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Woldu 2012/05/31 10: 37 : 57 1 /7 ����!`'��Ga MAY 3 f 2012 � _ � � ��`�",,� �,,�,�s-��� � To: From: Michelle Riveros Fax Number: 6512668574 No. of pages (including cover): 7 Phone: Date: 5/31/12 Re: Attn: Shari Moore/City Clerk Time: 10:37:57 AM Details: Attn: Shari Moore/City Clerk regarding: Jordan Woldu � I � 2012/05/31 10: 37 : 57 2 /7 � . BENNEROTTE & ASSOCIATES, P.A. - Helping you...tivhen help is needed most.TM TOM BENNEROTTE May 31, 2012 CONOR TOBINt Shari Moot�e City Clerlc, City of St Paul 7oxrr scorr VIA FAX ONLY 651-266-8574 JEFF MiJ12RAY RE: My Client: Jordan Woldu tAlso admitted in Wisconsin Your Insured: Nikkole Peterson Ow• File No.: I5322 Date of Injury: 10/3/11 Deac Ms. Moore: Please be advised our office has been retained to represent Jordan Woidu in the above- referenced accident. We undei•stand that you are the insurer for the defendailt in this accident. Please advise me of the adjuster's naane and the claim number, or if any information as captioned above is incorrect. Please do not contact my client directly. As the Iegal representative of my client,I hereby exercise my client's right to withdraw all authorizations for t•elease of information that you or any agent or representative of your company inay have previously obtained from my client, effective the date of this letter. Please direct any future requests for signed authorizations for retease of information to my attention. Please forward the following information as it becomes available to you: 1. A copy of all records you receive including,but not limited to, medical reports, wage records,police reports and any other records received; 2. Any statements in your file of my client, or any parties or witnesses in this accident; 3. A certified copy of the declaration pa�e;and 4. Documentation of property damage, including estiinates,photographs, valuations, and payments made. If there is a charge for obtaining copies of this inforination,please contact us for approval of the charges prior to sending. Pursuant to Minnesota Statute 72A.201, Subd. 11, an insurer must disclose the coverage and limits of an insurance policy within 30 days after the inforination is requested in writing by a claimant. Please consider this as a written request for your policy limits. The information requested above is deemed continuing,so that any information received by you subsequent to this letter should be forvvarded to me. Thanlc you in advance for your cooperation and assistance. 3340 Sherman Court, Suite 100•Eagan,MN 55121 PH: 651-203-5990•FAX: 651-288-0860•www.bennerotte.co�n 2012/05/31 10 : 37 : 57 3 /7 Jordan Woldu 15322 Current Medical Providers Aspan Medical Group Bandana Square Clinic 1020 Bandana Blvd. West St. Paui,MN 55108 � A�nity Medical Group 9446 36th Ave N New Hope,MN 55427 Prior Medical Providers Regions Hospital 640 Jacicson Stz•eet, MS 11503L St. Paul, MN 55101 Sincerely, BENNEROTTE&ASSOCIATES,P.A. l�U� � V' � Thomas R. Bennerotte Attorney at Law TRB/mar Enciosures Cc: Jordan Woldu (via email) 2012/05/31 10: 37 : 57 4 /7 .t�,Tl'�'�tt'�7EtT�A'T�OI'+i'�'D��Zl�J���,&��'.I'�1��1�:C�1.�G 1C1�T�'U�N.�.`.�`���7�`+x �ti�.(0�1�'��9illl6i �)►`�. � � � �' � C .I�tttv d£Buth: "T " � �-� t .�.�,-'�'^ - -- -- — i.I aut2tvriz4 th�use or disalo9urd nPthe above�aaxnvd�Tad�v�c�utt�'g t���Ith in�armflkiUZt��desexitbotX bc�low, 2. T�ze fioil�win,��ttdi�ridaax o��ox�aA�iz�����$n'u�fzozizod to�na�es�s d#gcla�me: Affinity Medical Grou� _ ,,,_„_ �, `I.'bb��7d&11CI aIilQ�ititG��A�OI't[lA�!)xi�4 Ut��lSCf�Ox't��4�tl3�[�1�8 RS���a1'V3� �J �3ntiY�i�ro0SC1 �I K�;ou�ds rflgardi�.A�.YI�S or x�4xeatnzsnt or di�nos� CJ k�eaoxd,g re�azcli.�g�au�.^c�iora!oF r�ten���teaXt,�sorvi�a4s C"J Keoords resga,rdi,u��xe�tmari�C fox�lao}�ol au�dru�uUuso C( Item�zad}3�lling Sfitttauzen�� C.� Othea•- -- - --�— � — ..� _.._._ 4. x v�aderstasad i�.a�the�nE'oi�tn.a�ton 1n tz�y hoa(t�xeooxcl ma�i�olt�do l:r�f.o�,�i�.t�v�t ra�a�in��o sexu�I�y �p�s�Yitted dzsqase�acqtiirad i�mtzn�do�cl.�i�0y SyitBaauao(�S),ar hu.ms�t�mmunadq�v�e:�cxy '9ACi1���IV�. r�Al��t�S�f SIICXUCI��A�UT1�t10U 1�OUt�1CS�a'�YIOT�OP fll0il.Ypl I](iti�(;�t 89�1tLOg8�&Qt� ��atmar��fox��cU�ot�n.d dt'�g�busa. 5. Tl�fs infozu�atian�t�y ba disa�osad t�a�d usect Gy tha;Fo�iowin�firr��or pi�;rpasva o�titig��oz�: City of St Paul 6. x uudorstsa�.d X�aave ttt�j�'tght tt�zavn���his&tt#bq�'���lu�at n�tinis. �:tauic�ei•sfand�P�re�a�o�ais �ut�aor��ttW T fnirst c�o so��vrlf.�A�tc�prosaritany�cvrltt4n roV�CAtIp�'�'t�&.a lae�.It�ii�'orciuAtlozt naar�age,manC depa���enf. x andexaG�zd 1�a�ev�o�tton wl��at npp�y tv f�ffirmc�tot�tita�E ha�air�atiy baen releasad r"n re�p�alsa ta f:E�s auil�ort�a�ioz2, �:�mdez�atnuc��e�evaow.f�ati xxril!�ot a�P�Y��' �Z�st1r�c�bom�y'whar�#�te�aw pxa'v�dgs�y in4urer�r1tL tt�e r�,��Zt�vo�.tsst a c�a?z�.Yutdoa•�� �nliGy. T7nless otlzdrwasg�svv�d,tSxis auttiai•izsfian wi11 e�,��F�s wii���ra aate�Qar o�ifs dato. 7. X undarstand t�iat autf�o�iz�n,g i��d�sGlnsuxe o�f}tts heul�ii 3.n��xma�ivci is vv�ant�t�y: Z ct,n rd�sa�o aig�thrs aut'hnriz�tion. x�1eod xxat s�a.fb�is��x�Ix in rnrdar�o asau���raatuza�at, Z zmcCaxa�an�Y n�ay �a,�eCk arao�y't110 infbr�t�f�On fi0 b0 tl$ed of di8C�O8e�,as�xo�v�ded�tt C'�.�E��.524. T u�c�er�t�nci ctz�y diac�dsuea af6i�'ormadf4Tx oar�ies w,�t�i{�ih�pofera�it���4z aau waatttb.dll�ar�xa.diffofos�rxa�ud t�1e �infor�nation�snsy z�oC�e�r�tacta�i hy�fod�1 oon�F��eni,�a�It�y�uts�. 8. <4�hotocopy a:t t1�is r�ut�.ori•r.a.t�Q�z shalt ba co�si.�exacl�s v�l�td as ax�c�'�giue�. 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Tho�ypa and am��at�f iwformat�ou to b�used ox�d�s��ns�d is as:�o��ovt�sy �I �3ntire r4�osd �l �:ords ragardisag.A.Y3�S or�'fxea�a�ent or dia�us�A f� I�eao�d,g re�azci3,���ev�.�c�iara!or r�ter�i��toaXt;�servi�ans �'/ Keaorde rogaxciT,u��e�4mar►-��r�lc�lani a�ad d��u�ui�us� Ci 7tem�zadAilIin��tn�aaaen�� �t 4the��- � - 4, r understand t�i.a�tbe 4nE'ortn.a�t�n 1n tt�y hea�t�t xeonxd ma,�i�olt�Jo iuf.o�,���.�t��t xa�atin��o sex�t�I�y �a�ts�Yittad dzsQaseR a�q�izrod is�msuiodo�a��ixC�sy�ldxom�{�iIDS),or h�ns�i�mmunodc�vxe�tay v,ic�s��l:l�. r�nt�.y utsct ia�cXud�z�'ormatiou abaut�ie��a�rIorai ur n�entax J1oxli�i aex�rioes,�ad �,'0&f131Bl1��OT tl�CUXI�II Aft�tlYtYg��US9. 5, T1xia infomaat��n��ba�iso�osed tQ a�d nseci 6y the�o11owT�,g firrr��ar�u;r�os�s o�litig�tloz�: City of St Paul 6. x uudorstaa�d X��gv'a tTi�right fin xpv��e tivs fw#�aq��Ld�ion�at�tTms. i uz�c�ei�si�n�d a�X rewoko�a�� �utborizat�bti T i�i�se do so��vvri�+�c�prosotat auy�vriEton ro��ut���p�t tci t�xa Jx��l�in#'orciaai��z� �riazxag�m�nt depa����nt. �az�dexaf.sud 1��e��voc�t��u wl�x�ot�pp�y tv f�rmafiio�t[ta�has a��a�y beei�rele�sad��}roBp�aiBd�a�ii�s c�uihorl�aGiou, �:�mdsz�str�u,c��a�evaoutioi�:vvil!�at a�A�y t�xc� LtJuSIiIA�lCO tl0111�}IU�j7'WIkAYI#�t0�8'EN��o'V�lI6$7f]�'I17.911C0x�rtfltl2�i6 T���lt�A Qp.t1tAS�A C�H�.hJ.�1l2fL01•t�� ' pait�p. 'CJ'nlsss�►�erwAs�;r�+�v�d,t��is autl�at�i�ation wi11��►���wit�uxa aaie�roar o�iis dato. I 7, x t1I1.f�07CS#aLld�IlAG AUfI�4�'�1Z�1,�'�ti tl�O�pSU.Y4 O�ft1I5$BAIFII I.IxY4X[12ftY.1.UI1.1S Vp�I��L�C}� Z Ct►ti 1'd�l$��O �Ign this autlzortzut�on. x�.eod y�at s�n fluts��xaa�n ordar�o aeaur��r�atrxia�at. X�ndaxa��nd r naay �,�ecx or aopy'tlio informa�iQn tv bv u$ed af dis�o�e�r ae�zo�v�ded�u C�.:E G4.524. T unq�ez��r�nci c�y dlse�sue�nfui�'ormatioix oatxrea w�tt�t�t sha pote��i�tl f�r�uu�aaut�tdXt�r�xa.d�aoidsE��a aud#J�e� 9nfQx�nai�an,anay z�oC�s pr�taciaci by�oda�pt oon.��enf�a��t,y rui�q. 8. A photocopy a�t�tis r�utT�uritat�oaz sl�alt b�co�zs�(exac��s val�d as azx�rlgiut�. , �+'�•-- ,���>� ..�.-. ------�_-. 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