Bradtmiller, LouisaRevised 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: ______Louisa ______________ Last Name: ____Bradtmiller_____________________
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? 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: _______________________________________________________________________
Street Address: ___244 Macalester St____________________________________________________________
City: ____Saint Paul___________________ State: ____MN________________ Zip Code: __55105_________
Daytime/Work Phone: __________________________________ Cell Phone: ___917-558-3870_______________________
Date of Incident or Date Discovered (Must Complete): 5/9/2023 Time: ______10:30pm________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: _I was exiting 35E Southbound at the Saint
Clair Avenue exit. Because it was dark, I did not see the enormous pothole just past the intersection with St. Albans St., and drove
over the pothole. The pothole punctured my tire in two places, requiring that I get two new tires since you can’t replace one tire at a
time on a front wheel drive car. __
Please state why or how you feel the City of Saint Paul is responsible for your Damages? There are two cones along the side of the
road here, suggesting that perhaps someone with the city already knew this area was a problem. In any case, this is a busy exit off a
busy highway, and a pothole of this size (see attached photos) could not have gone unnoticed for long. I think it is the city’s job to
ensure reasonably safe street conditions.
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.
Revised March 2023
☐ 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:
___Near the intersection of St. Albans St. S and Pleasant Avenue in Saint Paul, at the Saint Clair off-ramp from 35E southbound_____
What would you like to see happen to resolve this claim to your satisfaction?
__Fill the pothole and pay for my new tires.____________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
__My son Will Chatterjea was in the car with me when it happened. Because he is a minor (14) I would rather not provide his phone
number. I would be happy to talk with someone further about it if necessary. Two young women stopped by as I was waiting for a
tow truck, and said the same thing had happened to one of them a few days earlier. She shared photos she had taken at the scene; I
later shared my photos with her. I didn’t ask her name, but her cell phone number is 612-499-4645.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: __2010___ Make: __Toyota_____ Model: ____Prius_______ Color: ____Red____________
License Plate #: ____9TJ596__________ State vehicle is registered in: _MN____________________
Registered owner of vehicle: __Louisa Bradtmiller___ Driver: ____Louisa Bradtmiller____________
Area(s) damaged:___Front passenger side tire_________________________________________________
If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________
Was there City insignia on the vehicle? YES / NO Driver’s Name: ______________________________________________________
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: _I’m attaching 9 photos, 8 of
the site and one of the receipt for purchase of two new tires. ___
Revised March 2023
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: __Louisa Bradtmiller___________________________
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: ____self__________________________
Date document is being signed: 5/11/2023