Lochner, JoeNOTICE 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 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 ___Joseph_________________________ Last Name ____Lochner___________________________________
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His ☒_ 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, then provide your Insured’s/ Client’s Name ____________________________________________________________
Street Address: ______5015 38th Ave South___________________________________________
City: ____________Minneapolis_______________ State _________MN__________ Zip Code _________55417_________
Daytime/Work Phone ___________651-216-2208________ Cell Phone ___________651-216-2208______________________
Date of Incident or Date Discovered (Must complete) 3/15/2023Time ______8:15am___________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. I was driving, on my way to work in
Maplewood, North on Cretin Ave South near the intersection with Highland Parkway West and encountered a series of large
potholes. I dodged several before I was forced to remain in my lane by oncoming (southbound) traffic and hit a large pothole with
the front passenger side tire. The tire exploded. I had to jack up my car on the road and install the spare tire. I then drove to my
mechanic to have the issue resolved. The total bill for the incident is $415.90 (see attached receipt). I also missed 3 hours of
scheduled work time dealing with the incident.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? The sheer number, large size, and
consistency of potholes in the area made this incident nearly unavoidable. The stretch of road should be under a slow traffic
signal/warning, or the road needs to be shut down for repairs before people can safely use this stretch. The roadway here is
dangerous with cars swerving in both directions to avoid potholes. I did everything I could, within reason, to avoid the situation but
still had the described incident occur. Thank you for your consideration.
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.
☐ 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 Cretin Ave South and West Highland Parkway in St. Paul, MN _______________________________
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? ___Reimbursement for expenses incurred due to major
potholing on Cretin Ave South______________
Were there witnesses to this incident? Please provide names and contact phone numbers. _________No witnesses were gathered
but cars were swerving in the area to avoid the potholing_____________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year 2015______ Make __Honda________ Model _Fit_______________ Color ___Dark Grey___
License Plate # _____________________ State vehicle is registered in ________MN________________
Registered owner of vehicle _________Joseph D. Lochner________ Driver _____Joseph D. Lochner_______________
Area(s) damaged ________Front Passenger Tire exploded due to impact with pothole___________________
If a City vehicle was involved: License Plate # _______________________________ Color _______________________________
Was there City insignia on the vehicle? Yes No Driver’s Name _____________________________________________
Other property damaged: ________None______________________________________________________________________
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. __I have the invoice for the Tire
replacement attached- please contact me if additional information is needed____________________
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: ____Joseph D Lochner____________________________________________
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 3/15/2023
Revised December 2021