Northrup, EricNOTICE 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 is to the Saint Paul City Clerk’s Office. You may email, fax
(651-266-8574) or mail the form. Mailing address is “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”
Individuals: First Name __Eric__________________________ Last Name _Northrup____________________________________
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, then provide your Insured’s/ Client’s Name ____________________________________________________________
Street Address: _____2324 11th Ave E______________________________________________________
City: ___Menomonie_____________________ State ___Wisconsin________________ Zip Code ____54751________
Daytime/Work Phone ______612-462-5783_________________________ Cell Phone _______612-462-5763_______________
Date of Incident or Date Discovered (Must complete) 3/19/2023 Time 7:30pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _I hit a large pothole at the intersection of
St. Albans St and Fuller Ave on Sunday, March 19th at roughly 7:30pm. Upon hitting this pothole I noted that I had a flat tire. After
changing to my spare, I noticed I lost both tires on one side of my car. Meaning I could no longer drive the car home. I parked it at a
nearby gas station and waited for AAA to tow me to a shop to replace my tires.__________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _Had the city patched this pothole. It would
not have been able to damage my tires.____________________________
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.
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 ____________________
Revised December 2021
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.
______The intersection of St Albans St and Fuller Ave___________________________________________________________
Notice of Claim Form, page two. Failure to complete and return both pages will result in delays.
What would you like to see happen to resolve this claim to your satisfaction? The city of St. Paul reimburses me for the tires I had to
replace due to the presence of this large pothole. Unfortunately, as I run a staggered set of tires (larger in rear) I had to replace all
four of my tires due to the damage to the front and rear passenger side tire. ___
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 __2004____ Make ___BMW______________ Model ___330Ci_____ Color _____Black__________
License Plate # __ARA 6854________________ State vehicle is registered in _________Wisconsin_______________
Registered owner of vehicle ____Eric Northrup ___________ Driver _______Eric Northrup _______________________
Area(s) damaged ____Front and rear passenger side tires causing me to have to replace all four tires.________
If a City vehicle was involved: License Plate # _______________________________ Color _______________________________
Was there City insignia on the vehicle? NO Driver’s Name _____________________________________________
Other property damaged: ___________NA________________________________________________________________________
For injury claims of any type.
What part of your body was injured? _________NA_________________________________________________________________
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? NO
Did you miss any work as result of this incident? YES Employer(s) ________Ohly Americas_______________________
How much time have you missed from work?________One day_____________________________________________
If you are submitting other documents, please state what you are attaching and how many pages. _ In addition to this document, I
am submitting my invoice for the damage repaired on my vehicle (four tires), images of the damaged tires, the pothole and
intersection sign. Five additional images will accompany this report. One of the images will display my tire in the trunk. As I removed
the tire prior to recording the damage. On both tires you will be able to note where the sidewall burst, it appears as a distinct line.
______
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: ____Eric Northrup____________________________________________
Signature of Person submitting this form: __________________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 4/16/2023
Revised December 2021