Davis, Esther2Revised 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: ____Esther_______ Last Name: ____________Davis____________
Please Indicate Your Pronouns: ☒ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: __________________Full-time student at Bethel University________________________
Is this claim being made by an Insurance Company? NO If yes, what is your Claim/File Number? _________________________
Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: ___________3900 Bethel Dr MSC 569___________________
City: _______St Paul_______ State: _____MN______ Zip Code: _________55112___
Daytime/Work Phone: __________________________________ Cell Phone: ______331-305-7660________
Date of Incident or Date Discovered (Must Complete): 3/12/2023 Time: _______10pm__________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ____I was driving to Concordia and my
headlights don’t shine very far so I didn’t notice a pothole in the road. It was pretty deep and when my car hit it I went so far down
that the ground hit my shocks and completely destroyed them. The pipes bent to a 90 degree angle and became unsafe to drive the
car._____
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _____Because there was nothing wrong
with my shocks before I hit the pothole. If I hadn’t have hit it, I wouldn’t have had to pay such a large expense. I think Saint Paul is
responsible for covering this expense because the pothole was in St Paul. My car is older, but it’s in excellent condition and everyone
always assumes it’s new because of how well kept it is, I wouldn’t have had this expense had it not been for the pothole._____
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.
Revised March 2023
☐ 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:
_________Concordia Avenue in St Paul after exiting the highway but before reaching Concordia University___________
What would you like to see happen to resolve this claim to your satisfaction?
________I would like for the car expenses to be covered for me.__________
Were there witnesses to this incident? Please provide names and contact phone numbers:
____yes, Taaron Rudzitis (763-442-9260)_______
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _2006_ Make: __BMW__ Model: ____330i___ Color: __Silver__
License Plate #: _________KEN266_______ State vehicle is registered in: MN
Registered owner of vehicle: _____Esther Davis___ Driver: ______Esther Davis_____
Area(s) damaged:_________The shocks__________
If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________
Was there City insignia on the vehicle? NO Driver’s Name: ______________________________________________________
Other property damaged: _______________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? _______N/A___________________________________
Did you go to the emergency room or urgent care? NO Where? ___________________________________________________
Was medical treatment received? NO Where? ________________________________________________________________
First day of medical treatment? _____________ Are you still receiving medical treatment? NO
Did you miss any work as result of this incident? 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: ___invoice from mechanic, 1
page____
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: _____Esther Davis______
Revised March 2023
Signature of Person submitting this form: _________Esther Davis__________
Relationship of person signing to Party making the claim: _____Same Person______
Date document is being signed: 4/19/2023