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Blonigen 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 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 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 Name !l�.1 La�i Middle Initial � Last Name �C�� � x����`��'� Company or Business Name ���r, 3 1 2��1 Are You an Insurance Company? Yes No If Yes,Claim Number? � � , � . �� ( , �,' �' u��� Street Address �� City ��� ����� State Zip Code�1���1,J-�[ � � Daytime Phone(����ell Phone � �' ��Evening Telephone( ) - Date of Accident/Injury or Date Discovered � � � Time���am/pm Please state,in detail,what occurred(happened),and why you are submitting a claim.Please ind'cate why or hQ you feel the ity of Saj Paul o �ts employee��re invol ed and/or responsible for ur ages. v � � � - �C, �,h/ � ,�r'1 � r` r Cj ` Q ��-t�� ' � � �- � z .:+1: �, j - r.� (/' ' :i I'� �1 �1 �YI �v �')''j� � ✓ ) ` � , ,� ' � � � � ia�5 � � �. , 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 In order to process your claim you need to include copies of all anplicable 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 WII.L 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 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 �y � Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—please complete this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? Yes No Unknown (circle) If yes, what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street, intersectiq�,�nam�of p��or facility� closest,��dmar , etc. leas�be a�de�jl d� ossible. If nec�sary, attach a diagram. �J�" 7y,,1`� ��'��, � 'f 11 r ar�` '- '�i' � Please indicate the am unt you are seekin in compensation or wh�at}�u wou d like th , ity to do to resolve this claim to your sadsf ction. �.' l� / � ��✓ '..�7` �� � � , � ' Vehicle Claims—please complete this se�tion �check box if this section does not apply Your Vehicle: Year Make Model License Plate Number State Colar 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 bo if this section does not a 1 � How were you injured? ` �� Y-' ' r � � � Wha part(s)of your body were injured? `�� 'c r'� r � Have you sought medical treatment? es No Planning to Seek Treatment(circle) When did you receive treatment? r (provide date(s)) Name of Medical�Provider s): � f ` `a � • Address '�� � �1� � r� Telephone �� — � �� r ' � Did you miss work as a result of yo r injur ? es No When did you miss work? �" �? 1 t' `� (provide date(s)) Name of your Em oyer;. ( r' � Q � Address ' "� l � � '�_ ' � F � Telephone �/��� - � � � ❑ Check here if you are attaching more pages to this claim form. Number of additional pages� By signing this fornz,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. Submitting a false claim can result in prosecution. Date form was completed �/� Print the Name of the Person who Completed this Form: '�F'.����. ��Q�/n�� Signature of Person Making the Claim: /'►� , � Revised February 20]1 . i-_ � ad�olo9'sts�td• , .�onsultin9 R aN W a1` ��suran�e�ept.l M Ma�a9ment post�n9 � Pay 2�Nico\�et MaN'S54�3 244G 12 a o1is,M 2g MB�seg12-55�3�2�3 cor". om FaX 61 a\1@�r\rt�ed�`p1o9�s�s� ,�ar N�onsult�n9ra Documentation: �: Renee Blonigen PTO used for 8/22�2012 loni en stating that she wouon a°;be able e from Renee B g and falling I received a voice mail messag ust 22,d012 due to tripping ednesday, Aug • e�,,,alk was buckled and th ace forwa d and both to be at work°n w e in St Paul. The sid • ewalk near her hom �,as uneven. Renee statedenea S we��f sid to indicate that the sidewalk face was swollen, eth were broken and another tooth�'as�O° er her front te ust 23,2012,h Wh en Renee arrived at work fal hursday, Aug bruised and scabbed from the ����� ( Mary W all t� a ment Posting � Manager�Insurance Dep P y T Fi S� �� 1 � _�. � 34'! �S- 1 I ; t ■ Part�Dental Eagan 1895 Ptaza�rive, Suite 13�} Eagan, MN 55122 *** PATIENT STATEMENT *** 3860230 BLONIGEN, RENEE Park Dental CH APT 1 952-212-3949 2200 County Rd C West #2210 1994 SAINT CLAIR AVE 612-573-2200 Roseville, MN 55113 ST PAUL, MN 55105 STATEMENT PERIOD: 08/21/12 - 08/21/12 DATE PHYSICIAN SERVICES PERFORMED DIAG AMOUNT - ------- - ----- --- ------- ------ - -- ------------ ---`--- 08/21/12 DR IDZIOREK D9�1G PhLLIA`�'IV� TX-E�{TENSIVE 1 114 . 00 08/21j12 DR IDZIOREK D0220 PERIAPICAL FIRST FILM 1 30 . 00 08/21/12 DR IDZIOREK D0230 PERIAPICAL EA ADDITIONAL 1 26 . 00 08/21/12 DR IDZIOREK D0240 OCCLUSAL FILM 1 37 . 00 08/21/12 DR IDZIOREK D7270 TOOTH REIMPLANT/STABALIZ 1 483 . 00 08/21/12 7 Payment-Visa 210 . 60- ACCOUNT BALANCE: 960 . 20 TOTAL 479 . 40 DIAGNOSIS --- ----- ---------------- - ----- ------ 1 . 873 . 73 TOOTH BROKEN, TR.AUMA, COMPLICATED Park Dental Financial Plan Patient Copy 08/24/12 Patient Information Account Information Pt#: 3860230 Acct#: 386023 Acct Bal: 947 .80 BLONIGEN,RENEE Prim Cov: 1994 SAINT CLAIR AVE Sec Cov: ST PAUL,MN 55105 PROPOSED TREATMENT PLAN Tooth Est Est Pat Visit Prov Code Descri.ption Loc S;ir.f Fee Frim Sec Resp 3 7503 #7 PULPAL DEBRID 6 Units Sched 08/30/12 06:lOpm 3 7503 D9110 PALLIATIVE TX-EXTEN 7 114 .00 0.00 0.00 114 .00 3. Visit Totals $114 .00 0.00 0.00 114 .00 4 7503 ENDO #9 12 Units Sched 09/11/12 10:00am 4 7503 D3310 ANTERIOR ROOT CANAL 9 786. 00 0. 00 0.00 786.00 4 . Visit Totals $786.00 0.00 0.00 786.00 5 7503 ENDO #7 12 Units . . . . Unscheduled . . . . 5 7503 D3310 ANTERIOR ROOT CANAL 7 786.00 0.00 0.00 786.00 5. Visit Totals 5786.00 0.00 0.00 786.00 6 7503 CR PREP 7 & 9 12 Units . . . . Unscheduled . . . . 6 7503 D2999 CROWN PROCEDURE 7 0.00 0.00 0.00 0. 00 6 7503 D2999 CROWN PROCEDURE 9 0.00 0.00 0 .00 0.00 6. Visit Totals $0.00 0.00 0. 00 0.00 7 7503 CR SEATS 7 & 9 5 Units . . . . Unscheduled . . . . *Estimated patient portion due date of service* *Estimates do not include deductible or amounts that exceed yearly maximum* *Fees subject to change January 1* IF YOU HAVE INSURANCE Insurance is designed to reimburse the policyholder for a loss and is a contract between the policyholder and the company. We will submit your insurance claims for you and do all we can to help you collect legitimate claims. In the event your company is slow to pay or for some reason disallows the claim, payment of the account is your responsibility. ACCEPTANCE OF INSURANCE ASSIGNMENTS Our acceptance of insurance assignments does not absolve the patient of full responsibility for the charges in full for the treatment rendered. The estimate provided above is to be considered a guideline until the final insurance payment is received and the patient's account has been reconciled. This estimate cannot guarantee insurance payment. INTEREST CHARGES Accounts outstanding more than 90 days from treatment date will be charged 0.67% interest per month or 8% per annum. PATIENT OR GUARDIAN DATE Park Dental Financial Plan Patient Copy OS/24/12 Patient Information Account Information Pt#: 3860230 Acct#: 386023 Acct Bal: 947.80 BLONIGEN,RENEE Prim Cov: 1994 SAINT CLAIR AVE Sec Cov: ST PAUL,MN 55105 PROPOSED TREATMENT PLAN 'I'ooth Tst Est Pat Visit Prov Code Description Loc Surf Fee Prim Sec Resp 7 7503 D2740 CROWN CER(EMX,PROC, 7 1209.00 0.00 0.00 1209.00 7 7503 D2740 CROWN CER(EMX,PROC, 9 1209.00 0.00 0.00 1209.00 7, Visit Totals $2418.G0 0.00 0. 00 2418.00 Total All Visits $4104 .00 0. 00 0.00 4104 .00 *Estimated patient portion due date of service* *Estimates do not include deductible or amounts that exceed yearly max_imum* *Fees �ubject tc ch?._^.ge ��ari.:arY 1*� IF YOU HAVE INSURANCE � Insurance is designed to reimburse the policyholder for a loss and is a contract between the policyholder and the company. We will submit your insurance claims for you and do all we can to help you collect legitimate claims. In the event your company is slow to pay or for some reason disallows the claim, payment of the account is your responsibiliLy. ACCEPTANCE OF INSURANCE ASSIGNMENTS Our acceptance of insurance assignments does not absolve the patient of full responsibility for the charges in full for the treatment rendered. The estimate provided above is to be considered a guideline until the final insurance payment is received and the patient' s account has been reconciled. This estimate cannot guarantee insurance payment. INTEREST CHARGES Accounts outstanding more than 90 days from treatment date will be charged 0.67% interest per month or 8% per annum. PATIENT OR GUARDIAN DATE r � �+ � � r. . � � .,� m;,., s-,� ?�`V_ ` "xS� �., �.I I �k� � ��� ����a:, �, �� � � � I � � '�� - '_'�� � '�� _ � " �� j���� � ��,�. � - �" , ,; ,'_ �s. `� �iY _ fi<_� �, � ��'��� _ - . � , _ i �.a . �• � ' ."� � �. �.. i .:� - ,. „€' _ . y . _ a., ._, . ;�.�. y� .€- -- �?�-. . _ g .. .y ....:-�-r 9€ � `., ' � - �, �� �. 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