U of M Medical Center Fairview Rightfax 7/22/2013 2 : 48 : 16 PM PAGE 1/008 Fax Server
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RECEIVED �J FA1R�lE��
JUL 22 2013 Fair�rie�r Health Services
CITY CLERK
Fax
Date: Monday, July 22, 2013 2: 97:22 PM
TQ: Notice of Claim
Number of Pages: °8
From: Lisa Sommers
Notes:
Confidentiality The documents accompanying this fax transmission contain
Notice: confidential information belonging to the sender. This information is
intended only for the use of the individual or entity named above. The
authorized recipient of this information is prohibited from disclosing
this information to any other party and is required to destroy the
information after its stated need has been fulfilled, unless otherwise
required by state law.
If you are not the intended recipient, you are hereby notified that any
disclosure, copying, distribution, or action taken in reliance on the
contents of these documents is strictly prohibited. If you have received
this fax transmission in error, please notify the sender immediately to
arrange for return of these documents.
Fairview Rightfax 7/22/2013 2 : 48 : 16 PM PAGE 2/008 Fax Server
�1(�'I'IC� �F Ci��1I11�'I F4K1�1 tcr the City af Saint I'aul, Minnesota
Mi�rnesuta:Siuue.Si�trtiut•46(i:t75,1Rnrs thal "...r�rrn�rersnn.:.t��ltd cIclbns Jc+�nuses frt>rr+n���rttunti:il�celit>...sh<rtl c:�at+se tr+br jrri±sr�rlcd tr�the
governi»;�hotli�af thH nttRniCi(x:lify K�Ifktlt I K(1 r�t1'b ttfiet't7re(�flr!,�crttr,ia r,r,njun�;s rliar.r}�e,rd u n�ric:e s�utrnAflre trme:,Rl�ca:rrn�i
CiPru�rxler+tt�rslhrre��f.and the ttn�uunt nji'Rmjld��3irllirtt i+i�tthee rrlieJ`do,n�.;,dvd:"
Plcase ct►mplete this i:orn�i�i ifs Entiret.p hy clearly ty'ping tlr printirt�y�f11t-answ•er to earh qeesfioa lf tnore sp�ce is
necded,attach aticlitianxl�heeis. Please i�ute that you wi[I nW be ce�ntacted i�y tetepiwne to clrrify s�<»ars,sa proeide�s
inuch infnrmation sss nece.ssatY�n explain your rfatm,�nd Ehe u.n�ount oE cum4x:nsRtion t+�ing rE�i�uFSted. Yov wili rcrcive a
writien ac[tn��rltd�emerlt oncc yatir fiirnT is r�tieir•ed: Thc process t:an t4ke up to.ten weeks.ur to��er de��dln�ue thc
natute of vour ctaim. Tltis f�rni mitsf i�e si�nrd,and bntt�pakec cuml�ieted_ T#sumctl�in�dn+es nntap�sly,wr9t�'N1�,'.
SEND C(3��PI:I,Ti;i) F�R�T A.1`v� (�T��ER DC�CUI�TENTS TU: CITY C'I.F:RtC;
1S WEST I�FLLn�G B.G1�'D,31(� CI'TY FYAT,i�r,SAINT�AL�L,.�N 5510�
I�irst I�Tame_..______ _. :Niddle initi�l ___ T_s3�t N�mr: _... ___ _.____._.--
Gompan� or i3usi�tass �Vame__4,r, E � �-�;,. R: , _ ' �' ��' ;`;. ��{ t , ;;�":�;___�r.._��:��-���'i.:_.
.�1__i:.:�:_. '"'' f.� t.'i1_L�:_ ..F,.;.._i—� 1::;_i�_.C,.i.i--
-f-�-��—'-'-
1�i•� You an [nsurance Comv�n4�'? Yev�f!�'��>� 1f Ye:.f`l�im Numhc*r� --- _.__.
SLCt'Gi Af�tjR.45 _._c:,?j`f.`_:F� ` i�,Lt-° .L_�..�.L.S_�-`�`___.���•;:_:_: ___ __
Ci3Y���,r�i"y, , �T,�. ��i- , 5tate t'b'� /l ` _ .._.._ �i�Cotle�'�`�'`�r:f!
>r� r�� - �r- .
Davtin�e Phaic.t�"r`s."?�).�-�K'�- �._�'..�!�'Cel1 PfiOnC(. ).,............-:�.�Fvening Te]e{ltione( )_..r.__._.�
, .._._.
17ate u1 Ae;Ci�€cntf Ittjury or Da4e�iscnverc:d__.�I�.�.�,'.._�L.�i Time��" C,�":: t,�m�pin
Please state;in delail,wbat c�ccurred(happe�ietl);:jnd u�hy ynt�;�r�Sirhttl.iFli.n€?�i clai[n.. Plc'ace inrficate wfiy��r how yosi
feef the Ci�y c�f Sair�t F.�ui�r ics employees are invulrcd ansifor re5pon5ible Ct�r y�+ur tt�unages }+s,. , �.,L��` u�`1°:�,'i
{ 8 � L
f i_ � I'i{ � JE 1 i' J F . �L �.��}S .�_ j{.t.fl f ���f =11� 1 x �v r�+�..',t S:t—
--�2� e-:,� { .� x r._..x.�e..r.i�.t 13� t�' ��� �{s c. , _.� /�7 'r�.._.�. c.s�t t��--L--...---_ _�..��fri;.}
�,_�f�T��_2'�.-.}.-'— '-` �Y'--��.,.z....__..e::,1..i.�s.:L.#�n..:i:L.,..�._ ..=��'�c;�.:�;.� ..<<�.�----- �
. .......�..�.'... °i
Plea.se cheek thcbc�xles�that most cic�sely represent ttsc rea�sc�n fc�r c+i�nPle�ir►v this f�rm�
p�fy uehicl�:���s.dama�ed ii�a�:tecitlenl �.MY V@�11CI�W3SS.l�amaged tlx�ring a t.ow
O My°4ehicle was dama�e�4 E��=�pathc�le or c�ndit;�n c�f the:strex:t ❑1�1y vehrcle:u:��C1�117�t7gCd 6Y<t plpvw
D Viy vehicle�va�wrr�ngtully w��ed andlar�icketcd C]I avas inauied an Crty prc>p�rty
�. � r:_L!a ���ca 7k;z�"°c i f':: �4, �:-��.,,) i�i,'.1 1i'.:��
� C7cher t��pe�F�rcjperty c1<tmu�e-pl�ase spcci�ys.�,��.��3�:,_,s���s�- . �_�.. .� ,� °'!
O C?tlrer tvpe c�C injury-p�ease spectfy -----------
In orc3er tc�proeess yc���r claim•�uu need to include cc�ptes af all ar�plicablc d�cumenfs.
For the claims typee]isECd helc�4v,ple�se 6e sure tb�ncl�tiie r.ft�dc�eume.rrts indicatGd c�r it will ciefay the l�andtin�af
youz Glaim. Docum�nts 1h'1L1.NQT l�retur��c;ci and l�c�ine the prc��rty o�t)�c Grly. You are encoura��d ua keep a
cr�py�i'or yaurceif befaee stitibmitting your staim fonn.
U ['ropertv damage clainas xo a vehirle:twa��tutu�tes fci���he r�pairs tci}our vChi�le if ttae damabe excee;ds
�5()t�.tll);�r the�ctuat bills andloc rE.ceipi�fiir ihe repair�
U T�wing claims,ie�i�►le c��pies�t �►ny�icket is�ucd and s c��y�f the itt►pound!ot reteipt
�Other pm�rerty dlmae�claitns: lwci rcpair ectimates if the�arrtafie exceeds�5�O.UU;nr[he actua]bilis
and/or rec�'tp[s tor the rep�rs;cte�jiletii Eist nEdaxYi�tgr.d ilcin4
O Inju�•y cl�iims:mec3ica11iilis,Fc-'c:e�pts
O Plu�tog�'a{�lis are always welECyme t<►cicx:i�rn�:�nt:Ifl[j tll(Y�lCSff yOUi t'-I<tim h�it wi}L n�i be retumed.
Page 1 �}'2-Ylr.ase ctunplete and return:hoth psrges af Cl�in�Furm
Fairview Rightfax 7/22/2013 2 : 48 : 16 PM PAGE 3/008 Fax Server
Failure ta complet�and retFern lwth�a��es wiH result in deCar in lh��handling oP ynur claim.
All Cfa�ms-ptease r.mm�tete this sectian
'V�'t;re;there w��tnesses u.►the inci�ent'? Ye� F AIt�-•- l'nknown (circle)
Prnvttic iheir n�ttnes,dddre���ti i.nri lele�l�rn,r n�nnt��rs ; t � x.s J � �,t lr
: ; - � � , ;{ _..— _. :_ - --_
i S
_...R:�.;.,i;:LLi,,,. __.e.a..'i��:'t____!�r,�u t�,_�t..'.__!,�11t,.—.f..��GG.1=�C�i . ,... ��! . f'` .�� .;
VVerr the poEir.e�7r 1aw enPnreement r_alled`� Y�;s •`�V
�, ,U_ Ut�k��uwn f circl�)
If y4s,what dep�u-tm�:nt«r agency'? ___—C�se#nr rep�rt#
VJhere did thr.acc[clent��r injurytake P1,ic:t�? P��vic��stree4 ad�ress,erc��s ch•eet, imersection,name+of'par{:�>r Facility.
CIt�S�4l Id[t�tnf�rk,etc Pleas�be�s detailtti:��posciblc If nec�sary attach;i cfia,�;ram �,�,�w„i�,,,��,��:;�,:� c�r�.,•�-,�{y,�.
.. .. . �
.- w • , �
r:G:°� � _...:..__�C.r�.�..t�_.v._ �..�''��'�1�:�}�:�;��4 C�.�:..�T���_... _f��t'� �4.���.C_�..�—{�'��c.�. _F�*.�.': - - -- ,
P1c�se indicate the amc>t:rot you ue:sc.eking in cum�►ensniron�r whai vo��i�c�ul�i hke the Citv to do!o rc�olv�th�ti cl.��m
to your tiunstaction._ ,�' ! L .�`� `�'�- � ; -� �' � X ^ i t :�._.�. . ..tt�' � ; `,:,,C
,
.:: ,.. ,
_ t__ ..:j.�� I..X;:.., t J s. � �'t:� r ilt_r?._.._ � s �,�,� - i'.iCE
���ta�__ - � �?.�.;�'�_.r�_�+ �-r--��#.;J1.,,._...t:�.t.4�_l:.�cri.s�____t�t.ie�..�__t_t'.,.�i:r33..�:�;::�.�t _i;. �j�I':'_: .�;t�.:�.��
, �;
Veliicle Glaims-nttaSe eom.ulete thi.�sectiun 0 chec:k hux if ihis sec:ti�n�4��eti nc.zt epply
Yr�ur Vetii�le: Y�ar_ M��ke____�_ _.__ Nfrxiri
Licensc; Niate Numbr.r ---.---- St:aie_..._._C'o(�r __._.__ _..—
R�gisltn:ci ntvn�r _..._._...
Driver of Vchi�la �
Area Damaeed ---- ___.____ -_ --.__
-- - --------_ _ ._____- --
Cily Vehic(c: Ycar _.IViake _______T�:txlel ___, __. ___
[,ichns�Plate Nuint�r� Scare _Cc�lor
__..._. __
Driver c�f Vchicle lCity�Emplay�ee's:�(Nme)_ _ _._.._ _.,
Area t)a�n�gect--------
In�urv C�alnis-pleasr.eornolete this sution �ChCCk bQx if fhts seciio�i dcyes iiot 1nR1v
How�vere}��ou injurecf? _ _ .--_._ ------
- -- ---- ---- .._._._. _...__.
V1Fha1 p<vt��)of your bcxly�r�en injurtd? --,----_--- --_.- -
___- ----_._..�. _ .----- --- ___ _
}-1av�ynu souAht medical re�a[menc'? Yes vc, planninb tt�Seek Treacment(cir�le)
VVhen did you re�'eivc treatmenE? ___ {prp���de dat�(s)j
�1an�e of 14edical Pr<�vider(s1: _---- ---_._�� __
A.ddr�;s --_----,---- _.__.._._'�'elephone
____. ________ ---- -----
I)id you miss u�ark a�a result of your injury7 Yes No
��'hen diti��ou rniss work? __ ____.—._ _ __. _.._.__...._ _._.—_ _...._—(I�ro.ide cl,te(ti))
Name�t'yo,�r Ertrplovea•: ._---._____ __...----.-_ ___.-- ----
,4ddress ------ ----,-- -__ TeJephane_..
❑ Check here i�Toa sre attaching mare pag�s tn this cluim form. Numher of additir�nal p�ges__.__.
By signir�x t/ris,fbrrn,you are�lati.ng that all iaf�rmaticra yvu haue provided is lrue and correct ta the best
nf yo�tr kt�Qw�ed;e. Urtsigned furrns wilf nn!be prvices.red.
., � ��
Subneittu��n:fdlse clairn ca�:result in pro.recutinia. llate i'orm w�s rnm�letrd�fy_.r)r .�• _ ___
Print the Name uf the Pers�n who�`om�leted fhis Tor•m: `.<�;Y-{,� �{ � ,_;.t?��-t�':'�` �'_'��...
, .
Signature ot Person Making th��Cla�m•_�-�� -�`.��..,::"..._ .t_;�,s..-"-t--�:- u��`�...._
` �f _.�..__
r`
Re��te��i Februarv�201 E "
Fairview Rightfax 7/22/2013 2 : 48 : 16 PM PAGE 4/008 Fax Server
Page: 1
s,Y'� � ��C InVO�ce
����f:■C1�tQ�CIt�C
Invoica Number. D25B852-IN
���c tetzrtge L OOZ �c3ce.. Invoiee Date: 7It 312013
360 Coon Rapids Bivd.
Caon Rapids,MN 55433 OMer hlumber.
Phone:763-786-4730 Fex: OrderDate
763-786-978B Salesperson: DO
Customer Number: 01-2734508
Sold To: Ship To:
Fairview Universily/Riverside Fairview University/Riverside
2414 South 7th Sireet 2312 South fith Street
Minneapolis,MN 55454 Minneapolis,MN 55454
Confinn 70; Phone Number.
John Marshall 612-273-4544
Custamer P.O. Ship YIA F,O,B. Tertns
NET�0 DAYS
Ifiem Number Unit Ordered Shipped 8adc O�dered Prioe Amou�t
Emergency service.Removed seclion,reassembled and reinstalled_Service and adjust.
ICSLABft I�OUR 1.000 1.000 0.000 392.50 392.50
SERVICE LABOR
lStiOP 2.50
SHOP SUPPLIES
/FUEL 10.00
FUEL SURCHARGE
Net Invoice: 405.00
PLEASE REMIT FROM THIS 1NV010E Less Discount; 0.00
ALEASE REMIT TO:PO BOX 48928 M(NNEAPOUS,MN 55448 Freight: 0.00
q service cherge of 1-1/2°�per month.l8%APR,will be added lo all overdue accouMs. Sales Tax: �•�
Custorner is also liable(or aN iegat and cot�ection fees.This invoice is your receipt USD 1nV0iCe Total: 405.00
W!N a E260 VISA G[ft Card11
Log on to htps llvnav survevmonkev cr�mi,�idc-aut���natro to give us your commer�ls and feedback.
Aker you have compleied Ihe short 2 minule survey you will be entered irtto a drawing!o wirt a
$250 Visa gifl�rdi
Fairview Rightfax 7/22/2013 2 : 48 : 16 PM PAGE 5/008 Fax Server
.�� j�� Quote
�,,�'- ��.�lut�i 1 I�.A�I� QuotcNo: 0012032
4 7�C �a�2wC�eo. �e4Ce Q uoic D�te: 07/16/20 t 3
360 COOn Rapid3 BIVd. / Custnmrr No; 2734508
Coon Rapids,I�RN 55433 Salesperson No� DO
FhM 763-786-4730
Contacl o��Site: b�ikc
Fax#763-576-7299
e�u Ta: sn�r T�:
fuirvie��iJnivcrsity/Risersidc fain�ir�v lfoivcnily/Riversidc
241d South 9th Strc•rt 2312 5outh Gth Strcet
Mi�incaPnlis, N1N 354y1 Minneapulis, MN Si1$�t
l�i I I lo'I'rlephonc�612-273-4508 Sli ip to Telephone:G 12-273-:i548
Pa�:612-273-�i78 • fmt+il:
Quotc Dcscription:
Quo�e!o rcplsce bottom�eCtion,re�•crsing edge,and hin6c.
�tcm Number llem Description Qty.Ordered Ueit Price L'xtension
SVC-SPECJAL 12'X 24"'('HERNtUSI'Ah° l'5200 E30'I"fU;14 SL'C?'fON 1.00U i91,7S 59I.75
RROR'N
HIi�G-I IGA-0400 #�1- 11 GA.1•IING� i.040 8.25 8.25
SVC-SPGCIAL 2 WI(tL'h11LLER L'DGL"SAFF:1'Y I.000 368.44 368.44
CSLA[3R S�:RVICG I.AIiOR I.000 12G.00 12GA0
CSLAI3R SLRVICG LABOR I.500 91.Q0 13G,50
Net Total; 1.230.9J
Tasablc Amouut: O.OD Nomaxablc Antoum- 1,230.9.f Quotc Tot9t: 1,230.94
lf yon receive a lower quote from our competitors,t�Ec-automatic wil!match that pricin;. Just fax or em�il a
copy��'the quote tu us• P#ease re��iew tfiis price quo�e and,if y�ou have no quesli0��s,please ap�rove ihis quote by
signing below and lax back to idc-aulomatic at 763-57G-7299 ar email to service(a�idc-automatic.com. lf you have
any qiiestions/concerns, feel �ree to call the service depaitment at 763-786-473Q.
Approved 13y:
Date:
P.O.Number;
Fairview Rightfax 7/22/2013 2 : 48 : 16 PM PACE 6/008 Fax Server
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Fairview Rightfax 7/22/2013 2 : 48 : 16 PM PAGE 8/008 Fax Server
Arendarczyk,Jody L
From: Honsa,Courtney
Sent: Satu�day,July 13,2013 1:47 PM
To: Christen, Ci�dy 0
Su6ject: Door 1
Attachments: photo.JPG; ATT00002.bct
Cindy,
This am around 10 am St. Paul's BLS truck hit our garage door on the way out, denting the
door frame and breaking off a portion of the bottom. The crew came in to speak with Tim 5 but
no paperwork was filled out at that time. I've contacted the Deputy thief of the program,
Deputy Sanetra ( sp?) 651 228 6214 wF�om spoke with the B�S crew and they will be cor�ing out
to take photos. He also has the crew filling out a incident form for insurance purposes. They
have also contacted the head of the program, Qave Page to inform him about the crews actions.
Our engenering department and the ANS were contacted. They hope to have tF�e door secured in
the do.wn positon within 4 hrs and state that it will take a few weeks to fix the door, The
EMS Chie� Matt Simpson will be contacting you Monday am to discuss this.
-Courtney H
1