Slagle, EmilyNOTICE 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 _Emily Last Name Slagle
Please Indicate Your Pronouns: She/ Her/Hers ☒ He/Him/His ☐_ They/ Them/Theirs ☐
Company or Business Name: _________N/A_____________________________________________________________________
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: ___1240 Selby Ave. Apt. 1 _
City: Saint Paul State MN Zip Code 55104
Daytime/Work Phone _ Cell Phone 612-360- 1720 ___
Date of Incident or Date Discovered (Must complete) 3/15/2023 Time ____9:25 AM_____________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. While driving in the right lane of White
Bear Avenue, heading south, I hit a massive pothole. There were other cars around me, both in the left side lane and behind me, so I
could not avoid the pothole, although I did slow down as much as I could. This occurred on White Bear Ave approximately between
7th St. E and 3rd St. E. Hitting the pothole caused a flat tire, which became obvious to me right after I got on to Interstate 94
Westbound.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? My tires are only one month old (they were
purchased and installed on my car on 2/16/23), so the flat tire was caused by the pothole on White Bear Ave. I’ve included pictures
of the tire which shows a sizeable tear, consistent with damages from driving through a giant pothole.
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.
__Southbound on White Bear Ave, between 7th St. E and 3rd St. E.
______________________________________________________________________________________________________
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? ___Reimbursement for cost to replace tire.
______________________________________
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 __2016____ Make __Honda__ Model ___HR-V___ Color __Green
License Plate # _____EJC 323_____ State vehicle is registered in ___Minnesota_____________________
Registered owner of vehicle _Emily Slagle______ Driver _______Emily Slagle ______
Area(s) damaged ___Front passenger side wheel __
If a City vehicle was involved: License Plate # _____N/A__________________________ 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? _______N/A___________________________________________________________________
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
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. Pictures of damage (3 pages),
copy of receipt for repairs (2 page)
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: Emily Slagle
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 3/16/2023
Revised December 2021