Fillable Notice of Claim form
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 is to the Saint Paul
https://www.stpaul.gov/departments/city-clerkCity Clerk’s Office. You may <
mailto:cityclerk@ci.stpaul.mn.usemail, 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 _____Jennifer___________ Last Name _McNamara__________________________
Please Indicate Your Pronouns: She/ Her/Hers ☒ He/Him/His <☐_ They/ Them/Theirs ☐
Company or Business Name: ____N/A________________________________________________________________
Is this claim being made by an Insurance Company? </wNo </w:t> If yes, what is your Claim/File <Number?: _____________________
Is this claim being made by an Attorney? NO </w:t></w:rIf yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
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Street Address: ___417 N Huron Ave___________________________________________________________________
City: ___Spring Valley___________________________ State ___MN___________ Zip Code _____55975_________
Daytime/Work Phone ______Use cell_______________ </w:t><Cell Phone __1-507-272-0033____________________
Date of Incident or Date Discovered (Must complete) 2/1/2022 < </w:t></w:rTime _~7:10am______________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. I was on my way to school (NDSU in Fargo, ND) from home (Spring Valley, MN) when a car pulled
in front of me too close without a signal. I saw them and was able to hit my brakes but right in front of them was a pothole. I could not see it because the car was so close. I hit the
pothole going less than the speed limit (as it was rush hour) but still fast enough that it took my tire right off my rim and dented my rim. I had to be towed. I am filing this claim
because I think it is important that the state is notified about this pothole, so they can fix it. Especially since the damage was so bad, I had to be towed. In case you need to know
who towed me it was Car Doctor Towing – I still have my service number if needed. This also created an inconvenience to my mother as she had to drive to the cities to help with my car
which is a two-hour drive so I could go back to college as I already missed that day.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? I feel like the city of St. Paul is responsible because the incident happened on a road there
and could have been prevented if the pothole was not there.
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? NO </w:t></w:rIf yes, please provide the police report case number ____________________
Revised December 2021
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.
The incident took place on 94W before exit 215 for Weaver Lake Rd/county Rd 109, it happened in the middle lane on 94W about a mile back from said exit (could be a little more than a
mile back somewhere between 1-3 miles back from that exit). _______________________________________________________________________________________________________
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? I would like to be reimbursed for repairing my rim, some reimbursement for a new tire (as mine only had
30,000 miles on an 85,000-mile tire), and finally I would like the pothole to be fixed (it is in the middle lane of a 3 lane road on 94 – a very busy road).
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 _2012_ Make _Volkswagen_______ Model _Beetle__________ Color ___Red_____________
License Plate # __BUL030___________________ </w:tState vehicle is registered in Minnesota
Registered owner of vehicle _Joseph McNamara___ </w:t><Driver ____Jennifer McNamara____________
Area(s) damaged __Front passenger tire and rim_______________________________________________
If a City vehicle was involved: License Plate # _______________________________ <Color _______________________________
Was there City insignia on the vehicle? Yes No Driver’s Name </w_____________________________________________
Other property damaged: ___________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? __N/A_____________________________________________________________________
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. I am attaching the paperwork/bill from getting a new tire(s) at Tires Plus. As you will
see I had all my tires replaced because the back 2 were older tires and the other new front one got replaced because I cannot have different brands of tires paired together. Hence why
we just replaced them all at once. My tires are low profile tires, and most car shops don’t keep them on hand, let alone the Goodyear’s I had on them. The other document I am attaching
is my paperwork/bill from my rim getting fixed at Alloy Wheel Repair. In total there are 3 pages. One page is a front and back page, but the back page doesn’t have any important information
on it. Please note that Alloy Wheel Repair is located at 1025 Tomlyn Ave Shoreview, MN 55126 and not the address stated on the paperwork.
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: _Jennifer McNamara______________________________ <
Signature of Person submitting this form: ___Jennifer McNamara____________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 2/17/2022
Revised December 2021