Gadea, KellyNOTICE 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: Kelly Last Name: Gadea
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? 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 ____________________________________________________________
Street Address: __5300 Greystone Dr _______________________________________________________________________________________
City: Inver Grove Heights State: Minnesota Zip Code: 55077
Daytime/Work Phone _______________________________ Cell Phone ___612-442-3646_________________________________________
Date of Incident or Date Discovered (Must complete) _________January 19,2023____________________Time 8:06PM_________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. I was scratched with a city snow plow on the right side of my truck. I was parked on one side
of the street. When the plow slipped into my truck. I was told the city is self insured and would call me. I have not gotten a call.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Because I was parked on the side of the street where other vehicles were parked as well. The
truck was hit by a city snow plow while it slipped.
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? Yes No If yes, please provide the police report case number ____23-010615________________
Revised December 2021
If yes, what law enforcement agency responded? Saint Paul’s _______________________________________________________
Where did the incident take place? Please provide a street address, intersection or name of City park or facility.
1165 Bush ave, Saint Paul 55106 ________________________________________________________________________________________________________
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? To fix the damages that were caused due to the accident.
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: 2016 Make: Dodge Model: Ram Color Grey
License Plate #: 8BG003 State vehicle is registered in: Minnesota
Registered owner of vehicle Mariana Rodriguez & Candi Maltos ______________________________ Driver ______________________________________
Area(s) damaged: Right Quarter Panel, right side Bumper
If a City vehicle was involved: License Plate # _______________________________ Color _______________________________
Was there City insignia on the vehicle? Yes 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? Yes No Where? _________________________________________________
Was medical treatment received? Yes 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: Kelly Gadea
Signature of Person submitting this form: KG_______________________________________________________________________
Relationship of person signing to Party making the claim: Driver & Daughter
Date document is being signed 2/20/2023_____________
Revised December 2021