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Jorgensen, JackNOTICE 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 aBer the alleged loss or injury is discovered a noDce staDng the Dme, place, and circumstances thereof, and the amount of compensaDon or other relief demanded.” Please complete this form in its en@rety by clearly typing or prin@ng your answers to each ques@on. If you have addi@onal documenta@on you may add those documents to your submission. You will not be contacted by telephone unless clarifica@on is needed. The claim process for inves@ga@ons can take upwards of four (4) weeks. This form must be signed, dated with all applicable sec@ons 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 _________JACK____________ Last Name ________________JORGENSEN____________ 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 AHorney? NO If yes, what is your File Number? _______________________________ If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________ Street Address: ____5525 COLFAX AVE S_______________________________________________ City: ______MINNEAPOLIS_____________________ State ______MN___________ Zip Code ______55419_______ DayLme/Work Phone _____(952) 797-3930________________ Cell Phone _______________(952) 797-3930______________ Date of Incident or Date Discovered (Must complete) ___2/18/2023_________Time _____9:35AM__________ Please state, in detail, what happened that prompted you to file a NoLce of Claim Form. ON THE MORNING OF 2/18/2023, I MET UP WITH A RUNNING CLUB FOR AN 8AM WORKOUT AT EAST RIVER FLATS PARK LOCATED AT 351 EAST RIVER PARKWAY IN MINNEAPOLIS. AFTER THE GROUP COMPLETED THE WORKOUT, A HANDFUL OF MEMBERS OF THE CLUB, INCLUDING ME, DROVE TO THE CARIBOU COFFEE LOCATED AT 2134 FORD PARKWAY IN ST. PAUL. AS I WAS DRIVING SOUTHBOUND ALONG EAST RIVER PARKWAY, MY FRONT RIGHT WHEEL HIT A POTHOLE LOCATED IN THE SOUTHBOUND LANE. THE LOCATION OF THE POTHOLE WAS JUST NORTH OF THE SHORTLINE RAILROAD BRIDGE, WHICH ITSELF IS JUST NORTH OF THE INTERSECTION OF EAST RIVER PARKWAY AND ST. ANTHONY AVE. THE HUBCAP SEPARATED FROM MY FRONT RIGHT WHEEL AND ENDED UP ON THE SIDE OF THE ROAD. I PULLED OVER AT THE INTERSECTION OF EAST RIVER PARKWAY AND ST. ANTHONY AVE. A MEMBER OF THE RUNNING CLUB DRIVING BEHIND ME SAW ME HIT THE POTHOLE AND THEN PROCEEDED TO PULL OVER, WHERE HE HELPED ME RETRIEVE THE HUBCAP THAT SEPARATED FROM THE FRONT RIGHT WHEEL. THE RIM OF THE FRONT RIGHT WHEEL OF MY VEHICLE WAS VISIBLY BENT FROM THE IMPACT WITH THE POTHOLE. ON 2/28/2023, I TOOK MY VEHICLE IN FOR SERVICE, WHERE IT WAS DETERMINED THAT MY FRONT RIGHT RIM WOULD NEED TO BE REPLACED. AT THE TIME OF THE VISIT, THERE WAS NO OTHER DAMAGE THAT WAS DISCOVERED DURING THE VEHICLE INSPECTION. Please state why or how you feel the City of Saint Paul is responsible for your Damages? I ESTIMATE THAT THE POTHOLE WAS AT LEAST 12” DEEP, 12” WIDE, AND 2 TO 3 FEET LONG. WHEN I WENT TO RETRIEVE THE HUBCAP, I VISUALLY INSPECTED THE POTHOLE. INSIDE THE POTHOLE, I SAW THE REMAINS OF THE BASE OF AN ORANGE TRAFFIC CONE, WHICH I BELIEVE HAD BEEN PUT IN OR NEAR THE POTHOLE BY THE CITY AS A WARNING TO MOTORISTS. THE REMAINS OF THE BASE OF THE ORANGE TRAFFIC CONE INSIDE THE POTHOLE WERE WELL BELOW THE LEVEL OF THE STREET, MAKING IT INVISIBLE UNLESS YOU WERE STANDING DIRECTLY OVER THE POTHOLE. 15 TO 20 MINUTES AFTER MY VEHICLE HIT THE POTHOLE, ANOTHER MEMBER OF THE RUNNING CLUB WHO WAS DRIVING TO MEET THE GROUP AT THE CARIBOU OFF OF FORD PARKWAY PASSED THE SITE OF THE POTHOLE, WHERE HE NOTICED THERE WAS A DISABLED VEHICLE ON THE SIDE OF THE STREET. HE CALLED THE CITY OF ST. PAUL AND REPORTED THE POTHOLE, AND THE CITY EMPLOYEE REPORTED THAT THEY WERE ALREADY AWARE OF THE POTHOLE AT THAT LOCATION. BASED ON THE INFORMATION ABOVE, I BELIEVE THAT THE CITY OF ST. PAUL WAS AWARE IN ADVANCE OF THE POTHOLE ON EAST RIVER PARKWAY THAT DAMAGED MY VEHICLE, BUT TOOK INADEQUATE MEASURES TO A) WARN MOTORISTS OF THE UNSAFE ROAD CONDITIONS AND B) REPAIR THE POTHOLE IN A TIMELY MANNER. Please check the reason that most closely describes the reason for your submikng a claim. Please note the documents that will need to be provided with your completed form. Photographs will be accepted. All documents submiHed become the property of the City of Saint Paul and shall not be returned. √ Automobile damage from a motor vehicle accident: please provide two es@mates for repairs or actual bill that has been paid. ☐ Automobile damage from a street defect or pothole : please provide two esLmates 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 Lcket (if available), receipt from Impound Lot, and two esLmates for repairs or actual bill that has been paid. ☐ Snow Emergency: please provide copy of towing Lcket (if available), receipt from Impound Lot, and two esLmates for repairs or actual bill that has been paid. ☐ Property damage: please provide two esLmates 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. ☐ You were injured in the City of Saint Paul: please provide police report number, witnesses and details about injury. This sec@on 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 _____N/A_______________ If yes, what law enforcement agency responded? ________N/A_____________________________________________ Where did the incident take place? Please provide a street address, intersecLon or name of City park or facility. ____IN THE SOUTHBOUND LANE OF EAST RIVER PARKWAY, JUST NORTH OF THE INTERSECTION OF EAST RIVER PARKWAY WITH ST. ANTHONY AVENUE, CLOSE TO WHERE THE SHORTLINE RAILROAD BRIDGE CROSSES OVER EAST RIVER PARKWAY_____________ No@ce 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 saLsfacLon? __REIMBURSEMENT FOR AUTO REPAIR BILL___ Were there witnesses to this incident? Please provide names and contact phone numbers. _BRIAN DAVENPORT (651) 271-3644_ For property damage claims, including vehicle accidents. Your vehicle’s informaLon: Year _2016_ Make __TOYOTA___ Model __COROLLA_____ Color ___BLACK_____ License Plate # __NXX-200____ State vehicle is registered in ____MINNESOTA_________ Registered owner of vehicle ____JACK JORGENSEN____ Driver _______JACK JORGENSEN_________ Area(s) damaged ____FRONT PASSENGER SIDE RIM______________________ If a City vehicle was involved: License Plate # ________N/A____________________ Color _________N/A__________________ Was there City insignia on the vehicle? Yes No Driver’s Name ____________N/A_____________________________ 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? Yes No Where? _____N/A___________________________________ Was medical treatment received? Yes No Where? ________________N/A__________________________________________ First day of medical treatment? ___N/A_______ Are you sLll receiving medical treatment? Yes No Did you miss any work as result of this incident? Yes No Employer(s) _______N/A____________________________________ How much Lme have you missed from work?_________________N/A______________________________________________ If you are submikng other documents, please state what you are amaching and how many pages. ___I WILL BE ATTACHING THE SERVICE RECORD FROM MAINTENANCE PERFORMED ON 2/28/2023, THE PAYMENT RECEIPT FOR SERVICE PERFORMED, A SCREEN SHOT SHOWING RIM DAMAGE THAT WAS DISCOVERED DURING THE VEHICLE INSPECTION, AND THEN I WILL POST A LINK TO THE VIDEO OF THE VEHICLE INSPECTION PRIOR TO IT RECEIVING SERVICE ON 2/28/2023. By signing this form, you agree that all informa3on provided is true and correct to the best of your knowledge. Please NOTE that submiAng a false or misleading claim can and will result in prosecu3on under Minnesota Statutes. Name of Person compleLng form: __JACK JORGENSEN___ Signature of Person submiYng this form: _______________________________________________________________________ RelaLonship of person signing to Party making the claim: ____SELF________ Date document is being signed __MARCH 2, 2023___ Revised December 2021 Service Record Payment Receipt Vehicle Inspection Evidence Inspection Video Link from Walser Toyota: https://app.truvideo.com/v/vLtNeuPw?s=fn2Op1t0zpHYEuzubTGD1aoSRkyhn891PVv9OoP947 dDFoqu8RqwFg== Screenshot of Damage to the Front Passenger Rim: