Medin, Zach (2)Individuals: First Name: Zach Last Name: Medin
Please Indicate Your Pronouns: He/Him
Company or Business Name: N/A
Is this claim being made by an Insurance Company?
Not yet
If yes, what is your Claim/File Number?:
N/A
Is this claim being made by an Attorney?Choose an item.If yes, what is
your File Number?
Not yet
If yes, then provide your Insured’s/ Client’s Name:
N/A
Street Address:
6503 Harbor Pl NE
City: Prior Lake
State: Minnesota
Zip Code: 55372
Daytime/Work Phone: 952-905-4014
Cell Phone: 952-905-4014
Email: medin.zach@gmail.com
DocuSign Envelope ID: 412AD376-9614-441F-B16D-5EE7815EF6E4
Date of Incident or Date Discovered (Must complete)
Wednesday February 15, 2023
Time: 12:15 AM
Please state, in detail, what happened that prompted you to file a
Notice of Claim Form.
I had my vehicle towed to a repair shop, and received a quote Thursday morning stating
it had $2,300 in damages. I have attached the repair estimate to this email.
Please state why or how you feel the City of Saint Paul is responsible
for your Damages?
This pothole has the potential to cause extreme damage to any vehicle and leave
someone stranded, myself included. It was after midnight and I was on my way home
and I was stuck waiting for a ride for over an hour in my vehicle that was no longer
driveable due to hitting this pothole. It was full of water and it was raining, so with the
glare and being full of water, it was not visible. I saw four other vehicles hit it in the time
I was on the side of the road. I was only going 20 MPH as I was approaching a
stoplight when I struck the pothole. Now, I am without a vehicle until it is repaired.
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.
DocuSign Envelope ID: 412AD376-9614-441F-B16D-5EE7815EF6E4
☐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.
☐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:
Not yet
Revised December 2021
If yes, what law enforcement agency responded?
N/A
Where did the incident take place? Please provide a street address,
intersection or name of City park or facility.
DocuSign Envelope ID: 412AD376-9614-441F-B16D-5EE7815EF6E4
Heading north on Fairview Ave. S approaching the intersection of Ford Pkwy
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?
I would like and deserve a full reimbursement of all of the damages caused to my
vehicle.
Were there witnesses to this incident? Please provide names and
contact phone numbers.
Trevor Haglund: 612-227-7853
For property damage claims, including vehicle accidents.
Your vehicle’s information:
Year: 2013
Make: Tesla
Model: Model S
Color: Midnight Blue
License Plate #: GXK 921
State vehicle is registered in: Minnesota
Registered owner of vehicle: Zachary Medin
Driver: Zachary Medin
Area(s) damaged: Flat tire, upper link snapped, wheel is bent
DocuSign Envelope ID: 412AD376-9614-441F-B16D-5EE7815EF6E4
If a City vehicle was involved: License Plate #:N/A
Color:N/A
Was there City insignia on the vehicle?No
Driver’s Name:N/A
Other property damaged:Multiple other vehicles.
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 NoWhere?
N/A
Was medical treatment received? Yes No Where?
N/A
First day of medical treatment? _____________ Are you still receiving
medical treatment? Yes No
N/A
Did you miss any work as result of this incident? Yes No Employer(s)
N/A
DocuSign Envelope ID: 412AD376-9614-441F-B16D-5EE7815EF6E4
How much time have you missed from work?
N/A
If you are submitting other documents, please state what you are
attaching and how many pages.
I am submitting images of the repair estimates, the pothole that was hit, and the
damage done to the vehicle.
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:
Zachary Medin
Signature of Person submitting this form:
________________________________________________________
_______________
Relationship of person signing to Party making the claim:
Same person
Date document is being signed:
February 16, 2023
DocuSign Envelope ID: 412AD376-9614-441F-B16D-5EE7815EF6E4