Phillips, NormRECEIVED
MAR 06 2023NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
munrcrpalrty wrthin 180 days after the alleged loss or rnjury is discovered a notice stating the time, place, and circumstances thereof, and the amount of compensatron
or other rellef 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 Cit Clerk's Office. You may ,email fax
(651-266-8574) or mail the form. Mailing address is "Saint Paul City Clerk, IS West Kellogg Blvd., Suite 310, Saint Paul, MN 55102"
Individuals: First Name Norm Last Name Phillips
Please Indicate Your Pronouns: She/ Her/Hers € He/Him/His [X 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: 1805 Jefferson Ave
City: Saint Paul State Minnesota Zip Code 55105-2054
Daytime/Work Phone Cell Phone (847) 477-0260
Date of Incident or Date Discovered (Must complete) 2/15/2023Time 8:30am
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. I was driving south and hit a pothole.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The City is failing to maintain crucial roads.
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.
G 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 availablel receipt from Impound Lot, and two estimates for repairs or
actual bill that has been paid.
[3 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.
Southbound on Edgcumbe road near Quinia Ave in Saint Paul
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 ? 1) Fix the roads. 2) Pay for each 537.18 claim
Were there witnesses to this incident? Please provide names and contact phone numbers. Other than tow trucks, no
For property damage claims, includin@ vehicle accidents.
Your vehicle's information: Year 2019 Make Acura Model ILX Color dark Hrey
License Plate # 1RP533 State vehicle is registered in Minnesota
Registered owner of vehicle Norman R. Phillips, Jr. (me)Driver Norman R. Phillips, Jr. (me)
Area(s) damaged Passenger front tire
If a City vehicle was involved: License Plate #Color
Was there City insignia on the vehicle? 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? NO Where?
Was medical treatment received? NO Where?
First day of medical treatment?Are you still receiving medical treatment? NO
Did you miss any work as result of this incident? YES Employer(s) UnitedHealth Group / Optum Services, Inc.
How much time have you missed from work? 3 hours
If you are submitting other documents, please state what you are attaching and how many pages. 1 receipt
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: Norm Phillips
Relationship of person signing to Party making the claim: SELF
Date document is being signed 3/3/2023
Revised December 2021