Erickson, BarbRevised 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: _Barb ______________ Last Name: __Erickson__________________________________________
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: _______________________________________________________________________
Street Address: ___8995 Colby Court ___________________________________________________________________
City: _Inver Grove Heights_________________________ State: _MN_____________________ Zip Code: __55076___________
Daytime/Work Phone: __________________________________ Cell Phone: __651-261-4825_________________________
Date of Incident or Date Discovered (Must Complete): 4/24/2023 Time: ___11pm__________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: _Blew front driver side tire on pothole while
driving down West 7th near Lexington Ave. intersection___________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Pothole was large and should have been
repaired in a timely manner; the exposed rebar in photos demonstrates the negligence and delayed response of City staff to repair
or protect vehicles with cones/signage until repairs occurred.
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.
Revised March 2023
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:
_West 7th near Lexington Ave. intersection______________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?
_Reimbursement of cost of damages and repair the pothole to protect others from damages_____________
Were there witnesses to this incident? Please provide names and contact phone numbers: Tim Erickson 651-497-6941
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _2013__ Make: Ford Model: Edge Color: Black
License Plate #: 9NV163 State vehicle is registered in: MN
Registered owner of vehicle: __Barb Erickson____________ Driver: __Barb Erickson____________________________
Area(s) damaged: Front driver 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: _One document including 4
photos and copy of paid bill for damages____________________
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: _______Katie Erickson______________________________________________________
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: ______Mother/daughter__________________________
Date document is being signed: 5/15/2023