Murphy, BrettPage 1 of 14
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 is to the Saint Paul City Clerk’s Office. You may email, fax
(651-266-8574) or mail the form. Mailing address is “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”
Individuals: First Name :_Brett__________________________ Last Name: __Murphy______________________________________
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? If yes, what is your Claim/File Number?: _____________________
Is this claim being made by an Attorney? Choose an item. If yes, what is your File Number? _______________________________
If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________
Street Address: _906 Hastings Ave Unit 739_______________________________________________________________________
City: _Saint Paul Park______________________________________ State _MN______________ Zip Code ___55071_____
Daytime/Work Phone _(651)302-8630________________ Cell Phone ___(651)325-1564_______________________
Date of Incident or Date Discovered (Must complete): 3/16/2023 Time: _1835 hours_______________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form.: While on my way to work at
approximately 1835 hours, I was traveling northeast on 7th Street W, west of the intersection at Albion Ave in the right most lane. It
was snowing and traffic conditions were moderate. I observed a pothole in the roadway and was unable to avoid due to the traffic.
The pothole flattened both my passenger tires beyond repair. I then pulled into the Speedway gas station at 1734 7th St W, St Paul
to conduct repairs. I then had two remove both front/rear passenger side tires and go to two separate tires stores for the
replacement. I purchased two new tires from Costco Burnsville at approximately 2030 hours for $406.73. I returned to my vehicle at
approximately 2050 hours and installed both the new tires. No further damage was identified to the vehicle.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The potholes in the city of Saint Paul have
not properly been addressed. They have drawn numerous media outlets attention. While conducting the repairs to my own vehicle
another vehicle, a silver sedan (NTB838), struck the same pothole rendering their vehicle inoperable in the roadway. The city of Saint
Paul parking enforcement issued that person a citation. I am thankful the damage to my vehicle was not more severe due to this
pothole. Photos of the damage to my vehicle, the other vehicle, and the potholes were taken.
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.
Page 2 of 14
☐ You were injured in the City of Saint Paul: please provide police report number, witnesses and details about injury.
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 ____________________
Revised December 2021
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.
7th Street W, on the southside of the roadway between Elway Street and Albion Ave ________________________________
Notice of Claim Form, page two. Failure to complete and return both pages will result in delays.
What would you like to see happen to resolve this claim to your satisfaction? Reimbursement for the cost of repair or missed wages
from the night of work and the pothole be filled in/street repaired.
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 : 2005 Make : Pontiac Model : Grand Prix Color : Slate Blue
License Plate # KCS485 State vehicle is registered in : Minnesota
Registered owner of vehicle : Brett Murphy Driver : Brett Murphy
Area(s) damaged : Front and Rear passenger side tires.
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) : City of Woodbury
How much time have you missed from work?__: 8 hours
If you are submitting other documents, please state what you are attaching and how many pages. : Bill for tire
replacement/Receipt, and photos of the damage. 14 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: :Brett Murphy
Signature of Person submitting this form: __________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 3/18/2023
Revised December 2021
Page 3 of 14
Page 4 of 14
Page 5 of 14
Page 6 of 14
Page 7 of 14
Page 8 of 14
Page 9 of 14
Page 10 of 14
Page 11 of 14
Page 12 of 14
Page 13 of 14
Page 14 of 14