Davis, Esther
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: _____Esther______ Last Name: _______Davis_________________________
Please Indicate Your Pronouns: ☒ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: _______Full-time student at Bethel University________________
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, provide your Insured’s/ Client’s Name: _______________________________________________________________________
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Street Address: ____3900 Bethel Dr MSC 569_______________________________________________
City: ________St Paul______________ State: ______MN________ Zip Code: _______55112______
Daytime/Work Phone: _______331-305-7660__________ Cell Phone: _____________331-305-7660_____________
Date of Incident or Date Discovered (Must Complete): 3/9/2023 Time: ________9pm_______
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ___I was driving on St Anthony Ave heading towards the highway entrance and there was someone
in the lane next to me and then I saw a huge pothole so I slowed down since I couldn’t switch lanes and did my best to avoid it but still hit it and it put a huge gash in the side of
my tire.___
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _____Because the damage inflicted on my car was caused by a pothole and my car would’ve been
fine and not needing expensive repairs if it wasn’t there.__________
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:
_____St. Anthony Ave heading towards the highway entrance by Allianz stadium___________________________
What would you like to see happen to resolve this claim to your satisfaction? ______________For the state to refund me for my car repairs from this incident.________________________
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 __________no, I was
driving alone__________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _2006_ Make: ___BMW___ Model: ____330i___ Color: ___Silver___
License Plate #: ___KEN266____ State vehicle is registered in: _____MN________
Registered owner of vehicle: _____Esther Davis____ Driver: _____Esther Davis______
Area(s) damaged:_____Drivers side tire______
If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________
Was there City insignia on the vehicle? NO Driver’s Name</w: ______________________________________________________
Other property damaged: _______________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? ______none_________________________________________
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? _____________________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages: ___Invoice from Mechanic, 1 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: Esther Davis
Signature of Person submitting this form: ___Esther Davis_
Relationship of person signing to Party making the claim: ________Same Person_________
Date document is being signed: 4/19/2023
Revised March 2023