Contreras, Rosanne (Ramsey County)Revised 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: ____________________Rosanne ____________ Last Name: Contreras
_______________________________________________
Please Indicate Your Pronouns: ☒ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: Ramsey County Enterprise Risk Management, Compliance & Ethics Office
____________________________________________________________________________________
Is this claim being made by an Insurance Company? NO If yes, what is your Claim/File Number? 25-097V___________________
Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________________
If yes, then provide your Insured’s/ Client’s Name ___________________________________________________________________
Street Address: _______________________________________________________________________________________________
City: ______________________________________________ State _________________________ Zip Code ___________________
Daytime/Work Phone __________________________________ Cell Phone ______________________________________________
E-mail _________________________________________________
Date of Incident or Date Discovered (Must complete) 7/11/2025Time _________________11:41AM____________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. The City of St. Paul ambulance cut off the
Ramsey County Sheriff vehicle. The Ambulance took a right from the left lane______________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _______Dash Cam footage shows a clear
error on the party of the City of St. 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: _______RCSI25032485____________________
If yes, what law enforcement agency responded? ______RCSO
______________________________________________________
Where did the incident take place? Please provide a street address, intersection or name of city park or facility.
__________Based on the dashcam footage, the accident happened on Maryland Ave St. Paul near the Cub Foods on 1100 block of
Clarence St__________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?
____________________________________________________________________Please reimburse Ramsey County in the amount
of $10,825.90 ________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
____________________________________________________________Dashcam footage
________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year 2022 Make _____Ford____________ Model __Police Interceptor Utility________________ Color
______Grey______________
License Plate # ___JMY282______________________ State vehicle is registered in
______Minnesota_____________________
Registered owner of vehicle _______Ramsey County _______________________ 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? _____________________________________________________________________________
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? 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. _________________________
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: ____Ramsey County Claims Analyst Rosanne Contreras Rosanne.Contreras@co.ramsey.mn.us
_______________________________________________________
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: ____Ramsey County Claims Analyst 651.508.1096 Ramsey County
Courthouse_____________________________________
Date document is being signed ___11-5-2025___________________________