Saunders, PeterRevised 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: PETER____________________ Last Name: SAUNDERS_________________________________________
Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: __N\A_______________________________________________________________________________
Is this claim being made by an Insurance Company? NO If yes, what is your Claim/File Number? _________________________
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: _______________________________________________________________________
Street Address: _1975 MARSHALL AVENUE APT 303__________________________________________________________________
City: SAINT PAUL____________________________________ State: ____MN________________ Zip Code: __55104____________
Daytime/Work Phone: _612-200-7736______________________ Cell Phone: __612-200-7736_______________________________
Date of Incident or Date Discovered (Must Complete): 3/29/2023 Time: 1:50 P.M.____________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: I struck a very deep pothole while driving
on the 200 block of Fairview Ave N. between Marshall Avenue and Dayton Avenue on my way to work on Fairview Avenue. This
resulted in the right rear tire on my car being popped and the rim being bent.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The City of Saint Paul had awareness of this
previously reported pothole (which appeared in the St. Paul Pioneer Press) and the hazard that it and other potholes like it posed to
automobiles. The City has an obligation to repair deficiencies on this stretch of Fairview Avenue N and had sufficient time to do so.
Damage to vehicles traveling over this road was foreseeable to the City and its failure to correct this deficiency in a timely manner
resulted in the damage to my car’s tire and rim.
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.
Revised March 2023
☐ You were injured in the City of Saint Paul: please provide police report number, witnesses, and details about injury.
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? 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, intersection or name of city park or facility:
On the 200 Block of Fairview Avenue N. between Marshall and Dayton Avenues.
What would you like to see happen to resolve this claim to your satisfaction?
I would very much appreciate it if the City of Saint Paul could reimburse me for the cost of the tire and for the rim repair. I have AAA
which paid for the initial call and so that was free to me.
Were there witnesses to this incident? Please provide names and contact phone numbers:
No immediate witness that I can identify, but the damage can be attested to by the AAA driver who responded shortly thereafter
Please contact Mr. John Finch, Manager of Pete’s Mobile Services of Minnesota (who operates the truck that AAA dispatched shortly
after I struck the pothole). Their company is located at 2375 University Ave W., Saint Paul, 55114. Their Phone Number is 800-610-
5484 and Mr. Finch’s Number is 561-485-8125. AAA was contacted at 2:01 P.M. on 3/29/2023 (10 minutes or so after striking the
pothole) and the AAA Confirmation \ Incident Number is #62028.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: _2005____ Make: __Jaguar__________ Model: ___S-TYPE_________ Color: Silver____________
License Plate #: __AEM992_________________ State vehicle is registered in: __MINNESOTA_________________________
Registered owner of vehicle: _PETER SAUNDERS_____________ Driver: PETER SAUNDERS___________________________
Area(s) damaged:___REAR RIGHT TIRE & RIM________________________________________________________________
If a City vehicle was involved, License Plate #: __N\A____________________________ Color: _______________________________
Was there City insignia on the vehicle? NO Driver’s Name: ______________________________________________________
Other property damaged: __N\A_________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? N\A__________________________________________________________________________
Did you go to the emergency room or urgent care? NO Where? ___________________________________________________
Was medical treatment received? NO Where? ________________________________________________________________
First day of medical treatment? _N\A____________ Are you still receiving medical treatment? NO
Did you miss any work as result of this incident? NO
Employer(s): _________________________________________________________________________________________________
How much time have you missed from work? _____________________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages: _FIRESTONE RECEIPT_________
Revised March 2023
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: __PETER SAUNDERS___________________________________________________________
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: ____SELF______________________________________
Date document is being signed: 4/7/2023
276579
FINAL INVOICE
Out: 04/04/23 03:17PM
In: 03/31/23 11:48AM
Retail Invoice Store# 026239
www.FirestoneCompleteAutoCare.com
Cust Status: Unspecified Appt: Unspecified
Printed/Emailed on 04/04/2023
Emailed to advan2000@hotmail.com
FORD PARKWAY - 2269 FORD PKWY, SAINT PAUL, MN. 55116-1817 - 651.690.5123
1975 MARSHALL AVE
612.200.7736 xpeter
SAINT PAUL, MN 55104-4401
APT 303
2005 JAGUAR S-TYPE SPORT
4.2L V8 FI GAS
LIC #: 939HVL MN [GREY]
MILEAGE: 193,890
Service Advisor: 3 JASON Wheel Lock:
Customer Details:Vehicle Details:
SAUNDERS, PETER
Alt. Auth. Name & Phone:
N/A
Technician: 06 EH
VIN #: SAJWA01UX5HN18345
Unit Extended JobRev Hist
Description Qty Price Price TotalID/Article #
WHEEL REPAIR SERVICE 250.0003
7003189 06TN 250.00250.00WHEEL REPAIR SERVICE 1
BRIDGESTONE TIRE WITH WINTER, PACKAGE 193.00031
001132 06TN 172.99172.99001132 BLIZZAK WS90 BL 225/55R17 97H No Mileage Warranty 1
DOT# 1EJUP0DKC0722
7013632 06NS 12.9912.99NEW TIRE WHEEL BALANCE LABOR 1
7015040 06TN 2.992.99RUBBER VALVE STEM 1
7075078 06TN 4.034.03SCRAP TIRE RECYCLING FEE 1
7015016 06NS N/CN/CTIRE INSTALLATION 1
All parts are new unless otherwise specified.
Payment History:
Debit 006367 Sale3068 477.91
MID: 222220327556
Term: 0001 Card Inserted
PIN VERIFIEDAID:A0000000980840
Total Tendered 477.91
$477.91Total
33.87Tax (7.875%)
444.04Sub-Total
1.04Shop Supplies
Labor 17.02
Parts 425.98
Summary:
Revision History:Amt
Rev
04/03/2023 12:12PM SAUNDERS, 612.200.7736 Ext.peter208.221)
I acknowledge notice and oral approval of
a change in the original estimated price.
Signature or Initials
Information on tire warranty, maintenance, and safety can be located at
https://www.firestonecompleteautocare.com/tires/warranty-options/
or by calling toll free 800-847-3272 to obtain a free printed copy
I have received the above goods and/or services. If this is a
credit card purchase, I agree to pay and comply with my
cardholder agreement with the issuer.
Customer Signature
Inv1_WP 11.14.2022.002Page 1 of 2
Information on service warranty, maintenance, and safety can be located at
https://www.firestonecompleteautocare.com/maintain/service-warranty-options/
276579
FINAL INVOICE
Out: 04/04/23 03:17PM
In: 03/31/23 11:48AM
Retail Invoice Store# 026239
www.FirestoneCompleteAutoCare.com
Cust Status: Unspecified Appt: Unspecified
Printed/Emailed on 04/04/2023
Emailed to advan2000@hotmail.com
FORD PARKWAY - 2269 FORD PKWY, SAINT PAUL, MN. 55116-1817 - 651.690.5123
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Inv1_WP 11.14.2022.002Page 2 of 2
Information on service warranty, maintenance, and safety can be located at
https://www.firestonecompleteautocare.com/maintain/service-warranty-options/