Murphy, MichelleNOTICE OF CIAIM FORM to the Crty of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that " · municlpati·ty w .th. 180 d ,h-..• every person ... who claims damages from any municipa/ity ... sha/1 cause to be presented to the governing body of the 1 m aysa1,~rtheal/egedlossor· · · d" d · tnJury is 1scovere a notice stating the time, place, and circumstances thereof, and the amount of compensation
or other relief demanded."
Please complete this form In its entl ty by I rty
d re c ea typing or printing your answers to each question. If you have additional documentation you may add those ocuments to your submission You will t b ed ' ks Th · no e contact by telephone unless clarlflcatlon ls needed. The claim process for Investigations can take upwards of four (4)
wee( · ls form must be signed, dated with all applicable sections completed. Submission this completed form to the Saint Paul Ctty Clerk's Office by email
cltyderk@cl.stpaul.mn.us), fax (651-266-8574) or mall addressed to •saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 5510i-.
Claimant: First Name: Michelle Last Name: Murphy
Please Indicate Your Pronouns: They/Them/Theirs
Company or Business Name: --------------------------------
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 lnsured's/ Client's Name: --------------------------------
Street Address: 509 Saratoga Street South
City: Saint Paul State: MN Zip Code: 55116
Daytime/Work Phone: 651-900-1503 Cell Phone: 651-900-1503
Date of Incident or Date Discovered (Must Complete): 4/28/2023 Time: ___________ _
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: Brought vehicle to mechanic for rattle noise
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Mechanic stated that the damage to the
struts and springs and suspension stabilizer bar link were due to hitting potholes.
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.
This section must be completed for all claims.
Is there a police report for th'1 . 'd smcI ent? NO
:; ~es, pl~ase provide the police report case number-
es, w at law enforcement agency responded? . -----------
Where did the incident take place? Please . . .
We have attem ted to avoid all oth I P_rovid_e a street address, intersection or name of city park or facility:
to determine where the Poth 1 ° es th1s s rm however on Februar 14 2023 while drivin durin the rain it was im ossible
-0 es were and hit sever I d h I · south on Hamline between 94 d a eep pot o es gomg north on Snelling between St. Clair and Selby Ave and
d an Randolph In additi bl · · . . . an Randol h. And unfort 1 • on, we were una e to avoid potholes dally at the intersection of Lexington unate man otholes d Paul Ave Edgcumbe Ro d h were encountere on Randol h between Cretin and Snellin Davern north of St 1 a sout of Montreal. Elway St. near Shepard Road just to name a few from February April.
What would you like to see ha . . . . . . the repair costs, namely, $673~:4~n to resolve th1s claim to your satIsfact1on? We would be hke to receive compensation for half of
Were there witnesses to th' · 'd ? • IS mc1 ent. Please provide names and contact phone numbers: No
For property damage claims, including vehicle accidents.
Your vehicle's information: Year: 2014 Make: Chevrolet Model: Traverse Color: Black
License Plate #: NKP221 State vehicle is registered in: MN
Registered owner of vehicle: Dan and Michelle Murphy Driver: Michelle Murphy
Area(s) damaged:Front Struts and links
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): ___________________________________ _
How much time have you missed from work? ____________________________ _
If you are submitting other documents, please state what you are attaching and how many pages: :Copy of paid invoice along with
receipt of payment.
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: Michelle Murphy
Signature of Per.on submitting this form: I
Relationship of person signing to Party making the claim: SELF
Date document is being signed: ../V\-~ l S 1,0 2-3
Revised March 2023
PARKWAY AUTOCARE
1581 FORD PARKWAY
ST PAUL, MN 55116
651-698-3208
10
5/4/2023 2:28:14 PM CDT Repair Order #133697 Page:1
MURPHY, DAN & MICHELLE
509 SARATOGA ST. S. Phone: 651-900-5950 -DAN
SAINT PAUL, MN 55116 Service Writer : WJN
Vehicle : 2014 Chevrolet Traverse 3.6 L 217 CID V6 DOHC 24 Valve VVT
VIN : 1GNKVGKD3EJ300837 Tag/State Fleet # /Driver:
Created : 5/4/2023 6:39:03 AM CDT Odometer In
Completed : 5/4/2023 2:24:34 PM Odometer Out
: NKP221/MN
: 125419
: 125419
FRONT BRAKES Qty: 1
CodeCTech* ~1 Description
JG* PADS AND ROTORS Remove & Replace $247.50
Includes: Clean, lube and/or replace Brake Hardware as necessary. Adjust Brakes (where applicable).
Includes: Repack Wheel Bearings (where applicable).
DOES NOT include refinishing.
NB
ADO
FRONT STRUTS AND UNKS
CodeCTech*
JG*
Brake Rotor-Front
Brake Pads -Front -Ceramic
$190.48
$102.36
Qty: 1
Descdptioo
STRUT ASSEMBLY Remove & Install or Remove $577.50
& Replace
DOES NOT include disassemble or alignment (where applicable).
JG* TWO WHEEL ALIGNMENT $115.00
Price: $540.34
Price: $1,347.08
2 WHEEL THRUST ALIGNMENT, INCLUDES COMPLETE INSPECTION OF ALL FRONT AND REAR SUSPENSION AND STEERING
COMPONENTS. ADJUST CASTER, CAMBER AND TOE IN OF FRONT END TO FACTORY SPECIFICATIONS, STRAIGHTEN STEERING WHEEL
IF NEEDED. DOES NOT INCLUDE REPLACEMENT OF ANY WORN OR DAMAGED PARTS.
JJFV Front Strut & Spring Assembly $558.10
$96.48 WD61 Front Sway Bar Link Kit
Iecboiciao Code
JG
service/Notes
Certification #
Plenum Gasket Set -Intake
SPARK PLUGS Remove & Replace
Includes: R&I Intake Manifold.
Includes: R&I Ignition Coils.
Spark Plug -Laser Iridium -OE Type
DEXRON VI A TF
Labor
Parts
Shop Supplies
Hazardous Material Charges
Sales Tax
···························································· ····························································
····························································
····························································
$940.00
$947.42
$41.53
$3.50
Sales Tax@ 7.875% $78.16 -------Repair Total $2,010.61
PAYMENT $0.00
BALANCE DUE $2,010.61
Recommended Service
Que Interval 7/1/2022
7/1/2022
7/1/2022
7/1/2022
Not Repeating
Not Repeating
Not Repeating
Not Repeating
PARKWAY AUTO CARE
1581 FORD PARKWAY
SAINT PAUL, MN 55116
651-698-3208
SALE
Store: 0001
REF#: 00000015
Batch #: 008
05/04/23
RRN: 312421521944
16:05:58
Trans ID: 743106887586804
APPR CODE: 00406R
DISCOVER
************5376
Chip
**/**
AMOUNT $2,010.61
APPROVED
Discover
AID: A0000001523010
TVR: 00 00 00 80 00
TSI: EB 00
THANK YOU!
CUSTOMER COPY