Wilson, Thor
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: Thor Wilson
Please Indicate Your Pronouns: He/Him/His
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: 3111 4th st se apt 104, Minneapolis, Minnesota 55414
Daytime/Work Phone Cell Phone 651-333-0487
Date of Incident or Date Discovered 3/13/2023 Time 12:30 PM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. </I hit a large pothole in the middle of the road going southbound down cretin avenue, the pothole
was on cretin ave, right after goodrich avenue and I hit this pothole and it popped both of my drivers side tires. These were brand new tires, that were at the correct tire pressure.
Please state why or how you feel the City of Saint Paul is responsible for your Damages?
The pothole was gigantic, and I'm sure that many others have sustained damages on their cars with a pothole this large. I did my best to avoid the pothole but due to traffic conditions
I could not avoid hitting it.
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.
(X) Automobile damage from a street defect or pothole : please provide two estimates for repairs or actual bill that has been paid. $335.78
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. The incident took place near the corner of Cretin Avenue South and
Goodrich avenue, 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?
I would like to be compensated for the full damages done to my car from this pothole.
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:2009 Make:Volkswagen Model:Jetta Color: Black
License Plate # GMG 238 State vehicle is registered in Minnesota<
Registered owner of vehicle Thor Wilson Driver Thor Wilson
Area(s) damaged: Tires
If a City vehicle was involved: License Plate # _ Color
Was there City insignia on the vehicle? 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? Where?
Was medical treatment received? Where?
First day of medical treatment? Are you still receiving medical treatment?
Did you miss any work as result of this incident? 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. I am attaching the receipt from the shop I had to get service done on my car from.
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: Thor Wilson
Signature of Person submitting this form: Thor Wilson
Relationship of person signing to Party making the claim: Myself
Date document is being signed 3/13/2023
Revised December 2021