Samuelson-Day, MaryRevised 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: Mary Last Name: Samuelson - Day
Please Indicate Your Pronouns: ☒ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: _____N/A not applicable_____________________________________
Is this claim being made by an Insurance Company? NO If yes, what is your Claim/File Number? N/A
Is this claim being made by an Attorney? NO If yes, what is your File Number? N/A
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: ________677 Oakdale Ave.________________________________________________
City: __________Saint Paul_____________ State: _____MN__________ Zip Code: _____55107____
Daytime/Work Phone: _________651-387-8792___________________ Cell Phone: 651-387-8792______________
Date of Incident or Date Discovered (Must Complete): 3/26/2024 Time: __police report taken about 1:00 p.m.__
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: On March 26, a city of Saint Paul snowplow
truck knocked off the side-view mirror (driver’s side) of my vehicle (2015 Nissan Versa) that was legally parked. This act of negligent
damage was witnessed and promptly reported as a hit and run to the police with jurisdiction in the matter.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _The city of Saint Paul employs or contracts
the driver responsible for damaging my vehicle, through negligence, as it was legally parked and clearly visible. . The damage caused
is a greater amount than my insurance deductible which is shown in submitted documents. The cost to make whole / repair
damages are legally the responsibility of the city of Saint Paul.
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: ___24-053-052________________________
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:
__Morton Street, outside my home located at 677 Oakdale Ave. Saint Paul, MN 55107
What would you like to see happen to resolve this claim to your satisfaction? Full reimbursement for the out-of-pocket charges
incurred to repair the damage caused to my vehicle by the city snowplow driver.
Were there witnesses to this incident? Please provide names and contact phone numbers:
The witness to the incident is Michaela Day (cell: 612-296-6718), whose statement was taken by the police following the hit and run
incident.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: ___2015______ Make: Nissan Model: Versa Color: blue
License Plate #: NST – 249 State vehicle is registered in: MN (Minnesota)
Registered owner of vehicle: Mary Samuelson – Day Driver: The vehicle was parked, there was no driver.
Area(s) damaged: side-view mirror (external) on the driver’s side
If a City vehicle was involved, License Plate #: If there was a plate, it was not visible, however it was marked as a city of Saint Paul
snowplow_ Color: Click or tap here to enter text.
Was there City insignia on the vehicle? YES Driver’s Name: The driver that committed the hit-and-run failed to stop.
Other property damaged: Click or tap here to enter text.
For injury claims of any type.
What part of your body was injured? Click or tap here to enter text.
Did you go to the emergency room or urgent care? NO Where? Click or tap here to enter text.
Was medical treatment received? NO Where? Click or tap here to enter text.
First day of medical treatment? Click or tap to enter a date. Are you still receiving medical treatment? NO
Did you miss any work as result of this incident? NO
Employer(s): Click or tap here to enter text.
How much time have you missed from work? _Click or tap here to enter text.
If you are submitting other documents, please state what you are attaching and how many pages:
A) 1 page of an estimate from Nissan dealership totaling $725.40
B) 1 page of bill from Rodriquez Auto Service totaling: $455.90 (including receipt showing bill was paid in full
C) 4 photos of vehicle damage and D) an image of the police card with case/report number
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: ___ Mary Samuelson - Day______________________________
Signature of Person submitting this form: Mary Samuelson - Day
Relationship of person signing to Party making the claim: _____self______
Date document is being signed: 4/17/2024