Rassett, DrewNOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota
Minnesota State Statute466.05 states that “…every person…whoclaims damages from any municipality…shallcause to be presented tothe governing body of the
municipalitywithin180days after the allegedlossor injury is discovered a notice stating thetime,place,and circumstancesthereof,and the amount ofcompensation
orother relief demanded.”
Please complete this form in its entirety by clearly typing or printing your answers to each question.If you have additionaldocumentation,you may addthose
documentsto your submission.You will not be contacted bytelephone unless clarification is needed.Theclaim process for investigations can take upwardsof
four (4)weeks.This form must be signed,dated withall applicable sections completed.Submission this completed form tothe Saint Paul CityClerk’s Officeby
email(cityclerk@ci.stpaul.mn.us),fax(651-266-8574)ormail addressedto “Saint Paul City Clerk,15 West Kellogg Blvd.,Suite 310,Saint Paul,MN 55102”.
Claimant:First Name:Drew Last Name:Rassett
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?YES /NO If yes,what is your Claim/File Number?_________________________
Is this claim being made by an Attorney?YES /NO If yes,what is your File Number?_______________________________________
If yes,provide your Insured’s/Client’s Name:_______________________________________________________________________
Street Address:337 7th St.W Apt.531
City:St.Paul State:MN Zip Code:55102
Daytime/Work Phone:651-447-9663 Cell Phone:651-447-9663
Date of Incident or Date Discovered (Must Complete):03/31/23 Time:2:30 PM
Please state,in detail,what happened that prompted you to file a Notice of Claim Form:Whirring sound from my tire immediately
after hitting a large pothole at the intersection of 7th St.W and Smith Ave.N and my car’s front right tire needed to be replaced.
Please state why or how you feel the City of Saint Paul is responsible for your Damages?The pothole was unavoidable at a busy
intersection and the pothole wasn’t fixed for many weeks.
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.
RevisedMarch 2023
This section must be completed for all claims.
Is there a police report for this incident?YES /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:
At the intersection of 7th St.W and Smith Ave.N.
What would you like to see happen to resolve this claim to your satisfaction?
I would like to be compensated for the damages.
Were there witnesses to this incident?Please provide names and contact phone numbers:
Kaitlyn LaRocco,507-271-5311
For property damage claims,including vehicle accidents.
Your vehicle’s information:Year:2019 Make:Toyota Model:Camry Color:Silver
License Plate #:DPN701 State vehicle is registered in:MN
Registered owner of vehicle:John M.Rassett Driver:Drew J.Rassett
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:______________________________________________________
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:Drew J.Rassett
Signature of Person submitting this form:
Relationship of person signing to Party making the claim:Self
Date document is being signed:6/26/2023
RevisedMarch 2023
RevisedMarch 2023