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Smith �,r r National I]ocument Center F.` � � � � � � P. O. Sox 2G8992 �klahoma City, C�K 7312G-8992 clairnsdocuments a7�pcs.com Fax: 877-217-1389 Toll Fzee: S00-HelpPoint 02/13/2012 St.Paul Fire Dept RiskMgmt ����lyE� Attn: Cliari Moore 15 Kellogg Blvd W Room 310 F�B 1 6 2012 Saint Paul,MN 55102 Our Claim#: 099 SUB 1018762201-1 �'��� �'LC�� � Our Insured: Jolene Smith , InjuredPa�ty: AnthonyJefferson ' • ,..,....._.._,� . our F e um er. . _ _- I� Your Insured St.Paul Fire Department Tota1 Darnages: $11,013.06 ���'MEDICAL/PIP SUBROGATTONNOTTCE�'*�' Dear Cliari Moore: We have been informed that you are the liabilitycarrier for the above-captioned accident. Our investigation shows thax your insured is responsible for our insured's bodilyinjuries sustained as a result of this accident. Illinois Farmers Insurance Company has paid$ 11,013.06 to date in Med Pay/PIP benefits on � behalf of our insured We have a right of reimbursement for these expenses and request that reimbuisement be sent directlyto us. No other partyhas the right to represent our interest in this matter. Attached is a medical ledger of payments tendered on behalf of the injured party. Please submit payment promptly. If you have any questions you may contact me at 425-430-2329. I Thank you for your attention to this matter. Sincerely, Illinois Farmers Insw�ance Company �\ ��_,2_„��.� �,j..�_��%� Jo�J.Vegas Medical Subrogation Representative 425-430-2329 joanna.vegas@ hpcs.com N O c�.� / � � N �� N � O R:a O I O p O Q 'O C O C? � q O G O O a � , .�,� M C'1� , n �'....�n O- tn 'CI' 'V "sl; . 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