Brua, Xiang
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 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 ___________Xiang_______________ Last Name _____Brua_______________________________
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 ____________________________________________________________
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Street Address: _______11114 Xavier Court _________________________________________________________________
City: _________Bloomington_________________________ State _____MN__________ Zip Code <_____55437__________
Daytime/Work Phone _______________________________ Cell Phone ________952-564-4697_______________________
Date of Incident or Date Discovered (Must complete) ____03/10/2023________________Time _________9pm____________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form. __On March 10th, 2023 at 7:30pm, I went to my first singing rehearsal at church (1895 Laurel
Ave Saint Paul). I didn't notice lots of potholes on the street (Fairview Ave N , Saint Paul) until I fell into a pothole. _I slowed down. But because the road was narrow and it was
dark, I couldn't avoid all the potholes and fell into the other potholes again._After rehearsal , at 9 o'clock I used Google Navigation to choose another way home. Unexpectedly, that
road ( Prior Ave N，Saint Paul) was also full of potholes. It was dark, and I fell into a big pothole again._I don't have much experience in this area, and I was hurrying to go home,
so I didn't get out of the car to check immediately. I felt something wrong on the highway. I hurriedly got off the highway, parked on the side of the road( 1917 Colfax Ave S Minneapolis),
and checked to find out that my car had a flat tire. The next day, my husband helped me drive the car to the auto shop( Bobby & Steve’s Auto World, 10740 Normandale Blve, Bloomington)
for repairs. The clerk said my tires and sensors were broken and I had to replace them for $346.46.
Please state why or how you feel the City of Saint Paul is responsible for your Damages?
__Damage to my car tire due to potholes on roads in the city____________________________
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.
___ Fairview Ave N , Saint Paul near Prior Ave N，Saint Paul_________________________________________
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?
__Reimburse me for the cost of replacing tire and sensor________________
Were there witnesses to this incident? Please provide names and contact phone numbers. Long Ye 612-412-5180 (She is one of the members of the choir. I called her that night and asked
her what to do.）Bini 612-598-4599 (He was just passing there and saw my flat tire and he kindly tried to change the tire for me.)Brett Brua 952-217-7420 (He is my husband. That
night he came to help me change the tire.)_
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year _2014_____ Make _Toyota_______ Model ___Camry______ Color _____Silver__
License Plate # ___PCL328__________________ State vehicle is registered in _____Minnesota_______________
Registered owner of vehicle ____Brett Brua____________ Driver _________Xiang Brua_____________________
Area(s) damaged ______Front Right Tire_________________________________________________________
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? ____None______________________________________________________________________
Did you go to the emergency room or urgent care? NO Where? _________________________________________________
Was medical treatment received? NO Where? </______________________________________________________________
First day of medical treatment? _____________ Are you still receiving medical treatment? NO
Did you miss any work as result of this incident? 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. ______1_____________
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: _________Xiang Brua_______________________________________ <
Signature of Person submitting this form: _______Xiang Brua____________________________________
Relationship of person signing to Party making the claim: SELF
Date document is being signed 3/19/2023
Revised December 2021