Gray, GinaRevised March 2023
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 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: Gina Last Name: Gray
Please Indicate Your Pronouns: ☒ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: N/A
Is this claim being made by an Insurance Company? NO If yes, what is your Claim/File Number? _________________________
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: _______________________________________________________________________
Street Address: 2479 Pond Circle W
City: Mendota Heights State: MN Zip Code: 55120
Daytime/Work Phone: __________________________________ Cell Phone:612-964-6700
Date of Incident or Date Discovered (Must Complete): 1/13/2024 Time: 5:50pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: I was stopped at a stop light on Snelling and
Ford Parkway in Saint Paul and am ambulance backed into my front bumper. He didn’t see me. He immediately got out of the
vehicle and asked me to wait for his peer so they could get the patient to the hospital. I accepted and talked to Joel Ihrie, the
supervisor on duty.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? I was stopped at a light and the ambulance
backed into me. I tried to get out of the way but couldn’t in time. The driver and supervisor admitted fault.
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.
Revised March 2023
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? 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, intersection or name of city park or facility:
Corner of Snelling Ave and Ford Parkway, Saint Paul MN
What would you like to see happen to resolve this claim to your satisfaction?
I would like the scratch to be fixed. It is a leased vehicle and shouldn’t be my responsibility.
Were there witnesses to this incident? Please provide names and contact phone numbers: Paramedic Joel Ihrie 206-992-7065
____________________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2024 Make: BMW Model: 330i Color: White
License Plate #: KXB 298 State vehicle is registered in: MN
Registered owner of vehicle: Gina Gray Driver: Gina Gray
Area(s) damaged: Front Bumper
If a City vehicle was involved, License Plate #: Medic 19 Color: Click or tap here to enter text.
Was there City insignia on the vehicle? YES / NO Driver’s Name: The driver had to rush to the hospital so his partner, Joel Ihrie,
stayed.
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: Estimate from BMW. 3 pages.
Because this is a leased vehicle, I have to get it fixed through BMW.
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: Gina Gray
Revised March 2023
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: 2/5/2024