Stauff, ShannonNOTICE 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: __Shannon___________________ Last Name: _____Stauff__________________________________________
Please Indicate Your Pronouns: ☐ She/Her/Hers
Company or Business Name: ____________________________________________________________________________________
Is this claim being made by an Insurance Company? YES / NO If yes, what is your Claim/File Number? ______No_______________
Is this claim being made by an AIorney? YES / NO If yes, what is your File Number? ______________No_____________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: ________1898 Rome Ave ____________________________________________________________________
City: ______Saint Paul___________________________ State: _______MN_________________ Zip Code: ______55116_______
DayUme/Work Phone: ______651-955-7588_______________ Cell Phone: _____________________________________________
Date of Incident or Date Discovered (Must Complete): ____11/29___________________ Time: ____1:00 pm___________________
Please state, in detail, what happened that prompted you to file a NoUce of Claim Form: ____I was exiUng the pullout near Bolhand
Ave and Mississippi River Road coming back into traffic.. The barriers, large irons bars low to the ground, were secured with chains on
the lec side (drivers side) as I went to the exit, but the one on the right (passenger side) was unsecured at a 45 degree angle into the
drivers path. I was unable to see it because it was so low to the ground and it wasn’t visible over the hood of my Ford Explorer. I was
traveling 10-15 mph and was suddenly slammed into my windshield, the enUre car stopped with significant force. I didn’t know what
had happened because there was no object I could see. The iron bar has pierced my wheel well, and gone through into the engine
itself. Oil leaked, my engine cracked and the car smoked. I had to be towed and it took over 6 weeks to repair.______________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ___The iron bar should have been secured.
It was secure on the on the visible side (drivers side), with chains, signaling the exit was open and clear. Not only was the passenger
side iron bar unsecured, but it was placed directly in the line of the drivers path with low visibility because of its nearness to the
ground.
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.
X Automobile damage from a motor vehicle accident: please provide two esUmates for repairs or actual bill that has been paid.
☐ Automobile damage from a street defect or pothole: please provide two esUmates 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 Ucket (if available), receipt
from Impound Lot, and two esUmates for repairs or actual bill that has been paid.
Revised March 2023
☐ Snow Emergency: please provide copy of towing Ucket (if available), receipt from Impound Lot, and two esUmates for repairs or
actual bill that has been paid.
☐ Property damage: please provide two esUmates 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.
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, intersecUon or name of city park or facility:
___901 Mississippi River Road, Ford Dam Overlook____________________________________________________
What would you like to see happen to resolve this claim to your saUsfacUon?
__I would like to be reimbursed for the out of pockets costs, repairs and rental car, that exceeded my insurance policy maximums.
Totaling $2119.18. for the repairs over and above my policy payout_and $445.00 for rental car.__________.
Were there witnesses to this incident? Please provide names and contact phone numbers:
____Not to the incident itself, only to the acemath. ____________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s informaUon: Year: _2019________ Make: ___Ford__________ Model: __Explorer Sport______ Color______White__
License Plate #: _____2NK429____________________ State vehicle is registered in: ____MN_______________________
Registered owner of vehicle: __Shannon Stauff___________________________ Driver: ___Shannon Stauff_____________
Area(s) damaged:_____Passenger side body, wheel well, engine, steering, fender, bumper, Ure, (see aIached for full details including
photos)________________
If a City vehicle was involved, License Plate #: _______n/a__________________________ Color:
_______________________________
Was there City insignia on the vehicle? YES / NO Driver’s Name: __________n/a____________________
Other property damaged: _____________n/a___________________________________________________
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 sUll receiving medical treatment? YES / NO
Revised March 2023
Did you miss any work as result of this incident? YES / NO
Employer(s): _________________________________________________________________________________________________
How much Ume have you missed from work? _____________________________________________________________________
If you are submiBng other documents, please state what you are aKaching and how many pages: ___Rental Car out of pocket
costs exceeding policy maximum______________________
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 compleUng form: ________Shannon Stauff_____________________________________________________
Signature of Person submiing this form: _______________________________________________________
RelaUonship of person signing to Party making the claim: ____Self______________________________________
Date document is being signed: ____1/13/24_________________
Revised March 2023