,, v,r S P�rY��-^� , Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year �� Make Model �j� � C%�� License Plate Numb�S_ � � State��Color <; (U��' Registered Owner_1 r�� L�-�--•o � l 5 � Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged IqjurV Claims— please complete this section ❑ check box if this seclion dae5 not applv How were you in�ured? What part(s)of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment (circle) When did you receive treahnent? (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 ❑ Check here if you are attaching mo►•e pages to this daim form. Number of additional pa�;es By signing tliis form,you are stating tliat ull informatio�a yori have provided is true and correct to tlze best of your knowledge. Unsigned forms will ieot be processed. Submitting a false claim can result in prosecutioft. Date f'orm was completed � ��/�'/ � � , � Print the Name of the Person who Completed this Form: �j C�_�� t � ' Signature of Person Making the Claim: � Kevised February 201 I �'�� I � �� Keep these cards handy--in your glove compartment or wallet.And contact us anytime you have a question or need to report a claim. If you have a claim,we'll get you back on the road as soon as possible.And while you'll always have a choice where to repair your vehicle,when you use a shop in our preapproved network,we'll guarantee your repair for as long as you own or lease your vehicle. Thank you for choosing Progressive. ::7's""- +;... .. ——————————— r—.—___.———————————————————————————————————— I INSURANCE IDENTIFICATION CARD-Minnesote � I �' � i Bradley R Nicholls ;: a�r�r n�„�:9oo6e��ea NAIC Pium6cr.16322 � ' -SIIVE?f M0R1bef5I11 = Effective Date:OS/26/2013 E�iratian Date:11/26Q013 � ,:. _-P ; I�arer.Pragrasi+e Direct Insurance Ca 1-800•776-4737 � � _; Vdllled Ct1StOR1Ef 51�Ce2O�Z -' „' POBoz31260Tamp3 FL33631 � � ` , . Plarned In�red(s): � � : :, , . Bradley R Ncholks � � , 98 Mr ad�l I ,,...„ ' � 9� Oldsmo6de Autora G3GR62C3W41o1405 ,: ` ': , � I , �' : � � I t ��F� r I �,�? �.e.e;�.��'' � .za'F* 4a -r: � Y .. , ..5 � ,�e 4.;, ,, .,_ ; . ... I ,. � .: .�.. ..'. . I I .��- ` , . ... �.�: �... . .:: - � ::: . � .. .. . ��. . ... . .w:.<� .:: �: � � � FarmA022(031it) � I � � IF YOl1flE IN AN ACCIDEPIT � � 1. Remain at the scene.Don't admi[faut[ � � 2. Fnd a safe bation,call the police,and exchange driver infortnation. � � 3. Call Pmgmssi,re rightawaY� I I � TO REPORT A CIAIM : � I Call 1-800-274-4499 or go ta claims.pmgressire.mm. � Mana9e yQU r p�icy any,f i me � � Use your own repair shop,or chaose one in our network. Or,le[ � us manage the pmces start-m-fin'ah a[our5ervke Cen4er in Wlth'NS�a{�W L�1t�5 at � � Bumsville,MN. F1�O9fe551Ve.COIi1 � I � I � I � � !�',��`td�,�.�Ar�f",�=.........i: I I _.. ...; I , f�EP THIS CARD IN Y�UR VEHICLE WHILE IN OPERATION. ' �� ___________________ J L_________________________________ f rax 5erver y/L4/'LUl� 11 : �� : Lb AM rA�� iuu� rax �erver Progressive PROGRE.Il/UEn PO Box 31260 D/RECT Tampa,FL 33631 Company Code:16322 Policy Number: 900691188 Underwritten by: Progressive Direct Insurance Co Policyhd der: Bradley R Nicholls Page 1 of 1 September 24,2013 Customer Service 1-500-776-4737 24 hours a day,7 days a week Verification of Insurance for Bradley R Nicholls Please accept this letter as verification of insurance for the driver and vehicle listed below. Policy and driver ininrmation . ............ ................ ......... ..................... ............... Policy number: 900E91188 ................................ ............................................................ ................................................... Policy state: Minnesota ........................................ ................................................................................................... Policy period: May 26,2013-Nov 26,2013 ..................................................................................................................................................... Effedive date: May 26,2013 ............................................... ......................... y...................... .................. ...................... ... Driver. Bradle R Nicholls Named insured ............................................................................... Address: 375 Lexington Pathway North 201 St Pa�il, MN 55104 Vehicle information _ __ __ __ _ _ _ .. . . . _ _...... .. . ... ._. ... ._ _. .... _... . .. _.... . . Vehicle� 1998 Oldsmobile Aurora ..................................................................................................................................................... Vehicle identification number: 1G3GR62C3W4101405 Coverage information ....................... ..... ...... ................... ........................................................................... ............ ... Bodily Injury Liability: $50,000 each person/$100,000 each accident Property Damage Liability: $50,000 each accident ............................................................................................................... ............................. Collision: Deductible: No Coverage ........................................................................................................................................ Comprehensive: Deductible: No Coverage This verification of insurance is not an insurance policy and does not amend,extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement,term or condition of any contract or other document with respect to which this verification of insurance may be issued or may pertain,the insurance afforded by the policies described herein is subject to all the terms,exclusions and conditions of the policies. If you have any questions,please call Customer ServicP. Thank you. Fa�m V01(03A5) 400 Sibley Street • Suite 500 • St.Paul,MN 55101 phone:651-291-1979 � fax:651-291•7378 web:south-metro.org October 2, 2013 To whom it may concern, Bradley Nicholis was in the hospital during the months of August and September, and because of this, was unable to move his car from the street. Due to these extenuating medical circumstances, we are requesting that Bradley's storage fees from the impound lot be waived. We were under the impression that in these emergent situations, that leeway could be given regarding the amount of fees paid. Bradley is on a limited income and paying the full amount has caused financia� stress. Thank you for your consideration. � �C'Vv� Karen Meyer � Case Manager 651-256-1246 Karenm@south-metro.orq 400 Sibley St. #500, St. Paul, MN Your Rights and Responsibilities You have been set for a Court Trial to be heard before a Judge or Referee. ♦ If you choose to plead not guilty to a petty misdemeanor, the date set for court is the actual trial. It is important that you bring with you any witness(s) or evidence you want to present at the trial. If subpoenas are needed, information can be obtained at the Court offices located at: Room 900 City Halt/Courthouse, 15 West Kellogg, St. Paul, or 2050 White Bear Avenue, Maplewood. ♦ A court trial is heard by a Judge or Referee. The prosecutor for the city where the violation(s) occurred is present, S/he will be available for questions prior to your scheduled court trial. The officer who issued the citation will be present. The prosecutor will present probable cause for the citation. Both you and the officer will have an opportunity to explain the circumstances surrounding the incident. You or your attorney can question the officer. Upon completion of testimony the Judge or Referee will make a decision or take the case under advisement. If a fine is imposed proceed to the Traffic Violations Bureau to make payment or see a Hearing Officer to make payment arrangements. ♦ You are not required to say anything or answer any questions. Anything you say may be used against you at this or subsequent proceedings. ♦ There are no public defenders for traffic court. You may be represented by an attorney, but it is at your own expense. Failure to appear for a petty misdemeanor court trial constitutes a plea of guilty unless you appear within 10 days to show it was due to circumstances beyond your control. (M.S. 169.91) By court order, failure to pay shall result in one or all of the followi�g: additional fees may be added, a warrant may be issued for your arrest, your driver's license may be suspended, your account may be referred to the department of revenue which has collection authority and may access non-public government data on you for the purpose of collecting this debt. Ramsey County District Court may take the following actions: seek a judgement against you and your property, wage garnishment, bank levy, property seizure, offset your state income tax refund,credit bureau reporting,and/or collection agency refercal. 12JAN I � STATE OF MINNESOTA O RD E R DISTRICT COURT COUNTY OF RAMSEY SECOND JUDICIAL DISTRICT TO REPORT CITY OF VIOLATION FILE NO. ST PAU L 620900517180 DEFENDANT DEFENDANT'S PHONE NO. Bradle Nicholls 952-220-0231 YOU, THE ABOVE NAMED DEFENDANT, ARE ORDERED TO APPEAR ON: Mar. 17, 2014 at 1:OOPM for CRT TRL before the presiding judge in room# 130. FAILURE TO APPEAR FOR A SCHEDULED COURT APPEARANCE IS A CRIMINAL OFFENSE UNLESS FAILURE TO APPEAR IS DUE TO CIRCUMSTANCES BEYOND YOUR CONTROL. FAILURE TO APPEAR FOR A PETTY MISDEMEANOR COURT TRIAL CONSTITUTES A PLEA OF GUILTY UNLESS YOU APPEAR WITHIN 10 DAYS AND SHOW THE FAILURE TO APPEAR WAS DUE TO CIRCUMSTANCES BEYOND YOUR CONTROL. FAILURE TO APPEAR MAY RESULT IN A WARRANT FOR YOUR ARREST � St. Paul Courthouse...................................................15 W. Kellogg Blvd........St. Paul .........55102.....(651) 266-8180 ❑ Ramsey County Law Enforcement Center................425 Grove St.................St. Paul .........55101 .....(651)266-9696 ❑ Maplewood Branch ....................................................2050 White Bear Ave....Maplewood....55109.....(651) 266-1999 DEFENSE ATTORNEY PHONE NO. DATE October 2, 2013 JUDGE: Handed to the defendant by NX Comments: SIGNATURE DEFT DECLINED A FINE SUSP TO SETTLE CASE, RATHER HAVE A CRT TRL, R&R SHEET I HANDED TO HIM .� ,:- �� - :�;' �;�� c°• r!m. �; �;; '�� ,�:. . ,� ,� .....,) r o 0 � � ° � N J `� ,1;v� � �� O � ,�o � H �' � . -�lm�� . � � �; � w ntct� � O CO CD �' U � � p N t� O I� H �. .O � O � , ,�� O CO C� r�.n,: � tn '� 00 r- � � Z °-=�� cts � cfl c� Q W J N N � � W N aj �p � o � N �' m � � � s � � � U � N �`• ti (�j � c � � v U � m 0 � 3 0 � ii � Z � w O � a`Y'o I�— i� Q I� ci� in � Z Q � � � M Q . _.._- �ned 7S � � � ...w..v ��i�asu�un N +. � � 1?'US ssa.i:)nu.: Z � @ a�,., � , ��.,,��r,u�i-��s��„�i �H iiwt^ins�ini U � � `�- � (cA � . � . i�onr>o 1 a.;�iap,:, . (6 (n � t' C ,.. (A w • � � � °Q J .� m rn �� V � 7 = � � � � �' � �i � n" a `- � — o Z c¢i� a� s w a� a U Z v o .S -a� ' ui Q � N c c�0 � r '0 } ~ c M � `�° 3 °c o � u' p N � +. a i V p Y p U U � �- I � -s�noy . 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