Vue, Soua (3)Revised 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: ________________________________ 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? YES / NO If yes, what is your Claim/File Number? _________________________
Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? _______________________________________
If yes, 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.
Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays.
Soua Vue
Travelers claim #JAD8087
P.O. BOX 5076
Hartford CT 06102
(508)324-8332
11/01/2024 6:55 P.M.
Our insured vehicle was struck by a city
vehicle.
Local P.D. found the city vehicle to be
at-fault.
Revised March 2023
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: ___________________________
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:
____________________________________________________________________________________________________________
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: _____________________
24-206962
Saint Paul Police Dept.
Intersection of Cayuga St. and Phalen Blvd.
Travelers is seeking 100% repayment of our damages.
Yes; Kaytheus Moore, (651)226-1019.
2017 Toyota Sienna Black
LRF051 MN
SOUA VUE SOUA VUE
Front end; total loss.
Bryan R. Powers
Claim Handler as subrogee of Soua Vue
Chest, Legs
Yes; Regions Hospital, St. Paul 55101
Yes; same facility as above.
11/01/2024
Financials, 3 pgs.
06/12/2025
Expand All | Collapse All
Financials
Financials
Thursday, June 12, 2025
NOL Insured Information:Claim Number:
SOUA VUE
299 ATWATER ST
SAINT PAUL, MN 55117-5302
JAD8087
RP Sequence Number:
001
Responsible Party Information:
ST. PAUL EMS
375 JACKSON STREET
SAINT PAUL , MN 55101
Loss Date:Accident State:
11/01/2024 SAINT PAUL, MN
Summary of Loss:
Claimant Summary
Payment Details
Claimant Number Name Type Cov Code Deductible Reduction Total Subro Demand
001 SOUA VUE INSD COLL $ 500.00 $ 0.00 $ 39,595.01
001 CMT (SUBTOTAL) $ 0.00 $ 0.00 $ 39,595.01
002 SOUA VUE INJ BPIP MED $ 100.00 $ 0.00 $ 13,874.55
002 CMT (SUBTOTAL) $ 0.00 $ 0.00 $ 13,874.55
003 ANGELINA LEE INJ BPIP MED $ 0.00 $ 0.00 $ 6,732.25
003 CMT (SUBTOTAL) $ 0.00 $ 0.00 $ 6,732.25
TOTALS (AMOUNT DUE) $ 0.00 $ 0.00 $ 60,201.81
Clm Nbr PERS Auth
Id
Cov Cd Reference Seq Nbr Transaction Date Amount Payee or Sold to Name For Explanation
001 JZR1 COLL 0043951615 001 12/10/2024 $ 487.24 COPART AUTOAUCTIONS
001 SH6 COLL 0007631343 002 03/04/2025 $ 51,594.77 SOUA VUE TOTAL LOSS
001 CPT$COLL 0082209879-
001 03/13/2025 $ 12,987.00 CREDIT SALVAGE
002 KMW BPIPMED 0033821104 001 11/27/2024 $ 1,347.40 ELITE CARECHIROPRACTIC PA Prov Inv #: 471
002 KMW BPIPMED 0033884874 002 12/18/2024 $ 929.00 METRO DIAGNOSTICIMAGING LLC Prov Inv #: 1664
002 KMW BPIPMED 0033884708 003 12/18/2024 $ 220.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11143876
002 TM1 BPIP
MED 0033906994 004 12/26/2024 $ 220.00 TWIN CITIES CHIRO
& REHAB
Prov Inv #:
CDR11153188
002 KMW BPIPMED 0033918213 005 12/31/2024 $ 550.80 DIAGNOSTICRADIOLOGYCONSULTANTS
002 LKHA BPIPMED 0033927582 006 01/03/2025 $ 220.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11208941
002 KMW BPIPMED 0033941981 007 01/08/2025 $ 220.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11251902
002 KMW BPIPMED 0033941982 008 01/08/2025 $ 220.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11217556
002 AS BPIPMED 0034031597 009 02/05/2025 $ 3,044.35 REGIONS HOSPITAL Prov Inv #:11723960300
002 AS BPIPMED 0034031598 010 02/05/2025 $ 277.00 REGIONS HOSPITAL Prov Inv #:11723960301
002 MLA9 BPIPMED 0034045603 011 02/10/2025 $ 220.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11423043
002 XW27 BPIPMED 0034050467 012 02/11/2025 $ 220.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11433033
002 XW27 BPIPMED 0034073261 013 02/18/2025 $ 170.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11451881
002 RS BPIPMED 0034091681 014 02/24/2025 $ 170.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11513061
002 RS BPIPMED 0034091682 015 02/24/2025 $ 295.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11505700
002 KW BPIPMED 0034120054 016 03/04/2025 $ 170.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11577503
002 RS BPIPMED 0034120055 017 03/04/2025 $ 175.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11035641
002 AMY BPIPMED 0034120056 018 03/04/2025 $ 220.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11074931
6/12/25, 10:30 AM JAD8087 | 000 | FILE LEVEL | SOUA VUE | 11/1/2024
https://claimportalch.prodlb.travp.net/claimportalcommon2/SubTabContainer.aspx?StartPage=https://claimplatformch2.prodlb.travp.net/ClaimSummary…1/3
Indemnity Net Paid Amount( LESS CREDITS):
002 AMY BPIPMED 0034120057 019 03/04/2025 $ 220.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11098856
002 RS BPIPMED 0034120058 020 03/04/2025 $ 170.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11562519
002 RS BPIPMED 0034120059 021 03/04/2025 $ 220.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11064319
002 AMY BPIPMED 0034120060 022 03/04/2025 $ 175.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11035635
002 LKHA BPIPMED 0034120061 023 03/04/2025 $ 175.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11053598
002 KW BPIPMED 0034120062 024 03/04/2025 $ 425.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11020045
002 MLA9 BPIPMED 0034133763 025 03/07/2025 $ 170.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11585470
002 MLA9 BPIPMED 0034138521 026 03/10/2025 $ 38.00 GROUP HEALTH PLANINC Prov Inv #:4848698660
002 SCR9 BPIPMED 0034138523 027 03/10/2025 $ 56.00 MIDWESTRADIOLOGY Prov Inv #: ZD64V53
002 KMW BPIPMED 0034138524 028 03/10/2025 $ 31.00 MIDWESTRADIOLOGY Prov Inv #: ZD64V51
002 BAY BPIPMED 0034143183 029 03/11/2025 $ 170.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11613385
002 SBB1 BPIPMED 0034156933 030 03/14/2025 $ 25.00 MIDWESTRADIOLOGY Prov Inv #: ZD64V52
002 AMY BPIPMED 0034156945 031 03/14/2025 $ 170.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11631044
002 SMP BPIPMED 0034232337 032 04/07/2025 $ 170.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11524754
002 KMW BPIPMED 0034265080 033 04/16/2025 $ 1,481.00 SAINT PAUL FIREDEPARTMENT RUN NO: 24-2463310 SOUA VUE
002 KMW BPIPMED 0034329455 034 05/06/2025 $ 170.00 SCOT SORUM L Prov Inv #:CDR11895002
002 KMW BPIPMED 0034329456 035 05/06/2025 $ 170.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11708839
002 KMW BPIPMED 0034329457 036 05/06/2025 $ 170.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11728599
002 KMW BPIPMED 0034329458 037 05/06/2025 $ 170.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11758119
002 KMW BPIPMED 0034329459 038 05/06/2025 $ 170.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11805022
002 KMW BPIPMED 0034329460 039 05/06/2025 $ 170.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11914764
002 KMW BPIPMED 0034329461 040 05/06/2025 $ 170.00 TWIN CITIES CHIRO& REHAB Prov Inv #:CDR11955235
003 KMW BPIPMED 0033821105 001 11/27/2024 $ 1,194.40 ELITE CARECHIROPRACTIC PA Prov Inv #: 472
003 KMW BPIPMED 0033865216 002 12/12/2024 $ 170.00 SCOT SORUM L Prov Inv #:CDR11053842
003 KMW BPIPMED 0033865217 003 12/12/2024 $ 590.00 SCOT SORUM L Prov Inv #:CDR11035658
003 KMW BPIPMED 0033865218 004 12/12/2024 $ 170.00 SCOT SORUM L Prov Inv #:CDR11064270
003 XW27 BPIPMED 0033884709 005 12/18/2024 $ 170.00 SCOT SORUM L Prov Inv #:CDR11098842
003 RS BPIPMED 0033884710 006 12/18/2024 $ 170.00 SCOT SORUM L Prov Inv #:CDR11074946
003 MLA9 BPIPMED 0033906995 007 12/26/2024 $ 170.00 SCOT SORUM L Prov Inv #:CDR11143868
003 CLE2 BPIPMED 0033910030 008 12/27/2024 $ 413.10 DIAGNOSTICRADIOLOGYCONSULTANTS
003 BAY BPIPMED 0033914630 009 12/30/2024 $ 170.00 SCOT SORUM L Prov Inv #:CDR11153189
003 LKHA BPIPMED 0033923097 010 01/02/2025 $ 839.75 METRO DIAGNOSTICIMAGING LLC Prov Inv #: 1663
003 ALC BPIPMED 0033932536 011 01/06/2025 $ 170.00 SCOT SORUM L Prov Inv #:CDR11208934
003 MLA9 BPIPMED 0033946622 012 01/09/2025 $ 170.00 SCOT SORUM L Prov Inv #:CDR11217565
003 KMW BPIPMED 0034003155 013 01/28/2025 $ 170.00 SCOT SORUM L Prov Inv #:CDR11252213
003 MLA9 BPIPMED 0034040913 014 02/07/2025 $ 170.00 SCOT SORUM L Prov Inv #:CDR11423049
003 KW BPIPMED 0034068892 016 02/17/2025 $ 170.00 SCOT SORUM L Prov Inv #:CDR11433035
003 XW27 BPIPMED 0034077830 017 02/19/2025 $ 170.00 SCOT SORUM L Prov Inv #:CDR11451885
003 KMW BPIPMED 0034129399 018 03/06/2025 $ 295.00 SCOT SORUM L Prov Inv #:CDR11505686
003 KMW BPIPMED 0034129400 019 03/06/2025 $ 170.00 SCOT SORUM L Prov Inv #:CDR11524763
003 KMW BPIPMED 0034129401 020 03/06/2025 $ 170.00 SCOT SORUM L Prov Inv #:CDR11513067
003 SCR9 BPIPMED 0034189551 022 03/25/2025 $ 170.00 SCOT SORUM L Prov Inv #:CDR11044633
003 SCR9 BPIPMED 0034189552 023 03/25/2025 $ 170.00 SCOT SORUM L Prov Inv #:CDR11631049
003 SCR9 BPIPMED 0034189553 024 03/25/2025 $ 340.00 SCOT SORUM L Prov Inv #:CDR11577507
003 SCR9 BPIPMED 0034189554 025 03/25/2025 $ 170.00 SCOT SORUM L Prov Inv #:CDR11613378
003 ALC BPIPMED 0034301403 027 04/28/2025 $ 170.00 SCOT SORUM L Prov Inv #:CDR11914755
6/12/25, 10:30 AM JAD8087 | 000 | FILE LEVEL | SOUA VUE | 11/1/2024
https://claimportalch.prodlb.travp.net/claimportalcommon2/SubTabContainer.aspx?StartPage=https://claimplatformch2.prodlb.travp.net/ClaimSummary…2/3
$59,601.81
Expense Net Paid Amount:
$1,078.58
Expense Details
Clm Nbr Auth
Id Cov Cd Reference Seq
Nbr
Transaction
Date Amount Payee or Sold to
Name For Explanation
003 MTO9 BPIP 0033082699 015 02/08/2025 $ 145.20 ALLOCATED CHARGE CLAIM EXPENSE 23
003 KMW BPIP 0034218856 026 04/02/2025 $ 174.98 ONE CALL CARETRANSPORT &TRANSLATE CLAIM EXPENSE 2B
003 MTO9 BPIP 0077616216 028 05/29/2025 $ 38.80 LEGAL ALLOCATEDCHARGE CLAIM EXPENSE 12
003 MTO9 BPIP 0077625358 029 06/02/2025 $ 103.20 LEGAL ALLOCATEDCHARGE CLAIM EXPENSE 12
003 KAA BPIP 0034414994 030 06/03/2025 $ 235.00 American ArbitrationAssociation CLAIM EXPENSE 9A Lee, Angelina v. Stan dardFire Insurance
003 MTO9 BPIP 0077632209 031 06/03/2025 $ 38.80 LEGAL ALLOCATEDCHARGE CLAIM EXPENSE 12
003 MTO9 BPIP 0077640642 032 06/05/2025 $ 232.80 LEGAL ALLOCATEDCHARGE CLAIM EXPENSE 12
003 MTO9 BPIP 0077644814 033 06/06/2025 $ 36.60 LEGAL ALLOCATEDCHARGE CLAIM EXPENSE 12
003 MTO9 BPIP 0077657826 034 06/11/2025 $ 73.20 LEGAL ALLOCATEDCHARGE CLAIM EXPENSE 12
6/12/25, 10:30 AM JAD8087 | 000 | FILE LEVEL | SOUA VUE | 11/1/2024
https://claimportalch.prodlb.travp.net/claimportalcommon2/SubTabContainer.aspx?StartPage=https://claimplatformch2.prodlb.travp.net/ClaimSummary…3/3