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Brown, Courtney (4)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. Courtney Brown JNR Adjustment Company o/b/o CenturyLink X X 800-279-2567 ex 1070 PO Box 27070 Minneapolis MN 55427 04/25/2025 n/aCenturyLink's 1500 pair buried cable wasdamaged by St. Paul Regional Water Servicesduring boring work. For further information, contact CenturyLink's third party administrator, JNR Adjustment Company Inc.include the reference number 1MN208017.Boring work, X 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: _____________________ X 2090 Palace Avenue, Saint Paul, MN 55105 Payment for damages. NA - NA Notice of Claim & Claim for Damages Courtney Brown - JNR Adjustment Company Inc. 6/24/2025 P.O. Box 27070, Minneapolis, Minnesota 55427-0070 3300 Fernbrook Lane N, Ste. 225, Plymouth, MN 55447 800-279-2567 ~ 763-519-2710 ~ Fax 763-744-1480 06/24/2025 ST Paul Regional Water Services ATTN: Clerk / Risk Management 15 Kellogg Blvd. West 310 City Hall Saint Paul, MN 55102 Dear: St. Paul Regional Water Services JNR Adjustment Company, Inc. is a third party claims administrator for Lumen Technologies, which has assigned our firm to investigate and resolve claims for damages to Lumen Technologies facilities. This letter should serve as official notice of tort claim submitted with the St. Paul Regional Water Services. 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. CenturyLink’s 1,500 pair buried cable was damaged by St. Paul Regional Water Services during boring work. These damages were discovered or repaired on or about 04/25/2025 at the location of 2090 Palace Avenue, Saint Paul, MN 55105. If you need additional information or have any questions please email or call 800-279-2567 ext. 1070. Please include our reference number 1MN208017 when responding to this letter. Thank you, Courtney Brown Public Relations JNR Adjustment Co. PO Box 27070 Minneapolis, MN 55427 Fax: 763-744-1480 Courtney.brown@jnrcollects.com This communication is from a Debt Collector. This is an attempt to collect a debt and any information obtained will be used for that purpose. This Collection Agency is licensed is licensed by the Minnesota Department of Commerce. Claim Number:P-661721MB Bill Date:June 16, 2025 Payment Due Date:Upon Receipt PLEASE MAKE CHECK PAYABLE TO: CenturyLink C/o JNR Adjustment Company Inc. St. Paul Regional Water Services PO Box 27070 Attn: Keith Burket Minneapolis, MN 55427-0070 1900 Rice Street St Paul, MN 55113 FOR INQUIRIES CALL (800) 279-2567 OR FAX (763) 744-1480 D A M A G E S T O C E N T U R Y L I N K P R O P E R T Y Damage Location:2090 Palace Avenue, Saint Paul, MN 55105 Date of Damage:4/25/2025 Damage Description:1,500 pair buried cable B R E A K D O W N O F D A M A G E S A M O U N T Labor:$8,125.92 Vehicle:$0.00 Materials:$1,506.65 Contractor $0.00 Damage investigation and Billing:$1,540.59 Total$11,173.16 Return this portion with your payment - Please include our project number on your check June 16, 2025Bill Date:Work Authorization:P-661721MB Amount Due Amount Remitted $11,173.16 Please complete information below if you wish to pay by credit card Credit Card Number:Three digit security number on back of card: Name on Card:Expiration Date: Amount to be charged to your card: $Signature: CenturyLink St. Paul Regional Water Services Attn: Keith BurketC/o JNR Adjustment Company Inc. 1900 Rice StreetPO Box 27070 Minneapolis, MN 55427-0070 St Paul, MN 55113 0