Koller, Ronald
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 this completed form to the
mailto:Saint%20Paul%20City%20Clerk’s%20OfficeSaint Paul City Clerk’s Office by email (cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to “Saint Paul City Clerk, 15 West
Kellogg Blvd., Suite 310, Saint Paul, MN 55102”.
Claimant: First Name: ____Ronald_______________________ Last Name: ___Koller______________________________________
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? YES / NO If yes, what is your Claim/File Number? <_____No________________
Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? _____No_____________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
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Street Address: _____________1154 Valley View Rd_______________________________________
City: _____Lake City___________________________ State: ___MN_____________________ Zip Code: __55041______________
Daytime/Work Phone: ____651-927-9401______________________________Cell Phone: 651-927-9401
Date of Incident or Date Discovered (Must Complete): 4/4/2023 Time: _____8:40 pm______
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ____________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The picture clearly indicates a pothole that had been there a very long time since it was very
deep and no debris was around the area like it had just lost it filling or patch material. On top of that it was both tires that hit equally sized holes but only one tire was damaged.
I feel this pothole being as deep and large as it was should have been fixed or caution signs placed. Since I don’t live in the area, I was not aware that it was there and have never
hit any pothole that large in my life and driving for 47 years. I normally drive around them but had no chance on this one in the rain.The tire could not be repaired and needed to be
replaced. And because it is an all-wheel drive system (Quattro) all 4 tires needed to be replaced. Total cost $1256.72. I asking for ¼ of this or $314.18.
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.
Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays.
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: ___________________________
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:
Heading east on ST. Clair Ave at the end of the bridge that goes over 35E. I was going to get onto 35E North onramp when the tire was flat after hitting the dual pot holes seconds before.
I changed the tire myself with the help of a nice ST. Paul man that stopped to help with a better Jack. I didn’t get his name unfortunately. He just had left an AA meeting he told me.
Great guy.
What would you like to see happen to resolve this claim to your satisfaction? Please pay for 1 tire at $314.18. I will be paying for the rest.
Were there witnesses to this incident? Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent></w:sdt><w:r w:rsidR="0031571E" w:rsidRPr="00 ___Sara Koller 651-764-2008___________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: ___2017______ Make: __Audi_______ Model: ____A8L______ Color: __White_____
License Plate #: ___JEA 056______________________State vehicle is registered in: ___MN________________________
Registered owner of vehicle: ___Ronald J Koller____________ Driver: ____Ronald J Koller___________________
Area(s) damaged: Tire was cut from compression___________________________________________
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: ____Ronald J Koller_________________________________________________________ <
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: ___Self_______________________________________
Date document is being signed: 4/4/2023
Impact area and large cut in the tire that was unrepairable per the repair shop I went to.
Revised March 2023