Hellum, Jason original formNOTICE 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 presente d 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 compe nsation
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 is to the Saint Paul City Clerk’s Office. You may email, fax
(651-266-8574) or mail the form. Mailing address is “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”
Individuals: First Name Jason______________ Last Name Hellum_____________________________________
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His ☒_ They/ Them/Theirs ☐
Company or Business Name: Klodt Inc.___________________________________________________________________
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? Choose an item. If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
Street Address: 1001 Oxford St N________________________________________________________________
City: St. Paul__________________________________ State MN___________________ Zip Code 55103__________________
Daytime/Work Phone 612-221-1406_____________________ Cell Phone ____________________________________________
Date of Incident or Date Discovered (Must complete) 1/18/2022_______________Time 5:45AM_________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. Plow truck damaged vehicle _______
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Plow truck for the city of St.Paul
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.
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 22-009120__________
Revised December 2021
If yes, what law enforcement agency responded? St. Paul Police Department___________________________________________
Where did the incident take place? Please provide a street address, intersection or name of City park or facility.
1001 Oxford St N (Corner of Hatch & Oxford) St.Paul MN 55103
________________________________________________________________________________________________________
Notice of Claim Form, page two. Failure to complete and return both pages will result in delays.
What would you like to see happen to resolve this claim to your satisfaction? Truck damage repaired
Were there witnesses to this incident? Please provide names and contact phone numbers. No______________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year 2014 Make Dodge_______ Model Ram____________________ Color Red________________
License Plate # CVE 090________________ State vehicle is registered in MN________________________
Registered owner of vehicle Klodt Inc. __________________ Driver Jason Hellum__________________________
Area(s) damaged Driver side fender and bumper _____________________________________________________
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: Jason Hellum________________________________________________
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: Self___________________
Date document is being signed 1/18/2022_____________
Revised December 2021