Calubayan, JennyNOTICE 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:Jenny Last Name:Calubayan
Please Indicate Your Pronouns:☑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?_________________________
Is this claim being made by an Attorney?YES /NO If yes,what is your File Number?_______________________________________
If yes,provide your Insured’s/Client’s Name:_______________________________________________________________________
Street Address:3863 Westin Ave
City:Woodbury __________________________________State:MN ______________________Zip Code:55125 _____________
Daytime/Work Phone:763-954-2949 Cell Phone:651-434-8959
Date of Incident or Date Discovered (Must Complete):5/26/2023 Time:5:45 PM
Please state,in detail,what happened that prompted you to file a Notice of Claim Form:
I am filing a Notice of Claim Form due to an incident that occurred at the intersection of Fuller Ave and Virginia Street.While driving
around 5 MPH through the intersection,my vehicle struck a large and deep pothole,which I was unable to avoid due to the sudden
nature of its appearance.The impact of my vehicle hitting the pothole caused significant damage,resulting in a punctured tire and
two scratched rims.This unexpected incident not only caused an inconvenience but also necessitated an unplanned expense for the
replacement tire,as well as potential future repairs to the rim.
Please state why or how you feel the City of Saint Paul is responsible for your Damages?
I believe the City of Saint Paul is responsible for the damages I incurred due to their failure to adequately maintain the road
conditions.As a responsible entity tasked with ensuring safe and well-maintained roads,the city holds the duty to promptly address
any hazardous conditions,such as potholes,that may pose a risk to drivers.In this specific case,the presence of a large and deep
pothole at the intersection of Fuller Ave and Virginia Street indicates a lack of proactive maintenance and inspection by the city.By
failing to identify and repair the pothole in the timely manner,the City of Saint Paul allowed a hazardous road condition to persist,
directly leading to the damages I suffered.It is their responsibility to uphold their duty of care and take prompt action to mitigate
such risks.
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.
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☐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.
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?YES /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:
Intersection of Fuller Ave and Virginia Street
What would you like to see happen to resolve this claim to your satisfaction?
I kindly request a thorough investigation into this matter to determine liability for the damage caused to my vehicle.I expect the
responsible entity to provide compensation for the cost of the replacement tire and any additional expenses that may arise from
repairing or replacing the damaged rim.Furthermore,I urge the relevant department to address the dangerous pothole promptly to
prevent similar incidents from occurring in the future.
Were there witnesses to this incident?Please provide names and contact phone numbers:
Alex Meador,563-505-7662
For property damage claims,including vehicle accidents.
Your vehicle’s information:Year:2019 Make:Honda Model:Civic Color:White
License Plate #:DDY519 State vehicle is registered in:Minnesota
Registered owner of vehicle:Jenny Calubayan Driver:Jenny Calubayan
Area(s)damaged:Driver side rims,and rear 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.N/A
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
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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:
●Image of pothole (page 4)
●Image of damage to vehicle (page 5-6)
●Receipt of replacement tire (page 7)
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:Jenny Calubayan
Signature of Person submitting this form:_______________________________________________________
Relationship of person signing to Party making the claim:Self
Date document is being signed:_____________________
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