Egan, Jordan
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: ______Jordan_____________ Last Name: Egan
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? NO If yes, what is your Claim/File Number? <_________________________
Is this claim being made by an Attorney? YES If yes, what is your File Number? N/A
If yes, provide your Insured’s/ Client’s Name: N/A
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Street Address: 676 Geranium Ave E
City: St. Paul State: MN Zip Code: 55106
Daytime/Work Phone: 6055538492 Cell Phone: Same_
Date of Incident or Date Discovered (Must Complete): 3/4/2005 Time: _______8am______________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ___I hit a massive hole in the road on the way to work and my car made a noise for a long time
after and I brought it in and found out there was significant damage_________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _______This was not just a pothole, it was a giant rectangular chunk of road missing and it was
in the right lane of Wacouta Street as you approach 6th St right in front of La Venere and by The Bulldog. Some time after I saw a police officer was parked over it and there was a cone
from then on and it was filled in shortly after. The city was negligent in leaving this hole open in the street with no cone covering it as it was clearly deliberately created as it
had clear edges, and it was filled in shortly after. _____________________________
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:
On Wacouta St downtown St. Paul between 6th and 7th St E in the right lane going towards Mears Park right in front of La Venere and the side of the Bulldog. It is now filled in but it
is where there is a giant rectangle of new asphalt.
What would you like to see happen to resolve this claim to your satisfaction? Reimbursement for damages caused by St. Paul’s negligence_
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, I was driving to
work alone but called my husband right after to tell him my car was making a strange noise
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2014 Make: Subaru Model: Forester Color: Green
License Plate #: FPY119 State vehicle is registered in: Minnesota
Registered owner of vehicle: Jordan Egan Driver: Jordan Egan
Area(s) damaged:Front lower control arms loosened which had to be replaced and rear wheel bearing failing which had to be replaced with an alignment
If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________
Was there City insignia on the vehicle? YES / 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: _____Attaching two images of bill for car damage____________________
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: Jordan Egan, Esq. <
Signature of Person submitting this form: /s/ Jordan Egan
Relationship of person signing to Party making the claim: SELF
Date document is being signed: 3/27/2025
Revised March 2023