Yzermans, McKenziNOTICE 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 answer to each question. If more space is
needed, attach additional sheets. Please note that you will not be contacted by telephone to clarify answers, so provide as
much information as necessary to explain your claim, and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed, and both pages completed. If something does not apply, write ‘N/A’.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name ______________________ Middle Initial ____ Last Name ________________________________
Company or Business Name ___________________________________________________________________
Are You an Insurance Company? Yes / No If Yes, Claim Number? __________________________________
Street Address ______________________________________________________________________________
City ______________________________________ State _____________________ Zip Code __________
Daytime Phone (____)____-______ Cell Phone (____)____-______ Evening Telephone (____)____-______
Date of Accident/ Injury or Date Discovered _______________________ Time _________ am / pm
Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. ___________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Please check the box(es) that most closely represent the reason for completing this form:
My vehicle was damaged in an accident My vehicle was damaged during a tow
My vehicle was damaged by a pothole or condition of the street My vehicle was damaged by a plow
My vehicle was wrongfully towed and/or ticketed I was injured on City property
Other type of property damage – please specify ______________________________________________
Other type of injury – please specify _______________________________________________________
In order to process your claim you need to include copies of all applicable documents.
For the claims types listed below, please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills
and/or receipts for the repairs; detailed list of damaged items
Injury claims: medical bills, receipts
Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2 – Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims – please complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers: ________________________________________________
_____________________________________________________________________________________________
Were the police or law enforcement called? Yes No Unknown (circle)
If yes, what department or agency? __________________________ Case # or report # _________________
Where did the accident or injury take place? Provide street address, cross street, intersection, name of park or facility,
closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. _______________________
______________________________________________________________________________________________
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. ______________________________________________________________________________
______________________________________________________________________________________________
Vehicle Claims – please complete this section ________ check box if this section does not apply
Your Vehicle: Year __________ Make _______________ Model_________________________________
License Plate Number _______________ State _____ Color ________________________
Registered Owner __________________________________________________________
Driver of Vehicle ___________________________________________________________
Area Damaged______________________________________________________________
City Vehicle: Year __________ Make _______________ Model_________________________________
License Plate Number _______________ State _____ Color ________________________
Driver of Vehicle (City Employee’s Name)_______________________________________
Area Damaged______________________________________________________________
Injury Claims – please complete this section ________ check box if this section does not apply
How were you injured? ____________________________________________________________________________
_______________________________________________________________________________________________
What part(s) of your body were injured? ______________________________________________________________
_______________________________________________________________________________________________
Have you sought medical treatment? Yes No Planning to Seek Treatment (circle)
When did you receive treatment? _______________________________________________________(provide date(s))
Name of Medical Provider(s):_________________________________ ______________________________________
Address_________________________________________________________ Telephone ______________________
Did you miss work as a result of your injury? Yes No
When did you miss work? ____________________________________________________________(provide date(s))
Name of your Employer: ___________________________________________________________________________
Address__________________________________________________________Telephone______________________
Check here if you are attaching more pages to this claim form. Number of additional pages ____.
By signing this form, you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed ________________________
Print the Name of the Person who Completed this Form: ______________________________________________
Signature of Person Making the Claim: _____________________________________________________________
Revised February 2011