Bous, AndrewNOTICE 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 Saint 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: _______________Andrew___________ Last Name: _________________Bous__________________________
Please Indicate Your Pronouns: ☐ She/Her/Hers, ✓ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: ______________________________________None_________________________________________
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: _______________________________________________________________________
Street Address: _______________________1919 Ivy Ave E____________________________________________________________
City: __________________St Paul_______________________ State: ____Minnesota__________ Zip Code: _________55119______
Daytime/Work Phone: ____651-308-5930___________________ Cell Phone: _____________651-308-5930____________________
Date of Incident or Date Discovered (Must Complete): _______4/4/2026_______________ Time: _______3:50–3:56 PM__________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form:___See attached detailed statement (Page 3)
Please state why or how you feel the City of Saint Paul is responsible for your Damages? ___See attached detailed statement (Page 3)
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.
Revised March 2023
☐ 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? YES / 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:
_______________St. Clair Ave & Osceola Ave S (bridge/overpass), Saint Paul, MN__________________________________________
What would you like to see happen to resolve this claim to your satisfaction?
Reimbursement for all costs associated with the damage to my passenger side wheel and tire, including the rim, tire, mounting,
balancing, and any related service or repair costs resulting from the incident
Were there witnesses to this incident? Please provide names and contact phone numbers:
___________________________________________________None_____________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: __2023___ Make: _____Mazda______ Model: __________3_______ Color: ____Carbon Gray_____
License Plate #: __________JTC-383________ State vehicle is registered in: ________Minnesota______
Registered owner of vehicle: _Andrew J Bous_____ Driver: __________________Andrew J Bous____________
Area(s) damaged:________________Passenger side wheel rim and tire_______________________________
If a City vehicle was involved, License Plate #: ______________N/A_________________ Color: _____________N/A_______________
Was there City insignia on the vehicle? YES / NO Driver’s Name: _______________________N/A________________________
Other property damaged: ____________________________None______________________________________________________
For injury claims of any type.
What part of your body was injured? _____________________________None___________________________________________
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): _________________________________________________________________________________________________
Revised March 2023
How much time have you missed from work? ______________________________None____________________________________
If you are submitting other documents, please state what you are attaching and how many pages: Detailed written statement (1
page), photographs of damaged tire and rim (2 attachments), repair invoice (1 attachment), and location map screenshot (1
attachment).
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: ___________Andrew J Bous______________________________________
Signature of Person submitting this form: _______________________________________________________
Relationship of person signing to Party making the claim: ___________________Self____________________
Date document is being signed: _________4/8/2026_______
Revised March 2023
Notice of Claim – Detailed Statement
Name: Andrew Bous
Date of Incident: April 4, 2026
Location: St. Clair Ave & Osceola Ave S, Saint Paul, MN
1. Description of Incident
On April 4, 2026, at approximately 3:50–3:56 PM, I was traveling on St. Clair Avenue in Saint Paul, MN, near the intersection with
Osceola Ave S. The roadway at this location is a downhill descent into a bridge/overpass.
At the time of the incident, it was raining. While driving at a normal and safe speed, my vehicle struck a pothole located on the
bridge/overpass that was filled with water and not visible.
Due to the downhill grade and rain conditions, the pothole could not be reasonably detected or avoided. The impact was immediate
and severe, causing a loud noise and sudden loss of tire pressure.
After safely stopping and inspecting the vehicle, I observed that the tire was blown out and the wheel rim was visibly damaged and
bent. The vehicle required repair, including replacement of the tire and rim. Photographs and repair documentation are included
with this claim.
2. Responsibility of the City of Saint Paul
The damage occurred due to a pothole located on the St. Clair Avenue bridge (overpass), which is maintained by the City of Saint
Paul. The defect created a hazardous condition and was not repaired or adequately addressed.
At the time of the incident, the pothole was filled with rainwater, making it not reasonably visible or avoidable. The condition posed
a foreseeable risk to drivers and should have been identified and repaired through routine roadway maintenance.
The City’s failure to properly maintain the roadway directly resulted in the damage to my vehicle.
Revised March 2023