Loading...
Dosch, JeraldNOTICE 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." Individuals: First Name 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 is to the Saint Paul City Clerk's Office. You may email, fax (651-266-8574) or mail the farm. Mailing address is "Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102" \£RALs mane A>oseH Please Indicate Your Pronouns: She/ Her/Hers)( He/Him/His□- They/ Them/Theirs (_)FT)[Q[I\/ T [5(IS][)QSS []][[\@. ] 'i'le4 ls this claim being made by an Insurance Company? /\Jo If yes, what is your Claim/File Number?: _f'l_+-'-'A~----- Is this claim being made by an Attorney? Choose an item. If yes, what is your File Number?--+-/2__,,_h~O~----------- ~tor ate _ If yes, then TOVIde VOIT lnSured's/ (Client's Name sveotcaasres '/2 AToE Coo?T <7 fa / <s/oz City:), 4ls State /V/ ZipCode >- • l0.. 70 gs 3g3yo o/s/os • 3.05 f, ~ 7 . J SEs ATTA#ED SE AT6kc#ED» st complete) Please state, in detail, what happened that prompted you to file a Notice of Claim Form. Please state why or how you feel the City of Saint Paul is responsible for your Damages? 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. ~utomobile 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. L] 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. D You were injured in the City of Saint Paul: please provide police report number, witnesses and details about injury. This section must be completed for all claims, Is there a police report for this incident@o If yes, please provide the police report case number 25'// D 5<j f S, pp p 'p «evseabecemoerao fyes, what law enforcement agency responded? 2f-UT [a [otTcs DE/? 7 E 2"% 52%%%% a» = TUTsRSEcr±ow F ' ST AST ADS ('lrA Notice of Claim Form, page two. Failure to complete and return both pages will result in delays. What would you like to see happen to resolve this claim to your satisfaction? ; pfi.. fr,1 /k-f/Gf:J Were there witnesses to this incident? Please provide names and contact phone numbers. No1 mAT (,,Je. oF For property damage claims, including vehicle accidents. or eta=stores 3esrZ007-ska /1ousA cas Acco@ cos 'I&Vi aense a » ']F7/ see!es,sastarco /AA _JG.II-ALiJ JJDJ.(J/ A// . f, l Registered owner of vehicle, Dfx.TE 5HAFER over V/A CR LS U/occupT£ED I wabs) aaeca Roy7_ Er If a City vehicle was involved: License Plate# __ 9--'----'7'_,_7_¾_;__:.:>_,..-_f~----- Color ~L&£ owesowe ET Tuvs? Was there City insignia on the vehicle? Yes No (}f[of [[([Q[[\/ (]][]l]@Q(--- For injury claims of any type. \/pa[ [a[E QT \/OUT DQQ\y /GS IT[UFeQ?' Did you go to the emergency room or urgent care? Yes No Where? /as medical treatment received? Yes No /here? 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) {g/ IT7ICh [[mg [)3/@ \/QL] TT\[Ssg] frgr /Qfk;' If you are submitting other documents, please state what you are attaching and how many 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: _j----'· f=.,___fl__,_A-'-=LCC-,D __ Jj~~---O ... .S~L-'--+---+------ Signatu re of Person submitting this form: ~ / Relationship of person signing to Party making the claim: Ke/f ate documeats re seas O/24/2ozs SEE ATIAOMED» ! CD Mor kf/ o, 9a car} cukdsl)ell Q sPns lode»k ©, Cg kfk c» e car uk&sh#ell © op, sf' SD 5ct# re# 2%,s ( #zs-hes ?) (3) Do.-t co7k, res+ '·y«&5 p«s #, -6rd r«rd e, /k 4o-me,/ to<lf as /vs () peke}s of /k Ares /> a veh%, Revised December 2021 Notice of Claim Form to the City of Saint Paul, Minnesota Answers to parts A, Band C of the form when noted as "see attached". Submitted by Jerald Jay Dosch Please state, in detail, what happened that prompted you to file a Notice of Claim Form. • On the morning of Monday, June 23, 2005, a City of Saint Paul employee, Eric Ross Turner, was driving a City of Saint Paul (Saint Paul Regional Water Service) vehicle when the vehicle he was driving struck our legally parked, unoccupied car, and caused significant damage. I have enclosed a copy of the Saint Paul Police Department Incident Report (case number 25-110594 ). Please state why or how you feel the City of Saint Paul is responsible for your damage. • Eric Ross Turner, an employee of the City, was driving a Saint Paul Regional Water Service vehicle when the vehicle he was driving struck our legally parked, unoccupied car, and caused significant damage. We (myself and my spouse who co-owns the vehicle) were not present when the City employee struck and significantly damaged our vehicle. The only person present, Eric Ross Turner, is responsible. He is an employee of the City and was driving a City owned vehicle at the time he caused the accident. What would you like to see happen to resolve this claim to your satisfaction? • This claim needs to be quickly resolved. We need this vehicle in order to drive to work each day. • Our car needs to be towed, at City expense, to an auto body repair shop of our choosing. • Our car needs to be repaired, at City expense. • We need a rental car, paid for by the City, while our car is repaired. Photos (2) of the damage to our vehicle: 1 2 ----#--~~_!J_2_-__,__,,,~ ti ,v Bu r '-@ca. \Whr Serie S 11 DRIVER/VEHICLE INF ORMA Toy cs±wuws. ZS]lb.27H DRVER NAwe.. Er iCTurnr Ar ors. ll/ol IT]_ Manawa ApRss:. _[19 j' Sl EMAIL ADDRESS: easrealm7Hsu_ usunncs cow:_5h.fb.al fugioal wdg sgia? INSURANCE POLICY NUMBER: .. - 5l 0 z {730 1 ,. Ty vila . ....___ -· ACCIDENT INFORMATION CARD You have received this card because it has been determined that you have been involved in a motor vehicle crash. Minnesota State Law (169.09) requires that drivers involved In any accident shall provide the following information: 1 ¥ • Driver's Name © Date of Birth • Mailing Address or Email Address • Registration Plate Number • Insurance Company ~ • Insurance Policy Number • DL/Permit upon officer request On the back of this card, you will find a place to collect/provide the above information. Questions can be ; referred to the officer on-scene or the numbers listed on the card. Saint Paul Police Department 367 Grove Street " Saint Paul, MN55101 " Main: 651-291-1111 Records Unit: 651-266-5700 \ l CASE NUMBER: 25-110594 #, SAINT PAUL POLICE ',or .gg service with Purpose INCIDENT REPORT SAINT PAUL POLICE DEPARTMENT 06/24/2025, 13:05 Data Redactions Pursuant to Minn. Stat. $168.346 Incident Overview Case Status Case Number Reported Date Location Offenses Closed 25-110594 06/23/2025, 11:32:20 6 Street E / Maria, St. Paul Traffic Accident- Property Damage Accident 0cc Date From 0cc Date To 06/23/2025, 11:30 06/23/2025, 11: 30 o Incident Summary ~ ,I -----------Cre-ate_d.b-y: li_: _ MN Crash Report . ~ to 'h I ..... co Ch £ aboul:blank 1/7 CASE NUMBER: 25-110594 SAINT PAUL POLICE Service with Purpose INCIDENT REPORT SAINT PAUL POLICE DEPARTMENT 06/24/2025. 13:05 Staff Involved Officer Schissel, Maxwel (605585) Type Submitter BWC ICC Resistance Encounter Force Used Vehicle Pursuit Narratives Narrative 1 Created by: SCHISSEL, MAXWEL (605585) 06/23/2025, 12:09 Synopsis: MN Crash Report Narrative: *** This is an automated report generated from MN Crash. To see the full details of this report, please refer to the MN Crash Report Unit 1 was traveling South on 6th St. The driver of Unit 1 attempted to pull over and park in front of Unit 2. When Unit 1 moved over the rear wheel hubcap caught on the front driver side of Unit 2 and ripped the front bumper off. The owner of Unit 2 was not on scene. Information was left under the front windshield. about: blank 2 CASE NUMBER: 25-110594 SAINT PAUL POLICE Service with Purpose INCIDENT REPORT SAINT PAUL POLICE DEPARTMENT 06/24/2025, 13:05 Participants / Persons Person 1 St Paul Regional Water Service (Business) 1900 Rice Street, St. Paul, MN 551136810 Info Participant Type Business Name Business St Paul Regional Water Service Person 2 Eric Ross Turner DOB: 11/01/1971 4855 Babcock , Inver Grove Heights, MN 550771273 Info Attributes Participant Type Gender Driver Male License/ ID Number Person 3 Jerald Jay Dosch 40 Alice Court, St. Paul, MN 551072634 J p F co ~ L._ ___,....., ...--------------------------------------,~ a) co Info Attributes Participant Type Owner License/ ID Number 2976203484222 Person 4 about:blank 3/1 CASE NUMBER: 25-110594 SAINT PAUL POLICE Service with Purpose INCIDENT REPORT SAINT PAUL POLICE DEPARTMENT 06/24/2025, 13:05 Dixie Lee Shafer 40 Alice Court, St. Paul, MN 551072634 Info Attributes Participant Type Owner License/ ID Number o > D ti 2 ~ h ti - tO 'CJ I ..... ..... 0 Ch o 4 about:blank 4[7 CASE NUMBER: 25-110594 06/24/2025, 13:05 SAINT PAUL POLICE Service with Purpose INCIDENT REPORT SAINT PAUL POLICE DEPARTMENT Businesses Business 1 St Paul Regional Water Service 1900 Rice Street, St. Paul, MN 551136810 Role Type Name Business St Paul Regional Water Service to J I - - co Ch so .4 about:blank 517 CASE NUMBER: 25-110594 06/24/2025, 13:05 SAINT PAUL POLICE Service with Purpose INCIDENT REPORT SAINT PAUL POLICE DEPARTMENT Vehicles Vehicle 1 Info License# : 977454 Model TRANSIT Type 5 State MN Year 2023 Make : FORD Color BLU VIN Vehicle 2 Info o 'p> License# : 9PF764 Model ACCORD r Type 2 tr State MN Year 2007 £ Make : HOND Color BLU VIN ~ t 7 to 'h I - - co Jh « 4» about blank 617 CASE NUMBER: 25-110594 06/24/2025, 13:05 "%. guy PAu g POLICE u \g/ Service with Purpose INCIDENT REPORT SAINT PAUL POLICE DEPARTMENT Property Property 1 lnvolvment Type Make Article Description None HOND Vehicle Model Number ACCORD Property 2 lnvolvment Type Make Article Description o > ~ ~ 5 (Ti '-------------------------------------~?? None FORD Vehicle Model Number TRANSIT about:blank 717