Hall, LarryRevised 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: _Patrick _ Last Name: _Conlin_
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: _Gallagher Law Firm _
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? YES If yes, what is your File Number? _23-054_
If yes, provide your Insured’s/ Client’s Name: _Larry Hall
Street Address: _825 Fireside Drive_
City: _Apple Valley_ State: _MN_ Zip Code: _55124_
Daytime/Work Phone: __________________________________ Cell Phone: _____________________________________________
Date of Incident or Date Discovered (Must Complete): 1/8/2022 Time: _approx. 7:15 p.m._
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: _Larry was in elevator No. 12 in the St. Paul
RiverCentre Parking Ramp when the elevator got stuck and dropped. Larry fell to his knees and was injured from the drop._
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _The City owns the Parking Ramp and is
responsible for the maintenance of the elevators._
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.
Revised March 2023
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: _22-004164__
If yes, what law enforcement agency responded? __St. Paul Police Department and Fire Department _
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
_The St. Paul RiverCentre Parking Ramp, Elevator 12. 150 Kellog Blvd W, St. Paul, MN 55102_
What would you like to see happen to resolve this claim to your satisfaction? _Please contact Mr. Hall’s attorney at 651-222-4466_
Were there witnesses to this incident? Please provide names and contact phone numbers:
__None Known. Someone from maintenance responded to the incident along with fire and police, but their name and contact
information is unknown.__
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? __upper back, mid back, low back__
Did you go to the emergency room or urgent care? NO Where? _N/A_
Was medical treatment received? YES Where? _M Health Fairview & Summit Orthopedics_
First day of medical treatment? 2/1/2022 Are you still receiving medical treatment? NO
Did you miss any work as result of this incident? YES
Employer(s): _Xcel Energy Center/St. Paul Arena Company_
How much time have you missed from work? _from June 14, 2022 until October 1, 2022_
If you are submitting other documents, please state what you are attaching and how many pages: _Police & Fire Reports, 3 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: _Patrick M. Conlin_
Signature of Person submitting this form: _/s/ Patrick M. Conlin_
Relationship of person signing to Party making the claim: Attorney
Date document is being signed: 2/6/2024