Muller, Annalise
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: Annalise Last Name: Muller
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? 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: 2044 Brewster St., Apartment #4
City: St. Paul State: MN </w Zip Code: 55108
Daytime/Work Phone: 715-379-7531 Cell Phone: 715-379-7531
Date of Incident or Date Discovered (Must Complete): 4/12/2023 <Time: 10:15pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: While driving along Como Ave. I was forced to drive into a pothole that appeared to be less significant
than the nearby ones that I was trying to avoid. Unfortunately, the pothole that I hit left significant damage to my vehicle resulting in hundreds of dollars in damage.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The number of potholes on the road forced me to drive into the pothole while trying to avoid
others. The number of potholes on this road shows negligence by the city. I witnessed someone with a flat tire the next day who said they hit the same pothole that I did.
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:
On Como Ave. in the middle of the street. GPS placed my location at 1981-1999 Como Ave (U of M St. Paul Campus). Coordinates: 44.97663 degrees N, 93.18547 degrees W.
What would you like to see happen to resolve this claim to your satisfaction? I would like to be reimbursed for damage to my vehicle and see the pothole filled in.
Were there witnesses to this incident? Please provide names and contact phone numbers: NO </w:t> Click or tap here to enter text.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2009 </w:tMake: Pontiac </w:t></Model: Vibe </w:t></w:r><w:Color: Red
License Plate #: KGL592 </w: State vehicle is registered in: MN
Registered owner of vehicle: Annalise Muller Driver: Annalise Muller
Area(s) damaged: Drivers side front and rear tires ruined. Car out of alignment.
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: Photos of the pothole and the paid invoices from repairs that were necessary on the 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: Annalise Muller <
Signature of Person submitting this form: Annalise Muller </w:t></w:r></w:sdt
Relationship of person signing to Party making the claim: SELF
Date document is being signed: 4/18/2023
Revised March 2023