Due, Yuxuan
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: __Yuxuan ______________ Last Name: _____ Du ________________________________________
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: ____________________N/A__________________________________________________________
Is this claim being made by an Insurance Company? NO If yes, what is your Claim/File Number? <_______ N/A ______________
Is this claim being made by an Attorney? NO If yes, what is your File Number? ___________ N/A _____________________
If yes, provide your Insured’s/ Client’s Name: ___________________________ N/A ______________________________________
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Street Address: __2813 4th St SE Unit 524_________________________________________________________
City: _____________Minneapolis__________________ State: _______Minnesota________ Zip Code: __55414__________
Daytime/Work Phone: ___________ N/A ______________ Cell Phone: ____763 220 2229__________________________
Date of Incident or Date Discovered (Must Complete): 4/17/2023 Time: _________4:05 PM____________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ___I was trying to get mcdonald , but there’s a giant pothole on the road, I slowed down but
my car still went into it, the underbody parts were severely damaged and I couldn’t drive the vehicle anymore because the underbody splash shield is falling on the ground and one tire
is broken.___________ ________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ___The city of Saint Paul should repair pothole so giant urgently. If not, there should be a
warning sign to warn the driver there’s a pothole, there’s nothing there. I came back to where it happened and the hole is still there with no warning on Apr.20 _
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: ______ N/A _______________
If yes, what law enforcement agency responded? ______ _ N/A ____ _____________________
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
_The intersection of Pillsbury St and University Ave W, at the corner of Mcdonald (2213 University W)__________
What would you like to see happen to resolve this claim to your satisfaction? ____I would like the city to pay the repair cost of my car (underbody$319.45+tire$402.45+labor(BMW dealer
labor $240), estimate $1000 in total) I will take care of other costs, really appreciate it!
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, but I have full
dashcam recording ___________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _2019_ Make: ____BMW___ Model: ______M550i________ Color: ___Black_______________
License Plate #: ____18A71______ State vehicle is registered in: ______Minnesota__________
Registered owner of vehicle: ____Yuxuan Du____ Driver: ____________Yuxuan Du__________________
Area(s) damaged:__ Undercarriage, transmission splash shield, underbody protection shields, front left tire_________
If a City vehicle was involved, License Plate #: _____________ N/A ______ Color: ________________ N/A ___________
Was there City insignia on the vehicle? NO Driver’s Name</w: ________ N/A __________________________________
Other property damaged: ________ N/A _____________________________________________________________
For injury claims of any type.
What part of your body was injured? ____ N/A ______________________________________________________________
Did you go to the emergency room or urgent care? NO Where? ____ N/A __________________________________
Was medical treatment received? NO Where? </___________ N/A _______________________________________________
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): ________ N/A __________________________________________________________________________
How much time have you missed from work? _______ N/A __________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages: ___7 pages including the form and every attachment_________
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: _____Yuxuan Du_____________________________________________ <
Signature of Person submitting this form: ____Yuxuan Du____________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed: 4/20/2023
Attachments: 7 photos in this document, dashcam recording and damage recording can be accessed on the link below due to unable to attach
Please contact me if you can’t open the link
https://drive.google.com/drive/folders/19TH_roHIItsG6gw_FPnC0gvQJLF4-SZk?usp=sharinghttps://drive.google.com/drive/folders/19TH_roHIItsG6gw_FPnC0gvQJLF4-SZk?usp=sharing
Revised March 2023