Hicks, David
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 David____ Last Name _Hicks__________
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His <☒_ They/ Them/Theirs ☐
Company or Business Name: ___Hicks Trucking Inc. ___________________________
Is this claim being made by an Insurance Company? </NO </ </w:t></w:r 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 ____________________________________________________________
</
Street Address: 13 Beebe Ave
City: Mendota Heights </w:t></w:r><w:r><w:State MN___________________ Zip Code _55118_________________
Daytime/Work Phone ___651-554-9249___________ Cell Phone ___612-290-0760_________________
Date of Incident or Date Discovered (Must complete) 1/20/2023Time _6:30 pm________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form.
I was driving southbound on Western Ave and Charles Street, I hit a major size pothole. It caused damage to my Semi truck. It broke the motor mounts on my vehicle which caused my Fan
shroud to break, and it fell into the fan blades which caused damage to my radiator. I had to have it towed to the shop to be repaired. I missed four days of work while waiting for the
repairs to be completed.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The pothole should have been fixed and it was very large to where you could not avoid the pothole.
__
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< 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.
_WESTERN Ave and Charles street, in St.Paul, mn the block is 540 Charles street <________________________________________________________________________________
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? __Compensation for Damages done to my Commercial Vehicle_
Were there witnesses to this incident? Please provide names and contact phone numbers. ______________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year 2004Make __Kenworth ______ Model _____W900L____ Color ______White_____
License Plate # ____YTE5217___________ State vehicle is registered in _____________MN_______
Registered owner of vehicle ____David E Hicks Jr___ Driver ________David E Hicks Jr_________________
Area(s) damaged Motor mounts, Fan Shroud ,Fan Blade ,Radiator, wheel alignment___________________
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? ___na_______________________________________________________________________
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) <_Yes____________________________________
How much time have you missed from work?__4 days__________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages. _I am submitting pictures of the pothole and damages. I am also submitting tow receipt
and estimates of repair. ___________________
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: _____David Hicks Jr. ___________________________________________ <
Signature of Person submitting this form: ____David Hicks Jr._____________________________________
Relationship of person signing to Party making the claim: ____self_______________
Date document is being signed 2/12/2023
Revised December 2021