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Fournier
i��C�l�'�Ci , �} � NOTICE OF CLAIM FORM to the City of Sa�iJn't�an1;lVlinnesota r�I���`.; '`4t •-:=:-ii�: Minnesota Srate Statute 466.05 stntes that"...eve erson.._who claims dama es or+t an mtinici ali ''s�a�l cause ta be resented to the rY P g .f�' Y P �Y... p governing body of the muaicipality wit/un 180 days after the aUeged loss or injury is discovered a notice stating the time,place,axd circu�nsrances rhereof,and the amower of co�npensation or other relief demanded." Please complete this form in its entirety by clearly typing or printing yonr answer to each qnestion. If more space is needed,attach additional sheets. Please note that you w�l not be contacted by telephone to ciarify answers,so provide as much information as necessary to explain your claim,and the amonnt of compensation being requested. You will receive a written acl�owledgement once your form is received. The process can take ap to ten weeks or longer depending on the nature of your rlaim This form must be signed,and both pages completed. If something dces not apply,write`N/A'. SEND COMPLETED FORM AND 4THER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 3i0 CITY HALL, SAINT PAUL,MN 55102 First Name F�bb Middle Initial J Last Name T�t`")(� i t°'� � Company or Business ame�� Are You an Insurance Company? Yes�N If Yes,Claim Number? Street Address J�d� /U . (Y1 L°'E'1��( ��, City, �C�n�C�t�e. State A Z Zip Code��k���a Daytime Phone(,�) )���I Cell Phone(�i )�l�°�9�oISEvening Telephone f�� 1 O�.-�� Date of Accidend Injury or Date Discovered�� .��O�O�c� Time��am� Please state,in detail,what occurred(happened),and why you are submitting a claim_Please indicate why or how yg�t ' feel the City of S 'nt Pa�or its employees are involved andlor responsib�fo�our damages. �°' � f � � G 1 `� �c ` � , �-� � e �� t� Please check the box(es)that most closely represent the reason for completing this form: �My vehicle was damaged in an accident ❑My veiucle was damaged during a tow ❑My vehicle was damaaed by a pothole or condition of the street ❑My vehicle was damaged by a plow 0 My vehicle was wrongfully towed and/or ticketed �I was injured on Ciry property ❑ Other type of property damage—please specify ❑Other type of injury—please specify In order to process your claim vou need to include coaies of all aoalicable 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 retumed and become the property of the City. You are encouraged to keep a copy for yoursel€before subnutting your claim form. O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds $500.00;or the actual bills and/or receipts for the repairs O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt O Other property damage claims:two repair estimates if the damage exceeds$SOO.OQ;or the actual bills and/or 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 retumed. Page 1 of 2—Please complete and return both pages of Claim Form . . . , � y. � �a � ,� ..�, , .... .� . r{.i�a'�+ . ��,...., ._ _.3 �+.6.aa _ � K..�'�, �. . . '. � . �x.�°. L a,a , � _. �4�„ _:' . �.. - � .. . .,... .., ,,.>>...... ., , .,. , w,t-��. .. _)'� .. ..� �.. .. , . . � .. �i'=`E'� t ,.. "y. ..-:g4y�,: ..�e ..,. . .. . . .j� . . . ;i .. .. .. ... . .,. �. ' . � _.._a .... . , ._ . .. , ,.. - �.`-� .-.�i;i'.�".S:i','. �:,33.�I,yb.�x�'�*'. , i.:.�. '.iG?t �..$. ,; .. . , y.��� , , `4i r .v-�' ,':.. .3:A1 .., . ,.,. . : . �:. -..:s,1t :,:..�::�rR ��... �.t�: . ,.t: . �-� ;'.i�t;` . r. . ... . . . . ... . .rj�:: .._ ;� , r<.t,n -�e` _ r '°: t , .S..- +"4, �S ,...,. . ,« '?:[��l..�...�).��.*,.�1�i .. ., � . �°,__-, . . . . .. ss�' . _ . .. ..�,. , ',Sx. ._='�!S � '.:S.Fx _ ��:Ai�e F.?: � .. .i"". . ��!'.,,f e., -:'�#"° ,�r:?•1Mf .`,.^'. . .. ra, ...., 1`. ,"<:Jr... . , , �J:. _ . .. r.:��., .�5. , z .s� , .... - °', .c�:.d':lfi. 3. #E-�:. ,.. . ,:if. � ..c���' `-i�i.. . ,3 3"'%�. . . . . :!..t�:... .�fit'::e �.:r-i . . :r . ,'._� - f �� � , b ��'.3.��."�_ . ;".k... �. - s�8�,_. . . �k: ,a . . + aS',.i� .k ',.. . �?a !'l .-_..dr tf'-'�•"�' - ... , .... . .. . < . _ c : �.:,.' .� �;.` .� ':.� . .,:'',;�rt zi1'>o^t. '�::.• !. �r#;�';�..:.. ..: ?�:>�, .,-..y;.��i ,,� _ 13i� _. �.. ie: ,-.'�r��.--.i, _;"!'fi- . ....,:5 , . . : . : . .. . '*s. c. :'r.-- .. '� . .e a . .... ��.. 3° ..�.�,`T . �t i�� �d�.�, f Y. > .� .��`+.;�. .,, ,s. ..�'r�r,: c�,..�..�e� �_� ��b. >.?..� a�:"32�-.t-".. , - + . w " . � , � g � �,i,? ���..k.7� .. « a' -'. . . '� - .... . »_ .. .- . _ . ... - . r '� � .- =:�. • .._'x .�.' ... _ . .� . < _i t_F. �� .. t : -r, , . ; . . , � j .. �: . . F :, ; . ,,;. �: .:. '. * _ . , , , . , _. _ .. . .. _ ., .a.. _:..0 _ .., _ _,.._ ,..�. _ ,,F•, ... �..... , _ .'".=r�r�i';��i tlli-ii.� �`Yz- .�,J "�,... ' __ ' ",i . �'.'+ . t 3 .._�1 �: f,�Ea_.}... .r�,.r1ds�,:'C{�: �;�i . �.i _ ."�." `'E�i . '._ ;: i � f� rS��."..'. i t.f�. - �•.....,.�...,...�,.��wu rc,.�u•,.�nnu�e�wu�reswc m ae,iay m tne n�nc�ung oi yonr claum. All Claims—nlease comDlete this section � Were there wimesses to the incident? -Yes U (circle) vide ir names, and lephone Q � �• - t7 Were the police or law enforcement called? Yes No Un�own (circlej If yes,what depactment or agency? Case#or report# Where did the accident or injury take pIace? Provide street address,cross st�t,inteasection,name af park or f ty, cl t dmiark,etc. be as as pa��. If ,attach a diagram. C�IU /'YI j h� ..P���; P�:as� �- �'j�sary �"�- f�+ Please inriicat+e the amoum you kin in co� tion hat you would like the C'ty to do to resolv this cl ' ' fl Y � -�,^ II r q . VeLicle Claims—�easc comnlete this sectiun �f check box if this section does not nlv Your Vehicle: Year Make Model License Plate Number State Color Registered Owner Driver of Yehicle Area Damaged City Vehicle: Year Make M� License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged In' Claims— lease c:om lete ' 'on O check box if this 'an Ho ere you in � Q - � What part(s)of your body wece injuired? Have you sought medical treatvaent? Y No Plnnning to Scck Treatment(circle) When did you receive treatrnent? :�( � � {provide date(s)) Name of Medical Provider(s): Address �-�- �� a �� Telephone Did you miss work as a resul of your injury? Yes � When did you miss wark? �`St� �/.i�/,,-�_���� 1 ti>t� �� (providc date{s)) Name of your Employer: Address Telephone 1�t Cbeck here if yoa are attaching more pagcs to this ciaim form. Namber o�additional pages�. r� By signing this forni,you are stati�tg thart all inforrnation you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed Submitiing a false cla�tt can result in prnsecution. Date form was comple�ed Print the Name of the Pezxon wlw Compieted this Form: t Siguadue af P�rson Maiang the Cla�u: Rrvised Febivary 2011 ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ARIZONA LONG TERM CARE SYSTEM(AHCCCS) NOTICE AND CLAIM OF AHCCCS LIEN CASE NUMBER:732989612 CLAIMANT: MERCY CARE PLAN(MCP) 4350 E.COTTON CENTER BLVD.,BLTILDING 4 PHOENiX,AZ 85040 - - _ AUTHORIZED REPRESENTATIVE ON BEHALF OF THE DIRECTOR OF AHCCCS: SUSAN WOMACK NAME OF PATIENT :ABBY FOURNIER RECIPIENT ID#:A8096Q056 ADDRESS OF PATIENT:3205 N MEADOW DR, AVONDALE AZ 85392-5392 DATE(S)OF OTHER HOSPITAL OR/AND NON-HOSPITALIZATION CARE:6/7/2012 AMOUNT DUE FOR CARE OF PATIENT:$15,000.00(EST.)PLUS ANY ADDITIONAL AMOUNTS FOR HOSPITAL,MEDICAL AND/OR LONG TERM CARE SERVICES PROVIDED TO THIS PATIENT DUE TO THIS INJiJRY FOR WHICH AHCCCS IS RESPONSIBLE. I COUNTY IN WHICH INJURIES WERE SUSTAINED:MARICOPA TO THE BEST OF THE DIRECTOR'S KNOWLEDGE,THE NAMES AND ADDRESSES OF ALL PERSONS,FIRMS OR CORPORATIONS CLAIMED BY THE ABOVE-NAMED PATIENT,OR THE PATIENT'S LEGAL REPRESENTATIVE,TO BE LIABLE FOR DAMAGES ARE AS FOLLOWS: RECIPIENT: ABBY FOURrTIER ADDRESS : 3205 N MEADOW DR, AVONDALE,AZ 85392-5392 ADVERSE PARTY: ADDITIONAL COPIES HAVE BEEN SENT TO TI-IE FOLLOWING: RECIPIENT ATTORNEY: THE RECORDING OFFICIAL IS DIRECTED TO RECORD AND RETURN THIS INSTRUMENT: MERCY CARE PLAN(MCP) C/O RECOVERY MANAGEMENT SYSTEMS,INC PO BOX 32714 PHOENIX,AZ 85064-2714 (602)952-1188 OR TOLL FREE(800)93?-1339 � � s , � � � �,�"�` � � � �� �'� ��� ���, �.,: � � �� � : r, � _�� � � -�� ��-. � �" , , �: � � , � I�r�;, � � u �.= � ; t- � � �� � � � . � � ., � ' .. k�,:�� ' ` .�+ .� -s - � � ���, i.k {. . � �r ��$ . �,.�,.�^ .. :$ ��" � �. � _ s ; . _ � � � � ai..:�X .Y.:: 3� � # :�' Y,� .-,� � �' � � ^ �`i� � 4 `•�F '� ,�x �.u.�'i. . � � t� �° #' � e$; - � �. a��N � o. �.; � � .. � . € ��Y �� �=�` �- � .��»w'q��"'� ��,'r:- - - �� -_. . . - t�' � - °�" . . a� � � � �4 x� '� � ++' k ;{�M•�� � � .::�����S.,t ' . ���_ ��'� . . � - �'c � �._ �. , <a �='� �_ . .F'�. � � ����� ��� �'�'� ��3� � � � � � � � '�°` . .. 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