Tomai, JerryRevised 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: ______Jerry_____________ Last Name: ___Tomai______________________________________
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: ___Cushman & Wakefield for Securian Financial_____________________________________________
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: ___400 Robert Street N, Suite 208_______________________________________________________
City: St Paul State: _____MN________________ Zip Code: ___55101________________
Daytime/Work Phone: ______651‐665‐3092_________________ Cell Phone: _______612‐366‐3381____________________
Date of Incident or Date Discovered (Must Complete): 5/3/2023 Time: Approximately 9PM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: __See Attached__
Please state why or how you feel the City of Saint Paul is responsible for your Damages? __The officer causing damage admitted to it
when reporting it to security and Commander Laura Bolduan is aware.
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.
Revised March 2023
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? _Commander Laura Bolduan is aware of the incident
___________________________________________________________
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
__401 Robert Street N, Suite 219, St.Paul MN 55101
What would you like to see happen to resolve this claim to your satisfaction?
___Full Payment of attached invoices
Were there witnesses to this incident? Please provide names and contact phone numbers:
_Commander Laura Bolduan knows the officer who damaged the door.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _________ Make: _________________ Model: __________________ Color: __________________
License Plate #: _________________________ State vehicle is registered in: ___________________________
Registered owner of vehicle: _____________________________ Driver: __________________________________________
Area(s) damaged:______________________________________________________________________________________
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? ________________________________________________________________
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: Reason for Claim and incident
report; Brin Invoices x2; Parsons Invoice; Gardner Invoice; Building engineering service work order_________________________
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: _Kevin Kurpierz__________________________________________
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: ___Agent for owner of property_________
Date document is being signed: ___12-26-2023__________________
Revised March 2023
Reason for Claim:
Downtown Command has a location at the Securian 401 Building on Robert Street. The officers have various types of vehicles for
moving about the city easily. When entering the office on one of these vehicles, the officer hit the glass door causing it to shatter. It
was reported immediately to Securian security. Security’s incident report is below:
On May 3rd 2023 around 2136hrs, St. Paul Police reported to the command center that they hit their glass entry door
with a segway and shattered it. Security took a look and reported it to Cushman engineers. After speaking to Cushman
on 05/04/2023 they noted that the door would be around $10,000 if they use the glass type doors. They also stated that
a company was coming out to give options on replacements. There is no time on replacement as of yet.
Nothing further to report. End of report.
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Justin Mrugala
Security Specialist
Security
justin.mrugala@securian.com
400 Robert Street North, Mail Stop 02-1559, St. Paul, MN 55101-2098
651-665-1120 (8AM-11:30AM Mon-Wed) | 651-665-1559 (11:30AM-3:30PM) | 651-318-9390 (mobile)
Securian Financial Group, Inc.
securian.com