Reilly, Ann
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 _Ann___________________________ Last Name Reilly
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: ___1378 Charles Ave______________________________________________________________________________________
City: __________________________St Paul__________________ State ________MN___________ Zip Code ________55104__________
Daytime/Work Phone _______________________________ Cell Phone ________651 357 6795____________________________________
Date of Incident or Date Discovered (Must complete) 1/25/2023Time ____9:00 am_____________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. ___car hit pothole on December 17 2022 on Hamline close to Hamline and Randolph (on Hamline
going south, just north of Hamline/Randolph intersection). I took my car in the service station was able to straighten the rim on 12/21/2022. That cost $63.77. Then 1/25/2023, I hit
a pothole on Hamline close to Hamline and Osceola (going south on Hamline, and just north of Hamline/Osceola intersection). This time both rims/tires on the right side were damaged
beyond repair and I had to replace two tires. That cost $675.83. The tires I had on my car are snow tires and they had a lot of tread left. __________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __Hamline is a main street for travelling in St Paul. The potholes I hit were large. Hamline
is one lane in each direction. There is little room to maneuver away from potholes. There is even less room than usual because the snow is not plowed all the way to the curb. Also
I had good quality snow tires with a lot of tread that can handle minor potholes.____________________________
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.
__close to Hamline and Randolph intersection and close to Hamline and Osceola intersection.______________________________________________________________________________________________________
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? _______be reimbursed for costs due to damage caused by potholes__________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers. __________No____________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year 2016______ Make ___VW______________ Model ____Sedan________________ Color ____white____________
License Plate # ____anp162_________________ State vehicle is registered in ______MN__________________
Registered owner of vehicle _______Ann Reilly_______________________ Driver _______Ann Reilly_______________________________
Area(s) damaged ____________both right side tires_______________________________________________________________________
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? __________________________________________________________________________
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? 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: _____Ann Reilly___________________________________________ <
Signature of Person submitting this form: ___Ann Reilly_______________________________________________________________
Relationship of person signing to Party making the claim: ___same________________
Date document is being signed 1/27/2023
Revised December 2021