Arpin, LauraNOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota
Minnesota State Statute466.05 states that “…every person…whoclaims damages from any municipality…shallcause to be presented tothe governing body of the
municipalitywithin180days after the allegedlossor injury is discovered a notice stating thetime,place,and circumstancesthereof,and the amount ofcompensation
orother relief demanded.”
Please complete this form in its entirety by clearly typing or printing your answers to each question.If you have additionaldocumentation,you may addthose
documentsto your submission.You will not be contacted bytelephone unless clarification is needed.Theclaim process for investigations can take upwardsof
four (4)weeks.This form must be signed,dated withall applicable sections completed.Submission this completed form tothe Saint Paul CityClerk’s Officeby
email(cityclerk@ci.stpaul.mn.us),fax(651-266-8574)ormail addressedto “Saint Paul City Clerk,15 West Kellogg Blvd.,Suite 310,Saint Paul,MN 55102”.
Claimant:First Name:Laura Last Name:Arpin
Please Indicate Your Pronouns:X She/Her/Hers
Company or Business Name:Not applicable
Is this claim being made by an Insurance Company?NO If yes,what is your Claim/File Number?Not applicable
Is this claim being made by an Attorney?NO If yes,what is your File Number?Not applicable
If yes,provide your Insured’s/Client’s Name:_______________________________________________________________________
Street Address:1333 Juno Avenue
City:Saint Paul State:MN Zip Code:55116
Daytime/Work Phone:651-260-9877
Date of Incident or Date Discovered (Must Complete):May 15,2023 Time:12:15pm
Please state,in detail,what happened that prompted you to file a Notice of Claim Form:I discovered that my right front tire was flat
on May 15,2023 after hitting a large pothole a couple of days earlier.
Please state why or how you feel the City of Saint Paul is responsible for your Damages?I hit a large pothole on Edgcumbe Road
right before my tire went flat.The potholes are large and have been growing since at least the winter of 2022-2023.The potholes
are not marked with cones or lit,and are essentially unavoidable while staying in the northbound lane.
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.
☐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.
RevisedMarch 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:Not applicable
If yes,what law enforcement agency responded?Not applicable
Where did the incident take place?Please provide a street address,intersection or name of city park or facility:
Edgcumbe Road near the Highland Par 3 golf course
What would you like to see happen to resolve this claim to your satisfaction?
I would like the City to pay for the four new tires I had to purchase after one was damaged beyond repair by the pothole.I needed
to buy four new tires because this is the standard practice for an all wheel drive car.
Were there witnesses to this incident?Please provide names and contact phone numbers:
Eddie Arpin phone:612-817-3667
For property damage claims,including vehicle accidents.
Your vehicle’s information:Year:2019 Make:Honda Model:HRV Color:White
License Plate #:DYS 548 State vehicle is registered in:Minnesota
Registered owner of vehicle:Laura Arpin Driver:Laura Arpin
Area(s)damaged:Front right tire
If a City vehicle was involved,License Plate #:Not applicable Color:Not applicable
Was there City insignia on the vehicle?YES /NO Driver’s Name:Not applicable
Other property damaged:_______________________________________________________________________________________
For injury claims of any type.
What part of your body was injured?Not applicable
Did you go to the emergency room or urgent care?NO Where?Not applicable
Was medical treatment received?NO Where?Not applicable
First day of medical treatment?Not applicable Are you still receiving medical treatment?
Did you miss any work as a result of this incident?NO
Employer(s):_________________________________________________________________________________________________
How much time have you missed from work?Not applicable
If you are submitting other documents,please state what you are attaching and how many pages:3 pages (photos of the flat tire,
and receipt for new tires)
RevisedMarch 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:Laura Arpin
Signature of Person submitting this form:
Relationship of person signing to Party making the claim:self
Date document is being signed:5/18/2023
RevisedMarch 2023