Gurstelle, Bill
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 ____WILLIAM_________________ Last Name _______GURSTELLE___________________
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His x<☐_ They/ Them/Theirs ☐
Company or Business Name: ______________________________________________________________________________
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? no . If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
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Street Address: ___1536 Mississippi River Blvd S
City: ________________St. Paul_________________ State __________MN_________ Zip Code _____55116_______
Daytime/Work Phone ________612-791-2111______________ Cell Phone __612-791-2111_____________
Date of Incident or Date Discovered (Must complete) ___Feb 17, 2022____________Time _____1: 00 PM approx_
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _I was driving westbound on Shepard Road between Rankin St and Alton and hit a very large pothole.
The impact blew my tire and badly dented my rim. The tire was not new so I’m not asking for the tire cost, but the rim was destroyed (see photo, attached. ) The cost of the rim (which
the tire shop got from a salvage shop) is $250 ____________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _That pot hole was in a city street.________
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.
☐XX 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 ___NO_________________
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.
___________Shepard Road westbound between Rankin and Alton streets.______
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? ______A check for $250, please_
Were there witnesses to this incident? Please provide names and contact phone numbers–.Karen Hansen: 612 710 2715_
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year _2017__ Make ___Infiniti_____ Model ____QX-50_______ Color _______White_________
License Plate # ____BNS024____ State vehicle is registered in _____MN___________________
Registered owner of vehicle ___William Gurstelle____ Driver ____William Gurstelle_____
Area(s) damaged _______Driver side back tire rim__________________________
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. __one page receipt for new tire rim and a photo of damaged rim____________________
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: __William Gurstelle______________________________________________
Signature of Person submitting this form: ________________________
Relationship of person signing to Party making the claim: _____self______________
Date document is being signed ___2/21/2023__________
Revised December 2021