Dean, Rhonda
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: __Rhonda______________________________ Last Name: Dean_______________________________________________
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☐ He/Him/His, ☒ They/ Them/Theirs
Company or Business Name: National General Insurance
Is this claim being made by an Insurance Company? YES / NO If yes, what is your Claim/File Number? <____Yes 240596487_____________________
Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? __________No_____________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
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Street Address: ______________PO Box 1623_________________________________________________________________________________
City: __________Winston Salem____________________________________ State: _____NC___________________ Zip Code: _________________27102__
Daytime/Work Phone: ________________216-266-0620__________________ Cell Phone: _____________________________________________
Date of Incident or Date Discovered (Must Complete): 6/28/2024 Time: _____________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: Some police officers shot pepper spray balls into our insured’s vehicle causing damage to outside
and inside. The officers were arresting the passenger in our insured’s vehicle. ____________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ______Our insured and their vehicle was an innocent party in this arrest. ______________________________
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? Yes
If yes, please provide the police report case number: ___24114354________________________
If yes, what law enforcement agency responded? _______Saint Paul PD_____________________________________________________
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
___________Burger King drive thru in South Saint Paul_________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction? __________________We are requesting reimbursement for amount we had to pay for our insured’s vehicle repair__________________________________________________________________________________________
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 ____________________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _2024________ Make: __Kia_______________ Model: ________Forte__________ Color: White__________________
License Plate #: ER80161 State vehicle is registered in: ______IL_____________________
Registered owner of vehicle: _______________Rhonda Dean______________ Driver: Mickale Dean__________________________________________
Area(s) damaged:______Interior and exterior of vehicle. Windshield damage as well. ________________________________________________________________________________
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? _____________________________________________________________________________
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: _________________________
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: ___Jonathon Kost__________________________________________________________ <
Signature of Person submitting this form: ____Jonathon Kost___________________________________________________
Relationship of person signing to Party making the claim: __Insurance adjuster ________________________________________
Date document is being signed: 8/27/2024
Revised March 2023