Bedeau, JasonRevised 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: Jason Last Name: Bedeau
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? NO If yes, what is your Claim/File Number? GEICO 0629122380101018
Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________________
If yes, then provide your Insured’s/ Client’s Name ___________________________________________________________________
Street Address: 7766 Inskip Trail South
City: Cottage Grove State Minnesota Zip Code 55016
Daytime/Work Phone 612-709-8821 Cell Phone 612-709-8821
E-mail Jason.Bedeau@outlook.com
Date of Incident or Date Discovered (Must complete) 8/14/2024 Time 5:48 PM CST
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. I was involved in auto accident with a City
of Saint Paul owned vehicle. Driver was Rigoberto Bustamante Aguirre – Rigo.Aguirre@stpaul.gov. Rigoberto failed to yield the
right of way and struck my vehicle in a city owned vehicle. A 2018 Chevrolet Impala VIN:2G11X5S33J9117656 MN Tag#110WZK
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Driver provided City of Saint Paul insurance
information. Insurance company listed as “State of Minnesota Department of Commerse” and the Policy Number is listed as “City
of Saint Paul”. Driver of the City of Saint Paul owned vehicle failed to yield right-of-way and stuck my vehicle. GEICO determined
that I am not at fault. Rigoberto admitted to being at fault on the scene and to the police officer on the scene.
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.
Revised March 2023
☐ 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: CG24025368
If yes, what law enforcement agency responded? Cottage Grove Police Department
Where did the incident take place? Please provide a street address, intersection or name of city park or facility.
70th ST S, Cottage Grove, MN 55016
What would you like to see happen to resolve this claim to your satisfaction? Reimbursement for total loss of vehicle or repairs.
Were there witnesses to this incident? Please provide names and contact phone numbers:
____________________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year 2016 Make Hyundai Model Sonata Color White
License Plate # DUT160 State vehicle is registered in Minnesota
Registered owner of vehicle Jason Joseph Bedeau Driver Jason Joseph Bedeau
Area(s) damaged Rear Drivers side in the following areas: Wheel Assembly, door, bumper, and side panel.
If a City vehicle was involved: License Plate # 110WZK Color Charcoal Gray
Was there City insignia on the vehicle? YES / NO Driver’s Name Rigoberto Bustamante Aguirre
Other property damaged: Only the two vehicles involved were damaged.
For injury claims of any type.
What part of your body was injured? No Serious Injuries.
Did you go to the emergency room or urgent care? NO Where? ___________________________________________________
Was medical treatment received? 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? NO
Employer(s) Click or tap here to enter text.
How much time have you missed from work? Click or tap here to enter text.
If you are submitting other documents, please state what you are attaching and how many pages. Minnesota Department of
Public Safety Motor Vehicle Crash Report – Obtained from Cottage Grove Police Department on 08/20/2024.
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: _____________________________________________________________
Jason Bedeau
Revised March 2023
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed ______________________________ 08/22/2024
Self