Johnson, Karl ��cEivE�
�u� �� 20��
NOTICE OF CLAIM FORM to the City of Saint Paul, Mi��t�L E R K
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipaliry 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 e�lain 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 Ka r 1 Middle Initial�Z Last Name John s on
Company or Business Name NA
Are You an Insurance Company? Yes No If Yes,Claim Number? NA
Street Address 3 5 S O Je r r�r S t
c�cy White Bear Lake sc�ce MN ZipCode 55110
Daytime Phone(651)602-4525_Cell Phone( ) -�T�Evening Telephone(651)779-7150
Date of Accidend Injury or Date Discovered April 17, 2014 Time 4 am/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.
Please see attached description of incident.
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
C�My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim •
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILZNDT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
�'L 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 No nknow (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unlrnown (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.
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to youi SatiSfaction. $158.33 cost of replacement tire and mounting
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year 2010 M�e Subaru Model u aC
License Plate Number 6 8 2 DHZ State�]�Color �.,�e r
Registered Owner Sarah Bede� 1
Driver of Vehicle Karl Johnson
Area Damaged lg Y'Ori 1 r'2
City Vehicle: Year NA Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please comnlete this secNon C�check box if this section does not annlv
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 form,you are stating that all information you have provided 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 May 2 9 , 2 014
Print the Name of the Person who Completed this o K Johnson
Signature of Person Making the Claim:
Revised February 201 I
/.
After dropping my daughter Sarah Bedell,the vehicle owner, at the Minneapolis/St. Paul airport
on April 17, 2014, I was northeast bound on West Seventh Street in route to I-35E. South of
Montreal Ave while traveling in the right lane I hit an extremely deep pothole where West
Seventh takes a slight bend. I was unable to avoid the pothole as there was a vehicle on my left
and behind me.The shock to the vehicle was unlike any pothole I've experienced in the past!
Upon examination of the front right tire a large bulge was found on the sidewall.The rim
showed a scuff where the tire impacted but appeared undamaged. See attached pictures.
Upon my arrival at home, about 4:30 PM, I called the Public Works Department and talked to
Julie. When I explained I had hit a "killer" pothole on West Seventh south of Montreal,Julie
completed my description of the location by stated `in front of Mickey's Diner'. She indicated
that Public Works was aware of the pothole and would be dispatching someone.
As Julie did not take my name or any contact information, I logged into the City web site and
reported the pothole. It was then that I saw that this location had been reported days earlier
(Issue# 1035826).
A replacement tire of the same model was not readily available locally and had to be ordered
from Walmart. See attached invoice for order#32677059473590 in the amount of$147.83 for
the replacement tire.
As the vehicle was needed for daily transportation and only had a 'donut' spare, I moved the
damaged tire to the right rear of the vehicle. So that in the event the tire 'blew', I would have
steering control. The damaged tire location on the vehicle is noted in the Walmart invoice for
mounting and balancing the tire. See attached Walmart Service Order#90184 for$10.50.
My daughter's vehicle does not appear to have sustained any other damage; the tire taking the
majority of the impact. She recently had the Subaru dealer check the vehicle for any additional
damage at the vehicles last servicing. No additional damage was found.
As the City was aware of this hazard and failed to either repair the pothole or take action to
properly direct traffic away from the hazard, I am requesting compensation in the amount of
$158.33 for the tire and mounting.
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Pothole-St.Paut,MN-Issue#1035826-SeeClickFix t�tp://enseeclicl�ixcomlissues/1035826-pothole
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IS&UE6 AN3WERS I NtlON60RS I WA7CWAREAS I
HOME > ISSUES >PO1F10LE
Acknowletlged by:City of SaiM Paul 2 vo� T !
Pothole Acknowledged Main
1955-2021 7fir Steet West Saint Paul,Minneso� • SFaw on Map Photns ard�ldeos
Not'rfied o
�ssue ro:�o35sz6
"�0R7� Follow
Viewed:14 dmes .�.as asm(c�sq
Neighborhood:St.Paul Flag Issue
Reported:on 2Q14-04-15
Taggetl:pothole NEARBYISSUES
Pothole
DESCRIPTION Re°°"e°°y^"°"Y'"°"5
Extremely dargerous potta�e goirg rorth on 7th St W(nst prbr W Mickeys Dmer.On Surday,ApN 13th
at 4:00 p.m my ear drove in[o the potFale resul[irg in rty tire beirg darreged.!ls I pulled in to the ne�c[
available paridrg bt(Midceys Direr)thete were tMce othu cars that had flat tires as a resuk of the Pothole
53m8 pOthOIC. Reparted bY Mouse hause
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bad pothole
� ReyMed by Hai DaJs
NEARBYISSUES
�Advertisement in right of way
Pothole Pothole bad pothole Advertisemerrt . R�art�ey sho.dtoat
� in rigM of way
Advertisement in right of way
Reparted by s�o.eXoat
1 COMMENT
aciaow�oceo Public Works Admin 1(VerifiM Olfieiaq �
Thank you.Your wmplaiM has been sent tn Piblic Works Stred MaiMenance for repaira
aEOUt 3 hmrs ago�Fmg
NEW COMMENT
I want to...
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1 of 1 4/17/2014 6:04 PM
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�-���� WALMART# 02087
. I ar �'�e�,. 850 EAST COUNTY RD E
Tire & Lube Express V.ADNAIS HEIGHTS, MN 55127-0000 US
(651)486-7001
LIC#
Service Order: '
DATE NAME PHONE# 485700 90184
04-21-2014 BEDELL,SARAH SHOREVIEW,MN 55126 (651)734-5794
YEAR MAKE MODEL COLOR
2010 SUBARU OUTBACK Grey
LICENSE ODOMETER CUSTOMER ARRIVAL TIME SERVICE COMPLETED TIME
682DHZ 49567 2014-04-21 03:28 PM 2014-04-21 (k�:07 PM
Service Description Service
TPMS RESET 0.00
-TPMS Reset-Pass Rear-NOT APPLICABLE
N/C MOUNT ONLY 0.00
-Mount Tire-Pass Rear-COMPLETE -Tire Service Accepted-Pass Rear
TIRE HAULER FEE L50
-Dispose Tire Accepted-Pass Rear-COMPLETE
WHEEL BALANCE LIFE 9.00
-Balance.Accepted-Pass Rear-COMPLETE
PREPAfD DOTCOM TIRE ����
-Tire Pressure-Pass Front-CHECKED,32 -Tire Pressure-Drv Rear-CHECKED,30
-Tire Pressure-Pass Rear-CHECKED,30 -Tire Pressure-Drv Front-CHECKED,32
-Valve Stem-Pass Rear-DECLINED
Not Appticable -New Tire-Pass Rear-COMPLETE
-DOT NumUer-Pass Rear-A341 A V VJ4913
LUG TORQUE
Pass Rear 90 FT-LB
Merchandise Description Quantity Unit Price Merchandise
225/60R17SL PROCONTA I 133A0 Included j
Walr�nart :':..
Save mflney..Live better. �
1 do agree and fully unders[and that mv motor
�� .�,651.).486�—.�TOO�.. , vehicle had a low oil level when I bmu�ht it w
�.. . .. .MANAGER.JEREMY.LYONS. . .. . .. .. �val-Man for an oii chanEe.This was pooued out io
...... ., .$5O.EAST.COUNTY.RD.E. . . . . .. . . me,that I willingly requested�Val-hlan to chan�e
the oil. I will no�I�old Wal-Mart resprnisible I'or aiq•
VADNAIS.HEIGHTS.MN.55127. . �a,,,��e,o,,,y,»o,or�ei,;�ie b,•,i,e io,Y�;i,e„ei.
ST#.2087.OP#.00008493.TE�.95.TR#.07532
.. ... .... , .TLE.ITEMS.FOLLOW. . . •.• • • � �� otal Excludin Tax&Govt. Fees �0.50
ORDER.NUMBER.004$570090184 � g )
TIRE.FEE.. .. .000003700848. . . .. . .1 .50.0 DISCLAIMER
LIFE.WHL.BAL.0078T4224343. .. . . . .9.00.N �rize the stated sen ice to be canpleted with the necessary materials.
. ..... . , ..TLE.ITEMS.CQMPLETE. . . . . pennission to opei�ate the vehicle. •
• ..•. . . . . ... . . .. . .SUBTOTAL.. . ..10.50. . �ERSTAN�:
� � ••• • • • ••.. . . . .TOTAL.. . . ,10.50. . �hnart is not responsible for lossldamage to the vchicle or items leR in it. SfGNED
• • ••• . • . . ... . . . .CA$H. .TEND. . . . .20.50. . ��nart does not inspecl tires tu detennine if they are sate. Only the service on
CHANGE.DUE.... .�O.00. . ��''�e order is perfonned. Tires are not inspected for conditions dia[may affect
#������������������##����������#�#��## ;tome�s I otold ensure�the�ir tires are�pmperly mflaled�have tr Td depth)gi�eater
����. ..... .�UPLICATE.RECEIPT.. .. . .#�## ,3z"in all��rooves,and have no wts,punctw�es.cracking.bulges.or uneven DATE
#��������#�����#���#����#����#��#����# �vear.
press mechanic's lien is hereby acknowledged on the above vehicle lo secure CO�LbION TGCHNICIA�:7'HA1 8493
# ITEMS SOLD 2 1OUntofservicesperfoimed.
ig conditions will affect the saFety and peifonnanct��f my hres. QUALITY'CONTROL TECH:JOSHUA 5447
SERV�VRT2'GREETER:LLOYD G98?
..TC�.9556.5T56.5212.8306.6933. . .. .. ���,j,4, IHIRDQCTECH:THAI8493
I IIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIII II IIIIIIII�I ` TIRE TECHNICI.4N:THA1 3493
04-21-2014
.Be.one.of.the.first.to.save! . .. ., JSTOMERSIGNATURE DATE
. . .Go.to.Walmart.co�n/SavinesCatcher. . _���
, . ... . ..04/21/14.. . . .16:to:o4. .. . . . . .. ) AFTER THE FIRST 50 MILES.