Notice of Claim Form - Fillable - 2023- K. GerhartRevised March 2023
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 compensat ion
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 this completed form to the Saint Paul City Clerk’s Office by email
(cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”.
Claimant: First Name: _Korinne ______________ Last Name: Gerhart ____________________________________
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? YES / NO If yes, what is your Claim/File Number? _________________________
Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? _______________________________________
If yes, then provide your Insured’s/ Client’s Name ___________________________________________________________________
Street Address: 65 Garfield Street ____________________________________________________
City: Saint Paul ________________ State MN __________________ Zip Code 55102 ___________
Daytime/Work Phone __________________________________ Cell Phone 267-912-1989 _______________________
Date of Incident or Date Discovered (Must complete) 4/5/2023Time 6:30 AM______________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. Hit a pothole that caused a hole in my tire.
Had to pay for a tow and new tire. __________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _Not fixing potholes that become deeper
with time causing more damage to cars and it’s unsafe to swerve around them into other lanes.
___________________________________
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.
Revised March 2023
Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays.
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: ___________________________
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.
__7th Street West and Scheffer Ave.
________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?
_Pothole fixed and reimbursement for towing and tire.
___________________________________________________________________________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
I was taking my husband to work and he ended up missing a day of work. His name is Micah Gerhart and his number is 267-733-
3219.
____________________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year _2016_ Make __Mini___ Model __Countryman____ Color ___Red_____
License Plate # _______FEJ618__________________ State vehicle is registered in __MN_________________________
Registered owner of vehicle _Korinne_____________ Driver __Korinne_____________
Area(s) damaged ____________________________Front passenger side tire. ____________________________
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) _My husband missed a day of work with Twin Cities Orthopedics.
________________________________________________________________________________________________
How much time have you missed from work? __10 HR Shift.
___________________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages. _Towing and tire replacement
receipt. 2 additional pages. ________________________
Revised March 2023
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: __Korinne Gerhart___________________________________________________________
Signature of Person submitting this form: Click or tap here to enter text.
Relationship of person signing to Party making the claim: ____Self______________________________________
Date document is being signed 4/6/2023