Countryman, Kira
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: __KIRA_________________ Last Name: _COUNTRYMAN_______
Please Indicate Your Pronouns: ☒ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: ___NATIONAL GENERAL INSURANCE SUBMITTING CLAIM___
Is this claim being made by an Insurance Company? YES If yes, what is your Claim/File Number? <_ 240688882____
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: _______________________________________________________________________
</
Street Address: _______________________________________________________________________________________________
City: ______________________________________________ State: ________________________ Zip Code: ___________________
Daytime/Work Phone: __________________________________ Cell Phone: _____________________________________________
Date of Incident or Date Discovered (Must Complete): 8/24/2024 Time: _Approx 7:35a____________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: _Insured vehicle hit while parked and unattended_
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _Vehicle owned by the City that caused the damage_
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: _242370005__________________________
If yes, what law enforcement agency responded? __St Paul Police Department_______________________
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
__ N Schuneman Ave and Hague Ave _______________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction? _We are currently handling our insured’s damage and will be seeking reimbursement ____________________
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 _None that we are aware
of _________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _2015________ Make: SUBARU Model: OUTBACK Color: RED
License Plate #: AHF273 State vehicle is registered in: _____MN______________________
Registered owner of vehicle: __Kira Countryman_________ Driver: ____parked and unattended_____
Area(s) damaged:_driver side fender,bumper, door,hood, front suspension _____________________________________________________________________________________
If a City vehicle was involved, License Plate #: _3-484________________________________ Color: UNK_____________
Was there City insignia on the vehicle? YES / NO Driver’s Name</w: __Joseph Gerard Grant________
Other property damaged: _______________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? __N/A_____________
Did you go to the emergency room or urgent care? YES / 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): _________________________________________________________________________________________________
How much time have you missed from work? __N/A_____________________________________
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: _Angela Hargrave – Subrogation with National General Insurance_____________ <
Signature of Person submitting this form: __Angela Hargrave_____________________________________________________
Relationship of person signing to Party making the claim: Insurance Company Representative
Date document is being signed: 10/16/2024
Revised March 2023