Sannoh, Yayah
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 this completed form to the
mailto:Saint%20Paul%20City%20Clerk’s%20OfficeSaint 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: Yayah Last Name: Sannoh
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: Progressive Insurance
Is this claim being made by an Insurance Company? YES If yes, what is your Claim/File Number? <23-4375919
Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
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Street Address: _______________________________________________________________________________________________
City: ______________________________________________ State: ________________________ Zip Code: ___________________
Daytime/Work Phone: __________________________________ Cell Phone: _____________________________________________
Date of Incident or Date Discovered (Must Complete): 9/4/2023 Time: 3:30 PM CT
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: City of Saint Paul vehicle failed to yield the right of way in intersection, entered the intersection
from a stop sign, and struck a vehicle going through the intersection from a direction that did not have any traffic control devices.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? City of Saint Paul is the registered owner of the claimant vehicle. When I called the City, I
was directed to complete this form.
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.
This section must be completed for all claims.
Is there a police report for this incident? YES
If yes, please provide the police report case number: 23510176
If yes, what law enforcement agency responded? MN State Patrol
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
Intersection of N Xerxes Ave onramp to Hwy 100 SB and Hwy 100 SB exit lane.
What would you like to see happen to resolve this claim to your satisfaction? I would like a summary statement from the driver of the City Vehicle.
Were there witnesses to this incident? Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent></w:sdt><w:r w:rsidR="0031571E" w:rsidRPr="00 No.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2016 Make: Mazda Model: 3 Color: Gray
License Plate #: 220 VJR State vehicle is registered in: MN
Registered owner of vehicle: Same as claimant info above Driver: Same as claimant info above
Area(s) damaged: Passenger side rear door, quarter-panel, rear wheel, rear bumper. Being processed as a probable total loss.
If a City vehicle was involved, License Plate #: 970101_ Color: White
Was there City insignia on the vehicle? YES / NO Driver’s Name</w: BALLARD-LEROY, AMAREAH R
Other property damaged: Light pole
For injury claims of any type.
What part of your body was injured? Yes, our insured sustained injuries.
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: Destry Brink <
Signature of Person submitting this form: Destry Brink 651-234-5384
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: _____________________
Revised March 2023