Yuska, ThomasNOTICE 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 aBer the alleged loss or injury is discovered a noDce staDng the Dme, place, and circumstances thereof, and the amount of compensaDon
or other relief demanded.”
Please complete this form in its en1rety by clearly typing or prin1ng your answers to each ques1on. If you have addi1onal documenta1on, you may add those
documents to your submission. You will not be contacted by telephone unless clarifica1on is needed. The claim process for inves1ga1ons can take upwards of
four (4) weeks. This form must be signed, dated with all applicable sec1ons 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: Thomas. Last Name: Yuska
Please Indicate Your Pronouns: ☐ She/Her/Hers, X 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 AIorney? NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: 1249 Osceola Avenue
City: Saint Paul. State: MN. Zip Code: 55105
DayVme/Work Phone: __________________________________ Cell Phone: 651-315-1686
Date of Incident or Date Discovered (Must Complete): March 25, 2023. Time: 1:15 pm
Please state, in detail, what happened that prompted you to file a NoVce of Claim Form: Bicycling east on St. Clair, at Ann St. I rode
into a pothole that spanned the width of my lane. The front wheel got stuck in the hole and I was thrown off my bicycle, hi‘ng the
pavement first on my right shoulder, then on the side of my head (I was wearing a helmet). Medical examinaVon has revealed that
my right clavicle is fractured.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The City is responsible for negligence in road
repair. This pothole spanned the width of the eastbound lane, causing addiVonal safety hazards by potenVally forcing eastbound
traffic into the oncoming lane to avoid the hazard. (One of the aIached photos documents that happening). No effort was made to
temporarily decrease the depth of the pothole to make it safer for passage.
Please check the reason that most closely describes the reason for your submiBng a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submiIed become the property of
the City of Saint Paul and shall not be returned.
☐ Automobile damage from a motor vehicle accident: please provide two esVmates for repairs or actual bill that has been paid.
☐ Automobile damage from a street defect or pothole: please provide two esVmates 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 Vcket (if available), receipt
from Impound Lot, and two esVmates for repairs or actual bill that has been paid.
☐ Snow Emergency: please provide copy of towing Vcket (if available), receipt from Impound Lot, and two esVmates for repairs or
actual bill that has been paid.
Revised March 2023
☐ Property damage: please provide two esVmates 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.
X You were injured in the City of Saint Paul: please provide police report number, witnesses, and details about injury.
ConEnue to page 2 of NoEce of Claim Form. Failure to complete and return both pages will result in delays.
This secEon 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, intersecVon or name of city park or facility:
On St. Clair Ave at Ann St.
What would you like to see happen to resolve this claim to your saVsfacVon?
I want the City of reimburse me for $742.17 of medical expenses related to this accident.
Were there witnesses to this incident? Please provide names and contact phone numbers:
No. There were no vehicles or pedestrians present when the incident occurred.
For property damage claims, including vehicle accidents.
Your vehicle’s informaVon: Year: _________ Make: _________________ Model: __________________ Color: __________________
License Plate #: _________________________ State vehicle is registered in: ___________________________
Registered owner of vehicle: _____________________________ Driver: __________________________________________
Area(s) damaged:______________________________________________________________________________________
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? Right shoulder
Did you go to the emergency room or urgent care? YES Where? Allina Health Urgent Care—Bandana Square
Was medical treatment received? YES, as defined as x-rays and an anVbioVc regimen. Where? Allina Health-Urgent Care & Clinic—
Bandana Square
First day of medical treatment? March 25, 2023. Are you sVll receiving medical treatment? No. I completed at-home physical
therapy.
Did you miss any work as result of this incident? NO—I am reVred.
Employer(s): _________________________________________________________________________________________________
How much Vme have you missed from work? _____________________________________________________________________
Revised March 2023
If you are submiBng other documents, please state what you are aKaching and how many pages: 2 medical evaluaVon reports; 4
receipts for paid medical services; 3 photos of injury locaVon and roadway condiVon. Total pages: 9
By signing this form, you agree that all informaEon provided is true and correct to the best of your knowledge.
Please NOTE that submiBng a false or misleading claim can and will result in prosecuEon under Minnesota Statutes.
Name of Person compleVng form: Thomas Yuska
Signature of Person submi‘ng this form:
RelaVonship of person signing to Party making the claim: Self
Date document is being signed: June 8, 2023
Revised March 2023