On April 28, 2017 a
Summons
was filed
involving a dispute between
and
for Conciliation
in the District Court of Carlton County.
Preview
09-CO-17-175
Filed in Sixth Judicial District Court
4/28/2017 1:05:02 PM
Carlton County, MN
State of Minnesota Conciliation Court z
0
County of Carlton SLxth Judicial District Case No.
I
STATEMENT OF CLAIM AND SUMMONS
Plaintiff #1 Plaintiff #2
Name: Integrity Mutual Insurance Company p Name
c/o Benjamin C. Sorenson L Address
E
Address: 220 S. 61h Street, #2050 A
City/State/Zip: Minneapolis, MN 55402 s City/State/Zip
E
VS. VS.
Defendant #1 p Defendant #2
Name: Patrick Charles Lussier R Name:
Address: 409 Arch St. Apt. I I Address:
N
T
City/State/Zip: Cloquet, MN55720 City/State/Zip:
PLAINTIFF'S STATEMENT OF CLAIM
l:8J 1.The Defendant(s) owe(s) me $3,158.55, plus filing fees and costs of $80.00, for a total of$ 3,238.55
because (state what happened and when it happened):
On or about April 4, 2016, Defendant Patrick Charles Lussier drove a motor vehicle owned by Defendant in such
a negligent manner as to cause a collision with the motor vehicle owned by Plaintiffs insured, Morgan Murray. As
a direct and proximate result of Defendant Patrick Charles Lussier's negligence, Plaintiff and its insured were
damaged in the amount of $3, 158.55. Plaintiff seeks reimbursement pursuant to its right of subrogation.
02. The D efendant(s) has/have the following property that belongs to me (list prope1ty), valued at
$ , plus filing fees and costs of$ , for a total of $
I want the Court to order this prope1ty returned to me or make the Defendant(s) pay me money for the value of
the property.
3. I believe the person(s) I am suing is/are at least 18 years old and not in the rnilitary service.
4. I understand that if I do not come to court on my hearing date, my case will be dismissed and I may have to pay
money to the Defendant(s) on any counterclaim that has been filed.
NOTARY STAM P OR COURT SEAL SWORN TO BEFORE ME ON : THE ABOVE STATEMENT OF C ~ IS TRUE AN D
•
~
~
~
-
My
--
-
·
----- -- - --
Notary Public
Minnesota
-----
§!'EVELLE MARIE CLATER~ELFREV ~ Date:
~
er25
: Signature:
ommission Expires Januarv 31, 2020
~ -~ ---- · -~
~~s
CORRECT~TH E BEST OF MY
Signature:
Name:
.~. ~..._
.I:"-
~in C."Sorenson
Telephone:
'
_ CQ.!1) 338-6000
-
WLEDGE
,
Title (if representative): Attorney for Plaintiff
Our fi le#:
6206w-0356
Notice of Settlement
The above-entitled case having been settled, the same may be and hereby is dismissed with my consent.
Date: Plaintiffs Signature:
SUMMONS: IMPORTANT NOTICE TO THE PARTIES
You must come to couti for a h earing on at
Date Time
- -.m. at
Location/Add ress
If you do not come to court for this hearing, you may lose the case and have to pay money to the other
party.
Dated: Comi Administrator/D e puty
Document Filed Date
April 28, 2017
Case Filing Date
April 28, 2017
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09-CO-17-175 Filed in Sixth Judicial District Court 4/28/2017 1:05:02 PM Carlton County, MN State of Minnesota Conciliation Court z 0 County of Carlton SLxth Judicial District Case No. I STATEMENT OF CLAIM AND SUMMONS Plaintiff #1 Plaintiff #2 Name: Integrity Mutual Insurance Company p Name c/o Benjamin C. Sorenson L Address E Address: 220 S. 61h Street, #2050 A City/State/Zip: Minneapolis, MN 55402 s City/State/Zip E VS. VS. Defendant #1 p Defendant #2 Name: Patrick Charles Lussier R Name: Address: 409 Arch St. Apt. I I Address: N T City/State/Zip: Cloquet, MN55720 City/State/Zip: PLAINTIFF'S STATEMENT OF CLAIM l:8J 1.The Defendant(s) owe(s) me $3,158.55, plus filing fees and costs of $80.00, for a total of$ 3,238.55 because (state what happened and when it happened): On or about April 4, 2016, Defendant Patrick Charles Lussier drove a motor vehicle owned by Defendant in such a negligent manner as to cause a collision with the motor vehicle owned by Plaintiffs insured, Morgan Murray. As a direct and proximate result of Defendant Patrick Charles Lussier's negligence, Plaintiff and its insured were damaged in the amount of $3, 158.55. Plaintiff seeks reimbursement pursuant to its right of subrogation. 02. The D efendant(s) has/have the following property that belongs to me (list prope1ty), valued at $ , plus filing fees and costs of$ , for a total of $ I want the Court to order this prope1ty returned to me or make the Defendant(s) pay me money for the value of the property. 3. I believe the person(s) I am suing is/are at least 18 years old and not in the rnilitary service. 4. I understand that if I do not come to court on my hearing date, my case will be dismissed and I may have to pay money to the Defendant(s) on any counterclaim that has been filed. NOTARY STAM P OR COURT SEAL SWORN TO BEFORE ME ON : THE ABOVE STATEMENT OF C ~ IS TRUE AN D • ~ ~ ~ - My -- - · ----- -- - -- Notary Public Minnesota ----- §!'EVELLE MARIE CLATER~ELFREV ~ Date: ~ er25 : Signature: ommission Expires Januarv 31, 2020 ~ -~ ---- · -~ ~~s CORRECT~TH E BEST OF MY Signature: Name: .~. ~..._ .I:"- ~in C."Sorenson Telephone: ' _ CQ.!1) 338-6000 - WLEDGE , Title (if representative): Attorney for Plaintiff Our fi le#: 6206w-0356 Notice of Settlement The above-entitled case having been settled, the same may be and hereby is dismissed with my consent. Date: Plaintiffs Signature: SUMMONS: IMPORTANT NOTICE TO THE PARTIES You must come to couti for a h earing on at Date Time - -.m. at Location/Add ress If you do not come to court for this hearing, you may lose the case and have to pay money to the other party. Dated: Comi Administrator/D e puty