Hagstrom, AaronRevised March 2023
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 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: _____AARON___________________________ Last Name:
__________________________________HAGSTROM_____________
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? ___I have made a claim to my
insurance company _______006469731000000006001_______________
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: ___________________1430 Orkla
Drive____________________________________________________________________________
City: ________________Golden Valley______________________________ State: _______MN_________________ Zip Code:
___________55427________
Daytime/Work Phone: ________6128025335__________________________ Cell Phone:
_____________________________________________
Date of Incident or Date Discovered (Must Complete): 3/8/2023 Time: ______________9:30_______________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ___I need to pay extensively for my car to
be fixed_________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _______I went over a pothole. The road
was damaged causing damage to my car_____________________________
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.
Revised March 2023
☐ 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: ___I called the police about it but didn’t make a report. Also made a
report through city of Saint Paul________________________
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:
___________Near intersection of Snelling and St. Anthony Ave outside Allianz
Field_________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?
____________________________________Reimbursement_for
repairs_____________________________________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
____________________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _2014________ Make: _____Toyota____________ Model: __Corolla________________ Color:
______blue____________
License Plate #: __CML4325_______________________ State vehicle is registered in: ___North
Carolina________________________
Registered owner of vehicle: __Andrew Hagstrom___________________________ Driver: ________________Aaron
Hagstrom__________________________
Area(s) damaged:_______Two
tires_______________________________________________________________________________
If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________
Was there City insignia on the vehicle? YES / NO Driver’s Name: ______Aaron
Hagstrom________________________________________________
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?
__________________NO_________________________________
Was medical treatment received? YES / NO Where?
___________________BO_____________________________________________
First day of medical treatment? _________NO____ Are you still receiving medical treatment? YES / NO
, rims, and Tires Plus say the struts and sway bar are damaged and need replacing as well.
Revised March 2023
Did you miss any work as result of this incident? YES / NO
Employer(s):
___________________________NO______________________________________________________________________
How much time have you missed from work?
_______NO______________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages: _____________3-
4____________
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: _____________________________________________________________
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: _____________________
Aaron Hagstrom
5/3/23