Luzum, Steven
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 is to the Saint Paul
https://www.stpaul.gov/departments/city-clerkCity Clerk’s Office. You may <
mailto:cityclerk@ci.stpaul.mn.usemail, 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 ____Steve________________________ Last Name _Luzum___________________________________
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His <☐_ They/ Them/Theirs ☐
Company or Business Name: ______________________________________________________________________________
Is this claim being made by an Insurance Company? </w:t </w:t></w:r If yes, what is your Claim/File Number?: <_____________________
Is this claim being made by an Attorney? Choose an item. If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
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Street Address: 1262 Sargent Ave_________________________________________________________________________
City: ________Saint Paul_________________________ State _______MN_______ Zip Code _____55105______
Daytime/Work Phone _____651-303-3678______________ Cell Phone ____________________________________________
Date of Incident or Date Discovered (Must complete) 1/4/2023Time _____________10:00____________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. __Because of the lack of plowing on my street during and after the last snow storm on and
around 1/11/23, the ruts in the street became so bad, that the drivability of my vehicle became so bad, I took it into Precision Tune to see what was making all the noise when driving
through the horrible ruts in the street (from the lack of plowing). There is was discovered that the front upper control arm bushings and the rear anti-sway bar bushing were destroyed.
See attached estimate___________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __ After the last snow storm, on about Jan 8, 2023, the city of Saint Paul waited too long to
call a snow emergency, then called a modified snow emergency, didn’t plow my street, then called it off half way through, then finally called another snow emergency. The delay in plowing
the streets and the need of citizens to get to work cause huge ruts in the streets that wreaked havoc on my suspension._________
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.
This section must be completed for all claims.
Is there a police report for this incident? 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, intersection or name of City park or facility.
________________________________________________________________________________________________________
Notice 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 satisfaction? ___I would like the City of St. Paul to pay for the repair to my suspension______________________________________
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 ___2002___ Make ____Oldsmobile______ Model __Bravada____ Color _____Grey___________
License Plate # ___212UTX__________________ State vehicle is registered in _____MN___________________
Registered owner of vehicle Steve Luzum_____________________ Driver ______________________________________
Area(s) damaged _______Rear and front suspension______________________________________________
If a City vehicle was involved: License Plate # _______________________________ Color _______________________________
Was there City insignia on the vehicle? Yes No Driver’s Name </w_____________________________________________
Other property damaged: ___________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? ________NONE_____________________________________________________
Did you go to the emergency room or urgent care? 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? Yes No Employer(s) <_______________________________________________
How much time have you missed from work?___________________________________________________________________
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: ____________Steve Luzum____________________________________ <
Signature of Person submitting this form: __________xxxxxxxx___________________________________________
Relationship of person signing to Party making the claim: ___________________
Date document is being signed _____________
Revised December 2021