Lemere, JamesRevised 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: __James____________________ Last Name: ____Lemere________________________
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: __Nicolet Law, Attorney Lindsay Lien Amin________________________________
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? YES If yes, what is your File Number? ___26622________________________________
If yes, provide your Insured’s/ Client’s Name: __James Lemere__________________________________________________
Street Address: __517 2nd Street, Suite 205__________________________________________________________
City: ___Hudson_____________________ State: ___WI_____________ Zip Code: __54016________
Daytime/Work Phone: __715-245-2415____________ Cell Phone: _____________________________________________
Date of Incident or Date Discovered (Must Complete): 9/23/2024 Time: _____________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: __Officer rear-ended Mr.
Lemere____________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __Officer at fault for auto collision_______
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.
24179834 – injury to head, neck, back, and shoulders ☐ 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.
Revised March 2023
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: __24179834_____________________
If yes, what law enforcement agency responded? ____St. Paul _______________________________________
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
______35E near Robert Street____________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?
____________________________________________________________________________________________________________
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: __2003___ Make: __Dodge_ Model: __Ram__ Color: __________________
License Plate #: _________________________ State vehicle is registered in: ___________________________
Registered owner of vehicle: ______James Lemere________ Driver: _____ James Lemere _____________
Area(s) damaged:____rear of truck, trailer________________________________________________________
If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________
Was there City insignia on the vehicle? YES Driver’s Name: ___Oscar Aguirre_____________
Other property damaged: _______________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? ___ injury to head, neck, back, and shoulders ____________________________
Did you go to the emergency room or urgent care? YES Where? _Hudson Hospital______________________________________
Was medical treatment received? YES Where? ________________________________________________________________
First day of medical treatment? 9/25/2024 Are you still receiving medical treatment? YES
Did you miss any work as result of this incident? YES Employer(s): ______self-employed_______________________________________________________________________________
How much time have you missed from work? _____________________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages: __Letter – 1 page__________
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: _Lindsay Lien Amin_____________________
Signature of Person submitting this form: ___s/ Lindsay Lien Amin____________________________________________________
Relationship of person signing to Party making the claim: Attorney
Date document is being signed: 10/7/2024