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/ , . JUL 1 0 2Q12
NOTICE OF CLAIM FORM to the City of S��`�'��t�;�$Vlinnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by ciearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something dces not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name /� Middle Initial�Last Name T ,!1
Company or Business Name
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address �o�/� Q�¢.C� l���tJlLk
City �FS/ o�iS��/ ��L State �N• Zip Code 6�/�
Daytime Phone( ,�[)���Cell Phone(,f���'�/19 Evening Telephone(��J}��7�f�!�
Date of Accidend Injury or Date Discovered J��o?lr -/�, Time G��/$ m/�
Please state,in detail,what occuned(happened),and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.� �
l�YI ��jF l4i �u1�1L,� %.J fiQisfl� Df �'�E. �i`bG�CoT cS110I�' Al� /D�� CoiP�n�/9dEA7k� ,l./�.rl�,�
N• ,� u E�F,�� �-: o T �r e .�
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e.'�y �S /Q�sOi�7S%.6CE .�'••� it LG A'Jt4!`c.�G E ��a.r,� 2� .[ess 4,�l�tt cDtra Yo ,�.fe f•I�<!
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 fl�.�c�i�.�i�-�o�,t F��t t' P4�lic/ ?-%En�o�as.
In order to process your claim vou need to include copies of all applicable 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 andlor 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
andlor receipts for the repairs;detailed list of damaged items
� Injury claims: medical bills,receipts
� 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-ulease complete this section
Were there witnesses to the incident? � No Unknown (circle)
Provide their names,addresses and telephone numbers: �'I :r • ,v - w A �
�c•C �`/-.�39•2YG•/��'i� A�So r��c �le��es 1 A�vAyE2 fOl�SJ�n.PE: '�'�s�• ��o•s7�5 ee �s�• 9i'1•�97�,
Were the police or law enforcement called? Yes � Unknown (circle)
ff 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 detailed as possible. If necessary,attach a diagram. �F_� 'iJ�'O�(ht/J o?��
�1L:lE ,�±.��2e P A�- � /08'a� �Q.�n�c� �r1iE, Si p,Qrl�l'17�U. SS/OS
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.��r/i'��L ,��.[.l E� .C.ss o� L.�A9ES
Vehicle Claims- lease com lete this section check box if this saction does not a 1
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims- lease com lete this section ❑ check box if this section does not a 1
How were you injured? /"•' ?� os ^ m ' 6 / -
�1Q�� f'� f dar'�F FE'!� m ",tr�'E �,I,r�.c.Yi 1 f'.0�io W �F b.�r.:�sd s.�••w�ie�
Wh�at part(s)of your body were injured? r• � s - �� ��(
of 1-06!- ��'�;S�� cSer �kc�l ctFr K�ee , FCbo v,Q:si_ r. .s�bP �tEj.► c: s' •"
Have you sought medical treatment? Y�e No Planning to Seek Treatment(circle) �' �� %t Pt�te.y',
When did you receive treatment? �/.. A ��..� � J'i5 3•�o P� .v� tL��f���/..�p.(Provide date(s))
Name of Medical Provider(s : /� :tF f/•s�:t�►l-��. ��cL ��. ��s t�(.� ,��B L �e f �.�.�+:f 02�a�rc�zS,
Address a7�90 G9000�ld��s �-�r7sad� �� • Telephone laS/- 9LiS�• Sao/
Did you miss work as a result of your injury? Yes No
When did you miss work? S�.t,eE J-d.ls-/� -� �`� " �"'��%•'�' (provide date(s))
Name af your Empioyer: 1 �"'� � � `s�'r�
Address -' Telephonec X 4�2•7S/�-��95
�Check here if you are attaching more pages to this claim form. Number of additional pages �Q.
By signing this fornz,you are stating that all information you have provided is true and eorrect to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed �' 3- ��
Print the Name of the Person who Completed thi orm: �u- ��
Signature of Person Making the Claim: ��01
Revised February 201 l
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,/EMC�e� P.�.BaX,252 '
Minneapolis,MN 55440-1252
u1S�l�+111.G '►.�.1��1�5 FAX 888,992�.8132 O
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Email:Minneaoolis.Claims[�emcins.com
www.emcins.com
June 11, 2012
City Clerk
310 City Hall
15 Kellogg Blvd., West
Saint Paul, MN 55102
Notice and tender of liability claim to the City of St. Paul
Our Insured: The Bibelot Shop, Inc.
Our Claim: 879072 MS
Loss Date: May 26, 2012
Claimant/Injured: Kay Krupenny
Location: Sidewalk in front of 1082 Grand Avenue, St. Paul, MN
Dear City Clerk's office,
We are the general liability insurance carrier for The Bibelot Shop, Inc. We were
notified of this incident by our insured as the claimant was coming to our insured's
location to do some shopping. The claimant reported the incident to our insured after
it occurred. The incident occurred on May 26, 2012.
The accident involved Mrs. Kay Krupenny who alleges she tripped and fell due to the
condition of the sidewalk that is in front of our insured's store. Mrs. Krupenny suffered
a fractured bone and ligament damages to her foot as well as having knee pains.
Based on our investigation, the incident occurred on the city sidewalk that runs in front
of our insured's store. The sidewalk continues down in front of many other store
fronts. It is our understanding that the City of St. Paul is to maintain and repair the city
sidewalks via Public Works.
Therefore, we are tendering this claim to the City of St. Paul and ask that you
investigate and handle the claim�for Mrs. Krupenny accordingly. Please accept this
letter as our tender of the claim to the City of St. Paul and we ask that you notify us of
acceptance of the same.
The contact information for Kay Krupenny:
Address: 1214 Hall Avenue, W St Paul, MN 55118-2205
Telephone: 651-457-3680 or Cell 612-749-1995
Employers Mutual Casualty Company Dakota Fire Insurance Company
EMC National Life Company EMC Reinsurance Company Hamilton Mutual Insurance Company �1�!�/�
EMCASCO Insurance Company EM�Risk Services,LLC Illinois EMCASCO Insurance Company ���
EMC Property&Casualty Company EMC Underwriters,LLC Union Insurance Company of Providence
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/EMC� Minneapolis,MN 55440-1252
��y�� �p �� A„'• Phone 812.843.4700
� S Lll CL�I.v 'W1I�Q�111�S FAX 888.992.6132 r
:� Email:Minnea�olis.Claims(�emcins.com
� www.emcins.com
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'� June 11, 2012
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Mrs. Kay Krupenny
� 1214 Hall Ave
West St Paul, MN 55118-2205
Our Insured: The Bibelot Shop; Inc.
Our Claim: 879072 MS
Loss Date: May 26, 2012
Dear Mrs. Krupenny,
This letter is to follow our past conversation and then further conversations we had
with your husband, Keith.
We are the general liability insurance carrier for The Bibelot Shop, Inc. You had
notified our insured of an incident occurring on May 26, 2012 on the sidewalk in front
of their store at 1082 Grand Avenue, St. Paul.
t
As the incident occurred outside of our insured's premises and on the sidewalk, our
j investigation would indicate the City of St. Paul would be responsible for any claims
' ` arising from the sidewalk.
i���� �
Based on our investigation to date, any repairs to the sidewalk would go through the
City of St. Paul and their Public Works Department.
Please find enclosed a copy of a letter we have mailed to the City of St. Paul Clerks
Office in which we are notifying them of your incident and asking them to assume
handling of your claim.
Also enclosed is a "Notice of Claim Form"that was obtained from the City of St. Paul's
website (www.stpaul.qov under Government-City Clerks-Claims). The Clerks Office
asks you to complete the form and mail to them at: City Clerk, 310 City Hall, 15 West
Kellogg Blvd., St. Paul, MN 55102. --
Employers Mutual Casualty Company Dakota Fire Insurance Company
EMC National Life Company EMC Reinsurance Company Hamilton Mutual Insurance Company �1�!��
EMCASCO Insurance Company EMC Risk Services,LLC Illinois EMCASCO Insurance Company v��
EMC Property&Casualty Company EAVIC Underwriters,LLC Union Insurance Company of Providence
rr.;... . .. . .... . .
/f ,�
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, " �MC
f Insuranoe Companies
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If you are now in a position to provide a recorded statement of the accident details,
please do contact me to complete. Please do contact me with any questions or
concerns you may have. �
Sin rely,
Mike Samuelson
Senior Claims Adjuster
EMC Insurance Companies
612-643-4727 (direct)
Enclosure: Copy of letter to City of St. Paul City Clerk & City of St. Paul's notice of
claim form
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Page 1 of 5
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ALLI NA. �
IIus�itc�.Zs cY� C�Iiri�cs
United Emergency Department
333 N SMITH AVE
ST PAUL MN 55102
Phone: 651-241-8755
IMPORTANT: You were examined and treated today on an emergency basis. This was not a substitute for,
or an effort to provide, complete medical care. In most cases, you must let your doctor check you again. Tell
you doctor about any new or lasting problems. A copy of the record is available to the staff that will provide
follow-up care. We cannot recognize and treat all injuries or illnesses in one Emergency Department visit. If
you had special tests, such as EKG's or X-Rays, we will review them again within 24 hours. We will call you if
there are any new suggestions.
After you leave, you should follow the instructions below. If you do not understand any of these instructions
or have any questions and/or concerns we would be happy to assist you. Or you may call your health care
provider for further information. �
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In a couple of weeks you may receive a survey in the mail. We value your feedback and hope you will take
the time to complete and return it. We feel it is very important to monitor how well every area of the hospital is
performing from our patienYs perspective.
Krupenny, Kay M ' ncy Department
Department: United Emerge
MRN: 1003537549 Date of Visit: 5/26/12' •
Your E.D. Dia nosis is:
Your diagnoses were JONES FRACTURE , FOOT PAIN , ANKLE PAIN, RIGHT , and ABRASION, ELBOW
W/0 INFECTION .
You were seen by Sirek, Emily M, PA-C.
The followin were performed during our Emer enc Room Virit:
Right Ankle -3 Views
The following medications were administered during your Emergency Room Visit: from 05I26I2012 1532
to 05/2612012 1618
Date/Time Order pose Route Action
05/26/2012 ibuprofen 600 mg tablet(ADVIL; 600 Oral Given
1613 MOTRIN) mg
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Krupenny, Kay M (MR# 1003537549) Printed at 5/26/12 4:18 PM Page 1 of 5
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' Page 2 of 5 '
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� Discharge Instructions e
You were seen at United Hospital Emergency Department tonight. Please bring this paper
work to your follow up appointment for the next provider to review and continue providing
your care.
4.
A fractured 5th metatarsal is the cause of your foot and ankle pain and swelling today. We
splinted the fracture with a CAM boot. For your comfort while walking, please use crutches.
Keep the leg elevated and ice the 3 times a day for 20 minutes over the next 2 days.
Foilow up with Summit Orthopedics in one week to follow up
For your pain, please use Ibuprofen 600mg every 6 hours as needed for pain. For pain not
responding to Ibuprofen, you may also use Vicodin 1-2 tabs every 6 hours as needed for
pain not responding to Ibuprofen. Piease do not drive or operate dangerous equipment
while on Vicodin or Percocet as these narcotic pain medications can make you sleepy and
slow your reflexes.
Please take your medicines as recommended above and review the discharge instructions
for concerning signs/symptoms that would require your prompt return to the emergency
department for further evaluation. Please follow up in clinic as we have recommended
below. If your symptoms worsen prior to your follow up appointment, do not hesitate to
return here to the emergency department for further evaluation. We'd be happy to see you
again. ,
--------------------------------------------------------------------------------•----------�- --..
Whil�you were in the emergency department today your blood pressure readings were as
follows:
Patient Vitals for the past 8 hrs:
BP
05/26/12 144/83 mmHg
1534
If your blood pressure was greater than 140/90, it was abnormal. Your blood pressure may
be high today related to your emergency visit or you may have poorly controlled blood
pressure which puts you at risk for heart attack, stroke or kidney failure if left untreated.
Please have your blood pressure rechecked in clinic within one to two weeks to determine if
you have high blood pressure that needs treatment.
Metatarsal Fracture(s), Undisplaced
A metatarsal fracture is a break in the bone(s) of the foot. These are the bones of the foot that
connect your toes to the bones of the ankle. _
DIAGNOSIS
The diagnoses of these fractures are usually made with X-rays. If there are problems in the forefoot
and x-rays are normal a later bone scan will usually make the diagnosis.
TREATMENT& HOME CARE INSTRUCTIONS --°-• ��� �� h,� ��������,��
�p°�" w/ f2.���,z,�,i.
. Treatment may or may not include a cast or walking shoe. When casts are needed the use is usually for
short periods of time so as not to slow down healing with muscle wasting (atrophy).
,.
Krupenny, Kay M (MR# 1003537549) Printed at 5/26/12 4:18 PM Page 2 of 5
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Page 3 of 5
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. Activities shouid be stopped until further advised by your caregiver. , ,
. Wear shoes with adequate shock absorbing capabilities and stiff soles.
. Alternative exercise may be undertaken while waiting for healing. These may include bicycling and
swimming, or as your caregiver suggests.
. It is important to keep all foilow-up visits or specialry referrals. The failure to keep these appointments
could result in improper bone healing and chronic pain or disability.
� . Warning: Do not drive a car or operate a motor vehicle until your caregiver specifically telis you it is
safe to do so.
IF YOU DO NOT HAVE A CAST OR SPLINT:
. You may walk on your injured foot as tolerated or advised.
. Do not put any weight on your injured foot for the first 1-2 weeks or as directed by your caregiver.
Slowly increase the amount of time you walk on the foot as the pain allows or as advised.
yG • Use crutches until ou can bear wei ht without ain. A gradual increase in weight bearing may help.
'�` . Apply ice to the injury or 15 to 20 minutes each hour while awake for the first 2 days. Put the ice in a
plastic bag and place a towel between the bag of ice and your skin.
. Qnly take over-the-counter or prescription medicines for pain, discomfort, or fever as directed by your
caregiver.
SEEK IMMEDIATE MEDICAL CARE IF:
. Your cast gets damaged or breaks.
. You have continued severe pain or more swelling than you did before the cast was put on, or the pain is
not controlled with medications.
. Your skin or nails below the injury turn blue or grey, or feel cold or numb.
. There is a bad smell, or new stains and/or pus-like (purulent) drainage coming from under the cast.
MAKE SURE YOU: '
. Understand these instruc�ions.
. Will watch your condition.
. WII get help right away if you are not doing well or get worse.
Document Released:04/07/2004 Document Re-Released:03H6/2010
ExitCare�Patient Information �2011 ExitCare, LLC.
If you develop chest pain, trouble breathing, weakness or severe dizziness prior to your
follow up appointment return here to the emergency department for further evaluation. We'd
be happy to see you again. Otherwise, follow up in clinic as recommended.
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Your Medications
START taking these medications. If you need a refill,you will need to make an appointment with your
primary or specialty care doctor.
IBUPROFEN (ADVIL; MOTRIN) 600 MG TABLET Take 1 tablet by mouth every 6 hours if needed
for Pain. Maximum of 3200 mg in 24 hours.
_.._._: ._ ........ a_. . _. _..____ ____.__. __.._w.�____,_.��,__..�_._.__a___ _..___..__ .._.
__ .
OXYCODONE-ACETAMINOPHEN, 5-325 MG, Take 1-2 tablets by mouth every 6 hours if
(PERCOCET) PER TABLET needed for Pain. Max acetaminophen dose:
4000mg in 24 hrs.
CONTINUE taking these medications which have NOT changed and were NOT talked about during visit. If
you have any questions about these medications,you will need to make an appointment with your
primary or specialt care doctor.
ARMODAFINIL (NUVIGIL) 250 MG TABLET
�
Krupenny, Kay M (MR# 1003537549)Printed at 5/26/12 4:18 PM Page 3 of 5
' 1 '1 � 1
� . _ _._ . _:_�:..�_._
. CHECK CARD USING � � �� � y�SA ❑ ❑ �
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Ailina Hospitals&Clinics �DNUMBER A EXP.DATE '
- ALLI NA. 2925 Chicago Avenue , '
� Minnea olis, MN 55407-1321 � � � ' '�� �"' � �
Hospitals&Clinics p SIGNATURE AMOUNT PAID
Bilfing Questions ?
Please call us at 612-262-9000 or 1-800-859-5077, STATEMENT DATE ACCOUNT NUMBER PLEASE PAY THIS AMOUNT
� Monday-Thursday 8am-4:30pm ' 05/31/2012 7960960 a1,183.35�
Friday 9am-4:30pm
❑Please check box if address below is incorrect or if your � pay Online:www.allina.com/payhospltalblll DATE DUE
Insurance updates and indicate change(s)on the reverse side. see reverse side for addlt�onal payment options 06/21/2012
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� ALLINA HOSPITALS 8�CLINICS
g KAY M KRUPENNY PO BOX 9125
N 1214 HALL AVE MINNEAPOLIS MN 55480-9125
� SAINT PAUL MN 55118
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HOSPITAL STATEMENT
ACCOUNT NUMBER PATIENT NAME HOSPITAL NAME
7960960 KAY M KRUPENNY United Hospital
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� Date � ��,Descriptian.' �'� Charges/Payments�
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SERVICES FROM 05/26/2012 to 05/26/2012 at
If you require an itemization of charc�es,please call(612)262-9000 or(800)859-5077.
05/26/12 Pharmacy $23.15
05/26/12 Medical/Surgicat Supplies � $148.50
05/26/12 Radiology-XR $269.00
05/26/12 Emergency Room $742.70
- TOTAL CHARGES $1,183.35
BALANCE: $1,183.35
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' ' ' ' " ' ' ' ' FOR BILLING INQUIRIES: 612-262-9000 or 1-800-859-5077(if you
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are outside the Twin Cities area).
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.• . .., . . . .. � EMAIL ADDRESS: Contact.CenterC�allina.com �
Allina Hospitals 8�Clinics:2925 Chicago Ave�Minneapolis, MN 55407
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IF PAYINO BY VI811,MASiEpGAHD,DISCOVER OR AMERICAN EI�RESS,FlLL OUI'BELOW i
Emergency`Care Consultants - -' �---
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For all billing questions, catl: 866-951-6774 06/06/2012 $556.00 281 1419820 j
Office Hours : IvI-F 8:OOam-8:OOpm EST pAYMENT DUE WITHIN 30 DAYS SHOW AMOUNT � '
Or visit our web site at www.emergencybills.com �
PAID HERE '
� MAKE CHECKS PAYABLE T0: �
��"'��'�I'I�'��I�II'I�����"���'I�I�'�I���IIIII�II��'�������I��I 2zsas-z�z EmergenCy Care Consultants
KAY M KRUPENNY PO BOX 86
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p SAINT PAUL MN 55118-2205 MINNEAPOLIS, MN 55486-0086
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� Please check box it the above address is incorrect or your insurance � � PLEASE DETACH AND RETURN TOP PORTION WITH
intormation has changed,antl indicate change(s)on reverse side. YOUR PAYMENT IN ENCLOSED ENVELOPE
PATIGNT NAMG ` F�,,;PAT�I�T NIJN]BCR :, YQUR PRQVIDCR
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Voucher: 3852820` �' � Diaqnosis: 825.25 -
05/26/2012 99284 ER EXAM . 394.00
05/26/2012 29515 SHORT LEG SPLINT � 16�.00 556.00
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P�ease ��S�t Emergencybills.00i21 for a more convenient and secure way to provide us with your Heaith
Insurance Information, Motor Vehicle Accident infOrm8ti0n, Workers Compensation insurance information and to pay by
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Credit Card. Or see reverse side to complete and mail in. �
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www.emergencybills.com TOtal AmOU11t Due � $ 556.0� a
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THIS SEPARATE BILL IS FOR'1'F-�E EMERC3ENCY PHYSICIAN AT AF,3B0�'T Office Hours:M-F 8:OOam-8:OOpm EST
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STATEMENT
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. ALLINA ORIGINAL INVOICE � '� '. � �-:�"- �� ,
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''`` MEDICALEQUIPMENT 06/26/12 W3348 02719509 J ' '
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Card Number SIC
Amount Authorized Exp Date ALLINA HOME OXYGEN MEDICAL EQU
Signature PO BOX 9344 NW 7365
MINNEAPOLIS MN 55440-9344
AMOUNTENCLOSED$ (612) 262-1700 FAX: (612) 262-4088
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SAINT PAUL MN 55118-2205 SAINT PAUL MN 55118-2205
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ORDER NUMBER ORDER DATE CUSTOMER ORDER NUMBER LOC SLS# TERR r SHIP VIA TERMS iNiTiALS PAGE
03061504-00 05/26/12 UNI MTO CON DELIVERY UPON RECEIPT BLR 1
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QT�' Qn' <DESCRIPTION UOM UNIT AMOUNT
ITEM SHIP�o e�o PRICE
** Balance Forward ** 0.00
** Location: I **
GUA91214 1 0 CRUTCHES ADULT MED 5'-1"-5'-9" PR 71.39 71.39
PR CS 8 275#CAP MEDLINE
BLUE CROSS 80 44 36
Allow: 55.4 TAdj : 15. 4 Tax: 0.00 Patient portion: 11.09
NOTE: THIS MAY NOT REFLECT YOUR
ENTIRE BALANCE. QUESTIONS?
PLEASE CALL 612-262-1700 OR
1-800-737-4473 OPTION 3 �
www.allina.com/PayHOMEBill
Subto al 71.39
Cash/Dep R ceived 0.00 I
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PA LE U ON RE EIPT - NO CREDIT Adjustm nt 15.94- I�
IS ED FO PART AL PAYMENT i
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Subto al 55.45
009 - BLUE CROSS BL 44.36
TAXABLEAMOUNT p�✓ppg�99 W9�9�• PAYABLE UPON RECEIPT • � 11.09 !
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r.. ALUNA HOME OXYGEN&MEDICAL EQUIPMENT �. . i
REMIT TO:P.O.Box 9344 N.W.7366 Minnea lis MN 55440-9344
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Adjuster Name: Milke Samuelson Date Photos Taken: 6-07-2012
Claim#: CA 879 072 NT Photos Taken By: Neal Testin
Insured's Name: Bibelot Shop Inc Date Of Loss: -
Address: 1082 Grand Ave, St Paul, MN 55105
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Claim#: CA 879 072 NT Photos Taken By: Neal Testin
Insured's Name: Bibelot Shop Inc Date Of Loss: 5-2
Address: 1082 Grand Ave, St Paul, MN 55105
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Adjuster Name: Milke Samuelson Date Photos Taken: 6-07-2012
Claim#: CA 879 072 NT Photos Taken By: Neal Testin
Insured's Name: Bibelot Shop Inc Date Of Loss: 5-26-2012
Address: 1082 Grand Ave, St Paul, MN 55105
` City of St Paul sidewalk
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Claim#: CA 879 072 NT Photos Taken By: Neal Testin
Insured's Name: Bibelot Shop Inc Date Of Loss: 5-26-2012
Address: 1082 Grand Ave, St Paui, MN 55105
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Adjuster Name: Milke Samuelson Date Photos Taken: 6-07-2012
Claim#: CA 879 072 NT Photos Taken By: Neal Testin
Insured's Name: Bibelot Shop Inc Date Of Loss: 5-26-2012
Address: 1082 Grand Ave, St Paul, MN 55105
Crack in city sidewalk
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Adjuster Name: Milke Samuelson Date Photos Taken: 6-07-2012
Claim#: CA 879 072 NT Photos Taken By: Neal Testin
insured's Name: Bibelot Shop Inc Date Of Loss: 5-26-2012
Address: 9082 Grand Avs, St Paul, MN 55105
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� Adjuster Name: Milke Samuelson Date Photos Taken: 6-07-2012
Claim#: CA 879 072 NT Photos Taken By: Neal Testin
insured's Name: Bibelot Shop Inc Date Of Loss: 5-26-2012
Address: 1082 Grand Ave, St Paul, MN 55105
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