Betlock Microsoft Word-Claim form 2.1 l.doc- 15774 http://www.stpaul.gov/DocumernCentedHome/Vew/15774
�
� NtJTICE OF GLAIM FURM to the City of Saint Paul, Minnesota
�
:i�lirriresnkr SKrre Sicttute-fl6.IJ�rur�e.r nc�tr "...e��ei�•persor....�,•/rv ctairxs rf�trarr,�es fi•ora en>i•rn�r.=ici�xrlirs•...rhr�tf ca�re to he presen�e�t to t/te
Km�crr.itrL hrxft•nf rlte t�rut:=iciyrrtitt'xrirhir�/RO du�°s«frer rhe ullege�l lr�rs nr ir,jur�•is�fisco�r��d cs i:oti��e:ctarirrQ the ti�Ne,jrkrce,�u*c1
circ•u�xstarac e.s ilte�ro/;ci%d tltr uixaant of rornper,se�tioiz oi•otl�er relicjdera�asulcrA...
I'lease canplete this forni in its entirety by-ctea�y t�1w��or printing�our ansW�er to each question. [f more spare is
nec�cl�i,:�ttach ack3iticx�f she�ts. Ptease rxxe that��oa will nat be ccx�t�cted bv teiephotte ta etarif�at�sK�ers,so provicle as
rn�ch infonnation as i�cessarv�t�et�fain t�our iiairn,:�nci the arnoeutt of c�[i�,nsatic�n Ix ing myuestfxl. 1'au riiII receti°e a
c+�rittee�ackrto�+�leclgernent once ycxir forn�is f�eceived. 'The process can take up to ten w�eeks�r kx�g�r dependi�tg on the
zk�ture of}�cxir cf�irn. This form rnus#be si��ecl,and both E�ages cotnp(eterl. If sar�ething does�wt a�pl�,�f�rite°Nl.A'.
SEND C011�IPLETED FORNI AND C�►THER DUCUIt�ENTS TO: CITY CLERK,
1S WEST KELL�GG BL�D, 310 CITY HALL, SAINT PAI?L, MN SS1Q�
Fir�t Narne���' Middle Initial �La.t Nanx ,�ETL o�/�
Cc�ni���n1•c?r E3ia�i ne��Nern�, /� !�
:�re You ain Insurance C'omp��n}'`? Ye� No 1�Yes,Claim Nutnber`?
str�:et Adcic�.5 o�0/O ��lAff� Kc (.f/A�
('it� L'�f�SKA Sr.�te M�:✓��SoiA 7_-ipC'�de- 5�
Daytime Phon��)�-,G3d.7 ��ell Pli�.�ne(�)�3��Eveiun�Telephone 1���i 7���/
� ����
D�te of�.ceidentl Itijur�ot-17�t�Diuc�vereci�/9R�/y .� � �O[.�Ti��e an�/ n
Pl�a�e�st�t�,i n cle�tail,whal.o�ct�z7•ed t L1,��EaeT�e�l,i, .�nd wh�voG�ar�sub�nittin��a+�fr�irn. Pte�se i�dicat�why or how you
tz�� [he�C'itb ot Sai nt P�ul c,r its�mploYe�s��u�e inv��lve�:�nd/c�r re�:E>onsibi�t�ar y�our dam�g�s.
S N/A� !.r/A�Kin/�: L�/i'T'i� flclSffAi✓O A.✓�7 Gi1.9i✓�r'H�LD QE'n/ FiFosN
;,Y L v A�K � H 1/v '(.�/ L T�,Y`j'
—� GC/R� N A vi'4 F)T�� G�E N ��.��_l�(d✓cI�C.S .Z� .�L i iOf+C�i
c�/Y /9N OG� �AT �II F�Ll� LJ Olrt/� �� �/7 L �/rR l�lRi�L^ r
G � 2 E �: � �' E
�',q.N,�9�oC. �s�'E' �n�<�C� f7"A T E�'f��✓,� P .G .z�.✓vo��E�
F'le���ch�ek the tx�xi�e�)tl�a nx�st cla�l��repre:znt the rtasor�toe c�mpletin�th�s torm:
❑ M�= ���hicle��as d��ma��d in an���ci�lent � ❑ M4� vehicle��a:�dam�Eed durittg�tc7v��
❑Ivty v�hic(e w�a: dama,��d E�yT ii putho(e c,rzondition of Che street O Mv vehirle�+�as darn�ge�bti a plaw
0 h1y v�hicte«�u. ���run�Ft�llv to�i�ecl��ndlor tick��ted �[���a;injtired Gity pr��pertv
�Cht}ert�pe c�t pre�E�e�t� cia�t�age—plea:� ;�eeify FyG �LAss������� 97
�t7tE�erty��r. �1'inju€-� —p(ea:e specify°
In order tc� pr�cets vour claim v'ou need to inctudc copies of all applicable doeurnents.
Far the c.laiil��h��c�s liste�i I�elc��. ple��se be sure to inclui�e tha doeiime��t,in�ic<�ted c�r it u��ill �iel��y�the tlandlin�of
y���r clairn. L7�uinent.l�i ll.L_NOT t�e r�t�irneci and t�ecoiix the prc�perty of the City. Yc�u a►i enccxira�e�� to ke�p a
cop? for youc�c(f bei'oiY �ubmittin�your claim t�orEn.
O F'ro�eR}' c�an�aRe clain�,te�a vehic le: twa�sti�natc�f�r the rep.�irs to�°c�i�r vehicle if the d��maa�exeeeds
:�500.00: �r the actuul bills�ndlor receipts for th�r�pairs �
O To�cin�c�Iaim�: le�ihte eopie�c�f��nti ticket is�eci ar�d <i c�}��'<>f the imp�unil lot receipt
j�(�ther prc,perty dan�age claim�: tw o repair�;timate; if the da�7rr�*e exceed;��00.00:or the actual bills
� anciFor receipts fc�r the rc��aie�;detailed li,t e�f d.�ma�ed iteit� �
O Inj�ir��il:�irn,: ►��e�cii���t t�il1;. reczi�pt� �
� �'hatu`:ra�?h•��e�atN i��u�etco��ye to iio�tirl�cnt and u�pp«tt you�-claim hut«il1 n��t b�retur�ieJ.
Page 1 af 3—Please complete and return both pa�es af Claim Form
1 of 2 4/2/2013 12:43 PM
I
Microsoft Word-Claim form 2.l l.doc- 15774 http://www.stpaul.gov/DocumerrtCenter/Home/Vew/15774 '
�ailur�to eomplete anci return hoth pages��ill result In tlelati�in the handling of y�our ciaim.
All G"laims-p���SE COIiipl���tI1�5 S£C�lOil
VV�re there«�itne��,to the incident'? � '�� No tlnki�oti�n (circle!
k'ro�tz�e th�i��n��n�es,ad�lresse,ancl tel��hun� nu�i�ees:
�A V��i f= (�G TL O�'i K .�O/� �TAH�C/C,E I�tJR�/ f.�i�//4SKRi /'r �Sa' .�G l-33�-�
We re the p�lice ar la« enf«rte�l�nt c:�ltcd'' Yes � t1nE�no«•n fci►r lel
If ye,.��ii�it depa�tment or.Y�4nc:�-'? C::L,e#or rc�?��rt#
�'h�re clid the �ieeici�nt or inju���t��ke �l�ee'? Prc���i�le �tre�t adc�ress.:-r��.. �treet,i��tei�:�ction.nan��oti park or f�n ilitt�.
clo�u landmar{:.etc. �'leus�t��.i5 dc:t��it�a.�;po;�iblc. If nece„�Gr}.��tt��ch �i dia�rait�.
,Si�CLtJ,9LK LEA F/loly /'�i9RK�iJ�j ��T T!� MAi%✓ I�A[�I�dAY �'.✓T�,q,✓�,+t
— � T—
l=O�C, G'on/,f�ldv �o.��
Pl�a� indicate.t � anx�unt�`ou <ir�:eck�ng in 011l�l]4�t1C111 Uf'l�'IlilC�`OU W(111Id Ill�t III�C'it� to do to •es�7lve thi.claim
tc�votir.�iti�factic�n. � �1'1+C OF �� a � � � LA.S.�F /.� 9
/= c=/j
��ehicle C'laims—please complet�this section ❑c:t�eck b��x it tlii��_�tion doe:�xc�t applv
1'o��r VehiclE;: Ye�ar MrMk� MUde{
Licen� Plate Nun�er State C�?lE�r
Registzreil fJwnet�
Dri�e.r of�ehicie
r1�'e�Danui�ecl
Citv Vehi�l�: Year M.ike Model
License. Yl��t�Nun�l?er State Culs�r
Driver of'ti'ehicle{City Emp(c��ee's Name)
t�CP.(i r)illllil`�ti:(�
Iniur��C'laims—please romplete this section ❑check box if thi.�ec tion do�not ap�lv
Ho�t ��e�e vou itt}ured'? FEL[ d'r✓ .�ii�Ct,�lla�(�
W'h:�C p.�rtts) aF y�ur 170�1�� wc�re ini��recl� � e7�t — f'/A�/1�S—��/EE�
Ha�•���ou �t�ugfit tneciiial trratn�ent'' �c Pl��nni►�i� k��eek Treatrt�ent(ciirl�)
�'4'heE���i�l vou recei�e treutrnent'? / i T �pr���ide datel,s})3 1�' /�
Nan��:of Medic��E �'rc,vic3erts): .L��f� ,/�O// /yE//✓Y'2 T C�
Addre�: �leph�ne_
Did vou ini;•v�ork as�re:«ir of�c,t�r injur�'' Ye: o
�L'hen di<I vou mi•� ���rk? (pre�viJ�date(�))
N.ime uf vc,ur Ei���layer:_ ,Q, �l �i 7�%L c()
.�ddre�� Te[�:pti��ne
'(�Gheck here if��ou are attaching m�re pages tfl thls elaim form. Number of additional pages u .
/ �
By stgnirtg thi.s form, yocc are stating that all irt far�tati��t yott hnve provided is trire a�rrt correct to fl�e best
cif y+o�rr kiaawlc�dge. I��e,sig��ed for»rs ►+�i11 r�ot be prr�sessed.
Stihr�aittirr�a fttlse cXaitn ccrn res�tlt in prosectctior�. Date form was completed � 0��
�'rint the Name af the�'eru�n who Completecl this Forrn: �AVir.l �C iL 6G� ( /�us'BOi!✓l�')
Signature afPerson Making tlte(7alm: �
[Zr�•i sed!c�.k�u<�r� ,�.1 l l
2 of 2 4/2/2013 12:43 PM
CITY OF SAINT PAUL
DIVISION OF
PARKS AND RECREATTON
�...�.
PARTICIPANT/VISITOR ACCIDENT REPORT
NAME OF ACCIDENT VICTIM�Gl1��hX- � 0 AGE
ADDRESS � l.i -�— �' Ot � PHONE �a�`r t � �
FACILITY SITE, ADDRESS, PHONE ZZ �d `r• -��
DATE OF ACCIDENT NI�.iO�� �� , �d I � TIME OF ACCIDENT `
I YPt Cir IN,iUrtY° (DCSCRIFTiuN) 6��t%1 �� Y �t��J � � ��J� _ _ _ --- ---------
TREATMENT ADMINISTERED -; � U��I ���C S
TREATMENT RECOMMENDED: ❑ DOCTOR ❑ PARAMEDICS ❑ HOSPITAL
EXPLAIN CIRCUMSTANCES OF ACCIDENT IN DETAIL- USE OTHER SIDE IF NECESSARY
_ 1 ` << � �..w ` G�,I�_
�� ` ' � �- r U i�d
e , �"'S ��- �S �
OTHER PARTIES INVOLVED: WITNESSES
NAME /IN�� �V�-�t O Ca� ADDRESS �
RELATIONSHIP �lr��ti�Gf
NAME ADDRESS
RELATIONSHIP
EMPLOYEE ADMINISTERING FIRST AID- NAME DATE
ADDRESS PHONE
,
EMPLOYEES ON DUTY
PERSON IN CHARGE OF PREMISES I V��'�
I HAVE READ AND UND RSTAND THI REPORT(SIGNA URE OF ACCIDENT VICTIM OR GUARDIAN)
SEND TO PARKS AND RECREATION ADMINISTRATION OFFICE,300 CITY HALL ANNEX
DISTRIBUTION: White-CA;Yellow-Rec.File: Pink-Admin. File;gldrd-Facility File
2/95
Pearle Vision
106 Pioneer Trail
Chaska,MN 55318
www.pearlevis ionchaska.com
Phone(952)368-2325
Fax(952)368-2328
� , ,. � � , , `���� ��
� .� =�- � � � ,
����`"�� ��� a�^a�� � � ��� �, ,� ��� ;��� ,.:
.,�a.. ��a r,.r, ,�: �: ,_- ""�'��.. r r..: _ -;u- . -cnH..a, '°:�. ;:. � .�.. . .; -� ..�:r, ,.. , . ,�..�_ ..'�.
��:
Darlene Betlock
2010 Stahlke Way i
Chaska, MN 55318
Primary Insurance Ucare
Secondary Insurance
tnvoice�iumb�r:����
Patient: Darlene Betlock Invoice Date:03/30/2013
Practitioner: C Krietlow- Statement Date: 03/30/2013
Date Item# Description Diagnosis U/C # Gross Insurance Savings Patient
03/30/2013 V2781 Essilor Ovation Polycarbonate $142.50 1 $142.50 $0.00 $0.00 $142.50
03/30/2013 V2750 A/R Coating 367.1 $40.00 1 $40.00 $0.00 $0.00 $40.00
03/30/2013 V2784 Polycarb $0.00 1 $0.00 $0.00 $0.00 $0.00
03/30/2013 19539 LC 367 $189.95 1 $189.95 $0.00 $0.00 $189.95
03/30/2013 ADJST Adjustments $-260.71 1 $0.00 $0.00 $0.00 $-260.71
03/30/2013 TAXES Tax 1 $2.23 1 $0.00 $0.00 $0.00 $2.23
03/30/2013 PAYMT Vsa Card $-113.97 1 $0.00 $0.00 $0.00 $-113.97
� �� ���: '�a�"� ��'` �� s�.; .�# �'�� '��i 8 �'c�-` � ' :� x ��"'.
�^� �, `��` � �� � ������' � s�-�'��'t-�«��� �°.. � - E:. � ��.
� , _,�` ",�'i� °v �a : �'o' �`�^� � �;r�:_ . °u,, *a.�
.�;_ vre�� "� �" � €'. S `�c �v.�, �&�y '3 �, � �; �.�`.
�._. '.�` �� �� �� ,:�� � �,_ ��,�.
� �,:-, � ��' ��i f��'�`� �`.0.�r .�. � ` 5 �,_ � x -�: �*,q�^" , �
'
��ry �
� �
��:f ,��������.-. ^` "s5u^ :..'iY5».. � �;�_ � , w ,:x i±�.�-��.4,-a �'., ;a..<-:. � .> -.. a._ .. ,.. .., �. . .
Invoice Balance $0.00 $0.00
__ .. _ _. _. .
_ 50.00
Please Pay
Thank you for supporting your local Pearle Vision! Like us on Facebook for current promotions,and the latest stylesl.
� ��� � C � .tvo � �-° -°-''
� __ o � o � a�'„ �. �o
� � d Xz_ m xt: v�++ .�-. o "
� � � w
O °� a `° o -°- `�' O J
� ` -- � m t'� � ` 3
c —� r� � o°, � � m
-�'i •-�- �'�i'rn � •-�-- ^�' S
O
3 a � Z � n
� n f� Z rn � --�
t'� rn � v. 7c O ' t'�
o � o o W -iz o
� Q � '-° y <
o �
o ^'
o '--'
{�q_ o 0
� �"�� N O'O � fN'- N ' .
��
. w � � o °o o �+ � m W �
v w o w o m �"-'
V 7� � rn a�i, � °w a�"o � o �