Hernandez, Rosa
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: _______Rosa ______________________ Last Name: _______________________________Hernandez________________
Please Indicate Your Pronouns: ☒ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: ______American Family Insurance ______________________________________________________________________________
Is this claim being made by an Insurance Company? YES If yes, what is your Claim/File Number? <__01006330565_______________________
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: ____Delmi Martinez and Rosa Hernanadez___________________________________________________________________
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Street Address: ___ 5239 Greenfield Ave____________________________________________________________________________________________
City: ____________Saint Paul__________________________________ State: MN Zip Code: 55112
Daytime/Work Phone: ________ 612-743-3826__________________________ Cell Phone: _____________ 612-743-3826________________________________
Date of Incident or Date Discovered (Must Complete): 6/18/2023 Time: 7:15 pm_____________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: _ ambulance sideswiped insured’s vehicle as insured was waiting to turn left___________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _____city ambulance caused damages _______________________________
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: ____ 23107320_______________________
If yes, what law enforcement agency responded? ________ St Paul PD____________________________________________________
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
___ Maryland Ave E AT Payne Ave, St Paul, MN 55130_________________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction? __Repayment for repairs __________________________________________________________________________________________________________
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 ____________________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: ____2009_____ Make: _____Honda____________ Model: Pilot Color: silver
License Plate #: ____KCV111_____________________ State vehicle is registered in: Minnesota
Registered owner of vehicle: ____ Delmi Martinez_________________________ Driver: Rosa Hernandez__________________________________________
Area(s) damaged:_____ entire passenger side is scratched, front door makes noise when opening_________________________________________________________________________________
If a City vehicle was involved, License Plate #: _________________________________ Color: ambulance
Was there City insignia on the vehicle? YES Driver’s Name</w: ______ Frank Daly________________________________________________
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: ____Diane Gallagher_________________________________________________________ <
Signature of Person submitting this form: ____Diane Gallagher___________________________________________________
Relationship of person signing to Party making the claim: ____Claims Adjuster ______________________________________
Date document is being signed: 11/16/2023
Revised March 2023