Blanchard, Brandon
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: Brandon Last Name: Blanchard
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: Liberty Mutual Insurance
Is this claim being made by an Insurance Company? YES If yes, what is your Claim/File Number? <053406769
Is this claim being made by an Attorney? NO If yes, what is your File Number? ___NA____________________________________
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): 5/6/2023 Time: 4:00 AM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: Our insured, Brandon Blanchard, was going south on Roberts St. in Saint Paul, MN. Our insured
was going straight through the intersection of 7th St., on a green light. A City of Saint Paul, unmarked police car was traveling straight on 7th St, and had a red light. The unmarked
police car went through the red light and entered the intersection, causing the front of the police car to hit the driver’s side of our insured’s vehicle. The unmarked police car did
not have emergency lights on when it went through the light and into the intersection.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The unmarked police car did not have emergency lights or a siren on when the officer went through
a red light and hit our insured’s vehicle. Our insured had the right of way.
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: 23075852
If yes, what law enforcement agency responded? St Paul Police Dept
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
Intersection of 7th St and Robert St, St Paul, MN
What would you like to see happen to resolve this claim to your satisfaction? Liberty Mutual is requesting reimbursement for the damages paid for our insured’s 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 _________________n/a________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2020 Make: Ford Model: F-150 Color: silver
License Plate #: FDG582 State vehicle is registered in: MN
Registered owner of vehicle: Stacy Torkelson Driver: Brandon Blanchard
Area(s) damaged: Drivers side fender, wheel, front and rear door and cab
If a City vehicle was involved, License Plate #: 698WVE _ Color: unknown
Was there City insignia on the vehicle? NO Driver’s Name</w: Brian Michael Wanschura
Other property damaged: no
For injury claims of any type.
What part of your body was injured? _____________________________________________________________________________
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? YES / NO
Did you miss any work as result of this incident? 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: full demand with estimate, supports, including color photos of vehicle
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: Dawn Chavez <
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: Subrogation Representative for Liberty Mutual Insurance
Date document is being signed: 10/3/2023
Revised March 2023