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Lunde 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 municipaliry 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 answer to each question. If more space is needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Iv`ame 't��►'��'�� r��c��`�� Middle Initial Last Name �-i.�°���-- R E C E I V E D Company or Business Name ��� NQV 2:) �013 Are You an Insurance Company? Yes/No If Yes, Claim Number? (`IT�I�ERK Street Address � � City �� (,�+��( State ✓��" Zip Code S�� � ���j, �,� ����� �y/'�rC�� C�`�� �e Yhone(� �S�-C� ��`}Cell Phone((9 S j )_�3Cz 3`sh�;. Evening Telephone�` ) - �,Mc S�� Date of Accidend Injury or Date Discovered ���?> � ! 3 Time am/pm E��i Cs�>"a�U ��t�� Please state,in detail, what occurred(happened),and wk�y you are submitting a claim.Please indicate why or how you feel the City of Saint Paul or its employges�e involved and/or responsible for your damages. �� �t�tztC G� Please check the box(es)that most closely represent the reason for completing this form: ❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow ❑My vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow ❑My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property ❑ Other type of property damage-please specify ,�Other type of injury-please specify C'c�\C u SS t U�1 � �l; (��k.)/ ��7.�n� / In order to process your claim vou need to inctude couies of all annGcable documents. For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds $500.00;or the actual bills and/or receipts for the repairs O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt O Other property damage claims: two repair estimates if the damage exceeds$500.00;or the actual bills and/or receipts for the repairs;detailed list of damaged items O Injury claims: medical bills,receipts O Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2-Please complete and return both pages of Claim Form Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—nlease comnlete this section Were there wimesses to the incident? Yes No Unknown (circle) Provide their names,addresses and telephon mbers`• �U'�7' i�G�.1'S �C�'���.'� � M l��r ) C�i`(}d�� S�"�N���� --a t�53�5 Tt�.l��e`i- /�z,h', S f (�,�c SS r c�S c1�i� a7 � �;� h v�s�4�E' S�'`P� Were the police or law enforcement called? Yes No Unlrnown (circle) If yes,what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, closest landmark,etc. Please be as etailed as possible. If necessary, attach a diagram. t-4��r i c�1c� �P��Z�� S�i �l.(Z. � Please indicate the amount you are seeking in compens tion or what you would like the City to do to resolve this claim to your satisfaction. ��C��e �-e' ��� �� S ���`fS d" b ���S ',l� �. � � {�� a (r'cxCr �- MCte N�p,'��f 7v �k'-'�t° . Vehicle CI s— lease com lete this section �check box if this section does not a 1 Your Vehicle: Make Model Li nse Plate Number State Color Regi red Owner Driver Vehicle Area Dam ed City Vehicle: Year Make Model License Plate ber State Color Driver of Vehicle ity Employee's Name) Area Damaged � I 'ur Claims— lease com lete this section ��� �e ❑check box if this section does not a 1 % How were you injured? ' �S What part(s)of your body were injured? C=�'�-��SS�� ` � � �� '�' Have you sought medical treatment? es No Planning to Seek Treatment(circle) When did you receive treatment? � � a��\���`'� (provide date(s)) Name of Medical Provider(s): '' Address G� `� Tel Did you miss�srk as a result of your injury? Yes No S'.��C�� When did you miss work? � �(provide date(s)) Name of your Employer: Address Telephone —�,k- �Check here if you are attaching more pages to this claim form. Number of additional pages �� �`J By signing this form,you are stating that all information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed Submittin a false claim can result in proseculion. Date form was completed �! ��` �> ���` S Print the Name of the Person who Compl this Fo • i��� �� `� G�"`-' Signature of Persoo Making the Claim: � Revised February 2011 S��nopsis of Nils Lunde's Accident at St. Paul Highland Pool August 13, 2013 Three 1�-year old boys, including Nils Lunde and his friend Luke Moses-Thomsen and Charlie Sutmeyer, were sliding down the water slide. They were not always follo«�ing the rule of waiting until the person in front had gotten out of the slide to go. According to Luke, the lifeguard noticed this and knew and did not tell them to stop. The lifeguard would chuckle and roll her eyes. Luke thinks she was blonde with long hair but he does not know her name. One time Charlie went down, then Nils went right after Charlie. Charlie and Nils stopped inside the slide about half-way down. Luke did not know they had stopped. He waited and figured they were almost out; then he went. Luke heard them, realized they were still in the slide, and he yelled that he couldn't stop, so GO. Luke tried to stop himself but could not. Nils and Charlie were right next to each other, but Charlie had moved. Luke hit Nils in the back and Nils hit his head on the top of the slide and he said "Ow." The seriousness of the injury was not apparent until a couple days later when Nils became very ill and had to be taken to the emergency room. The ER doctor confirmed that Nils had suffered a concussion when he hit his head on the slide. Nils was not able to start school on time and is still not able to attend school full � time, complete school assignments or participate in sports. It may take him months to recover fully. We are submitting this claim because it occurred on City property and because the lifeguard did not enforce the rules. The damages we are seeking are the total of our out-of-pocket expenses for medical care as well as other expenses such as a tutor, which has now become necessary. . � �.,,.� Kennedy Eye Association - i790 Lexington Avenue Roseville, MN 55113 Phone 651-488-6771 � � Fax 651-488-5576 �/� � ` . D�a�le d Seivice: 1 QA04�2013 tnvoice: 1� Nis Lunde ��t Lun�.9� 2008 Prinoe�on Ave �rovider= Dr_W�ly�rs, Daniel St Paut, I�IN�51Q5 �Code Proc Code DescriPtioa �� Insnra�ce �ot �6 ��eo�s ��:�c 2'4�..� ��3 " -f:ast�Pa��t 5..9� ��fICE' ��-,�: �� . a�a���� ���� �o�g acraou�et nat Pad M t�e�ue-acre crsr�s s��-;t��.-_ ^ � ' �' . : � _._ . ' �---"'�. _ _ _ . - _„� � � r I � �. � I i ,i � �,,,i; � w _ _ .�— � – .. - ._i�i i � d � � � �` � 3 � i � � . � `� :�� � \ �\x` \ . ,��, 1�a�c _ \ :� ,.�. � '_ _� _� ___. \ .i � es s xx � Piease dled[bOX if adclfeS.S haS t�arlged ."�� ,�,�� ��, 12569673 '�' � OG6 0� : arxi w�ite ir�onnation on�everse s� � ��, - �: S��e�Sea�: 09-�0-2013 �� ��� �ac!O�te af Servic:e= 09-�2013 � N�Gabier Ltnde �2-01 2Q13 � Na�e= Nas G�le�Lt�de � ,'� '�r = - — � 125(i9673 � — - �- �� Date= 11-06-2O13 � �� �`, ��e: 12-01 20�� :.��e ��: ��� �! � �;�� ���-� � D�WIEL LUNDE PRINCETON AVE ���l�iEALTH CARE �tVT PAUL.,,1►AN 5510�1527 P-�-��0261 �` i1�It�lE1�POL1Sr MN 564�6-0'Z6� .�: 1.1.1..4I...,IW....61....11.1.1...6t6..1lI...I..I....Itl � I.I.I..I.I..I..II..I..II..IL..II...I..I..II..I..I..II..J..1! _ O100U125696�3000�,0660�0910137 ----__ _ _ __» � �--- _ -- _ _. _ ---- - ----- — ------ _ � Please ci�ecic box if addres.s Itas ch � �"-� «,'�� �' �'4 ����_dbi �;. arid wri�e i�onna�ion on r�everse side� ----- -- - — y �;�aa� ��::.f �d�e�Servnc:�_08-'6 7 20'i 3 !Ws Galbler'Le�nde 12-07-2�'i3 ��e�Sexvic�e= 08-17 2013 --- — .,��n� a.r.e - � $o{�id@: NI�S�Ll1Il�E' ""'" t�� 12545706 -- '�=�_ .-._. _ ,--- — `�� �� ' Date= 11-12-2013 �e�= 12-07-2013 �,� �arrt Paid= �, j; "� � � �� ----- -- --- �; � �.,.,�;�,- ' � � t�DANIEL LUNDE - CHILDREMS HE/4LTH CARE �21NCETON AVE P_O_Bo�c 86�26� ��@T PAU1.,MN 5510�1527 NAINNEAPOLISn I�dIN�r�6-(�61 4 i.1.i..1.1....1111....1.1....11.l.1...1.11...111...1..1....111 i.i.l..i.l..l..li..l..11..11...li...l..l..ii..l..l..11...l..11 O1t1�0125q5706U0UU289U1U837Z35 .__ ` �"°��`�,,, �, �,fi �,:.-.,� ;,�u-. r p, . / �j ,1; ... 't�"= �� �\��V13.� +�.�PJ�I'EI�L�H�.A� �': ...� g!1�C" ; �, � "�..� ,� . <� '6fb.__".�iaL'XV?II;�� 't��.t�u�= �". � z{�i�'ki.�F��t5 � � �.. —_ � 29�� r('H�fiRE P'O�ITE OR!!IE F�s x.c.. _,�--r���.� ; Y ��lnres.;.: �@ii n5��3 atr,�wan� ;�w�=u?� Olioe PMr� (661)85�2345 T�Fte.e= �j8�6) ��oraa� ii i1m-Fr�8�Ai�4_3�Y Voic�e��avada6le 24 6�aa�a day � Ee�i us at PPFS. _--- - ,_ - -- ¢� i; �7 ss�ra�r� �a�rs� Yau c�n now pa�►yotr bis arir�at: , 11/1?12013 2341371 i ��L - - � S1tf0�i -- - Pw�xr_�ays c��t� ��a,�' �l�61HU6 CABLH2 Ll1P�E f�-�.DRB�'S t�/�LTFK',J1RE ��EfON B1VE PO BOX 860089 � � 6'�!A 9Mf�l 551�1� i�l9�FJ1POLIS M�15698('r008'9 . �—� From: "Dr.Les Alsterlund"<dr.les@comcast.neb Subjeci: Invoice from Dr.Les Alsterlund,Optometry,LLC Date: November 4,2013 11:18:12 PM CST To: <marthaOmarthasfiora�studio.com> 1 Attachmeni,502 KB Dear Martha: Your invoice for Nils's evaluation is attached. Please remit payment at your earliest convenience. Thank you for your business-we appreciate it very much. Sincerely, � Dr.Les Alsterlund,Optometry,lLC 612-724-5125 � Dr.Les Alsterkx�d.Optometry,LLC ���O�a� 3319 E 25th Street � Mmneapolis,MN 55406 Date ta2312ot3 i�voice# 355 - _ __ ----__ _ ---- Bill To - Patient _ -- ----------- _.._._: --___------- -- ---- Martha and Daniel lunde Nds Lunde 2008 Princeton Avenue 2008 Princeton Avenue St.Paul,MN 55105 St.Paul,MN 55105 P.O.# _-_ _ _ _ _ --–--___—._ Terms Due Date 11/1�t2oi3 S3tt,`.�t _ .._ _ ___ _ � � , � �� ___ _____ _. _ <:_ -°---- -'— ------------- -------- -�_� {r"�°1;� r °'' Eg�e a�t�is� 'F3Q HC' 4� �� �-�'�'�'�-�= �'�i.�' "'t��` � �� i: I� �' �; i ii � �i i' 1,, ' '1 !{ i P I �` y 'i � -- �--�------ ---�--' -- -�--�---------- --- �y�; �� �--- SiB�S TdZ�-� �41�8 ------ __. -__ Total S�9FS Dr.LesAlsterlund,Optomefry,LLC PaymentSJCredi[s �� or.�espcomcast.net 612-724-5125 t�x�-.Y� b51-389-9295 Balance Due 5249.90 �� , , j , , _ .. ��r``! ��_`'�=� > � ?�� Smith ��en��� 'v'.,Surte 201 St. P ;i.�'(innesota 5510?-?69� FA.\' 651.241.5248 6�1?41.5�90 N..�,;r-r j ��� �:?��,l�fti ' __��'•. .. _ �_e A � � ,: .. r —„ , " �. _ �.� �"`f_��,�," M,t� �,, �,-� ?'' Srlith���enue N..Suite 201 St. P:uil.MinnesoCa SS102-�697 FA� 6�1.241.5248 651.241�.5290 Neuropsychological Testing Date: Friday,September 27`h,2013 @ 8:OOam If this date does not work for you please call Kym to find a mutually agreed upon date. 651-241-7431 Dear ParendGuardian: You�c�nild�b�mm�f+ened for a���ological��aluad�io�This�aluadtion�7111ake�a�t 1li�e�E��t�C1-� _ .� aa-�,fi P�'��e��r p��h�n and aqlher�n�al n�uolo�ical issues,,in addi�ion tb��� ��3�- � ��t�wll meeat�peae.�ot(�)f�a�l"anical i��_ D�in�the�,a ������irh yo�c�eild This tc��f n�aarops��cbological e�atua�ion is �i� m 3-4 ho�u�.Afibe�id��e���ol�isit�71 mee�t�ith p�s)andNar c�1d tb��e on 1�he t�t r�uitt�and �3���g��n i��h�es of di$ere�dt�ab�lii�es sucb �i�tellec�ual�a me�a��fl�-������ic�lbed.,academic�. "�����on and fo�os finm d�pa�ent In oider�ro obrtain the m,os�t it is e�iall�impc�nY��wu'c�iid be�ell-�e�d_Ple�e make�ay ��tbm e�l�/�has a typi�al ni�t of��t�r to the�aluatio� ff�ea���as aH IEP„or h�s�oae mdnridual�at acbool or pri�tdw Ln�aa �pa�o�al ' speecb/las�aa�e�olo��� ar cL�nt chelo�niea�brn�conies of�e reporls irom�ese e�ralaahoaa bo the��� Yon�1i b� �fo�the�ia�if i�is fo�ci t�it�our i�c��an does naqt c��er *����looa����������:.������s�s:a�����'i.`.�-�s rr+�ot a�.�e.�t�,f��' ��be co�aer�,d. �e tt�.t��u i6�iliaziz��rours�lf�ith�'msuranoe pl�n"s c��e of p�ch�lo�cal�nie�,.Po���d f���i�b�t�re pama�ca�e p�n,and da�ord�9'ciia�for�-i�icb co�etage is ima�ailable.If you�rish to speak willh a ��from i�e billing offioe abo�at in.�c��for ldris psoc�d�,pi�e c�11 C651) 241-7431_ � � E � � � � . _. . � Expert evaluation,treat pe�c mentusiand Sew'ngsV:icazro�oschnadbei�Des�kt p\CON USSIOMConneusslon Clinie Neui pisychpileer�L).doc �_ '�:=E ._.,`�',*�.�.�'�«�+%FYi4£t7.Si ����,�# ..:. ' y — r� —�..^ . i4��.#.�. ��.TM� :_ �_�.. '�Z ���il�.. � ��; ..J� ��� ...� , .47.x:5".�i`...ii?G ._� '7_._._��__�: �� �i'E,z� � x;cAk:.b:tl�:ch?�+.�'� .•� _'."'__.-�.-..�__._�-_-.[. _ ._ ��AO���E� ��� x�.C.�'+'Y�'��`§�'�Y...! '`e.•...z- �.+-..��J�13 � .-'�Ii"� ����1� -,�:��r �-�� s ��ae:: ��'�� � Tai IF�. �8��4�3899 _ wioa�-�:�_�1l�4= !/acerteai awaia6Re 24 hous a day �_-�"°'� _ �rrtraa a�s at�°IFS_ �g 3�T0 Yas c:�ro rtomos�g/��s�iree a� �.a c��t��.rn`^�?s � .. ....;,.;. , �;5e,_r�;xRaa7��utsl? :` .. _ 1Q►913PL013 2341371 , $43_53 , �. J Pw�rr=�s c�r►siER Lu� �a�e�dF ro s m �YF�CABLHR 1�E �-� � � 20�P6iNCETON AVE �BOX a SAl�lf P/6l��6.`a570.ra-152� � S�1 � � � ❑ Please check box if insurance information has changed or address is incorrect and indicate changes on the reverse. Please detach and return top portion with payment. �C�.P�1DBR�-�465-lQQCI(T � D�TION PRdV�E7t CHAR('ES PAY� PAY�BI7S �T" BALAMCE @I(AtlN7Ht�1Z5�6416 LOCJ►T101� CL-S �fA�`/�'13 B9LL.� $�3..�3 ��lfll� $�.� Cti+e�Batass Past D�BaL�oe f�ou I�are a balanoe i�the 31+b�ad are not ane�on a P�P�4 P��' d pa�ent i�fi�today Q pie�a��ca�t a�r aioe�yon hare que�o��'d�9 s0_� �p3-�3 tli6 hi at(iBt)�r?3�6 v(siq 1033999 Uo P����f'��9 P�^d �a oo■eciow a9�*ol-1��ll� �yes se f�plys�sa�s a�and fhe re�reining beia�oe is your��y_�you w�e seen i�gee ha�ai„yand vm�l�ae a sqpart�e STATEWENT� ACCOUNT NUMBER PLEASE PAY s8ss2�o 2�1371 THIS AMOUNT � � � �-53 C�11�C�Ten_� Statement Date: 10-30-2013 Patient Name: Nils Gabler Lunde Hospitals Clinics Children's Hospitais and Clinics of Minnesota Account Number. 12547152 . of Minneso� Hospital Patient Finan�ial Services 2910 Centre Pointe Drive Start Date of Service: 09-27-2013 Roseville, MN 55113 End Date of Service: 09-27-2013 Balance Due: $433.00 Payment Due Date: 11-24-2013 Dear ROBERT DANIEL LUNDE: Your insurance company has processed this claim.The balance due is your responsibility. Please send payment in full. Hospital charges: $433.00 Insurance payments: $0.00 Patient payments: $0.00 Adjustments: S0.00 Total balance due: $433.00 ! If you are unable to make payment and would like to discuss financial assistance, an uninsured discount, or have other questions, please contact us. �Cu�anar�re�ac�e R��es are aeraiialble Mond�y�FR�,8=0�Akl�8�Pl�lr� Sa�eirt9aq/81U0/�1�01�12�t10 Pf4A at�651)85�2200 to assist you with questionsn oonoerr►sr ac to provide y�ou wi�h arn�e�re�e�be�_Yaaa cx�rn�SO ernal yayr�ons to _ _a'g-Pl�se inc�ide y�our�c�our�dt �eaar�a�er�moat�esn eart�_l6ioe also dFer the option to P0Y Y'o�r�it��9s�Gree at de�:�",lrawre►_d�eero_aro� payhospitalbill. If you continue to have concerns that have not been addressed,you may contact the Minnesota Attorney General's Office, at 651-296-3353 or 1-800-657-3787. Thank you for your prompt payment, Children s Hospitals and Clinics of Minnesota Hospital Patient Financial Services piora�o�P s 1�'��°IdC 3s-�s��-��o�-�sa�nro�-� �a-�:��� ❑ Pk�ase d�ecic box if addr�ess has d�nged ���'i52� ` g4.�i�� i� "; i' _ and wri�e i�+orma6on on retierse side. --;;�,,,,_�--- ��, ,; Staur�Dalte a�Seavi�c�e: 09-2�-20'93 �Ntls G�Lunde ��-2�-2�� i; En[9 Da�ee a�S�rtvioe= 0�-27-2013 — ,,�y--:: — �!!■ _ � � �'�. Paitier�Na�ee: t�s�r Lunde — �- — _ —' �' AocanG I�m�olber 1���5�2 �a� L �� �i Sta�emer�[Dalte= 1 f}-30-2013 �' p�p,�= 11-242013 �� '�' M�oiri Paid: �' � �` �� I w I� � ..,w�H .r...<.� � �ROBEKT�ANF1 LIA� C�lILDREN'S�TH(:14RE �ppg p�TON AVE P_O_Box 5�69 SAINT PA�,1►AIV 551[�i-1527 MII�IEAPOL4S,AAN 56486-0'ffi7 I.I.I..I.I....Illl....l.l....11.l.t...l.11...11l...i..l....11l I.I.f..l.l..l..ii..l..11..11..,11...1..1..11..1..1..11...1..11 �100012547152�000433��0927138 k�'" ,Y. : S��€�e_ 0�12-220'1'93 �`-`'� ��� Na�e= I�s�� +�;1-..�*�_— "�,-,-.�: "S�'Mos�itals amnd C�cs o�I�1"r� _ . .. .�>�.. �a�.F'a�t F' " � Na�rr� 125460'LO 2��0�Pa�alte Dri�ao�e ��e a�SeQVec�e_ ���-2013 R��fl�.��6�'�13 �:s��e of Seavime_ ���-�9� ��Uue' $100.00 Payment Due Date: 10-07-2013 Dear MARTHA GABLER LUNDE: Your insurance company has processed this claim. The balance due is your responsibility. Please send payment in full. Hospital charges: �824.48 Insurance payments: $468.81 Patient payments: $0.00 Adjustments: $255.67 Total balance due: $100.00 If you are unable to make payment and would like to discuss financial assistance, an uninsured discount, or have other questions, please contact us. Our Customer Service Representatives are available Monday through Friday, 8:00 AM to 8:00 PM, and Saturday 8:00 AM to 12:00 PM at(651) 855-2200 to assist you with questions, concerns, or to provide you with an itemized bill. You can also email your questions to PFSCa�child�ensmn.orq• Please include your account rcm�r _We adso ai�er 4t� to���� - Ibe����e a�iaf9�:�'6�m_a� _�'/ �� �haMe c:o��ns 1trr��v���ad�.y�an nnay tt�e pA"r�r�Al�o� �5�„�s��zss-���-so�-ssi��sa_ _ � -�n�C�an f��our�roeee��a,�., _ f�- -- te� f ^= � Cb ����c����a�,� � Hospital Patient Financial Services CHDRNMSPI07P 6 Ill�dll�$���1& 39-PSARSLTR-1835432-1506992426-P;7816395-1-179;33662064-2;358 I Children's Hospitals and Clinics of Minnesota Hospital Patient Financial Services 2910 Centre Pointe Drive Roseville, MN 55113 _3'�' ozoz MARTHA GABLER LUNDE CHILDREN'S HEALTH CARE 2008 PRINCETON AVE P.O. Box 860261 SAINT PAUL. 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