LeClair, Logan
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
about:blankSaint 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: Logan
</w:t></w:r><w:r Last Name: LeClair
Please Indicate Your Pronouns: ☐ She/Her/Hers, x 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: 225 Main St S
City: Lonsdale
State: MN
Zip Code: 55046
Daytime/Work Phone: 612-207-1714
Cell Phone:
Date of Incident or Date Discovered (Must Complete): 4/11/23
Time: 3:15 PM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form:
Traveling East on St.Clair Ave S, crossing over Cleveland Ave S I encountered a substantial pot hole that resulted in damage to both my driver's side tires. The front tire was torn beyond
repair, the rear tire was damagee resulting in a unrepairable bulge in the side wall.
Please state why or how you feel the City of Saint Paul is responsible for your Damages?
St.Clair Ave is covered in potholes, this one in particular is of incredible size that it should have been repaired long ago.
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.
X 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? YES / (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:
2052 St. Clair Ave S ____________________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction? Reimbursed the cost of my tires and effort to repair the pot hole so no one else has to go through this.
Were there witnesses to this incident? Please provide names and contact phone numbers:
Not to my knowledge, school bus drivers from across the street may be able to recall seeing me pull over and complete the spare tire swap. ____________________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information:
Year: 2005
Make: Subaru
Model: Legacy
Color: Black
License Plate #: BXM901
State vehicle is registered in: MN
Registered owner of vehicle:
Logan LeClair
Driver: Logan LeClair
Area(s) damaged: Both drivers side tires
If a City vehicle was involved, License Plate #: _________________________________ 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? _____________________________________________________________________________
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: Photo of tire damage and photo of bill________________________
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: Logan LeClair_____________________________________________________________
Signature of Person submitting this form: Logan LeClair_______________________________________________________
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: 4/13/23
Revised March 2023