Bivens, HowardNOTICEOFCLAIM FORMtotheCityofSaintPaul,Minnesota
Minnesota Stote Statute 466. OS states that"...every person... who cams rbmages from any mumcipalrty...shall cause to be presented to the governrng body of the
munrcipal% within 180 days after the alleged loss or injury is discovered o notice statrng the time, place, and circumstances thereof, and the amount of compensation
or other relref 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: FirstName: %lp CAI Last Name: '8 I S/ ('3
Please Indicate Your Pronouns: € She/Her/Hers, '$lHe/Him/His, € They/ Them/Theirs
Company or Business Name:
Is this claim being made by an Insurance Company? YES /(Nq If yes, what is your Claim/File Number?
Is this claim being made by an Attorney?(YE9 / NO If yes, what is your File Number?
Date of Incident or Date Discovered (Must Complete): 3 / ;' l / 2"C";"3 Time: ? 'i 15 P M
Please state, in detail, what happened that prompted you to file a Notice ofClaim Form: ln'luv\( S %%\yi(@t :iQ S+, 'pl
Please check the reason that most closely describes the reason for your submitting a claim. Please note
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.
[1 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.
JYou 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.
Revrsed March 2023
This section must be completed for all claims.
Is there a police report for this incident? YES / NO ') (4VWCV'e'UX'
Where did the incident take place? Please provide a street address, intersection or name qf city park or facility:
What would .u like to see happen to resolve this claim to your satisfaction?
Were there witnesses to this incident? Please provide ryames and contact phone numbers;
For property damage claims, including vehicle accidents.
Your vehicle's information: Year:Make:Model:Color:
License Plate #:State vehicle is registered in:
Registered owner of vehicle:Driver:
If a City vehicle was involved, License Place #: Color:
Was there City insignia on the vehicle? YES / NO Driver's Name:
Other property damaged:
For injury claims of any type.
First day of medical treatment? 3 / '}>[ :Are you still receiving medical treatment? (E!)I NO
How much time have you missed from work?
If you are submitting other documents, please state what you are attaching and how many pages:
By signing this form, you agree that all information provided is true and correct to the best of your knowledge.
Signature of Person submitting this forrti
Relationship of person signing to Party making the claim
Revrsed March 2023