Wies, Connor
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 is to the Saint Paul
https://www.stpaul.gov/departments/city-clerkCity Clerk’s Office. You may <
mailto:cityclerk@ci.stpaul.mn.usemail, 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 Connor Last Name Wies
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 ____________________________________________________________
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Street Address: 801 Lakeview Ave
City: Saint Paul State MN Zip Code 55117
Daytime/Work Phone 805-801-4132 Cell Phone 805-801-4132_
Date of Incident or Date Discovered (Must complete) 3/24/2023 Time 5:30pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. I was turning left from Larpenteur Ave W onto Victoria St N when my right front tire struck
a large pothole, this resulted in a ruptured tire forcing me to replace the tire.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? This pothole is extremely deep indicating poor maintenance on the road over a prolonged period
of time. There are additional potholes and poor surface conditions for the following ½ mile along Victoria St N, indicating additional lack of maintenance
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 _____NO_______________
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.
Intersection of Larpenteur Ave W and Victoria St N
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? Reimbursement of expenses to replace my tires
Were there witnesses to this incident? Please provide names and contact phone numbers. ______________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year 2016 Make Honda Model Civic Color Black/grey
License Plate # __7TW898_____________ State vehicle is registered in CA
Registered owner of vehicle Connor Wies/Susan Wies/Frank Wies Driver Connor Wies
Area(s) damaged Front right 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? __None___________________________________________
Did you go to the emergency room or urgent care? No Where? _________________________________________________
Was medical treatment received? No Where? </_____________NO_________________________________________________
First day of medical treatment? ___NO__________ Are you still receiving medical treatment? No
Did you miss any work as result of this incident? Yes No Employer(s) <___NO____________________________________________
How much time have you missed from work?________NO___________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages. _Image of pothole, image of intersection, receipt from tire replacement_____________________
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: ____Connor Wies____________________________________________ <
Signature of Person submitting this form: Click or tap here to enter text.
Relationship of person signing to Party making the claim: ___Self________________
Date document is being signed 4/24/2023
Revised December 2021