Bonfe, Connor
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
mailto:Saint%20Paul%20City%20Clerk’s%20OfficeSaint 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: ___Connor_____________________________ Last Name: _______Bonfe________________________________________
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? <_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: _______575 Burlington Road___
City: __Saint Paul___ State: ________________________ Zip Code: __55119
Daytime/Work Phone: __651-3191-1714___ Cell Phone: _____________________________________________
Date of Incident or Date Discovered (Must Complete): 7/18/2023 Time: ________________5:15 PM_____________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: _My tire tread had ripped from the front wheel/tire and a big pothole on the Mcknight road and
the pothole has not been filled since last winter and it is very deep hole.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? It is July and it still has not been filled by the city._I try to avoid that pothole but its
on a crossroad so I am always hitting it and hard to avoid. It’s a road I always drive on.
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.
☐ 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: __No___
If yes, what law enforcement agency responded? ____No______________
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
_____Right across the home from 346 Mcknight Road S in Saint Paul MN. Intersection street closest to it is Londin LN E.
What would you like to see happen to resolve this claim to your satisfaction? ______I would like a refund as I needed to replace my tire due to the pothole not being filled.____There
are multiple potholes in this area that are big enough to cause damage.________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent></w:sdt><w:r w:rsidR="0031571E" w:rsidRPr="00 ___My spouse Emily Bonfe
and phone number is 651-3191-1714__________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: ____2022__ Make: _Hyundai___ Model: _Santa Fe____ Color: __Silver__
License Plate #: _HNB 133___ State vehicle is registered in: _Minnesota___
Registered owner of vehicle: __Connor Bonfe__ Driver: __Connor Bonfe_____
Area(s) damaged:___Front driver side tire_______________
If a City vehicle was involved, License Plate #: _____N/A___ Color: _______________________________
Was there City insignia on the vehicle? YES / NO Driver’s Name</w: ______________________________________________________
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? YES / 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: _________________________
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: _____________________________________________________________ <
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: __________________________________________
Date document is being signed: _____________________
Revised March 2023