Doran, Joseph IINOTICE 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 Doran
Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His ☒_ They/ Them/Theirs ☐
Company or Business Name: Not Applicable
Is this claim being made by an Insurance Company? No If yes, what is your Claim/File Number?: Not Applicable
Is this claim being made by an Attorney? NO If yes, what is your File Number? Not Applicable
If yes, then provide your Insured’s/ Client’s Name Not Applicable
Street Address: 275 Syndicate Street South
City: Saint Paul State Minnesota Zip Code 55105
Daytime/Work Phone (612) 203-2696 Cell Phone (612) 203-2696 _
Date of Incident or Date Discovered (Must complete) 2/23/2023Time 6:00pm
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. While traveling in the right, northbound
lane of Snelling, en-route home from the airport, I struck a massive pothole in the road and punctured my tire.
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
maintaining the roads within the city and the pothole caused significant damage to my car.
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 Not Applicable
Revised December 2021
If yes, what law enforcement agency responded? Not Applicable
Where did the incident take place? Just north of the intersection of Snelling and Ford Parkway, in the right most lane.
________________________________________________________________________________________________________
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? For the city of Saint Paul to fully reimburse me for the
damages caused, $286.06.
Were there witnesses to this incident? Please provide names and contact phone numbers. There were no witnesses, I was driving
alone.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year 2022 Make Subaru Model Impreza Color Black
License Plate # GZZ-703 State vehicle is registered in Minnesota
Registered owner of vehicle Joseph Doran Driver Joseph Doran
Area(s) damaged Front Right Tire
If a City vehicle was involved: License Plate # _N/A_______________________ Color __N/A_______________________
Was there City insignia on the vehicle? N/A 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? N/A Where? __N/A______________________________________
Was medical treatment received? N/A Where? ___N/A____________________________________________________
First day of medical treatment? __N/A______ Are you still receiving medical treatment? N/A
Did you miss any work as result of this incident? N/A Employer(s) ___N/A_____________________________________
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. ______________________
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 Doran
Signature of Person submitting this form: _______________________________________________________________________
Relationship of person signing to Party making the claim: Self
Date document is being signed 3/24/2023
Revised December 2021