Harle, MatthewRevised 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: Matthew Last Name: Harle
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 If yes, what is your Claim/File Number? C59991
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: James Harle – vehicle owner/damage claim. Matthew Harle – driver of the vehicle,
injured party_______________________________________________________________________
Street Address: 1182 County Road C
City: New Richmond State: WI Zip Code: 54017
Daytime/Work Phone: 715-220-3446 James Harle Cell Phone: 715-222-4809 Matthew Harle
Date of Incident or Date Discovered (Must Complete): 1/3/2026 Time: 12:55pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: Harle vehicle was rear ended while stopped
waiting to turn into a private driveway. The vehicle that rearended Harle is owned by the City of St. Paul and driven by Adam Paul
Bravo.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Party operating city vehicle failed to
maintain proper lookout, failed to stop to avoid an accident, failed to control the 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.
☐ 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.
☐ You were injured in the City of Saint Paul: please provide police report number, witnesses, and details about injury.
Revised March 2023
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: 502026-67
If yes, what law enforcement agency responded? St Croix County Sheriff (WI)
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
East bound County Hwy C .62 mi east of 118th Street, Town of Star Prairie, WI
What would you like to see happen to resolve this claim to your satisfaction?
Vehicle damages and bodily injury claim.
Were there witnesses to this incident? Please provide names and contact phone numbers:
Yes. Chayden Melby 715-338-8603 / Alison Gau 612-358-5338
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 1993 Make: Chevrolet Model: Blazer Color: Gray
License Plate #: AWA8405 State vehicle is registered in: Wisconsin
Registered owner of vehicle: James & Jody Harle Driver: Matthew Harle
Area(s) damaged: Rear
If a City vehicle was involved, License Plate #: DSC873_ Color: Silver
Was there City insignia on the vehicle? YES / NO Driver’s Name: Adam Paul Bravo (unknown if city insignia was visible on vehicle.
Other property damaged: No
For injury claims of any type.
What part of your body was injured? Neck, head
Did you go to the emergency room or urgent care? YES Where? Westfields Hospital
Was medical treatment received? YES Where? _____________Westfields ED; physical therapy
___________________________________________________
First day of medical treatment? 1/3/2026 Are you still receiving medical treatment? YES
Did you miss any work as result of this incident? YES / NO
Employer(s): unknown
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: Lisa Schowalter, Badger Mutual Insurance Co.
Signature of Person submitting this form: LS
Revised March 2023
Relationship of person signing to Party making the claim: Claims adjuster
Date document is being signed: 2/11/2026