The URL can be used to link to this page

Hill F�E�EIVE� AUG 05 2013 NOTICE OF CLAIM I��-��ity of Saint Paul, Minnesota Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...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 pmvide 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 weel�s 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 '�� {'� Middle Initial�Last Name �� I ��' Are You an Insurance Company? Yes/�To� If Yes,Claim Number? Street Address �(L'� l��l"aCC'��Q ��L,.��g City ��( u[ State ��,��, Zip Code �Sl Daytime Phone(�)!��Ce11 Phone(`�' -`�—Evening Telephone(----�-- �?Y�/�iz�X%rrw� Date of Accidend Injury or Date Discovered �r�J/�P f��Time�am/ r�i Please state,in detail,what occurred(happened), and why you aze submitting a claim.Please indicate why or how you feel the City of Saint Pau1 or its employees ar�involved and/or responsible for your damages. � � '( � �o �-� k � �( � � �' � ' '�, � '? �ev +.,,� C� °`- U` 1�(y '_ , t v e � � tiL C - c�v K c� �E ►r� 5 _ ��V a l� ��'�n �cc 1 fi �� 1,� !�L� � lra l Y.Z � �b � L 1,��'�1�' L�7 -� i �l �C�Yl� �G� �lx� 7� �" � : � �-L'��'T�, C '� i �G. � �� C� S �1 L� � . � 1 � � � �� fti 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 ❑M,y vehicle was wrongfully towed and/or ticketed �was injured on City property�yy-�� ,� _ __�___ ❑ Other type of property damage—please specify ❑ Other type of injury—please specify �� In order to process your claim you need to include couies 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 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 exc�e-ds$500.00• or the actual bills ��t. �h�l.t!"�j �'�pt71�.�' and/or receipts for the repairs;detailed list of damaged i emst1 (�(' �{,, �- �Injury claims: medical bills,receipts � C�� f`►°lt I T� ��u�J�� " 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 � �- ��, _ >- , _ _._ . , . __ i -- ----- f__-----_ - _ --- _ , _ - j i i I ,,.. ` Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-nlease comnlete this section Were there witnesses to the incident? Yes � Unknown (circle) Provide their names, addresses and telephone numbers: '�.�— —�-- --��. Were the police or law enforcement called? Yes o �"' Unknown r(circle) If yes,what department or agency? �S�'�P�� 1., ��. (:ase#or report# �-P°c,tef vw��(o.vv7� ��c �r.t��u1,-✓�� c�-. c R-e ov�fi a�t ��, f e pk �5 �I�-o� r�.� 5�'• �P��I ��B�,�c��3 t'cc� K z�C" • Where did the accident or in�ury take place? Provi�de stieet address,�ross street,intersection,name of park or facility, closest landmark,etc. Pleas be as det 'led as pos ibl�� If�e ess�y,�ttach a diagram. �l"Y)L� �� p S� � Cl��i�� S-��e n � C c�'�.'-t�e � +�-t 7 Please indicate the amount yo are seeking in com ens�tion or what you would like the City to do to resolve this claim to youF satisfaction.� S PG/ �J �� C�/k�oy�� ,S�� f�p,!-��,� '� S S�('1�.�• �_f� VeWde Claims-nlease comnlets.tLis section R9.c��,�lc box i�this section does not apvlv 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 ❑ eck box if thi section does no a 1 How we�re yo i jured? �I� �Q f. G�t� �,f 5�j %�'� B'Y1 '� �� S t � U��f�t� � 1 Ct� QJl(�`Q � Q�YV _A � hat part(s)of your body were injured? f C� �Q ` S � �n� ' � � � "�LQ.'u Q � • 4 Q �� t�' �S r1e4 Have you so ght medical treatmenr� y No Q`j' ning to Seek Treatment circle) �W �'�� u-P � When did ou receive treatment? 1' ,? /3 �'� V�� ' Y (provide datPls)� Name of Medical Provider(s):_,�'�- �� '""�{"a � � `.�� - ��^��,e�rc`� �- , , �.' ` � ��r�� Address �� L C�.x�� 1 /�h' Tel�phone .,�Q,� i -',��_-Z�� Did you miss work as a result our injury? Yes L�Io 5{.!1�C�'�?l"y--�(�,�'�-�a3 i7�7 � When did you miss work? (provide�at�(s)) Name of your E 1 er: _ _ _ --- -- _ __ _ . Address Telephone Check here if you are attaclung more pages to this claim form. Number of additional pages Z '�3/K�a-' �' By signing this form,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 p�osecution. Date fo s completed d�`� Print the Name of the Person who Completed this Form: �' ��r16�'�� L � Signature of Person Making the Claim: �p5 ��e��Y��', L� �� t_. �,Q Revised February 2011 � �'1.�� K • '•. _ - _. - - -- - 4 ___ _�- - - - - - _ _ ' �� {.' ' ,v. �. � .. __ ----- -- -- -_- - - -��- �� ►°u� �Cro r !Y� �- . _l Z`Z-� p8'.h.�.� �, p� i�N, �5 �03 �� 87- 8� I . , aE� R _ . �� -� �� >��,� _��5 � ) ��2-5�50 _ . ,��-�� :��.�f Cc�� m2 - �,`�/ �C�r.�,'�. C�}e��-� �-�� , ��7� J��.''n l�v� �la pl�. �.�c��r� � ��; ��CG j .��rni�-'Zc�..G� � G��/- c' �2 - ��"��% � _. �_ __--- ._ � �/ - ` � Z �T�7 �� t✓�� C,�re S�s�n� ,�.1 Date: July 30,2013 Patient Name: Ramona Hill Hospital: St.John's Account#: 0127696853196 Date of Service: 07/23/2013 •, Account Balance: $55002.90 ✓Medicare's rule states: If any insured is injured anywhere other then his/her own property,regardless of fault, the liabiliry insurance of that property owner must be billed � before Medicare. Medicare Regulation �ode 411.50 Please note that this is Medicare's poli�y,not HealthEast's policy. HealthEast must comply with these rules. Please complete this form, and retum it to us as soon as possible, in the enclosed self-address envelope. We then may follow the proper procedures to have your claim paid. Even if there is no faultJliability, if injury happened on a property other then your own,we st�ll must bill the liability insurance of the property owner. In most cases,when there is no fa�ult/liability, the liability company will mail us a denial letter. HealthEast can then submit�our claim to Medicare along with the denial letter,to let them know that you followec�all necessary procedw�es. It is your responsibility to provide the liability insurance company informatian to HealthEast. If you refuse to provide us with this information,we will be forced to submit your claim to Medicare,with the remark�that you refuse to comply. Medicare will then deny your claim as patient responsibility. HealthEast will then be able to, under Medicare's rules, look to you for payment. Thank you in advance for your anticipated cooperation. , Was this a motor vehicle accident? Y `�N Did t6is happen at work? Y � Did this happen at a property you own? Y �N� p � � =:��' J�� ,1 �� , i� � � �l t' 1C�, � � � � -� �� -�� - � � � �� . �i�� "" �t� r� �� `� ��,►��',"`� � �1 � ' ,�-�:�a�?�/F! -�r""�ir7 �� ; S,� ��-�� WL. lid this injury take place? � Please provide us with the liability,auto,workman's comp,or homeowners � insurance of the place of injury:Not your Health Insurance. Insurance Company Name: �' I Insarance Company Address: L' Insur�nce Company Phone: ` , Policy Holders Name: '� Claim Number: � ' Accident Date: '' ..� If you have any questions,please call�he at 651-23Z-1195. Thank you, -��_.___ . Kat�lyn Mazzitello Govemment Specialist Patient Accounting HeaithEast Care System 651-232-1195 Pussioar_for Caring al�d Service 2.,