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Junemann, ManuelaNOTICE 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: ________________________________ Last Name: _______________________________________________ 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 AIorney? YES / NO If yes, what is your File Number? _______________________________________ If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________ Street Address: _______________________________________________________________________________________________ City: ______________________________________________ State: ________________________ Zip Code: ___________________ DayNme/Work Phone: __________________________________ Cell Phone: _____________________________________________ Date of Incident or Date Discovered (Must Complete): _____________________________ Time: _____________________________ Please state, in detail, what happened that prompted you to file a NoNce of Claim Form: ____________________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? ____________________________________ 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. ☐ Automobile damage from a motor vehicle accident: please provide two esNmates for repairs or actual bill that has been paid. ☐ Automobile damage from a street defect or pothole: please provide two esNmates 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 Ncket (if available), receipt from Impound Lot, and two esNmates for repairs or actual bill that has been paid. ☐ Snow Emergency: please provide copy of towing Ncket (if available), receipt from Impound Lot, and two esNmates for repairs or actual bill that has been paid. ☐ Property damage: please provide two esNmates 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. Revised March 2023 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? 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, intersecNon or name of city park or facility: ____________________________________________________________________________________________________________ What would you like to see happen to resolve this claim to your saNsfacNon? ____________________________________________________________________________________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers: ____________________________________________________________________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s informaNon: Year: _________ Make: _________________ Model: __________________ Color: __________________ License Plate #: _________________________ State vehicle is registered in: ___________________________ Registered owner of vehicle: _____________________________ Driver: __________________________________________ Area(s) damaged:______________________________________________________________________________________ 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 sNll receiving medical treatment? YES / NO Did you miss any work as result of this incident? YES / NO Employer(s): _________________________________________________________________________________________________ How much Nme have you missed from work? _____________________________________________________________________ If you are submiBng other documents, please state what you are aKaching and how many pages: _________________________ 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 compleNng form: _____________________________________________________________ Signature of Person submiYng this form: _______________________________________________________ Revised March 2023 RelaNonship of person signing to Party making the claim: __________________________________________ Date document is being signed: _____________________ Revised March 2023 Page of 1 1 NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Manuela Junemann — Attached Writing Please state, in detail, what happened that prompted you to file a Notice of Claim Form: On August 20th 2023 I went on a walk with my daughter Clara Junemann at Crosby Farm Regional. Just around 10am we walked onto the landing to look at the little lake. When I turned around my leg went into a narrow slit/hole due to a missing plank in the landing. I fell all the way in until my upper leg got stuck and stoped the downfall, with my full body weight slamming against it. I screamed in pain and couldn’t move. A woman doing yoga ask if I was okay and offered offered us her help. There was a metal beam (see pictures) that went into my leg that made most of the damage to my leg. The swelling increased rapidly. We considering calling 911. My daughter, who is an EMT, suggested getting ice to quickly stop the swelling and she drove us to the nearest Starbucks to get a bag of ice. I put pressure and ice on my leg for the rest of the day and rested in bed. The next day I still could not put weight onto my leg, which is when I decided seek help at Como Urgent Care. I could not walk at all for 2 weeks. The incident resulted in pain in mostly my right leg, my hips and my right shoulder. My body was twisted and slammed into this metal beam. As of today I still feel pain in my leg and it still shows deformation from the metal beam that slammed into it. I have consistent pain in my right shoulder and go to physiotherapy. At this point, I am not sure if the pain will ever go away. Please state why or how you feel the City of Saint Paul is responsible for your Damages? I reported the missing plank to the City of Saint Paul to prevent others from going through this painful experience. Almost 6 months later, it still has not been repaired. I am disappointed about how little the City cares and have now decided to recover damages for missed work and ongoing pain that I had to endure from the negligence of the City of Saint Paul. I have not retained an attorney in the hope that this can be resolved without. PUeIeUUed QaPe: MaQX JXQePaQQ (LeJaO QaPe: MaQXeOa JXQePaQQ) _ DOB: 10/23/1964 _ MRN: 94648865 PCP: NeKa SaNRZVNL, MD CC: INJURY, LEG (PresenWs Woda\ ZiWh injXr\ Wo righW leg. PaWienW fell inWo open space Zhile Zalking on dock. RighW leg is brXised and abrasions presenW. ) SUBJECTIVE: ManXela JXnemann is a 58 \.o.female Zho presenWs Wo UrgenW Care for eYalXaWion of righW leg injXr\. RLJKW OHJ PaLQ OnseW: 8/20/23InciWing eYenW: righW leg fell beWZeen Zooden plank LocaWion: righW leg Pain characWerisWic: sore Progression of s\mpWoms: pain and sZelling improYing AssociaWed s\mpWoms: FeYer: no SZelling: resolYed Redness: no Pain limiW fXncWion: can Zalk Woda\ HisWor\ of similar pain: no LasW Tdap 3/23/2023 ROS: 8 poinW ROS Zas negaWiYe oWher Whan noWed aboYe. OBJECTIVE: ViWal Signs: BP 122/73 (BP LocaWion: RighW Arm, BP CXff Si]e: RegXlar) _ PXlse 80 _ Temp 97.9 F (36.6 C) (T\mpanic) _ Resp 16 _ SpO2 99% . PK\VLFaO E[aPConsWiWXWional: Appearance: Normal appearance. HENT: Head: Normocephalic and aWraXmaWic. MoXWh/ThroaW: MoXWh: MXcoXs membranes are moisW. E\es: E[WraocXlar MoYemenWs: E[WraocXlar moYemenWs inWacW. CardioYascXlar: RaWe and Rh\Whm: Normal raWe. ASSRLQWPHQW GHWaLOV NRWHV APaQXHO S ZHZGLH aW 8/21/2023 b2:20 PM PURJUHVV NRWHV PXlmonar\: EfforW: PXlmonar\ efforW is normal. MXscXloskeleWal: General: No sZelling or deformiW\. Tenderness: PLOG WHQGHUQHVV RI ULJKW WKLJK TXaG, bXW QRW RI IHPXU; QR SaOSabOH HIIXVLRQ.Normal range of moWion. RighW loZer leg: No edema. LefW loZer leg: No edema. Skin: Findings: BrXising (ULJKW WKLJK) presenW. NeXrological: MenWal SWaWXs: She is alerW. Sensor\: No sensor\ deficiW. MoWor: No Zeakness. CoordinaWion: CoordinaWion normal. GaiW: GaiW normal. Ps\chiaWric: ThoXghW ConWenW: ThoXghW conWenW normal. Labs: None. Imaging: None. ASSESSMENT/PLAN: PaWienW is a 58 \.o.female Zho presenWs ZiWh righW Whigh pain afWer WhaW leg falling beWZeen WZo planks. AmbXlaWing Zell and no bon\ Wenderness, so fracWXre Xnlikel\. No neXrological or YascXlar deficiWs noWed. Offered XR Wo rXle oXW fracWXre; paWienW declined Zhich is reasonable. Plan noWed beloZ discXssed aW Wime of YisiW. SXpporWiYe care discXssed - aceWaminophen and ibXprofen; heaW on sore mXscle Plan discXssed ZiWh paWienW DiscXssed concerning signs/s\mpWoms WhaW ZoXld caXse Whem Wo reWXrn Wo clinic or seek emergenW care To folloZ Xp ZiWh PCP as needed 1. RLJKW OHJ SaLQ AmanXel ZeZdie, MD ManXela JXnemann is a 58 \.o.female presenWs Wo Whe UrgenW Care for INJURY, LEG (PresenWs Woda\ZiWh injXr\ Wo righW leg. PaWienW fell inWo open space Zhile Zalking on dock. RighW leg is brXised and abrasions presenW. ) Pain LocaWion/s:Whigh, righW, scaWWered, Xpper, loZer loZer leg, righW, scaWWered, Xpper, loZerHoZ long haYe \oX had Whis pain?: 1da\(s) HoZ freqXenW is \oXr pain: inWermiWWenW (on and off) pain is ZorsW ZiWh moYemenW HoZ seYere is \oXr pain (1-10): 4 WhaW does \oXr pain feel like: dXll Does \oXr pain e[Wend Wo an\ oWher parW of \oXr bod\: No Is Where an\ sZelling/redness/brXising aW Whe area? YES Is Whis dXe Wo an injXr\: YES Where did Whis InjXr\ happen? PaUN, 08/20/2023 aW 11aP DaWe/Wime of InjXr\: 1 da\(s) agoDid \oX feel a snap, pop, crack, or WXg aW Whe Wime Whe pain began? YES Since onseW of pain, hoZ has \oXr condiWion been: improYed Do \oX haYe an\ pain Zhen Zalking? YES MaL V aW 8/21/2023 b2:20 PM NXUVLQJ NRWH Do \oX haYe nXmbness or Wingling? No Do \oX haYe an\ Zeakness? YES HaYe \oX eYer had sXrger\ Wo Whe area? No HaYe \oX eYer had a similar episode before? No Does Whis limiW Zork or acWiYiWies: YES Does \oXr pain keep \oX aZake aW nighW: No WhaW haYe \oX Wried for pain: Ice: Relief: YES MedicaWions: T\lenol/AceWaminophen: Relief: YES PaWienW reqXesWs an e[cXse leWWer for Zork/school: Yes Mai Nong Vang 8/21/2023, 2:39 PM M\CKaUWn OLceQVed IURP ESLc S\VWePV CRUSRUaWLRQ i 1999 - 2024