French, GinaNOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466'05 states thot "...every person...who claims damages from any municipotity...shall cause to be presented to the governing body of themunicipolity within 180 doys after the olleged loss or iniury is discovered o notice stating the time, place, and circumstonces thereof, ond the amount of compensotion
or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answers to each question. lf you have additional documentation you may add thosedocuments to your submission. You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards offour (4) weeks. This form must be signed, dated with all applicable sections completed. Submission is to the Saint paul City Clerk,s Office. you may email, 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,,
lndividuals: First Name _Gina
French
Last Name
Please lndicate Your Pronouns: she/ Her/Hers X He/Him/His I_ They/ Them/Theirs n
Company or Business Name
ls this claim being made by an lnsurance Company? NO lf yes, what is your Claim/File Number?
ls this claim being made by an Attorney? NO lf yes, what is your File Number?
Name Gina Fren
Street Address: _2320 Lower Afton RD
#418
City: _Maplewood
55119
Daytime/Work Phone _
5833
CellPhone 61,2-7so-rg+2
State _M Zip Code
Date of lncident or Date Discovered (Must completel3/IO/2OZ3T|me _6:45 pM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. Hit HUGE pothole which resulted in
immediate flat tire._Split sidewall - unfixabl
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _HUGE UNMARKED pOTHOLE-There was an
additional car pulled over with same issue - flat tire._
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.
n Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid.
X Automobile damage from a street defect or pothole : please provide two estimates for repairs or actual bill that has been paid.
X Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt
from lmpound Lot, and two estimates for repairs or actual bill that has been paid.
n Snow Emergency: please provide copy of towing ticket (if available), receipt from lmpound Lot, and two estimates for repairs or
actual bill that has been paid.
n Property damage: please provide two estimates for repairs or actual bill that has been paid.
n You were injured during a motor vehicle accident: please provide police report number, details about injury.
n 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.
lsthereapolicereportforthisincident? NOlfyes,pleaseprovidethepolicereportcasenumber
Revised December 2027
lf yes, what law enforcement agency responded?
-MN
State Trooper notified for lights while car was being loaded on flatbed
tow truckJ called 911 for trooper lights - busy rd where I was stopped
Where did the incident take place? Please provide a street address, intersection or name of City park or facility. West Lower Afton
Road
West Lower Afton Rd near HWY 61 intersection - pulled over right away on HWY 61 (in front of ANOTHER car with the same issue)
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? _Reimburse 5zo for new tire and fill potholeJ side
wall of tire was split - not able to
Were there witnesses to this incident? Please provide names and contact phone numbers. _Bryan Bergquist 763-567-
1773
For propertv damage claims, including vehicle accidents.
Your vehicle'bla(K s information:Year _201.4_ Make _B MW Model _328i xdrive-- Color
License Plate # BAM039 State vehicle is registered in _MN
Registered owner of vehicle Gina French Driver Gina
French
Area(s) damaged _Right front tire - FLAT/side wall split - unable to patch_-
lf a City vehicle was involved: License Plate #Color
Was there City insignia on the vehicle? Yes No Driver's Name
Other property damaged
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)
l\,e- !
How much time have you missed from work?
For iniurv claims of anv tvpe.
What part of your body was injured?
lf you are submitting other documents, please state what you are attaching and how many pages.
By signing this form, you qgree thot all information provided is true and correct to the best ol your knowledge.
Pleose NOTE that submitting a folse or misleading claim cdn and will result in prosecution under Minnesota Stotutes.
Name of Person completing form: _Gina Fr
Signature of Person submitting this form
Relationship of person signing to Party maki claim
Date document is being signed 3/13/2023
LF
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