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Notice of Claim Form - Fillable - 2023_0 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 this completed form to the mailto:Saint%20Paul%20City%20Clerk’s%20OfficeSaint 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: _Shirlee______________________________ Last Name: Jordan_______________________________________________ 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? NO 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, provide your Insured’s/ Client’s Name: _______________________________________________________________________ </ Street Address: __583 Pleasure Creek Dr ___________________________________________________________________________________________ City: __Blaine____________________________________________ State: __MN______________________ Zip Code: 55434___________________ Daytime/Work Phone: _763-287-5607_________________________________ Cell Phone: _651-492- 3119____________________________________________ 9:45 Date of Incident or Date Discovered (Must Complete): 4/1/2023 Time: ______9:45 pm_______________________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ____Hit a very large pothole on George St. and it popped two tires________________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? __The potholes are out of control. They aren’t even filled with gravel, which would mitigate the issue. It’s virtually impossible to avoid the potholes. __________________________________ 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. 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? 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: _Near 171 Bellows and George St. in Saint Paul __________________________________________________________________________________________________________ What would you like to see happen to resolve this claim to your satisfaction? Reimburse for the cost of new tires. ____________________________________________________________________________________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent></w:sdt><w:r w:rsidR="0031571E" w:rsidRPr="00 Kathy Connolly 651-247-6533 ____________________________________________________________________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year: _________2018 Make: Toyota_________________ Model: Camry__________________ Color: Black__________________ License Plate #: BCZ845_________________________ State vehicle is registered in: Minnesota___________________________ Registered owner of vehicle: Shirlee Jordan_____________________________ Driver: Shirlee Jordan__________________________________________ Area(s) damaged: Passenger side front and rear 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? NO Where? ___________________________________________________ Was medical treatment received? 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? 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: _ Photos of potholes, receipt for two new tires, plus area where damage occurred. _______________________ 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: ___________Shirlee Jordan__________________________________________________ < Signature of Person submitting this form: ____Shirlee Jordan___________________________________________________ Relationship of person signing to Party making the claim: ____Self______________________________________ Date document is being signed: 4/7/2023 Revised March 2023