Bonin, Luke
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 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: ______Luke_______________ Last Name: _______Bonin________________________________________
Please Indicate Your Pronouns: ☐ She/Her/Hers, * He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: ______N/A___________________________________________________________________
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, provide your Insured’s/ Client’s Name: _______________________________________________________________________
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Street Address: __________2001 Portland Ave ________________________________________________________________
City: ______St. Paul__________________________ State: ____________MN____________ Zip Code: _55104_______
Daytime/Work Phone: _____612-666-3850_____________________________ Cell Phone: _________612-666-3850________
Date of Incident or Date Discovered (Must Complete): ____3/13/2023_________________________ Time: ________________2:00_____________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: _____My front bumper is dented and a piece of the protection on the under-belly of my car has
been detached. ________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ___The street I was driving on wast Finn St. off of Snelling Ave. and it had not been plowed
for weeks. There lanes from cars driving overt but it was icy and not safe.
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? 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:
___________________Finn St. and Snelling Ave., right outside of Dunkin’ Donuts and Play it Again Sports__________
What would you like to see happen to resolve this claim to your satisfaction? ___________I would like some reparations to help pay for the damages caused. ___________________________
Were there witnesses to this incident? Please provide names and contact phone numbers: _____________________________No________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: ___2018______ Make: ___Nissan_______ Model: ___Murano_______ Color: ______Blue______
License Plate #: ______GHP_ 570_______________ State vehicle is registered in: ______MN_____________________
Registered owner of vehicle: ____Mark Bonin_____________ Driver: _____________Luke Bonin________
Area(s) damaged:______Front Bumper, Under tow ____________________________________
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? _________________________N/A________________________________
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: ____________Luke Bonin_________________________________________________
Signature of Person submitting this form: ________________Luke Bonin_______________________________________
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: _____4/12/2023________________
Revised March 2023