Miller, BjornNOTICE OF CIAIM FORM totheCityof Saint Paul, Minnesota
Minnesoto Stote Stotute 466.05 stotes thot "...every person...who cloims domoges from ony municipolity...shall couse to be presented to the governing body of the
municipolity within 780 doys after the olleged loss or injury is discovered o notice stating the time, ploce, ond circumstances thereof, and the omount of compensotion
or other relief demonded."
Pleasecompletethisforminitsentiretybyclearlytypingorprintingyouranswerstoeachquestion. lfyouhaveadditional documentation,youmayaddthose
documents to your submission. You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards offour (4)
weeks. This form must be signed, dated with all appllcable sections completed. Submission this completed form to the 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:Bjorn Last Name:
Miller
Please lndicate Your Pronouns: tr She/Her/Hers, X He/Him/His, n They/ Them/Theirs
Company or Business Name:
N/A
lsthisclaimbeingmadebyanlnsuranceCompany? YES/NO lfyes,whatisyourClaim/FileNumber?
No
ls this claim being made by an Attorney? YES/ NO lf yes, what is your File Number?
No
lf yes, provide your lnsured's/ Client's Name:
N/A
Street Address:
55105
1218 Summit Avenue, St Paul, MN
City: St Paul State: Minnesota Zip Code: 55105
Daytime/Work Phone: 651-230-8056 Cell Phone:
Date of lncident or Date Discovered (Must Complele\ 3/3/2023 Time: 5:00 pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: Driving on Summit Avenue, I was unable to
avoid a pothole do to traffic. Upon hitting the pothole, my tire became flat.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The potholes are so severe on
Summit Avenue and Grand Avenue that it is sometimes not possible to swerve around them for safety reasons. This puts my safety
in jeopardy and results in damage to my vehicle.
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.
E Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid.
X Automobile damage from a street defect or pothole: please provide two estimates for repairs or actual bill that has been paid.
E Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt
from lmpound Lot, and two estimates for repairs or actual bill that has been paid.
ESnowEmergency: pleaseprovidecopyoftowingticket(ifavailable),receiptfromlmpoundLot,andtwoestimatesforrepairsor
actual bill that has been paid.
Revised March 2023
E Property damage: please provide two estimates for repairs or actual bill that has been paid.
E You were injured during a motor vehicle accident: please provide police report number, details about injury.
n 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.
ls there a police report for this incident? NO
lf yes, please provlde the police report case number:
lf 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:
Summit Avenue and
Milton
What would you like to see happen to resolve this claim to your satisfaction?
_Reimbursement for the cost of
repa i rs
Were there witnesses to this incident? Please provide names and contact phone numbers:
No
For propertv damage claims, including vehicle accidents.
Your vehicle's information: Year: 2020 Make: Audi Model: 44 Color: Black
License Plate #: NZS918 State vehicle is registered in: Minnesota
Registered owner of vehicle: Bjorn Miller Driver: Bjorn Miller
Area(s) damaged :_Front Passenger
Tire
lf a City vehicle was involved, License Plate #:
Was there City insignia on the vehicle? YES / NO Driver's Name:
Color:
Other property damaged :
For iniurv claims of anv tvpe.
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 tlme have you missed from work?
Revised Morch 2023
lf you are submitting other documents, please state what you are attaching and how many pages: _2 pages of bill incurred from
repairs
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:Christine Miller
Signature of Person submitting this form:
Relationship of person signing to Party making
Date document is being signed: 4174/2023
hec
Revised Morch 202i