Larazi, JackieNOTICE 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:JACKIE
Last Name:LARAZI
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?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:
1015 WATSON AVE.
City:SAINT PAUL State:MN Zip Code:55102
Daytime/Work Phone:__________________________________Cell Phone:6128051122
Date of Incident or Date Discovered (Must Complete):APRIL 4 2023 Time:AROUND 9pm
Please state,in detail,what happened that prompted you to file a Notice of Claim Form:
I WAS DRIVING ON GRAND AVE.I AM AWARE THAT THE ROAD HAS MANY POTHOLES,SO I WAS BEING CAREFUL.I HIT A LARGE ONE
IN FRONT OF SPEEDWAY.AFTER MAYBE 500 FEET MY CAR STARTED TO SHAKE BADLY.SO I PULLED OVER AND SAW THAT MY TWO
FRONT TIRES WERE TURNED ALL THE WAY.I TRIED TO MOVE MY CAR MORE TO THE SIDE BUT THE CAR WOULD NOT MOVE WHEN I
PUT IT IN DRIVE.I HAD TO CONTACT A TOW TRUCK TO BRING TO MY HOUSE.
Please state why or how you feel the City of Saint Paul is responsible for your Damages?
THE POT HOLE WAS SO LARGE.I BELIEVE THE CITY OF STPAUL IS RESPONSIBLE BECAUSE IT SHOULD HAVE BEEN COVERED UP OR AT
LEAST CONES TO LET DRIVERS KNOW.
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.
X 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.
RevisedMarch 2023
☐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?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:
ON GRAND AVE.IN FRONT OF SPEEDWAY NEAR PARK DENTAL.
What would you like to see happen to resolve this claim to your satisfaction?
REIMBURSEMENT
Were there witnesses to this incident?Please provide names and contact phone numbers:
NO
For property damage claims,including vehicle accidents.
Your vehicle’s information:Year:2015 Make:TOYOTA Model:COROLLA Color:BLUE
License Plate #:_________________________State vehicle is registered in:MINNESTOA
Registered owner of vehicle:EUGENE LARAZI
Driver:JACKIE LARAZI
Area(s)damaged:2 FRONT WHEELS
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?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:
IMAGES OF DAMAGE
RECEIPTS
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:JACKIE LARAZI
Signature of Person submitting this form:
Relationship of person signing to Party making the claim:__________________________________________
Date document is being signed:May 25,2023
RevisedMarch 2023