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Bradshaw, BrendanRevised March 2023 NOTICE OF CLAIM FORM tothe City of Saint Paul,Minnesota MinnesotaState Statute 466.05 states that“…every person…who claims damages from any municipality…shall cause tobe presented tothe governing body of the municipality within 180 days after thealleged loss orinjuryis discoveredanotice statingthe time,place,and circumstances thereof,and the amount of compensation or other reliefdemanded.” Pleasecomplete this formin 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 contactedby telephoneunless clarification is needed.The claim processfor investigations can take upwards of four (4) weeks.This form must be signed,dated with allapplicable sections completed.Submission this completedform tothe Saint PaulCity Clerk’sOffice 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:________________________________Last Name:_______________________________________________ Please Indicate Your Pronouns:☐She/Her/Hers,☐He/Him/His,☐They/Them/Theirs Company or Business Name:____________________________________________________________________________________ Is this claim being made by an Insurance Company?YES /NO If yes,what is your Claim/File Number?_________________________ Is this claim being made by an Attorney?YES /NO If yes,what is your File Number?_______________________________________ If yes,provide your Insured’s/Client’s Name:_______________________________________________________________________ Street Address:_______________________________________________________________________________________________ City:______________________________________________State:________________________Zip Code:___________________ Daytime/Work Phone:__________________________________Cell Phone:_____________________________________________ Date of Incident or Date Discovered (Must Complete):_____________________________Time:_____________________________ 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. ☐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 amotor 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. Continue to page 2 of Notice of Claim Form.Failure to complete and return both pages will result in delays. Bradshaw 2285 University Avenue W APT C263 8:00 AM Car damaged by snow emergency tow Brendan (612)-210-6263 NO Damage caused by city contracted company Saint Paul X 55114 12/11/2025 X NO Minnesota Revised March 2023 This section must be completed for all claims. Is there a police report for this incident?YES /NO If yes,please provide the police report case number:___________________________ If yes,what law enforcement agency responded?____________________________________________________________ Where did the incident take place?Please provide a street address,intersection or name of city park or facility: ____________________________________________________________________________________________________________ What would you like to see happen to resolve this claim to your satisfaction? ____________________________________________________________________________________________________________ Were there witnesses to this incident?Please provide names and contact phone numbers: ____________________________________________________________________________________________________________ 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?_____________________________________________________________________________ Did you go to the emergency room or urgent care?YES /NO Where?___________________________________________________ Was medical treatment received?YES /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):_________________________________________________________________________________________________ How much time have you missed from work?_____________________________________________________________________ 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:_____________________________________________________________ Signature of Person submitting this form:_______________________________________________________ Relationship of person signing to Party making the claim:__________________________________________ Date document is being signed:_____________________ Silver Brendan Bradshaw CHARLES AV,INTERSECTING STREET:CARLETON ST,2ND CROSS STREET:HAMPDEN AV Brendan Bradshaw ZXE301 8 hours Brendan Bradshaw 12/11/2025 Damages must be paid in full LS430 YES 2005 Front bumper,Fog light assembly,Washer fluid reservoir,Wheel alignment, fender liner Lexus NO NO Minnesota Walser Automotive Group