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Porter, SteveNOTICE 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 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: First Name Steven______________________ Last Name _Porter______________________________________ 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? No If yes, what is your Claim/File Number?: _____________________ 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 ____________________________________________________________ Street Address: 341 Regent Dr.Click or tap here to enter text. City: La Crescent_________________________________ State __MN_______________ Zip Code _55947____________ Daytime/Work Phone N/A_________________________ Cell Phone 608-780-2827___________________________________ Date of Incident or Date Discovered (Must complete) 11/8/2022Time __7:30AM_________________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form. Walking along Kellogg Blvd to go to the River Center for a conference, I was on the right side of a group of walkers. All of a sudden tripped, nearly falling into the road, but got my feet under me without falling down. I thought it was a cut-off tree stump, and upon getting to my conference at the River Center I saw my show was torn. Back at my hotel later that day, I saw my sock had a hole in it and I had lost a chunk of skin and had blood on the left side of my right foot. I looked at the spot I tripped on Kellogg Blvd. and saw a jagged piece of dull gray cut metal just above ground length. At other trees outside The Hockey Lodge, the metal pieces (longer) look to hold an electrical outlet. It appears where I tripped the tree was cut and the metal was left in a jagged “Z” shape with two sharp points just above the ground line. Please state why or how you feel the City of Saint Paul is responsible for your Damages? It was irresponsible by a worker to remove the tree and electric box holder metal and leave a jagged piece of metal as a hard to see tripping hazard and sharp piece of metal to tare a shoe and hurt a foot. The dull gray blends in the with the ground and took inspection to actually see it and capture it on camera. Upon notifying the city on the evening of 11/8, they must have agreed as the next day on 11/9 they put out a caution cone so no one else would walk there. The $120 receipt for a new pair of shoes as well as a 2nd website is attached.__ 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. _Kellogg Blvd. just southwest of the Hockey Lodge entrance at the Xcel Energy Center _______________________________________________________________________ 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? _Reimbursed for replacing my shoes. Medical coverage of my injury if needed.________________________ Were there witnesses to this incident? Please provide names and contact phone numbers. Other walkers were around but none knew I had cut my shoe/foot on a jagged piece of metal they are strangers to me.____________________________ 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 # _______________________________ Color _______________________________ Was there City insignia on the vehicle? Yes No Driver’s Name _____________________________________________ Other property damaged: __Dress Shoes were damaged. The jagged metal was sharp enough to tare a hole and will need to eb replaced. Receipt is attached for exact same pare from the same vendor._ For injury claims of any type. What part of your body was injured? ___Foot__________________________________________________________________ Did you go to the emergency room or urgent care? NO Where? _________________________________________________ Was medical treatment received? NO Where? ______________________________________________________________ First day of medical treatment? _N/A_________ Are you still receiving medical treatment? NO, waiting to see if it heals or needs additional attention Did you miss any work as result of this incident? NO Employer(s) _______________________________________________ How much time have you missed from work?_______N/A_________________________________________________________ If you are submitting other documents, please state what you are attaching and how many pages. __I am attaching four pictures that includes the incident location and damaged shoe as instructed by the assistant to the City Clerk.______________ 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: ____Steven Porter_______________________________ Signature of Person submitting this form: _______________________________________________________________________ Relationship of person signing to Party making the claim: SELF Date document is being signed 11/10/2022 Revised December 2021