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Sanchez, SantanaNOTICE 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 answers to each question. If you have additional documentation you may add those documents to your submission. You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards of four (4) weeks. This form must be signed, dated with all applicable sections completed. Submission is to the Saint Paul City Clerk’s Office. You may email, fax (651-266-8574) or mail the form. Mailing address is “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102” Individuals: First Name ____________________________ Last Name _____________________________________________ Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His ☐_ They/ Them/Theirs ☐ Company or Business Name: ______________________________________________________________________________ Is this claim being made by an Insurance Company? If yes, what is your Claim/File Number?: _____________________ Is this claim being made by an Attorney? Choose an item. If yes, what is your File Number? _______________________________ If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________ Street Address: _________________________________________________________________________________________ City: ____________________________________________ State ___________________ Zip Code __________________ Daytime/Work Phone _______________________________ Cell Phone ____________________________________________ Date of Incident or Date Discovered (Must complete) _____________________________Time _________________________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _____________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? ______________________________ Please check the reason that most closely describes the reason for your submitting a claim. Please note the documents that will need to be provided with your completed form. Photographs will be accepted. All documents submitted become the property of the City of Saint Paul and shall not be returned. ☐ Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid. ☐ Automobile damage from a street defect or pothole : please provide two estimates for repairs or actual bill that has been paid. ☐ Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or actual bill that has been paid. ☐ Snow Emergency: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or actual bill that has been paid. ☐ Property damage: please provide two estimates for repairs or actual bill that has been paid. ☐ You were injured during a motor vehicle accident: please provide police report number, details about injury. ☐ You were injured in the City of Saint Paul: please provide police report number, witnesses and details about injury. This section must be completed for all claims. Is there a police report for this incident? Yes No If yes, please provide the police report case number ____________________ Revised December 2021 If yes, what law enforcement agency responded? _______________________________________________________ Where did the incident take place? Please provide a street address, intersection or name of City park or facility. ________________________________________________________________________________________________________ The Claims Center, LLC. on behalf of Xcel Energy, Inc. Santana Sanchez The Claims Center, LLC. on behalf of Xcel Energy, Inc. No, TPA 2MN146987 No Xcel Energy The Claims Center, LLC. PO BOX 47604Minneapolis MN 55447 866-233-0353 reference# 2MN146987 09/28/2023 Xcel Energy's gas service linewas damaged during water utilities excavation work by St Paul Regional Water Service. unknown x (_) 1195 GOODRICH AVE, ST PAUL, MN ____ Notice of Claim Form, page two. Failure to complete and return both pages will result in delays. What would you like to see happen to resolve this claim to your satisfaction? _________________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers. ______________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year ______ Make _________________ Model ____________________ Color ________________ License Plate # _____________________ State vehicle is registered in ________________________ Registered owner of vehicle ______________________________ Driver ______________________________________ Area(s) damaged ___________________________________________________________________________________ If a City vehicle was involved: License Plate # _______________________________ Color _______________________________ Was there City insignia on the vehicle? Yes No Driver’s Name _____________________________________________ Other property damaged: ___________________________________________________________________________________ For injury claims of any type. What part of your body was injured? __________________________________________________________________________ Did you go to the emergency room or urgent care? Yes No Where? _________________________________________________ Was medical treatment received? Yes No Where? ______________________________________________________________ First day of medical treatment? _____________ Are you still receiving medical treatment? Yes No Did you miss any work as result of this incident? Yes No Employer(s) _______________________________________________ How much time have you missed from work?___________________________________________________________________ If you are submitting other documents, please state what you are attaching and how many pages. ______________________ By signing this form, you agree that all information provided is true and correct to the best of your knowledge. Please NOTE that submitting a false or misleading claim can and will result in prosecution under Minnesota Statutes. Name of Person completing form: ________________________________________________ Signature of Person submitting this form: _______________________________________________________________________ Relationship of person signing to Party making the claim: ___________________ Date document is being signed _____________ Revised December 2021 see attached Claim For Damages unknown N/A N/A NOC letter &CFD Santana Sanchez TPA - The Claims Center, LLC. 02/07/2023 reference# 2MN146987 3300 Fernbrook Lane North, Suite 180 Plymouth, MN 55447 PO Box 47604 Minneapolis, MN 55447 866-233-0353 Fax: 866-233-9627 02/07/2023 City Clerk 15 Kellogg Blvd. W. #310 City Hall Saint Paul, MN 55102 Dear: CITY OF ST PAUL The Claims Center, LLC is a third party claims administrator for Xcel Energy Inc, which has assigned our firm to investigate and resolve claims for damages to Xcel Energy Inc facilities. This letter should serve as official notice of tort claim submitted with the CITY OF ST PAUL REGIONAL WATER SERVICE. If additional information is required to affect official notice of claim, please respond to include any necessary forms, or specific procedure mandated by statute. Enclosed is a demand for property damage. These damages were discovered or repaired on or about 09/28/2022 at the location of 1195 GOODRICH AVE. in ST PAUL, MN. If you need additional information or have any questions please call 866-233-0353 ext. 1536. Please include our reference number 2MN146987 when responding to this letter. Thank you, Public Relations The Claims Center, LLC PO Box 47604 Minneapolis, MN 55447 Fax: 866-233-9627 Santana.sanchez@theclaimscenter.com Work Authorization Number: 108499060 Notification Date: 02/06/2023 Claims Center P.O. Box 47604 Plymouth, MN 55447 Upon Receipt Payment Due Date: PLEASE MAKE CHECK PAYABLE TO Xcel Energy Claims Center PO BOX 47604 PLYMOUTH, MN 55447 ST PAUL REGIONAL WATER SERVICE OVERNIGHT DELIVERY ADDRESS 1900 RICE ST Xcel Energy ROSEVILLE MN 55113 Claims Center 3300 Fernbrook Lane North Suite 180 Plymouth, MN. 55447 F O R I N Q U I R I E S C A L L 8 6 6 - 2 3 3 - 0 3 5 3 O R F A X 8 6 6 - 2 3 3 - 9 6 2 7 DAMAGES TO XCEL ENERGY FACILITIES Location: 1195 GOODRICH AVE Date of Loss: 09/28/2022 Description: Buried Gas Service Line BREAKDOWN OF DAMAGES AMOUNT Labor: $2,733.14 Material: $0.00 $179.96 Vehicle: Contract Labor and Miscellaneous Total: $0.00 Damage Investigation and Billing: Lost Product: $299.75 $84.45 TOTAL PLEASE DO NOT PAY WITH YOUR XCEL ENERGY BILL OR TO ANY OTHER XCEL ENERGY LOCATION $3,297.30 Work Authorization Number: 108499060 TOTAL AMOUNT DUE Amount Remitted Notification Date: 02/06/2023 $3,297.30 Please visit https://theclaimscenter.com/payments to make a payment through our Credit Card Payment Vendor. Xcel Energy ST PAUL REGIONAL WATER SERVICE Claims Center 1900 RICE ST PO BOX 47604 ROSEVILLE MN 55113 PLYMOUTH, MN 55447