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Fuller, HaileyNOTICE 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 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” Individuals: First Name ____________________________ Last Name _____________________________________________ Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His ☐_ They/ Them/Theirs ☐ Company or Business Name: ______________________________________________________ ________________________ Is this claim being made by an Insurance Company? 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? _______________________________ If yes, then provide your Insured’s/ Client’s Name _____________________________________________________ _______ Street Address: ______________________________________________________ ___________________________________ City: ____________________________________________ State ___________________ Zip Code __________________ Daytime/Work Phone _______________________________ Cell Phone ____________________________________________ Date of Incident or Date Discovered (Must complete) _____________________________Time _________________________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _____________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? ______________________________ 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 ____________________ 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. ______________________________________________________ __________________________________________________ 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? _________________________________________ 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 ______ 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 _____________________________________________ 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. ______________________ 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: ________________________________________________ Signature of Person submitting this form: ______________________________________________________ _________________ Relationship of person signing to Party making the claim: ___________________ Date document is being signed _____________ Revised December 2021 3/15/23, 6:08 PMPage 1 of 1