Pedersen, Nicholas RECEIVED
APR 2 9 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, M��o�ERK
Minnesota State Starute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipa[ity 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 answer to each question. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something dces not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name�,�1�.��`�� Middle Initial ��- Last Name �{-'�e f S�r��
Company or Business Name ��k
Are You an Insurance Company? Yes� If Yes, Claim Number?
Street Address �L� � �-�'S S 0.M �� ��� �
City �k \��^'� State �l l� Zip Code 5��v�
Daytime Phone (j��)�9 7-�7?•t Cell Phone(l¢�)U'i?-Y,72, Evening Telephone((r�l )'-117- ��7 Z�
Date of Accidend Injury or Date Discovered p.� 7_9 . Zu�y Time � `.�s r�pm
Please state, in detail,what occurred(happened), and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. T V�c:.vc= C�.:����`
c� S�4c�c-n-,zr�- �p l�',�. �5 L,.>�y Z be+.a.�� -h-� c.,:1y s r;�oc,�<��bk
�'j 1.�2 �'Jlzr ,^ ��- DY�G•�� '' .� twt: �'e�ea- ;.. lt'✓��j jc..
Please check the box(es)that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
1�,My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed andlor ticketed ❑ I was injured on City property '�
❑ Other type of property damage—please specify I
❑ Other type of injury—please specify
In order to process your claim vou need to include copies of all aqulicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
�Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds$500.00; or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
�Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-nlease comnlete this section
Were there witnesses to the incident? Yes � Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes � Unknown (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. 1_ 1n�.t <x-�l-��4e.�
i.� �M�P � Ic»� �- �ki�l�i�s c l�i E-- c�►2•�� �`1 f,�d vvt�;� P�.re..
Please indicate the amount vou are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.�i-� �'�+�.3 ti�k �vi�'c�' �1'`'�`'y �y� -1'1.��^'�� ��r �� �-�ne:- @I�(kt,,�d- SC;�,c�u
�``��, �;L ux.�1R► 1 ilr� 1� 7_i� _3� c� �•- 1�?S 1.'S l c1.,•e 1-� -Tt,�- ,Cc..� i'1.ts1- ~�'�.�
�.Ve�.c� f�G�4- �1105��� i1t W G� ';'Ir++ �lM� o� .�, ,n�:av.,r-
Vehicle Claims-please comnlete this section ❑ check box if this section does not applv
Your Vehicle: Year C> '3 Make�f c���5 W��.r. Model �e k��� ��}�,,..,
License Plate Number �7Sj�.� State��Color Qlc,��r�'�
Registered Owner N��hc:lGtti (L 1�ec�e�.n
Driver of Vehicle lJ,�,.�1�, 2 P�:�n
AreaDamaged_�-�r� : �►cX�} dv'�-�'
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In_iurv Claims-please complete this section ,�Ccheck box if this section does not applv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Name of your Employer. '
Address Telephone '
�Check here if you are attaching more pages to this claim form. Number of additional pages�.
By signing this fornt,you are stating that all information you have provid'ed is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed�tJf�.� 2`l��.� ��`�
Print the Name of the Person who Completed this Form: �v(�-`'l�� 12 P�r�-�.�
Signature of Person Making the Claim�f�,ra��u��' � ,�j��
Revised February 2011
On April 29th, 2014, at approximately 0130, I, Nicholas R Pedersen was driving my car
westbound through Saint Paul on Summit Ave. Prior to this I had read many news articles and
posts on Facebook about how bad the pot holes were and that many people were ending up
with flat tires and damaged wheels because of this. Up until this trip, I was able to avoid them. In
addition, during the time of my drive, it was raining. Due to the knowledge of how bad the roads
are in Saint Paul, I was exercising a significant amount of caution while driving. I was only
driving 25 MPH and remaining extremely vigilant looking for potholes and other road hazards.
Despite all these efforts, after I passed the intersection of Chatsworth St and Summit Ave, the
potholes became quite bad. I ended up driving into a pothole on Summit Ave (closest address is
999 Summit Ave). The impact was quite violent and sharp, immediately after driving into it, my
car began to vibrate and drift to the left. I came to a complete stop and as soon as I could safely
do so, exited my vehicle and inspected it with the aid of a flash light. Immediately I could tell that
the driver side front tire had lost most of it's air pressure and was now flat.All other tires tested
at 40 PSI in accordance with the cars manual. I called for assistance and put the spare tire on
and started to head home to go to bed. Shortly after resuming my travel, I hit another pothole
but did not experience any pull or vibration so I continued on my way.
On April 29th, 2014 at 1230, I took my car the shop to get the damage to the front driver tire
assessed and repaired. Upon the removal of the tire from the rim, the technicians discovered
two cuts and a bulge. I was then informed that repair of the tire was not feasible and that it
would need to be replaced. In addition, I was informed that the spare rim had also suffered
damage. My car is 5 months old. It has never had a flat, the spare has never been mounted
before this incident, and I am the only person to have driven the car since it's purchase in late
November.
I have been a homeowner in St Paul since April of 2013. During this winter and the months that
have followed, I don't have any neighbors who would disagree that the road maintenance
department has been extremely negligent in it's duties and responsibitities. Throughout the
winter, road conditions were extremely hazardous. Snow was not removed from the roads in a
timely manner, weeks would go by in many areas after a snowfall before many of the roads
received any salt or sand or snow plows. In neighboring cities, these issues were resolved much
faster or preventive actions were taken to avoid them. Since the snow has melted, many of the
same roads that were neglected during the winter, continue to be neglected. , while neighboring
cities have repaired the vast majority of their streets already and have put up cautionary signage
to alert drivers to hazards that have not been dealt with yet. Nearly every road I travel on in
Saint Paul is extremely rough and pothole ridden. I have taken all the precautions I can, but I
submit that the damages suffered to my car, are due to neglect on behalf of the city. I am
therefore seeking reimbursement for the new tire. I will not seek any damages to the spare as
the technicians stated that the damage it received would not negatively affect longevity or safe
operation.
SO#: 209256 Auth#: III II�IIIIIIIIIIIIIIIIIIIII
Taq#: * Service Invoice Customer Copy * F,�t:
Customer NO: 4978729 Advisor: JOHN Invoice Date: 04/29/2014 Term: CASH
NICHOLAS License No Odometer In Odometer Out Delivery Date Stock No
PEDERSEN
747 JESSAMINE AVE E 575NF 7983 7985 11/25/2013 3D459
SAINT PAUL,MN 55106 Year Make Model Model No Color
Home:(651)497-8729 Bus: (763)443-8168 2013 VOLKSWAGEN JETTA 2.OL TDI WGN AJ559M PLATINUM
Vehicle ID No Selling Dealer SO Date InServ Date Lxation
Cell: (000)000-0000 Today:(651)497-8729 3VWPL7AJ8DM618611 COUNTRYSIDE VOLKS 04/29/2014 11/25/2013
Email: pedey@me.com Fleet#
RequesUConcern Type CSR# Amount
1 0 CUSTOMER STATES THE DRIVER'S FRONT TIRE WENT FLAT.
SPARE IS ON VEHICLE
MOUNT1 FOUND SLIT IN SIDEWALL OF TIRE.MOUNT AND BALANCE CPSX 144 25.00
ONE NEW TIRE ON DRIVER'S FRONT WHEEL
1 DT0352246 CONTIPROCO CPSX 209.00
Technician 47 ANDREW
Cause: CUSTOMER STATES THE DRIVER'S FRONT TIRE
WENT FLAT.SPARE IS ON VEHICLE
Correction: FOUND 2 CUTS AND A BULGE IN THE TIRE
MOUNTED AND BALANCED A NEW TIRE
ADJSUTED TIRE RPESSURE
TORQUED LUG BOTLS-89 FT LBS
TPMS RESET
DECLINED FILTERS
DECLINED SPARE RIM REPLACEMENT
SERVICE COMPLETED
•----------------•
Request Total 234.00
2 p MAINT NOT DUE
•----------------•
Request Total 0.00
3 NO NO OPEN RECALLS FOUND AT THE TIME OF THE APPOINTMENT
#: 209256 Auth#: III IIIIIIilllllllllllllll III
so * Service Invoice Customer Copy * Fleet:
Taq#:
Customer No: 4978729 Advisor: JOHN Invoice Date: 04/29/2014 Term: CASH
NICHOLAS License No Odometer In Odometer Out Delivery Date Stock No
PEDERSEN
747 JESSAMINE AVE E 575NF 7983 7985 11/25/2013 3D459
SAINT PAUL,MN 55106 Year Make Model Model No Color
Home:(651)497-8729 Bus: (763)443-8168 2013 VOLKSWAGEN JETTA 2.OL TDI WGN AJ559M PLATINUM
Vehicle ID No Selling Dealer SO Date InServ Date Location
Cell: (000)000-0000 Today:(651)497-8729 3VWPL7AJ8DM618611 COUNTRYSIDE VOLKS p4/2g/2014 11/25/2013
Email: pedey@me.com Fleet#
Request/Concern Type CSR# Amount
Request Total � 0.00
4 SXINSP PERFORM VEHICLE INSPECTION CHECKING TIRE TREAD
DEPTH,BRAKE PAD THICKNESS AND BRAKE SYSTEM,AIR AND
POLLEN FILTERS,BELTS,STEERING AND SUSPENSION,
BATTERY CHECK,WIPER CONDITION AND OPERATION,
INTERIOR AND EXTERIOR LIGHTING AND TOP OFF OF FLUIDS.
Request Total � 0.00 '
LABOR 25.00 �
PARTS 209.00 �I
SUPPLIES 2.50 ',
SUBTOTAL 236.50
SALES TAX 15.07
TOTAL INVOICE 251.57
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