Marks, Charles & KathleenRevised March 2023
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 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 this completed form to the Saint Paul City Clerk’s Office by email
(cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”.
Claimant: First Name: ____Charles & Kathleen____________________________ Last Name: Marks
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? NO If yes, what is your Claim/File Number? _________________________
Is this claim being made by an Attorney? NO If yes, what is your File Number? Click or tap here to enter text.
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: ____251 Lexington Pkwy So
City: St. Paul State: MN Zip Code: 55105
Daytime/Home Phone: 651-224-3133 Cell Phone: 651-295-5304_ (Kathleen)
Date of Incident or Date Discovered (Must Complete): 11/16/2023 Time: approximately 10:30 a.m.
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ________Our sewer line was
damaged when Excel Energy contracted with M.J. Electric to replace an existing electrical pole on the boulevard in front of our home. The replacement electrical pole was moved north from its original location and when placed in the new location the pole went directly through our sewer line which eventually caused a sewer backup in our basement. We therefore contacted Roto Rooter to help clear the drain. That is when it was
determined that the pole had intersected with our sewer line, as shown on the attached photos. We contacted Excel Energy and they forwarded the claim to the sub-contractor M.J. Electriic who has denied responsibility for the damage and expenses incurred in this matter. The following is their response which was emailed to us on January 29, 2024
Good morning, Charles, My name is Krista and I’m a claim specialist at Helmsman Management Services where we manage claims for M.J. Electric. I attempted to reach you at 651-224-3133 and 651-295-5303 to discuss a claim I received for sewer damage. I have received all documentation and wanted to discuss the claim in greater detail with you. It’s important to note that before any project begins each utility company is responsible for marking their own lines in the proposed evacuation area. The sewer lines are marked by The City of St. Paul and it’s the City’s responsibility to mark the sewer lines and mark them accurately, so MJE doesn’t hit a line. In this case The City of St. Paul had cleared the proposed evacuation area stating there were no lines in conflict. During evacuation MJE had damaged a sewer lateral that wasn’t marked by The City of St. Paul. There was no way for MJE to know a sewer lateral was present since The City of St. Paul advised them that there wasn’t a line in
this area. With that being said, liability wouldn’t fall on MJE. I would encourage you to either file a claim with the City of St. Paul and/or your Homeowners insurance. Your Homeowners Insurance will investigate and be able to further direct you. For your convenience I’ve included a screenshot from The City of St. Paul’s website on how to file a claim with them. Feel free to call me at 715-870-6199 to discuss any questions/concerns you
Revised March 2023
may have.
Therefore, we are now filing our claim with the City of St. Paul.__As to their reference to filing a claim with our homeowners insurance – we have contacted our insurance carrier and have been told this is not a coverable event.________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _____See comments
above_______________________________
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. Because this was an emergency
situation – due to sewer back up in basement – Roto Rooter was called out to assist in clearing the drain. That is when we found out
that the new pole had damaged the sewer line and was obstructing the flow. Copies of invoices, which we have already paid in full,
are attached along with photos of the damaged sewer line. ☐ 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.
Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays.
This section must be completed for all claims.
Is there a police report for this incident? NO
If yes, please provide the police report case number: ___________________________
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:
251 Lexington Pkwy. So., St. Paul, MN
55105_______________________________________________________________________________________________________
___
What would you like to see happen to resolve this claim to your satisfaction? Reimbursement of costs incurred.
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: __________________________________________
Revised March 2023
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: ____________Kathleen Marks_________________________________________________
Signature of Person submitting this form: /e/ Kathleen Marks
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: 2/5/2024
EXCA INV BR TC1 3 - 5/21
Representative Signature
Printed Name
BILLING ADDRESS
CUSTOMER PHONE NO.
CUSTOMER NAME CUSTOMER NO.EMAIL ADDRESS
CUSTOMER CLASS
RESIDENTIAL COMMERCIAL
CITY
ZIP/POSTAL P.O. NUMBER/AUTHORIZATIONSTATE/PROVINCE
SERVICE ADDRESS (IF DIFFERENT THAN BILLING ADDRESS)
FEDERAL I.D. #
CITY
APT. NUMBER
ZIP/POSTALSTATE/PROVINCE
REASON FOR NO GUARANTEE
REPRESENTATIVE NAME
DATE OF SERVICE
#
LOCATION
I acknowledge completion of the above described work.
LABOR $
LABOR TAX $
PARTS $
DISCOUNT $
PRODUCTS $
OTHER $
TAX $
NET 10 DAYS
CHECK NO.*
OVER 30 DAYS = LATE CHARGE OF 1 1/2% PER MONTH
*In the event check is returned, the CUSTOMER is responsible
for all related bank fees.
CASH
CREDIT CARD
(PRINT NAME)
(SIGNATURE)
Roto-Rooter Services CompanyRemit to: 5672 Collections Center Drive, Chicago IL 60693-0056For Service Please Call 1-800-GET-ROTO (438-7686)
TOTAL $
EXCAVATION INVOICE
GUARANTEE
SEE BINDING TERMS
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DocuSign Envelope ID: 01FF3E69-0692-4C6E-8877-417017475316
SAINT PAUL
12/04/2023
0.00
charliekathie@comcast.net
MINNEAPOLIS MN 55447
251 LEXINGTON PKWY S
251 LEXINGTON PKWY S
6512243133
0.00
Excavated in front yard down to existing service, found telephone pole/ electric pole was drilled
directly through service, excavated a 12x6 hole in road to re route the pipe around pole, replaced
aprox 13' of clay tile with schedule 40 pvc, City inspection backfill. Telivised remainder of line and
looked to be in OK condition.
All pvc repair has 1 year guarantee.
Aaron Frisk
55105
Minneapolis
X
14530 27TH AVE N
License #: Master Plumber License PM058657; MN
Plumbing Bond PC644621
55105
25512087
SAINT PAUL MN
0.00
0.00
0.00
0.00
KATHLEEN MARKS
MN
4384
188995674
Aaron Frisk
0.00
42-0499300
1 Year
26,000.00
X
KATHLEEN MARKS
The following terms apply to all work performed by Roto-Rooter Services Company or its affiliates (“us”) for the customer indicated onthe front of this form (“you”).
1. Your Responsibilities. You agree to (a) remove any hazards, obstructions or dangerous conditions around the job site not caused byour work, (b) limit access to the job site so that people not working on our job are not exposed to dangerous conditions relating to our job, (c)place appropriate warnings to warn of dangerous conditions when we are not on the job site, and (d) provide us with adequate access.
2. Exceptions to Our Responsibilities. WE ARE NOT RESPONSIBLE FOR (a) personal injury, property damage or other damageor loss to you or others arising out of our work, except to the extent caused by our negligence or failure to perform the work in accordance withthe contract between us; (b) DEFECTIVE, DAMAGED, OR DETERIORATED LINES, MOLD, LEAD PIPING, OR OTHER UNEXPECTED OR UNDISCLOSED CONDITIONS, AND THE CONSEQUENCES OF SUCH CONDITIONS, INCLUDING DELAYS, BROKEN FIXTURES OR LINES, AND LODGED EQUIPMENT (if we encounter such a condition, we may stop work, and you will pay us a reasonablecharge for the work performed); (c) the time required to complete our work with reasonable diligence; (d) unless explicitly stated in writing, anydamage necessary to complete our work, including damage to landscaping, walls, painting, tile or concrete or similar items; (e) damage caused by the removal of any clean out, drain cover or cap; or (f) tasks we perform in accordance with your specific instructions.
3. Release and Hold Harmless. You release us from (and if you are a commercial customer, you will defend and indemnify us and holdus harmless against) all damages, claims, demands, settlements, judgments, liabilities, costs and expenses, including reasonable attorneys’ fees, allegedly arising out of (a) breach of your responsibilities under paragraph 1, or (b) matters for which we disclaim responsibility under paragraph 2.
4.Our Guarantee. If we provide a parts or equipment guarantee, as your exclusive remedy, we will give you the benefit we receive, ifany, under the manufacturer’s warranty. If we provide a service guarantee, it covers only drainage failure in the line serviced, and defectiveplumbing workmanship, during the guarantee term. As your exclusive remedy under our service guarantee, we will, at our option, either do thework again at no labor cost or refund your payment. Guarantees do not apply to problems arising out of main sewer line backup or improper, abnormal or unanticipated use or conditions. Except as explicitly stated in writing, we are not giving any guarantees or making any warranties.TO THE EXTENT PERMITTED BY LAW, WE DISCLAIM ANY IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. You may transfer a guarantee of plumbing repair or replacement to a person who purchases the property,but you may not transfer a drain cleaning or toilet auger guarantee. Your transferee must present the warranty claim to Roto-Rooter at the time we perform our work. We do not guarantee that our site inspection will identify all existing or potential problems. Any damages or necessary repairs arising from plumbing problems, either identified or unidentified, are the sole responsibility of the customer.
5. Limitation of Damages. Our liability to you for any claim arising out of our work on any job (other than a claim permitted by theseterms for personal or bodily injury) will in no event exceed three times the amount you actually pay us for the work on that job. EXCEPT FOR ACLAIM PERMITTED BY THESE TERMS FOR PERSONAL OR BODILY INJURY OR PROPERTY DAMAGE, YOU WAIVE ANY RIGHTTO RECOVER INCIDENTAL DAMAGES, CONSEQUENTIAL DAMAGES, OR DELAY DAMAGES.
6.Payment Terms. When you provide a check as payment, you authorize us either to use information from your check to make aone-time electronic fund transfer from your account or to process the payment as a check transaction. In the event check is returned, you are responsible for all related bank fees. If you fail to pay us any amount when due, we will charge you interest on the amount due at the rate of 1.5% per month (but not exceeding the highest rate legally permissible). You will reimburse us for the reasonable attorneys’ fees we incur in all stages of collection.
7. General. These terms are part of our contractual agreement and will prevail over any inconsistent terms in any other agreementbetween us, including the terms of any purchase order, and may be modified only in a written instrument signed by both of us which specificallyrefers to the provisions to be modified. If any of these terms is held invalid or unenforceable, the remaining provisions will not be affected and will continue to apply.
8. Nondiscrimination. We will abide by the requirements of 41 CFR SS 60-1.4(a) and 60-741.5(a). These regulations prohibitdiscrimination against qualified individuals with disabilities, and prohibit discrimination against all individuals based on their race, color,religion, sex or national origin. Moreover, these regulations require that we take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin or disability.
Roto-Rooter Services Company Terms and Conditions
• Contact the manager at your Roto-Rooter office. Everything will be done to resolve yourproblem at the local level.
•If your problem cannot be resolved locally, please contact Pat Swanson, Customer ServiceCoordinator, in our national headquarters:
Roto-Rooter Services CompanySuite 2500255 East Fifth Street Cincinnati, OH 45202
or email pswanson@rrsc.com
HOW TO RESOLVE A PROBLEM
DocuSign Envelope ID: 01FF3E69-0692-4C6E-8877-417017475316