Shaw, StephenRECEIVED
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota MAR 06 2023
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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 Stephen Last Name Shaw
Please Indicate Your Pronouns: She/ Her/Hers € He/Him/His [X They/ Them/Theirs €
Company or Business Name:
Is this claim being made by an Insurance Company? NO Ifyes, what is your Claim/File Number?:
Is this claim being made by an Attorney? NO If yes, what is your File Number?
If yes, then provide your Insured"s/ Client's Name
Street Address:2035 Morzan Ave
City:Saint Paul State MN Zip Code 55116
Daytime/Work Phone 651-736-1471 Cell Phone 763-355-7722
Date of Incident or Date Discovered (Must complete) 2/15/2023 Time 7:55 AM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. Durinz my morninz commute, I hit
several of the unavoidable potholes alonz 7th St W, resultinz in a puncture of my rizht front tire and subsequent replacement of the
2 front tires of the vehicle. These potholes had gone unrepaired for over 2 months prior to the incident. The road condition has also
worsened since the incident and needs immediate repair.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The City of Saint Paul is responsible for
maintaininz the portion of 7th St. W in question, and a large number of major potholes have been present in the road for nearly the
entire winter season and have steadily worsened without any patches or repairs applied. The road surface has deteriorated to the
point that drivers cannot reasonably avoid potholes in this area. Repair costs for the resulting damage to the motor vehicles of Saint
Paul residents should be paid in whole or in part by the City of Saint Paul if the road condition remains this poor.
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.
Z 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.
€ 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? 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.
Intersection of 7th St. W and Montreal 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? I would like reimbursement for the tire replacement
cost incurred (!>674.88), and for the City of St. Paul to fill the potholes alonz 7th St. W in this area as soon as possible, before sprinz.
Were there witnesses to this incident? Please provide names and contact phone numbers.N/A
For property damage claims, includinH vehicle accidents.
Your vehicle's information: Year 2015 Make VolkswaHen Model GTI Color Gray
License Plate #NNP 046 State vehicle is registered in MN
Registered owner of vehicle Stephen Shaw Driver Stephen Shaw
Area(s)damaged FrontRiHht(passenHer)tire-sidewallpunctured,tirecouldnotberepaired
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 iniury 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 Employer(s)3M
How much time have you missed from work?1.5 hours
If you are submitting other documents, please state what you are attaching and how many pages. 7 pazes total:
Service Report (3 paies), Repair Invoice (2 pazes), Images of punctured tire (2 items/pazes)
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 daim can and will result in prosecution under Minnesota Statutes.
Name of Person completing form:Stephen Shaw
SignatureofPersonsubmittingthisform:W#
Relationship of person signing to Party making the claim: SELF
Date document is being signed 3/2/2023
Revised December 2022