The URL can be used to link to this page

Gardner, DaynaNOTICE 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 Saint 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: Dayna_________________________ Last Name: Gardner___________________ Please Indicate Your Pronouns: ☐ She/Her/Hers, ☐ 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: _______________________________________________________________________ Street Address: 475 WHITALL STREET _____________________________________________________________________________ City: ST PAUL______________ State: MN_______________________ Zip Code: 55130______________ Daytime/Work Phone: _____________________ Cell Phone: 6513368054 _____________________________________ Date of Incident or Date Discovered (Must Complete): 4/20/2023______________ Time: aprox 8pm___________ Please state, in detail, what happened that prompted you to ﬁle a Notice of Claim Form: Hit a series to potholes on Concordia, between Mackubin and hwy 94 (if you see for yourself it is literally a series of 30+ potholes). My tire had a gash when I checked it when I got home. Luckily it did not completely blow. I have all wheel drive, and run ﬂat tires, so had to get all 4 replaced. Please state why or how you feel the City of Saint Paul is responsible for your Damages? These potholes have been here weeks and have gotten worse and worse, There is literally no way around them on that road, especially at night. My daughter has basketball practice around that corner 4 times a week, so there is no getting round it all. 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. Revised March 2023 ☐ 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: __NO_________________________ If yes, what law enforcement agency responded? ___NO_________________________________________________________ Where did the incident take place? Please provide a street address, intersection or name of city park or facility: CONCORDIA AVE BETWEEN MACKUBIN AND 94 __________________________________________________________ What would you like to see happen to resolve this claim to your satisfaction?   Reimbursement for my tire replacement in the amount of $1319.96 Were there witnesses to this incident? Please provide names and contact phone numbers:   My child and I in the vehicle (she is 10) and my parents after we made it home. They were not present in the car but I can provide information for them if needed. I had my dad come out to verify and check my tires after. ____________________________________________________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year: 2014____ Make:BMW___________ Model:320i__________ Color: Black________ License Plate #: _________________________ State vehicle is registered in: Minnesota Registered owner of vehicle: Dayna Gardner________________ Driver: Dayna Gardner Area(s) damaged: tires _____________________________________________________________________________ If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________ Was there City insignia on the vehicle? YES / NO Driver’s Name: _____no_________________________________________________ Other property damaged: _______________________________________________________________________________________ Revised March 2023 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: A picture of the damage to the tire and the bill from the auto shop. (Tires plus had an old address in the system from last time I used them and did not update, so it has an old address on the receipt) 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: Dayna Gardner Signature of Person submitting this form: Relationship of person signing to Party making the claim: __________________________________________ Date document is being signed: 04/26/2023 Revised March 2023