Bell, GabrielleNOTICE 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 aBer the alleged loss or injury is discovered a noDce staDng the Dme, place, and circumstances thereof, and the amount of compensaDon
or other relief demanded.”
Please complete this form in its en1rety by clearly typing or prin1ng your answers to each ques1on. If you have addi1onal documenta1on, you may add those
documents to your submission. You will not be contacted by telephone unless clarifica1on is needed. The claim process for inves1ga1ons can take upwards of
four (4) weeks. This form must be signed, dated with all applicable sec1ons 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: _____________Gabrielle___________________ Last Name: _________Bell________
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 AIorney? YES / NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: ___________________1612 Huron St________________________________________________
City: ______________Saint Paul________________________________ State: _________MN_______________ Zip Code:
______55108_____________
DayVme/Work Phone: _____________651-366-8042_________ Cell Phone: _________________651-366-8042__________
Date of Incident or Date Discovered (Must Complete): _____3/22/26________________________ Time:
_______3:40pm______________________
Please state, in detail, what happened that prompted you to file a NoVce of Claim Form: I was driving northbound on Lexington ave
when I hit a pothole on the right side of the road. My vehicle began to make a grumbling noise and I brought it in for a diagnosVc
concern the I was noVfied that the exhaust pipe was shiaed out of place. This
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The potholes all over the city conVnue to go
unpaved. My car would not have been damaged or needed repairs had the potholes been covered.
Please check the reason that most closely describes the reason for your submiDng a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submiIed become the property of
the City of Saint Paul and shall not be returned.
☐ Automobile damage from a motor vehicle accident: please provide two esVmates for repairs or actual bill that has been paid.
☐Automobile damage from a street defect or pothole: please provide two esKmates for repairs or actual bill that has been paid.
220.51 was the total for the diagnosis and labor costs for the repair.
☐ Automobile was towed and may or may not have sustained damage: please provide copy of towing Vcket (if available), receipt
from Impound Lot, and two esVmates for repairs or actual bill that has been paid.
☐ Snow Emergency: please provide copy of towing Vcket (if available), receipt from Impound Lot, and two esVmates for repairs or
actual bill that has been paid.
Revised March 2023
☐ Property damage: please provide two esVmates 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.
ConKnue to page 2 of NoKce of Claim Form. Failure to complete and return both pages will result in delays.
This secKon must be completed for all claims.
Is there a police report for this incident? YES / NO
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, intersecVon or name of city park or facility:
_________________________Lexington Avenue near Como Lake parking lot_____________
What would you like to see happen to resolve this claim to your saVsfacVon?
_______________Reimbursement for auto repair costs____________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
____________________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s informaVon: Year: _2019___ Make: ___Honda__________ Model: ______CRV____________ Color:
____Blue___________
License Plate #: _________RTP766_______________ State vehicle is registered in: _____Minnesota________
Registered owner of vehicle: ____Gabrielle Bell_______________ Driver: ______________Gabrielle Bell_______________
Area(s) damaged:____________Exhaust Pipe____________________
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 sVll receiving medical treatment? YES / NO
Did you miss any work as result of this incident? YES / NO
Revised March 2023
Employer(s): _________________________________________________________________________________________________
How much Vme have you missed from work? _____________________________________________________________________
If you are submiDng other documents, please state what you are aQaching and how many pages: _________________________
By signing this form, you agree that all informaKon provided is true and correct to the best of your knowledge.
Please NOTE that submiDng a false or misleading claim can and will result in prosecuKon under Minnesota Statutes.
Gabrielle Bell_____________________________
Signature of Person submihng this form: ___________Gabrielle Bell____
RelaVonship of person signing to Party making the claim: __________________________________________
Date document is being signed: __________3/23/26___________
Revised March 2023