Pliego, YazminNOTICE 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 aBer the alleged loss or injury is discovered a noDce staDng the Dme, place, and circumstances thereof, and the amount of compensaDon
or other relief demanded.”
Please complete this form in its en1rety by clearly typing or prin1ng your answers to each ques1on. If you have addi1onal documenta1on, you may add those
documents to your submission. You will not be contacted by telephone unless clarifica1on is needed. The claim process for inves1ga1ons can take upwards of
four (4) weeks. This form must be signed, dated with all applicable sec1ons 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: Yazmin ________________________________ Last Name: Vazquez Pliego
_______________________________________________
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 ALorney? YES / ✔NO If yes, what is your File Number?
_______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: _______________________________________________________________________________________________
City: ______________________________________________ State: ________________________ Zip Code: ___________________
DayQme/Work Phone: __________________________________ Cell Phone: _____________________________________________
Date of Incident or Date Discovered (Must Complete): 12/05/2023_____________________________ Time: 9am
_____________________________
Please state, in detail, what happened that prompted you to file a NoQce of Claim Form:
Piece of metal sQcking out of the side walk popped my Qre. I had to call AAA to help me change out my Qre. Tire is not patchable and
had to be replaced. This caused me a two hour delay into work the day of, then another 3 hours the next day get a new Qre, plus a
$300 charge! This side walk is a safety hazard for people, pets and vehicles. ____________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? City property, this is a safety hazard that the
city has to fix to avoid anyone gebng hurt or anyone’s property gebng damaged. ____________________________________
Please check the reason that most closely describes the reason for your submiBng a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submiLed become the property of
the City of Saint Paul and shall not be returned.
☐ Automobile damage from a motor vehicle accident: please provide two esQmates for repairs or actual bill that has been paid.
✔☐ Automobile damage from a street defect or pothole: please provide two esQmates 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 Qcket (if available), receipt
from Impound Lot, and two esQmates for repairs or actual bill that has been paid.
Revised March 2023
☐ Snow Emergency: please provide copy of towing Qcket (if available), receipt from Impound Lot, and two esQmates for repairs or
actual bill that has been paid.
☐ Property damage: please provide two esQmates 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.
ConEnue to page 2 of NoEce of Claim Form. Failure to complete and return both pages will result in delays.
This secEon 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, intersecQon or name of city park or facility:
Maryland and Jessie st in Saint Paul MN
____________________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your saQsfacQon?
I would like a reimbursement for the replacement of my Qre plus an addiQonal $200 for the Qme I had to take away from work.
____________________________________________________________________________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
____________________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s informaQon: Year: 2017_________ Make: Jeep_________________ Model: Grand Cherokee __________________
Color: white__________________
License Plate #: KUU 312_________________________ State vehicle is registered in: MN___________________________
Registered owner of vehicle: Yazmin Vazquez Pliego_____________________________ Driver: Yazmin Vazquez Pliego
__________________________________________
Area(s) damaged: Passenger front Qre
______________________________________________________________________________________
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? YES / NO Where? ___________________________________________________
Was medical treatment received? YES / NO Where? ________________________________________________________________
Revised March 2023
First day of medical treatment? _____________ Are you sQll receiving medical treatment? YES / NO
Did you miss any work as result of this incident? YES / NO
Employer(s): _________________________________________________________________________________________________
How much Qme have you missed from work? _____________________________________________________________________
If you are submiBng other documents, please state what you are aKaching and how many pages: _________________________
By signing this form, you agree that all informaEon provided is true and correct to the best of your knowledge.
Please NOTE that submiBng a false or misleading claim can and will result in prosecuEon under Minnesota Statutes.
Name of Person compleQng form: Yazmin Vazquez Pliego _____________________________________________________________
Signature of Person submibng this form: Yazmin Vazquez Pliego_______________________________________________________
RelaQonship of person signing to Party making the claim: __________________________________________
Date document is being signed: 12/06/2023_____________________
Revised March 2023