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Arcade-Phalen American Legion Post #577 (8.26)220944 PO BOX 819 APPLETON, WI 54912-0819 (800)318-2136 Ext. 4606 August 13, 2025 CITY OF ST PAUL 15 W KELLOGG BLVD ST PAUL MN 55102 RE:Claim: Date of Loss: Insured: Claim Amount: Sincerely, Dear Sir/Madam: Enclosed please find our Notice of Claim and itemized statement of claim. We are making a claim against City of St Paul due to an incident which occured on the above date. Pursuant to Minnesota statutes, please notify us in the event the claim is disallowed. If you have any questions, please contact the undersigned. C0188265 ARCADE-PHALEN AMERICAN LEGION POST #577 07/23/2025 PENDING JODI S., CSRP SR SUBROGATION REPRESENTATIVE Phone: (920)830-4606 Fax: (800)318-2209 CLAIMS@SECURA.NET SUB 33 ASC 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 a%er the alleged loss or injury is discovered a no’ce sta’ng the ’me, place, and circumstances thereof, and the amount of compensa’on or other relief demanded.” Please complete this form in its enrety by clearly typing or prinng your answers to each queson. I f you have addional documentaon, you may add thos e documents to your submission. You will not be contacted by telephone unless clarificaon is needed. The claim process for invesgaons can take upwards of four (4) weeks. This form must be signed, dated with all applicable secons completed. Submission this com pleted 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: __Arcade-Phalen American Legion Post #577 __________________________________________________________________________________ Is this claim being made by an Insurance Company? YES If yes, what is your Claim/File Number? _C0188265 ________________________ Is this claim being made by an AEorney? NO If yes, what is your File Number? _______________________________________ If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________ Street Address: _____1129 Arcade Street __________________________________________________________________________________________ City: _St Paul____________________________________ State: _MN__________________ Zip Code: _55106______________ Dayme/Work Phone: _651-249-8336_________________________________ Cell Phone: _____________________________________________ Date of Incident or Date Discovered (Must Complete): 7/23/2025 Time: __dayme___________________________ Please state, in detail, what happened that prompted you to file a Noce of Claim Form: _Construcon cr ew’s equipment struck building causing damage while the City of St Paul was removing sidewalk in front of business. ___________________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? City of St Paul was overseeing and conducng the job____________________________________ Please check the reason that most closely describes the reason for your submi"ng a claim. Please note the documents that will need to be provided with your completed form. Photographs will be accepted. All documents submiEed become the property of the City of Saint Paul and shall not be returned. ☐ Automobile damage from a motor vehicle accident: please provide two esmates for repairs or actual bi ll that has been paid. ☐ Automobile damage from a street defect or pothole: please provide two esmates 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 cket (i f available), receipt from Impound Lot, and two esmates for repairs or a ctual bill that has been paid. Revised March 2023 ☐ Snow Emergency: please provide copy of towing ck et (if available), receipt from Impound Lot, and two esmates for repairs or actual bill that has been paid. ☒ Property damage: please provide two esmates for r epairs 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. Con%nue to page 2 of No%ce of Claim Form. Failure to complete and return both pages will result in delays. This sec%on 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, intersecon or name of city park o r facility: _1129 Arcade Street, St Paul MN 55106 ___________________________________________________________________________________________________________ What would you like to see happen to resolve this claim to your sasfacon? _A claim is pending with our business insurance carrier. We would be seeking reimbursement for the damages once they are paid by insurance. Thank you. ___________________________________________________________________________________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers: The employees who were working at the job site locaon. ____________________________________________________________________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s informaon: 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: _Building located at 1129 Arcade Street, St Paul MN 55106 ______________________________________________________________________________________ For injury claims of any type. Revised March 2023 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 sll receiving medical treatment? YES / NO Did you miss any work as result of this incident? YES / NO Employer(s): _________________________________________________________________________________________________ How much me have you missed from work? _____________________________________________________________________ If you are submi"ng other documents, please state what you are a+aching and how many pages: _________________________ By signing this form, you agree that all informa%on provided is true and correct to the best of your knowledge. Please NOTE that submi"ng a false or misleading claim can and will result in prosecu%on under Minnesota Statutes. Name of Person compleng form: _Jodi Schumacher____________________________________________________________ Signature of Person submiLng this form: ____________________________________________________ Relaonship of person signing to Party making the c laim: Insurance Company Representave Date document is being signed: 8/26/2025