Fillable Notice of Claim form.docx - Google Docs 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 a er the alleged loss or injury is discovered a no ce sta ng the me, place, and circumstances thereof, and the amount of compensa on
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: Brian ____________________________ Vega _____________________________________________
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His ☐ _ They/ Them/Theirs ☐
Company or Business Name: __ _N/A _________________________________________________________________________
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 A orney? No If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name Brian Vega __________________________________________________________
Street Address: _ 1206 Prairie Street ______________________________________________________________________
City: ________ Chaska _________________________________ State ______ MN ___________ Zip Code ___ 55318 ____________
Day me/Work Phone ____ _952-594-0642 ____________________ Cell Phone _____________ 952-594-0642 ______________
Date of Incident or Date Discovered (Must complete) _____ 03/06/2022 ____________________Time ____ 11:40am __________
Please state, in detail, what happened that prompted you to file a No ce of Claim Form.
On 03/06/2022, I, Brian Vega, was traveling eastbound on highway I-35E and Ramsey St. At 11:40am, on Ramsey St, which was above
me while I was traveling eastbound on I-35E, a St. Paul snow plow was plowing snow off of Ramsey St. onto I-35E. Now I obviously do
not need to explain why that is extremely dangerous but I will so that there is no misinterpreta on. If you plow snow off of a street
onto a highway below, it could cause an accident to happen on the highway below, damage a vehicle, injure a driver etc. That is
exactly what happened to me. As I was traveling eastbound on I-35E, while the snow plow was plowing snow off of Ramsey St, The
snow that the snow plow was plowing off of Ramsey St. onto I-35E below, hit my vehicle. There was a lot of snow and ice chunks.
Fortunately, I did not get into an accident but the snow and ice chunks ended up cracking my windshield pre y badly. I will provide a
picture of the cracked windshield.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The City of Saint Paul is responsible for my
damages because one of their snow plows caused damage to my vehicle.
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 submi ed become the property of
the City of Saint Paul and shall not be returned.
☐ Automobile damage from a motor vehicle accident: please provide two es mates for repairs or actual bill that has been paid.
☐ Automobile damage from a street defect or pothole : please provide two es mates 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 cket (if available), receipt
from Impound Lot, and two es mates for repairs or actual bill that has been paid.
☐ Snow Emergency: please provide copy of towing cket (if available), receipt from Impound Lot, and two es mates for repairs or
actual bill that has been paid.
☐ Property damage: please provide two es mates 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 ____________________
Revised December 2021
If yes, what law enforcement agency responded? _______________________________________________________
Where did the incident take place? Please provide a street address, intersec on or name of City park or facility.
_______ I-35E and Ramsey St. _______________________________________________________________________
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 sa sfac on? _I would like the city to pay for an installa on AND a
new windshield for my vehicle.
Were there witnesses to this incident? Please provide names and contact phone numbers. ________ No. ___________________
For property damage claims, including vehicle accidents.
Your vehicle’s informa on: Year 2012 ___ Make __ Mazda _____________ Model ___ 3 _______________ Color ___ White ______
License Plate # ___ MUN330 _______________ State vehicle is registered in ____ MN ________________
Registered owner of vehicle _____ Daniel Vega _______________________ Driver ______ Brian Vega _____________
Area(s) damaged ___________ Front Windshield _______________________________________________________
If a City vehicle was involved: License Plate # _______________________________ Color _______________________________
Was there City insignia on the vehicle? Yes No Driver ’s Name _____________________________________________
Other property damaged: ___________________________________________________________________________________
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 s ll receiving medical treatment? Yes No
Did you miss any work as result of this incident? Yes No Employer(s) _______________________________________________
How much me have you missed from work?___________________________________________________________________
If you are submi ng other documents, please state what you are a aching and how many pages. _I am a aching two price
es mates of a new windshield for my vehicle. I am also providing a picture of the windshield damage to my vehicle._________
By signing this form, you agree that all informa on provided is true and correct to the best of your knowledge.
Please NOTE that submi ng a false or misleading claim can and will result in prosecu on under Minnesota Statutes.
Name of Person comple ng form: ____ Brian Vega _______________________________
Signature of Person submi ng this form: ______ Brian Vega ____________________________________________________
Rela onship of person signing to Party making the claim: ___________________
Date document is being signed _____ 03/08/2022 ______
Revised December 2021