Capra, CiaraPersonal Injury Law
Sieben Carey
Know your rights
Hany A.Sieben,Jr.
John W.Carey (1937 -2018)
Mark G.Olive
James P.Carey
Arthur C.Kosieradzki
Susan M.Holden
Paul K Downes
MichaelF.Scully
Cory P.Whalen
Jeffrey M.Montpetit
Jeffrey S.Sieben
ShannonC.Carey
MarciaK Miller
Matthew E.Steinbrink
Eric W.Beyer
Robert T.Brabbit
Amy C.Wallace
Nicholas E.Carey
William O.Bongard
of Counsel
Robert J.Hauer,Jr.
of Counsel
AT&T Tower
901 MarquetteAve,Suite 500
Minneapolis,MN 55402
February 1 6,2023
Sent via:racquel.nay/or@ci.stpaul.mn.us
City of St.Paul-Attn:Raquel Naylor
St.Paul Fire Department
1675 Energy Park Drive
St.Paul,MN 55108
RE:Our Client:
Your Insured:
Date of Injury:
Our File No.:
Ciara A.Capra
Steven D.Sampson
11/11/2022
2202573
Dear Ms.Naylor:
Please be advised our law firm has been retained to represent Ciara
Capra for injuries sustained in an automobile accident on November 11,
2022.It is my understandingSteven Sampson was insured with your
company at the time of this collision.Enclosed is a copy of the traffic
accident report for your reference.
Enclosed is the completed Notice of Claim Form for the City of St.Paul.
Please confirm the existence and amount of liabilitycoverage and provide
us with the name of the adjusterwho will be handlingthis file.Please note
that pursuant to Minn.Stat.§72A.20 I,subd.I I,"An insurer must disclose
the coverage and limits of an insurance policy within 30 days after the
information is requestedin writinq by the claimant."
In addition to the above,pleasesend me copies of the following:
1.Certified copies of your insured's policies in effect on the date of
the collision,includingdeclarations pages;
2.Statements;
3.Property damages estimates for the involved vehicles;
4.Photographs of the scene,vehicles or parties;and
5.Medical records and/or reports pertainingto my client.
Office:612-333-4500
Toll Free:1-800-474-4487
Fax:612-333-5970
www.knowyourrights.com
S 75
Please be advised that any prior authorizations signed by my client are
hereby revoked.I would ask that all future correspondencebe directed to
the undersigned.
Please feel free to contact me at (612)333-9750 should you have any
questions or concerns.
Sincerely,
James P.Carey
FOR THE FIRM
JPC:msg/jla
Enclosures
2202573/NOL3
NOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damagesfrom any municipality ...sha/1 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 additionaldocumentation 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 Cit11 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:S:°t'J9.en(.a,. ? /?:/-·u-;;law,lù"r>'\.,
Is this claim being made by an Insurance Company?__
If yes,what is your Claim/File Number?:
yIsthisclaimbeingmadebyanAttorney?If yes,what is your File Number?
Cl A.
sueet Addcess,<JP/¡If ;îßlk'-Ârf' @kbuJe.art.>'/;f.I\.'J
City:.Áftb b:.,State A11\1
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Daytime/Work Phone (/ti }5,3 3 -'-/\/JC>
If yes,then provideyour Insu red's/Client's Name
Date of Incident or Date Discovered (Must complete)
Cell Phone { tz_).?,33
It/11 /Z-02-Z-I
Zip Code ¿'.)..z_
Time
97.S-D
/0118
Please state,in detail,what happened that promptedyou to file a Notice of Claim Form.
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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 propertyof
the City of Saint Paul and shall not be returned.
L Automobile damage from a motor vehicle accident:please providetwo estimates for repairs or actual bill that has been paid.
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Please state why or how you feel the City of Saint Paul is responsible for your Damages?
_Automobile damage from a street defect or pothole :please providetwo estimates for repairs or actual bill that has been paid.
_Automobile was towed and may or may not have sustained damage:please providecopy of towing ticket (if available),receipt
from Impound Lot,and two estimates for repairs or actual bill that has been paid.
_Snow Emergency:please providecopy of towingticket (if available),receipt from Impound Lot,and two estimates for repairs or
actual bill that has been paid.
_Property damage:please providetwo estimates for repairs or actual bill that has been paid.
j_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 providepolice report number,witnesses and details about injury.
This section must be completed for all claims.
Is there a police reportfor this incident?t;;;'l..10 If yes,please providethe police report case number ,Z')--2. qq /?"Cfu•Revised December 2021
Notice of Claim Form,page two.Failure to complete and return both pages will result in delays.
If yes,what law enforcement agency responded?1f!/n :r IP/lee, r
Where did the incident take place?Please providea street address,intersection or name of City park or facility.
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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.l/fJt¡,Jat1n af-fl7¡s
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For property dama,:e claims.includin,:vehicle accidents.
Your vehicle's information:Year -'Jll'J-Z-Make (h¥rt?f f Model t/t¡, Color
License Plate#-::J¡;¿,.lJ.,_g7
Úa,ta Ûl(Jr¿[,;Driver (',,,(
f;wn,p 1frb\J\.\\ f s,'Ù'-eÁrotJ à-l'-\,'M
If a City vehicle was involved:License Plate# (p,/p,2-Color t/
State vehicle is registered in MAJ
Registered owner of vehicle
Area(s)damaged 1r,,;nf
Was there City insignia on the vehicle?Yes No Driver's Name JA"" !):;na/e/ l:>Y?
Other propertydamaged:
$For injury claims of any type.e.,v itJ..'
What part of your body was injured?JlfAr/.ntc-L /.e,,.f .eov tt\SSÍOÑ s ""f "'° Cm.>1 1•0
'•O'1 ltJS,-:64liH-!Vtlt..Did you go to the emergency room or urgent care?Yes No Where?
7 ,Ñ e,""-ic.S arf...,pt.J,Jt'f./N.-Jcwll..r Ö\tro }Was medical treatment received@o Where? \\ 4',fV {!T"/tf'.)/ tl..&£
First day of medical treatment?Are you still receiving medical treatment No
Did you miss any work as result of this incident@No Employer(s)3 {Y\(ù..J lJÇ..e..+, {I\J!.SJ
How much time have you missed from work?.,,-&.()
If you are submittingother documents,please state what you are attaching and how many pages.
,î ,\C (\W r,r-rfn/J (¡ fn{>ts follc.t_ -
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: 5 L.ùft>{-
Relationship of person signing to Party making the claim: rn8(4
Date document is being signed ö '\.... -e:P'Ô""'Ï
Signature of Person submitting this form,._)"ô Revised December 2021