Rossing, Andrew (8.19)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 o 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: Andrew Last Name: _Rossing _
Please Indicate Your Pronouns: □She/Her/Hers, X He/Him/His, D] 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: _N/A _
StreetAddress: N/A _
Zip Code:_ [l/A City; N/A_Stale. N/A
Daytime/Work Phone:_952-201-8077 Cell Phone: _952-201-8077 _
Date of Incident or Date Discovered (Must Complete): 7/20/2025 Time: 1O:38PM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: A Saint Paul Police Officer backed a Polaris
Ranger Police vehicle into my vehicle, resulting in damage to my driver's door in the form of scratches and dents. Pedestrians were
crossing in front of my vehicle and cars were behind us, so we could not move out of the path of the Police Officer's vehicle.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The damage to my vehicle was the result of
an accident caused by an on-duty Saint Paul Police Officer in a City owned and marked Police vehicle
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.
Note: I am only able to provide 1 estimate, as there is only 1 company in Minnesota who is Certified by the Manufacturer of my
vehicle to repair it. https://rivian.com/support/article/certified-collision-centers
□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.
Revised March 2023
□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.
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: _25-130-226_filed by Officer Tamm, badge #131 _
If yes, what law enforcement agency responded? _Saint Paul Police _
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
Intersection of Ohio St. and Isabel St. W. in Saint Paul ---------------------------
What would you like to see happen to resolve this claim to your satisfaction? I would like the City of Saint Paul to pay for the repairs
that are necessary as a result of the damage to my vehicle and for an equivalent vehicle rental for the duration it takes to repair my
personal vehicle. Estimate from LaMettry's Collision is $7,103.81 (note this is the only body shop in Minnesota that is certified to
repair Rivian's, so I am only able to provide one quote, which is attached) plus $2,000 for an equivalent rental vehicle for
approximately 3 weeks while my vehicle is being repaired, for an approximate total of $9,103.83.
Were there witnesses to this incident? Please provide names and contact phone numbers:
Kelley Phillips = 651-295-9416, Thomas Currier -612-418-5723, Robin Lindeman- 301-717-9518, and I have attached video footage
from my dash cam. This should also be documented in the Police Incident Report #25-130-226
For property damage claims, including vehicle accidents.
Make: _Rivian Model: _RlS Color:_ /hite Your vehicle's information: Year: _2023
License Plate #:_ZXD-587 State vehicle is registered in: _Minnesota _
Registered owner of vehicle: Andrew Rossing Driver: Kelley Phillips (Ph: 651-295-9416)
Area(s) damaged:_Driver's Door _
If a City vehicle was involved, License Plate#: No Plate visible on the Polaris Ranger. May be in Police Report, which I have
requested, but have not received to date_ Color: _Black _
Was there City insignia on the vehicle? YES Driver's Name: I was not provided this when on the scene by the Police Officers, but
am hoping it is in the Police Report, which has been requested _
Other property damaged: _N/A. _
For injury claims of any type.
What part of your body was injured? _No injuries were sustained _
Did you go to the emergency room or urgent care? NO Where? _
Was medical treatment received? 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): ----------------------------------------
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If you are submitting other documents, please state what you are attaching and how many 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: _Andrew Rossing, _
Signature of Person submitting this form: ~ ~~
Revised March 2023
Relationship of person signing to Party making the claim: SELF
Date document is being signed: d'rcz bs-