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Peisert 07l22/a0i3 KON 9: 28 F�x 6912666878 @J003/04a NUTICE UF CLAIM FURM to the CYty of Sa�fnt Paul, Minnesota M�nnc.ro�a Stace Sraacue�ld6OS itates rlai ".,.�rvery ptr,rua�..wlw clat�na d�r�q,�w frorn m�y�nkntclpc►/Iry.--.rl�al!aawx to Ge p�re:exted to tf�e gavsrnir�,►body�f d�s munlctpattry wtthLi t�t1 day��ter ths a(b�ad in.ta or lyury�s discova�ed a Ka�t�s.�r�rlee tleu,pj�.nr�d clr�u»�8lanort lhereof,'and lhs c�iavaet af co�npee�tta[lox or a�htr rellef rlsnianc�saL" Pla�se complete this form In tta estlrety by cleariy typing or printing ynur an�wer to eieh qne�ettoe. I!more'pace V needed,attach adtfitionAl el�cet�. Ptcau autts tAat yon wW not be contactod by tekphoae to cieril�aaswcr�,sa provide as much inform�tion aa nsce�ry to expMin your c1Aim,�nd the pmount of compenastioe beIn�raque�ted. Xon will rece�ve a wHtlaa acknowledge�nent oace your form is reee�ved. The proce�s c�a t�kc ap to ten Nak�Or louger d�pendin=on the iatarc oY your ctttim. Thl�form must be aigned,and both ps�es completetl. it som�ing daQS no!rppiy,write`N/A'. SENU COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERIf, 15 W�ST KEL�,OGG BLVD, 314 CITY HALL, SAINT PAUL, MN 55102 First Name , if1'! � Middle Initial,�. L.ast Name P�fse r-� �T�C Com an or Husine�8s Namc ' V P Y � �Q Are You an lnsurance C"Ampany'1 Yes N� Yes,Claim Numbefl .,,,,_.___, �? 13 Street Address �� C� City.��n� �r�xs L State ` Zip Codo��i'S,� Day�r�Phone(��}��Cell Phone(�,�-��Fvening TcloQhone��,� ' Date of Acciden�/I�}iury nr Date Discov� ��—a�13�� Time��'�!��Pm Pleasc state,In datail,what accurrcd(hapQened),and why you are submitting a claim.Plesse indicatc why or how yau feel the City of Saint P�u!or its employees are involved gnd/or re.sponsibte for yonr damsges. ' e Please check the bax(es)that most ciosely rept�nt the�eascm for campl�ting this form: �i My�vehiete was damaged in an accident$f� �efo S ,.t g ❑My vehiale was damaged during a tow ��Nty vehicle wa�dam�ged by a pothole ar eonditlon of tt�stro�t 0 My vehiole was damaged by a glaw C] N�y vo�iclv was wrongfuqy tawcd and/ar tickotcd was injurcd on Gity ro rty P�'r�� Other type of P�P�Y dam�ge—plr.a�e sp�ifY ' � ' f.�rQq G�",� thee type of injury—please specify J In arder to process your claim YQU need to inetudo couie�af�tit�pplicable docutqe�t�. Eor the ctaims type�s llstod bebw,please be surc ta inolude the dooumcnts indicated or it wlll dolay the handl(rtg of I your ctaim, Documonts WILL T�ba raturned and become the prope�t of the City. You are encouraged to k�p a , copy for youtsalf bCfom submitting your ciaim form. �cProperty dama�e+alalms ta a vehicle,tw�estlmates for the re irs�°you�vehi te if� age e� $St,�Q.UO;ar tho�otu�l bIlla and/or reoelpta for the repatrs/yf Y��j�C(L��j�j� J � �� Towin�clsitnr: l�gible copie�of�nny ticket i�sued snd a copy of the impnund!nt recetpt„ ,�L '` Q Other pioparty damage ctaims;two r�rair estimatas if the da.mage exce�ds SSOO.OA;or the al bi11s aod/or roceipts for the repairs;detailed list of damaged items �Injury claime:me�dkk�ll bills,receip�s Photngraphs are alw�tya welccYme tv doc:ument snd support your cleirn bui will not be returnc�d.��' Ps�e i of Z—P�aae coopkto And return bo�pages of Cl�im Form . Faa'I�r+c ts c�plN�e asd r�einrn both pages�vill nsalt�delay ia t�c handling of yaur claim. All('�—�c�ple�e t6is section Were there witnesses to the incident? Yes No Unknown (circle) provide their names, addresses and telephone numbers: si Were the police or law enforcement called? Yes No Unlrnown (circle) If yes,what departine.nt or agency? ��„Z Case#�report# )��,,'��,J Where did the accident or injury take place? Provide street address,cross street,intersectiaq name of park or facility, closes�landmark,etc. Please be as detailed as possible. If necessary,attach a diagram., � �,4G E} '�.�-. _ nc� ' please mdicate the amount you are seelring in co ?on or what yau would like the City to do to resolve this claim to your satisfaction. � ' � Pr► 'i' ,�i �G�h b wl`S�M1�1T �f' 4CG6S� ��'R tat psv't1d ra�' e'�"� 7^1�'1� � � - � �°aZ- VeWcle Claims— kase com lete this sect�n check box if this se,chon does not�piv Your Vehicle: Year l�_Make Model � /p 1[ Lic�e Plate Number Z State Color l-4�t�T Registered Owner y • — �'yk�F' Driver of Vehicle + * Area Damaged City Vehicle: Year�_Make Model License Plate Number State Color Driver of Vehicle(City EmQloyee's Name) Area Damageci In�ury Claims-please com letc this section ❑c eck box if this section d s not 1 How were you injttred� � �t �; What part(s of your body were injured? -�.. Have you sought medical treatment? es N Plannin to Seek Tre�trnen cir le�, ` When did you receive treatment? ��le date(s)} Name of Meciicai Provider(s): ^'^"''' c�v Address Telep�one , Did you miss work as a result of our ' ' ? Yes N , When did you miss work? �" (provide date(s)) Name of your Employer: Address Telephone - Lg'Cl�ck here if you are att�ching more pages to this ctaim form. Number of additiooal p�ges, �(� t By signing diis for►t�you are staa'ng that all information you hm�e provided is tnie and correct fo t/te bes[� ' of your knowled►ge ilnstg�red forms will not be processed Submitting a false clalin can result in prosecnetari. Date forcn was completed ��pr �a � �r�I3 Print the Nsme of the Person who Completed this o � s T a Signatun of Person MAking the Claim: • Revised February 2011 I �� ;�:_, s � PAGE 2: From Page I: NOTICE OF�LA(lU FORIU to�ity of Saint Paul,IUinnesota �fease state,in detal,u�hat oeeurred(happenedl,and why you are submitting a elaim. p(ease indica�e u�hy or haw you feef fhe �ity of Saint paul or its employees are involved and/or responsible for your damages. See,Detaled Aecident(nformation,(3 Sheets),Dated 0'I-19-2013,Friday See,Sl'ATE OF MINNFSOTA-DFpA�2TlUENT OF pUgLIC SAFETY,A(3GDFAIT�2EPORT,LOCAL C',ASE N0. 13150231 SEE page,#2: (st E�aragraph where I state As I'm approaching Montana Ave cuhieh also runs Fast/UUest everyfhing is fine,( notice in the disfanee a blue vehiele,In the middle lane by the center(ine in fhe Northbound Lane as I'm approaehing Noyt Ave u�hieh a(so runs East/(�es+(notiee the vehie(e is stopped witf�out any tum signals on or flashers on,The blue vehiele appears b be over fhe crosswalk that erosses U�ite Bear Averwe just before reaching Noyt street as 1'm approaehing i�he nPxt t�ing"I fel+ Impact---------I knau the Driver of the Saint paul�2,egional�Uater Service Uehicle was not driving along side of ine while 1 was going North on(�lhite Bear Averwe,l feel he was distraeted by what he was doing in the drivers seat,Possib�lity looking at a map, Stops of to make for the day,Transmitting on a eefl phone,Or ta(king to a dispateher,Ne may have been unfamliar to the area, Yes he did the right ffiing by admitting guilt to the Offieer but he was not driving along side of ine while I uias going A(orffi on Gfiite Bear Rverx�e t11 that Last Instant IUoment u�her►he hit me,U)hen he deeided to turn from the lane that he was siiting in for a unspecified duration of time and at that second decided to tum into my lane of traffie in a reekless nature. I did not give a refleetion of the aceident to any Offeers,(was in the Ambulance. Now hau does the City of 3aint paul get to the botbm of this_ I�lease indieate why or hau you feel the�ity of Saint Paul or its empfoyees are involved and/or r�esponsible for your damaged. A: Admission of gult to Officer Ronald�ehner #514,From Driver of Saint paul Regional l�ater Seruice Vehiele,SE.E pA�AG�N 3 at tfie baffom of pAGE,#2. g: �TATE OF IUINNF.SOTA-DEpA�2TIUEM OF pUguC SRFEIY AC'�IDENT�EPORT �O�A�C'ASE N0. f3150231 Aecident Diagram at Interseetion of U�ite Bear Ave&Noyi�Ave. �: STATE OF M(NNFSOTA-DEpARTIUENT OF pUgLIC 3AFETY,A(',GDENT RE.pORT, LOCAI.CASE N0. 13150231 Aecident NA�2RATNE,Vehiele I u�as in the left lane and made a sudden lane ehange wifhout signalir►g strking vehiele 2 that was in the rigfit lane neact to vehicle I_ Driver stated tfiat he did nat see vehiele 2 because it was in his blind spot Afier fhe edlision, vehiele 2 went off the road strking a fight po(e. Driver of vehie(e 2 suffered(eft arm pain arxl was franspo►�ted to United via SPFD Driver of vehiele I was cifed for Unsafe ehange of course wifh oitation#620900177618 D: page AA,NotariZed C'opy of Citation#620900177618 E: Page AAI,OFFIGA�RE�E(I�T Second Judieial I�istrict,Suburban graneh,2050 Ufiife I3ear Averwe,Maplew�od,MN 55109. �2eceipt No. SUg62-2013-03106,Transaetion Dafe 09/5/2013,08:19 AAA �: page#3,(6 Pages(neludedl See 3rd page,�ig�t pole(hit is simifar to i�he one outlined in Red. G: page#3,(6 pages(ncluded) Page I of I & Page I of 2, �ustomer Inforn►ation(Name,Customer)Is blackened out I�Uhy is �ustaner Infom�ation being Ulithheld. ', N: Page#3,(6 pages ineluded) page 2 of 2, Summary Totals,gottom of Page,Giarge to�ighting,B11 to Gient (�)hy is '' �ustomer(nformation being G)ithhefd. I � I , � �,! AcciUent Keport Page 1 of 1 ••.��,�� .••�� SU1!Of�•/�T�I'�K iAi�Tt�' o 13150231 N ��' � 1 pF 1 � FYf.FMfiRIM� M1H011GP 'JEMiCIE< NILEL• .1Rft} 31101 l711 Ou.TF YE�R �rl TMrTlE C N Y 02 00 Ol Y �� 7 19 2013 0853 m NOI�IGSY$'FLI NMIIEXUNBEHU151REETNAIE . 1�Y T101'1 ,�� Y h E _ 1 O Whi te Bea r Ave. 6 « �M1FRVlTqM I Oi1 -- (K � W�SN W Bar Bs w �r { COt.'N1VN(` �N'ftEM 12lFtFEK,'E+'fTtl X(MITFCYS RfAi7CY5�ETftlRPI'AtlT.iMi�FJ.1UR! 62 �,„F St. Paul +_ • 10 Hoyt Ave +►.► ui.�: F4f.ff7N1 �`�T� ��yER41C8NSE�A�F.R�t STATC CLA65 IRtifAIIC: MA4TKN IM°IERI.If(4iltllMVlFq-i SfAIE CtA<A IX.67ATUS f TpGt� a$ Ol 437908287 NY D O1 Ol C703Q97026210 MN D O1 � FACTORI ��tiM51Mi(XNFl.nrl; fMlt[1F'WR�N NAVf��1�R5TNf`f1:F1A5T� DAiLd'BIRTN 4A(:(()fi] Taylor Theodore Barton 07 08 92 MICHAEL GEORGE PEISERT OS 14 52 wwvea �eas cavKxi ars.nu:r ,u„.�.ss oawa� aestmc. r,x��uveN 14 4408 Snail Lake Blvd. Y Ol 1925 E NEVADA N O1 O1 r-.�vsn. ra*r sroTt.mro pn s*nic iw v�vs::� O1 Shoreview 55126 6°"':';-°t°i ST PAUL 55119 65I-774-5660 Ol �1 �f �M �V4 ' �EO� A•06 [h�5 �N T S fi L'1 �V7� �iCYT � FEOS ��"'v Ia:OMMt Q 1 AICK iW!', ff2lll: �vGF it;'KW fkrW..pf'�JNI 4AB�'IANCF"'.fR1ti(.0 4:MWI�N6n . tIx ��*`E MiU(: �vf� 1'�H(1:.p i�y�v'p�Mt� �u�y.'��p��E H�MNUYIi[li "t3 98 �3'� I 98 N p�R '�1 98 l�;' 98 Y �""' SPFD M24 20693 p nT�a �GG1F ('M1H.fFNANF fOt1 05YMRNAIIF FNE f1CGW' O1 ST PAUL REGIONAL WATER SERVS N PEISERT MICHAEL GEORGE N O1 VEM?vP 4'V?'�E55 1(`NS� AA.IRE59 Q3 1900 N RICE ST Y 1925 E NEVADA Y� ��i'� O1 ��r_•c urr�r.rF rT r��n�►w: nma -:r,.:iAn ,�r rutunc r,im'cr �.tHi� 17 S'f PAUL MN 55113 "IV` O1 ST PAUL MN 55119 ''"!� O1 O1 Ildt.it)': MKKE FfwEl tkaW (::i�M MNtC W'I1Ft rfaR (:J1tw tl�IS.IOC 02 FORD � SPE 200 CHEV C/S 997 Red 11 lk.K15EJ PthTE tl �Yi RFG YEAq 4CG �p.'EMt h UI tvi:TL M7,'�+4w L�tM pNfl� ST^E i "EM NEC ��+CF O�l'�Mlb +�M. n .r. . �� Y0.ST�NiW FrEM1 QSI(SfV �9 925321 � MN 4 O1 Ol 206HGC MN 14 O1 2�4 j � O1 04 un�ew+ce �x�cv nu�.7: r�c�.�u�i^� irx�cv r.ix.t[a City of St. Paul Self-Insured Farmers Ins. 19560975I ._. _... t:Wl[�� Kl�AA VwNF� iNFPC:iN�Nr ..•.• _ ..__ !tl4!`NMf'Sa • .•. WItNE? HA11MT :ARGOlWY T°� R^� IF ACCIDENT INVOIVED A COMMERCUI MOTOR 4EHICLE,SCHOOL BUB,OR NEAD START BUS w�� •rvF � �REMEMBER TO NOTIFY THE STATE PATROL(mqulroA un0er MS 168.T83 end 1Q9.J511�. t[+.WFitGi�t1 JFNA;IF A111a'I�H� u(Pl1N('.AkVIFR NPLtF fY�'M1VNt+ I�;twW�RrY>:�RM�(�E`+�MUCN. 1pTCYtC�RR�EW NnA1k ()O'f!(�ll;a ( !'.tS.YFN(�fi.S'YJIii{54[5 IMI:T I:1GI�tr.NWNTi tiFX ivh 1� At(ilMfi E�T MUSCV Ffa1K45P7RNi4�f.R7 �� Y91S�RNi.I AIMWMFtR �qiHtM O�Ytl AMM:::hW.L HUNXUMNlN �UI.{E{� O'yN n4Tti=RVKX fiIM1UW(i� �(I�f9N MvNFk p�nTr�FR GM1nGkU"N(1fkN IY NXO JF.S[;RP'K1N Oi pa4A6ED�RlWkRiY aNIXRt YF11 cP.V 7A(i NNMER;S)'"' LMUMliFO�'ROPFRTV:)4LOW TAG N�N.6gR �ity of St. Paul Old fashior.ed Light pole I none kt;'�m � -� µy+�t�rrot tKVi� �1 I ! � � �O� �� i,��: 03 �I � � " A� Vehicles 1 and 2 weie North bound on White Bear ��n,� � � � i ; ` 1 r Ave approachinq Hoyt Ave. Vehicle 1 was in the �� I � � � � left lane and made a sudden lane chanqe without g 8 �1 y i �v �_�___� signaling striking vehicle 2 that was in the !ln MiH�GE� m IG � �� riqht lane next to vehicle l. Driver stated that �NTes �--- N -- --""---- " �'r� 1 / — ----- he did not see vehicle 2 because it was in his 04 �'�°��+� blind spot. After the collision, vehiCle 2 went I — — — — - -- — — �� 98 F HoytAve. �� off the road strikinq a light pole. Driver of � �T ,,,,;,� ------- --_,,�-� � N---------- vehicle 2 suffered left arm pain and was CRA91W! � � i I t , transported to UnitPd via SPFD. both vehicles :�An�R� � �,�x,_ � I ; were severely damaqed and towed. Photos of the Q1 i ''"`bFNT � i ' I � accident were taken. ICC footage of the accident � � � in Squad 1087. Info recieved from the drivers wrp1"t"` I �� I for reports. Driver of vehicle 1 was cited for 05 I Unsafe chanqe of course with citation „�,,, � 'Ki4J1i � � � #620900177618. oL i ��I�; ol I �� , ' ! Y ��:� � � � �� Ol � ( t � 02 ; .s��+c}K:u.�a.�a+wu�r!aw�< ur.w:. ummxsr�Trol: �suc��wcx �oCx Officer Ronald Lehner 514 St Paul PD ❑sHCH�� nT�n https:l/www.dvslesupport.orgidvsinfo/accidentrecords_2008/Includes_LE/PrintReportIndiv_LE.asp?ACC... 7/31/2013 � �� _�'�-�- Ct�MPLAiNT � s�.o�� a�,�,ca�� ►� � qUC. t;iffi�on� fi2�9QQ'!77�'t 8 szo�oa�rrs�e �N�� f�7-9�s- �s N� �MN O CQL �� Cti �C �7'ht A�s- s�, �c� y Sr,+�i 1.+� ��a, �'� Sl�r�cvl,r� S �1 �'SS'/tb _ „ f �y �erJ ��i" '" y� � ��'� VeF�ie VCense No. Ptate Y r State 9�S3.Z t n+f�i rd S�V � �c. or _ � nme r ,�� y ' • •4�� v41 ��RA�1{AI Parldng MeDar t�umber Neigtabcxfi�ood Code Cl Hcx�si 'ng � � � D Baoked ❑C)wner ❑P � �� t�� ' assenger ❑Driver Q ��il�C �� , orte,�e I -, !?�R�C (,'�} b� tGtlrf� , �f No 2 4ffense s,��o„�„a,�e pf i No 3 Offense ��,a� O� O Speed 169.14(subd�}: rw,►► zone T �No Seat Beft Use 169.686.1(a) ❑Nv Proof of insurance 1�4,791{2) AG Take+r-AC: Test type: p R�used D Br�th p Bbod � Urine O Hazardous Materiat CDOT} ❑Unsefe Concitior�s p� Zq� O Endan Llfe d� P ❑Work Za�e C�Canmereiai Veh. OOT� ' Ida��rt: Dl.qr D QVS VVeb Q Photo !D p p� , �oe�.e c�+u�st�t�uerr: r�.ca►�t�unuutr�q a,+�v,w«,,,,,,�,.�,��„�a can nac a�e r�e�a aaaw�6h p�nbebla ax+ae�seRe►e rret il+e oe+�rrwr rio i � s . k/ �tS � � , � w � , � � � � i i ,alcila;�mb," ,,, _ . �` m �� .;+?�,-,�' ��.t� .. . "':� i- �-. ; . �, r,,q° ��v. �v�. � _� •-. � `�""'��l.g?�rr�t r � r�� ` .�i,ed� ' �� _ �� b o�a ❑�t�so� ,t: � �~� � COURT iViREN 11.t�AAI�CK.Di�dict COIMAdminip�lor, � Riur�aey caunty,stace a MirnMOfs,doss l�nby oertify that the atts►ched tnatnxnerq a a Mre and c�rred t�py ot 0te otf�in�l on�and of�oad in ny dRce. rh D�fed Ihie�_dsy of s�_��'20 � '� KI1�N M.AAAF�CIC.OMt�C�t A�rrurostrata �Y—.��"��C�� P�Y � �,�� OFFICIAL RECEIPT 1�� Second Judiciai District Suburban Branch 2050 White Bear Avenue Mapiewood, MN 55109 Payor Receipt No. Michael Peisert SUB62-2013-03106 Transaction Date 09/5/2013 Descri tion Amount Paid Miscellaneous Payment Misc Certified Copy-Single 16.00 SUBTOTAL 16.00 PAYMENT TOTAL r- 16.00 Cash Tendered 16.00 Total Tendered 16.00 Change 0.00 09/05/2013 Gashier Audit 08:19 AM Station 62KSUBWtN2 1630180894 OFFICIAL RECEIPT �?��1 �",� ' n „ q� �.+. -4 �� n !iq �. �, � q, 3 � ��'� � � �.� ��' � •� � , � 6 .� .�. Search Youar�Mr•:r ,,�>ShfDiradory .. Arehires a.�e..oE.aor� �� s.rr tw,rN ssta� c.or�d� r�►a�,.:tes��z�srrt t�.�m ame� Et�plOYmaret Roc�.va C�vkar facitlss �A� N�wz.Fbqch CYilkw Fnrm� �?rolo C�;+Mv1Y Qa��k LEdo t9rtt pka�clory + � � � ��r��d �-�q- 1� : q=s�a,�► � � '•v� I 1 �J f r 1 �a � �� a�cs��n.ile Transmitt�l City of 5aint Pau! � , Trafflc t?perations 899 North Dale Street Saint Paul, Minnesota 55103 Phone: 651-Z66-9777 Fax: 651-z66-9765 Date sent:�/ 29 23 'I�me sent; 10:32am , T'a: Alfcheal Pe�sert Loca�ion: 65�-774-5660 Frorn: ,C�n LOCQt10111 �JT'�6�-�777 Subf ec�•_Tlota.,,l Cost of Renairs �,�4„_9 Instruct�ons: Ni�m�+Pr �f runQso o�►at inoltYdis�g h.laio aovor o�aoot: � rf you h€�ve an�questions r��ardin� thia trs�nsmittal plcase call 651-266-97'7? ' s�,�� f'� �s � }� � "� , �3 � � ,�°�� Search _ You are Mro.� • �. ,..,�� _:S'_��.v��i:':'_'i;��:i!e."�1,(w-.:�_::I ,_ ,e��.t:'til� ..._::...t-!:.i'I�i)_i� - � ..__..:._1.. Stre•twpht Test�y Street�ght Testing a t,. rs�:�s,��,*a: �r {` Seiect Language = , �. � � ry. ,-u�, Tnoslate . . <<t ,. ,��. � ,, , !.�„<,,i, „ wny y�e'.Cg Testin� FdiaaRng the 6rection of Maya Ch�Ootetnan and his desire for city de�ime�s to eenb�ace'geen"Practicee in the delivery of city serv'tces,the Traffic 8�t.igMing Division of Sairrt Paul Pudic Works is currentty teetinp new street lights designed to la�st longer and use iess�ergy.This divreion operates and mai�taira 37,000 IigM fixtur�and 32,OQp stteet li�t pdes,so uaing enetgy efficieM streeR lamps thet last Ionper can dramatic�y reduce the pudic � costs for electricity and marrter�ance. '�, We currently use thres main types of lights:laMem style,�obe style decoraative li�tir�and cobrsfiead higtnnray�tyle lightirg. At pregent these fixtures arc ecp�ipped with tfii�Pressure Saium(FIPS)b�bs. '�. � -x-� t �"'� �.`�: � *�� `� :i �. �� . . .. . , � � ' � � � � f � � �4 �x¢"�` I I � �.+i'P ,.. . . _ . __- _ � _ II Technology in the fighting industry is continually evdving- Given the pranise d reduced costs the�flows from ��, ��j�� L t°� chenges in the industry,we believe we have an obligation to the public to examine new pro�cts as they emerge. �T , Types of L'gldinp Beiop Tesbed a Pe�1 e .,��l m7�� tFDs(G�t-emitting daadas}have been arour�d since the 7960s.Youlre probebly seen them used as ind'icator li�ts in _�,� ` �� conswn�proc�cts.Urer the p�t few y�s,we have replaced our t[affic si�al incandescent lamps with LED lamps, resulting in sigrificant energy savings.Althou�►they cost more upfront than ttia biAbs they repl�e.LED IigMs use less ene�r and Iast longer than converrtional bulbs,which caYd rest#t in savings on energy and maintenance costa. I � �r�� Z,"�� Other advantag�of LF�'s is thet the�r produce drection�IigtR,which give us more coMrd over v�fiat we light, � � i produce a wfiit�type of light,and caMain no hazandous materi�s. ; h i� M��na�6�ti� ! Induc:tion Lit�hting ,�jt� p�1�. C�(M � U�bn9 fnduction{arr►ps are N�frec�cy(FIF)light sources,wtrch fdlow the seme besic pinciples of carverting G ' fM� f�j� e{ectric�power irto viside radiation as converitiorr�d fluorescent lamps.The Nfe af induction i�nps an the market a�„� � ,��{� today reaches 10Q,000 hours.This malcea it beneficial to use such lamps in appicatio�s where lamp maiMenance is L � expe.r�ive.OMer advarrtagea ot itxluction li9hting a►e they ere capade of producing a wide renge of cdor �{¢�� temperatures and they m�atain lumen Qight)output over their life. v S� � �� Pf�@s�M St8tU8 °L� ( We are workfng witA va�ous manuFacturers to develop,install and test energy etficierrt Street LigMir+g.The testing wii! examine�er�ca�sumption,e�e and cost of rstrafit,�aumination tev�s,and commun�acce�Ce.One critical Q�(�5� p� � ��s _ r questlon to be answered is whether e�elficient street IfgMing produces light lev�s which meet ous cu�re�t{ight � ( (� ��7° Ievel sta�dards in St. Paul. �1��'� J��` Let Us Hear Ftom Yar... Although scie�tfic tests are impottant in the decision-making process pudic r�ction v,nN also help to guide our �.��t� ,, fq� � decisions. Ple�.se share your commer�ts with us by e-mail at: ',_� �:�?� ._. .. _±:>. W ��s 1 ! js�� (�� WORIVAMEM,ALTLANTE�I STYLE S?REET UGHTING: �( _ �vy beiweai syl�n and just west of Park ��lQ� �j'� Four 55 watt inducti�lamps were instaNed on ivy betvween Sylven and just west cR Park in eady 20Q7.These were 1 instalted as a replacemerd for 70 watt HPS lamp in our city sten�rd Ariingt�Style tatdem stre�Il�►ts. ��1 ��)t 'C,3 ��A�,��o�.a�a v��a � : �la� � ►� , �..�R��•A!1 � • ,,,, � y�� - . - - . . . � n�+. 71YJ ;. y / Detailed R,eport fc�x R-1321957 �'age I of 1 -------._._• Ca$ N'ain Curttr�er B�t�i�tg 7�r„�re. , Prabx�m�ode:�OCKED I70�VN SI(3IJ � �Ye�t��ra��►Fn�:w�-u��r�R&xo��r rrn�cN#i 3-13az3 i Servlce Ittguest�irr�tus Dai�e: 08IO2l2013 .`�rtruiro 1Pe�.....�i l'tan...T`Y2�Iax� �en►tCe R@[�ftdsl?"ypE:S-SIQri�TS Work Cammerr#�: SIGI�l,PQST�AIREI7 DIJ�TO ACCIU�NT V�TB BE�1�.��OYT N�R.CN#13-150-23 I �}et�iled Repa►rt far R 13�1957 rletailecl�teport for R 132i957 Mste��I �r_ �G.�sT CODE C D ��rrT��l�tOUrtT R 132195?tMi1787 S�4N NPKC3,LM'!'D TM,T�tK LDG,pT'1 ?�4 ro�r:$z�.00 .. Labor C.�TARG�: � NAME C� � � � � B�G �� R- �T� RATE 132I957 �� .$ 1 68.75 84.43 r�r;$34.3s - ��r�,�,t t�iAKGE Q� Y��ANDARD p�tYCE QIIAI�I'ITY�,p�L A1V�CIUNT R-I321357 ST',E-2543 13 ,� �,Sp Totpl.�$d.SQ Tnvafcea .�RC� D '!"��'��'I'ANDA�tD PRICE OUANfIT`Y 1�TAL A,�10[JN�' �''�tat.•�tl.� Misc ��-�.�c 5��1'c e�T�l�1�PRIG�OtJ��pTAI.AMOUNT Tvral:$O.OQ Specisl � ��i Qb_�.. ��LVD��CE QUAN�'ITY TOTAL AMOi�t'I` Tatal�$0.00 Tot�Is 11�attriel; �2+�.p4 Tnvo#�ea: �U.00 ' N�ac: �U.00 Spc�i: $U.OQ �q'uipmeat: 56.54 T�1wr; �34.38 . Totat: $64,$8 P�Oi�3/l013 i � i � .'��'� .`�� l�i'�, � J°, ��+m�. I � I � � � � ��. � I � �� VY°� � :iv. / iT/ i . [ T�atarled Report for`W-1343130 Page 10�'2 _____.____ _ � Cu�t � o Na Custom �8itltng , Problerri Code: T�Tm PpLE Prcrbler»17escriptiv»: VV1�YT�B�?AR&HOYT 687-1-1 - CI�#13-150-231 Serv�ce Request Stu�'us Dale: O7/19/2013 se�rvtce�teqrr�sr Status: WOT�oRll�R. Serv�ce Itequest T�ie: $�LYC��TTING � � �`o�k Commerrts: P4LE T�'�,ACEr.7 V�TT�BEA�t&�iQYT 6$7-1-I -CN#13-150-231 'W�iITE B�AR.8t HOYT 687-1-1 -CN#13-15t}�231 -�TvfO�PCiL& . W�TE BEAR&HOYT 687-�-1-CN#13-150-231�BU.�I,,D Up T`WIN�An ��.1I�,T UP T'WIN HEqp WHI'Y'E�EA.R&HOYT 687-1-1 CN#13-150-23 -�PY.ACED Pa�.E 4�iven'I�V'ark Order 1Yumber; 1303 i34,Fattnd Assc�ciated Sc�vice Iteqt�st: l3�Ob�1 �l►etailed Report for R�1320611 Material CHAJ C�E S�`OCIC COAE�QCK D�SC UCIA�I�IT��O�' Tvtal� $0.00 �abor �� ' �� tE� P� �� G�,� � ; �Q � � � � �,�L ING RATE RAT� Total:${1.p0 ' E�ufpnwent C�G�aD,��STANTIA�P�TCE Q�T��I��TOTAL AMt)UN�' Tatal. $0.00 . Invo�ccs ��L�'�Sr�OD�STANDARD PRIC�CI� 1'�ITY T4TAL AMUUN'�' �'otad: $Q.00 . .""` Misc �H�.�O�C TYPE 3'�'ANDARD PI7�C�0�7ANTIT��AM�'lY7N"f i Total: �U.00 � spec�al A17GE�1��;,;��STANDAItD PRIC'��f�{j��1VTIT�TOTAL AMOUNT Total: $0.00 Detailed Report far W-1303130 Materi�l C�AR.�E STO��COD� STQCK�1E5C UANTITY AMpUNT W 13Q3I30 001513 HOLO D�CdRATN�LANT 2 1,931.14 'W-�303130001577 SiJNVALLEYT'V�IIVARM 1 �93,3g � �a�G�� . ..� .,.. . � u� i � � v f�G t 4 l �V i!� �(}. 7 �T� �, ' ..% Detailcd R�part for W 1303130 p e 2 of 2 W-1�0�130 OQl34l L�MP 100W I�S CT.�AR 2 2b.44 W-1303130 001576 SUNVAY,�,EY TALL POLE 1 1,154.25 7'otal: $3,345.21 Labor �x� � � � �� lY� �� w- �� 3� 1303130 1�2"$ � l 102.93 130,�1 W- 1303130 162'B 1 1 102.93 130.91 W- 1303130 162-B .5 1 142.93 130.�1 W- 130313Q 1�2-� 2�� 1 IO2.93 134,91 W � 130313Q 162-B 2,50 I 102,93 13Q,91 Total: $$74. E�ufpment ' �� ODC'�'YPE��A�tri PRICE OUANTI�"Y�QTA�AMOUNT ' W-1303130 ST��b42 23 2 4g W-1303130 S'I'E-2639 23 2.50 57.50 Total. $1U3.50 �nvolces CT�tGE riC TYPE�I'AND� P� QUAAiTi�'X'�'OTAL AM0�7NT` Total� $fl.00 Mfsc ' �;`�A�tGE Q ' P�STA�ARD PktICE Q T�1"Y TOTAL A1V�OUNT Totai: $4.40 ', Spec�al �I Ck�AI�ODC�'XPE�TANDARri�'�tTCE OU,�N'�'ITY O�Jt�t'I' 7'ota1; �O.QO Sammary�'otats I! ChAr�c to Li�h'tfn��]��'(��fent Totat ' Mater�al �3305.21 �4.Q{?�3305.21 Tn�vo�ccs $O,OQ $0.00 50.0� m� a4.o� �o.vo so.oa sn�� xa.� �a.00 �o.ao �i�pm�t $IQ3.so so.oa ��a�.sa L�tbor �$74.9� ,EQ,QO $74. 0 �4283.61 50.00 54283.G1 � PrMN1C d�/9ff1A13 �' •,• �1 • '�. '",•'.��.• � . r„� . ._.. . . '�I ! i i I � � � � �Q UUhat part�s)of your body were injury di�ziness, (fntermittent) IigMhesdedness,(Intermitfent) left arm pain (eft shoulder pain left torso pain left neck pain upper&lower lef�arm pain (eff elbow pain upper lef�chest pain upper rig�t ehest pain center of ehest pain left hand pain, Top,bottom left laver side pain,under(eft rib pain beiween feft shoufder blade and spine confusion after the aceident,(Intermittent) argumentative after the aecident,(can't seem to handle stress sinee the aeeident,Intermitfent) Ieft wrisf,inner and outer joinfs sore top of(eft hand sore multiple abrasions to vo(ar surface of(ef�forearm,a{�er acadent wenf auiay hyperu�ntlating at night on oce�sion after aceident trsuma r�elafed signs and symptoms pressure in right/(eft ir�er ears,(Intermitfent) uave been very forgetfvl nausea,(Infermiftenf) unsteadiness on my feet(Intermittent) left abdominal pain headaehes,localized/left ec�;soeket pain,(eft front foref�ead above left eye but belau fop hairline and to ffie rig�t of fhe(eft vertical hairline,lef�top of f�ead about 2 inefr baek from fEie front hairline,fe{�baek of head u�he�e the finek and ihe side of ihe head meet at the top,!eft side of head above the(ef�ear,Baek rear feff of head in direet horizontal line witti left ear but in the baek of the head,All(Intermiitenf). nervous/anxious (eft trapPZius diseomfor� (ef�(ower(eg-irner and outer ankles bofher me a(ot as welf as the botfom/left side and rigfit side of my foof,also the bp of my lef�foot is bofhering me a lot j rig�t lower leg-ir�er and outer ankles bofher me a(ot sinee the aecident as wefl as the boftom of my right foot,afso(auer feg bottoms of my feet hurt after the aecidenf pain in Ieft feg abave(eft knee cap � �� pain in left(eg on front imer and oufside lauer leg pain in left back of(auer(eg pain in(eft leg just belau butfoeks inerease pain in legs,standing/walking left leg pain(left a�ter side of leg belau the knee), (right inner side above the knee) lef�leg pain(left outer lower side of leg ineluding left ankle),(left inner side of lauer leg ineluding right imer ankle). Contusion of(eft(eg,u�ent away �ontusion of rigfit leg,went away localized maculopapular rash right and left leg,�uent away short breaths,(infermiitent :�a - -- -, 'i�: d �-.� _ ��, °1 •�]� ��9 a�.:�3 :: ,l �''?�l� `��iu°�i=��- ^��'�l� ,�"''i 4�.. � , , ' _ -'..,'.�.��.'�'` � �� ,- ;�rZ?: y: ,..�a_��'.4v?__ —ati°cl°v``. ��f S':'_.; ,,>1�i' i �"':vt��";� i�'i`I^iL.°;�: ._!;, �;)� G ��., — Dafi�/Tim� R�leas�d: 071�J120i3 13:3� i o�s,��ha��e: � ��i.�G ��> , �f./•�'��-�.,,�y'" �zS�as�d tc�: �iorat�s C�;�r��: � �;.�� '� . -� !'aid by: CRE�}IT CARD �'� � � �drt�in C�arge: � 8�.Ot7 ''._� �-�-'-�'� L�� Released by: t�NERI Tax: (7.625%; $ 10.26 � r ;� rt�.�.; �.� /.��'�.-�. I,the undersigned,have recov�red the vehicle described above. Subtotai: � �8�,78 � will check the vehicle for dama�e or any other problems that mav �ave occurred wi�ile this vehicie was in the custcdy of the Service Charge: $ O.QO Sa+nf Paul Police Qepartment. I acknowledge !will report �amage and/or any o#her problems to the Impound L+�t stafi Tota! Charges: $ 144.76 i �n this form pnar to leaving the impour�d lot. �amage and/or other problem: �' Pol�ce Rzport made: Yes_�Jo_!F Yes, C�1 , If NO, Why? TO PROTECT YOUR RIGHTS. R�PORT A�IY P(��F3LEMSlDANiAGE 8EFORE LEAVING THE LOT Signature 5/2000 ��e�� P��. %r�� CL�S � �� ` i';,',' : � � �a�ourrn ��;:�.Kr,. �o� ��,�i� ,�ain. ru��w5��ai;R�' F ,._, /�'� �'G � �y� `'�' =�-b ��az za�� ,� � � � ^ � ��.✓' '��' ��, � 1�� i.,i1 �`; nr,,.��;� ?v: � �t"- (L: r�,�y7�t�tj�l�1� �� °r / a�JE;::Ul�i3k7d •� ��jY' Jl�if:. � 1 �S a J � � l � � �S ��''��`��`� �� '��Y� i� x�;:;,;xzx�xxo93P _. � �;r� �a: `-�1� �nfrV Prrfnod; S�iNe� ) � � 1 � =- la!�I: � � � u� c,=,t " �r��7%!� � !��.r� � Im�q,,:�i�; 13,a�;�12 �_, - ° � i �ar.ra O�,f�n� �'Ar Cod�: 439187 � �%° �j�-� —' � �� ' ; , r�>��•r ,�t,.: �� rHF.�a: ;�r�,� ��p//� �� ._. Pbpular�K88.corn �ny�,�m ' ' > ' , ,I , > G'Mn"°kt : Cava1M : 1497 : RS Coupe 2D Your Blue Book°Vatue , �p .� I �I�l�if•..-'+ RS Coup�2D �'tt�Fs=. • �'3g�: 1�Q0f)0 i�C8! Private Party Value wfNm tradYg h at a deNe� u�t�en�eNng Hxt car Ya�sllF ExcNlent $1,636 Shop fiar your , -��n�-�,t Very�Good ��,.�Jv. _ ; � . �� Good Offer '��'��.` �"_'�''�� .� ��. � $1.436 ' � � ��_� � 1 � �, �� a , Falr ;� ,w.,� _ � .. S�� - ��.�'� ' � i?wn +t? Love it?Tet1 Us. � � � � , . `�� ;� i ; , � Set!your current r.ar �.; .`�i i � ��.� _ � cwxa�oa wmwa„> .��,,,:,.,��K Helpfiit Resources from K88.com �r eo.FM,.� ce�sNU��. c�ea��Qrrc� Search Cara for Sate Get a Used Car Report near Safrrt Paul �,�,r� a � � G�the In�utmabon You Need an This 8�rou Buy 1997 Chevrolet Cavalier VL Coupe 2D Prices,Values& Sgecs- NAllAguides Yage t ot 1 '1~� .�� NADA GU4DF5 The Powe�of Yehick informotion �Ciose W,nduw NADAgoid�s.com 9/?/2�13 1997 Chevrotet Cavatier VL �flup'� �t� Ciean Trade- NADAguides.�om Price Rebort C�ean Trade-In vai� condition. This me� defects and pesses Rough Average Ciean ease. Paint, boay e Trade-In Trade-In Trade-In scratch�ny witn a t, reflecYs m�nlmai so Base Price �sso �800 �1,150 �ompiete workiny� histary. Vehicle wil Mileage: (140,000} mdes �250 ;250 #250 made ready for re� Totai Base Prite $60Q ;1,050 �1,400 conditio�varies gn may need ta make �� '�� 1�ti(��P, �6�� f��p9 �+�.l�� vehlde condition. r.d7 ld ��,. The h�sfiory af a veh�cle - o ' ' � rmp�a�s Fts value' . . AutoChecic.00m�h��at N�D�uides • �. , � ' ., � AGYEF YI',fMf NT C�1,[�l4t� � . ,...,. , w_. :i,>�!��riif�'fFt'?C:•SiiGR:�I:AC.Dr.i�..nl G�..�"�� . . L'��>:. l+;l ki;c:� kC•.'•• ,. • .�ut��',�hl ..'t�i;kAi:A:•i.. !•}I f:�gl; < Hi:'>u�vt•d I httTt'UWVIi�JV�fAf�AOt11�AC t+nfril�are/�QQ7/(�{�n�rrnlo*rr.,.,.,�inr \TT /(�,,,..,,, '1Tl/i7../.___/T_I._� n�ninn... ►.,, . r •:I`';.^�'�� t, , � '1 :� ' ' � • ' ,� �.,, ,,,, . � � � ` ' � :,.i��r �� . ,: ' , - . .�-�, - . �1Ltilll�l�:�i /!t�'J'�� :i.(1 �'►1 � �- . - �,�i�U . _ _ y r- . . . . , � r =��r s � � . , . . .. � � L �,�.. c � 1� J/ i.µT"R }+�A� Tr�• �` �� f"/t�I 11I� �� /4 L I /�I _�, ��3'�' _ #:. 3 tt`i4� � ,y � 4 �Y ! .. ! ' ' { '- ' ` , � u'� �p S' �� ) Y:_'. � . . . . . •. . .. . . . ' ., ` f 4 �J. 3s. � - wIK '�} Y�,`�' . . � � ._ ' . 7; F �—��.-��r .�-. ►� . °� •, ► � ■ �j-1 , ■ �1�� . r, n�r.� !-' ■ ' ,, . z , ,.-- , �� t�,, .. ■j � ��.� .. . .. - ..,'- .�. . �` f� . .� :.;p�.�. .. . - .. . _. :■,' ..ii'; � �'� . .�'� ■�+.'i .., .... k s-. ( ti.# ►'�„!'T" � � � �.. .+.. � -�� ` � � � �il�' � � � '" '� � , ■ `� ■ ■ • ■ '4'� •'�.. •, ' - .si.'Lk ��µ i j S ��•�?a7f:-1� 'C�`.'�.. •x..,f � ■ L' � Tr �a i �-. �1�� l ./�' � lr �,�" � - 1 � ��1t� / � ' ' .��rLJ t� / G ',,;., / � ,/ . . � ' ' L�`',�� :�si / � ' , , � . - � . � ��: , . : . « - ' . . :� �: i�i�� ' «: ■ � - ■ � «. � • .. � � . . �.. .._ � ..� _ ., _ ,, � . 4. . .� r �� . . . , . _ . _ ;}. N+-1. ��.a _ ' r, Y� .."t �., �y F4 ? f.�rM.�.� 'y%.,`�J � . � .. . � . �.. � ..:�. �"` �� ' -r�,.'.r «�, 4 . I i � : • �• :�� : �� •�, • i .� � ° �l� �� s� �►'1�u`' �� , . �,�)y � �.� ' �.�� ALLINA HEALTH � � I 710 E 24TH ST ! MINNEAPQLIS, MN 55404-3840 Ph: {612} 775-1900 Account ID Guarantor Name & Address 50072240 PEISERT,MICHAEL G 1925 NEVADA AVE E Visit ID 40841570 SAINT PAUL, MN 55119-3055 i Detailed Bill For '� Patient Name: PEISERT,MICHAEL G Total Charges : 2, 126. 50 ' Account CZass: Emergency Admission Date: 47/19/2013 ', Attending Physician: ROUSH, DENISE L Discharge Date: 07/19/2013 '� Location: UNITED HOSPITAL� ( ��I Charges y� ' -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Service Cost Rev. Proc. Descript�on Qty. Amount ' Date Ctr. Code Code I --- ---- -------------- ---------------------------------------------- Haspital Charges 0?/19/13 U7660 0320 707313000 RAD XR HAND 3 VIEWS OR M 1 222 . 00 07/19/13 U7660 0320 707110100 R.AD XR RIBS UNI INCLUDIN 1 222 . 00 07/19/13 U7660 0320 707307000 R.AD XR ELBOW 2 VIEWS 1 222. 00 07/19/13 U7770 0730 110760 HCHG EKG 12LEAD TR.ACING 1 217 . 20 07/19/13 U7060 0450 110377 HCHG ED EMERGENT LEVEL I 1 1, 243 . 30 Total hospital charges: 2, 126. 50 Payments ------------------------------------------------------ Post Date Recd From Amount No payments on this account. Adjustments -----------j----------------------------------------------- Post Date Ad For Amount No adjustments on this account . Total balance: 2, 126. 50 Page 1 of 1 ALLINA HEALTH 71Q E 24TH ST MINNEAPOLIS, MN 55404-3840 Ph: (612) 775-1900 Account ID Guarantor Name & Address 50072240 PEISERT,MICHAEL G 1925 NEVADA AVE E Visit ID 40938105 SAINT PAUL, MN 55119-3055 Detailed Bill For Patient Name: PEISERT,MICHAEL G Total Charges: 145 . 00 Account Class : Outpatient Service Date From: 07/22/2013 Attending Ph�rsician: Service Date To: 07/22/2013 Location: MAPLEWOOD CLINIC Charges A��, ��,�� -----------------------=---�Y--------- --------------------------- -------------- Service Cost Rev. Proc. Description Q Amount Date Ctr. Code Code _______________________________________ ----------------------------------------- ---- Professional Charges 07/22/13 99213 . 0 OFFICE/OUTPT VISIT EST P 1 145 . 00 Total professional charges: 145. 00 Payments ---- ------------------------ --------------- ----------------- ------------- Post Date Recd. From Amount No payments on this account. Adjustments ------------=------------------------ ---------------------------- ----------- Past Date Adj . For Amount No adjustments on this account. Total balance: 145 . 00 Page 1 of 1 ALLINA HEALTH 710 E 24TH ST MINNEAPOLIS, 1�T 55404-3$40 Ph: (612) 775-I.900 Account ID Guarantor Name & Address 50072240 PEISERT,MICHAEL G 1925 NEVADA AVE E Visit ID 41063358 SAINT PAUL, MN 55I19-3055 Detailed Bill For Patient Na.me: PEISERT,MICHAEL G Total Charges: 214. 00 Account Class: Outpatient Service Date From: 07/29/2013 Attending Physician: Service Date To: 07/29/2013 Location: MAPLEWOOD CLINIC Charges All��` ------------------------------------------------ Service Cost Rev Proc Description Qt Amount Date Ctr. Code Code Y• ________________________________ -- ----------------------------------------- Professional Charges 07/29/13 99214 . 0 OFFICE/OUTPT VISIT EST P 7. 214 . 00 Total professional charges: 214 . 00 Payments ----=---=--------------- --------------------------------------- -------------- Post Date Recd. From Amount No payments on this account. Adjustments ---------------------------------------------------- ----_____==_ Post Date Adj . For Amount No adjustments on this account. Total balance: 214 . 00 Page 1 of 1 ALLINA HEALTH 710 E 24TH ST MINNEAPOLIS, MN 55404-384b Ph: (612) 775-190Q Account ID Guarantor Name & Address 50072240 PEISERT,MICHAEL G 1925 NEVADA AVE E Visit ID 41196357 SAINT PAUL, MN 55119-3055 Detailed Bill For Patient Name: PEISERT,MICHAEL G Total Charges: 5, 506 .48 Account Class: Emergency Admission Date: 08/07/2013 Attending Physician: INDRITZ, AUSTIN N Discharge Date: 08/08/2013 Location: UNITED HOSPITAL Charges �� ________________________________________________________________y=====___- Service Cost Rev. Proc. Description Qt Amount Date Ctr. Code Code ---------------------------------------------------------------- --------------------------------- Hospital Charges -° 0$/07/13 U7770 0730 110760 HCHG EKG 12LEAD TRACING 1 217 ,2p 08/07/13 U7720 0351 7�7045Q00 RAD CT HEAD BRAIN WO Z 646.00 08/07/13 U6122 0272 515984 HCHG SYR STELLANT DUAL 1 42 .68 08/07/13 U6122 0636 514828 HCHG OMNIPAQUE 350 500ML 90 63 . 00 08/07/13 U7720 0352 707126001 RAD CT CHEST W CONTR.AST 1 646.00 08/07/13 U7720 0352 7074177dd RAD CT ABDOMEN PELVIS W 1 2, 008 .30 08/07/13 U6301 0301 17002580 HCHG ISTAT CREATININE 1 ?3 .60 08/07/13 U6301 03Q7 17005780 HCHG URINALYSIS 1 46.4Q 08/07/13 U6301 0301 17003630 HCHG LACTATE BLOOD 1 21. 70 08/07/13 U6301 0305 17006425 HCHG D-DIMER QUANT 1 135 . 00 08/07/13 U6301 0301 17100064 HCHG TROPONIN I 1 41.10 08/07/13 U6301 0305 17006210 HCHG CBC 1 100 .70 08/07/13 U6341 0301 17001365 HCHG COMPREHENSIVE METAB 1 189.80 08/07/13 U7060 Q450 110377 HCHG ED EMERGENT LEVFsL I 1 ]., 243 .30 08/07/13 U7060 0300 110023 HCHG ROUTINE VENIPUNCTUR. 1 31 . 70 Total hospital charges: 5, 506.48 Payments ------=----------------------------- ------------------------------------------------------------------------- Post Date Recd. From -----------Amount ________________________________________________________________________________ No payments on this account. Adjustments Post Date====________________AaJ==For=====____________________________________- ' Amount ________________________________________________________________________________ No adjustments on this account. ' Page 1 of 2 I Total balance: 5, 505.48 Page 2 o f 2 �' ALLIIIA HI3ALZ`H 710 $ 24TH ST . . MINNEAPOLIS, NIlJ 55404-3840 Ph: t612)7T�-1900 Account ID Guarantor Name & Address 500?2240 PEISffiZT,MICHASL G 1925 NBVADA AVE E Visit ID 41233259 SAINT PAUL, MN 55119-3055 �etailed Bill For Patient Name: PEISERT,MICHAEL G Total Charges: 536.00 Account Class: Outpatient Service Date From: 08/09/201: Attending Physician: Service Date To: D8/09/20I: Lacation: UNITED HOSPITAL Charges �x � _ ___________________________��_�__=__=___�_________=___=__===__= Service Cost Rev. Proc. Description Qty. Amou Date Ctr. Cod.e Code �.____--�z�--=cna.=c==aam�==�=s==c=====s===c==�=�c=cc==__c==s==�=s=��=os�=s��a�x Professional Charges � QBIagfI3 99244 .0 PR OFFICE CONSIII,TATI4N L 1 535. Total professional charges: 536. Payments --------------==---s---__----__--- ------ -------- - -----___ ---�_____________________ ------------Amou ' ----------------------- Post Date Recd. Frotn ;_._-____==°=°=====n======a_=_^o_a=�===c=a===a==cc=c====n=====_==�==c_=r_=s==aa; No payments on this account. Adjustments =--.�=ac�aaao==�a===a=-n_a==a=a=c==3xaa=n=aocc;==a.�-�---- -�� __ __ _ Post Date Adj For -------------------------=--- • Amou vcvc=cca=s�cca----^s-�-----r=cac========ac== ^-_.__�-�-•��---_=cc�srcc�=a��==sn= No adjustments on this account. Total balance: 5��.� Page 1 of 1 ' ALLINA HEALTH 710 E 24TH ST MINNEAPOLIS, MN 55404-3840 Ph; (612) 775-1900 Account ID Guarantor Name & Address 50072240 PEISERT,MICHAEL G 1925 NEVADA AVE E Visit ID 41267008 SAINT PAUL, MN 55119-3055 Detailed Bill For Patient Name: PEISERT,MICHAEL G Total Charges: 214 . 00 Account Class: Outpatient Service Date From: 08/12/2013 Attending Physician: Service Date To: 08/12/2013 Location: MAPLEWOOD CLINIC Charge s �� _________________________________________________________ Service Cost Rev. Proc. Description � Qty Amount Date Ctr. Code Code ---------------------------------- --------------------------------------- --------------------------------------------- Professional Charges Q8/12/13 99214 . 0 OFFICE/OUTPT VISIT EST P 1 214 . 00 Total professional charges: 214 . 00 Payments _____________________________________ ______________________________________________________ Post Date Recd. From Amount No payments on this account. Adjustments --------------------------------------------------------------------------- -------------------------- Post Date Adj . For Amount No adjustments on this account. Total balance: 214 . 00 I Page 1 of 1 ALLINA HEALTH 710 E 24TH ST , MINNBPiPOLIS, l�I 55404-384Q Ph: (612} 775-1900 Aceount ID Guarantor Name & Address 5d072240 PEISERT,MICHAEL G ' 1925 NEVADA AVE E Visit ID 41276184 � SAINT PAUL, MN 55119-3055 Detailed Bill For Patient Name: PEISERT,MICHAEL G Total Charges: 1, 938.70 Account Class: Outpatient Admission Date: 08/15/2013 Attending Physician: Discharge Date: Location: UNITED HOSPITAL Charges f/�� _______________________________________________________________________________= Service Cost Rev. Proc. Description Qty. Amount Date Ctr. Code Code ________________________________________________________________________________ Hospital Charges 08/15/13 D7210 0731 110771 HCHG PT ACTIVATED EVSN't' 1 191. SC 08f15/13 U6122 0272 514015 HCHG EL�'sCTRODE PR1 3 45 . 6C 08/15/13 U7210 048U 112454 HCHG ECHO 2D COMP WO CON 1 1, 701 .3C Total hospital charges: 1, 938 .7C Payments --------------------------------------- Post Date Recd From Amount No payments on this account. Adj us tment s --------------------------------j------- Post Date Ad For Amount Na adjustments on this account. Total balance: 1, 938 . 7( Page 1 of 1 ST PADL FIRE AND SAFETY PO BOX 18157 ST. PAUL, MN 55118 RETURN �ERVICE REt,�UESTED 07/26/2013 $1554.80 SP32C?693 FHONE: (651) 450-7133 OR 1-888-424-69�44 ,_�',.},,,.,A'y.,�,�,�,P,�.. y,, Federal. Tax III: 41-6005521 ,,,.;;,;,�,�t. wa .,�,��- � �.. . . : ��!� ..�,��'�.��.' ' � MICHASL PEISERT ST PAUL FIRE AND SAFETY i925 1�EVEDA AVE E PO BOX 18157 SAINT PAUL, MN 55119-3055 ST. PALfL, MN 55118 'i�l'��'1�}I��I��t1��1��1��iH��sl�l�t�i��ll��I�i�� 00494 ��i�'��f��l��{IN�'�1'fl1��i,1��i{tfl'�I�I�I��i��,i�l�i�l) _.. _ : . . ,, ��.,t tn;*'�� , v ri�_.� _._ � .�:=.�� Patient Number: 772Z7702 Ca3ler: g11 CALL UPZN A SLF00� Call Number: SP320693 From Location: HpYT AY E 8 f�H2TE BEAR AV N Patient �iame: MICHAEL PEiSERT Ta Location; t�IITED HOSPITAI. Insurance: HEALTHPARTNERS 01205561 D3tL Of Ccill: 07J19/2013 R@350I1(S) 798.2 Call Time: U9:03 AM For 785.1 Transport 959.8 DESCRiPTIQN OF CHARGE HCPl. QUANTITY UNIT PRlCE AMOUNT BLS TRANSPORT A0429 1.0 1462.fl0 1462.00 MILEAGE A0425 5.8 16.�Q 92.80 Total Charqes 1554.8fl *�*�PLEASE PROVIDE YQIIR NO FAUI.T INFORl�U4TI0N OAl REVERSE SIDf OF THIS. YOl! MAY ALSO CAIL 011it (lPFICE t1R VISZT t�1R WEBSITE BELOM fOR ASSISTANCE IN FI�ING YOUR NO FAtl1.T. TFiAPiC YOU.*** DESCRIPTION QF PAYMENT RECE{PT PAYMENT DATE AMOUNT Total Credits 0.00 PLEASE PAY THlS AMOUNT y $1554.80 PO BU7C 18�.57 SAIt�I'!' PAUL, l� 55118 vw_ta�e nn t i an t na v_r n� _.. _ _ _ �PAYaNi BY MABTBIC�RD.CNCOAI6N OR AIEI�CAl1 Ei�i.F�A.t.OUT 9ElOW - °Emergency Care Consultants � �� .�,� ��1 ❑� _ � Oak Park Drive �''°"'� ""°`�" Bedford, M:4 t)i 73fi — ADDRESS SERVICE REQUESTED �� `�"`�°""3�""" ; - BAC!((]F t:AFl[1 �'or all billittg questions,cali: SGC,�}�1-(?7�i C�7/31/2013 $3��C►t► ?8[ � if��}2� Offsce HUUrs: Monday-'I�lEUSda>'Heun ta 9}�nl Frida��Srrm to�Spm Tax ID:4l-i722�i4 Or�•i�i#.our web site at i��w��•.�tucturpayments.som -4'".�"' '��'lll'�'i�l'tl'�I�1��I�Ui��i�Ii��E��ill�'t�l�tl��'I�il,�� zze�-sss Emergency Care Consultants MICNAEI� 6 PEISERT PO 80X 86 s �;� 1925 NEVADA kVE E LQCK BOX 12-091D � SAZNT FAUL MN 551��9-3�55 MINNEAPOLIS� t1N 55486-�086 LI,(��IJ„1��II��L�IL�iI��IL��{�J��If,�1��i��It��L�ll � � r = , :.��.:�� x �:, ; f'ATIG�T tiAMG PATlGtJT,1�IiMF3i:R YOt;R PRnVIDGR MICHAEL G PEI5ERT 1855�20 *z default DG.SCRIF''t!()1� CHARGGS rnYraexrsr NGT DUG DATG CP'T ,w»;srWENTs l Frovider: ROUSH, DENISE L � Voucher: 5047710 uiagnosis: 786.50 � �?Ii9It�13 59284 ER EXAM 399.00 394.f PLEASE FORV7ARD THIS BILL TO `lOt3R AUTO INSURANCE RND i CALL US WITH AUTO INS INFO I I I i I l E � � � � i E r f � Please visit WWW.doetarpRyments.COill far a rnore convenient and secure way to provide us with your i Heatth tnsusance Information, Nlotor Vehicle Accident infofm8tion, Workers Compensation insutance information and to pay k by Credit Card. Or see reverse side fo compiete and mail in. � I � � ca�,rw.aoc�orpayments.com T'otal Amount Due � � �g�� HiS SEPAEtAT7� F3II.L iS f�OR TI�EMI:RGENCY PHYSICL'�N A"C AI3}�QTC ��ce Hours: Monda��-`I�hur�3z�y 8ani to�1pm NW/LTN117;D I�OSPITAL Friday Rran to 8ptn ' For alt billing questiaos,call;8G6-95t-(i??4 Txx ID: al-1'I225S-! _ _. . Account Number: 2fii-Ib55')2t) � �� 22946-358 iF WE DO NOT HAVE YOUR INFORMATION, OR !F ANY OF'�HE FOL[.OWlNG HAS CHANGED SINCE YOUF LAST STATEMENT, PLEASE iNDICATE... PATIENT INFQAt�AT10N lNSURANG� INEORMATtON Your Name(Last,First,Middle Initiaq Date o1 Birth �Your P 1 tnsurance ort�parry's Name � '�� Primary irosurarxe Comparry's Address i �� s�ate z� � 1 C�ty state zip �Te�phone � i � a Policyhoider's ID Number Group Plan Number SoualSecurdy 41 Subscriber's Name SubscrSber's Daie nf 8irih Empfoysr;Name Telephone � { } Emptoyer's Address Subscriher's Address Subscnber's Sociaf Security# ��y S�ate Zip Your SECOIdDARY insurance Companys Name Plaase indicate e#Applicabte Date o(injury � �t�tJTO ACCEDENT ��dary€nsurance Canpany's Address �WORKER'S COMPENSATIO�; Gh+ Siate Z'+p iF THtS VISIT WAS RELATED T�AN AUTC3 PoGcyh�lder's ID Number ��o„F Pi�,r�„m�, ACCIDENT COMPLETE THE FQLLOWING: Auto insuranCe Name ��y�e SuUscr�ers Date of Birth Aufa insurance Address Subscribers Address S�tsc+7be�'s Sociai�ecunty q C�Y State Zip Aut��nsu�a�+•�_e c�im w�n�er IF THI&V1SI1'WAS WORK RELATED COMPLETE THE FOLLOWING: Giaim F�presenta6va's Riame EmpioYar Name Ci��ri S�e�rresentative's Te��hane Aturnber Wn�#cers Comp tnsurance Nanie f! ) ��Woskers Comp Insurance Address C�9 Stats 7�y Wwk2rs C',omp Clairtt Number Claim Representative's Name ��.laim P.e�x�nEativ2'�Tek;phone Piumtrer 1 ) This staternent is not a duplica#e charge, but a separation of the facility and physician or provider's fees. These services were provided while you were under our care, or at the re uest of your other physicians ar providers. Your bif{ from the facility may include a separate charge for use of its equipment, supplies, and technical personnet. You may alsa receive bills from nther physicians or providers wfio were involved with your ears if youu were a patisr�t in a hospital or other facility. If yflu have any questions concerning your bi!(, please cail our office and we will be happy to assist you. � IF YOU REQUlHE ASSISTAF3CE,YOU MAY CONTACT QUp OFFICE AT TH� PHQNE NUMBER ON THE REVERSE SIDE. PAGE,#f. G'ase#,13150231 G�ere fhe po(iee or(aw enforoement ca�ed? YFS Saint Paul pdice Deparlmer�t U�ides Amved,Oflicers on�site Saint Paul Fire Department,Uehieles Arri�d,See 6efow �R�pA��e u�rr,«u�e#24� FIi2E ENGINE,t#4) I � � pAGE,#2. Ist paragraph I,Uher�e did the accident or injury take place? provide street address,cross street,inferseefion,name of park,or fae�lity,elosesf landmark,eet please be as detaled as possibfe. (f necessary,aftach a diagram. "(A brief statement taken from my detaled reporl�. pA�E,#I-R a 3 page defaled�Zepori�. Starting in the middle of a sentenee)",There is a urn�►arked�rosswalk, there s also a Stop 3ign to stop for North/Soufh 1'raffie onto GJhite gear Averwe. ( eheeked eaeh direetion for Pedestrians and Traffie than I proceeded to tum inb the closest lane by the curb to fhe rigf�to go North onto U)hite gear Aver�ue,There ulere no cars in front of ine nar behind me nor on tfie(eft side of ine by ifie�enter Line, f brought my speed up to 30 mph,As I'm approaching Nebraska Ave wfiieh runs East/�Vest everything is fine,As I'm approaehing Monfana Ave u�hieh also runs East/UUest everytf�irig is fine,l notice in the distance a blue vehie(e,In the midd(e lane by the cenfer line in the Nor�bound Lane as I'm approaching Noyf Ave whieh also runs East/U)est I notice t�e vehiele is sfopped without any turn signals on or flashers on,The blue v�hiele appears to be over the erosswalk that crosses U)hite Bear Averwe just before reaehing Noyt sfreet as I'm approaehing The next t�ing,"l felt was(mpact and I hear myseff say"Uh",Vividly and Softly,Then(felt(mpact again,And again I hear myseff say"Uh�, Again Uividly and Softly.l fe(t myseff siifing in the car in a daZe and noticing my dashboard is smoking but not reafly r�ealiZing that it's smoking because I'm stin in a daze 1'm looking out my drivers door window opening kr�owing someone ran into me, Thinking fhe driver of t�e other vehie(e fhat hit me took off,Not realizing u�here impaet took place and hau far(traveled before( stopped. Znd paragraph,A��IDENT�2EpORT,Case#13150231 �lease see,STATE OF MIMUESOTA-DEK�ARTMENT OF PUBLI�SA�ETY,ACGDF�NT REPORT diagram drau�ing of immediate aceident seene u�here first Impaet bdc plaee in the interseetion of(AThite Bear Aup,►we,North and Noyt Averx�e,E.ast in the Northbound l.ane elosest to the Fast Curb where 1 was traveling North on I�Uhite Bear Avenue in(UNIT#2)my�d �hevro(et U1hen aecording to the diagram,Vehiele I and 2 were North bound on Ulhite gear Ave approaehing Noyt Ave. Vehiele I uias in the left(ane and made a sudden lane ef�ange wifhout signaling strking vehiele 2 that was in the right(ane n�act fi vehiele L Driver stated that he did not see vehiele 2 beeause it was in his blind spot After the edlision,vehiele 2 went off the road striking a light pole. Driver of vehiele 2 suffered lef�arm pain and uias transported to United via SPFD. goth vehieles�uere severely damaged and towed. i�hoto's of the aecident were taken. fC�foofage of the aceident in Squad 1087. (nfo received from drivers for reports Driver of Vehiele I was cited for Unsafe ehange of eourse with citation#620900177618 Of�icer Ronald�ehner #514,Stopped by l�ited Nospital Emergeney Room uihere(was being treated and notified me the Driver of it�e other Vehicle Admitted Fault ar►d was given a Traf�ie Viofation. l tha�ced the Officer for coming daun out of his way to see me and telf ine tfiis information,I asked if( could sE�ake his hand,Then,I thanked him again. �Ot3 Fridau (lef�my house fo(eave for work,�ot iMo my car rdled daun bofh driver and�sssenger wir�daus as it was a nice momir►g out arid proceeded to loek my doors,buckle my seaf be(t and dieek the rear view mirror�nd the door mamfed mirror's to make sure no one was coming daur►4he street, (started my car�d put it into gear to go(A)est«,IUe�da Av�x�e,As I'm go�g down Nevada fhere s a alley one house doum from mine it n,ns N/S,I lookied eaeh way everything was fine,(coniirx�ed down Neuada to Naa�St u�here#here is a�marksd Crossu�alk,There is slso a 3fop�ign to stc�p for traf�ie for Norfh/South Nazel Street I eheeked each direetion for pedestrians and Traffiq 1�hen(continued U)est on Nevada begiming to shiF�into gear to drive down to UJhite gear Ave,As Pm passing ft►rough the interseetion of E Neu�de and Naael St going U1est tliere�a house on the N/t�U eomer of Nevade at Naze(,There is al�o a s�ey tfiat nms NIS afler tf�at haue as I approached(bok�d eaeh way eueryihing was fine and I continued on my way with eacrtion in mind as the�e u�ere a fot of ears on the lVort(�/S�Sides of our R�esidential Street. f t�med on my right siynal io go Nor�h anto(�Jhite Bear Avenue u�h�e approaehir�g fhe Avenue it�ere is a a(ley that runs N/S just before ihe Taco bell tttiat is on the N/E comer of f�)hife Bear Ave and Nevada,f looked eaet►ulay and everything u�as fine fhan 1 eortt�rued to the eomer, Tl�ere i�a u�xr�arlaed Crossu�lc the�e slso a Stop Sign to stop for Norfh/Sa�ih Traf�ie a�to UJhite Bear Av�enue. (eheeked eaeh direetion f�r K�edesfrians and Traff'�e ff�l proceeded to tum into fhe dosest iane by the curb b tfie right to go Nor�th onto V�ite gear AuPxwe,There were no cars in fi�orit of ine nor behind me nor on 4he(eft side of rr� by the CeMer t_irie,(brought my speed up to 30 m�,As I'm approaef�ing Nebraska Ave u�hic�rur�s Fast/U)est everyihing is fine,As 1'm appro�eE�ing A+foMana Ave u�+di also►vr►s EasflGJest ever'yth�9 is f�►e,(notice in tfie distar+ee a b�ue vehide,in fhe middfe lane by fhe t�nter iine�the No�thbaxxi lane as('m approsctwrg Noyt Ave u�ieh also runs Ea�t/l,�est 1 notice the vehiele is stopped without any fum signals or flasher�on,The blue vehicle appears to be over the erossu�alk that erosses Ulf�ite Bear AUerwe�just before reaehing Noyt st�eet as Pm approaehing The►�ct thir�g,"I fdt u�as(rnp�ct and 1 hear rr�sdf say'Uh',Vividfy arxl Softly,Ther►l{�t lmpact again,And again(hear myself say "Uh',Again Vividly and Sof�(y. I fdf myself sitting in my car in . a daae and noticing my dashboard is smo{c�g but not reaAy realizirg that it's smoking becau�('m st�in a daae Pm Iooking out � my drivers door windau ope�ng knowing someone ran into me,Thinking the driver of tfie ofher vehic(e that hit rr�took of� Not realilir►g where impaet todc pla�e�d ho�u far!t+�ave(ed before(sbpped. Then ff�ere uias someone by my drivers door they had ' said Sir stay in your vehide a Ambulanee is on its way,(t seerned Idce I was Gumg a dream(heard,Are you hurt,!said yes,( ean t � move my ieft arm,!ca�Ch't even say af�tf�at po�what gender tE�e perscx�ta�cing to me u�as,(realy uaas c�ut of it (sta�ed ' yeI(ing out. My dasf�is smoking/my dash is smoking you�ave to f�elp me get out of here(don t wanf to be tr�d in here if a ' fire siarts,l couldn t do anythir�g witf�my(eft side as it seemed to fwrt badly,I was ye�ing open the door it uias foreed shut from ; the aecident(said I cbn't think I can crawl out the passer�ger'side or fhru the drivers door wir►dow openirx�. Again(asked,Try i� to foree my door open then it uaas open'. A woman was i�ding a+my drivers door,l also notieed a m�npact b her,She uia� on ihe righf(North�ide),Ne ulas on the(ef�(South Side)�s fhe fra�t of my car was pointed to fhe Il�rth and they were on tt►e G)est side of my ear,Or►ce the door was opened she said Sir('m going to take your pulse at that pomt(reac�ed wifh my righf hand fo the right side of rr�body to ur�uelded my seat belt,sfauly and tumed my body,slou�y to fhe(e{�{o ihe west and puf my feet onto f�e street but stayed seated,S'he said Sir please stay sealed untl ihe Arnb�anee Arrives. Then she took my pulse, ( asked her if she ea�(d dia(a pfane number fior me I was st�l�a daZe,l reaef�ed for my cell phorie it was in my rigi�t Eweke� ( gave it to her, Agam I a�d that she dial s�one rx�mber for me, It didn't eomect,I aslaed for her again to di�a phone number f�r me,A�in it didn t cor�eet Eac;h c�l u►as placed by her at 8:4-bam, f could not haue dialed the phorie mys�f at that point as my hands were shakirig a(ot At 8:52am I tried eaping the phone r�rrnber ihat she hed dia(ed fwice before, T�time the number was rin9�9��P�W��@�ork,'(NOTEr prior to the aceident I u�as m my u�y to utorlc. As I'm .,.,.� .......m. ........�.... ._..�.....__..........o.....�.�...� � i � i � t��Cing b my goss!�xp(aa�ed whet hed happened,Ne asked if�et(keep him updafed,(said I didn't thir�c I ulotdd be in today a Ambulanee is on its wac� At 8:55am(cal(ed my wife at uark and�pla�►ed u�hat happened,She askad if(was hurt,I said Y�es, f said a Ambulanee u�as on fhe way,I said rd probably be faloen to�uospital, S'he said she was going fo leave Work and sfie uauld see me af the Nospit�. (had a esmera in my eenter consde behind me I slow(y reaehed to open the compartmenf for i+, I didn't fmd it rigl�t away, Then(found it at that poirrt(proceeded to get up and e�crf my car,Tl�e u�said Sir please sit badc in ya�r ear I said�fiis r�eeds fo be Doaxnented,(Ice�t repeating out foad so everyone could fiere me,An�one that t►epperwd fo be nearby,I said out load mare t�an onee that ofher uehiele ran inb me and piciures nePd to be taksn. If I das't fake them who w�l. 1 started taking pietures from the Sa��Side of Noyt Ave by the�ast eurb in tf�e Atorit�bound l.ane,I got both vel�ieles in if�e pieture, A Pdice SW arrived mirx�tps later and pa►{ced'm fhe 3outhbo�d Lane by the eenterline aeross from�he Bus sfop that's an tf�e N.IrU.C'.omer of E Noyt,Tu►o other Squads arrived,One IUarked Squad Car,It par(ced in fhe Norlfibound lane of Glhite gear Ave kx�ihe�ast�urb a few feet South of the Painted G�ssuralk that erosses GJhite gear Avenue beftueen SU�.Comer of E Noyt and fhe S.E Comer of E Noyt,There was also a Unmarked Squad that parked on ihe S.E.Comer of ENoyt,On the south side not bfodcing tE�e unpainted erosswa(k that erosses E Noyt from the S.E�omer of Ulhife Bear Ave to the N.E.�omer of Gfiite�ear Averx�e,Nis Vefu�le u�as faeing East,I didn't notice any other Uehic(es arrive(wes f�ang�fiofo's A police 0�'ieer said who's i�e driuer of ihe red esr.Somea�e said the guy taking f�e pictu�es,A Oflicer asked for t�roof of fnsuranee( opened the door on the passengers side knelt doum to go ihraigh the Glov�ox a Offieer asked if if u►ou(d be Ok if he fooked for �t for me,I said Yes,The�I said Thank You, I said to fhe offieer this needs to be documented,The Ofl'icer said,The pdiee wip talce fheir oum piefures,(sfopped. T�he Ambu(anee had a�ri�ed fhey asked 1 gef in so they ca�(d ehedc me out T�hey decided fo iransport me to tffe hospital,They aslo�d if I hac!a pr�eferanoe f�r a Nospita(,(said Unifed I as(ced for my car keys before(eaving tf�ey said fhe(gnifion key u►oufd have fo sfay witfi the uehiels.(r�.quesfed my of�er keys be given to me and one of fhe po(ieemen broug�t them to fhe Ambulanee,(sat down u�here a paramedie's c�ecked me and asked questions then fasfen the seat belt f�r me. Arrived at the�tospita(,Cheek in fime 9:30am!was eheeked by a U)oman I�oetor,Answered Questia�s,X-rays were Ordered,I was in ihe X-ray Room nau and ifie Teehnician said to me IUiehael it boks Gke we11 be x-raying tfie rig(�t side of yair body,(said the right side I said lhaf's wrong it's the lef�side the ted�nie+an said urait a m�x�e�l be rghF badc,(`m going to eap tf�e Doefor to pre-approve fhe ehan�s,fhe fechnieian came baek and said she u�as sorry+hat a mistake was made,I said[t's a good thing I dich't eome fo tfie hospit�to have a leg rexnoved and have ihe wraig one removed,She continued she took x-rays of my(e{�front side from bdau my sha�lders to my u�ist,She also taok x-rays of my baek lef�side,Sfie said[Uic�hael were done I�1 be taking you badc to your roam,'1 said wait a minufe I�NAT ABOUT MY IEFT NAND IT'S ALSO fNJURED,She said she ean`f just X-ray it wifhout Orders(said I unde►stand but the Doebr made a misiake for you to x-ray my right side lU�1YBE YOU SNOUID CAI.t.NER AGAIN, The Teehnician did,It was approved'. She took fhe X-r�y of f(�e l.eft�Nand. S�e said I�f u�eef you baek to your room(said thar�c you f�r eheeking wit��he doeror,S'�e said your u�elcome. (Uy G�ife arrn�ed. A�int psul police OfFieer Arrn�ed he c�ne to the Nospital from ttie sciene of fhe aeeident to see me,Ne infom�ed me the oti�er Driv�er,(A)�o was driving a Saint paul�?egional Ulater Serviees Vehide admitted he uias in the uira�g�nd he was(ssued e G''fstion. Saint peul pofiee(3ase Afumber is 13150231. Unifed Nospital Aduised me to see my Doetor in a few days,United Nospifal provided me with a G)ork E�couse for 0?/19&07/20/2013,Also provided me with a Reference Number to eal(them and provide billing ir�f'ormation �rged at 11:09am Arrnied�,(Uy wife provided a ride. At 12:30pm on 07-19-20(3(caaed Aspen Medica(�roup of Map(ewood fo make a fonau up Appointmenf for IUor►day 07-22-2013 Appointment time u►�be 9:30am At 12:39pm 1 faxed a Copy of tf�e(�ork Exeuse slip to my Employer for 0?/19&0?/20/20f3,l ca�ed our�2eceptionist �xl asked if she u►a�d provide a eopy to my�oss also i�o N�r►an R�esourees,I asked she eaq me badc to(et me knau she received the fa�c,She did. On 07I21/20131 worked at U)ork from 9:am.to 4:30pm,These are my twurs,5 day's per weelc fo l�ak. Only ihe clay's charge. I�lhie I was at work my Boss ca�ed me at n:30am,Ne u�s off buE he e�ne in to s�ee hau f was,Ne as�ced me u�had happ��ed,l bld fmri,!also said my car was bfaled,Ne aslaed if(fwve another car to drive l said my brofher has offer�b bornow me one. �-te asked if!was going fo 6e ok,l said fime un�fe�. I fold t�m I hau�en't fold anyone at wor(c about ihis. Ne tdd me fhe ady persa►he shared'm�m�atan uritf�is the A�r►�isfratw of the Bu�g. 1 notif'�ed[�n that( hav�e a Doetor's Appoirtirrie,nt on lUonday s�fhe moming. On 0?/2112013(eaYed n►y Urion Sieu�art n fhe evening fo haue fum be knou�edgable�s to u�hat's going on wifh rr►y situation so(don't t�aue any conflids with my Err�aloyer,I ra�riinded f�n fhat �►.�,;��i��,�d��`s(-{IPPA Relat�d. On 07/22/2013 I went�o see my Daet�ftx a Foaow-up apport,h�n+for,r�e Ca�Aceiden+,Ne�a.�a�me i�ar,a he told me f�e�n�ea me ro be off of!�?ork for or,e I�Veek,A t�lork Slip was praickd,Da�07I2.2I2QI3 e�(aining t uun�be r+�ef�ec�aed in c�ne week.Ar►d un�be reassessed. Lef� QfFice at tI:35 AIU. Ar►�ived Nane. Af t220pm t Fa�d a Copy of the Doebr's sl�prwided to me to for'my�yer,l ca(led our Receptior�ist,[asked she pnx►ide a ec�py to my Boss and also to Nt�r►an Resoum.es,I a(so askecl f�r a Uerificatia► LeNer,5'he sent it. pn the lUcrirHng of 07/23/20t3 af 459am I eaqed my Boss's U)ork Uoic�nad To Notify h�n a Fax was s�nt y�terday regardi�9 my poebr`s Appointment I nated my Doetor had found sane fh�gs and u�anted me to take if�is week off,(said i w�as sary. On 07/2312013 at 429p.m.(ea�ed the Reee�tionist at wcxlc io tiotify he�Cm sending a faac, And l want it fo go to�-lu►nan�2esourees Only, She a�lced if(was ok,I said 1 didt u�t to talc about it,She said to stay on the I�e and she'd(et me(vww if she reeeiued 1he fax,She did,I seid Tha�c Ya,,This Fa�c is a update of a sequenee af eua►fs from the Mobr Veh�de Acciden�T�nes of c.au's�re(�tian to what ihey t�eed to Icr�au,Doctor's�finent t�nnes and Dat�s,Vaicemsil �rr�es and Dates,�f�UUork u,if�Trnes,Dales,Ve�ifieatior►s to(a�fhern updsted witfm reas�n. �.Sh��fs . , , , . . ,..� . ;�.�� r �►��,�d �� r,.�� '� �i a�� . -�- `�'�._, �� _. ��_ .�>� �� '�r �"" CERTtFICATE t7F TITL� FOR A VEHICLE 3�'� , � ___ _ 1 '1�,� 1G1JC1249VM154636 G 97 � CHEV CP C/S _ �- .KQ080N4b8 `�`�' '�i�♦ j i I � � !I �itail._I� : i. ��4t �. ' _ _... . � �i _..vl�ilN_!.E tDrIJ(If�MCA(kltdNUi�A(sL-F.... - r - -�- ':�dh ' . '•W.!'l ...., A�).:ti i"��C'• . .___. .. . , ,,, _ _. .- --_ _-- -- ___� _ _. _ _ _ _f. 450PWC � _ �� `/��r Ol/08/Ol � 16 � 11480 � 09 , � �� V,^,TC I':'a�[t� � f7fH;�FAG�Ef-� � 7r1X t:A:i- � ;. .t1E' , i_ �It hl� �i;�== �� Y` ,� � ; .� --- -- _ EXP 0.5 I ��# � �•rt.li•At �.;��i i �r,i ..,� t _ � _ ._ _ Y; � �__�._._._ ..... _._.__ . .. .. _..___ __ _._ . . .. _ . . �B �w� . _._.__.__ .___...._._._ _ .. .. _ .. _.____ ._�--_._�.,._ ____. �� FIRST SECURED PARTY 09108/00 OWNER � §;�� ST PAUL POSTAL EMPL CR UN PEISERT MICHAEL GEORGE 51452 d� PEISERT DEBORAr •„� N215�` �3 , � q�'°�� 2401 N MCKNIGHT RD %� x � �' N ST PAUL MN 55109 1925 E NEVADA AVE � ��" SAINT PAiTL MN 55!19-3055 : �" a` TOTAL LIENS 1 ,� �,�gt,�, r �.�: ls� � � � �LL � Z ' � �� 'A� ; ASSiGNMENT BY SELL�R (TRANSFEROR) y ;;. ��": �-i-�N-►..+� ai�+�.+..�ratttlAVV:1fMf!�.Y.!r�'fu.`.{y.wi514i�'ft"�H�t��'�u. � N,��r. �w.uw.�}} �a..� �w�;N-N�v _:N+�;�+wMt�� j-atY.t..+4y .a. .. 7 ' . �. e. �.�. �� C��S��'1�?SURE�r't!3(?ttT THE F�OLk.UTI(1N CONTRC?I. EQIIIPMENI ANL�I�A414(�I� Tr <<:�=. V{HIf 7!= �hiL.�hF Tr, '.�`Mf'L�"TE �)Fi S'F?i)Jlf`�Bvr, n �AL�f . , '�Fh'!"�+lE s�.A?� � �!t �`� t.r��i� � G�!��ilt� �� Ui��F 1Pr1FSii nNtiEt.iT �)►�E i >t �Fll� [�- �a; ,a�P .� '�3T.; �... !�.1 ., . ��[ .11(kF�ii�P�l il �:��t:ti, �1i,4 t�� i ...11l.iF.�. �. .�1- . ��,f:. ., y �.Ii'. .. ..IS...i?! . ,R� i_:1 .1'i. �I .� .. �n. 1.1-�� . � � � . � . �.,� F dn� i eh �1 ' i i.� f . . �� ,.�. .n.� ..��sx.. t " - 1 1 rt`:.' F.i I/1: �. �li1_ � 1!Fif I'�i il�. I ��i�,��. �4.i '•ti.� : Itn�t�'�;tF�.�tn#r�c!wi 4�r:�:r,+:t ci 16e r.r�r,wir'.a�it� �,�a1F,�i��,IN�el: ''t i .r . ;1'.� yCs �� C 1 �,:.J:IIri{.1 i�q1�!h } 411��'(1�f4 Itt'd!!-'.11 :1111�1.�1: .�..`1.. 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MUST BE SUBMITTED WtTHIN 10 UAY�(Please Print} �r ,:��; --- - _ _ __ , _ � - , �� i I �'� ' I , .. _ . , _ . ._ . ._-__ _ _ _- _ ; _ _. i __ :.__ _ _ _ _ _ ; ��° __ _ �- `�� _ . __ , � :s�„et n�t lit:��, i �,.�: i :�. ::i., ��,t:r;. . . � . � ._ . . _._ : � : _.- . � �•� .�.;. �. �,�� l.iittt vi _ �i u,., � my.: � t�w�t�lir+i . �sE �� :ultllk:t• � ... „i��:U�y' ----- - ..__._. __._�_._.._ _�. ... � I ._ ... _ , 9�.. ,�ti}. _,_ . _ _ _ , - _,� � �> 'l 1�;�{'d t t(}�rdj � '��- - -- IS Thil�VFHlt'I,C_�UBJECT Tt� SE�'UFi1T'r AGREENIENT(:�1. iVf, tf_:a (.f YE5 I,UMf!.E k E l _ _ ;k�:4� � � r� ' �� _ __ c ? i , �:. �_ , �z � ' �1t$cf E 4.,Hflt`;.�1�a� t:n�dn` ' ��2 �ir5t -:t3�'ut��!f ri �,F�lttn�e f('rud Plt�ma� � --- — --, _ .._ _. _ � � . .. � ;, :, � p "° - - - - � �. ��. �. _ _ , rtc4�nn�lre � �'�' ! �,.,�r 'i `- , �v _ _ _._ _ �� , n_ { �,i �,� �?cn: vf�� ,�i ru tt� r. fi�i ticdut:t,.. , ,i��,t l .:�ri�;i,��. rc, tr i �r,�� ?C �� : t itvr�) r.�.r,q� ! twei .irn (araY �x 1 t��i �il� tk�y uur�h�.t� h� cEh�ek i �:�� _ WIU1e upr,r.�t nq�.G,�n tt�r �et�di t�reL ti� r,�ha,} ,1.: J i��r�, te �h-,r �-;�� it�M.: i�t�,.v �,'S A-s� � If�f'(1FifANT - 1'LCA;iF: REMI�. AJ d.:ta a�tl�ct_:v ,«, tc a;eu. .iE�A�aUr,n sra rz;u�rE,i y I�,k. t 4 Ja.r,a ra:, �Ni�ai; y�u ur t� :�i f � ii�.r �,i � 7� ,: ! ,^,,,1 �d�° m;��h in�1�-:i«�I u� ih<; r.�q�a.�tFr� �I�,ri Ex� Yt i!x r.;A,vn u�3 { mdt-f 1 ��hrul ��t t�i rh L�� ^ , niorttk��, cad3nxul c� y�svi a�,.4:at�r.x� „ 1.., r:i.-, . ,ro;�. . �tt�.v�t � 6"�° �w ir.�.�r. ��,,•_��L��xt tP�,c 54 � ir,... �..i-,� i r}:.;+n � t.:. �3 mS �^�t a }.,: + .� t1Yn-.�a aL• i �. � , . 7cqi rni;}ri vi:�sF ny 1"��.�il n�,a�,��i n;�k �i�y�v,>- �.�� , �r,_ _. m;r,��s.��..�, �.�i�f �k:�.:.��r iaYnr,I�'� �li..i.iu�r. p�* ,� ��.. ��: `tY � �� a '� '�r�� :1't�l IC{�N1'`:`;illtdr�TURE�;�.;�l'�� .i=,�.r''I�i:�,,.� t��L��i .',,�, � �� ,3',.� o � � � _ - ' e � . -,. - . 6 0 ,„ .� � � -,.'0i4 �, wc ' , �� .�,, � � i ��A+�,�`q��Jl��.. I 3 • i � ' � c�v cp c�s 1G1JC1Z49VM154b36 21480 K0080N468 1G1JC1249VM154636 450PWC OS/31/Ol A1800146 130.00 PELSERT MICHAEL GEORGE PEISERT DE�RAA ANN 1925 E NEVADA AVE SAINT PAUL MN 55119-305 �I . � APPLICATION FOR TITI.E AND RfGISTRATiON BY BUYER(S)CONTINUED � CONTRQ�NUMBER ` ' � � ' ' BUYER'S SALES TAX DECLARATiON A FALSE OR FRAUDULEN7 STATEMENT OF PURCHASE PRICE BY ANY PERSON IS R GROSS MISDEMEANOR OR FELONY. REGISTRATION TAX � FULL PURCHASE PR10E . . . . - . . . - - • - $ PLATE FEE LESS TRADE-IN ALLOWANCE . . . . . . . . ARREARS TAX NET PURCNASE PRICE . . . . . . . . . . . . . %OF NET PURCHASE PRiCE . . . -- — P.S.V. FEE LESS TAX PAID TO ANOTHER STATE . . . . TRANSFER TAX NET SALES TAX DUE $ TITLEIfRANSFER FEE TRP,DE-IN WAS R: MODEL YEAR MAKE PLATE QR VEHICLE IDENTiFiCAIION NUMBER SALES TAX t�ECLARE THiS Minnesota Dealer License Number. LATE TRANSFER PENALTY $ TAx EXEMPTION SUBTOTAL CODE: Minnesota Sales Tax Account Number: i intemal Revenue Cocie Number(fRC): STATE/dEPUTY �WNG FEE Prorate Acccunt Number� �� { I (Saies tax d�e when reyistered) TOTAL DUE $ TO DETERMINE EXEMPSION CODE OR ANY TAX AMOUNT,CONTACT A DEPUTY REl31STR R OR THE � � DRNER AWD VEHICIE SERYICES DIVISION I Post Uffice WiH � Not Qeliver Mail VY'�thout Proper Pastage MINNESOTA DEPARTMENT OF PUBLIC SAFETY DRIVER & VEHICLE SERVICES DIViSiON I 445 MINNESOTA STREET SUITE i68 ; ST PAUL MN 55101-5168 � • ; '� i I � , i � � MINI�IEJOrTA DFJ'ARThIFNT OF f"UHI.lC SAF�El�Y narv��vF��r.ss�vic�s wv�atn�a �c�: ��iMN�50TA i7' S'i'.�111��MN '� u IiMD f M!1��iN61Fi.lLP' -�7t) 1!! �I�41�; 'lMl� R[�TlR.�-SS pyrrnrt No.171 PEISERT MICHAEL 6E�R6E s��.� PEISERT DE�ORAH ANN � 1425 E NEVADA AYE ST PAtfL MN 551i9 450PMC � 97 C�H�EV CP�C1S KA0�8�O�,N46 IST SEGURED PARTY 161JC1249YNI5463 Q9/881Q NQ - �E� �� "� _____�_ �«t� �t��f.�� r �F.��tt�1 �li�i'� ��'i��'p��F��f� - ti.�, ;�.,,.,,;. �rck•��I it�r i.�t�� tnt ruri�Kn�F` thc. lacn. S� PAUL POSTAL EMPL CR UN 2�i02 N MCKNICNT RD MORTH SAINT PAUI. MMI 551�9-2290 L.�P f � . . . *�. ��'�!�'�� IIV MESO�TA ��,�,.� � . ♦ +��FtYtFICyII`�� '� LlEN RELEASE ' � . '�� . �i�?'��i►�14lEH�CLE ♦�� l�fs ,��curlty inter�s� �� h��+by rele�sed an � � - l�ate a , ., � x_.__.,,_�:_._.._,.�_.. , . ....w.....�. --- `...,' Tt tle - ti� Sfgnaturs of�AUPA�ari2�d��err; �'� � �� 'ilAp►p�`��f� . �� I�T [�ESTROY '�s -�`� T�is Certlflc�� o� l.i�R .��i�ase musr be attacaed ro rne origlnaJ Certfficate �� 1gle to estabilsh clear ownesship. � �� _ tNVAilD I�FSS��IM IS PAiD F A R M E R� � tERT�KATE Qf LIANttiY I��KE-STATE OF MINNESOU �� : 195609751 1#ICNAEL G PEIS6RT Effedivedde: o3-a6-aoi3 DEBQRRII A PEISER'i' ��; 09-26-Z013 f 925 NGYADI► AYE L SAI NT PAUL YN 55119-3055 �AlCe�er: 21679 I I.LT NOI S f ARAIERS I NSURANCG CO�tP ANY, AURCRA, I LLI NOI S ,an authacized Minnesorn tnsurer, certihes that it has issued a policp of motoc vehicle Gability insurance as required by Secrion 65B 48 oE the hiinnesota statute,Eor the desccibed motor vehicle(s). Yelr�le�sniptlorc �agBter�d Uras: 1997 CHfVRdLET CAYI�I.IGR 20 BASE/ft5 1Gi JC124$VA1154636 1��L G PEZ�T OffICE1SSUIN6THISURD: P. 0. BOX �49044 ,AU5TI N, TX 78714 Agcntname:TERRY DURBIN INS AGENCY iNC Phoneno: (651) 738-6685 ts-��o e-u Ksep Il�is certiNate m�reNde�t�t�es. a�� 0 � Notice ro Mwnesota Drivers ' Under hlinnewta law,nwnerc of nm�or�•ehicics driven on puhfc rosels must carry no-fsuft and Iiability insum��re on rheir cehicles.�'alid pmof of insurance must he carried in thc vel�icle at all ta�xs.faih�rc to pvvidc Y�ror;t,s��A�d��r�sc�r:�Iqw en:occement oflicer is n misdemeanor and may kad to fines,urryxisonment,snd mvocation oEyour drnnrr.license and vehir.le mt�stcation. Under hfim�esata Iaw,o�xrnlion of au miii�a��rcd motor vchic!c cau reavit in x revocation oC iiceuxc plaics and registmtion tiu thc rc:L•irle 'll�c opent�t's drivistgpricileges mny lx•mvokcd for up to onr ycar.Anqoeu alm is comicte�i oEope�ati��xn uninsumd�•.•laick mnY�: tined up�o=1,000 and stntenced to up to 90 days in jail. Our award-�vi�u�iug I-1clpPoine°�Cl�i�n Scrvicca by t�armcrr tcart�iz nvnilnble 24 houcs e day�3�'�C(1 cjf1�3 A\�'t'Ck l0 IIRt1CIIC�'04iC AUIO CIAtlII IOSS fCtJOC�9[TIIII$L•(09<ISldl:NSS151NIICC�lOVilfly O(Ct'Ct'•I:OOfC�lllfl�[A1110�*IASE lC�A{f O�fC�1IqCCI1H:lll A1 f(�L1C IC7LICSI. P�cesc c�mwct us at:i�or I'snglish:1 N(NI I IclpPoint(1-8110--�35-77G1);nr Pun[ispanot:1 877 Rcc:lamo(l-tt77-7.i2-52GC.) \X�HAT"T'O I)O[N CASG OF AN ACCID("sN'1': 1. 13e aware of yoi�r�xrso�uil saf�ty and diat of od�ers at d�e�ccidcnt sccnc.Chcck for inju;ics and call 911,i�nccded. 2 \i�arn other dnvcrs to prevcnt Cudhcr damagc.Tum on y4tlL I�:t5I1GIT AOd fCt O8fC1�if availablc.Sigual with flesliligLt at niglu. 3. Iro�iCy tlx policc.Afanq tunes a passingdrivcr or bpatander�viU do tl�is t'or you. 4. GeLl�cr the facts.Get die r�ines of witnesses,ab�g priili other ixrunent infomixtion like driver s license y�d phana nuinlxrs, nccidcnt sce�k:xnd vel�icle danagc pl�otos,insur.�nre mfomulion aud veLicle descriptinnt. 5. T3c a�relul whrc pou say-an imeshpuion may�atcr al�ow y�x�rn're not responsible Cor tlu nccident. 6. Report thc nrcidcnt to proper snuhoritics.l3ach stnte has its own myuiremcros for socl�reports.Know»ud compl)'WIfII YOt�C SWLC'S IAV1�. i. CONTACf I U:LYYOINT a.AIM SI'sltViCrS IMMGI)IA ITI.I'!C/.l.L[JS 2�!-tIUURS A UAY A'f (8011)11Ti1.P1'QINC(8W-d.15-77G4).1�OR ASSIS'CANCI•:1'ARA Is.CPAIOUI.�L.I.AMIi AL(877)RI:CI.AMO. Visit www.hpcs.com to kain more alwut}our r.laim xlf-scrv�cc options.It's quiek,conrcnunt and:ilways o�een!Scc pn(iey far ��31� actuul co�•eragc(angua�;c. � Q Ufiat part(s)of your body u�ere injury dizziness, (Intermittent) IigMf�eadedness,flr►termitter►f) (eft arm pain left shoulder pain left torso pain left neck pain upper&lower left arm pain left elbau pain upper left ehest pain upper right ehest pain center of chest pain left hand pain,Top,bottom left fauer side pain,under left rb pain between(eft stioulder blade and spine eonfusion after f�e aceident,(Intermi+tent) argumentative after the aecident,l can t seem to f�andle stress sinee the aecident,(ntermittent� lef�wrist,inner and outer joints sore top of left hand sore multiple abrasions b volar surface of(eft forearm,after aceident u�ent auiay hyperventlating at night on oceasion after aecident trauma relafed signs and symptoms pressure in right/left inner ears,(Intermittent) Nave been very forgetfuf nausea,((ntermittent) unsteadiness on my feet(Intermittent) left abdominal pain fieadaehes,(ocaliZed/left eye socket pain,le{�front forehead above(eft eye but belau top hairline and to the right of the left vertica(hairline,lef�top of head abaat 2 inch baek from the fra�t hairline,left back of head u�ere the back and the side of the head meet at f�e top,left side of head above the lef�ear,Badc rear(eft of head in direet hori2ontal line with(eft ear but in the baek of the head,A!I((ntermittent). nervous/anxiaas lef�trapPZius diseomfort Ief�lauer leg-imer and outer anldes bother me a lat as u�efl as the botbm/left side and rigM side of my foat,also the top of my (ef�foot is 6ott�ring me a lot rig�t lower leg-inner and outer anldes bother me a fot sinee fhe aceident as uiell as the botbm of my right foot,a(so(auer leg boffoms of my feet hurt af�er the aecident pain in left leg above lefl�knee eap /Pr-ror� kirte. �nff J�'' �� .,.�--- pain in lef�leg on fiont imer and outside lauer leg pain in(eft baek of lauer(eg pain in left leg just belau buttoeks inerease pain in(egs,standing/u�alking (eft leg pain(left outer side of leg belau the kriee),(rig�t imer side above the Imee) lef�leg pain(left oufer lauer side of leg ineluding left ankle),(lef�inner side of lower leg including right imer ankle). C;ontusion of(eft leg,uient away (,'ontusion of right feg,u�ent away (oca(ized maculopapufar rash right and lef�leg,u►ent away short breaths,(intermiii�ent 1�-1 _._.- Ulhen did you receive treatment? A: �uly 19,2013 g: �uly 19,2013 �: �ufy 19,2013 D: July 22,2013 E: July 29,2013 F: August 07,2013 G: August 09,2013 N: August 12,2013 I: August 15,2013 J: 3eptember 12,2013 This appointment is preseheduled. For Late in the aftemoon. K September 16;2013 This appoinfmment was preseheduled for early afternoon,Short IUotice: 'i � Oetober 03,2013 This appointment is preset�eduled. For La�e in the aftemoon. � ; Name of IUedical Pr�ariderfs) A: ST'PAU�fl�E AND SAFEIY B: DENISE L.ROUSN/Emergeney(',are l�roviders �: United Kospital,Emergency D: Aspen Medical-�roup,Mapleu�ood E: Aspen MedieaF�roup,I�lapfewood F: United Nospital,Emergeney G: Allina Nea(th United Neart&Vaseular Ginic N: Asped Medical-�roup,Maplewood I: A(lina Nealth llnited Neart&Uascular Ginic J: Allina Group-Nealfh,lUapleuaod K Alfina Nealth United Neart&Vaseular Clinie l.: Allina(-�ealth United Neart&Uascular Ginie Address D`� r-_--° a: po.gox i8i5� St.Pauf,Mn 55118 g: P0.gOX 86 �OCK BOX 12-0910 IUINNEApO�IS,AAN. 55486-0086 �: 333 N.SA�tITN AVE. ST.pAUL, IUN. 55102 D: 1850 geam Ave. IUapleu�ood, MN. 55109 �: 1850 geam Ave. IUapleu�ood,IUN. 55109 F: 333 N.SIUITN AVE. ST.pAUL,MN. 55102 G: 225 Smifh Ave,North Suite 400 St.Paul,IUN. 55102 N: 1850 geam Ave. IUapleu�ood,IUN 55109 I: 225 Smith Ave,Norffi Suite 400 3t.paul,IUN. 55102 J: 1850 geam Ave. IUapleuaod, (UN. 55109 K 225 Smith Ave.North Suite 400 St.paul,IUN. 55102 l: 225 Smith Ave.Norlfi Suite 400 St Paul, lUn.55102 Telepfior►e A: (651)450-7133 0�2 I-888-424-6944- g: I-866-951-6774 C: 651-241-8755 I�: 651-241-9500 E: 651-241-9500 B'� F: 651-241-8755 G: 651-290-0133 N: 651-241-9500 I: 651-290-0133 J 651-241-9500 K 651-290-0133 � 651-290-0133 AllG-02-2813 15:32 From:MApt_Eki00(� GS 65179Si359 To:977456i60 Paae:1�1 � e -C � � ` `��;� 55Q�OOelawtl�'�t�E 661-7933353 � ,,,,, �.. St P4�,i,M11 S519 7�2t�#9 C�O�'t �� A.ugust 2,Z413 To WhatXt�t May Concern: M�ce Pciscrt missed wark from 7/19-29,2413 for a total 4�44.5 haurs. He�oaakcs 17.74 per�aur �ting in 789.43 in lost wages. Katie Estliq Payroll 6512418717 MQdfcal Records Neakh i 12:15:23 p.m. 07-26-2013 2/2 REQUEST F'OR RECORD AMENDMENT Attina Faci(ity Name �� J I PATIENT NAME: I(:J1 d1�1 �. �� r"'�' LEGAL REPRESEIVTATIYE NAME: j�, I .� �p-1 �`3`P��r�#- �:��;�, A��: I9'� il/��►,�� S�P�.��,,/��q ' MEDICAL RECORD��$�,_ PHONE#: �.�j��'�'��5 � Pleate n�e:The facility genaalf�r cannot m�f�e anxndmenb to docurneets that wse�e nat ori�inerod at this faciiity,�tess the ai�l prnvidedfscilety is ncw u�va�abk.Pkase car�a tbe appe�oprire�ciiity if cbcxtments in quation wene arahed and a�aielsined at a�odier�'licy. iNFORMATtON YOU WtSH TO H�►VE AMENDED: �r. RQUSh� ��n�dE �. I,g-t,,y ra 3 D�e of Admission or Tr�t QT-1�;�,,Q j,� Autbor of docu� Docue�enr. ', .�K Discharge Sunuaary �Opastive Report Q E�y R,eoord(s) �7Casa�ation .K �Histocy�Physicai (7 Ch�nicat Uepeedaacy/Dtw�or AkoM!Ab�ae Treabae�Rtoords ��Pro�ress No�e(s) U Ctnric OtRne Y'�t Note(a) OOtfier Pla�e espbis iq detail t�s specilic�[ormstioe}ror wirh b b�ve amead�: Your F_D_ niaQnnaic ic�� Your diaQnoses �rere M� (MOTOR VEFiICLE ACCIDENT) ,ELBOW PAIN, RIGHT _3,,'�___ 1_N�REGT. IT SHOULD ��AY ELBOW P�N�� . T SID .,`�I�PORT DID NOT SAY 1 HAD ISSUES WITH MY LEFT HAND NOR MY LEFT BACK. THANK YOi � Patlest/Lepi R�p�tativc Sipest�rr. p� �'1� FOR FAClLfTY USE ONLY D�e uaen�nent tequest[ecdv�od: Sta�'Reaivins: Approvrd PaMy APPruved Not APPo+rod Explain wlrst was sPpv�+not apProved: I 8r Tide: pme sy Pn�►�;,�, � Date R�od�n+�db t�k.shh!a�'ornatioo Mgmc Heafth Information ServlOa United Hospital ��r� 333 North Smith Ave. � -•�.r , t „ " ' ! � � i ��; � � � . �r` ;: . � . � .� , �;. . �, . � �. M �,1 � � : �� jll ; -�:. ; . 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