Collins, Jenna
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: Jenna Last Name: Collins
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? <_________________________
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: 7664 Woodlawn Drive, Apt 10
City: Mounds View State: MN Zip Code: 55112
Daytime/Work Phone: __________________________________ Cell Phone: 6513299868_
Date of Incident or Date Discovered (Must Complete): 8/21/2024 Time: 1:15 pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: I was with two friends, walking across the cross walk at the intersection of Lafayette and 7th
St, walking toward The Listening House. When I stepped into a Water Supply Manhole That didn’t have the cover on it. My leg went in just under my knee. My leg buckled and my other knee
hit the pavement hard the shock stunned me. It took me a few second to realize what had happened. My friends ran over to me and pulled me out. I then was helped across the street. I
started to black out and I had to sit down. My friends called 911 but after a few minutes I felt well enough to have one of my friends drive me to the hospital. There were no signs indicating
that there was no cover on the manhole. I was Seen at United Hospital for my leg injuries and to make sure I was ok. I filed a police report as well in hopes the cops could make sure
the manhole was covered up to prevent anyone else from getting hurt.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? I believe the City is responsible for the damages because that manhole cover should have been
there and it was not. There was no warning or signs indicating that it wasn’t their.
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: 24814506
If yes, what law enforcement agency responded? They told me to file a police report online.
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
Lafayette/ 7th Street East, St Paul, MN
What would you like to see happen to resolve this claim to your satisfaction? I would like to have my medical bill for the hospital visit be covered and to see the city fix the missing
Manhole cover so no one else gets hurt.
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 Rebekah Gaiovnik 6513738148
Paige Leigh 6513918206
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? Both of my legs
Did you go to the emergency room or urgent care? YES Where? United Hospital Emergency Room
Was medical treatment received? YES Where? </________________________________________________________________
First day of medical treatment? 8/21/2024 Are you still receiving medical treatment? NO
Did you miss any work as result of this incident? 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: I am attaching my after visit summary for my emergency room visit 3 pages and 2 pictures.
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: Jenna Collins <
Signature of Person submitting this form: Jenna Collins
Relationship of person signing to Party making the claim: Self
Date document is being signed: 9/3/2024
Revised March 2023