Levine, Erika
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 _Erika________________________ Last Name _____Levine___________________________________
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? <No </w </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: __623 Laurel Ave, Apt 2E______________________________________________________________________
City: ____St. Paul____________________________________ State ____MN________ Zip Code _____55104_____________
Daytime/Work Phone ____920-222-6601__________________ Cell Phone _____920-222-6601________________________
Date of Incident or Date Discovered (Must complete) 1/17/2023Time _____1:40pm____________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. __I was driving below the speed limit northbound on Lexington Parkway North when I hit a giant
pothole slightly before the Como Avenue intersection on 1/17/23 around 1:45pm. The pothole was mostly obscured by snow and was more like a sinkhole into the ground. My tire immediately
popped upon impact. __________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _ I was forced to pay $354.92 just to replace that tire and fix the alignment issues the pothole
caused to my vehicle. I later learned that this pothole had been reported to the city by multiple residents as many cars had suffered the same damage. I have attached two posts from
the Como Neighborhood Facebook group identifying this pothole and the damage it was doing. Comments on that post confirmed that residents had been contacting the City of St. Paul to
repair this pothole. A subsequent post shows multiple hubcaps from vehicles that hit that pothole and lost hubcaps. _____________________________
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 ____________________
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.
_Intersection of Lexington Parkway N and Como Avenue_______________________________________________________
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? _Payment for the expense of repairing the tire and rebalancing. ________________________________________
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 __2022____ Make Honda </Model __Civic____________ Color __Black______________
License Plate # _____JXK 986________________ State vehicle is registered in ______MN__________________
Registered owner of vehicle ______Erika Levine________ Driver ____Erika Levine________________________
Area(s) damaged _____Passenger side front tire ______________________________________________________
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? __________________________________________________________________________
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. _6 pages total._Bill from tire repair (3 pages); two screenshots of Como Neighbor group
Facebook posts regarding damage done by pothole (2 pages); Photo of flat tire on car (1 page) ____________________
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: ____Erika Levine____________________________________________ <
Signature of Person submitting this form: _____/s/ Erika Levine_____________________________________
Relationship of person signing to Party making the claim: ___Self________________
Date document is being signed 2/4/2023
Revised December 2021