Solomon, Mike
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: ______________Michael_________ Last Name: ____Solomon_____________________________________
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? 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: _______________________________________________________________________
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Street Address: 539 St. Clair Ave
City: ________________________________St. Paul_ State: __________MN___________ Zip Code: ________55102______
Daytime/Work Phone: Click or tap here to enter text. Cell Phone: 651-308-4891_
Date of Incident or Date Discovered (Must Complete): 3/16/2023 Time: _____________________7:00pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: _I was forced to go through a pothole located near St. Clair and Pleasant Ave in the Eastbound
lane of traffic coming down the hill towards the river by oncoming traffic. The large holes in the pavement take up the entirety of the lane (see attached photo) and with oncoming traffic
was unavoidable. Upon contact with the hole even at low speeds the tire sidewall was punctured leading to a total flat and requiring complete replacement of the tire due to the size
and severity of the holes. In the dark these holes are less visible especially with oncoming traffic lights that prevent identification of a safe path through them.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __The City is responsible for this damage as it allowed these multiple large potholes to exist
for more than a month prior to the incident in this high traffic location. I am aware of previous reports of this pothole made by neighbors in the area. The depth and severity of the
holes makes them particularly damaging and the location of multiple holes across the lane of traffic makes them unavoidable. The City had knowledge of these holes as they are in such
a high use area between the entrance and exit ramps at 35 E interstate St. Clair. The City’s further knowledge is shown by the fact that the potholes have since been marked with high
visibility neon colored tape and yet still not repaired in any way as of today’s date. This action shows the City’s liability and that the holes should have been marked or repaired.__________________________________
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:
This incident took place at the enormous pothole near St. Clair Ave and Pleasant Ave just before the Avenue Bridge over 35E in the east bound lane coming down the hill.
What would you like to see happen to resolve this claim to your satisfaction? ______________________The City should pay for the cost of the damaged tire that needed to be replaced in
the amount of $212.59_________
Were there witnesses to this incident? Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent></w:sdt><w:r w:rsidRPr="003033E3" w:rsidR="00 ___________No______________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: ____2013 Make: __________BMW___ Model: ______328i_____ Color: _____Blue_________
License Plate #: _____MKW__147________________ State vehicle is registered in: __________________MN________
Registered owner of vehicle: ___________Michael Solomon_ Driver: __Same as owner____________________________
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</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? 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: ______________Michael Solomon_____________________________________ <
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: 4/11/2023
Revised March 2023