French, Gina (2)NOTICE OF CIAIM FORM to the City of Saint Paul, Minnesota
Minnesota stote stotute 466.05 stotes thot "...every person...who claims damoges from ony municipolity...sholl cause to be presented to the governing body of themunicipality within 780 doys ofter the alleged loss or iniury is discovered o notice stoting the time, place, and circumstonces thereof, ond the omount of compensotion
or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answers to each question. lf 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 offour (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(551-255-8574) or mail the form. Mailing address is "Saint Paul City Clerk, 15 west Kellogg Blvd., Suite 310, Saint paul, MN 55102,,
lndividuals: First Name _Gina Last Name
_Fren
Please lndicate Your Pronouns: she/ Her/Hers X He/Him/His n_They/Them/Theirs E
Company or Business Name
ls this claim being made by an lnsurance Company?No lf yes, what is your Claim/File Number?:
ls this claim being made by an Attorneyl choo$J$ item. rf yes, what is your File Number?
lf yes, then provide your lnsured's/ Client's Name Gina
F
Street Address: 2320 Lower Afton RD
#41q
City: _Maplewood State MN _ Zip Code
55119
Daytime/Work Phone Cell Phone 612-750-
583
Date of lncident or Date Discovered (Must completel 3/IO/2O23T|me _6:45 pM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. Hit HUGE pothole which resulted in
immediate flat tire - side wall split - could not
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _HUGE UNMARKED pOTHOLE-There was an
additional car pulled over with same issue - flat ti
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.
n 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 billthat has been paid.
[1 Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt
from lmpound Lot, and two estimates for repairs or actual bill that has been paid.
EsnowEmergency: pleaseprovidecopyoftowingticket(ifavailable),receiptfromlmpoundLot,andtwoestimatesforrepairsor
actual bill that has been paid.
n Property damage: please provide two estimates for repairs or actual bill that has been paid.
! You were injured during a motorvehicle accident: please provide police report number, details about injury.
n You were injured in the City of Saint Paul: please provide police report number, witnesses and details about injury.
This section must be for all claims.
lsthereapolicereportforthisincident? Yes Nolf yes,pleaseprovidethepolicereportcasenumber
Revised December 2021
lf yes, what law enforcement agency responded?
-MN
State Trooper notified for lights while car was on side of road & being
loaded on flatbed tow truck - l'm sure there is a record of the non emergency 911
ca ll
Where did the incident take place? Please provide a street address, intersection or name of City park or facility. West Lower Afton
Road
West Lower Afton Rd near HWY 61 intersection
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? _Reimburse Sz0 for temporary tire (BMW have run
flat tires and no spares - Run Flat was ruined so needed a temp replacement until I get new tires) I have included (2) quotes for
different tires from Discount tire - they are the most reasonable priced. I need all new tires so they wear evenly - I had just gotten
new tires last year - so total of 57277.98 or Stt53.5e depending on tires the city chooses to
reimburse.
Were there witnesses to this incident? Please provide names and contact phone numbers. _Bryan Bergquist
763-567-1773
For propertv damage claims, includine vehicle accidents.
Your vehicle's information: Year 20L4 Make BMW Model 32gi xd Color
-BLACK-License Plate # BAM039
Registered owner of vehicle _Gina French_ Driver GinaFrench_
Area(s) damaged _Right front tire - FLAT - side wall split - could not
State vehicle is registered in _M
lf a City vehicle was involved: License Plate #
Was there City insignia on the vehicle? Yes No Driver's Name
Color
Other property damaged
For iniurv claims of anv tvpe.
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 missanyworkas resultofthis incident? yes No Employer(s)
How much time have you missed from work?
lf you are submitting other documents, please state what you are attaching and how many pages. _l am submitting (1) invoice
fromATMtires(fortempfix) and2quotesfortiresalongwithphotosofmycaronflatbedtow. Myinsurancepaidforthetow,sol
will not submit that charge._
By signing this form, you agree that all information provided is true and correct to the best of your knowledge.
Please NOTE thqt submitting a false or misleoding claim can dnd will result in prosecution under Minnesota
Stdtutes.
Name of Person completing form: _Gina French
Signature of Person submitting this form
a