Christie, StephenNOTICE 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 aBer the alleged loss or injury is discovered a noDce staDng the Dme, place, and circumstances thereof, and the amount of compensaDon
or other relief demanded.”
Please complete this form in its en@rety by clearly typing or prin@ng your answers to each ques@on. If you have addi@onal documenta@on you may add those
documents to your submission. You will not be contacted by telephone unless clarifica@on is needed. The claim process for inves@ga@ons can take upwards of
four (4) weeks. This form must be signed, dated with all applicable sec@ons completed. Submission is to the Saint Paul City Clerk’s Office. You may email, fax
(651-266-8574) or mail the form. Mailing address is “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”
Individuals: First Name _Stephen Last Name _CHRISTIE
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His X_ They/ Them/Theirs ☐
Company or Business Name: ______________________________________________________________________________
Is this claim being made by an Insurance Company? If yes, what is your Claim/File Number?: _____________________
Is this claim being made by an AJorney? Choose an item. If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
Street Address: __1384 Victoria St N, St Paul, MN 55117____________________________________________________
DayVme/Work Phone _______________________________ Cell____651-332-6736______________________________________
Date of Incident or Date Discovered (Must complete) __December 5, 2024 Time _ 08:45 am
Please state, in detail, what happened that prompted you to file a NoVce of Claim Form. _ A St Paul Regional Water Service team
came to my residence at 1384 Victoria St N to update and refit the water meter as part of its citywide program. Outside I personally
observed a SPRWS technician (name unknown) drill a hole into the siding of my house near the wrong cellar window near the NW
corner. The technician admiJed the error and his confusion as to which access window , and both he and I immediately contacted
his supervisor Joseph Tronson. Shortly thereaber Tronson came to my house to inspect the issue along with two other SPRWS
personnel, including Ty Vidal. Vidal photographed the damage and noted some addiVonal damage to the glass block cellar window
caused by the errant drilling (i.e., a drill hole into a glass block). Vidal advised me how to iniVated the claims process. The tech who
drilled the hole profusely apologized to my wife and me aber finishing the job at a different, appropriate access located at the rear of
the house.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __See above_____________________
Please check the reason that most closely describes the reason for your submi_ng a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submiJed become the property of
the City of Saint Paul and shall not be returned.
☐ Automobile damage from a motor vehicle accident: please provide two esVmates for repairs or actual bill that has been paid.
☐ Automobile damage from a street defect or pothole : please provide two esVmates 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 Vcket (if available), receipt
from Impound Lot, and two esVmates for repairs or actual bill that has been paid.
☐ Snow Emergency: please provide copy of towing Vcket (if available), receipt from Impound Lot, and two esVmates for repairs or
actual bill that has been paid.
X Property damage: please provide two esVmates 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.
This sec@on must be completed for all claims.
Is there a police report for this incident? Yes No If yes, please provide the police report case number ___No_________________
Revised December 2021
If yes, what law enforcement agency responded? _______________________________________________________
Where did the incident take place? Please provide a street address, intersecVon or name of City park or facility.
________________________________________________________________________________________________________
No@ce of Claim Form, page two. Failure to complete and return both pages will result in delays.
What would you like to see happen to resolve this claim to your saVsfacVon? _ Compensatory damages paid to repair the property
damage___________
Were there witnesses to this incident? Please provide names and contact phone numbers. _ See above incident details
For property damage claims, including vehicle accidents.
Your vehicle’s informaVon: 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 _____________________________________________
Other property damaged: _ Home siding and cellar glass block window______________________________________________
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 sVll receiving medical treatment? Yes No
Did you miss any work as result of this incident? Yes No Employer(s) _______________________________________________
How much Vme have you missed from work?___________________________________________________________________
If you are submi_ng other documents, please state what you are aaaching and how many pages. ______________________
By signing this form, you agree that all informa3on provided is true and correct to the best of your knowledge.
Please NOTE that submiAng a false or misleading claim can and will result in prosecu3on under Minnesota Statutes.
Name of Person compleVng form: ___Stephen J ChrisVe_____________________________________________
Signature of Person submigng this form: __/s/ Stephen J ChrisVe__________________________________________________
RelaVonship of person signing to Party making the claim: _the same
Date document is being signed _ December 17, 2024
Revised December 2021