Pedrick, MicahNOTICE 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: ____micah Pedrick ____________________________ Last Name: ________________
Please Indicate Your Pronouns: x 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? _________________________
Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: __520 Payne ave ________________________
City: _saint paul____________ State: __MN______ Zip Code: _55130____
Daytime/Work Phone: 763.703.0368________ Cell Phone: _________________________
Date of Incident or Date Discovered (Must Complete): ______4/22/2023 discovered -5/11/2023 tire popped at 12pm____ Time: _
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: _tired popped due to bubble and bent rim from pot hole on 7th and hiawatha getting onto 94. Very
bad, very deep pot hole. _I was not driving my car due to the found bubble, but had to on may 11th and that's when tire popped______
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _because the pothole is at a very busy intersection right before the 94 on ramp. I've hit it
several times since moving in to my new address a block away, on March 10th. Discovered the bubble and bent rim on april 22nd. cant see it and forget it was there and hit it badly 3-5xs
.
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.
X Automobile damage from a street defect or pothole: please provide two estimates for repairs or actual bill that has been paid.
currently being fixed. Waiting for mechanic to call.
☐ 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 NO. Report necessary
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:
_______7TH STREET AND HIAWATHA AT 94 ON RAMP.
What would you like to see happen to resolve this claim to your satisfaction? ____________REIMBURSEMENT AND SOMEONE PLEASE FIX THAT POTHOLE__________
Were there witnesses to this incident? Please provide names and contact phone numbers: ___________Eric Prosser
__651.728.1729____
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: ___2006__ Make: __Chrysler ____ Model: ______PT Cruiser_____ Color: silver__
License Plate #: __nuh-949________ State vehicle is registered in: _MN____
Registered owner of vehicle: _______MICAH PEDRICK _______ Driver: _MICAH PEDRICK ___
Area(s) damaged:__Back passenger side wheel, tire and rim. ____
If a City vehicle was involved, License Plate #: ____________NA_____________________ 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? ___________NA__________________________________________________________________
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 have pictures.__
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: __micah Pedrick _________________
Signature of Person submitting this form: _Micah Pedrick __________________
Relationship of person signing to Party making the claim: __Self____________
Date document is being signed: __5/11/2023_
Revised March 2023