Benkufsky, Sharon
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 ____________________________ Last Name _____________________________________________
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His <☐_ They/ Them/Theirs ☐
Company or Business Name: Metropolitan Council ______________________________________________________
Is this claim being made by an Insurance Company? NO If yes, what is your Claim/File <Number?: 2022015280001
Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
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Street Address: 390 North Robert Street _______________________________________________
City: _St Paul__________________ State _MN____________ Zip Code ____55101__________
Daytime/Work Phone __651-602-1788______________________ Cell Phone ___N/A_________________________________
Date of Incident or Date Discovered (Must complete) 7/23/2022Time _______6:34_______________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _Police car drove in reverse and hit a Metropolitan Council bus________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __The police officer was at fault for this auto accident_________________
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. Tiffany Thompson -Waddell is injured worker <
☐ 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? YES If yes, please provide the police report case number ____22005718________
Revised December 2021
If yes, what law enforcement agency responded? ___Metro Transit Police_________________________
Where did the incident take place? Please provide a street address, intersection or name of City park or facility.
___Wacouta St / 4th St St Paul, MN 55101____________________________________________
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? _Reimbursement of cost of repairs in the amount of To be determined____________
Were there witnesses to this incident? Please provide names and contact phone numbers. ____N/A___________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: 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 # ___Police________________________ Color ____Black_____________________
Was there City insignia on the vehicle? YES Driver’s Name </w_Sean Mcmanus______________________________
Other property damaged: ___N/A____________________________________________________________________________
For injury claims of any type.
What part of your body was injured? _________Concussion_________________________________________________________________
Did you go to the emergency room or urgent care? Yes No Where? ________No_________________________________________
Was medical treatment received? Yes No Where? </_____________ Yes Allina Health 8/11/2022_________________________________________________
First day of medical treatment? 8/11/2022 Are you still receiving medical treatment? Yes
Did you miss any work as result of this incident? Yes No Employer(s) <______Yes _________________________________________
How much time have you missed from work?_______8 Weeks ____________________________________________________________
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: _Sharon Benkufsky___________________________ <
Signature of Person submitting this form: ___Sharon Benkufsky____________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 12/8/2022
Revised December 2021