Gilbery, ColeNOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota
Minnesota State Statute 466.05 states that“…every person…who claims damages from anymunicipality…shall cause to be presented to the
governing body of the municipality within 180 daysafter thealleged loss orinjury isdiscovered anotice statingthe time,place,and
circumstances thereof,andthe amount ofcompensation orother relief demanded.”
Please completethisform in its entirety by clearly typing or printing your answers to each question.If you have additional documentation,
you may addthose documentsto your submission.You will not be contacted bytelephone unless clarification is needed.Theclaim process
for investigations cantake upwards of four (4)weeks.This form must besigned,dated withall applicable sections completed.Submission
this completed form to the Saint PaulCity Clerk’sOffice by email (cityclerk@ci.stpaul.mn.us),fax (651-266-8574)or mail addressed to “Saint
PaulCity Clerk,15 West Kellogg Blvd.,Suite 310,Saint Paul,MN 55102”.
Claimant:First Name:Cole Last Name:Gilbery
Please Indicate Your Pronouns He/Him/His,
Company or Business Name:
Is this claim being made by an Insurance Company?If yes,what is your Claim/File Number?
Is this claim being made by an Attorney?If yes,what is your File Number?
If yes,provide your Insured’s/Client’s Name:
Street Address:6620 166TH St W
City:Rosemount State:MN Zip Code:55068
Daytime/Work Phone:Cell Phone:952-666-0609_
Date of Incident or Date Discovered (Must Complete):4/7/23 Time:4:00 PM
Please state,in detail,what happened that prompted you to file a Notice of Claim Form:I was riding my motorcycle
on Friday 4/7 on Exchange St S through the tunnel next to the Science museum and hit a large pothole that bent
the front wheel on my motorcycle.I could not see the pothole because I was wearing sunglasses and it was dark in
the tunnel.
Please state why or how you feel the City of Saint Paul is responsible for your Damages?
I feel that the city of St.Paul is responsible for the damage because the tunnel is not well lit and the hole is not
coned or marked in any way.I feel it is especially dangerous because of the location of the hole in a tunnel.I am
lucky that I did not crash due to the hole.
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.I have attached the receipt for the replacement wheel.
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 a copy of the 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?
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:
Exchange St S tunnel near Science Museum.
What would you like to see happen to resolve this claim to your satisfaction?
I Would like compensation for a replacment wheel.
Were there witnesses to this incident?Please provide names and contact phone numbers:
Ian Fladhammer-952-905-9903
Jake Meisinger-651-341-7203
For property damage claims,including vehicle accidents.
Your vehicle’s information:Year:2022 Make:Yamaha Model:MT-10 Color:Black
License Plate #:22355MK State vehicle is registered in:MN
Registered owner of vehicle:Cole Gilbery Driver:Cole Gilbery
Area(s)damaged:Front Wheel
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 have Attached photos of the pothole and damage to my Vehicle.
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:Cole Gilbery
Signature of Person submitting this form:Cole Gilbery
Relationship of person signing to Party making the claim:
Date document is being signed:4/10/23