Neururer, Theodore
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: First Name __Theodore____________________ Last Name _________Neururer____________________________
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His <☒_ They/ Them/Theirs ☐
Company or Business Name: _______NA_______________________________________________________________________
Is this claim being made by an Insurance Company? </w:t <NO </w:t></w If yes, what is your Claim/File <Number?: Click or tap here to enter text.
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 ____________________________________________________________
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Street Address: 6700 210th Lane Circle North
City: ___Forest Lake_______________________ State ___MN________________ Zip Code __55025________________
Daytime/Work Phone _______________________________ Cell Phone __6518290988_________________________
Date of Incident or Date Discovered (Must complete) 3/20/2023Time ____Afternoon_____________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. I was driving on Creatin Ave N going towards highway 94. I was in the right lane and right
at the corner of Cretin and Selby Ave, I hit a very large pothole. This pothole was unavoidable as there was another car on the left of me so I couldn’t swerve out of the way. After
hitting the pothole, my breaks started to seize up. I pulled over as soon as I could and got it to a local mechanic shop. Turns out that hitting that pothole made one of my break lines
rupture. I believe that this is not my fault nor my responsibility to pay for.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? I feel that the City of Saint Paul is responsible because the road conditions on Cretin Ave are
dreadful. There is nothing you can do to avoid these massive potholes when driving in the outside lanes. Attempting to avoid them could either cause further damage to my vehicle or harm
to human life.
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.
Near intersection of Creatin Ave N and Selby Ave
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 the city to reimburse me for the damages done to my vehicle due to poor road conditions.
Were there witnesses to this incident? Please provide names and contact phone numbers. Grant Neururer: 6518290020
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year _2013_____ Make _Dodge________________ Model _Avenger___________________ Color __Grey______________
License Plate # ____3761CD____________ State vehicle is registered in ________MN________________
Registered owner of vehicle ___Richard Neururer__________ Driver __Theodore Neururer______________
Area(s) damaged _Front Brake Lines_____________________________________________________
If a City vehicle was involved: License Plate # _______________________________ Color _______________________________
Was there City insignia on the vehicle? Yes No Driver’s Name </w_____________________________________________
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: _Theodore Neururer_______________________________________________ <
Signature of Person submitting this form: __Theodore Charles Neururer____________________________________
Relationship of person signing to Party making the claim: ___________________
Date document is being signed 3/21/2023
Revised December 2021