McMahon, John
NOTICE 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 this completed form to the
mailto:Saint%20Paul%20City%20Clerk’s%20OfficeSaint Paul City Clerk’s Office by email (cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to “Saint Paul City Clerk, 15 West
Kellogg Blvd., Suite 310, Saint Paul, MN 55102”.
Claimant: First Name: ______John____________________ Last Name: _______McMahon_________________________________
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? YES / NO If yes, what is your Claim/File Number? <_____No_______________
Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? ___No________________________________
If yes, provide your Insured’s/ Client’s Name: _____N/A____________________________________________________________
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Street Address: ______3709 Grand Way, #126____________________________________________________________________
City: _______St. Louis Park________________ State: ___Minnesota_____________________ Zip Code: ________55416_______
Daytime/Work Phone: _____952-393-5752_____________________________ Cell Phone: ________952-393-5752_____________
Date of Incident or Date Discovered (Must Complete): 4/28/2023 Time: _________4:45 PM____________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ______Driving down West 7th Street (under the speed limit) and could not escape a massive pot
hole. It was the largest pot hole I have ever seen and my tire immediately burst upon impact. The car had to be towed (via AAA) to the car dealership and they had to replace all of
the tires plus complete an alignment test/restructure in order for it to be safe to drive. (Note: other maintenance was also done, so the bill includes all of this)______________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ______This pot hole needs to be filled. Saint Paul streets are unsafe to drive on with how many
pot holes are all around, even on side streets. I do not feel comfortable driving my car on the streets when I am unsure how they are taken care of, especially after the traumatizing
experience last Friday night.______________________________
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.
Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays.
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: ___________________________
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:
____Saint Paul. West 7th and Montreal Ave ________________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction? _______I would like to be reimbursed for my new tire and alignment ASAP _____________________________________________________________________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent></w:sdt><w:r w:rsidR="0031571E" w:rsidRPr="00 _________No, other than
the AAA guy who towed the truck afterwards from the McDonald’s parking lot ___________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: ___2015______ Make: ___BMW___ Model: ___X1_______________ Color: ____Black______
License Plate #: __NHS130___________ State vehicle is registered in: ______Minnesota_____________________
Registered owner of vehicle: ______John McMahon_____ Driver: _______John McMahon______________________
Area(s) damaged: Front Tire and undercarriage/alignment Other tires had massive damage too but did not explode like the front tire, but were still replaced___________________________________________________________________________
If a City vehicle was involved, License Plate #: _______N/A__________________________ Color: ___N/A________
Was there City insignia on the vehicle? NO Driver’s Name</w: ______________________________________________________
Other property damaged: _______________________________________________________________________________________
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: _________2 attachments, photo and bill________________
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: ______John McMahon_______________________________________________________ <
Signature of Person submitting this form: _______John McMahon________________________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed: 5/1/2023
Revised March 2023