Kessler, Sharon
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: Sharon S.______________________ Last Name: Kessler__________________________________________
Please Indicate Your Pronouns: ☒ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: _The Idea Dept.________________________
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: _______________________________________________________________________
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Street Address: ___1343 Magnolia Ave. E. ______________________________________________________________________
City: _______St. Paul_______________________________________ State: _MN_________ Zip Code: 55106___________________
Daytime/Work Phone: ___________________________ Cell Phone: 701-871-0309
Date of Incident or Date Discovered (Must Complete): 5/30/2024 Time: _____11:30 a.m.________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: __________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _I tripped on a sidewalk panel in the Highland neighborhood that was more than an inch out of
alignment. It caused me to fall, and I dislocated three fingers on my left hand and broke two of them. The bones in my left index finger were shattered and are being held together by
wires until they mend. I am facing a difficult yearlong recovery process and will likely not regain complete use of my left (dominant hand) because of this sidewalk. That sidewalk is
a hazard. I am an avid walker, have good balance and no cognitive impairment. I had surgery on May 30th, and tomorrow (7/25/24) I will have a second surgery to remove the pins from my
ring finger. Even with therapy, it is likely I will not regain complete use of my left (dominant hand) because of this uneven sidewalk. ___________________________________
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? 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:
_On the sidewalk in front of 2096 W. Highland Parkway, St. Paul______________________________________________
What would you like to see happen to resolve this claim to your satisfaction? My surgeon told me before surgery that my left hand (my dominant hand) will never be the same, and he estimates
I will have a year of OT to regain function. On July 25, I am having another surgery to remove the wires holding the bones in my left ring together. I will also have 2x weekly OT appointments
for the next year and regular check-ins with the surgeon. I have not yet been billed for a DEXA scan and an appt. with a bone density doctor. I would like the city to reimburse me $5,600
for my deductible for 2024 and 2025 ($2,800 per year) because I would not have had these co-pays and long healing track if not for a very uneven sidewalk. (My 2x weekly OT co-pay is
$29.20 per session. Over 50 weeks, that would come to $2,920 in copays. This does not include co-pays for return visits to the surgeon and X-rays, etc. I would also like some compensation
for losing the ability to work for the rest of the year. I am left-handed and this injury has also temporarily made everyday tasks difficult, including typing, holding a cell phone,
driving, using a hairdryer, washing dishes and doing household and work tasks. Along with financial compensation for my medical costs, as a taxpayer and a 10,000-step daily walker, I
implore the city to get the sidewalk fixed, because it is dangerous.___________________________________________________________________________________________________________
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 _After I fell, nobody
came to help, so I don’t think there were any witnesses. I walked back to my car, called my husband, and he took me to urgent care. The X-rays show the result of tripping on the uneven
sidewalk.
For property damage claims, including vehicle accidents.
Your vehicle’s information: 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</w: ______________________________________________________
Other property damaged: _______________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? Left hand, knee and shoulder________________________________________________
Did you go to the emergency room or urgent care? YES Where? _Summit Ortho Urgent Care Woodbury__________________
Was medical treatment received? YES Where? </ Summit Ortho doctor’s office in Woodbury for assessment, then Woodwinds Hospital for surgery___________________________________________________________
First day of medical treatment? 5/30/2024 Are you still receiving medical treatment? YES
Did you miss any work as result of this incident? YES <
Employer(s): __Yes. Freelance writer and currently unable to accept assignments because typing is very difficult. I also run a small nonprofit and am having difficulty writing grants,
fundraising letters, etc.________________________________________
How much time have you missed from work? _53 days so far_________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages: I am submitting three documents: an invoice from Summit Orthopedics for urgent care, surgery
and therapy appointments; an invoice from Metropolitan Anesthesia Network; and a photo summary showing an X-ray of my hand before surgery and one after surgery showing the pins holding
the bones in place in my ring finger, my bruised shoulder and scaped knee from the fall. This accident happened on the 2000 block of Highland Parkway, and there is a photo of the heaved
sidewalk that tripped me. The sidewalk has lots of such tripping hazards; it appears the city made asphalt ramps to make some uneven sidewalk panels less treacherous, but others remain.
___
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: _Sharon S. Kessler____________________________________________________________ <
Signature of Person submitting this form: Click or tap here to enter text.
Relationship of person signing to Party making the claim: _self_________________________________________
Date document is being signed: 7/24/2024
Revised March 2023