LaRose, Sember (2)
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: Name Click or tap here to enter text. Attorney Lori Peterson o/b/o claimant Sember LaRose
Please Indicate Your Pronouns: She/ Her/Hers ☒ He/Him/His <☐_ They/ Them/Theirs ☐
Company or Business Name: _____Lori Peterson Law Firm __________________________________________________
Is this claim being made by an Insurance Company? </w:no </w:t></w:r 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? _ n/a __________________
If yes, then provide your Insured’s/ Client’s Name <_____Sember LaRose____(resident of St. Paul) __________________
</
Street Address: ____attorney address is 222 S. 9th Street, #1600_____________________________
City: ___Minneapolis________________ State __MN____________ Zip Code _____ 55402<__________
Daytime/Work Phone ________ attorney phone 612-321-0606____ Cell Phone __________________________________
Date of Incident or Date Discovered: Click or tap to enter a date.Time Approx. Dec. 21, 2021-August 29, 2022
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. LaRose suffered damages during her employment at the St. Paul Public Library when patrons were
allowed to abuse her and other staff. Also, see attached.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Repeatedly allowed and encouraged a dangerous and hostile work environment and more. See attached.
Click or tap here to enter text.
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 police were called at various times but Claimant is not aware of what reports
were made_
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. St. Paul Public Library, George Latimer Branch. See attached.<
________________________________________________________________________________________________________
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 injuries and changes in policies and procedures so the misconduct experienced
does not happen to others_________________
Were there witnesses to this incident? Please provide names and contact phone numbers. ___ Catherine Penkert, Maureen Hartman, Katrina Hartz Taylor, Joanna Brookes, Toni Newborn, Margo
Bock, Allie Affinito, Ronald Paulson, Tati Terfa and others.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year ______ Make _________________ Model ____________________ Color ________________
License Plate # _____________________ State vehicle is registered in ________________________
Registered owner of vehicle ______________________________ Driver ______________________________________
Area(s) damaged ___________________________________________________________________________________
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? Claimant suffered/continues to suffer damages including but not limited to fear, anxiety, grief, humiliation and other emotional distress and physical
manifestations of same and physical sickness ranging from nausea, vomiting, sleeplessness and more.
Did you go to the emergency room or urgent care? Yes No Where? _________________________________________________
Was medical treatment received? Yes No Where? </__ Yes____________________________________________________________
First day of medical treatment? _____________ Are you still receiving medical treatment? Yes
Did you miss any work as result of this incident? Yes No Employer(s) <______ YES<_________________________________________
How much time have you missed from work?_____Since I left work in August of 2022___________________________
If you are submitting other documents, please state what you are attaching and how many pages. ____ 1 page email_______
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: ________Lori Peterson________________________________________ <
Signature of Person submitting this form: ______L/P_________________________________________________________________
Relationship of person signing to Party making the claim: ______ attorney_____________
Date document is being signed 1/5/2023
Revised December 2021