Roiger, KeithRevised 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: Keith Last Name: Roiger
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: N/A___________________________________________________________________________
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: 3010 Bluffs Lane
City: Mound State: Minnesota Zip Code: 55364
Daytime/Work Phone: 612-702-3581 Cell Phone: 612-986-7507 (Back-up phone #)_
Date of Incident or Date Discovered (Must Complete): 12/13/2023 Time: 4:45pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: A parking enforcement officer car hit my car
while it was parked on the street near the corner of Dayton Ave. and Montrose Place. I arrived at my car and found both the parking
enforcement officer and a St.Paul police officer waiting at the car. The parking enforcement officer had written a note stating, “I was
backing up and not sure if I did the scratch on your bumper-driver side.” and left it on the windshield of the car in the case that I did
not come out by the time they left. They also filled out a case number card (CN: 23-227-470).
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The St. Paul parking enforcement officer
admitted fault for the damage done to the car that was hit. This was verbally stated as well as shown in the note that was left by him
in the windshield. It is clear that the car has some damages that should be fixed as a result of the officer hitting the car.
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? YES
If yes, please provide the police report case number: _23-227-47____
If yes, what law enforcement agency responded? Saint Paul Police Department
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
The car was parked on Dayton Ave. right past the intersection of Montrose Place and Dayton Ave.
What would you like to see happen to resolve this claim to your satisfaction? I would like the full cost of the repairs for the damages
to be covered.
Were there witnesses to this incident? Please provide names and contact phone numbers:
No one that I know of witnessed the incident. My roommate was with me as I interacted with the police officer and parking
enforcement officer after the incident occurred. The name of the parking enforcement officer involved should be stated in the police
report.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2015 Make: Honda Model: Accord Color: Gray
License Plate #: JBY-561 State vehicle is registered in: Minnesota
Registered owner of vehicle: Keith Roiger Driver: Anna Roiger
Area(s) damaged: Front drivers-side bumper, and front drivers-side wheel
If a City vehicle was involved, License Plate #: Do not know – Should be recorded in police report Color: White – Parking enforcement
car
Was there City insignia on the vehicle? YES Driver’s Name: Do not know – Should be recorded in police report
Other property damaged: N/A
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: Photos of damage (2), photo of
note left on car (1), Cost estimate from Collision & Color (3 pages), Cost estimate from R&S Collision Services,inc. (3 pages)
Revised March 2023
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: Keith Roiger
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: Car Owner
Date document is being signed: 12/27/2023