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Employee Injuries/OSHA 200 Logs/Insurance Claims Basic Instruction Sheet Employee Injuries: When an employee is injured while on the job or if an employee J job reports an injury they must fill out a REPORT OF INJURY FORM. The employee's supervisory must fill out a SUPERVISOR'S REPORT OF ACCIDENT FORM. Both of the forms can be found in my desk in the top left-hand file cabinet drawer under the Safety or the Insurance folder. After you receive both forms they should be faxed to Berkley Administrators at 651-215- 4185. They will send you a claim confirmation. I usually keep all of the forms, correspondence, bills, insurance paperwork and related items paper clipped together. For the current year you can keep them in the Forms: 1 S`RPT of In u folder in my desk or P I r1' Y in the First Report of Injury Forms in the master file in the vault filed under insurance. J rY surance. OSHA 200 LOGS: These forms must be kept up to date. After you receive a FIRST REPORT OF INJURY FORM from an employee you should review the instructions for OSHA 200 which are located in the OSHA 200 LOGS File in the master insurance file in the vault. Basically, "you are required to record information about every occupational death; every nonfatal occupational illness; and those nonfatal occupational injuries which involve one or more of the following: loss of consciousness, restriction of work or motion,transfer to another job, or medical treatment (other than first aid)." The 200 log is located on the computer system in the Excel Program under(My Documents/Saftey/(the Year)you can use the blank one to start u p a new year. The reports must be kept for 5 years. The reports must be posted no later than February 1 and must remain in place until March 1st. Insurance Claims: From time to time citizens my want to file a claim against the Y g City. After the City receives notification you should sent a written letter or fax to the League of Minnesota Cities Insurance Trust(LMCIT) claims department or to Landmark Insurance (our insurance company). Make sure you gather the following information from the person making the claim—name,phone, date of occurrence, a description of the circumstances. The City itself may also have to file a claim with the insurance company, such as a vehicle accident or a property claim. The best way to do this is to contact Landmark Insurance. Each of the two types of claims described above receives their own folder and all related paper work is kept in the folder in the redrope file of the insurance master file in the vault. C:\My Documents\Insurance Instructions.doc t OMB DISCLOSURE STATEMENT Public reporting burden for this collection of information is estimated to vary from 4 to 30(time in minutes)per response with an average of 15(time in minutes)per response,including the time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments regarding this estimate or any other aspect of this information collection,including suggestions for reducing this burden,please send them to the OSHA Office of Statistics,Room N-3644,200 Constitution Avenue,N.W.Washington,D.C.20210 Instructions for OSHA No.200 I.Log and Summary of Occupational Injuries and Illnesses Each employer who is subject to the recordkeeping requirements of the Occupational Safety and Health Act of 1970 must maintain for each establishment,a log of all recordable occupational injuries and illnesses. This form(OSHA No.200)may be used for that purpose. A substitute for the OSHA No.200 is acceptable if it is as detailed,easily readable,and understandable as the OSHA No.200. Enter each recordable case on the log within six(6)workdays after learning of its occurrence. Although other records must be maintained at the establishment to which they refer,it is possible to prepare and maintain the log at another location,using data processing equipment if desired. If the log is prepared elsewhere,a copy updated to within 45 calendar days must be present at all times in the establishment. Logs must be maintained and retained for five(5)years following the end of the calendar year to which they relate. Logs must be available (normally at the establishment)for inspection and copying by representatives of the Department of Labor,or the Department of Health and Human Services,or States accorded jurisdiction under the Act. Access to the log is also provided to employees,former employees and their representatives. II.Changes in Extent of or Outcome of Injury or Illness If,during the 5-year period the log must be retained,there is a change in an extent and outcome of an injury or illness which affects entries in columns 1,2,6,8,9,or 13,the first entry should be lined out and a new entry made. For example,if an injured employee at first required only medical treatment but later lost workdays away from work,the check in column 6 should be lined out and checks entered in columns 2 and 3 and the number of lost workdays entered in column 4. In another example,if an employee with an occupational illness lost wordays,returned to work,and then died of the illness,any entries in columns 9 through 12 would be lined out and the date of death entered in column 8. The entire entry for an injury or illness should be lined out if later found to be nonrecordable. For example,an injury which is later determined not to be work related,or which was initially thought to involve medical treatement but later was determined to have involved only first aid. III.Posting Requirements A copy of the totals and information following the total line of the last page for the year,must be posted at each establishment in the place or places where notices to employees are customarily posted. This copy must be posted no later than February 1 and must remain in place until March 1. Even though there were no injuries or illnessed during the year,zeros must be entered on the totals line,and the form posted. The person responsible for the annual summary totals shall certify that the totals are true and complete by signing at the bottom of the form. IV.Instructions for Completing Log and Summary of Occupational injuries and illnesses �!C 5ey)'^z..4,z Column A-CASE OR FILE NUMBER.Self Expanatory –use- -~ — Column B-DATE OF INJURY OR ONSET OF ILLNESS For occupational injuries,enter the date of the work accident which resulted in the injury. For occupational illnesses,enter the date of initial diagnosis of illness,or,if absence from work occurred before diagnosis,enter the first day of the absence attributable to the illness which was later diagnosed or recognized. Columns C through F-Self Explanatory Columns 1 and 8-INJURY OR ILLNESS-RELATED DEATHS-Self Explanatory Columns 2 and 9-INJURIES OR ILLNESSES WITH LOST WORKDAYS-Self Explanatory Any injury which involves days away from work,or days of restricted work activitiy,or both,must be recorded since it always involves one or more of the criteria for recordability. Columns 3 and 10-INJURIES OR ILLNESSES INVOLVING DAYS AWAY FROM WORK-Self Explanatory Columns 4 and 11-LOST WORKDAYS--DAYS AWAY FROM WORK. Enter the number of workdays(consecutive or not)on which the employee would have worked but could not because of occupational injury or illness. The number of lost workdays should not include the day of injury or onset of illness or any days on which the employee would not have worked even though able to work. NOTE:For employees not having a regularly scheduled shift,such as certain truck drivers,construction workers,farm labor,casual labor,part-time employees,etc.,it may be necessary to estimate the number of lost workdays. Estimates of lost workdays shall be based on prior work history of the employee AND days worked by employees,not ill or injured,working in the department and/or occupation of the ill or injured employee. Columns 5 and 12-LOST WORKDAYS--DAYS OF RESTRICTED WORK ACTIVITY. Enter the number of workdays(consecutive or not)on which because of injury or illness: (1)the employee was assigned to another job on a temporary basis,or (2)the employee worked at a permanent job less than full time,or (3)the employee worked at a permanently assigned job but could not perform all duties normally connected with it. The number of lost workdays should not include the day of injury or onset of illness or any days on which the employee would not have worked even though able to work. Columns 6 and 13-INJURIES OR ILLNESSES WITHOUT LOST WORKDAYS-Self Explanatory Columns 7a through 7g-TYPE OF ILLNESS. Enter a check in only one column for each illness. TERMINATION OR PERMANENT TRANSFER-Place an asterisk to the right of the entry in columns 7a through 7g(type of illness)which represented a termination of employment or permanent transfer. V.Totals Add number of entries in columns 1 and 8. Add number of checks in columns 2,3,6,7,9,10 and 13. Add number of days in columns 4,5,11 and 12. Yearly totals for each column(1-13)are required for posting. Running or page totals may be generated at the discretion of the employer. In an employee's loss of workdays is continuing at the time the totals are summarized,estimate the number of future workdays the employee will lose and add that estimate to the workdays already lost and include this figure in the annual totals. No further entries are to be made with respect to such cases in the next year's log. VI.Definitions OCCUPATIONAL INJURY is any injury such as a cut,fracture,sprain,amputation,etc.which results from a work accident or from an exposure involving a single incident in the work environment.NOTE:Conditions resulting from animal bites,such as insect or snake bites or from one-time exposure to chemicals,are considered to be injuries. OCCUPATIONAL ILLNESS of an employee is any abnormal condition or disorder,other than one resulting from an occupational injury,caused by exposure to environmental factors associated with employment. It includes acute and chronic illnesses or diseases which may be caused by inhalation,absorption,ingestion,or direct contact. The following listing gives the categories of occupational illnesses and disorders that will be utilized for the purpose of classifying recordable illnesses. For porposes of information,examples of each category are given. These are typical examples,however,and are not to be considered the complete listing of the types of illnesses and disorders that are to be counted under each category. 7a. Occupational Skin Diseases or Disorders.Examples:Contact dermatitis,eczema,or rash caused by primary irritants and sensitizers or poisonous plants;oil acne;chrome ulcers;chemical burns or inflamation,etc. 7b.Dust Diseases of the Lungs(Pneumaconioses). Examples:Silicosis,asbestosis and other asbestos-related diseases,coal worker's pneumaconioses,byssinosis,siderosis,and other pneumaconioses. 7c.Respiratory Conditions Due to Toxic Agents. Examples:Pneumonitis,pharyngitis,rhinitis or acute congestion due to chemicals,dusts,gases, or fumes;farmer's lung;etc. 7d. Poisoning(Systemic Effects of Toxic Materials). Examples:Poisoning by lead,mercury,cadmium,arsenic,or other metals;poisoning by carbon monoxide,hydrogen sulfide,or other gases;poisoning by benzol,carbon tetrachloride,or other organic solvents;poisoning by insecticide sprays such as parathion,lead arsenate;poisoning by other chemicals such as formaldehyde,plastics,and resins;etc. 7e. Disorders Due to Physical Agents(Other than Toxic Materials). Examples: Heatstroke,sunstroke,heat exhaustion,and other effects of environmental heat,freezing,frostbite,and effects of exposure to low temperatures;caisson disease;effects of ionizing radiation(isotopes, X-rays,radium);effects of nonionizing radiation(welding flash,ultraviolet rays,microwaves,sunburn);etc. 7f. Disorders Associated with Repeated Trauma. Examples:Noise-induced hearing loss;synovitis,tenosynovitis,and bursitis. Raynaud's phenomena;and other conditions due to repeated motion,vibration,or pressure. 7g. All Other Occupational Illnesses. Examples:Anthrax,brucellosis,infectious hepatitis,malignant and benign tumors,food poisoning, histoplasmosis,coccidioidomycosis,etc. MEDICAL TREATMENT includes treatment(other than first aid)administered by a physician or by registered professional personnel under the standing orders of a physician. Medical treatment does NOT include first aid treatment(one-time treatment and subsequent observation of minor scratches,cuts,bums,splinters,and so forth,which do not ordinarily require medical care)even though provided by a physician or registered professional personnel. ESTABLISHMENT:A single physical location where business is conducted or where services or industrial operations are performed(for example:a factory,mill,store,hotel,resturant,movie theater,farm,ranch,bank,sales office,warehouse,or central administrative office). Where distinctly separate activities are performed at a single physicial location,such as construction activities operated from the same physical locations as a lumber yard,each activity shall be treated as a separate establishment. For firms engaged in activities which may be physically dispersed,such as agriculture;construction;transportation;communications and electric,gas,and sanitary services,records may be maintained at a place to which employees report each day. Records for personnel who do not primarily report or work at a single establishment,such as traveling salesmen,technicians,engineers,etc., shall be maintained at the location from which they are paid or the base from which personnel operate to carry out their activities. WORK ENVIRONMENT is comprised of the physical location,equipment,materials processed or used,and the kinds of operations performed in the course of an employee's work,wether on or off the employer's premisis. 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Li 0 j • L o � 8 sa _g y � Q T a ?D Q 3 3. m t,�j `J o:000 ,< '2° :O. p �O ; ; C § °- V I p°2a�_.w�?3°43mm 3 o' g ° D 3? °pc °mend o i.' o m m I gg ° 5 (� le 3 X�iAa °m Ca` �' s r> I'a °, r g. to ( $ t ?= °.: ; r a ° ° S" = 'r N o a�9.09 - s i° -� - � ' - (n -n Q ` ?' Occupational skin Z o < 7'�' o Z diseases or disorders m / ii- o <7 T w T ' Dust diseases of =O x �• the lungs Z. a 3 Cl. = n Respiratory condition 0 { m 0 ■ . due to toxic agents i Sap G W or D E- : Poisoning(systemic et- p 3 c g r _ Ci ■ ■ , facts of toxic materials) 3 5 o Disorders due to Z 3' D (j physical agents 1 o mai• Disorders associated 3. Z G r M with repeated trauma . z r m' Q C ° All other occupa- r don;illnesses D —� m n= -Ti ii b a _ S v,7N, m M ', g-F igo ;fix° II tt to C ?..< 81/74 I 3> 0 0 3d x° -< o i _ pgm a 0 al o 3 a _ D Or 1151- 3 0 .____ I -c m _ o ' ill 133 ° `� m8 � x 0 St JcaJe /0 ',ai" .9a a wq3 ✓` " ` L �"d r . = � � z`(-`4- d /."-'- ` City k Park Heights 14168 of Oak Park k Blvd. Box 2007 fffr Oak Park Heights,MN 55082 7Qd Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: Matt Hanley—LMCIT Fax: 651-281-1297 From: Judy Holst Date: 9-30-04 Re: File No. 1104887—Stone Damage Pages: 2 CC: ❑ Urgent ❑For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle I Notes: The City of Oak Park Heights has now paid George Siegfried Construction Company $880.00 for installing the stone monument at the entrance to City Hall. The invoice is attached. The damaged plants will not be replaced until next spring. The City Arborist thinks that although they were damaged,they may come back in the spring. I will let you know when or if any need to be replaced. Thanks, Judy Holst GEORGE SIEGFRIED CONSTRUCTION COMPANY General Contractors 510 Perro Creek Dr. - P.O. Box 67 - Bayport, MN 55003 (651) 275-1112 • FAX (651) 275-1113 REQUEST FOR PAYMENT September 23, 2004 TO: City of Oak Park Heights PO Box 2007 Oak Park Heights, MN 55082 Invoice No: 0904-51 Project: City of Oak Park Heights Installation of stone monument sign. Project Manager: Eric Johnson Contract/PO No: Contract/PO Date: Our letter dated 6/24/04. Contract/PO Amount: $880.00 Change Order$$: Revised Contract: Pay Request No: 1 &final. Period Covered: Aug-04 We request payment for work complete on above project as follows: Total complete and stored to date $880.00 Less Retainage $0.00 Total earned less retainage.............................. $880.00 Less Previous Payments.................. $0.00 Current Payment Due............................................. $880.00 SEP 2 7 2004 ,,Lr t It CITY OF OAK PARK HEIGHTS mAr 14168 North 57th Street•P.O.Box 2007• Oak Park Heights,MN 55082 • Phone:(651)439-4439 - Fax 439-0574 Municipal Arborist-Katharine Widin Recommendations - City Tree Program Date: 144 / ,4 Name: f "' - 6i.45-k--- Address: P \ Boulevard Tree` Tree in Yard Problem: saftuLi.„7 . c� t v-c-e5 Recommendations: "4,"°.) WHEN USING PESTICIDES, OBSERVE PROPER SAFETY PRECAUTIONS AND ALWAYS FOLLOW LABEL DIRECTIONS. Tree City U.S.A. • Matthew Hanley Claims Adjuster League of Minnesota Cities League of Minnesota Cities Claims Department Insurance Trust 145 University Avenue West,St.Paul,MN 55103-2044 ` 145 University Avenue West (651)281-1200 • (800)925-1122 L i K St. Paul, MN 55103-2044 Fax:(651)281-1297 • TDD:(651)281-1290 (651) 215-4096 www.lmnc.org (651) 281-1297--Fax ' mhanley@lmnc.org w Cities promoting eelle a www.lmcit.lmnc_org JWLEDGMENT OF CLAIM o ;l OAK PARK HEIGHTS, CITY OF • 14168 OAK PARK BLVD JUL I fi 2004 P.O. BOX 2007 STILLWATER MN 55082 Date: 7/12/04 RE: Our File No. : 11048897 LMCIT Member: OAK PARK HEIGHTS, CITY OF Claimant Name: OAK PARK HEIGHTS, CITY OF Occurrence/Loss Date: 6/10/04 Claim Description: STONE MOVEMENT AT CITY HALL DAMAGED Supervisor: DARIN RICHARDSON Phone No. : (651)281-1283 Fax No. : (651)281-1297 Adjuster: MATT HANLEY Phone No. : (651)215-4096 or 1-800-925-1122(outstate), Extension 4096 Fax No. : (651)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also available to you at any time. LMCIT Claims Department C.C. FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS 232 S LAKE ST FOREST LAKE MN 55025- AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER • • • • : ''' 1'4 le . `� „ lit r IPS .4 s City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 1 facsimile transmittal To: Matt Hanley Fax: 651-281-1297 1 1 From: Judy Hoist Date: 7-14-04 Re: File#11048897—City Hall Damage Pages: 2 CC: ❑ Urgent ❑For Review ❑ Please Comment ❑ Please Reply ❑Please Recycle Notes: Attached is a copy of the fax I received from the City Arborist with a cost estimate for the plants that were damaged when the City monument sign was pushed over. Please let me know if you need any further information. Thanks, Judy udy Hoist From: kdwidin @comcast.net Sent: Wednesday, July 14, 2004 6:45 AM To: Judy Hoist Subject: Plants Damaged in Sign Vandalism Judy- The perennial plants which were damaged when the City monument sign was pushed over include: 3 'Stella D'Oro' daylilies, 3 hardy geraniums and 2 coral bells. Replacement plants will cost approximately$10 apiece for a total of$80. Contact me if you need more information. Kathy Widin Arborist City of Oak Park Heights CJG1UPROPH OAK PARK HEIGHTS POLICE DEPARTMENT DATE 7/02/04 TIME 9 :31 : 14 INITIAL COMPLAINT REPORT 104702369 DATE/TIME REPORTED: 6/10/04 8:29 :49 DISPATCHER: PGHOPPE DATE/TIME STAMP: 6/10/04 8 :29 :49 ENTERED BY: PGHOPPE LOCATION OF INCIDENT: 14168 OAK PARK BLVD N GRID: OAK PARK HEIGHTS, MN 55082 INCIDENT RECEIVED BY: DEPUTY OFFICERS ASSIGNED: 472 HOPPE NAMES ASSOCIATED PAUL HOPPE WITH THIS INCIDENT: PHONE: (H) (W) SEX: DOB: ASSOCIATION: COMPLAINANT DAMAGE TO CITY PROPERTY CITY HALL OAK PARK HEIGHTS 14168 OAK PARK BLVD N OAK PARK HEIGHTS, MN 55082 PHONE: (H) 651/439-4439 (W) SEX: DOB: ASSOCIATION: VICTIM OWNER OF STONE PILLAR OFFICER COMMENTS: SOMETIME OVER NIGHT SOMEONE HAD TIPPED OVER THE STONE 472 6/10/04 PILLAR AT THE ENTRANCE TO CITY HALL. UNKNOWN SUSPECTS . 472 6/10/04 CLASSIFIED AS: PROP DAMAGE—MS—PRIVATE—INTENT INJURE P3111 c.a.a D?__i-t1- 7 --/-3 tr; 34 7.' a `SIEGFRIED CONST Fax : 651-275-1113 Jun 24 '04 08:49 P.01 I GEORGE SIEGFRIED CONSTRUCTION COMPANY General Contractors 510 Perro Creek Dr. - P.O. Box 67 - Bayport, MN 55003 (651) 275-1112 • FAX(651) 275-1113 June 24, 2004 Eric Johnson City of Oak Park Heights Re: Stone Monument Sign Eric; We submit two options and prices for the installation of your stone sign as follows. option I; Clean base and bottom of stone. Lay bed of Hilti HIT-HY 150 epoxy adhesive on base. Set stone in epoxy bed. Labor and material $ 880.00 option II; Clean base and bottom of stone. Drill and epoxy six #5 dowels in bottom of stone. Drill six holes in concrete base to receive dowels. Fill holes with epoxy and set stone. Labor and material $ 1,338.00X We could have the work done by August 1st. John Siegfried oph.l ja City of Oak Park Heights <• 14168 Oak Park Blvd,Box 2007•Oak Park Heights,MN 55082•(651)439-4439•Fax 439-0574 ssti� -0,37-27f— Memo April 4, 2000 To: Tom Melena From: Kris Danielson, Community Development Director 1;%,, ,._.,,,r Q ��,. .. a '7,.. Please be advised that staff has received revised proposals for the entrance sign to City Hall. As you are aware, we have researched and obtained proposals for a variety of signage styles that include natural stone signs, custom wooden signs, and cast concrete signs. A copy of the revised proposal from Rivard Stone is enclosed for your review. Please let me know if you have any questions regarding this type of sign which is comparable to the sign at the Bayport Marina. The total estimated cost for this sign is $3,226.00. TREE CITY U.S.A. PROPOSAL • • Page No `MJ 715- ' .'/7- ✓ "LAG X57 - y.5 '7- os 3 of Pages PROPOSAL SUBMITTED TO: PHONE DATE _ f_c"u" ., +IE JOB NAME �/ OF / /L� ■ , STREET ✓ STREET . .•E' C : � STY V TATE � r^ ht• 4CITY T t r !4 1 STAT . r '. , Ye�gr+t G c �w� i x� � s't r * ' 3 ( �+ z` !x k y..d : Fa s s •) ,mspee a i ors arid esama�e fo . y r , � ,: _hereby s b gt z :1 , L We � e AK P.ok 17676-75 . - ctry /4 Ai( • �M /may y c'rf v'r s i.. . x • + rrti ix• We hereby propose to furnish labor and materials - complete.i accordance with the above specifications,-for the sum of dollars ($ iTGrzr�.o�-' ) with payment to be made as follows: • All material is guaranteed to be as specified All work to be completed in a workmanlike,manner according to standard practices any alteration or deviation from above specifications involving extra costs, will be executed only upon written orders, and will become an extra charge over and above the estimate All agreements contingent upon strikes,accident or delays beyond our control.This proposal subject to acceptance within days and is void • thereafter at the option of the undersigned. r• Authorized Signature ACCEPTANCE O' PROPOSAL Tli above prices, specifications and conditions are hereby accepted You are authorized to do the work as specified.Payment will be made c tlined above. ACCEPTED: Signature DATE Signature 11/4E-Z Contractors Forms FORM NO.EZ 110 � Ho ,. l From: Eric A. Johnson Sent: Friday, July 30, 2004 10:08 AM To: Judy Holst Subject: RE: Stone Repair Early august Original Message From: Judy Hoist Sent: Friday, July 30, 2004 9:08 AM To: Eric A. Johnson Subject: Stone Repair Have you heard anything from Geo. Siegfried Construction as to when they are going to fix the stone? r PARTS&SERVICE HOURS: Sreaciettee,r MON-THURS.7:00 A.M.TO 7:00 P.M. FRI 7:00 A.M.TO 6:00 P.M. SAT 8:00 A.M.TO 4:00 P.M. M 0 T®R S BUS: (651)439.4333 COMPLETE BODY SHOP HOURS: FAX 651 439 4425 MON-THURS.7:00 A.M.TO 6:00 P.M. ( ) FRI 7:00 A.M.TO 5:00 P.M. BUICK • CHEVROLET • JEEP TOLL FREE(800)544-3592 FREE ESTIMATES •FAMILY OWNED SINCE 1922• SALES HOURS: 5900 Stillwater Boulevard North•P.O.Box 337 MON-THURS.8:30 A.M.TO 9:00 P.M. Stillwater,MN 55082 FRI 8:30 A.M.TO 6:00 P.M. SAT 8:30 A.M.TO 5:00 P.M. CUSTOMER NO. ADVISOR TAG NO. INVOICE DATE INVOICE NO. 4428 CARL CHRISTIANSON 260 014 08/02/04 CVCB40584 LABOR RATE LICENSE NO. MILEAGE 110 701 CO LACKWHITE/ STOCK NO. CITY OF OAK PARK HEIGHTS 14168 OAK PARK BLVD YEAR/MAKE/MODEL DELIVEAY DATE DELIVERY MILES P 0 BOX 2007 95/CHEVROLET/IMPALA/CAPR 07/24/95 0 OAK PARK HEIGHTS, MN 55082 VEHICLE I.D.NO. 1O 1 BL 5 2 P 4 SR 1 8 4 5 2 1 SELLING DEALER NO, PRODUCTION DATE F.T.E.NO. P.O.NO. Rdi7 9/04 RECbI�EO{CE PM_3639 Tins.S21-1,723 COMMENTS (J// MO: 110701 O 11 I `F3`1 �}�L JUK# 1 GHARU.S- --•------•--------------- ------------....-----------r---__,_-•---•--- STATEMENT OF DISCLAIMER LABOR The factory warranty constitutes all of the war- J# 1 96CVZ BODY REPAIR HOURS: 1.50 TECH(S):988 69.00 ranties with respect to the sale of this LT FRT DOOR MIRROR BROKEN / REPLACE item/items.The Seller hereby expressly dis- claims all warranties either express or implied, PARTS QTY---FP-NUMBER------•-•------DESCRIPTION•-•- ---------1-UNIT PRICE- including any implied warranty of merchant- 1 10231121 MIRROR OS 10.185' 222.24 222.24 ability or fitness for a particular purpose.Seller TOTAL PARTS 222.24 neither assumes nor authorizes any other person to assume for it any liability in connec- JOB# 1 TOTALS-•------------•--------•__...-----_________................. tion with the sate of this item/items. PARTS 222.24 JOB# 1 JOURNAL PREFIX CVCB JOB# "1 TOTAL 29L24 4 JOB# 2 CHARGES _ ----- -- _ ))/)C' LABOR ---- -- ----- - - --. --- - r J# 2 95CVZ BODY REFINISH HOURS: 0.50 TECH(S):251 23.00 7 REFINISH MIRROR s� G.O.G. & SUPPLIES { 1.0 PAINT MATERIALS @ 12.500 /UNIT 12.50 TOTAL - GOG 12.50 - ' r` a JOB# 2 TOTALS LABOR 23.00 ' G.O.G. 12.50 JOB# 2 JOURNAL PREFIX CVCB JOB# 2 TOTAL 35.50 �• `�1 TOTALS 0. ************************************************ TOTAL LABOR,._• 92.00 * * TOTAL PARTS.... 222.24 GOOC�1Alrr21'iCh i * C ] CASH C ] CHECK CK NO. [ ] * TOTAL SUBLET... 0.00 Service Service ice TOTAL G.O.G.... 12.50 N * [ ] VISA [ ] MASTERCARD [ ] DISCOVER * TOTAL MISC CHG. 0.00 * * TOTAL MISC DISC 0.00 See us for guarantee details. 8 * [ ] AMER XPRESS [ ] OTHER [ ] A/R * TOTAL TAX...... 14.45 www.gmgoodwrench.com * * t * DATE PAID / / CASHIER INITIALS * TOTAL INVOICE $ 341.19 rr i THANK YOU FOR YOUR BUSINESS!! a'nERIGw I'::RI OF OAK PARK HEIGHTS LESS 1attc GIAIMS ENDORSEMEN k I ' MasterCard CUSTOMER SIGNATURE ALLOWED IN THE SUM OF$ , Y —DISALLOWED IN THE SUM OF$..-113 41, a DATE 41 . r, „155:?]7 E SIGNATURE fli ••- .w - "7":!-74.-": i $ PAGE 1 OF 1 CUSTOMER COPY [ END OF INVOICE ]12:04pm ALL PARTS NEW ORIGINAL EQUIPMENT, UNLESS OTHERWISE SPECIFIED • - $ CJG1UPROPH OAK PARK HEIGHTS POLICE DEPARTMENT DATE 8/02/04 TIME 15 : 34:24 INITIAL COMPLAINT REPORT 104702938 DATE/TIME REPORTED: 7/16/04 16:47 :01 DISPATCHER: SLBUCKL DATE/TIME STAMP: 7/16/04 16 :47 :01 ENTERED BY: SLBUCKL LOCATION OF INCIDENT: 5600 OSGOOD AV N GRID: 56TH ST AT OSGOOD AV OAK PARK HEIGHTS, MN 55082 INCIDENT RECEIVED BY: DEPUTY OFFICERS ASSIGNED: 475 BUCKLEY NAMES ASSOCIATED STANLEY BUCKLEY WITH THIS INCIDENT: PHONE: (H) (W) SEX: DOB: ASSOCIATION: COMPLAINANT DAMAGE TO SQUAD #51 OFFICER COMMENTS: FOUND SOMEONE HAD BROKEN THE LEFT OUTSIDE MIRROR OFF OF 475 7/16/04 SQUAD #51 WHILE IT WAS PARKED ON OSGOOD AT 58TH AT. 475 7/16/04 CLASSIFIED AS: PROP MG—GM—PRIVATE—INTENT INJURE P2111 h•. rzywc w 4V5 cr(- -- hvayE THEW 41- cz V -�c ON) CQAN—T'?ez 4 ---,tv i ` . ���� ` pufzA Catitx. _ Lfriqc, r/ 7 J ( \ City of Oak Park Heights "-C ) 14168 Oak Park Blvd. Box 2007 d,LL d-•.7 6-to Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 -z-4.)Y facsimile transmittal To: Ian Coakley Fax: 651-281-1297 From: Judy Hoist Date: 5-28-04 Re: File No. 11048303-Ford Expedition Pages: 2 CC: ❑ Urgent ❑For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle Notes: Here's the bill from Grafix Shoppe for repairs to the 2003 Ford Expedition. I assume you will pay Grafix Shoppe for the repairs. Please let me know when these bills have been paid. Thanks,Judy E • G� \�S.S.O.�/- E Invoice 3240 Mike Collins Drive e ,x Eagan, MN 55121 651-683-9665 Main 5/26/2004 35757 651-683-9740 Fax Oak Park Heights Police Dept. Oak Park Heights Police Dept. Accounts Payable Att: Chief Lindy Swanson P.O. Box 2007 14168 Oak Park Blvd N. Oak Park Heights, MN 55082 Oak Park Heights, MN 55082 K Net 30 6/25/2004 SHA THERE 1 Custom POLICE Lettering for the Tailgate of a 48.00 48.00T White 2003 Ford Expedition 1 Unit Number 32 for the Tailgate of a White 2003 8.00 8.00T Ford Expedition 1 Application There. 55.00 55.00T Application 5-25-04 at 8:30 CITY OF O AK PARK HEIGHTS CLAIMS ENDORSEMENT yz._ ~ALLOWED IN THE SUM OF$ : e DISALLOWED IN THE SUM OF$ DATE -7-2-----6 1�,/ SIGNATURE w'I �'4 Subtotal $111.00 Thank you for your business. Sales Tax(6.5%) $7.22 Check us out on the web at www.grafixshoppe.com Total $118.22 Payments/Credits $0.00 Balance Due $118.22 I • • fil • ' b 7a � City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: Ian Coakley Fax: 651-281-1297 Y From: Judy Holst Date: 5-27-04 Re: File No. 11048303—Ford Expedition Pages: 7 CC: ❑ Urgent ❑For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle NOteS: Here's the bill from Stillwater Motors for repairs to the 2003 Ford Expedition. Per our conversation you will pay Stillwater Motors for the repairs less the$500 deductible. The City will remit$500 to Stillwater Motors. When I receive the bill for the graffics I will submit it to you for payment. Thanks for your help. PARTS&SERVICE HOURS: Sec,Ilyee,(Aelereejt MON-THURS.7:00 A.M.TO 7:00 P.M. FRI 7:00 A.M.TO 6:00 P.M. SAT 8:00 A.M.TO 4:00°P.M. MOTORS BUS: (651)439-4333 COMPLETE BODY SHOP HOURS: FAX: (651)439-0425 MON-THURS.7:00 A.M.TO 6:00 P441: FRI 7:00 A.M.TO 5:00 P.M. BUICK • CHEVROLET • JEEP TOLL FREE(800)5443592 FREE ESTIMATES •FAMILY OWNED SINCE 1922• SALES HOURS: 5900 Stillwater Boulevard North'P.O.Box 337 MON-THURS.8:30 A.M.TO 9:00 P.M. Stillwater, MN 55082 FRI 8:30 A.M.TO 6:00 P.M. SAT 8:30 A.M.TO 5:00 P.M. CUSTOMER NO. ADVISOR TAG NO. INVOICE DATE INVOICE NO. 4428 CARL CHRISTIANSON 260 084 05/19/04 CTCB35268 LABOR RATE LICENSE NO. MILEAGE COLOR STOCK NO. CITY OF OAK PARK HEIGHTS 29,803 / 14168 OAK PARK BLVD YEAR/MAKE/MODEL DELIVERY DATE DELIVERY MILES P 0 BOX 2007 03/FORD TRUCK/EXPEDITION/4 DOOR UTIL OAK PARK HEIGHTS, MN 55082 VEHICLE I.D.NO. SELLING DEALER NO. PRODUCTION DATE 1 F M P U 1 6 L 7 3 L B 7 9 5 9 6 F.T.E.NO. P.O.NO. R05/i3/04 "Elf!-41116-3639 B�JSJ,NfSS Ty 73 COMMENTS MO: 29804 JOB# 1 CHARGES - [}�L STATEMENT OF DISCLAIMER LABOR - The factory warranty constitutes all of the war- J# 1 96CVZ ` BODY REPAIR HOURS: 10.20 TECH(S):572 448.80 ranties with respect to the sale of this REAR END DAMAGE item/items.The Seller hereby expressly dis- claims all warranties either express or implied, PARTS QTY- FP NUMBER DESCRIPTION UNIT PRICE- including any implied warranty of merchant- - - "-" ability or fitness for a particular purpose.Seller 1 P/044747 FASCIA 530.23 530.23 1 P/044747 BUMPER 345"62 345.62 neither assumes nor authorizes any other 1 P/044747 LAMP 74.34 74.34 person to assume for it any liability in connec- 1 P/044747 PLATE 23.05 23.05 twn with the sale of this item/Items. 1 P/044806 GATE 816.91 816.91 TOTAL - PARTS 1790.15 JOB# 1 TOTALS-----•- •------•---- - - -------- ------- - ,__-- LABOR 448.80 .PARTS 1790.15 JOB# 1 JOURNAL PREFIX CTCB JOB# 1 TOTAL 2238.95 JOB# 2 CHARGES LABOR-----•--•--•-----------•---------- - -------- •---- ---- "---? 4 05/19/2004 at 04 :28 PM Job Number: 951 35238 STILLWATER MOTOR COMPANY Federal ID #:410561600 5900 STILLWATER BLVD NO. PO BOX 337 STILLWATER, MN 55082 (651) 393-2399 Fax: (651) 351-5197 PRELIMINARY SUPPLEMENT 1 WITH SUMMARY Written by: CARL CHRISTIANSON # Adjuster: Insured: OAK PARK HEIGHTS Claim # Owner: OAK PARK HEIGHTS Policy # Address: Deductible: Date of Loss: Day: Type of Loss: Evening: Point of Impact: Inspect Location: Insurance Company: Days to Repair 2003 FORD EXPEDITION 4X4 XLT 8-5 .4L-FI 4D UTV WHITE Int: VIN: 1FMPU16L73LB79596 Lic: Prod Date: Odometer: Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Keyless Entry Rear .Wiper Body Side Moldings Dual Mirrors Privacy Glass Luggage/Roof Rack Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Driver Seat Power Mirrors Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes Cloth Seats Split Bench Seats 3rd Seat Styled Steel Wheels NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT 1 REAR BUMPER 2 0/H rear bumper 1 . 5 3* SOl Repl Bumper cover XLT, w/o reverse 1 530.23 Incl. 1 . 0 sensing system titanium 4 Add for Clear Coat 0 .4 5* 801 Repl Reinforcement 1 345 . 62 Incl . 6 REAR LAMPS 7* SOl Repl RT Tail lamp assy 1 73 . 34 0 .3 8 LIFT GATE 9* SO1 R&I Trim panel parchment Incl . 10 SO1 R&I Handle XLT black Incl . 11* R&I Emblem Ford oval 0 .2 12* SO1 Repl Nameplate "EXPEDITION" 1 23 . 05 0 .2 1 1 05/19/2004 at 04 :28 PM Job Number: 951 35238 PRELIMINARY SUPPLEMENT 1 WITH SUMMARY 2003 FORD EXPEDITION 4X4 XLT 8-5 .4L-FI 4D UTV WHITE Int : NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT 13# Rpr SAVE DECALS ROGER 0 .5 ++++++++++++++++++ 14* SO1 Repl Lift gate 1 816 . 91 5 . 5 3 .4 15 SO1 Add for Clear Coat 1 .4 16 SO1 QUARTER PANEL 17* SO1 Rpr RT Quarter panel w/wheel 2 . 0 1 .2 opening molding 18 S01 Overlap Major Adj . Panel -0 .4 19 SO1 Add for Clear Coat 0.2 Subtotals ==> 1789 .15 10 .2 7 .2 Parts 1789. 15 Body Labor 10 .2 hrs @ $ 44 . 00/hr 448. 80 Paint Labor 7 . 2 hrs @ 44 . 00 hr 316 . 80 Paint Supplies 7 .2 hrs @ $ 25 . 00/hr 180. 00 SUBTOTAL $ 2734 . 75 Sales Tax $ 1789 . 15 @ 6 . 50001 116. 29 GRAND TOTAL $ 2851 . 04 ADJUSTMENTS: Deductible 0 . 00 CUSTOMER PAY $ 0. 00 INSURANCE PAY $ 2851 . 04 Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR2MC03 Database Date 3/2004 and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (-) items indicate MOTOR Not-Included Labor operations. a gn Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Prices are provided from National Auto Glass Specifications, Inc. Pound sign (#) items indicate manual entries. Pathways - A product of CCC Information Services Inc. 2 05/19/2004 at 04 :28 PM Job Number: 951 35238 PRELIMINARY SUPPLEMENT 1 WITH SUMMARY 2003 FORD EXPEDITION 4X4 XLT 8-5.4L-FI 4D UTV WHITE Int: NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT CHANGED ITEMS 3 Repl Bumper cover XLT, w/o reverse 1 -578 . 50 Incl . -1 . 0 3* SO1 Repl Bumper cover XLT, w/o reverse 1 530 .23 Incl . 1. 0 5 Repl Reinforcement 1 -327 . 77 Inca . 5* SO1 Repl Reinforcement 1 345 . 62 Incl . 7 Repl RT Tail lamp assy 1 -67 .43 -0 . 3 7* S01 Repl RT Tail lamp assy 1 73 .34 0. 3 9* R&I Trim panel parchment -0 . 5 9* SO1 R&I Trim panel parchment Incl . 10 R&I Handle XLT black -0.4 10 SO1 R&I Handle XLT black Incl . 12 Repl Nameplate "EXPEDITION" 1 -19 . 08 -0 .2 12* SO1 Repl Nameplate "EXPEDITION" 1 23 . 05 0 .2 DELETED ITEMS 14* Rpr Lift gate -9 . 0 -2 .4 15 Add for Clear Coat -1 . 0 16# INCLUD SPOT UNDER GATE 1 ADDED ITEMS 14* SO1 Repl Lift gate 1 816 . 91 5 . 5 3 .4 15 SO1 Add for Clear Coat 1 .4 16 SO1 QUARTER PANEL 17* SO1 Rpr RT Quarter panel w/wheel openi 2 . 0 1 .2 18 SO1 Overlap Major Adj . Panel -0 .4 19 S01 Add for Clear Coat 0 .2 Subtotals ==> 796 .37 -2 .4 2 .4 Parts 796 .37 Body Labor -2 .4 hrs @ $ 44 . 00/hr -105 . 60 Paint Labor 2 .4 hrs @ $ 44 . 00/hr 105 .60 Paint Supplies 2 .4 hrs @ $ 25 . 00/hr 60 . 00 SUBTOTAL $ 856 .37 Sales Tax $ 796.37 @ 6 . 5000% 51 . 76 TOTAL SUPPLEMENT AMOUNT $ 908 . 13 NET COST OF SUPPLEMENT $ 908 .13 Estimate 1942 . 91 CARL CHRISTIANSON Supplement S1 908 . 13 CARL CHRISTIANSON CUSTOMER PAY $ 0 . 00 Job Total $ 2851 . 04 INSURANCE PAY $ 2851 . 04 3 c 05/19/2004 at 04:28 PM Job Number: 951 35238 PRELIMINARY SUPPLEMENT 1 WITH SUMMARY 2003 FORD EXPEDITION 4X4 XLT 8-5 .4L-FI 4D UTV WHITE Int: Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR2MC03 Database Date 3/2004 and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. Asterisk (*) or Double Asterisk (**)indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (-.) items indicate MOTOR Not-Included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Prices are provided from National Auto Glass Specifications, Inc. Pound sign (#) items indicate manual entries. Pathways - A product of CCC Information Services Inc. 4 k 05/19/2004 at 04 :28 PM Job Number: 951 PARTS LIST Owner: OAK PARK HEIGHTS 2003 FORD EXPEDITION 4X4 XLT 8-5 .4L-FI 4D UTV WHITE Int: VIN: 1FMPU16L73LB79596 LIC: Prod Date: Odometer: NO. DESCRIPTION PART NUMBER QTY EXT. PRICE 3 Bumper cover XLT, w/o reverse 2L1Z17K835EAA 1 530.23 5 Reinforcement 2L1Z17906BA 1 345 .62 7 RT Tail lamp assy 2L1Z13404AB 1 73 .34 12 Nameplate "EXPEDITION" 2L1Z7842528BA 1 23 . 05 14 Lift gate 2L1Z7840010AA 1 816 . 91 1 rs* ,, City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 one(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: Ian Coakley Fax: 651-281-1297 From: Judy Hoist Date: 5-19-04 Re: Damage estimate 2003 Ford Exp. Pages: 5 CC: ❑ Urgent ❑For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle NoteS:_Here is the estimate for damages on the 2003 Ford Expedition,your file no. 11048303. If you need further information,please contact Lindy Swanson,Police Chief at 651-439-4723 or mayself at 651-439-4439. I will be on vacation until Tuesday,May 25t. 05/19/2004 at 08 :55 AM Job Number: 951 35238 STILLWATER MOTOR COMPANY Federal ID #:410561600 5900 STILLWATER BLVD NO. PO BOX 337 STILLWATER, MN 55082 (651) 393-2399 Fax: (651) 351-5197 PRELIMINARY SUPPLEMENT 1 WITH SUMMARY Written by: CARL CHRISTIANSON # Adjuster: Insured: OAK PARK HEIGHTS Claim # Owner: OAK PARK HEIGHTS Policy #. Address: Deductible: Date of Loss: Day: Type of Loss: Evening: Point of Impact: Inspect Location: Insurance Company: Days to Repair 2003 FORD EXPEDITION 4X4 XLT 8-5 .4L-FI 4D UTV WHITE Int : VIN: 1FMPU16L73LB79596 Lic: Prod Date: Odometer: Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Keyless Entry Rear Wiper Body Side Moldings Dual Mirrors Privacy Glass Luggage/Roof Rack Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Driver Seat Power Mirrors Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes Cloth Seats Split Bench Seats 3rd Seat Styled Steel Wheels NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT 1 REAR BUMPER 2 0/H rear bumper 1. 5 3 Repl Bumper cover XLT, w/o reverse 1 578 .50 Incl. 1 . 0 sensing system titanium 4 Add for Clear Coat 0 .4 5 Repl Reinforcement 1 327 .77 Incl . 6 REAR LAMPS 7 Repl RT Tail lamp assy 1 67 .43 0 .3 8 LIFT GATE 9* SO1 R&I Trim panel parchment Incl . 10 S01 R&I Handle XLT black Incl . 11* R&I Emblem Ford oval 0 .2 12 Repl Nameplate "EXPEDITION" 1 19 . 08 0 .2 1 05/19/2004 at 08 : 55 AM Job Number: 951 35238 PRELIMINARY SUPPLEMENT 1 WITH SUMMARY 2003 FORD EXPEDITION 4X4 XLT 8-5 .4L-FI 4D UTV WHITE Int : NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT 13# Rpr SAVE DECALS ROGER 0. 5 ++++++++++++++++++ 14 SO1 Repl Lift gate 1 918 . 00 5 . 5 3 .4 15 SO1 Add for Clear Coat 1 .4 16 SO1 QUARTER PANEL 17* SO1 Rpr RT Quarter panel w/wheel 2 . 0 1 .2 opening molding 18 SO1 Overlap Major Adj . Panel -0 .4 19 SO1 Add for Clear Coat 0 .2 Subtotals ==> 1910. 78 10.2 7 .2 Parts 1910. 78 Body Labor 10 . 2 hrs @ $ 44 . 00/hr 448 . 80 Paint Labor 7 .2 hrs @ $ 44 . 00/hr 316 . 80 Paint Supplies 7 .2 hrs @ $ 25. 00/hr 180. 00 SUBTOTAL $ 2856 . 38 Sales Tax $ 1910 .78 @ 6 . 5000% 124 . 20 GRAND TOTAL $ 2980 . 58 ADJUSTMENTS: Deductible 0. 00 CUSTOMER PAY $ 0. 00 INSURANCE PAY $ 2980. 58 Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR2MC03 Database Date 3/2004 and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (-) items indicate MOTOR Not-Included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Prices are provided from National Auto Glass Specifications, Inc. Pound sign (#) items indicate manual entries. Pathways - A product of CCC Information Services Inc. 2 05/19/2004 at 08 : 55 AM Job Number: 951 35238 PRELIMINARY SUPPLEMENT 1 WITH SUMMARY 2003 FORD EXPEDITION 4X4 XLT 8-5 .4L-FI 4D UTV WHITE Int: li NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT CHANGED ITEMS 9* R&I Trim panel parchment -0 .5 9* SO1 R&I Trim panel parchment Incl . 10 R&I Handle XLT black -0 .4 10 SO1 R&I Handle XLT black Incl . DELETED ITEMS 14* Rpr Lift gate -9. 0 -2 .4 15 Add for Clear Coat -1.0 16# INCLUD SPOT UNDER GATE 1 ADDED ITEMS 14 SO1 Repl Lift gate 1 918 . 00 5 .5 3 .4 15 S01 Add for Clear Coat 1.4 16 SO1 QUARTER PANEL 17* SO1 Rpr RT Quarter panel w/wheel opens. 2 . 0 1 .2 18 SO1 Overlap Major Adj . Panel -0 .4 19 SO1 Add for Clear Coat 0.2 Subtotals ==> 918 . 00 -2 .4 2 .4 Parts 918. 00 Body Labor -2 .4 hrs Q $ 44 . 00/hr -105 . 60 Paint Labor 2 .4 hrs Q $ 44. 00/hr 105. 60 Paint Supplies 2 .4 hrs @ $ 25 . 00/hr 60 . 00 SUBTOTAL $ 978 . 00 Sales Tax $ 918 . 00 @ 6 .5000% 59. 67 TOTAL SUPPLEMENT AMOUNT $ 1037. 67 NET COST OF SUPPLEMENT $ 1037 . 67 Estimate 1942 . 91 CARL CHRISTIANSON Supplement S1 1037 .67 CARL CHRISTIANSON CUSTOMER PAY $ 0 . 00 Job Total $ 2980 .58 INSURANCE PAY $ 2980. 58 Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR2MC03 Database Date 3/2004 and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (-) items indicate MOTOR Not-Included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Prices are provided from National Auto Glass Specifications, Inc. Pound sign (#) items indicate manual entries. 3 k 05/19/2004 at 08: 55 AM Job Number: 951 35238 PRELIMINARY SUPPLEMENT 1 WITH SUMMARY 2003 FORD EXPEDITION 4X4 XLT 8-5 .4L-FI 4D UTV WHITE Int : Pathways - A product of CCC Information Services Inc. 4 LMC Lea gue of Minnesota Cities Claims Department 145 University Avenue West,St.Paul,MN 55103-2044 League of Minnesota Cities (651)281-1200 • (800)925-1122 Cities promoting excellence Fax:(651)281-1297 • TDD:(651)281-1290 www.lmnc.org ACKNOWLEDGMENT OF CLAIM OAK PARK HEIGHTS, CITY OF 14168 OAK PARK BLVD P.O. BOX 2007 ire , - 'T' Y 1 STILLWATER MN 55082 ";any 17 9n Date: 5/14/04 RE: Our File No. : 11048303 LMCIT Member: OAK PARK HEIGHTS, CITY OF Claimant Name: OAK PARK HEIGHTS, CITY OF KATHY JUNKER Occurrence/Loss Date: 5/08/04 Claim Description: INSD VEH BACKED INTO CLMNT VEHICLE Supervisor: KELLY ROBOTNIK Phone No. : (651)281-1288 Fax No. : (651)281-1297 Adjuster: IAN COAKLEY Phone No. : (651)215-4078 or 1-800-925-1122(outstate), Extension 4078 Fax No. : (651)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also available to you at any time. LMCIT Claims Department C.C. FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS 232 S LAKE ST FOREST LAKE MN 55025- AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER CJG1UPROPH OAK PARK HEIGHTS POLICE DEPARTMENT DATE 5/10/04 TIME 8 : 07 : 15 INITIAL COMPLAINT REPORT 104701761 DATE/TIME REPORTED: 5/08/04 7 :21 :09 DISPATCHER: PGHOPPE DATE/TIME STAMP: 5/08/04 7 :21 :09 ENTERED BY: PGHOPPE LOCATION OF INCIDENT: 5900 OAKGREEN AV N GRID: OAK PARK HEIGHTS, MN 55082 INCIDENT RECEIVED BY: DEPUTY OFFICERS ASSIGNED: 472 HOPPE i ti NAMES ASSOCIATED PAUL HOPPE /C/ --e WITH THIS INCIDENT: f 0//7144;-k ,,. S. PHONE: (H) (W) SEX: DOB: ASSOCIATION: COMPLAINANT 10-50 DAMAGE TO SQUAD TONNA CHRISTINE JUNKER 1171 LECUYER CT STILLWATER, MN 55082 PHONE: (H) 651/439-6975 (W) SEX: DOB: 3/16/1987 <** J U V E N I L E **> ASSOCIATION: OTHER VEHICLE DRIVER GGN930 KATHLENE MARIE JUNKER 1171 LECUYER CT STILLWATER, MN 55082 PHONE: (H) 651/439-6975 (W) SEX:F DOB: 1/06/1962 ASSOCIATION: OTHER REGISTERED OWNER OFFICER COMMENTS: WHILE ON PATROL I WAS TRAVELING S/B OAKGREEN AVE. I STOPPED 472 5/08/04 IN THE TRAFFIC LANE AND STARTED TO BACK ONTO 60TH ST CT 472 5/08/04 TO TURN AROUND AND STOP A VEHICLE N/B OAKGREEN AVE. 472 5/08/04 I STARTED BACKING UP THE SQUAD AND DID NOT SEE JUNKERS 472 5/08/04 VEHICLE PULL UP BEHIND MY SQUAD. I BACKED INTO THE FRONT 472 5/08/04 OF HER FORD EXPIDITION CAUSING MINOR DAMAGE TO THE FRONT 472 5/08/04 BUMPER AREA OF HER VEHICLE AND THE REAR BUMPER AND DOOR 472 5/08/04 OF SQUAD #32 . WCSO 179 WAS CONTACTED AND WROTE THE MINOR 472 5/08/04 10-50 REPORT. NO INJUIRES, DRIVER' S PARENTS CAME TO THE 472 5/08/04 SCENE. 472 5/08/04 SEE WC ICR#104014588 472 5/08/04 CJG1UPROPH OAK PARK HEIGHTS POLICE DEPARTMENT DATE 5/10/04 TIME 8 :07 :15 INITIAL COMPLAINT REPORT 104701761 DATE/TIME REPORTED: 5/08/04 7 :21:09 DISPATCHER: PGHOPPE DATE/TIME STAMP: 5/08/04 7 :21 : 09 ENTERED BY: PGHOPPE *WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING *WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING THIS CASE IS CLASSIFIED AS CONFIDENTIAL AND IS NOT AVAILABLE FOR PUBLIC INFO *WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING *WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING CJG1UPRWCSO WASHINGTON COUNTY SHERIFF'S OFFICE DATE 5/10/04 TIME 8 :06 :48 INITIAL COMPLAINT REPORT 104014588 DATE/TIME REPORTED: 5/08/04 7 :12 : 03 DISPATCHER: MFFERGU DATE/TIME STAMP: 5/08/04 7 :12 :30 ENTERED BY: MFFERGU LOCATION OF INCIDENT: OAKGREEN GRID: 60TH CT OAK PARK HEIGHTS, MN 55082 INCIDENT RECEIVED BY: TELEPHONE OFFICERS ASSIGNED: 179 LIVINGSTON NAMES ASSOCIATED PAUL HOPPE WITH THIS INCIDENT: PHONE: (H) (W) SEX: DOB: ASSOCIATION: COMPLAINANT 10-50 OFFICER COMMENTS: OPH SQUAD BACKED INTO ANOTHER VEHICLE SEE REPORT 179 5/08/04 'Mal.CAZ NO• AMENDED a /aro! VS-11 I 3 .7 "if VOU XLCO MIMED MONTH oa DA J ART THE ,; pr o$ oy . /T 0730 ea rn ROU:ESYeTa ROUTL AMRIER ORiTREET NMIE ••// N<YbMMY DYfCCTIPI- 0 en od�r /'a e� /1�1 a I/ $a w ®Aw�rH1 C' I or /+ ❑PT $ re a COWIYRO� WTf181. IIEFENEAFEPOM-' PM/TEMP ROUTE+,I0"r1( L" {I- YYii44 o d f/ T . rADTOR• nneTTIDN DIYS6ftmet Kamm..1 MITE WISP 0LETAJUe POCnOM ofYVEA LCCCmi UWER•SK LIATZ CL.95 DL STATUS'. FACTOR 7 1 ///O a a-7 ' art . 0 .44 / 1 ..Tsa6 799 lir /99 nW o I fACION 2 NOE ow LRDI;LA/TI OF6emN fMRE OWE mom;W'Tf _/ / non or MIR FACTORS VOA/ G ear /1' ■�, 'y /0 67 '7 , • C' ral 104 t 4nkev d3 lc 87•7 •• /V/CP ode,d/A Blvd DR Mt PERRfCi• AOOnE/17/ ,C e e to c i RESTRICT YrNBL 7 ? lam/ , MfEEOif r dpi EECT IM __ !!s _ APE r i11EEr EMT AMMO =CT DOTE/Al RC01lC PLOP- TYPE DAUC TTP! 19 TDT'p•E YTRANSPORT PLAAfaWAt(+ RUNIC! _•liDINr RVNEER OMbILL T4PE/Ir/1'TDFm�+*O� TTTCFE � WE'TTRI.I C T/ A IA. EREM10E u�r MN RIMER 1 ti �( (]AMT 1- 0 m I f " 0 OTNCN O oYRDR rl '6, 4f Qa1� Pork ' 1 t . �/�/ /ia4� ..... �kA![�'� ' PERIM ADDRESS 67 Ott/c/it • /A ik / waile/nt lecda ee GI 7 3 YErIUlE =tale A,,t /> �J , ..r.rb 3 J/.//�. ;- r,111) sIslarg2" IT 171-. IvE I f tea DMa 9E11 mosa FIDELeir YEAR AFS rw, K�UEAPidi A .... aon mei Nm 'PIAT[A Q Y..p.'t M WEOfE E �N wfr-- py.7, �- �? 3 i i 7 i i ��iv 93 //$$1 i VS 7 1 1 I 1� �hfa � rem-,r1RYOCR INIURANCE WI, Kw,NIe e Zdot. II"C• �/. 1'E'- Ci AIL F ACCENT INVOLVED A COMMERCIAL MOTOR VEHICLE.SCHOOL BUS,OR HEAD START BUS VOWED T REMEMBER TO NOTIFY THE STATE PATROL(required under NIS 10.703 and 1 MAIM. MIRMICKROPME MAKER I.ROTOR GAMER rem COT*MIER WwERCNLVEWCA ROM ER NDI01 camel RANG DOT WARM -.. _ . -.. __.aw._.--'_._._._.. _ - .............. .. . .. ... RUMMERS SVET ENE! a 0 mom AM MIME OATEOF TRAMPrtT a0 "SERVICE 111m IMAM AIM HIe ii •uu■■■u Q e071 PM PEARCE RIM RyIgBR OIAAfff or WWI M A N E°PROPERTY AND OESCREPRDR N DAMA9ED pglopory mom mu .ym...tool DAMMED PROPERTY- ROPERTY,Mu/M. TM WIMP - _ _ 'CC 1W j 1 j j I i t I■ DEVICE/ _ � - ,i .......a_i I _ Ch 1 f O r G 4 ;3 •_• • ..._ • I MGM c... /A // 1, , . R[ R6 f" I .• : ._. � I . . . d .T Lf nN !arm.L i .: ; . _� I, 4ln / I r � R/OT 7 tal au ;t____1 I j III I :-! . 3o —j '.b-:—H'.- I Pi, r °' ' ' i_ ...._ _ .... DART , : : 1 M17 _ 1._.I._' I t i ._-_ - •..-.._ .. r r_i , . I •---. L - • — Max RCMP I ,MORMI • li RD 1 L__r �. � , .. , • ■n111 - . oR•Ics1 IU.w. - . .• f - / ream nelson 0 VeE WPM =AL U fir91EXPP 0 DTI@I Page 1 of 1 Judy Hoist From: Lindy Swanson Sent: Wednesday, May 12, 2004 12:03 PM To: Judy Hoist Subject: 2003 Ford Expedition VIN 1 FMPU16L73LB79596 05/12/2004 League of Minnesota Cities I.4] 4C Claims Department 145 University Avenue West,St. Paul, MN 55103-2044 League of MinnesoEa Cities (651)281-1200 • (800)925-1122 Cities promoting excellence Fax:(651)281-1297 • TDD:(651)281-1290 www.lmnc.org ACKNOWLEDGMENT OF CLAIM OAK PARK HEIGHTS, CITY OF 14168 OAK PARK BLVD @ M O v��7 IE P.O. BOX 2007 j STILLWATER MN 55082 I�} 1 FEB I 1 Date: 2/13/04 RE: Our File No. : 11047312 LMCIT Member: OAK PARK HEIGHTS, CITY OF Claimant Name: OAK PARK HEIGHTS, CITY OF JOHN KAREL Occurrence/Loss Date: 2/07/04 Claim Description: INSD SQUAD 201 BACKED INTO CLMNT VEHICLE Supervisor: KELLY ROBOTNIK Phone No. : (651)281-1288 Fax No. : (651)281-1297 Adjuster: IAN COAKLEY Phone No. : (651)215-4078 or 1-800-925-1122(outstate), Extension 4078 Fax No. : (651)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also available to you at any time. LMCIT Claims Department C.C. FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS 232 S LAKE ST FOREST LAKE MN 55025- AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER CJG1UPROPH OAK PARK HEIGHTS POLICE DEPARTMENT DATE 2/09/04 TIME 8 :23:23 INITIAL COMPLAINT REPORT 104700546 DATE/TIME REPORTED: 2/07/04 12: 40: 57 DISPATCHER: CLBENGS DATE/TIME STAMP: 2/07/04 12 : 41:22 ENTERED BY: CLBENGS LOCATION OF INCIDENT: 14399 60TH ST N GRID: NAPA PARKING LOT OAK PARK HEIGHTS, MN 55082 INCIDENT RECEIVED BY: TELEPHONE OFFICERS ASSIGNED: 482 KISCH NAMES ASSOCIATED DAVE KISCH WITH THIS INCIDENT: PHONE: (H) (W) SEX: DOB: ASSOCIATION: OTHER SQUAD INVOLVED ACCIDENT JOHN JOSEPH KAREL 13731 47TH ST CT N STILLWATER, MN 55082 PHONE: (H) 651/439-8196 (W) 651/643-6534 SEX:M DOB: 7/19/1959 ASSOCIATION: OTHER R/O OF GBV537 INVOLVED IN 10-50 OFFICER COMMENTS: I WAS PARKED RUNNING STATIONARY RADAR IN SQUAD #201 IN THE 482 2/07/04 NAPA PARKING LOT. THE SQUAD WAS LOCATED IN THE NORTHWEST 482 2/07/04 CORNER STALL, FACING WEST. I BEGAN TO BACK UP WHEN I HEARD 482 2/07/04 A HORN HONK, AND THEN MY SQUAD HIT A VEHICLE BEHIND ME. THE 482 2/07/04 VEHICLE WAS STOPPED, FACING NORTH. I GOT OUT AND THE DRIVER 482 2/07/04 IDENTIFIED BY MN DL AS KAREL SAID HE WAS NOT INJURED. KAREL 482 2/07/04 SAID HE WAS PARKED IN THE SOUTHWEST CORNER, AND WAS GETTING 482 2/07/04 READY TO LEAVE THE LOT WHEN HE SAW MY SQUAD REVERSE LIGHTS 482 2/07/04 GO ON. HE STOPPED AND HONKED HIS HORN PRIOR TO CONTACT. I 482 2/07/04 CHECKED BEHIND MY SQUAD PRIOR TO BACKING UP AND DIDN'T SEE 482 2/07/04 KAREL'S VEHICLE. KAREL' S VEHICLE WAS STOPPED, AND MY SQUAD 482 2/07/04 CAR WAS TRAVELING AT LOW SPEED DURING BACKUP . NO DAMAGE TO 482 2/07/04 SQUAD #201. DAMAGE TO KAREL ' S VEHICLE WAS DRIVER SIDE FRONT 482 2/07/04 DOOR AND CORNER PANEL DENTED IN. WCSO #142 RESPONDED AND 482 2/07/04 WROTE THE ACCIDENT (ICR# 104004008) . I GAVE KAREL ICR 482 2/07/04 INFORMATION. 482 2/07/04 CLEARED. 482 2/07/04 02/08/04 08:58 WCSO RECORDS 9P6514393639 NO.751 1702 CJG1UPRWCSO WASHINGTON COUNTY SHERIFF'S OFFICE DATE 2/08/04 TIME 8:58:54 INITIAL COMPLAINT REPORT 104004008 DATE/TIME 2 :51 :16 DISPATCHER: CJKLONT ATE/ TII7� REP'ORTID. 2/07/0 4 1 DATE/TIME STAMP: 2/07/04 12:51: 16 ENTERED BY: CJKLONT LOCATION OF INCIDENT: 14399 60TH ST N GRID: OAK PARK HEIGHTS, MN 55082 INCIDENT RECEIVED BY: DEPUTY OFFICERS ASSIGNED: 142 KLONTZ . NAMES ASSOCIATED CHANIN KLONTZ WITH THIS INCIDENT: PHONE: (H) (W) SEX: DOB: ASSOCIATION: COMPLAINANT 10-50/2 VEH OPH #482-SQUAD 201 VS VEH MN GBV537 DAVE KISCH PHONE: (H) (W) SEX: DOB: ASSOCIATION: OTHER OPH SQUAD 201 JOHN JOSEPH KAREL • ' 13731 47TH ST CT N STILLWATER, MN 55082 PHONE: (H) 651/439-8196 (W) 651/643-6534 SEX:M DOH: 7/19/1559 ASSOCIATION: OTHER DRIVER MN GBV537 VEH INSURANCE TRANS CONTINENTAL #BUA1077012444 NAPA AUTO PARTS 14399 60TH ST N OAK PARK HEIGHTS, MN 55082 PHONE: (H) 551/439.2638 (W) 651/439-4319 SEX: DOB: ASSOCIATION: OTHER POLICE DEPARTMENT OAK PARK HEIGHTS 14168 OAK PARK BLVD N OAK PARK HEIGHTS, MN 55082 PHONE: (H), 651/439-4723 (W) SEX: DOH: ASSOCIATION: VICTIM OFFICER CANTS: REQUESTED TO RESPOND TO NAPA AUTO PARTS STORE PER OPH #482 142 2/07/04 TO TAKE ACCIDENT RPT OF HIS SQUAD TO A PERSONAL VEH THAT 142 2/07/04 HAD OCCURED IN THE PARKING LOT. NO INJURIES, 142 2/07/04 02/88/84 08:58 WCSO RECORDS + 9P6514393639 NG.751 6103 CJG1UPRWCSO WASHINGTON COUNTY SHERIFF'S OFFICE DATE 2/08/04 TIME 8 :58:54 INITIAL COMPLAINT REPORT 104004008 DATE/TIME REPORTED: 2/07/04 12: 51:16 DISPATCHER: CJKLONT DATE/TIME STAN: 2/07/04 12: 51: 16 ENTERED BY: CJKLONT OPH SQUAD #201 APPEARED TO HAVE SLIGHT DAMAGE TO BUMPER. 142 2/07/04 VEH MN GBV537 APPEARED TO HAVE MODERATE DAMAGE TO LT FRONT 142 2/07/04 QUARTER PANEL AND DRIVER DOOR AREA. 142 2/07/04 SEE REPORT. 142 2/07/04 CLASSIFIED AS: OTHER TRAFFIC ACCIDENT/VEH DAM/OTHER DAM 9015 • • • E 02/08/04 08:58 WCSO RECORDS 4 9P6514393639 NU.Y51 WW4 CJG1UPRWCSO WASHINGTON COUNTY SHERIFF'S OFFICE DATE 2/08/04 TIME 8 :58:54 INITIAL COMPLAINT REPORT 104004008 DATE/TIME REPORTED: 2/07/04 12 :51:16 DISPATCHER: CJKLONT PATE/TIME STAMP: 2/07/04 12 :51 :16 ENTERED BY: CJKLONT BCA RESPONSE: 104/02/07 9 :28:16 PXS TO: WCZMDT-19515 Sat Feb 07 , 2004 15 :28:18 CZLYWAQKD8Y5 FROM: NCICSYN2 Sat Feb 07, 2004 15 :28:18 1L01CZLYWAQKD8Y533F MN08200L1 NO RECORD LIC/GBV537 LIS/MN TO: WCZMDT-19516 Sat Feb 07, 2004 15:28 ;19 CZLYWAQKD8Y5 FROM: A36MPQ41 Sat Feb 07, 2004 15;28; 19 TXT LIC/GBV537. LIY/05. LIT/PC, NAM/APPLIED BUSINESS COMM INC. NM2/KAREL,JOHN JOSEPH.*RECORD DISSEMINATION RESTRICTED* SNM/2300 TERRITORIAL RD. CTY/ST PAUL. STA/MN. ZIP/55114 . VIN/1J4GW58N01C620335. VYR/01. VMA/JEEP. VCO/TAN/TAN. VMO/GCK,4DR WAGON EXM/JAN. DOB//19590719, STICKER:E0052824, TO: WCZMDT-19517 Sat Feb 07, 2004 15:28:20 CZLYWAQKD8Y5 FROM: A36MPQ41 Sat Feb 07, 2004 15 ;28:19 FIELD (DOB) MANDATORY QMW LIC/GBV537.LIS/MN TO: WCZMDT-19518 Sat Feb 07, 2004 15:28:23 CV3YWAQKD8Z5 j FROM; A36MPQ43 Sat Feb 07, 2004 15:28:23 • TXT NAM/KAREL,JOHN JOSEPH.*RECORD DISSEMINATION RESTRICTED* SNM/13731 47TH ST CT N. CTY/STILLWATER. STA/MN, ZIP/55082 . SEX/M, DOB/19590719 . HGT/511. WGT/200 . EYE/HZL. DISABILITY CERTIFICATE S:N OLN/K640429441569. OLT/1. CLS/D. EDR/ M. EXP/071906 STATUS:VALID DONOR:N DESIGNATED CAREGIVER:N PHOTO:2682190046 .ISU/072402 .DNR TRAINING=FIREARM:N, SNOWMOBILE:N 08/11/02 SPEED 82 20030 62 10/27/89 REINSTATE DRIVING PRIVILEGES - REGULAR DL RETURNED H9 09/29/89 SURRENDERED DL 09/29/89 SUSPENSION FEE PAID 10/27/89 *09/29/89 * LIMITED UNTIL *09/29/89 * SUSP - 4 VIOLATIONS IN 12 MONTHS 00030 10/27/89 08/27/89 SPEED 65 03 03/20/89 DEV WARNING LETTER RETURNED /27/89 02/06/04 08:58 WCSO RECORDS + 9P6514393639 NO.751 D07 • ICR 104004008 -- • • Page I of 1 • initial Complaint Report ICR Number: 104004008 Agency: Washington County Sheriff's Office ICR Created: 02/07/200412:51:16 DEPUTY KLONTZ#142 DATE/TIME OCCURRED: 020704- 1240 HRS. DA TE/TIME REPORT MADE:020704- 1524 HRS. On 020704 approximately 1251 Hrs.,I was dispatched to.the address of 14399 60th St.No.,the NAPA AUTO PARTS business in the City.of Oak Park Heights,to take a 10-50(property damage accident)of an Oak Park Heights Squad#201 driven by Officer Kisch versus a passenge r vehicle,MN LIC: GBV-537,driven by a subject IIYed by MN PDL as JOHN JOSEPH KAREL,DOB: 071959, Officer Kisch stated that he was running stationary radar in the NAPA AUTO PARTS parking lot at the above listed address.When he was completed running stationary radar,he proceeded to leave the parking lot by backing out p u t from the space that he was parked in.Officer Kisch stated that he beard a vehicle's horn honk and he depressed on his brakes as he was backing up his squad.At this point,his squad slid into the left front corner of the vehicle,MN LIC:GBV-537,in the.parking lot. I spoke to the driver of the vehicle,GBV-537,JOHN KAREL.KAREL stated that he was proceeding to exit the NAPA AUTO PARTS parking lot when he observed the Oak Park Heights Squad backing up. KAREL stated that he honked his horn,but by the time he had honked his horn to his vehicle to alert the officer,the officer's • squad had already backed into his vehicle in the parking lot. No injuries were obtained by either parties.Vehicle insurance was given by KARL as Trans Continental Policy #BU'A1077012444.Officer Kisch gave KAREL his Oak Park Heights business card for him to contact after his vehicle has been assessed for the damage and needed to be repaired. At this time,I then cleared from the address of 14399 60th St. No.without further incident. KLONTZ:mb cc:Oak Park Heights P.Ddfax 439-3639 020804-0853 Hrs. • • http://crmdomlf'icr/icr.nsf/PrintView/C1858E556D9EF 41386256E3400470FFC?OpenDoeument 2/8/2004 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 0053793 POLICY #: CMC 25101 INSURED NAME: OAK PARK HEIGHTS, CITY OF CLAIM #: 11050636 CLAIMANT NAME:OAK PARK HEIGHTS, CITY OF ///��� CHECK #: 0053793 CHECK DATE 02/04/05 -fl-1 PAYMENT: 500.00 j /" f LOSS DATE: 12/10/04 I CMP PAYEE: OAK PARK HEIGHTS, CITY OF DESCRIPTION: DEDUCTIBLE REIMBURSEMENT - SUCCESSFUL SUBROGATION RECOVERY f \ Washington 3� °"� County .,&.,____,,, , RESTITUTION AFFIDAVIT ,,,--„--4' 1 nir.,Rocv . _ ItC8A Victim Name:�-J- 1 C k k_� `l " Phones: (Home) /�1, 22 nn Work Address: )(-11(0� l�*J2 . �r,,n ' _ l� v� (Work) E4:39— 4-1723 City, State, Zip:_0 _ -e0,4_12 *,Ad_k\A J) d g (Cell) Email: Court File Number Offender Name Offense Date of Offense r1-o5 - Looi .Avg luines e >,r O is-71 OA L( �CA S ) Please use the ortion of the form to prow a ny comments/information that you wish the court to be aware of and use page 2 to detail any financi osses. Victim Impact Statement — (Please attach additional pages as necessary.) "DAM (-10E--�S 4 R-- �-a i v eV)N c. 1 �...V vscO S w �,a - " �-Q I 4o 3 w�ci4 • c)t21L S Q .\ ceS A request for restitution may include, but is not limited to, any out-of-pocket losses resulting from the crime, including medical and therapy costs, replacement of wages and services, expenses incurred to return a child who was a victim of a crime under§ 609/26 (DEPRIVING ANOTHER OF CUSTODIAL OR PARENTAL RIGHTS), and funeral expenses. The Judge determines restitution based on this affidavit and any documents you submit. Providing copies of actual medical bills, repair or replacement receipts, and/or estimates for repairs will help us present your request for restitution to the Judge. Please check one of the following: ❑ I AM NOT CLAIMING ANY MONETARY LOSS ON THIS OFFENSE OR I DO NOT WISH TO RECEIVE RESTITUTION (You do not need to have this form notarized if you are not requesting restitution.) I HAVE SUFFERED MONETARY LOSS ON THIS OFFENSE AN61 D0 ,6,11 �' RESTITUTION. ' I- L 1'_'cl`t St�,7 ''�1 ' r 1,•r o),tM _,.ik J< Financial Impact Worksheet Please use this portion of the form to list any expenses that were a result of this crime. Some of the sections may not apply to you. Please attach copies of bills, recei is estimates mate s of value, replacement costs, or other evidence of the costs listed below. Please attach additional pages as necessary. Medical/Counseling/Other Expenses: (Include expenses that were a direct result of the offense) Expenses Cost/Deductible 1. 2. 3. • 4. 5. TOTAL: Wo Have you submitted a claim to the Minnesota Crime Victims Reparation Board? ❑Yes Claim #: Stolen or Damaged Property 9 p rh/ Item Please check if item Repair/Replacement was recovered Cost: 1.2009 F( .rzO• Lxp.O', ICeA $1139.FY. 2. ❑ $ 3. ❑ $ 4. ❑ $ 5. Total $ 5-31,re Insurance Information: (You are not required to make an insurance claim or provide insurance information.) Have you submitted a claim? IYes ❑No Claim Number: 1CS-063k) Insurance Company: LG. MO C Policy Number: C,YvI L Z5i O( Contact Person:""Mcw GOB i4 ley Phone#: (05/ Z 15 - 4/0-7g Deductible Amount: $ 500 .pQ Amount covered by insurance: $ 3 3'1, THIS FORM MUST BE SIGNED BEFORE A NOTARY The above statement of claim is true and correct the best of my knowledge. F �►� •. - For~ tql ICe ignature of Victim/agent/representative or parent/guardian if victim is under age 18 Subscribed and sworn to before me on �.SlY Q JULIE R.JOHNSON ti r NOTARY PUBLIC-MINNESOTA 9i 'Y • • " • j N: ary Public LEAGUE OF MINNESOTA CITIES US BANK 0053644 INSURANCE TRUST t7-2-910 L Mc PROPERTY CASUALTY FUND CLAIMS ACCOUNT 222 SOUTH NINTH STREET,SUITE 1300 t.,,..�xr...&qiw MINNEAPOLIS,MN 554024332 orc.. �.i�,. 0011 CRC 25101\ 11050636 PAY EIGHT THOUSAND THREE HUNDRED THIRTY-NINS 'DOLLARS AND EIGHTY-FOUR CENTS TO THE �DATB AILOUNT ORDER OF OAK PARK HEIGHTS, CITY OF JANUARY 25, ,1005 $*****8,339.84 MailTo: OAK PARK HEIGHTS, CITY OF ATTN: J. HOLST 14168 OAK PARK BLVD P.O. BOX 2C07 STILLWATER MN 55082 THIS IS WATERMARKED PAPER-DO NOT ACCEPT WITHOUT VERIFYING ARTIFICIAL WATERMARK ON REVERSE SIDE.HOLD AT AN ANGLE TO VIEW. u'00536441I' u:09 L0000221: L60 2 34 548 3 54x' i LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 0053644 POLICY 6: CNC 25101 INSURED NAME: OAR PARR HEIGHTS, CITY OF CLAIM 8: 11050636 CLAIMANT NAME:OAK PARR HEIGHTS, CITY OF CHECK 8: 0053644 CHECK DATE 01/25/05 PAYMENT: 8,339.84 LOSS DATE: 12/10/04 I CMP PAYEE: OAK PARK HEIGHTS, CITY OF DESCRIPTION: PHYSICAL DAMAGE LOSS TO SQUAD 41, LESS $500.00 DEDUCTIBLE PL/'11 ‘,SiN 2 8 nasrl League of Minnesota Cities Claims Department LMC 145 University Avenue West,St. Paul,MN 55103-2044 �e of Cities/ (651)281-1200 • (800)925-1122 � f Fax:(651)281-1297 • TDD:(651)281-1290 Cities promoting exaence J www.lmnc.org January 20, 2005 State Farm Insurance Attn: Connie Bell PO Box 25026 Woodbury,MN RE: LMCIT FILE NO.: 11050636 TRUST MEMBER: City of Oak Park Heights INSURED VEHICLE: 2004 Ford Expedition(Police) YOUR CLAIM NO.: 23174692 D/OCCURANCE: 12/10/04 YOUR INSURED: Mary Sheila Burnes LOSS AMOUNT: $8,839.84(includes$500.00 deductible) Dear Ms. Bell: The League of Minnesota Cities Insurance Trust provides automobile collision coverage for our trust member,the City of Oak Park Heights. I am putting you on notice of our subrogation interests regarding the above-referenced matter. I have finished my investigation regarding the accident between an Oak Park Heights Police Department vehicle and your insured. My investigation reveals that your driver was at fault for this accident. I have enclosed final invoices for repair of the insured vehicle. Photographs of the vehicle damage are also attached. The insured vehicle was restored to its pre-accident condition at a total cost of$8,839.84. On behalf of the Oak Park Heights Police Department we are seeking to recover the loss to our insured. Please issue a payment in the amount of$8,839.84 payable to the League of Minnesota Cities Insurance Trust and sent to my attention at the above address. If you have any questions or concerns I can be reached at 651-215-4078. Thank you for your cooperation. Sincerely, Ian Edward Coakley Claims Adjuster Enclosures cc: Judy Holst,City of Oak Park Heights Brian Alm, Landmark Insurance Agency Kelly Robotnik,LMCIT IE CCU `' O Y IEC/ss JAN 2 4 , i J AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER / League of Minnesota Cities L NIC Claims Department 145 University Avenue West,St.Paul,MN 55103-2044 League of Minnesota Cities (651)281-1200 • (800)925-1122 Cities ofMi promoting excellence Fax (651)281-1297 • TDD:(651)281-1290 J www.lmnc.org ACKNOWLEDGMENT OF CLAIM OAK PARK HEIGHTS, CITY OF 14168 OAK PARK BLVD P.O. BOX 2007 STILLWATER MN 55082 Date: 12/16/04 RE: Our File No. : 11050636 LMCIT Member: OAK PARK HEIGHTS, CITY OF Claimant Name: OAK PARK HEIGHTS, CITY OF Occurrence/Loss Date: 12/10/04 Claim Description: DWI DRIVER HIT PARKED SQUAD Supervisor: KELLY ROBOTNIK Phone No. : (651)281-1288 Fax No. : (651)281-1297 Adjuster: IAN COAKLEY Phone No. : (651)215-4078 or 1-800-925-1122(outstate), Extension 4078 Fax No. : (651)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also available to you at any time. 1 LMCIT Claims Department C.C. FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS 232 S LAKE ST FOREST LAKE MN 55025- AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER • • 7/0 •• City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: Ian Coakley-LMCIT Fax: 651-281-1297 From: Judy Hoist Date: 1-20-05 Re: Claim No. 11050636 Pages: 7 CC: ❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle Notes: Here are the bills I received for our claim no. 11050636 for a DWI driver that hit a parked squad car. I believe this is all of them. The City will pay these bills and is requesting reimbursement from LMCIT. I assume you will seek reimbursement/restitution for the deductible. Let me know if you need anything further. Thanks, Judy gaol cc 'DwrrvalD csr<tAph,*C, 1C -.Z`-'"1-4-- 4-Y43 L6 NI sr Invoice 3240 Mike Collins Drive 1/5/2005 39107 Eagan,MN 55121 651-683-9665 Local 888-683-9665 Toll Free ,fs"1 x,•s Y w' r.�k�.; er w �,`*h•ti t,b *a�t 9 �«z m'' > r u,. z a 4 u a. `:.. > '' * x,> £;w„q�. a �q°v."Y"` z ,z h a"'° .•,,, t $ 8 " 1,gyc. -°.. ^s <a y v+.q y„i �� rv, 5. ";�E.;k..a,.�.d�a...,a «i?.,z.�,�:...��,.:ae Oak Park Heights Police Dept. Oak Park Heights Police Dept. Accounts Payable Att: Chief Lindy Swanson P.O. Box 2007 14168 Oak Park Blvd N. Oak Park Heights, MN 55082 Oak Park Heights, MN 55082 c h'Ei"'FS.�'.• �+p i'�".,}.u.,"-ti-" " �h3u� � � � �,b. i'� Y aE.^r; T q'i°1. kh,y,� � ���.,,�ys rt� 4,,,.���za«• N`�f�''} it�.,p.�.�1+,� ty; <,?��,�Y: �*�E s �� 1.'°.�,k. �v"y�j i x'�'Ay.-"°�. 8 4 - y:t 9 g'; '• yn 2� '�&y S i'�Y�y 1 ' ; a ytr x. �.bs�%' i„ G q }, j i9 6 �:�.d "•+syEfY: �"d+g F'" s` � ,� � �` r�x�.,�2 '�r �r .� � 1 � �.s � a.�, r•:n ?$ sy+.2 i" „..bat tea xasm Net 30 2/4/2005 SHA THERE a ' e . 135.00 13:��5`�$ .aw''O. Ou r..�.T 1 Driver's Side Quarter Panel and Tailgate Complete for a White 2003 Ford Expedition Unit Number 41. 1 Application There. 75.00 75.00T Application 1-3-05 at 11:30 nt 1S4 ,, J• N - 7 2005 jy s t. J Subtotal $210.00 Thank you for your business. Sales Tax(6.5%) $13.65 Check us out on the web at www.grafixshoppe.com Total $223.65 Payments/Credits $0.00 Balance Due $223.65 Washington County Sheriffs Office ��� ���� Washington P.O. Box 3801 �' � 3 Vit Count 15015 62nd Street North ` § Stillwater, MN 55082-3801 Invoice Number: 43740 Account Number: 32404 Due Date: 02/17/05 TO: OAK PARK HEIGHTS POLICE DEPT 14168 OAK PARK BLVD PO BOX 2007 Amount Enclosed: $ OAK PARK HGTS MN 55082 Federal Tax Id: 41-6005919 Please return top portion with payment. Thank You. -� TIl'i Date Type N ber"`H !ue D >a 01/18/05 RI 43740 001 02/17/05 FLASHER REPAIR UNIT 41-PARTS 49.5 01/18/05 RI 43740002 02/17/05 LABOR 7 HOURS @ $85/HOUR 595.00 1W -1-.2XK)---E, Lig YY1 CITY OF JAK PARK HEIGHTS CLAIMS ENDORSEMENT ALLOWED IN THE SUM OF$ � —DISALLOWED IN THE SUM OF $ U I DATE SIGNATURE G"' � — 644.50 I declare under the penalties of law that this account claim or Invoice Total demand, is just and correct and no part of it has been paid. Sales Tax Please make check payable to Washin!,t. Coun y and mail to the address above. 644.50 t,,,(AcAt �� y" Balance;Due 7q 7 PAT &SERVICE HOURS: , Seeeeatareer MON-THURS. T 7:0 RS.7:00 A.M.TO 7:00 P.M. FRI 7:00 A.M.TO 6:00 P.M. T c + -- -- SAT 8:00 A.M.TO 4:00 P.M. M0 ■ ® �S BUS: (651)439 43331 1 3 +l \ i t. (' FAX: (651)439-4425; + Y :{r I r a IJ �� tj `� MON•THURS.70 0 A.M.OTO 6:00 P.M. TOLL FREE(800)544-3592' J � '-- — — FRI 7:00 A.M.TO 5:00 P.M. BUlCK • CHEVROLET • JEEP ,I / I i 9 FREE ESTIMATES •FAMILY OWNED SINCE 1922• j ( y i I 5900 Stillwater Boulevard North•P.O.Box 337 '; J i „ '" 7 7.r'4�i SALES HOURS: Stillwater,MN 55082 1 1 1 i MON-TOURS.8:30 A.M.TO 9:00 P.M. J � ! .. i FRI 8:30 A.M.TO 6:00 P.M. SAT 8:30 A.M.TO 5:00 P.M. L_._ CUSTOMER NO. ADVISOR TAG NO. INVOICE DATE INVOICE NO. 4428 MIKE GLADIS 217 098 12/30/04 CTCB50499 LABOR RATE LICENSE NO. MILEAGE COLOR STOCK NO. _ CITY OF OAK PARK HEIGHTS POLICE 17,908 WHITE/ 14168 OAK PARK BLVD YEAR/MAKE/MODEL DELIVERY DATE DELIVERY MILES P 0 BOX 2007 04/FORD TRUCK/ OAK PARK HEIGHTS, MN 55082 VEHICLE I.D.NO. SELLING DEALER NO. PRODUCTION DATE 1 F M P U 1 6 L 6 4 LB 2 6 6 1 6 F.T.E.NO. P.O.NO. R12DAT 3/04 REySI icEP}y §_3639 4Syss4"�° 3 COMMENTS Z/ MO: 17908 TOTALS 4�y STATEMENT OF DISCLAIMER ************************************************ TOTAL LABOR.. 3677.95 The factory warranty constitutes all of the war- * * TOTAL PARTS.... 3489.11 ranties with respect to the sale of this * [ ] CASH [ ] CHECK CK NO. [ ] * TOTAL SUBLET... 0.00 item/items.The Seller hereby expressly dis- TOTAL G.0.G.... 577.84 claims all warranties either express or implied, * [ ] VISA [ ] MASTERCARD [ ] DISCOVER * TOTAL MISC CHG. 0.00 including any implied warranty of merchant- * MISC DISC 0.00 ability or fitness for a particular purpose.Seller * [ ] AMER XPRESS [ ] OTHER [ ] A/R * TOTAL TAX 226.79 neither assumes nor authorizes any other person to assume for it any liability in connec- * DATE PAID / / CASHIER INITIALS * TOTAL INVOICE$ 7971.69 tion with the sale of this item/items. ************************************************ THANK YOU FOR YOUR BUSINESS!! CUSTOMER SIGNATURE 744,04 *eat 1A 1s auv2 \oitI C V,& - 0 1 �GIcp 2�p 4;)z. Goodvvrendi Service til I I -P temp cyx Slis. i `�U t iQ� See us for guarantee details. w www.gmgoodwrench.com w I. ■1r.�(Z ,N C r .3 V"t i AMERRC .1t 01 i p e 4 bi w 1 4c, Y"Y i .c` -,.Cc"t I 6u Imill MasterCard ‘ski:1/4*1)7 —___ 9 T ILIA I GOOdwrex:h rrtrterr.nrne.a 6' PAGE 2 OF 2 CUSTOMER COPY [ END OF INVOICE ]09:08am ALL PARTS NEW ORIGINAL EQUIPMENT, UNLESS OTHERWISE SPECIFIED PARTS&SERVICE HOURS: r•/ Y MON-THURS.7:00 A.M.TO 7:00 P.M. Sefejedge FRI 7:00 A.M.TO 6:00 P.M. SAT 8:00 A.M.TO 4:00 P.M. M 0 T O R S BUS: (651)439.4333 COMPLETE BODY SHOP HOURS: FAX: (651)439-4425 MON-THURS.7:00 A.M.TO 6:00 P.M. BUICK • CHEVROLET • JEEP TOLL FREE(800)544-3592 FRI 7:00 A.M.TO 5:00 P.M. FREE ESTIMATES •FAMILY OWNED SINCE 1922• 5900 Stillwater Boulevard North'P.O.Box 337 SALES HOURS: Stillwater,MN 55082 MON-THURS.8:30 A.M.TO 9:00 P.M. FRI 8:30 A.M.TO 6:00 P.M. SAT 8:30 A.M.TO 5:00 P.M. CUSTOMER NO. 4428 ADVISOR TAG NO. INVOICE DATE INVOICE NO. MIKE GLADIS 217 098 12/30/04 CTCB50499 LABOR RATE LICENSE NO. MILEAGE COLOR STOCK NO CITY OF OAK PARK HEIGHTS POLICE 17,908 WHITE/ 14168 OAK PARK BLVD YEAR I MAKE!MODEL DELIVERY DATE DELIVERY MILES P 0 BOX 2007 04/FORD TRUCK/ OAK PARK HEIGHTS, MN 55082 VEHICLE I.D.NO. 1 F M P U 1 6 L 6 4 L B 2 6 6 1 6 SELLING DEALER NO. PRODUCTION DATE F.T.E.NO. P.O.NO. Rf1 y3/O4 RE b? {1j 3639 WI T//3 COMMENTS MO: 17908 JOB# 1 CHARGES - STATEMENT OF DISCLAIMER LABOR The factory warranty constitutes all of the war- J# 1 96CVZ BODY REPAIR HOURS: TECH(S):932 2875.00 ranties with respect to the sale of this REAR END DAMAGE item/items. The Seller hereby expressly dis- claims all warranties either express or implied, PARTS QTY---FP-NUMBER DESCRIPTION- -----------------UNIT PRICE- including any implied warranty of merchant- 1 2L1Z17906BA 2L1Z1790 BUMPER 342.93 342.93 ability or fitness fora particular purpose.Seller 1 4L1Z17K835CAA 4L1Z17K8 FASCIA 555.50 555.50 neither assumes nor authorizes any other 1 2L1Z13405AB 2L1Z1340 LENS 73.19 73.19 person to assume for it any liability in connec- 1 2L1Z7840010AA 2L1Z7840 GATE 927.18 927.18 tion with the sale of this item/items. 1 2L1Z7842528AA 2L1Z7842 EMBLEM 27.60 27.60 1 2L1Z7842528BA 2L1Z7842 EMBLEM 23.77 23.77 1 1L2Z7842528GA 1L2Z7842 EMBLEM 21.02 21.02 1 2L1Z7843400BAZ 2L1Z7843 HANDLE 142.37 142.37 1 2L1Z7828371AA 2L1Z7828 SHIELD 20.29 20.29 1 3L1Z7827841AA 3L1Z7827 PANEL 834.42 834.42 1 4L1Z7831013AAB 4L1Z7831 PANEL 282.58 282.58 1 3L1Z7846404MB 3L1Z7846 INT TRIM 116.28 116.28 1 3L1Z7845626AAA 3L1Z7845 FILLER 121.98 121.98 TOTAL - PARTS 3489.11 JOB# 1 TOTALS PARTS 32488795:0310 489.11 7cs��4 d„ JOB# 1 JOURNAL PREFIX CTCB JOB# 1 TOTAL 6364.11 JO B# 2 CHARGES LABOR J# 2 95CVZ BODY REFINISH HOURS:- TECH(S):630 : 713.00 REFINISH REAR END DAMAGE E31. G.O.G. & SUPPLIES 1.0 PAINT MATERIALS 0 577.840 /UNIT 577.84 Goochivrench TOTAL GOG 577.84 Service 1 JOB# 2 TOTALS U LABOR 713.00 See us for guarantee details. G.O.G. 577.84 www.gmgoodwrench.com JOB# 2 JOURNAL PREFIX CTCB JOB# 2 TOTAL 1290.84 JOB# 3 CHARGES LABOR MERluw � 1 5 J# 3+98CVZ BODY MECHANICAL ;"HOURS: TECH(S):972 89.95 ERE55 (ot1c�`�R 2. DON DID 4 WHEEL ALIGNMENT S JOB# 3 TOTALS I v®I MasterCard I LABOR 89.95 3 r JOB# 3 JOURNAL PREFIX CTCB JOB# 3 TOTAL 89.95 LM'Gooch/wench' z m 'V7,,,r�errwr s PAGE 1 OF 2 CUSTOMER COPY [CONTINUED ON NEXT PAGE]09:O8am ALL PARTS NEW ORIGINAL EQUIPMENT, UNLESS OTHERWISE SPECIFIED 12/30/2004 at 08 :58 AM Job Number: 1085 35238 STILLWATER MOTOR COMPANY Federal ID #:410561600 5900 STILLWATER BLVD NO. PO BOX 337 STILLWATER, MN 55082 (651) 393-2399 Fax: (651) 351-5197 PRELIMINARY SUPPLEMENT 1 WITH SUMMARY Written By: MIKE GLADIS Adjuster: Insured: CITY OF OAK PARK HEIGHTS Claim # Owner: CITY OF OAK PARK HEIGHTS Policy # Address: 14168 NO 57TH ST PO BOX 2007 Deductible: OAK PARK HEIGHTS, MN 55082 Date of Loss: Day: Type of Loss: Evening: Point of Impact: 7 . Left Rear Inspect Location: Insurance Company: Days to Repair 2004 FORD EXPEDITION 4X4 XLT 8-5.4L-FI 4D UTV WHITE Int: VIN: 1FMPU16L64LB26616 Lic: POLICE MN Prod Date: Odometer: 17908 Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Keyless Entry Rear Wiper Dual Mirrors Privacy Glass Roof Console Luggage/Roof Rack Fog Lamps Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Driver Seat Power Mirrors Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes Cloth Seats Split Bench Seats Running Boards/Side Steps Aluminum/Alloy Wheels NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT 1 REAR BUMPER 2 0/H rear bumper 1 .5 3 Repl Reinforcement 1 342 . 93 Incl . 4 Repl Impact bar 1 77 .08 Incl . 5 Repl Step pad 1 39 .22 Incl . 6 Repl Bumper cover XLT, w/o reverse 1 555 .50 Incl. 1.5 sensing system XLS, XLT 7 Add for Clear Coat 0 . 6 8 Deduct for Rear Bumper R&I -0 . 8 9 REAR LAMPS 10 Repl LT Tail lamp assy 1 71 . 50 Incl . 11 LIFT GATE 12 Repl Lift gate 1 927 .18 5 .5 3 .4 13 Add for Clear Coat 1 .4 1 t 12/30/2004 at 08 :58 AM Job Number: 1085 35238 PRELIMINARY SUPPLEMENT 1 WITH SUMMARY 2004 FORD EXPEDITION 4X4 XLT 8-5.4L-FI 4D UTV WHITE Int : NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT 14 Repl Emblem Ford oval 1 22 .38 0 .2 15 Repl Nameplate "EXPEDITION" 1 19.27 0 .2 16 Repl Nameplate "XLT" 1 13 . 80 0 .2 17 Repl Handle XLT black 1 71 .58 Incl . 0 . 5 18 R&I Lift gate glass Ford green Incl . tint 19 SO1 Repl Trim panel dark flint 1 77 .52 Incl . 20 REAR BODY & FLOOR 21* SO1 Rpr Rear floor pan AFTER PULL 8 .0 2 .2 22# SO1 Rpr PULL REAR FLOOR PANEL 2 .0 F 23 R&I Cover assy medium flint Incl . 24 R&I Scuff plate dark flint Incl . 25* R&I Cover jack stowage medium 0 .5 flint 26* SO1 Rpr Crossmember assy PULL & SQUARE 2 .0 F 27* S01 Repl Cover assy black w/o seat 1 116 .28 Incl . 28* S01 Repl Liner w/logo flint 1 121. 98 29 QUARTER PANEL 30 R&I LT Quarter glass Ford w/fixed Incl . window green tint 31* SO1 Rpr LT Inner panel s 6 . 0 1 .5 32* Rpr LT Wheelhouse panel 3 . 0 33 R&I RT Qtr trim panel w/o 1 . 0 auxiliary AC dark flint 34 Repl LT Qtr trim panel w/o 1 282 . 58 Incl. auxiliary AC dark flint 35 Repl LT Quarter panel w/o wheel 1 834 .42 19 . 0 3 .1 opening molding 36 Overlap Major Adj . Panel -0 .4 37 Add for Clear Coat 0 . 5 38 Repl LT Splash shield 1 15 . 13 0 .2 39# Repl URETHANE GLASS INSTALL KIT 1 24 . 95 40# Repl PANEL BONDING ADHESIVE KIT 1 24 .95 41# Refn COVER CAR 0 .2 42# Refn BLEND 1 . 0 43# HAZARDOUS WASTE 1 3 . 00 X 44# CORROSION PROTECTION 1 13 . 00 X 0. 5 45# DIAGNOSIS & SET UP TIME 1 1 . 5 46# PULL AND SQUARE 1 5. 0 F 47# SO1 R&I REAR SEAT CAGE (PATROL CAR) 2 . 0 48# SOl R&I REAR CARPET 0 .5 49# SOl Subl 4 WHEEL ALIGNMENT 1 89 . 95 X Subtotals ==> 3744 .20 58 . 0 15. 5 2 12/30/2004 at 08 :58 AM Job Number: 1085 35238 PRELIMINARY SUPPLEMENT 1 WITH SUMMARY 2004 FORD EXPEDITION 4X4 XLT 8-5 .4L-FI 4D UTV WHITE Int : Estimate Notes : DECALS & LETTERING---PRICE OPEN Parts 3638 .25 Body Labor 49 . 0 hrs @ $ 46 . 00/hr 2254 .00 Paint Labor 15 .5 hrs ® $ 46 . 00/hr 713 . 00 Frame Labor 9 . 0 hrs ® $ 69 . 00/hr 621.00 Paint Supplies 15 .5 hrs ® $ 26 . 00/hr 403 . 00 Sublet/Misc. 105 .95 SUBTOTAL $ 7735 .20 Sales Tax $3638 .25 @ 6 . 5000% 236 .49 GRAND TOTAL $ 7971.69 ADJUSTMENTS : Deductible 0 .00 CUSTOMER PAY $ 0 .00 INSURANCE PAY $ 7971 .69 Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR2MC03 Database Date 12/2004, CCC Data Date 12/2004, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (-) items indicate MOTOR Not-Included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Prices are provided by National Auto Glass Specifications, Inc. Pound sign (#) items indicate manual entries. Some parts that are described as Recon. may be OE Surplus parts or other OE parts offered at a special pricing discount. For further clarification please review the Suppliers List attached to this estimate, or consult the appraiser or estimator. CCC Pathways - A product of CCC Information Services Inc. 3 • • • • Vro • City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile -transmittal To: Cindy—LMCIT Fax: 651-281-1297 From: Judy Holst Date: 12-14-04 Re: Accident Claim 12-10-04 Pages: 12 CC: ❑ Urgent 0 For Review ❑ Please Comment 0 Please Reply ❑ Please Recycle Notes:,Here are copies of the accident reports for the vehicle accident on 12-10-04 and a copy of the estimate for repairs from Stillwater Motors. The graphics will be additional when the body work is completed. If you have questions please contact our police Chief: Lindy Swanson 651-439-4723. Thanks, 5 /- , Judy Hoist � 7 } CJG1UPROPH OAK PARK HEIGHTS POLICE DEPARTMENT DATE 12/13/04 TIME 8 : 09: 48 INITIAL COMPLAINT REPORT 104704945 DATE/TIME REPORTED: 12/10/04 23 : 44 : 44 DISPATCHER: BMFRY DATE/TIME STAMP: 12/10/04 23: 45: 05 ENTERED BY: BMFRY DATE/TIME OCCURRED: 12/10/04 23: 44 : 44 - 12/10/04 23: 44 :44 LOCATION OF INCIDENT: HWY 5 N GRID: BETWN 58TH AND HWY 36 OAK PARK HEIGHTS, MN 55082 INCIDENT RECEIVED BY: RADIO FF O ICERS ASSIGNED: 474 HAUSKEN 477 CROFT NAMES ASSOCIATED JOSEPH CROFT WITH THIS INCIDENT: PHONE: (H) (W) SEX: DOB: ASSOCIATION: COMPLAINANT 10-50 OPH SQUAD #41 INVOLVED STATE PATROL ICR #04412002 MARY SHEILA BURNES 2501 HAWTHORNE LN STILLWATER, MN 55082 PHONE: (H) 651/351-7930 (W) 651/224-3995 SEX: F DOB: 5/22/1955 ASSOCIATION: SUSPECT DRIVER OF MN LIC #FPX846 ARRESTED BY STATE PATROL FOR DWI W/F JOSEPH A CROFT OPH PD OAK PARK HEIGHTS, MN 55082 PHONE: (H) 439-4723 (W) SEX:M DOB: ASSOCIATION: OTHER DRIVER OF OPH SQUAD #41 HEIGHTS CITY OF OAK PARK 14168 OAK PARK BLVD N OAK PARK HEIGHTS, MN 55082 PHONE: (H) (W) 651/439-4439 SEX: DOB: ASSOCIATION: OTHER OWNER OF OPH SQUAD #41 SCOTT SCHNEIDER 3489 HADLEY AV N OAKDALE, MN 55128 PHONE: (H) (W) 651/779-5900 CJG1UPROPH OAK PARK HEIGHTS POLICE DEPARTMENT DATE 12/13/04 TIME 8 : 09 : 48 INITIAL COMPLAINT REPORT 104704945 DATE/TIME REPORTED: 12/10/04 23 : 44 : 44 DISPATCHER: BMFRY DATE/TIME STAMP: 12/10/04 23 : 45: 05 ENTERED BY: BMFRY STATE TROOPER WHO WROTE ACCIDENT REPORT AND ARRESTED SUSPECT DRIVER OFFICER COMMENTS: 477 REPORT THAT HIS SQUAD WAS HIT ON HWY 5 474 12/1 SEE OFFENSE 474 12/1 WHILE ON DUTY IN SQUAD #41 MY SQUAD WAS STRUCK FROM BEHIND 477 12/1 BY AN INTOXICATED DRIVER. SGT HAUSKEN WAS ON DUTY AND WAS 477 12/1 NOTIFIED. HE REQUESTED STATE PATROL TO WRITE THE REPORT. 477 12/1 STATE PATROL STATE TROOPER #304 ARRIVED AND WROTE ACCIDENT 477 12/1 REPORT AS WELL AS ARRESTED THE INTOXICATED DRIVER FOR DWI . 477 12/1 SEE OFFENSE REPORT. . . 477 12/1 SEE STATE PATROL REPORT. . . 477 12/1 ICR ONLY? N 1CR 104704945 Page 1 of 2 f Initial Complaint Report 1 ICR Number: 104704945 Agency: Oak Park Heights Police Department ICR Created: 12/10/2004 23:44:44 CROFT#477 OFFENSE REPORT 12-10-04 2337 FRS SYNOPSIS While on duty operating squad#41 I was struck from behind by an intoxicated driver N/B Hwy 5 in the 5900 block., State Patrol wrote report and arrested driver of suspect vehicle for DWI. Suspect vehicle appeared to be totaled. Squad received moderate damage to left rear. OFFICERS OBSERVATIONS/ACTIONS On 12-10-04 at approximately 2335 hours I was on routine patrol N/B Hwy 5 from 58th when I observed a vehicle pull into the Stillwater motors lot. As we have had several thefts from vehicles in the car dealership lots over the last couple of months I pulled onto the shoulder of the road N/B Hwy 5 in the 5900 block and watched to see what the vehicle was doing in the car dealership at this late hour. As I was sitting in my squad on the shoulder of the road I was struck from behind by a Dodge Caravan. My squads headlights and taillights were on at the time,I was completely off the highway and onto the right shoulder of the road, and the vehicle was in"drive" thus my foot was on the brake. Note: after the accident I checked and found both rear brake lights to be operating correctly. After my squad was struck I called WCSO dispatch and advised them of the accident and requested another squad to respond to my location. I then exited my vehicle and approached the drivers door of the vehicle that had struck me. I observed a female in the drivers seat and both of her front airbags had deployed. The vehicle was occupied by 1 lone female driver. After approaching the vehicle I asked the driver if she was O.K. and she stated that she was. I then asked her what had happened and she stated that she was "just daydreaming I guess". I then asked her for her drivers license and insurance information. She retrieved these items and handed them to me. I then advised her that another officer was on the way to write the report. Sgt Hausken arrived and spoke with the female and detected the odor of an alcoholic beverage on her breath. She admitted to him that she had been drinking alcohol tonight. State Patrol Trooper#304 arrived and wrote the accident report as well as performed field sobriety tests on the driver of the mini- van. The driver was arrested by State Patrol for DWI. See state patrol state accident report for further info (State Patrol ICR#04412002). Squad#41 received moderate damage to the left rear however I was able to drive it back to the office where it was parked. The suspects mini-van appeared to be a total loss and was towed by State Patrol. Motor Vehicle Crash Report filled out by this officer, to be sent to DVS within 10 days. EVIDENCE I took 7 photos of the accident scene with my OPH PD issued disposable camera. Photos were entered http://crmdom 1/icr/icr.nsf/PrintView/556B8BE0C5F5CA0586256F670032E9F3?OpenDoc... 12/13/04 ICR 104704945 Page 2 of 2 onto my photo log and camera was placed into evidence. END OF REPORT Croft#477 Supplemental: Sgt M. Hausken 474 I heard Officer Croft radio that he had been involved in an accident with his squad. I arrived and found him N/B Hwy 5 Between 58th and Hwy 36. The vehicle that hit him had a lone female driver still sitting in the drivers seat. Both air bags had deployed. I checked on her and she stated she was fine. Officer Croft had no apparent injury's. She had given Officer Croft her MN Picture DL and also her insurance card. He handed these to me. I Checked the insurance card and it was for a 84 Honda and she was driving a newer Dodge Caravan. I asked her for her correct card and she was fumbling thru her wallet looking for it. As I was taking with her I could smell a strong odor of an alcoholic beverage coming from her breath. She was slurring her speech. I gave her a PBT and it showed that she was over.10. SP 304 arrived on the scene to write the accident and I informed him of the smell of alcohol and the PBT. He conducted SF ST and she was arrested for DWI. I informed Chief Swanson of the accident and Officer Croft finished his shift. SUPPLEMENTAL CROFT#477 12-11-04 2200 hrs After getting off duty this A.M. I went home and slept. Upon waking up I had mild muscle soreness in my upper and lower back as well as a slight stiffness in my neck. The soreness and stiffness has decreased over the course of the day however upon the start of my work shift I notified Sgt Hausken. He advised me to fill out a first report of injury. First report of injury was thus filled out and placed into case file. http://crmdom 1/icr/icr.nsf/PrintView/556B8BE0C5F5CA0586256F670032E9F3?OpenDoc... 12/13/04 FAX COVER.SHEET _ �MINNESoTA ' • Minnesota Department of Public Safety ' ��"esor s State Patrol Dist. 2400 -4- ;► �" 3469 Hadley Ave N. a + c Oakdale, MN -55128-3309 F p■. . r • • PATRo J Phone# 654:779-5900 r1 Fax# 651-779-5925 Date: la!P'f°c1 # of Pages to Follow: 3 TO: ' FROM: pP t �� , . sue- Pic-_ ors- 6g0 Fr- s wo -gtior Phone #: Phone #: 651-779-5900 Fax#: Fax#: 651-779-5925 SUBJECT/ REMARKS:• • -gier-- 5- 2a/9- ' e.i/fs, • CONFIDENTIALITY NOTICE: The documentls) accompanying this fax contain confident information which is legally privileged. ' The information is intended for the use of the intena recipient named above. If you are not -the intended recipient, you are hereby notified that a action in reliance on the contents of this telecopied information, except its direct delivery to intended recipient named above, is strictly prohibited. . If you have received this fax in en please notify us immediately by telephone to arrange for return of the original documents to Non-compliance could result in criminal or civil action. Thank you! I •d dSE =OT b0 ai oaj rJ-OLVUJ-IL) J I A I t yr NIIIVIVCJLI H-UtrMt<I!VIC IN I yr IUGLIL.WirtI T ' • LOCAL CAR NO. AMENDED ACCIDENT REPORT 04412002 N (LAW ENFORCEMENT ONLY) Page 1 of 1 FLIT-AND-RUN Pup PITOV VENCLES KILLED ' WANED S M N MONTH DATE YEAR DAY MILITARY TIME N N 2 0 0 Y IF DIVIDED HIGHWAY _ 12 10 04 Fri 2341 ROUTE SYSTEM ROUTE NUMBER OR STREET NAME I ROADWAY DIRECTION ` A I ❑MI ®N ❑E Q N ®E • I ❑ INTERSECliON I OR ❑FT ❑S ❑W of ON MATH 5 a N ❑E rt" COUNTY ® c,TY INT ELIM f REFERENCE POINT ROUTE EYE I ROUTE e,STREET.CORP LIMIT.REF POINT OR FEATURE 82 ❑ TRW OAK PARK H ,GTS NONE I -+ - LS 58TH ST ,...•I UNIT 2 •VEHICLE 0 NONMO:ORisT Fe-1 R t I POSITION DNIVER LICENSE NUMBER-1 STATE CLASS STATUS °OSITON LIMNER UCENSB NUMBER-2 'STATE 'CLASS STATUS re-,1 'G 1 18 1 )B652587765386 MN D 1 1 C61 3441 031 057 MN D 1 1 FcI 2 Pei 2 NAME(FIRST,MIDDLE,LAST) `GATE OF BIRTH NAME(FIRST.MIDDLE.LAST) DATE OF BIRTH Fd 2 d 2 18 MARY SHEILA BURNES 05/22155 JOSEPH ADAM CROFT 01/21/69 1 INUVER -ADDRESS ON VIOL. RESTRIC ACDRESS DR VIOL RESTRIC MNUVER 1 2501 HAWTHORNE LN y 1 14168 OAK PARK BLVD N 1 23 PHYSCL CITY.STATE,2/v 'CITY.STATE.ZIP PFYSCL 2 STILLWATER,MN 55082 OAK PARK HEIGHTS,MN RCUMND ADDRESS SEX SA'E E3PT SAFE EOPT AIRBAG EJECT INJ SEV -+AOODDREESS SEA SV E EOPT SAFE EOPI AIRBAG EJECT INJ SEV RCeOMND 3 CORRECT TYPE USE 6 5 N I Y F 4 4 1 5 N Y M 4 4 PLC TST TYPE CR T5T 'TYPE ITo Fbs 'TRANSPORT 'AMBULANCE SERVICE RUN NJMNER 4 ALC TST TYPE DR TST TYPE Tn Hoop j PASSPORT ORTS I IAK AMBULNACESERV-CE RUN NUMBER Y 3 N 98 N ❑AA■L.`IiCE N 98 N 98 N 0 DU ❑OTHEO I- 1 OCCUP OWNER NAME FIRE OWNER NAME FIRE OCCUP 1 SAME AS ABOVE N CITY OF OAK PARK HEIGHTS N 1 VEH TYP ADDRESS TOW ADDRESS T01Y VEHTYP 4 y SAME AS ABOVE N 1 VEH USE CITY,STATE.LIP P./1 DIRECT CITY,STATE.ZIP PL-4 DIRECT VEH USE UNIT UNIT 1 N 3 N 3 DWG LOC MAKE WOOEL ' YEAR (COLOR MAKE MODEL YEAR ' COLOR DIG LOC 2 DODGE CARAVAN 01 RED FORD EXPDTION 04 WHITE 5 DMO SEV PLATE a ST REG YEAR REG SEC) Or EVE NTS Mosl lonolul PLATE a ST REG YEAR REG 1 SE 2 OF EVE NTS ram HUnVV DIAG SEV I4 FPX846 MN 04 s 2 POLICE MN I 3 . ■I ■ INSURANCE POLICY NUMBER INSURANCE POLICY NUMBER STATE FARM UNK LEAGUE OF MN CITIES I KUD1 TYPE 1405 MAT -»A VED INSPECTION 8 DaCge s IF CRASH INVOLVED A COMMERCIAL MOTOR VEHICLE,SCHOOL BUS,OR NEAR START BUS I WRIVEU T HA!MAT 80OY TYPE 1'LAC Pus REMEMBER'TO NOTIFY THE STATE PATROL(REQUIRED UNDER MS 764.787 AND 169.4511) COMMERCIAL VEHICLE NUMBER 1-MOTOR CARRIER NAME DOT NUMBER COMMERCIAL VEHICLE NUMBER 2-MOTOR CARRIER NAME DOT NUMBER m PASSENGER'WITNESSES UNT P05TN DATE OF BIRTH SEX TYPE USE AIRBAG EJECT -NJ SC•V TO HOER TRANSPORT NONE D"AS ❑OTHER ❑0745 ❑OT/f_R QAWB ❑OTHER OWNER Or OTHER DAMAGED PROPERTY AND DESCRIPTION OF DAMAGED PROPEFRTYANOION YELLOW TAG NUf4BER(S) DAMAGED PROPERTY I YELLOW TAG NUMBER NONE NONE Ace Typo NARRATIVE: DENCE 2 Nor VEH 2 WAS ON THE RIGHT SHOULDER OF E/B HWY 5 NORTH 98 ,rD OF 58TH ST. VEH 2 WAS INVESTIGATING A SUSPICIOUS DAVIS w. VEHICLE THAT HE OBSERVED DURING THE COURSE OF HIS 3 A / E_-'T3 S 5C.�.}t POLICE DUTIES. Lrr-1 on Iv WORKING 2 VEH 2 HAD TAILLIGHTS AND BRAKE LIGHTS ACTIVATED. 98 I,NT REL Do BmkOe 'I • N VEH 1 WAS E/B HWY 5 AND DRIFTED OFF THE ROADWAY TO Speed Lima Irp•WE THE RIGHT AND STRUCK VEH 2. 98 , 45 LIC oI 1 'Weather I CoasroW2 I. DRV 1 WAS ARRESTED FOR DUI AND SUPPLIED A .14 AC ON 1 98 THE INTOXILYZER. WOel5r2 Workers P.MAnI N I Lgnl Rdos.3 _ • 4 'Mows Taken Rd sun Y 1 1 Diagram I Re Cnnr I 1 If - Officer Rank,Name and badge if Agency Palyd$111188 EI State Patrol ❑Local I TROOPER S.SCHNEIDER#304 MSP 2430 ❑Sheriff ❑Other PLEASE SEND COMPLETED REPORT WITHIN 10 DAYS TO.DVS)ACCIDENT RECORDS 445 MINNESOTA STREET SUITE 181 ST PAUL MN 55101-51B1 • E 'd dSE :0T ivo ET oaa MINNESOTA'. MINNESOTA STATE PATROL 1 ESO ( DWI ARREST REPORT - SUPPLEMENTAL I=PATROt� CASE CONTROL NUMBER: 04412002 DEFENDANT: MARY SHEILA BURNES 05/22/55 DATE OF ARREST: 12/10/04 PRELIMINARY INFO: On 12/10/04 at 2341 I was dispatched to a crash at Hwy 5 north of 58th St in Oak Park Heights. Dispatch reported the crash involved an Oak Park Heights Police squad. When I arrived I spoke with Officer Joseph Croft #477. Officer Croft told me he was stopped on the right shoulder of E/B Hwy 5 watching a suspicious vehicle in an adjacent parking lot. Officer Croft stated his taillights were on and the vehicle was in drive, so his foot was on the brakes and the brake lights activated. Officer Croft was then hit by MN license FPX846 while on the shoulder. The vehicle was E/B Hwy 5 in the right lane and drifted off the roadway and onto the shoulder. The vehicle's right front struck the police squad's left rear. The driver of the vehicle was still in the driver's seat when I arrived. INITIAL OBSERVATIONS: I identified the driver as Mary Sheila Burnes 05/22/55 by her MN driver's license. I smelled a strong odor of alcohol emitting from Burnes. Burnes had watery and glassy eyes. Burnes also had slurred speech. Burnes admitted to drinking three glasses of wine while at the 242 bar in St. Paul. Burnes later stated she had four glasses of wine. Burnes stated she knew she should not have been driving because she was fatigued and exhausted. However, Burnes did not think she was impaired. Burnes did not know how the crash happened. SFST'S: Burnes failed the HGN test. I did not conduct any balancing or walking tests because of the crash. Burnes denied she was injured but stated she was shook up. Burnes denied medical attention. The air bags did go off. Burnes could not say the alphabet correctly from the letter c to the letter y. Burnes also could not count correctly from 71 to 55. See SFST sheet for additional information. e 'd dSE :oi bo zI pall ARREST: Burnes was told she was under arrest, handcuffed, searched, and placed in my squad. Burnes was taken to the Washington County Jail. IMPLIED CONSENT/MIRANDA INTERVIEW: I read Burnes the Implied Consent Advisory at 0038. Burnes declined an attorney and stated, "Yes" to a breath test. Burnes then supplied a .14 AC on the Intoxilyzer at 0103. At 0056 I read Burnes her Miranda rights. Burnes declined to speak to me. There was a time difference between my watch and the Intoxilyzer clock. I read Burnes her Miranda rights after the Intoxilyzer test. Burnes was observed for 15- 20 minutes prior to the test. MISC INFO: The vehicle was towed by Stillwater Towing. Photographs of the crash scene were taken by Oak Park Heights PD. Officer Croft complained of no injury at the time of the crash. See crash report for additional information. See Oak Park Heights PD reports for additional information. CHARGES: 169A.27 4th Degree DUI FINAL DISPOSITION: Burnes was booked into the Washington County Jail and issued citation RT08201 for 4th degree DUI. Signature: Arresting Trooper: Scr iovYc Yoc! DATE:a/ 11 /oy •d dsE :OI .,o 2I oaa FROM, : STILLWATER MOTOR CO PHONE NO. : 6513515197 Dec. 12 2004 09:11AM P2 12/13/2004 at 0 1 ::39 PM Job qumber• 35238 STILLWATER MOTOR COMPANY Federal ID #:410561600 5900 STILLWATER BLVD NO. PO BOX 337 STILLWATER, MN 55082 (651) 393-2399 Fax: (651) 351-5197 PRELIMINARY ESTIMATE Written By: MIKE GLADIS Adjuster: Insured: CITY OF OAK PARK HEIGHTS Claim # Owner: CITY OF OAK PARK HEIGHTS Policy # Address: 14168 NO 57TH ST PO BOX 2007 Deductible: OAK PARK HEIGHTS, MN 55082 Date Of Loss: Day: Type of Loss: Evening: Point of Impact; 7. Left Rear Inspect Location: Insurance ' Company: Days to Repair 2004 FORD EXPEDITION 4X4 XLT 8-5.4L-FI 4D UTV WHITE Int: VIM: 1FMPU16L64LB26616 Lic: POLICE MN Prod Date: Odometer: 17908 Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Keyless Entry Rear Wiper Dual Mirrors Privacy Glass Roof Console Luggage/Roof Rack Fog Lamps Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Driver Seat Power Mirrors Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes Cloth Seats Split Bench Seats Running Boards/Side Steps Aluminum/Alloy Wheels NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT 1 REAR BUMPER 2 0/H rear bumper 1 .5 3 Repl Reinforcement • 1 342.93 Incl. 4 Repl Impact bar 1 77. 08 Incl. 5 Repl Step pad 1 39.22 Incl. 6 Repl Bumper cover XLT, w/o reverse 1 555. 50 Incl . 1.5 sensing system XLS, XLT 7 Add for Clear Coat 0. 6 8 Deduct for Rear Bumper R&I -0. 8 9 REAR LAMPS 10 Repl LT Tail lamp assy 1 71.50 Incl. 11 LIFT GATE 12 Repl Lift gate 1 927. 18 5. 5 3 .4 13 Add for Clear Coat 1.4 1 FROM : STILLWATER MOTOR CO PHONE NO. : 6513515197 Dec. 12 2004 09:11AM P3 12/13/2004 at 01: 37 PM 35238 ,:c.c. "Number: PRELIMINARY ESTIMATE 2004 FORD EXPEDITION 4X4 XLT 8-5.4L-FI 4D UTV WHITE Int : NO. OP, DESCRIPTION QTY EXT. PRICE LABOR PAINT 14 Repl Emblem Ford oval 1 22 .38 0 .2 15 Repl Nameplate "EXPEDITION" 1 19 .27 0.2 16 Repl Nameplate "XLT" 1 13 .80 0 .2 17 Repl Handle XLT black 1 71 .58 Incl. 18 R&I Lift gate glass Ford green 0.5 tint Incl . 19 REAR BODY & FLOO$ 20* Rpr Rear floor pan 21 R&I Cover ass ' n medium flint 8 . 0 2.2 � t incl. 22 R&I Scuff plate dark flint Incl. 23* R&I Cover jack stowage medium 0. 5 flint 24 QUARTER PANEL 25 R&I LT Quarter glass Ford w/fixed Incl . window green tint 26* Repl LT Inner panel 1 392 .45 s 6 . 0 27* Rpr LT Wheelhouse panel 1.5 3 .0 28 R&I RT Qtr trim panel w/o 1. 0 auxiliary AC dark flint 29 Repl LT Qtr trim panel w/o 1 282 . 58 Incl. auxiliary AC dark flint 30 Repl LT Quarter panel w/o wheel 1 834 .42 19.0 3 .1 opening molding 31 Overlap Major Adj . Panel -0.4 32 Add for Clear Coat 0.5 33 Repl LT Splash shield 1 15 . 13 Repl URETHANE 5 .95 0.2 P HAKE GLA3 • S INSTALL KIT 1 24 .95 35# Repl PANEL BONDING ADHESIVE KIT 1 24 . 95 36# Refn COVER CAR 37# Refn BLEND 0.2 38# HAZARDOUS WASTE 1.0 39# � 3 .00 X 40# DIAGNOSIS & SET UP TIME CORROSION PROTECTION 1 13 . 00 X 1 .5 1 .5 41# PULL AND SQUARE 1 5 . 0 F Subtotals ==> 3730. 92 51. 5 15.5 , Estimate Notes: DECALS & LETTERING---PRICE OPEN 2 FROM : STILLWATER MOTOR CO PHONE NO. : 6513515197 Dec. 12 2004 09:12AM P4 12/13/2004 at 01 :37 PM Jo.o Number: 35238 PRELIMINARY ESTIMATE 2004 FORD EXPEDITION 4X4 ELT 8-5 .4L-FI 4D UTV WHITE Int: Parts 3714 .92 Body Labor 46. 5 hrs 0 $ 46. 00/hr 2139 .00 Paint Labor 15. 5 hrs @ $ 46. 00/hr 713 .00 Frame Labor 5. 0 hrs P $ 69.00/hr 345. 00 Paint Supplies 15.5 hrs @ $ 26. 00/hr 403 . 00 Sublet/Misc. 16. 00 SUBTOTAL $ 7330.92 Sales Tax $ 3714 .92 0 6.5000$ 241 .47 GRAND TOTAL $ 7572 .39 ADJUSTMENTS: Deductible 0.00 CUSTOMER PAY $ 0.00 INSURANCE PAY $ 7572 .39 Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR2MC03 Database Date 12/2004, CCC Data Date 12/2004, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (-) items indicate MOTOR Not-Included Labor operations_ Non-Original: Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LEO, Qual Recy Parts, RCY, or USED Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Prices are provided by National Auto Glass Specifications, Inc. Pound sign (#) items indicate manual entries. Some parts that are described as Recon. may be OE Surplus parts or other OE parts offered at a special pricing discount. For further clarification please review the Suppliers List attached to this estimate, or consult the appraiser or, estimator. CCC Pathways - A product of CCC Information Services 'tnc. 111Q.\(-\ VIi9N C ( )(:)(= 12)(4)-V-- \ic te) -c..\,/ yy\p) bob wov) QE. c --\ A` erzAApv\ (2..,-ect\mk_,D 4-1\ EILT: 3 1 hcrP . , _____;_ , , ,..,, ,_ Lmc ,..0 `j ;}145 University Avenue West, St. Paul, MN 55103-2044,, , Phone: (651) 281-1200 • (800) 925-1122 h TDD (651) 281-1290 League of Minnesota Cities LMC Fax: (651) 281-1299 • LMCIT Fax: (651) 281-1298 Cities promoting excellence J Web Site: http://www.lmnc.org ACKNOWLEDGMENT OF CLAIM OAK PARK HEIGHTS, CITY OF 14168 OAK PARK BLVD P.O. BOX 2007 STILLWATER MN 55082 Date: 1/17/03 RE: Our File No. : 11042975 LMCIT Member: OAK PARK HEIGHTS, CITY OF Claimant Name: RANDY & LYNN GARAVALIA Occurrence/Loss Date: 8/16/02 Claim Description: SEWER BACKUP Supervisor: CURTIS HEITSCHMIDT Phone No. : (651)281-1284 Fax No. : (651)281-1297 Adjuster: IAN COAKLEY Phone No. : (651)215-4078 or 1-800-925-1122(outstate), Extension 4078 Fax No. : (651)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also available to you at any time. LMCIT Claims Department C.C. LANDMARK INSURANCE SERVICES 232 S LAKE ST FOREST LAKE MN 55025- AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER • • • t_ ' r ` ,--; '+ .4. } V, r-. 4.` c- �' .�' „.} ... '�a^¢yv, .�+nAV,.k�" �in, �, 4 City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal . . / Fax: From: c GC 'f 1 l S Date: � r � c• _) / r Re:( �C� (2�.�, c{- / Pages: CC: ❑ Urgent ❑For Review ❑Please Comment ❑ Please Reply 0 Please Recycle Notes: � i—irr � City of Oak Park Heights 14168 Oak Park Blvd N.•Box 2007•Oak Park Heights,MN 55082•(651)439-4439•Fax 439-0574 Interoffice Memo To: Acting City Administrator From: Public Works Director, Jay Johnson, PE CC: Ian Coakley, LMCIT (Via email) Date: 01/23/03 Re: Sewer Back-up at 14245 53rd Street North Due to Lift Station Failure A failure of the sewer lift station at 53rd Street and Obrien Avenue occurred on August 16, 2002 after an electrical storm in the area. The backup of sewage in the sewer system and a failure of the backflow preventor in the home at 14245 53rd Street resulted in sewage backing up into the basement of the home. When our crew arrived on site everything was in failure mode. They reset power and everything worked. General Repair Company was called to investigate the failure and was unable to determine the cause. It appears that a close by lightening strike may have scrambled the electronics of both the operating system and the alarm system. By resetting the power the system returned to normal operations. The only apparent damage to the lift station was the external strobe light had to be replaced. TREE CITY U.S.A. WESTFIELD G R O U P S" January 6. 2003 AK 8 \\\11.-- CITY OF OAK PARK HEIGHTS P 0 BOX 2007 OAK PARK HEIGHTS MN 55082-5508 Re: Insured: RANDY GARAVALIA and LYNN GARAYALIA Claim No. : NR-OFH-1540895-081602-A Date of Loss: August 16. 2002 Dear City of Oak Park Heights: Our investigation of the loss that occurred on August 16. 2002 at or near 14244 53rd St. N., Stillwater. MN establishes that you are legally responsible for the damages. Our insured submitted the following claim, which we have paid. 1. BuildinglDwelling 9,344.76 2. Personal Property 1,135.17 3. Business Property 4. Additional Living Expense 5. Business Interruption 6. Scheduled Property 7. Deductible 500.00 SUBTOTAL 10.979.93 8. Less Salvage TOTAL CLAIM $10.979.93 If you carry insurance to protect you against a loss of this type, please give this letter to your insurance company. The Insurance Information form enclosed should also be completed and returned to us immediately. If you are not insured, please contact me within the next 5 days to make arrangements for payment of these damages. Thank you. Yourssfytruly, O Michael L. Ewy Regional Specialist ,• �' Enclosure - Insurance Information form (CD 321) I'\` Self-addressed envelope 4940 Viking Drive,Suite 404 CD 209 (Rev. 4 91) Edina, MN 55435-5320 (952)831-6446 or 1-800-757-9244 FAX(952)831-4015 www.westfleldgrp.com :.; WESTFIELD j G R O U P "' INSURANCE INFORMATION FORM DATE: 1-10-03 Res insureds RANDY GARAVALIA and LYNN GARAVALIA Claim No.; NR-OFH-1540895-081602-A Date of Loss: August 16, 2002 Claim Reps Michael L. Ewy The following information concerning my insurance is being furnished as requested in your letter: NAME OF MY INSURANCE COMPANY - League Of MN Cities xnsuxance Trust MY POLICY NUMBER - C'�C22977 NAMED INSURED ON POLICY - City of Oak Park Heights NAME OF MY INSURANCE AGENT - Kate Tipping - Landmark Insurance Svcs . MY AGENT'S ADDRESS - ' 232 'S S. Lake St. , Forest Lake, MN 55025 MY AGENT'S PHONE # - 651-464-3333 :// 651-439-4439 .SIGNED C c°' PHONE [ I CHECK BOX IF YOU ARE NOT INSURED 4940 Viking Drive,Suite 404 CD 321 (Rev. 1.90) Edina, MN 55435-5320 (952)831-6446 or 1-800-757-9244 FAX(952)831-4015 www.westfieldgrp.com WESTFIELD G R O U Ps, Continuation of CD 209 The language on this page is an integral part of the attached Subrogation-Initial Demand to Individual-Property, CD 209 form. Re: Insured: RANDY GARAVALIA and LYNN GARAVALIA Claim No.: NR-OFH-1540895-081602-A Date of Loss: August 16, 2002 STATE LAW REQUIRES US TO NOTIFY YOU OF THE FOLLOWING: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, SUBMITS AN APPLICATION OR CLAIM CONTAINING ANY MATERIALLY FALSE OR DECEPTIVE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, ANY MATERIAL INFORMATION COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME. 4940 Viking Drive,Suite 404 Edina, MN 55435-5320 (952)831-6446 or 1-800-757-9244 FAX(952)831-4015 www.westfleidgrp.com I _ 407 4 WESTFIELD GROUP January 6, 2003 \\\\ CITY OF OAK PARK HEIGHTS P 0 BOX 2007 OAK PARK HEIGHTS MN 55082-5508 Re: Insured: RANDY GARAYALIA and LYNN GARAVALIA Claim No. : NR-OFH-1540895-081602-A Date of Loss: August 16. 2002 Dear City of Oak Park Heights: Our investigation of the loss that occurred on August 16. 2002 at or near 14244 53rd St. N.. Stillwater. MN establishes that you are legally responsible for n claim, which we have paid. the damages. Our insured submitted the following c P 1. Building(Dwelling 9.344.76 2. Personal Property 1.135.17 3. Business Property 4. Additional Living Expense 5. Business Interruption 6. Scheduled Property 7. Deductible 500.00 SUBTOTAL 10.979.93 8. Less Salvage TOTAL CLAIM $10,979.93 If you carry insurance to protect you against a loss of this type, please give this letter to your insurance company. The Insurance Information form enclosed should also be completed and returned to us immediately. If you are not insured, please contact me within the next 5 days to make arrangements for payment of these damages. Thank you. Yours truly, `..12 Ofty04(dASJ) Michael L. Ewy �o " Regional Specialist ./LP Enclosure Insurance Information form (CD 321) (' 4 ciec Self-addressed envelope - ' II 4940 Viking Drive,Suite 404 CD 209 {Rev. 4 91) Edina, MN 55435-5320 (952)831-6446 or 1-800-757-9244 FAX(952)831-4015 www.westfieldgrp.com ip WESTFIELD G R O U P 9' INSURANCE INFORMATION FORM DATE: 1-10-0'3 Re: Insured: RANDY GARAVALIA and LYNN GARAVALIA Claim No.: NR-OFH-1540895-081602-A Date of Loss: August 16, 2002 Clain Rap: Michael L. Ewy The following information concerning my insurance is being furnished as requested in your letter: NAME OF MY INSURANCE COMPANY - League ,Of. MN Cl,tl-es insurance Trust MY POLICY NUMBER - 022977 NAMED INSURED ON POLICY - City o,£ Oak '•ark. Heights NAME OF MY INSURANCE AGENT - Kate Tipping — Landmark Insurance Svcs . MY AGENT'S ADDRESS - 232 ;S S. Lake St. , Forest Lake, MN 55025 MY AGENT'S PHONE # - 651-464-3333 `1� (4 PHONE 651-439-4439 SIGNED �L f [ ] CHECK BOX IF YOU ARE NOT INSURED 4940 Viking Drive,Suite 404 Edina,MN 55435-5320 (952)831-6446 or 1-800-757-9244 CD 321 (Rev. 1.90) FAX(952)831-4015 www.westfieldgrp.com WESTFIELD ••:-1";:t*ii: G R O U P5". Continuation of CD 209 The language on this page is an integral part of the attached Subrogation-Initial Demand to Individual-Property, CD 209 form. Re: Insured: RANDY GARAVALIA and LYNN GARAVALIA Claim No.: NR-OFH-1540895-081602-A Date of Loss: August 16, 2002 STATE LAW REQUIRES US TO NOTIFY YOU OF THE FOLLOWING: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, SUBMITS AN APPLICATION OR CLAIM CONTAINING ANY MATERIALLY FALSE OR DECEPTIVE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, ANY MATERIAL INFORMATION COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME. 4940 Viking Drive,Suite 404 Edina, MN 55435-5320 (952)831-6446 or 1-800-757-9244 FAX(952)831-4015 www.westfleidgrp.com OAK PARK HEIGHTS r Memo : To: Michael L. Ewy, Westfield Group, fax (952) 831-4015 From: Kimberly Kamper, Acting City Administrator Date: September 10, 2002 Re: Your Claim # NR-OFH-1540895-081602-A I am writing to follow up on the "Insurance Information Form" that was faxed to you on September 5, 2002. I would like to request that you provide us with a written explanation of the claim, the name(s) of the individual(s) filing the claim and their address and telephone number as well as where the incident took place. We will then pass this information along to our insurance company. Thank you. •Page1 09/05/2002 THU 14:32 FAX 6514647596 LANDMARK INSURANCE al001/004 SEP-05-2002 11:55 CITY OF OPH P.01/04 ' • •1 r•1 i a m . 1 _ • Mf 1 - • City of Oak Ptakgelf.10 14168 Oak ParkBlvd Box 2007 Oak Pelt Ileig11ta,MN 53081 • ' now(651)439.4439 Facsimile(651)439.0574 fäcsimilelransinittaL c(t5, 2A 1{g,re T-i' h Fay __'i -- Li6V - ?5-7 re EAt KAIN Kw Data: CC: 0 Urgent 0 For Review 0 Picege Comment El Plume Reply 0 Please Recycle Notes: • r.w/,•/�^f ? .��� r%,.,TIYIh Yf/.. ''jVM?. 7,(ti.l •.-' .F •'S' }�'"YU;'+.yM:- r,.�"s.lr y `ni- �•k:�f'•'��.•..1{.'. ♦� 1a �'iM.a :nyy..:n L� �y"I`�lt�; ! l`� `-eI(+(jjlj �.II !t'. a yt L t. ,.,..` F sr ri � ..i r c !I•i1,'�4 Gi l 9 ,,.4;t pl.Gr.y 'ii; �3 iy7�'L': ! s' .i1..�y'f�v.:Y~F. •'.'1� ,�l RR..SS�`M11fs'444- yp �iY l"k.�' ../9.f 7ly'�..�;r7"--.err f b. ;, :I :... 1. l` !.i f f r: `5y�,d_...'1 �........i.,...„...:'r+.: - ;b".. -11:-..:.Y; f`.' -'. �a.�t.11s ;.i t.. 'l.�ii�•},.! �'7'-.may"'•TT'•'�'S 09/05/2002 THU 14:32 FAX 6514647596 LANDMARK INSURANCE a002/004 SEP-05-2002 11:57 CITY OF OPH P.03/04 Ar WESTFIELD O R O U P w • INSURANCE INFORMATION FORM DATE: G ' - U Z Rev Insured; RANDY GARAVALIA and LYNN GARAVALIA C3.aio No.; NR-OFH-1540895-081602.A Date of Lou; August 16, 2002 Claim Repo Michael L. Ewv The following information concerning my insurance is being furnished as requested in your letter; �, 1� NAME OF MY INSURANCE COMPANY - °' ill ' vt►'►L 4"c9- 14-4"'" °t "t'Tr MY POLICY NUMBER - CM C. 2297`] NAMED INSURED ON POLICY - C. QosG ID , 14 NAME OF MY INSURANCE AGENT - �! _ � exAtr t l- &4 i c CJ2- MY AGENT'S ADDRESS - 3 Z- L Oc . S . .,en:C".....—� Mr.) DSO 2 5 MY AGENT'S PHONE * - & S I — LI G — ?13 3.3 -• SIGNED PHDNE [ 7 CHECK :OX IF YOU ARE NOT INSURED 4440 Viking Drive,Suite 404 W 321 !Rev, 1.901 Etllna,rMN /5543t 5 53 20•n r( 2.).8314448 ....+ 09/05/2002 THU 14:33 FAX 6514647596 LANDMARK INSURANCE (1003/004 SEP-05-2002 11:56 CITY OF OPH P.02/04 WESTFIELD .:.. Q R O U P �' September 3, 2002 CITY OF OAK PARK HEIGHTS P 0 DOx 2007 OAK PARK HEIGHTS MN 55082 Re: Insured: RANDY GARAVALIA and LYNN GARAVALIA Claim No.: NR-OEH-154089.5-0816,02-A __ _ _ . • Date of Loss: August 16, 2002 Dear City of Oak Park Heights: Our insured has made A claim against an insurance policy with this company for damages received as a result of a loss occurring on August 10. 2002. Our investigation establishes that you are responsible for those damages. we are legally entitled to recover any payments that we make to our insured as a result of this accident. Any settlement of this claim by you or your insurance company must recognize our right of subrogation as provided in the policy with our insured. If you are insured: 1. Send this letter to your insurance agent or insurance company. 2. Complete the enclosed form. and return it to us immediately. If you are not insured: 1. Complete the enclosed form, and return it to us immediately. 2. Contact this office within five days to discuss how you will pay for these damages. Yours truly, (rVgedDfCi.e--- Michael L. NY t CCU _C\ Regional Specialist Enclosure: Insurance Information Form (CD 321) , Self-addressed envelope 4840 Viking Drive,Suite 004 CD 322 Rev. 9 19 Edina.MN 55435-5920 (952)831-8448 or 14004574244 FU tniipl R91.4Mn www witsflinirinm.rnm 09/05/2002 THU 14:33 FAX 6514647596 LANDMARK INSURANCE ( 1004/004 SEP-05-2002 1i;57 CITY OF OPH P.04/04 WESTFIELD . r' G R Q U P Continuation of CD 322 page is an integral The language on t his p part of the attached 9 9 Subrogation-First Notification to Wrongdoer, CO 322 form. • Re: Insured: RANDY GARAVALIA and L YNN GARA VALIA Claim No.: NR-0FH•1540B95-001602-A Data of loss: August 16. 2002 S TATE LAW REQUIRES US TO NOTIFY YOU OF THE FOLLOWING: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE CO11dPANY OR OTHER,PERSON,..SUBMITS AN _._. _ . APPLICATION OR CLAIM CONTAINING ANY MATERIALLY FALSE OR DECEPTIVE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, ANY MATERIAL 7NFOATION COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME. 4840 Viking Drive,suite 404 Edina,MN 554353320 (052)5314445 or 1-830-7574244 FAX(952)531.4015 Www.westfleldgrp.com .4r. WESTFIELD G R O U P SM September 3, 2002 CITY OF OAK PARK HEIGHTS P 0 BOX 2007 OAK PARK HEIGHTS MN 55082 Re: Insured: RANDY GARAVALIA and LYNN GARAVALIA Claim No. : NR-OFH-1540895-081602-A Date of Loss: August 16, 2002 Dear City of Oak Park Heights: Our insured has made a claim against an insurance policy with this company for damages received as a result of a loss occurring on August 16. 2002. Our investigation establishes that you are responsible for those damages. We are legally entitled to recover any payments that we make to our insured as a result of this accident. Any settlement of this claim by you or your insurance company must recognize our right of subrogation as provided in the policy with our insured. If you are insured: 1. Send this letter to your insurance agent or insurance company. 2. Complete the enclosed form, and return it to us immediately. If you are not insured: 1. Complete the enclosed form, and return it to us immediately. 2. Contact this office within five days to discuss how you will pay for these damages. Yours truly. C et Michael L. Ewy n Regional Specialist Enclosure: Insurance Information Form (CD 321) Self-addressed envelope 4940 Viking Drive, Suite 404 CD 322 (Rev. 9 89) Edina, MN 55435-5320 (952)831-6446 or 1-800-757-9244 FAX(952)831-4015 www.westfieldgrp.com '' WESTFIELD G R O U P 5"' INSURANCE INFORMATION FORM — DATE: S - lid-- Re; Insureds RANDY GARAVALIA and LYNN GARAVALIA Claim No.s NR-OFH-1540895-081602-A Date of Loss: August 16, 2002 Claim Rep: Michael L. Ewv The following information concerning my insurance is being furnished as requested in your letter: NAME OF MY INSURANCE COMPANY - Lec,,9(t 01 f VIi1�n�SUi Sv c,- �� T�ST MY POLICY NUMBER - G '-v G a),1 .) -7 NAMED INSURED ON POLICY - C- "�-y O u)C. 1 `—k Hect3 Li7� NAME OF MY INSURANCE AGENT - L�""c/ e„-vic-es MY AGENT'S ADDRESS - a3 L c,k2 ST S_ Fai es 7 Lam . , r1 rk S S MY AGENT'S PHONE # - CS-1 -41 6 l - 3333 SIGNED 977/44• / PHONE �°57- 40.9 �`If [ ] CHECK BOX IF YOU ARE NOT INSURED 4940 Viking Drive,Suite 404 CD 321 (Rev. 1 90) Edina, MN 55435-5320 (952)831-6446 or 1-800-757-9244 FAX(952)831-4015 www.westfieldgrp.com .:_ WESTFIELD Continuation D 2 f o C 3 2 The language on this page is an integral part of the attached Subrogation-First Notification to Wrongdoer, CD 322 form. Re: Insured: RANDY GARAVALIA and LYNN GARAVALIA Claim No. : NR-OFH-1540895-081602-A Date of Loss: August 16, 2002 STATE LAW REQUIRES US TO NOTIFY YOU OF THE FOLLOWING: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, SUBMITS AN APPLICATION OR CLAIM CONTAINING ANY MATERIALLY FALSE OR DECEPTIVE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, ANY MATERIAL INFORMATION COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME. 4940 Viking Drive,Suite 404 Edina, MN 55435-5320 (952)831-6446 or 1-800-757-9244 FAX(952)831-4015 www.westfieldgrp.com • • • s 4-a .p �,. c ,'.g",t ,"°.,. n s x a;liars r .sq�K` $.`4 3 .5�T"€x`"5�+ S,wy.`...,5,�,.r,-.... .:*`.... -..« �3 ... '4tir� r v •e s + r a voartaii • City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: K4?e. 77)0K-A Fax: " (-1 - 25- From: �l riA �, ��� Date: Re: Pages: CC: ❑ Urgent ❑For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle Notes: • t J 145 University Avenue West, St. Paul, MN 55103-2044 Phone: (651) 281-1200 • (800) 925-1122 TDD (651) 281-1290 R-----\„7 L MC League of Minnesota cues LMC Fax: (651) 281-1299 • LMCIT Fax: (651) 281-1298 Cities promoting excellence J Web Site: http://www.lmnc.org August 9, 2001 Lynn Garavalia 14245 53rd Street Oak Parks Heights, MN 55082 RE: LMCIT FILE NO.: 11036777 TRUST MEMBER: City of Oak Park Heights CLAIMANT: Lynn Garavalia D/OCCURRENCE: 8/4-5/01 Dear Ms. Garavalia This letter will follow up our telephone conversation of August 8, 2001. The League Of Minnesota Cities Insurance Trust provides general liability coverage to our trust member, the City of Oak Park Heights. As we discussed, you will be looking to your homeowner's carrier for reimbursement of your damages. In the meantime I will be meeting with the city to determine the cause of the back up and any records and history they have. I'll let you know as soon as my investigation is completed. If you want to provide your claims adjuster with my name and phone number, I will answer any questions they may have. Also, I indicated that I could not make any commitment until I had completed my investigation into liability. Sincerely, Darlene Boese Senior Claims Adjuster ro DATE TIME 651-215-4077 /,l Oh d PM FR AREA CO OE cc: Kimberly Kamper, Adt mar-3 )11(1!"9711(: V ;7 ,/ No. rpee--- Cid 1 7 Curt Heitschmidt, LM( OF `/ EXT �'I" G i E b 6e \ U -a eiti- 1 AN EQUAL 4 S J D I,'PHONED❑ BACK ❑ CALL RNED❑ SEE YOU ❑ VSLL ALL ❑ WA N ❑ URGENT❑ m ('T G E I V F I i 13-2044 145 University Avenel y-- , _. '- u '_- Phone; 6 '.1) 281-1200 • (80B y11212920 LMC ' `.-----%---7 AUG 'I t 65 ) Leagueo`Minnesotacities LMC Fax: (651) 281-12 '� • LMCIT Fax: (65I .1-1298 Cities promoting excellence y J ,fe. 1 e: p: , , .1 nc.org City of Oak Park Heights 14168 Oak Park Blvd. So. Oak Park Heights, MN 55082-2007 - Date: 08/07/01 RE: Our File No.: 11036777 LMCIT Member: City of Oak Park Heights Claimant: Lynn Garavalia Occurrence/Loss Date: 08/04/01 Claim Description: Sewer Backup Supervisor: Curt Heitschmidt Phone No.: (651) 281-1284 Fax No.: (651) 281-1297 We have received this claim(s) at the LMCIT claims office. The assigned claims supervisor is listed above. If you are not contacted by an adjuster within a reasonable period of time or if you have comments or questions, please call the listed phone number and ask for the specific supervisor assigned to this claim. LMCIT Claims Department c: Landmark Insurance Agency 232 South Lake Street Forest Lake, MN 55025 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER Berkley Risk Administrators League of Minnesota Cities Fax: 651-215-4185 I am writing to inform you that Lynn Garavalia of 14245 53rd St., Oak Park Heights, MN 55082 would like to file a claim against the City of Oak Park Heights for two sewer back ups. The first sewer back up occurred during the evening of August 4, 2001 and the second occurred in the afternoon of August 5, 2001. You may contact Ms. Garavalia at 651-439-2349. Please contact me if you need further information. Sincerely, Kimberly Kamper Administrative Assistant r CITY OF OAK PARK HEIGHTS ► 14168 Oak Park Boulevard No. • P.O.Box 2007 • Oak Park Heights,MN 55082-2007 • Phone:651/439-4439 • Fax 651/439-0574 Berkley Risk Administrators League of Minnesota Cities Fax: 651-215-4185 I am writing to inform you that Lynn Garavalia of 14245 53rd St., Oak Park Heights, MN 55082 would like to file a claim against the City of Oak Park Heights for two sewer back ups. The first sewer back up occurred during the evening of August 4, 2001 and the second occurred in the afternoon of August 5, 2001. You may contact Ms. Garavalia at 651-439-2349. Please contact me if you need further information. Sincerely, Kimberly Kamper Administrative Assistant Tree City U.S.A. CITY OF a' OAK PARK HEIGHTS 14168 Oak Park Boulevard No. • P.O.Box 2007 • Oak Park Heights,MN 55082-2007 • Phone:651/439-4439 • Fax:651/439-0574 Berkley Risk Administrators League of Minnesota Cities Fax: 651-215-4185 I am writing to inform you that Lynn Garavalia of 14245 53rd St., Oak Park Heights,MN 55082 would like to file a claim against the City of Oak Park Heights for two sewer back ups. The first sewer back up occurred during the evening of August 4, 2001 and the second occurred in the afternoon of August 5,2001. You may contact Ms.Garavalia at 651-439-2349. Please contact me if you need further information. Sincerely. „. :�� Z'^90fl� Kimberly Kamper ((/� Administrative Assistant Tree City U.S.A. City of rd Oak Park Heights < + 14168 Oak Park Blvd N.•Box 2007•Oak Park Heights,MN 55082•(651)439-4439•Fax 439-0574 Interoffice Memo To: City Administrator and LMCIT From: Public Works Director, Jay Johnson, PE CC: Mayor and City Council, City Engineer, City Attorney, Finance Director Date: 06/17/02 Re: Injury to Mrs. Marilynn Gerhart on City Sidewalk Mrs. Marilynn Gerhart called and reported that she tripped on a City sidewalk that has settled in front of 5520 Nolan Avenue North. On the phone she told me that she tripped last Wednesday (June 12, 2002) afternoon as she was leaving a neighborhood gathering. She required assistance getting back up from several neighbors due the fact that she has multiple artificial joints. Her husband drove her to the Emergency Room. She received stitches inside her mouth and her jaw is so sore she has not had solid food since. She also reported that the resident at 5520 Nolan Avenue North Mrs. Wolford, had reported the sidewalk to Boutwell's Landing staff last fall. I went to the site and found three section of sidewalk had settled around the water curb stop that is located on the edge of the sidewalk. The southwest edge of the third section has settled approximately 1 - 3/8 inch . The north east corner of the first section has settled approximately 1 inch. The water curb stop has been broken off by snow plowing or mowing operations and the sidewalk at the curb stop pipe has settled around 1 1/2 inches to 2 inches. From the look of the sidewalk settling I believe that the soil around the sewer and water connection was not adequately compacted when the water line from the home was attached to the curb stop. Also when the sidewalk was installed the area should have been compacted as a part of that construction. A second possibility is that there is a leak in the water line causing the settling. For a leak to be eroding soil from underground the leaking water must be moving the soil out from under the sidewalk. Generally, a hole develops underground then, as the soil above collapses into it a hole develops on the surface usually with fairly steep side. This settling does not meet that profile and looks more like soil compacting and settling. The attached photographs show the three sections of sidewalk that has settled, the damaged curb stop, and the two edges. TREE CITY U.S.A. Injury to Mrs.Marilynn Gerhart on City Sidewalk 6/17/02 I spoke with Mrs. Gerhart when she stopped at the site. She has facial bruising on the right side of her face and a splint on her left little finger. She told me that she is worried that the cement in her artificial joints may be damaged by her fall. When she was at the emergency room, they could not determine if there had been any damage. I also spoke with Mrs. Wolford. She said that one day last fall when she was discussing a drainage with Debbie of Boutwell's Landing office that she also mentioned the sidewalk. She said that the focus of the conversation was on the water problem in her back yard and her comment about the sidewalk may not have been noted. 2 TREE CITY U.S.A. h . _, - _ i Et r. - i - :sue r. • t ter.. ; . � • A M6 r n r ,a d ' -.''..:-,....j..'''''''.-- psi f ` �q. ,,.S"f1 -` d SCI ,F Ra{ I* C jF �i�( �Yr .. .,. (r f r' , ♦ w ty • +'' ✓, F • y , ,r. • .. . •t - a s t i> a7d e` : , . rsed t E conr settled s a , Ne , z appor .xnc h • - .. � c/ ' .� t s -r— 791P` � �_ ;`�' a .� rt ��. Y ..' / ..ft ! ." �• _zY.r 4,, .r ..p.'" i...k 'x4` ^u ., , 'w., . M1 [ * M r f - 'b,R/ i„ 1 b� \uQ 1 2 \'•E�✓tq :, ° r 6 D�1.E. �a `, Curb Stop Pipe ,- �. .. ,...+� f i '• te c is ,', - 1 . B 1 , _ a as y i` ` ` '91/ r ,iVv„» f I. ,'<, o tiF r4 =r,..,,a w f t ew hreads of e '` � w ,xis . t at were sheared o .4 : QC 4 • . • • • , •,., • • • . " . •... . • , • . . "" •:. . "• A • • • .• • : :••••••:: • • • • • ' . • - . . • • . • „ • • Third section of settled sidewalk. Southwest corneri' 'settit . , 3( 1 - .Inc •,- oppro_ _ - - . • • 1 Judy Hoist From: Judy Hoist[jholst @cityofoakparkheights.com] Sent: Wednesday, August 28, 2002 2:02 PM To: 'K.D. Widin' Subject: RE: Swager Park Trees-Insurance Settlement Kathy, I pulled the file on this tree damage/insurance settlement. We did receive reimbursement from the LMCIT in January 2002 in the amount of$1,098.63. As far as I can tell, it has been settled. Let me know if you anything else. Judy Original Message----- From: K.D.Widin[SMTP:kwidin @mmmpcc.orgl Sent: Wednesday,August 14,2002 10:02 PM To: jholst©cityofoakparkheights.com Subject: Swager Park Trees-Insurance Settlement Judy- The adjustor from League of Minnesota Cities that contacted me for more info. regarding my estimate of tree replacement costs for the 5 trees destroyed by vandals at Swager Park in 2001 was Matt Hanley. In response to his query, I sent him a fax with a copy of Abrahamson's price sheet and a note on 12/28/01. His fax no. is 651-281-1297. I'm afraid I no longer have his phone no. Thanks. Kathy 1 Judy Hoist From: K.D.Widin [kwidin @mmmpcc.org] Sent: Wednesday, August 14, 2002 10:02 PM To: jholst @cityofoakparkheights.com Subject: Swager Park Trees- Insurance Settlement Judy - The adjustor from League of Minnesota Cities that contacted me for more info. regarding my estimate of tree replacement costs for the 5 trees destroyed by vandals at Swager Park in 2001 was Matt Hanley. In response to his query, I sent him a fax with a copy of Abrahamson's price sheet and a note on 12/28/01. His fax no. is 651-281-1297. I'm afraid I no longer have his phone no. Thanks. Kathy 1 @cityofoakparkheights.com,11/26/01 8:48 AM -0600,Vand To: lswanson@cityofoakparkheights.com Trees 1 �'°m: "K.D. Widin" °�Parkhe�.ghta.eorn Subject: vandalized ees - Swager ark Cc: Swager Park Bcc: .5l.J Qh j e X-Attachments: Lindy - I inspected the trees in Swager Park which were broken o earlier this month. The total is 5 off or earlier this crab). The The is replacement(2cthornless 28��p. hawtho pulled out of the ground you need any more info. for $ per tree r ee lilacs, 1 Jay Johnson. the police report or insurance $1,430. tot Let me know if ance purposes. z Val also send this info. to Kathy Widin a.� fie.". (K.,441-_ 3 —, 5t. .W47.02. 3...52.. 1"Di 4r4"A". C-0-"‘: 410.04.. Th-4-51A- Lr;,(Atf-- --CAA-S2.2.) of A kOO v-)'61i - (3L--- 2.. k-4n* Printed for "K.D. Widin" <kwidinC mnunpcc.or 8> : ...... ..-10Hrs, CITY OF 3 825 5 1,1)98.63.......,,,, vAft: 1/16/02 ..._.... . LOSS DATE: 11/13/0) ---1 PAYEE: OAK PAR/. HEIGHTS, CITY OF ii L.; ■':—..,, a vr t-, :- 1 ifiii ))1 DESCRIPTION: TREE DAMAGE AT - . ' PARK LESS $500 DEDUCTIBLE JAN I 7 am J1 r 1,09E.63 C C 21925 11038118 A BD OAK PARK HEIGHTS, CITY OF Vt/1/ 0147 )Vi\t' `43) ' Ill'Iti i result-i;--1 civil and/or-----'-—a liaty. /or criminl --""'-1/4- " raj-LUL LC) - U0 0 may 3/41-- ....3 *** D OAK — -ARK HEIGHTS, Cl CIR:sys 505737 !PP '" s ''' AccouNT . . ., -,' -, AMT PAID I C ...' ,, , ,, ,,,,,,,. s 1 1151.......,< 4,....1 ' '',. ' ' 4 ,' ASOMICE ' I MONEY 1 I-, alziriEII 1 -,.-PY=',,,, ' s V',"':',:--",,,-"=`,","-:`,'ikt.W''Z,'47571-Psk• ' CITY OF OAK PARK HEIGHTS O 14168 Oak Park Boulevard No • P.O.Box 2007 • Oak Park Heights,MN 55082-2007 • Phone:651/439-4439 • Fax:651/439-0574 November 26,2001 To: Landmark Insurance Services, 651-464-7596 From: Kimberly Kamper,Acting City Administrator This memo serves as notification of the City of Oak Park Heights filing a claim for damaged trees in Swager. On November 13, 2001 the City of Oak Park Heights discovered that 5 trees had been damaged. The trees had been broken off or pulled out from the ground. The following is a list of the trees: 2 Thornless cockspur hawthron 2 Japanese tree lilacs 1 flowing crab The estimated cost of replacement is$286 per tree or$1430. I am faxing a copy of the police report for your use. Please let me know if you need additional information. Tree City U.S.A. CJG1UPROPH OAK PARK HEIGHTS POLICE DEPARTMENT DATE 11/26/01 TIME 13: 52 :01 INITIAL COMPLAINT REPORT 101704407 DATE/TIME REPORTED: 11/13/01 9: 11 : 47 DISPATCHER: JACROFT LOCATION OF INCIDENT: SWAGER PARK GRID: OAK PARK HEIGHTS, MN 55082 INCIDENT RECEIVED BY: COURT OFFICERS ASSIGNED: 477 CROFT NAMES ASSOCIATED HEIGHTS CITY OF OAK PARK WITH THIS INCIDENT: 14168 OAK PARK BLVD N OAK PARK HEIGHTS, MN 55082 PHONE: (H) (W) 651/439-4439 SEX: DOB: ASSOCIATION: VICTIM CRIMINAL DAMAGE TO PROPERTY ROLLIE JEROME STABERG 1418 STAGECOACH TRL S AFTON, MN 55001 PHONE: (H) 436-8538 (W) 439-4439 SEX:M DOB: 3/30/1942 ASSOCIATION: COMPLAINANT CITY EMPLOYEE REPORTING DAMAGE OFFICER COMMENTS: COMP. REPORTED 5 TREES BUSTED OFF AT THE BASE IN SWAGER 477 11/13/01 PARK. DAMAGE OCCURED SOMETIME OVER THE WEEKEND. UNKNOWN 477 11/13/01 VALUE AT THIS TIME. 477 11/13/01 RECEIVED DAMAGE ESTIMATE FROM PUBLIC WORKS DIR. = PUT IN CAS 479 11/26/01 E FILE. 479 11/26/01 November 26, 2001 To: Landmark Insurance Services, 651-464-7596 From: Kimberly Kamper, Acting City Administrator This memo serves as notification of the City of Oak Park Heights filing a claim for damaged trees in Swager. On November 13, 2001 the City of Oak Park Heights discovered that 5 trees had been damaged. The trees had been broken off or pulled out from the ground. The following is a list of the trees: 2 Thornless cockspur hawthron 2 Japanese tree lilacs 1 flowing crab The estimated cost of replacement is $286 per tree or$1430. I am faxing a copy of the police report for your use. Please let me know if you need additional information. „Iktrr Kampeir . From: jjohnson [jjohnson @cityofoakparkheights.com] Sent: Monday, November 26, 2001 11:31 AM To: 'Brian Derosier'; 'Kim Kamper' Subject: FW:Vandalized Trees-Swager Park Brian I think I was told you were doing the police report on the Swager Park Tree Damage. If not forward this to who ever is. Jay Kim Do we need to file an insurance claim on this? Are you still handling insurance claims? Jay Original Message----- From:: K.D.Widin fSMTP:kw dinammmpcc.oral Sent: Monday, November 26, 2001 8:47 AM To: Ilohnsonc cityofoakparkheights.com Subject: Vandalized Trees-Swager Park Jay - I inspected the trees in Swager Park which were broken off or pulled out of the ground. The total is 5 trees (2 thornless cockspur hawthorn, 2 Jap. tree lilacs, 1 flowering crab). The estimated replacement cost is$286. per tree or$1,430. total. Let me know if you need any more info. for insurance claim. I will also send this to the police dept. Kathy Widin 145 University Avenue West, St. Paul, MN 55103-2044 Phone: (651) 281-1200 • (800) 925-1122 TDD (651) 281-1290 il____,,;,_ , LMC League of Minnesota cities LMC Fax: (651) 281-1299 • LMCIT Fax: (651) 281-1298 Cities promoting excellence Web Site: http://www.lmnc.org ACKNOWLEDGMENT OF CLAIM OAK PARK HEIGHTS, CITY OF 14168 OAK PARK BLVD STILLWATER MN 55082 Date: 11/29/01 RE: Our File No. : 11038118 LMCIT Member: OAK PARK HEIGHTS, CITY OF Claimant Name: OAK PARK HEIGHTS, CITY OF Occurrence/Loss Date: 11/13/01 Claim Description: `-I- TREES DAMAGED AT SWAGER PARK Supervisor: DARIN RICHARDSON Phone No. : (651)281-1283 Fax No. : (651)281-1297 Adjuster: MATT HANLEY Phone No. : (651)215-4096 or 1-800-925-1122(outstate), Extension 4096 Fax No. : (651)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also available to you at any time. LMCIT c Claims Department \(77 1, CE.0 1 C.C. LANDMARK INSURANCE SERVICES 232 SOUTH LAKE STREET P.O. BOX 188 FOREST LAKE MN 55025 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER LNIC 145 University Avenue Wes t P 1 J N453-.1' Phone: (651) :4-1200 • (8001"9�2�5- ��.% League of Minnesota Cities LMC Fax: (651) 281-1299 • u - Cities promoting excellence J Web Site: http://www.lmnc.org ACKNOWLEDGMENT OF CLAIM OAK PARK HEIGHTS ATTN: THOMAS MELENA 14168 OAK PARK BLVD. P.O. BOX 2007 STILLWATER MN 55082 Date: 5/11/01 RE: Our File No. : 11035538 LMCIT Member: OAK PARK HEIGHTS Claimant Name: OAK PARK HEIGHTS Occurrence/Loss Date: 5/08/01 Claim Description: VANDALISM DAMAGE TO BREKKE PARK RESTROOMS Supervisor: DARIN RICHARDSON Phone No. : (651)281-1283 Fax No. : (651)281-1297 Adjuster: DARLENE BOESE Phone No. : (651)215-4077 or 1-800-925-1122(outstate), Extension 4077 Fax No. : (651)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also available to you at any time. LMCIT S`� i/o Claims Department C.l c) 114A /S ---j- 1 QUO CeC'LiCribl- � C. C.C. LANDMARK INSURANCE SERVICES 232 SOUTH LAKE STREET P.O. BOX 188 FOREST LAKE MN 55025 AN EQUAL OPPORTUNITY/AFFIRMATF T CITY OF # OAK PARK I 0 K HE GHTS 14168 Oak Park Boulevard No • P.O.Box 2007 • Oak Park Heights,MN 55082-2007 • Phone:651/439-4439 • Fax:651/439-0574 (ten. \/ J r-ed `1/0 t o May 9, 2001 Cry Phoo) To: LMCIT Claims Fax: 651-281-1297 Subject: Damage to City Park Vandals broke the toilet in one of the restrooms at Brekke Park this week. The City of Oak Park Heights would like to file a claim for this damage. We are in the process of obtaining a cost for replacement of the toilet and will forward that information as soon as it is available., • If you have any questions or need further information,please feel free to contact Kim Kamper next week at 439-4439. Sincerely, • lie Johnson Administrative Secretary Tree City U.S.A. 0 rac • Berkley Risk Administrators Company,ac I SEP 13 2001 September-13 , 2001 Oak Park Heights Attn: Thoma Melena 14168 Oak Park Blvd. P.O. Box 2007 Stillwater MN 55082 Dear Accounts Payable: You may have overlooked payment on this account . Our records indicate the following claim deductible (s) are past due: Claim # Invoice Date Amount Policy 11033886 6/28/01 500 . 00 CMC 20796 Total Please pay the amounts shown. If payment is not received within 15 days from the date of this letter, a 10 percent late payment fee and 7 percent interest will be added to outstanding balances, per the enclosed LMCIT policy. Make your check payable to : League of Minnesota Cities Insurance Trust Please Mail to: League of Minnesota Cities Insurance Trust C/O Berkley Risk Services, Inc. 920 Second Avenue South, Suite 700 Minneapolis, MN 55402-4023 If payment has already been made or if you have any questions, P Yr"1 already you Y g. please call me at 612-376-4283 . We appreciate your business . Sincerel , Len Yoerger Program Accountant Encl : 920 Second Avenue South,Suite 700• Minneapolis,Minnesota 55402-4023 • (612)376-4200• Fax:(612)376-4299 Equal Opportunity Employer LEAGUE OF MINNESOTA CITIES INSURANCE TRUST r� - DATE: 06/28/01 t /�"l/11 OAK PARK HEIGHTS Attn: Finance Dept. ATTN: THOMAS MELENA 14168 OAK PARK BLVD. P.O. BOX 2007 STILLWATER MN 55082 RE: BRS CLAIM NO. : 11033886 TRUST MEMBER: OAK PARK HEIGHTS CLAIMANT: BRANDON HULL DATE OF LOSS/OCCURRENCE: 10/19/00 CLAIMS MADE DATE: 01/19/01 The above claim has been concluded. This claim occurred when - CLMT INJURED ON SLIDE AT BREKKE PARK On behalf of your city, we have paid the following to conclude this claim: Paid Losses Paid Medical Paid Expenses Total .00 1 ,000 .00 31 . 77 = 1 ,031 . 77 Ded.Recover PRIOR AGGREGATE This Bill This Claim This Covenant -500. 00 . 00 . 00 Your city ' s deductible is $500 per occurrence. This applies under covenant number CMC 20796 effective 07/07/00 thru 07/07/01 . Accordingly, please prepare a draft made payable to the "LEAGUE OF MINNESOTA CITIES INSURANCE TRUST" in the amount of $ 500 . 00 and forward it to Berkley Risk Administrators Company,LLC, 920-2nd Ave.So,Mpls, MN 55402-4023, Attention: Finance Department. Please include our claim number, as captioned above, with your remittance to insure proper credit. Should you have any questions relative to the disposition of this claim, please do not hesitate to contact the BRS examiner who supervised this claim, DARIN RICHARDSON , at 1-800-925-1122 , or locally at 651-281-1283 . Sincerely, i a ce Department F n n Agent of Record: LANDMARK INSURANCE SERVICES 232 SOUTH LAKE STREET P.O. BOX 188 FOREST LAKE MN 55025 ACCOUNTING COPY I 1-4("L M‘-'7C 145 University Avenue West, St Paul,MN 53103-204-1 Lear.ef M eta Cis Phone: (612) 231-1200 • (800) 925-1122 Fax: (612) 281-1299 • TDD (612) 281-1290 To: LMCIT member cities From: LMCIT Board of Trustees Re: Deductible reimbursement It is the policy of the LMCIT Board of Trustees that a 10% penalty will be added to any undisputed deductible reimbursements which have not been paid to LMCIT within 45 days of the invoice date. In addition, interest at the rate of 7%annually will be charged on the total amount including the penalty, beginning 45 days after the invoice date. LMCIT will offset any deductible reimbursements, penalties, or interest due to LMCIT against any dividends, premium adjustments, or other funds due to the city from LMCIT. If any reimbursements, penalties, or interest remain unpaid at the time the city's current coverage expires, the city's coverage will not be renewed until all such amounts are paid in fiill If you believe that the deductible reimbursement amounts requested are incorrect or if you believe that the requested reimbursement is inappropriate for any reason, you must notify LMC1T immediately to avoid incurring penalties and interest as described above. LMCIT staff will try to resolve such issues as quickly as possible. Issues that cannot be resolved at the staff level will be referred to the LMCIT Board. In that case, no penalties or interest will apply, provided the city pays any amounts the LMCIT Board determines are due within 15 days after the Board's determination. • 9/16/96 OAK PARK H]IGHTS gg #9,: Memo To: Mayor and Council From:Kimberly Kamper, Administrative Assistant Date: 02/05/01 Re: Insurance Claim The City has received additional information regarding the claim filed against the City for a young boy who fell while climbing up the slide at Brekke Park. The League of Minnesota Insurance Trust (LMCIT) has completed its investigation and has failed to find evidence of responsibility on the part of the City and, therefore, denied liability. However, the City has medical payments coverage as an addition to its insurance coverage. This coverage allows for up to $1,000 for reasonable medical and related expenses incurred within one year from the date of an accident to a claimant following a review of medical records. The payment made under the medical payments coverage does not constitute an admission of liability. LMCIT is in the process of reviewing the medical records. If you have any questions on this, please let me know. •Page 1 1)) .1 ! FEB - 1 2001 cc: Kimberly Kamper ! �'ti Administrative Assistant 1 City of Oak Park Heights Landmark Insurance Services Darin Richardson LMCIT t �y LMC 145 University Avenue West, St. Paul, MN 55103-2044 Phone: (651) 281-1200 • (800) 925-1122 TDD (651) 281-1290 League of Minnesota Cities LMC Fax: (651) 281-1299 • LMCIT Fax: (651) 281-1298 Cities ll promoting excellence Web Site: http://www.lmnc.org January 29, 2001 Lisa Hull 268 Frankland Street Mahtomedi, MN 55115 LMCIT #: 11033886 TRUST MEMBER: CITY OF OAK PARK HEIGHTS CLAIMANT: BRANDON HULL D/OCCURRENCE: 10-19-00 CLAIMS MADE DATE: 01-19-01 Dear Ms. Hull: This letter will follow up our telephone conversation of January 23, 2001. The League of Minnesota Cities Insurance Trust (LMCIT) provides coverage to our trust member, the city of Oak Park Heights. Our investigation is completed into Brandon's fall when he was climbing the ladder on the slide when he lost his balance and fell, breaking his left arm. As we discussed, I fail to find evidence of responsibility on the part of the city for Brandon's accident, therefore, I must respectfully deny liability. The city does have medical payments coverage of which I have extended to you. There is a limit of$1,000.00 for reasonable medical and related expense incurred within one year from the date of the accident. Any payments made under the medical payments coverage does not constitute an admission of liability. Before any payment can be made we will need to obtain the medical records. Attached is a medical authorization for your signature. Please date the form and fill in Brandon's birthdate and return in the enclosed self-addressed envelope for your convenience. Should you have any questions please call me at 651-215-4077. Sincerely, Darlene Boese Senior Claims Adjuster AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER 145 University Avenue West, St. Paul, MN 55103-2044 Phone: (651) 281-1200 • (800) 925-1122 TDD (651) 281-1290 LMC League of Minnesota Cities LMC Fax: (651) 281-1299 • LMCIT Fax: (651) 281-1298 Cities promoting excellence J Web Site: http://www.imnc.org ACKNOWLEDGMENT OF CLAIM OAK PARK HEIGHTS ATTN: THOMAS MELENA 2 © 2p4/7/-2 14168 OAK PARK BLVD. 1� P.O. BOX 2007 STILLWATER MN 55082 ' JAN 2 5 2noi j LI Date: 1/23/01 RE: Our File No. : 11033886 LMCIT Member: OAK PARK HEIGHTS Claimant Name: BRANDON HULL Occurrence/Loss Date: 10/19/00 Claim Description: CLMT INJURED ON SLIDE AT BREKKE PARK Supervisor: DARIN RICHARDSON Phone No. : (651)281-1283 Fax No. : (651)281-1297 Adjuster: DARLENE BOESE Phone No. : (651)215-4077 or 1-800-925-1122(outstate), Extension 4077 Fax No. : (651)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also available to you at any time. LMCIT Claims Department C.C. LANDMARK INSURANCE SERVICES 232 SOUTH LAKE STREET P.O. BOX 188 FOREST LAKE MN 55025 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER OAK PARK HEIGHTS emo To: Mayor and Council From:Kimberly Kamper, Administrative Assistant Date: 01/30/01 Re: Insurance Claim I am writing to inform you of a claim that was filed against the City. The claim was filed by a mother of a young boy who fell while climbing up the slide at Brekke Park in October. We have turned the claim in to our insurance company, the League of Minnesota Cities Insurance Trust, for processing and investigation. We will keep you informed as more information becomes available. - In the meantime, please let me know if you have any questions. •Page 1 January ry 1 9 2001 To: LMCIT Claims Fax: 651-281-1297 Subject: Claim from Lisa Hull The City of Oak Park Heights was informed today that Ms. Lisa Hull would like to file a claim against the City. Her son, Brandon Hull, fell while climbing up the slide at Brekke Park on October 19, 2000. Brekke Park is located at 5500 Omar Ave. N., Oak Park Heights, Minnesota. The Hull's can be reached at 268 Frankland St., Mahtomedi, Minnesota, 55115; 651-653-4877. Please let me know if you have any questions or need further information. Sincerely, Kimberly Kamper Administrative Assistant 145 University Avenue �, ;t� �'EP' + ? 044 Phone: (I. )�28 • ��10) i i5 1 122 fl__,,,,7 LMCTI • '1) . .: 1290 League of Minnesota Cities LMC Fax: (651) 281-1251 u Fax: 651) , 1298 Cities promoting excellence J I_,_ Web Site: http:Ilwww. in c.org May 31, 2001 Oak Park Heights Police Department 14168 Oak Park Boulevard P.O. Box 2007 Oak Park Heights, MN 55082-2007 LMCIT FILE NO.: 11-35073 TRUST MEMBER: CITY OF OAK PARK HEIGHTS VANDALISM 4-6-01 COMPLAINT #: 101701286 Dear Officer Kropidlowski: The League of Minnesota Cities Insurance Trust provides coverage to the Brekke Park Shelter. On April 6th vandals damaged windows and plexiglass on the west and south sides of the building, as well as scratches to the south side doors. I've been provided documentation of those damages from the Public Works Director Jay Johnson totaling$694.17. After application of the city's $500 deductible, the LMCIT has paid $194.17 to the city for their loss. The purpose of my letter is to request that you contact me in the event you determine the identity of the suspects and if they are charged with this crime. On behalf of the city,we would pursue recovery of their total damages. If you have any questions, please contact me at 651-215-4077. Sincerely, Darlene Boese Senior Claims Adjuster cc: Kimberly Kamper City of Oak Park Heights Landmark Insurance Services Darin Richardson, LMCIT AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER � �,e41'F' :a ()\e ,k. 145 University 1 t'v,� ( r 1 • J T'�-Q- r 1__,_,_\.,7 L MC T*� -�� c,� -e, c. i erre/ League of Minnesota Cities LNIC Fax (651) V/1 �� Cities promoting excellence Co ' `� J oz5 I"-, T-b.e- C — ACKNOWLEDGMENT OF C OAK PARK HEIGHTS ATTN: THOMAS MELENA 14168 OAK PARK BLVD. P.O. BOX 2007 STILLWATER MN 55082 s73?/v■ 1 Date: 4/13/01 RE: Our File No. : 11035073 LMCIT Member: OAK PARK HEIGHTS Claimant Name: OAK PARK HEIGHTS Occurrence/Loss Date: 4/06/01 Claim Description: VANDALISM DAMAGE TO BREKKE PARK SHELTER Supervisor: DARIN RICHARDSON Phone No. : (651)281-1283 Fax No. : (651)281-1297 Adjuster: DARLENE BOESE Phone No. : (651)215-4077 or 1-800-925-1122(outstate), Extension 4077 Fax No. : (651)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also available to you at any time. LMCIT Claims Department C.C. LANDMARK INSURANCE SERVICES 232 SOUTH LAKE STREET P.O. BOX 188 FOREST LAKE MN 55025 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER CITY OF OAK PARK HEIGHTS =► 14168 Oak Park Boulevard No •P.O.Box 2007 • Oak Park Heights,MN 55082-2007 • Phone:651/4394439 • Fax:651/439-0574 April 10, 2001 Kate Tipping Landmark Insurance Services 323 South Lake Street Forest Lake,MN 55025 Fax: 651-464-7596 Dear Kate, I just received notice from our Public Works Department that windows in the Brekke Park Shelter, located at 5500 Omar Ave. N., have been broken by what appears to be vandalism. We would like to file a claim for the damages. I am faxing a copy of the police report that was taken on April 6, 2001. The Public Works Director, Jay Johnson, and the Police department are still investigating and assessing the damage. I will keep you informed as further information becomes available. In the meantime, please let me know if you have any questions. Sincerely, 95,<J1-, Kimberly Kamper Administrative Assistant Tree City U.S.A. CJG1UPR OAK PARK HEIGHTS POLICE DEPARTMENT DATE 4/10/01 TIME 14: 20: 57 INITIAL COMPLAINT REPORT 101701286 DATE REPORTED: 4/06/01 TIME REPORTED: 16:33: 11 DISPATCHER: ARWOLFF LOCATION OF INCIDENT: 5500 OMAR AV N BREKKE PARK OAK PARK HEIGHTS MN 55082 GRID: INCIDENT RECEIVED BY: TELEPHONE 478 KROPIDLOWSKI NAMES ASSOCIATED WITH THIS INCIDENT: NATHAN WOHLERS 14571 55TH ST N OAK PARK HEIGHTS MN 55082 PHONE: (H) 651/430-1178 (W) SEX:M DOB: ASSOCIATION: COMPLAINANT VANDALISM PAVILION WINDOWS BROKEN OFFICER COMMENTS: ARRIVED AT BREKKE PARK AND FOUND SEVERAL WINDOWS ON THE WEST 478 4/06/01 AND SOUTH SIDES BROKEN. ENTRY TO THE BUILDING WAS NOT MADE. 478 4/06/01 UNKNOWN WHEN THE DAMAGE OCCURRED. CLEARED. 478 4/06/01 CLASSIFIED AS: PROP DMG-GM-PRIVATE-INTENT INJURE P2111 CITY OF OAK PARK HEIGHTS • +s , 1942404orth 57th Street • P.O. Box 2007 • Oak Park Heights, MN 55082-2007 • Phone:651/439-4439 • Fax:651/439-0574 Darlene Boese LMCIT Senior Claims Adjuster 145 University Avenue West St. Paul, MN 55103-2044 Re: Brekke Park Vandalism Attached is the receipt for the replacement windows ($434.00) receipt the Menards recei t for the Acrylic (109.98) and the self drilling screws($2.99)that we installed last fall and has now been broken. I have also enclosed a map to Brekke Park. (It may look a little familiar.) When we make the repairs we will submit the man-hours and their rates. If you have any questions please contact me. Jay Johnson,, P.E. Public Works Director Tree City U.S.A. ti n t-,O�b -7r� O►R�eR -t7 r> oAtro ° �z�^ D v _�a AUG 2 i 2000 1. , ?our .,� 1% .. 'REBATE B1G CARD ,,: .:.�: -- ME ARDS Stillwater Stern N Menards-Stillwater �g0o K ,-'�je`3�T Lane 5 5800 Krueger Lane North Hts . MN 550g� Oak Park Hts, MN 55082 Oak Park 43fJ- 9626 (651 ) 2 P . O .o - ---- 377 INVOICE 2 7 ACCOUNT • 31290289 Charge Sale 0 0 TRp,NSACTION # • 8118 PURCHASE ORDER ; 3129 G-CITY OF OM liAltdT ' YPE OF SALE ORD Charge Sale ACCOUNT # 31290289 AMOUNT P.O. NU 0 DESCRIPTION - 2 .35 PLASTIC CUTTER / 3.49 2" X 10 ' PVC P rE 0 .44 4334840 2" 90DEG PVC ELB•' 0 . 98 SELF 02 SCR44 PAN 1 44 2.59 2�� 22 . 5DEG PVC L=OW 0 . 59 X31532 2" 42 . 5D PVC BOW ACRYLIC 487(9b4.99 109:98 4334280 2 @54.99 - 4 .36 116.46 SUB-T*+ AL TOTAL 57 TOTAL 0 .28 TAX L SALE 124.03 TOTAL ' : 0 . 00 TOTAL SALE 124.03 CHARGE - TOTAL DUE: 4 . 64 I acknowledge this Purchase is yovernCd by the terms and conditions posted in the front of the stoma and `cthori HENARD, Inc. to bill the JY ooh account and'agr�etl to.pay for t:-:- ' according 'to the terms of the credit DER SIGNATURE AVAILABLE agreement which is on fi'e y a r_� r - 2--‘445100 -VA- y toe r _;�- �U Customer Signature HU 'i HIRING IT HAS BEEN A PLEASURE SERVING '''OUll I- YOUR CASHIER, 10SH YE 20384 14 1438 08/21/00 08:06PM 3 129 4 Stillwater Glass, Inc. Invoice 13951 - 60th Street N. Oak Park Heights, MN 55082 DATE INVOICE NO 651-439-9441 4/12/2001 6184 BILL TO SHIP TO City of Oak Park Heights Brekke Park 14168 North 57th Street PO Box 2007 Oak Park Heights, MN 55082 P.O.NO. ( TERMS Net 30 DESCRIPTION QTY RATE AMOUNT C4 sash hp terratone operators 2 192.00 384.00 Installation 50.00 50.00 Thank you for your business. Total $434.00 • • • OS 1 • • . y r1. . r 1.•• 3% 7,�.x,i. �; • _ .�� r a r', LCt.`r`ry� ��1aH�. -f. ,• t ,�� r i tr 7 ,<+._ P°•_ .$ ' -? S' n +� � •-.,k�' y�. w � • ..•Littoier. '''s 1_-.•'2 T yi I. T City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile 'ttal To: _ r)6,,,-Ier- )0fa S2 Fax: From. . • K' `' 4-7/ Date: •t/ 3 .O Re: I (?3 5-0 Pages: a_ CC: ❑Urgent ❑For Review ❑ Please Comment ❑Please Recycle Notes: y''v✓e , nf-arkt,,w-n^a-, . a• :,ie: i w ‹. fi .F y xy,t '*-1,ink i." ` 4 �.ck- 44 1 ' 7 ;� S •1 •., N.: .. r..r-..u...•i.wXt'd""°,�w.'t"��-«i`: ,s:r,.ii,:r;� CJG1UPR OAK PARK HEIGHTS POLICE DEPARTMENT DATE 4/13/01 TIME 7: 56:08 INITIAL COMPLAINT REPORT 101701286 DATE REPORTED: 4/06/01 TIME REPORTED: 16:33 : 11 DISPATCHER: ARWOLFF LOCATION OF INCIDENT: 5500 OMAR AV N BREKKE PARK OAK PARK HEIGHTS MN 55082 GRID: INCIDENT RECEIVED BY: TELEPHONE 478 KROPIDLOWSKI NAMES ASSOCIATED WITH THIS INCIDENT: NATHAN WOHLERS 14571 55TH ST N OAK PARK HEIGHTS MN 55082 PHONE: (H) 651/430-1178 (W) SEX:M DOB: ASSOCIATION: COMPLAINANT VANDALISM PAVILION WINDOWS BROKEN OFFICER COMMENTS: ARFIVED AT BREKKF PARK AND FOuND SEVERAL WINDOWS ON THE WEST 478 4/06/01 AND SOUTH SIDES BROKEN. ENTRY TO THE BUILDING WAS NOT MADE. 478 4/06/01 UNKNOWN WHEN THE .DAMAGE OCCURRP, C EA,1?ED- 470 4/06/01 FOLLOW UP ON DAMAGE: W/SIDE OF BUILDING HAS FOUR WINDOWS AND 478 4/12/01 EACH WINDOW HAS A PIECE DE 'T XAGLAS$ AVER IT. THREE PIECES 478 4/1210, OF THE PLEXAGLASS ARE BROKEN AND ONE OF THE WINDOWS. ON THE 478 4/12/01 THE S/SIPS THERE ARE ALSO FOUR WINDOWS AND THREE M'IECES OF 470 4/1.2/p1 PLEXAGLASS AND ONE WINDOW ARE BROKEN. IT APPEARES THE 478 4/12/01 SUSPECT OR SUSPECTS HAD RETURNED SINCE I. WAS TUEHE ON THE 478 4/12/81 040601. THE DAMAGE TO THE WINDOWS WAS MORE SEVERE ON THIS 478 4/12/01 PATE. I AbSO NOTICED A QOL 'EALL SIZE ROCK _BETWEEN TEE Q,.ASE 470 4/12/01 WINDOW AND THE PLEXAGLASS ON ONE OF THE WINDOW. THE ROCK WAS 478 4/12/01 NOT THERE ON 0400/0 . 4,78 442/Q1 I COULD NOT FIND ANY OTHER DAMAGE TO THE BUILDING. 478 4/12/01 CLASSIFIED AS: PROP DMG-GM-PRIVATE-INTENT INJURE P2111 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST +;i © [E a d E ") DATE: 05/08/01 1'1 ;\\ MAY ( 1 2001 OAK PARK HEIGHTS Attn: Finance Dept. -- ATTN: THOMAS MELENA 1. 14168 OAK PARK BLVD. P.O. BOX 2007 STILLWATER MN 55082 RE: BRS CLAIM NO. : 11035029 TRUST MEMBER: OAK PARK HEIGHTS CLAIMANT: LARRY & MARNIE RONDEAU DATE OF LOSS/OCCURRENCE: 04/03/01 CLAIMS MADE DATE: 04/09/01 The above claim has been concluded. This claim occurred when - CLMT ALLEGES SEWER BACKUP On behalf of your city, we have paid the following to conclude this claim: Paid Losses Paid Medical Paid Expenses Total 200.00 .00 .00 = 200.00 Ded.Recover PRIOR AGGREGATE This Bill This Claim This Covenant -200 .00 .00 .00 Your city' s deductible is $500 per occurrence. This applies under covenant number CMC 20796 effective 07/07/00 thru 07/07/01 . Accordingly, please prepare a draft made payable to the "LEAGUE OF MINNESOTA CITIES INSURANCE TRUST" in the amount of $ 200 .00 and forward it to Berkley Risk Administrators Company,LLC, 920-2nd Ave.So,Mpls, MN 55402-4023, Attention: Finance Department. Please include our claim number, as captioned above, with your remittance to insure proper credit. Should you have any questions relative to the disposition of this claim, please do not hesitate to contact the BRS examiner who supervised this claim, CURTIS HEITSCHMIDT , at 1-800-925-1122, or locally at 651-281-1284. Sincerely, Finance Department Agent of Record: LANDMARK INSURANCE SERVICES 232 SOUTH LAKE STREET P.O. BOX 188 FOREST LAKE MN 55025 m@mowE LMC APR 1 2 2001 {j , 45 University Avenue West, St. Paul, MN 55103-2044 Phone: (651) 281-1200 • (800) 925-1122 TDD (651) 281-1290 League of Minnesota cities C Fax: (651) 281-1299 • LMCIT Fax: (651) 281-1298 Cities promoting excellence it Web Site: http:// .lmnc.org ACKNOWLEDGMENT OF CLAIM OAK PARK HEIGHTS or -41:9100 S/ /o ATTN: THOMAS MELENA 14168 OAK PARK BLVD. P.O. BOX 2007 STILLWATER MN 55082 Date: 4/10/01 RE: Our File No. : 11035029 LMCIT Member: OAK PARK HEIGHTS Claimant Name: LARRY RONDEAU Occurrence/Loss Date: 4/03/01 Claim Description: CLMT ALLEGES SEWER BACKUP Supervisor: CURTIS HEITSCHMIDT Phone No. : (651)281-1284 Fax No. : (651)281-1297 Adjuster: DARLENE BOESE Phone No. : (651)215-4077 or 1-800-925-1122(outstate), Extension 4077 Fax No. : (651)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also available to you at any time. LMCIT Claims Department C.C. LANDMARK INSURANCE SERVICES 232 SOUTH LAKE STREET P.O. BOX 188 FOREST LAKE MN 55025 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER CITY OF OAK PARK HEIGHTS + 14168 Oak Park Boulevard No. • P.O.Box 2007 • Oak Park Heights,MN 55082-2007• Phone:651/439-4439 • Fax:651/439-0574 Kate Tipping Landmark Insurance Services Fax 651-464-7596 232 S. Lake St. Forest Lake, MN 55025 Dear Ms. Tipping: I am writing to inform you that Mr. Larry Rondeau would like to file a claim against the City for a sewer back up that he experienced on April 3, 2001. He reported that there was about 1 inch of water in his basement when he returned home last night. The floor rugs had to be washed and there is some wall damage. He has provided the City with a copy of a bill related to this occurrence, which is enclosed. His address is 14282 56th St., Oak Park Heights,MN 55082 and his phone number is 651-351-0637. Please le me know if you have any questions or need further information. Sincerely, Kimberly Kamper Administrative Assistant Tree City U.S.A. • Kate Tipping pp g Landmark Insurance Services Fax 651-464-7596 232 S. Lake St. Forest Lake, MN 55025 Dear Ms. Tipping: I am writing to inform you that Mr. Larry Rondeau would like to file a claim against the City for a sewer back up that he experienced on April 3, 2001. He reported that there was about 1 inch of water in his basement when he returned home last night. The floor rugs had to be washed and there is some wall damage. He has provided the City with a copy of a bill related to this occurrence, which is enclosed. His address is 14282 56th St., Oak Park Heights, MN 55082 and his phone number is 651-351-0637. Please le me know if you have any questions or need further information. Sincerely, Kimberly Kamper Administrative Assistant YOUR-GUARANTEE • G TERMS ON REVERSE LOCATION SEE BINDING A-1 ROOTMASTER MASTEA 1 fl178 A-1 ROOTMASTER S L."4,.Ties. 5 # j '� .. SERVICE TECHNICIAN'S NAME 3" v¢�f 7041 F;th Street North DATE OF SERVICE INVOICE NO. �t �. 3:Yii ;l r� :.`.c!at? MN �'`5128 M D Y Pi. II 14 VI 9 14 6 St Paul: (651)738-8355 EH,[011 off 1o03G7c( Minneapolis:is:(612)721-4036 SEWER&DRAIN Nj PLUMBING❑ PUMPING❑ INDUSTRIAL❑ EXCAVATION❑ DRAIN TILE❑ CUSTOMER NAME Rah CUSTOMER NO. CUSTOMER CLASS L. rr`y de2l, , N RESIDENTIAL ❑COMMERCIAL BILLING ADDRESS APT.NUMBER FEDERAL I.D.# I'-/ a s6 IL- 51. 42-04993{30 CITY 1 I STATE/PROVINCE ZIP/PO,STAL CU. TOMER HONE NO. P.O.NUMBER/AUTHORIZATION C7�-K_ 1'rk_ s 6s I v}'t ti 1 - 's; r- y 7-6 _, JOB ADDRESS(IF DIFFERENT THAN BILLING ADDRESS) CITY [STATE/PROVINCE IZIP/POSTAL ESTIMATE WORK ORDER AUTHORIZATION My estimate for I authorize the Company to perform the described services and I agree to pay the amounts indicated.I understand that the Company is not responsible for performing this work is: broken, settled, rusted,deteriorated,or lead pipes,fixtures,or clean outs and any damage res ting from cleaning or repairing such lines. 1 I L/ (PRINT NAME) (SIGNATURE .+ �/' _ C COMPLETIO I a nowledge completion of the belw describe work which has been done to my complete satisfaction. $ t' (SIGN TURE) °-airy 7 I° ...s., i -771 ' 3?6' tticri ■ !; S!G .. r r LABOR$ $n ®+ ?� GUARANTEE: PAYMENT ®=PARTS$ pl J /4 MISC.SUPPLIES$ 6.95 n CASH OFF HOURS CHARGE$ CHECK NUMBER ��� OTHER$ ❑ CREDIT CARD TAX$ ❑ NET 10 DAYS INVOICE TOTAL$ .//�,v M OVER 30 DAYS=LATE CHARGE OF 1 1/2%PER MONTH 'In the event check is returned,the COMPANY will ICAZ A W fW charge the CUSTOMER A$25.00 processing fee. V IN:`, ;,N1.` r PLEASE PAY FROM THIS INVOICE - EXCEPT IF PART OF A NATIONAL ACCOUNT PROGRAM An ounce of prevention . . . Please A list of simple • Fix leaky faucets promptly. In addition to wasting about 20 Complete maintenance tips to help gallons of water daily, a leak could ruin your faucet set. and return you avoid costly the plumbing repairs. • Do not rinse fats or cooking oils down the drain. Liquid fats solidify in the cold drain pipes and create clogs. attached 1 pinot usecausticli griddrai noenersona p survey. din that is completey clogged. It can severely Your daage your pipes. opinion is Priodically drain several gallons of water from yur water heater. This removes sediment from the bottom of important th tank to increase heating efficiency and prolong tank life. to us. City of Oak Park Heights 14168 57th Street N.•Box 2007•Oak Park Heights,MN 55082•Phone(651)439-4439•Fax 439-0574 Interoffice Memo To: Dar Boese 215-4077 LMCIT Fax 281-1297 From: Public Works Director, Jay Johnson, PE CC: Asibninistrative Assistant, PW Foreman Date: 04/19/01 Re: Sewage Backup at 14282 56th Street North, Oak Park Heights Attached is the map with 14292 56th Street highlighted. Stillwater Public Works jetted from the manhole by lot five and hit a stoppage at 200 to 240 feet which places the stoppage very near the manhole in front of the residence. Jeff reported that the manhole was full to within approximately 1.5 feet of the top. 14292 56th Street is a ranch style with full basement and is the lowest home on the block. The following day Stillwater returned with a root cutter and cut roots for the entire length of the 56th Street line, and the Oldfield Avenue line to the manhole on 57th Street. The 1995 sewer cleaning map indicates that 56th Street was cleaned in 1995. However,the Sewer Cleaning tickets have been archived. Judy is out of town until next week. We can get into the archives when she returns. Attached are the tickets for the work on the stoppage. The manholes on this street run down the middle. The trees are planted very close to the curb. If you need any more information please contact me. TREE CITY U.S.A. r 2 0. 0 0 AN . ° I 0 %.. °o©4r R Fd© n . o00 " ❑• ❑Q N '3AV .MO i o C.------.....t____________- eJn „e 0b• I te as No W One O , o D R o R • N I a o eq e n w e �> - n ,..4 _ m‘1.1 Z / iI I �I = a I y ® • Z W z e �. i a can I z ti il r. aJn 6 ..: LI I am•'11..t.,...N rt/ c,.. c„.. .„ h, in MOW - - '› -. CC I f - i -. i 1 . :::, n 1 9 n ,• a e. Lin,, ., NO _ .. . ' � 4 INI ®0 m o . ® . I tl IMO e �• ti 4 11.1 ®®p a i . y cc N r ~o a.-----..1 o3n• OM=,,,,,,... _ 0 a ft.:.-.41,04.m 1 . i i owskin a 00 e 4 I • N 6c - { #41**n H•- • n • n • w 4,4411111 n G - O �n U JA • l I y - dDA,B I ., �� �� . dJA 8 -- — N `�A1I Ol I�0"0 I n • l e w emi. Els pa®. a3MOd maw- ��.. e. El I .---.m. ■ 300 / y ,�� U TTN 1 7 e 4i ti / Co / •vim. 1 !IIhEHLJII1IIt ns= , / / N IT 11511:01,0 v id N ?2 ,.:l {= p b h tt:. r e J�� n ,4r QI w N 1H913H *Bid )iVO a j e = a� NMOlAtl9 �Qi f f �! �. v n ° a a' n I- 0 .an3Fa- _ / .r I 0 _.-2 _.--_. Zoo .31b CITY OF STILLWATER PUBLIC WORKS SEWER MAINTENANCE DATA FORM Date 14 l ;. Ztx City: 1 CM-K PAZt- Homeowner First Name ( Homeowner Last Name I House Number ,lg282 I Street Name 57.1 I . N. C (-t{{SA _ Employees Reporting to Call SEFF u;oN, SupoultS IJt YALt0)5 Regular ❑ Call Back 96,r_d /? s Call Received By (TEFL `Pii,v;•50/,4,c 45 I P&L i tf ;, aft PARE ffE,GNt 5 Start Time (o.y5-b,, End Time 8:115",/', Equipment on the Job /A cra . Outside Contractor Equipment Used Cause of Stoppage ROot5 r Description of Damage g c�k.tp i +-O mAN jlotS Statement r jot 4C-I2E 0/642 2 4m5 GNF AmivivW 5LIrthe-)EO- = u � 41-4 *F `Aft-rij Mo2211 o,. 1142 ✓1Crut . I Sl i f o 5iri, ik..►s Zoo-2yo Gf. A<t 2vo ft r l'o4/406 baAK tnev„,f, o619964cf2vv, W/0 56ittec 1,'-es . E P� wP S1bot,,A) hgokf Spa T4-, I b°"5 " biif Iwo lay otps roofs -0104" WEl*F ",y5;a4 re-OWED SEWER CLEANING ' ' SEWER CLEANING Date 114.ki gi - Date 44444;.f i/ ie On (/ G,�!'�"w(�-1 Street On J6 - Street 5�5 � /.� From o Street From Street To ,6-(o Street To /4437/. S-Ot( Street r Size Pipe 9 Q Size Pipe g„ Length /CC 1 Length 91 , No. Hours on Job No.Hours on Job Condition of Pipe Condition of Pipe Excessive Sand Excessive Sand Excessive Roots Excessive Roots Any Obstruction Any Obstruction Other Remarks: Other Remarks: e le;:ie ze.,,,, -,97aiffw. e 4 0.44/7zti, aeii _ ., ., Signed ,, cf 7 r - Signed ./ .., 'Ll..4a.6.0. // (Foreman) (Foreman)' N i ) 1i. 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BOX 2007 STILLWATER MN 55082 Date: 9/12/00 RE: Our File No. : 11032425 LMCIT Member: OAK PARK HEIGHTS Claimant Name: GARY & JUDY HOLST Occurrence/Loss Date: 9/03/00 Claim Description: SEWER BACKUP Supervisor: CURTIS HEITSCHMIDT Phone No. : (651)281-1284 Fax No. : (651)281-1297 Adjuster: SARIEM KIM Phone No. : (651)215-4078 or 1-800-925-1122(outstate), Extension 4078 Fax No. : (651)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also available to you at any time. LMCIT Claims Department C.C. LANDMARK INSURANCE SERVICES 232 SOUTH LAKE STREET P.O. BOX 188 FOREST LAKE MN 55025 , J �� 24520 • 8nhipitg � � v Home Furnishings & Design Since 1864 Furniture • Flooring • Appliances 2159 CURVE CREST BOULEVARD . STILLWATER,MN 55082 (651) 439-2110 • FAX (651) 439-2112 �1 1/ 1 /i 1 Date of Sale CUSTOMER NAME .. r7" / V !G�%,4 -2 ' PHONEL/ fJ� 5. `� t1 JJC� Delivery Date ADDRESS CI I Sd I WK —9V3 - fir TERMS J, ` CANCELLED SPECIAL ORDERS SUBJECT TO SALESPERSO fJ 20%RESTOCKIN CHARGE QUAN. MA Aalall STOCK NO. 1111MINNIMEMiESCRIFRON=, ,j LOCINSP. PRICE AMOUNT ►f ,._,,r, ,j_ e., I ___qm ArAr 1 AIM! / ,� �✓ MENEM - I �1J1 DELIVERY DIRECTIONS OR SPECIAL INSTRUCTIONS EXTENDED WARRANTY SUBTOTAL 40,12 ', � Sales Tax f � TOTAL ,. 76 I� S DOWN C.O.D. $ UNPADPAYMENT BALANCE SALE MERCHANDISE DESCRIBED ABOVE ACCEPTED BY No. BY DATE CUSTOMER'S COPY • • • • . i, .s r,.;,'. .a c`"+ax: "k&,..ns'�a;;,, <s,,r.r,:�.isY *s.es• e,,. ?. ✓ °'ass..,° . ym 4. � v. , , !1 k s City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: ' �i L/6 ��_ 75-`16 c,T6, ( 1 pci ,, Fax: •From: �i h Kh PT( �7/,,, c/o Date: / Re: H0137-- ( 1 v,-` Pages: CC: O Urgent 0 For Review ❑Please Comment 0 Please Reply ❑ Please Recycle Notes: ' 3 V to � � � � :�''-,, " ' ' h°' 1, c • ,11,,i a l!- ' i September 8,2000 City of Oak Park Heights 14168 Oak Park Blvd.N. Oak Park Heights,MN 55082 Attention: Thomas Melena,City Administrator Dear Tom, As you know,we had a problem with the storm sewer backing up in our basement rec room this past weekend. I am requesting the City cover my costs for damages as I feel the back up occurred as a result of the street reconstruction project of 1995/96. Here's a run down of the events. We were out of town for the Labor Day weekend. We left on Friday afternoon and returned late Sunday afternoon. When we returned home,we found the basement rec room soaking wet. Our stepson was home at the time the back up occurred. He woke around 1:00 a.m.or 1:30 a.m. Sunday morning to find the storm water backing up in the basement,we have a walk out basement with a parking area from the house to the street. He then went out the upstairs door and proceeded to clean out the storm sewer,which is located between 14676 and 14694 55th St.N. At that time the water in the street was just over his knees and was about a foot or farther up the side of the house. His jeep,which was parked in the parking area,had water up to the running boards. He fished around in the storm sewer drain and pulled out some branches etc. and managed to unclog at least 1/2 of the drain. I should also mention a police officer was there watching him,but I believe he had already unclogged the storm sewer by the time the officer arrived. Jeremy then got our shop vac and tried to suck up the water in the basement. He got some up and the shop vac burnt up which filled the house with smoke. He moved the furniture to a dry part of the basement and put fans on to try to dry the carpet out. Needless to say when we got home,the mess was there and there wasn't much we could do it being Labor Day weekend. I did call City Hall and leave you a message informing you of the problem. The Public Works Director,Jay Johnson stopped by on Tuesday and talked with my husband. Jay told my husband the storm sewer should be a minimum of 1 %2 feet lower than the house and he thought it looked to be only 8 inches lower. He also thought there should be 2 storm sewers in the culdesac,one on each side of the street. He thought that there might be a law on the books regarding the depth a storm sewer opening should be in a reconstruction area in relation to existing homes. I did not check this information with Minnesota State Statutes. We all pretty much agreed the street and storm sewer was not put in correctly when the reconstruction project was done. Gary called out homeowners insurance and found that we are not covered under our policy as they consider the claim a flood and we do not have flood insurance coverage. I did inform you of this on Wednesday, September 6. In the mean time,the top of the carpet was starting to dry but the smell emanating from the carpet was and still is pretty strong moldy,mildew smell. My husband pulled the carpet up to find the pad still completely soaked. He ripped the pad out and we have since put it in the garbage and they will hopefully pick it up for disposal. I called Simonet Furniture to come out and give me a price on the carpet,pad and installation. I believe we can save the stairs,but I think the pad and carpet will have to be replaced. The furniture appears to be ok and the ceramic tile in front of the door appears to be ok. I have not removed any of the molding from the walls to see if there is damage to the sheet rock. September 8,2000 City of Oak Park Heights Page 2 I would like to give you a little background on the street reconstruction. When they put the street in,they raised the street about a foot. We argued and complained to engineering at the time that we would be flooded out if we had a good rain,that the storm sewer and gutter was not low enough to let the water drain properly. We had 2 driveways put in to try to solve the problem. The first drive was blacktop and all the water pooled in front of the door and wouldn't drain as there was pretty much 0 pitch to the drive. Engineering tore that out and put in a concrete drive on the parking area. We were also told not to worry about it. Since the street reconstruction,my husband has been unclogging the storm sewer when we get a heavy rain or in the winter when it is covered with ice so it will drain and hopefully not flood our basement. We just didn't happen to be home this time. I also feel it is not our responsibility to clean City storm sewers. We do pay a monthly storm sewer fee like the rest of the residents of the City. I do want to get this taken care of as soon as possible. I do not want to live with the smell and mess any longer than I have to. you, dy and Zlst 14708 N.55th Street Oak Park Heights,MN 55082 • • • • • • **Iv City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal ____ To: c. -I- i'n Fax: �l 6 c/ ? `) 6• �� 5 •From: 1 „l,,, )�c, Date: 9/ -/00 Re: f4 ( �,j,,1-\ Pages: CC: 0 Urgent ❑For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle Notes: 1 Apt? , 0 , LMC 145 University Avenue West, St. *auLL MN 55103-2044 Phone: (651) 281-1200 • (800) 925-1122 League of Minnesota Cities Fax: (651) 281-1299 • TDD (651) 281-1290 Cities promoting excellence Web Site: www.lmnc.org April 6, 2000 Chad Linden 104 N. Harriet St. Stillwater, MN 55802 RE: LMCIT File No.: 11030121 Trust Member: City of Oak Park Heights Date of Occurrence: 01/27/00 Dear Mr. Linden: I have concluded my investigation on behalf of the League of Minnesota Cities Insurance Trust (LMCIT), the insurance carrier for the City of Oak Park Heights, and found that the City is not responsible for your damage. It would be considered as a"normal road hazard"when you run over objects in the road. The City did not have noticed of the water cap being in the roadway. You stated yourself that it could have been kicked up by a vehicle. The City cannot be held responsible for the water cap being in the roadway. Therefore,we will not be able to compensate you for your loss. If you have any questions, you may contact me at 651/215-4078. Sincerely, Sariem Kim Claims Adjuster SK/arm cc: Kim Kamper City of Oak Park Heights cc: Brian Alm Landmark Insurance Services cc: Kelly Robotnik, BRAC AN EOUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER 145 University Avenue West, St. Paul, MN 55103-2044 Phone: (651) 281-1200 • (800) 925-1122 TDD (651) 281-1290 r 1___,_,__,..,..7 L MC League of Minnesota Cities LMC Fax: (651) 281-1299 • LMCIT Fax: (651) 281-1298 Cities promoting excellence J Web Site: littp://www.lmnc.org ACKNOWLEDGMENT OF CLAIM D 1-1, © OAK PARK HEIGHTS ATTN: THOMAS MELENA P.O.BOX 2007 I F -- 3 4:,�i ti STILLWATER MN 55082 ___.J Date: 3/02/00 RE: Our File No. : 11030121 LMCIT Member: OAK PARK HEIGHTS Claimant Name: CHAD LINDEN Occurrence/Loss Date: 1/27/00 Claim Description: CLMT VEHICLE'S TIRE DMGD - HIT WATER SHUT OFF VALVE CAP ON 58TH AT KRUGER LANE Supervisor: KELLY ROBOTNIK Phone No. : (651)281-1288 Fax No. : (651)281-1297 Adjuster: SARIEM KIM Phone No. : (651)215-4078 or 1-800-925-1122(outstate), Extension 4078 Fax No. : (651)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also available to you at any time. LMCIT Claims Department C.C. LANDMARK INSURANCE SERVICES 232 SOUTH LAKE STREET P.O. BOX 188 FOREST LAKE MN 55025 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER • ,li .ems y � �wst • • • • 4�.. City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: i-"T-.e Fax: ` ��b S GI 6 • • From: ��I^k, �i�r,v„l G✓• Date: Re: ( j- cJ L t'c/ C ,' Pages: L CC: ❑ Urgent ❑For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle Notes: 6 5-1 (-16 - 13.) h P� Chad Linden FEB 2 5 2000 104 N. Harriet St. ul I Stillwater, Minnesota 55802 U U L_ _ 651-439-2113 While heading west on 58th St, Oak Park Heights at about 4:30 PM, I was following a white pickup. From the rear of the pickup truck, with an open tailgate, snow was blowing out of the truck. I was watching the snow, ironically, to be sure nothing hazardous was coming out of the bed, anything that would hit my car. On the ground of my lane was a small water cap, about eight inches in diameter, which I hit. The Cap hit my rear Passenger side tire and immediately slashed and flattened the tire. The rim was bent and ruined also. My friend drove me to the location the incident occurred and I picked the cap up out of the road. At about 10:00pm when I returned from a wrestling meet, I called the Oak Park heights police department and a police officer arrived at Stillwater High school to take a report. The police officer wrote the report and took the cap. The police department contacted me and told me to write a report on what happened and the price of the replacement. I've included a copy of the receipt for the charge. Below is a picture of the intersection the incident occurred. Menards CaP Thank y , ou can tact me at the above number, Chad M. Linden • VL, LTD rilligiliull""Ill."liIll""1/Iw)r 35 N. PA Box 216 r(-4 Soa dba NORTHV1EW SERVICE kergeti 54025. 715-247-3394 pornquR Fax 715424/4413 & MR. TIRE pri . .C1R1.) .... A' -14'. I :471N I = j 4 ii i .r•-;,,4 • • I 4 ..; " I • .”; i,‘.1 -; • • , • . • . • 2 A. F.•:. F;„• `4.••■ 19. . . . I Nor; 7't 14SE,E!4•.'1'..jr. k."I• r.s.; e /4 CJG1UPR OAK PARK HEIGHTS POLICE DEPARTMENT DATE 2/28/00 TIME 9 : 22 :45 INITIAL COMPLAINT REPORT 100700239 DATE REPORTED: 1/27/00 TIME REPORTED: 21 : 40 : 36 DISPATCHER: KMCAFFE LOCATION OF INCIDENT: 58TH ST KRUEGER LANE N OAK PARK HEIGHTS MN 55082 GRID: INCIDENT RECEIVED BY: TELEPHONE 474 HAUSKEN 482 KISCH NAMES ASSOCIATED WITH THIS INCIDENT : CHAD MICHAEL LINDEN 104 HARRIET ST N STILLWATER MN 55082 PHONE: (H) 651/439-2113 (W) SEX:M DOB: 2/06/1983 <** J U V E N I L E **> ASSOCIATION: COMPLAINANT PROPERTY DAMAGE TO VEH REPORT, HE RAN OVER A IRON WATER MAIN COVER, HAS FLAT T IRES, MEET COMP AT SW HIGH, AT THE REAR ATHLETIC DOORS . . . DAVID JOSEPH JOHNSON 104 HARRIET ST W STILLWATER MN 55082 PHONE: (H) 439-2113 (W) SEX:M DOB: 12/31/1957 ASSOCIATION: OTHER REG OWNER OF VEHICLE OFFICER COMMENTS : 474 TOOK THE CALL I CANCELED. 482 1/27/00 COMP WAS WEST BOUND ON 58TH ST N AT KRUGER LANE AND HE HIT A 474 1/28/00 WATER SHUT OFF VALVE COVER THAT WAS ON THE ROAD. IT APPEARS 474 1/28/00 THE THE COVER WAS KNOCK LOOSE BY SOMETHING AND THE BOTTOM 474 1/28/00 PART OF IT IS JAGGED AND BROKEN. THE PIECE PUNCHERED HIS 474 1/28/00 RIGHT REAR TIME ON HIS VEHICLE. HE HAD THE COVER. I TOOK IT 474 1/28/00 AND PLACED IT INTO EVIDENCE. HE WANTS THE CITY TO PAY OF THE 474 1/28/00 TIRE. I ADVISED HIM I WOULD LET THE PUBLIC WORKS DIRECTOR 474 1/28/00 KNOW. 474 1/28/00 CLASSIFIED AS: MV ACCIDENT - PROPERTY DAMAGE 9440 *WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING *WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING*WARNING THIS CASE IS CLASSIFIED AS CONFIDENTIAL AND IS NOT AVAILABLE FOR PUBLIC INFO • ROUN'TRIP MESSAGE 225518-AUTOFORMS,Inc., Chicago,Illinois •To Reorder Call-1-800-432-1630-2/94 • c Q k • FROM. .viik STILLWATER MOTORS TO 6 • 1 $ �= a _ __• • • •• ATER BOULEVARD, N. Q � � _• 5 e $ M @ [E Q v �I lb ATER, MN 55082 /J MISR , 2200{ SUBJECT: - , DATE: .3 - 8 -O 1 TOLD G•••• \taar.s1 ...d O•-■.. C c ' /6_ I. • . V (-J a Q . ), 1 ! !_ •tea TS • , � .. A.. __ _ . \ . 1 • ♦ , • - `/h., e1 _ iw __ Cam, a •4 ` ` - 1'2,3 4R 4 « • PLEASE REPLY T, ---* SIGNED ,,,_, � DATE SIGNED SEND WHITE AND PINK COPIES WITH CARBONS INTACT. PINK COPY WILL BE RETURNED WITH REPLY. AUTOFORMS,Inc.,Chicago,Illinois • Form No.A-177 ■ Sedeevettet PARTS&SERVICE HOURS: MON-THURS.7:00 A.M.TO 7:00 P.M. MOTORS FAX: (651)439-4333 SAT 7:00 A.M.TO 6:00 P.M. FAX: (651)439-4425 SAT 8:00 A.M TO 4:00 P.M. WISC.RES.1-800-544-3592 BUICK • CHEVROLET • JEEP COMPLETE BODY SHOP HOURS: MON-THURS.7:00 A.M.TO 8:00 P.M. •FAMILY OWNED SINCE 1922• FRI 7:00 A.M.TO 5:00 P.M. 5900 Stillwater Boulevard North•P.O.Box 337 FREE ESTIMATES Stillwater,MN 55082 SALES HOURS: MON-THURS.8:30 A.M.TO 9:00 P.M. FRI 8:30 A.M.TO 6:00 P.M. SAT 8:30 A.M.TO 5:00 P.M. CUSTOMER NO. ADVISOR TAG NO. INVOICE DATE INVOICE NO. 4428 FRANK GOVEKAR 792 081 01118101 CVCB45380 LABOR RATE LICENSE NO. MILEAGE COLOR STOCK NO. CITY OF OAK PARK HEIGHTS 578-LSM 51266 GREENI _ 14168 NO.57TH ST.P.O.BOX 2007 YEAR/MAKE/MODEL DELIVERY DATE DELIVERY MILES 951FORD►CROWN VIC VEHICLE ID.NO. SEWNG DEALER NO. `PRODUCTION DATE 2 F A L P 7 1 WSSX 1 9 1 8 1 7 _ OAK PARK HEIGHTS,MN 55082 F.T.E.NO. P.O.NO. R.0.DATE 12122100 _ RESIDENCE PHONE BUSINESS PHONE COMMENTS 439 4723 4394439 M0:51266 JOB# 1 CHARGES STATEMENT OF DISCLAIMER The factory warranty constitutes all of the LABOR warranties with respect to the sale of this J# 1 95CVZ BODY REFINISH TECH(S):630 767.60 item/items. The Seller hereby expressly REFINSH REAR DAMAGE disclaims all warranties either express or PARTS QTY- -FP-NUMBER DESCRIPTION UNIT PRICE- implied, Including any implied warranty of 1 P015179 FASCIA 460.62 460.62 merchantability or fitness for a particular 1 P015179 PAD ASM 62.40 62.40 purpose. Seller neither assumes nor 2 P015179 REINFORCE 25.97 51.94 authorizes any other person to assume for it 1 P015179 REINFORCE 46.38 46.38 any liability in connection with the sale of this 1 P015179 ABSORBER 53.40 53.40 itemrdems. 1 P015179 ABSORBER 53.40 53.40 1 PO15179 TAILLAMP 163.10 163.10 1 P015179 TAILLAMP 163.10 163.10 1 P015179 LIC LAMP 16.27 16.27 1 P015179 REFLECTOR 144.62 144.62 1 P015179 DECK LID 590.00 590.00 V 1 P015179 N/PLATE 10.72 10.72 1 P015179 N/PLATE 10.72 10.72 tO t-`-(I S tD -7-01 1 P015179 STRICKER 11.88 11.88 1 P015179 LWR PANEL 94.49 94.49 1 P015179 REINFORCE 59.57 59.57 1 P015179 BRACKET 55.02 55.02 1 P015179 MOLDING 85.13 85.13 1 P015179 SUPPORT 57.07 57.07 1 P015179 MOLDING 77.72 77.72 1 P015412 IMP BAR 245.70 245.70 1 P015472 LATCH 43.97 43.97 1 P015179 SUPPORT 41.92 41.92 1 P015520 COVER 3.52 3.52 1 P015520 PANEL ASM 150.66 150.66 El 1 P015635 MLDG & LA 27.45 27.45 TOTAL - PARTS 2780.77 Goodwrench G.O.G. & SUPPLIES soc��z I . 1.0 PAINT AND MATERIALS @ 420.850 /UNIT TOTAL GOG 420.85 JOB# 1 TOTALS LABOR 767.60 The 7Iiie means better.' PARTS 2780.77 See us for guarantee details. G.O.G. 420.85 www'gmg°odwrench.com JOB# 1 JOURNAL PREFIX CVCB J0B# 1 TOTAL 3969.22 JJ08# 2 CHARGES J# 2R96CVZ BODY REPAIR TECH(S):804 1311.00 AMERICAN �� , REPAIR REAR DAMAGE DRESS ,Ot1���R JOB# "DTA7 T,� § F 1311.00 l s ,_ 0 Mastercard A J0B# 2 JOURNAL PREFIX CVCB J( `2 TOT1 " 1311.00 7`��� j . , sy .4 :''''',4-14.:,,,, 2 ! ALL PARTS NEW ORIGINAL EQUIPMENT, UNLESS OTHERWISE SPECIFIED W PAGE 1 OF 2 CUSTOMER COPY [CONTINUED ON NEXT PAGE] 15:38:50 ' * St(4ed&tearer PARTS&SERVICE HOURS: MON-THURS.7:00 A.M.TO 7:00 P.M. BUS: (651)439-4333 FRI 7:00 A.M.TO 6:00 P.M. M0 T O R S FAX: (651)439.4425 SAT 8:00 A.M TO 4:00 P.M. WISC.RES.1-800-5443592 COMPLETE BODY SHOP HOURS: BUICK • CHEVROLET • JEEP MON-THURS.7:00 A.M.TO 6:00 P.M. •FAMILY OWNED SINCE 1922• FRI 7:00 A.M.TO 5:00 P.M. 5900 Stillwater Boulevard North•P.O.Box 337 FREE ESTIMATES Stillwater,MN 55082 SALES HOURS: MON-THURS.8:30 A.M.TO 9:00 P.M. FRI 8:30 A.M.TO 6:00 P.M. SAT 8:30 A.M.TO 5:00 P.M. CUSTOMER NO. ADVISOR TAG NO. INVOICE DATE INVOICE NO. 4428 FRANK GOVEKAR 792 081 01118101 CVCB45380 _ LABOR RATE LICENSE NO. MILEAGE COLOR STOCK NO. CITY OF OAK PARK HEIGHTS 578-LSM 51266 GREEN/ 14168 NO.57TH ST.P.O.BOX 2007 VEAR/MAKE/MODEL DELIVERY DATE DELIVERY MILES 951FORDICROWN VIC VEHICLE ID.NO. SELLING DEALER NO. PRODUCTION DATE • 2FALP71W5SX 191817 OAK PARK HEIGHTS,MN 55082 F.T.E.NO. P.O.NO. R.0.DATE 12/22100 RESIDENCE PHONE BUSINESS PHONE COMMENTS 439.4723 , 57 ? MO:51266 JOB# 3 CHARGES STATEMENT OF DISCLAIMER The factory warranty constitutes all of the LABOR warranties with respect to the sale of this J# 3+97CVZ BODY FRAME TECH(S):804 220.00 item/items. The Seller hereby expressly REPAIR REAR DAMAGE disclaims all warranties either express or JOB# 3 TOTALS implied, Including any implied warranty of LABOR 220.00 merchantability or fitness for a particular purpose. Seller neither assumes nor JOB# 3 JOURNAL PREFIX CVCB JOB# 3 TOTAL 220.00 authorizes any other person to assume for it JOB# 4 CHARGES any liability in connection with the sale of this item/items. LAB J#04R+98CVZ BODY MECHANICAL TECH(S):260 79.95 ALIGN FOUR WHEELS JOB# 4 TOTALS LABOR 79.95 JOB# 4 JOURNAL PREFIX CVCB JOB# 4 TOTAL 79.95 ESTIMATE CUSTOMER HEREBY ACKNOWLEDGES RECEIVING ORIGINAL ESTIMATE OF $5760.92 (+TAX) TOTALS **** TOTAL LABOR.... 2378.55 TOTAL PARTS.... 2780.77 * [ ] CASH [ ] CHECK CK NO. [ ] * TOTAL SUBLET... 0.00 TOTAL G.O.G.... 420.85 * [ ] VISA [ ] MASTERCARD [ ] DISCOVER * TOTAL MISC CHG. 0.00 III * [ ] AMER XPRESS [ ] OTHER [ ] A/R * TOTAL MISC DISC 180.75 * dwt�ench * DATE PAID / / CASHIER INITIALS * TOTAL INVOICE $ 5760.92 THANK YOU FOR YOUR BUSINESS!! % .� � i 33;`8" The 7 I means better. CUSTOMER SIGNATURE See us for guarantee details. DUPLICATE INVOICE www.gmgoodwrench.com CITY OF OAK PARK HEIGHTS CLAIMS ENDORSEMENT I� ,,..A „ ALLOWED IN THE SUM OF.$ 57)"1) ( '' mac, -� o� e �a,ti�•�R IISALLOWED IN THE SUM OF$ -a ; f 111.2a1.1 E'Card I VE: ; `x;15-0I SIGNATURE C , tV,; 1 ALL PARTS NEW ORIGINAL EQUIPMENT, UNLESS OTHERWISE SPECIFIED LL PAGE 2 OF 2 CUSTOMER COPY [ END OF INVOICE 3 15:38:50 • LEAGUE OF MINNESOTA CITIES US BANK 33927 INSURANCE TRUST 17-2-910 PROPERTY CASUALTY FUND CLAIMS ACCOUNT 920-2ND AVENUE SOUTH,SUITE 700 MINNEAPOLIS,MN 55402-4023 FOUR THOUSAND EIGHT HUNDRED THIRTY-THREE DOLLARS AND EIGHTY-FOUR CENTS PAY TO THE DATE AMOUNT ORDER OF CITY OF OAK PARK HEIGHTS & STILLWATER MOTOR COMPANY JANUARY 25, 2001 4,833.84 Mail To: CITY OF OAK PARK HEIGHTS ATTN: THOMAS MELENA 14168 OAK PARK BLVD. .id L AEI P.O. BOX 2007 Trir STILLWATER MN 55082 u'0339 271I' 1:09 L0000 2 21: L60 2 34 548 3 54u• LEAGUE OF MINNESOTA CITIES INSURANCE TRUST POLICY #: CMC 20796 INSURED NAME: OAK PARK HEIGHTS 33927 CLAIM #: 11033684 CLAIMANT NAME: OAK PARK HEIGHTS CHECK #: 33927 CHECK DATE: 1/25/01 PAYMENT: 4,833.84 LOSS DATE: 12/21/00 PAYEE: CITY OF OAK PARK HEIGHTS & STILLWATER MOTOR COMPANY DESCRIPTION: COLLISION LOSS TO '95 FORD CROWN VIC, VIN: 1817 LESS $500 DEDUCTIBLE 4,833.84 CMC 20796 11033684 A AC OAK PARK HEIGHTS ORDER-CHECK 039879 CITY OF OAK PARK HEIGHTS CENTRAL BANK 14168 OAK PARK BLVD. STILLWATER,MN 55082 P.O.BOX 2007 75-511/919 OAK PARK HEIGHTS,MN 55082-2007 39879 PAY EXACTLY FIVE HUNDRED AND 00/100 TO THE DATE AMOUNT ' ORDER OF , 3/13/01 ******500.0(Iw RKTREASUR STILLWATER MOTOR COMPANY /if i� a.e.,,cjt----- 5900 STILLWATER BLVD .1 -4//a. F O BOX 337 .Y--.. STILLWATER MN 55082-0000 °n•039879" a:09 L90510.1: 2 LI'pt, LIN91i° CITY OF OAK PARK HEIGHTS STILLWATER MOTOR COMPANY 039879 500.00 3/13/01 0340052 101 41510-701 DEDUCTIBLE CLAIM 500.00 ACCOUNTS DUE AND PAGE 1 PAYABLE BY THE lath: OF THE MONTH 12969 N 60th St. - Stillwater, MN 55082 1-800-328-0928 - Fax: (651) 351-9554 Ph: (651) 430-2400 r ACCT.NO 5236 CLOSING DATE OAK PARKS HTS POLICE DEPT - 30J1N01 CONTACT PAUL HOPPE P. O. BOX 2007 14168 57TH ST NO STILLWATER MN 55082 AMOUNT ENCLOSED PLEASE RETURN THIS PORTION WITH YOUR CHECK $ •tOATt otui TENT/TRANSACTION PURCHASES I PAYMENTS&CREt71TS BALANCE PREVIOUS BALANCE 210.97 27DECOO 1200 3 .11 27DECOO 26940 17.67 27DECOO 27109 190.19 27DECOO 109576 9.01 31DECOO 27498 9.01 04JAN01 177127 71.20 15JAN01 27688 71.20 18JAN01 177915 146 .71 /&/ 31 -7 , yr,70 Z., 5~c)(. �... £ c 1 ► ), bEl u c ■ vp7 V ti? �I1 (-t -�12c�h r:�� --�-o COL)-12 LArn Ol ,s44- 41" was % r prmvi. -C rzc)v\,- CJAK. wcC „Dt -$. ACCOUNT • PAST DUE CURRENT PLEASE PAY STATUS 0.00 146 .71 4 THIS AMOUNT N 146 .71 OVER SO OVER 60 OVER 90> OVER 9 Q 0. 00 0. 00 0. 00 0. 00 FINANCE CHARGES will apply if the new balance is unpaid one month from the closing date of statement. The "FINANCE CHARGES" are computed by a periodic rate of 1 5% : per month which is an ANNUAL PERCENTAGE RATE of 18% applied to the unpaid balance after deducting current payments and/or credits appearing on this statement from the previous balance. STILLWATER FORD L/M a '.w • .Hoeq uo stone° CD •PePnhul seinwej faunoe S -------- U) &I LD a) ' 0) N I a) Z c� D 0 NIL A a 1 0 0 ■ CM N.' 0 N • C7 1 I - Z W CC O " 0 kw I _ cc Y Q rn < U m N I-'-) \� j L)1 cc O a N a p i\ Pfl U O I Ell 3 W L. a0 1 r a U C >- l' ! I- I 0 I a 0 o o z o H W ru - - - - W W J N C0 X. X 0 2 2 V) KI U Z Y Y •- LLI g M J 'a 0: CC O I— CO 0 �� a a < _Z N < r- O Z fU '" N J cc Y J ru N Q Q •- J H- c I- D z O O V)W W O F N W •• W a 0 a N V) a I W f a •• V) - U W 0 J 0 V Z Z I- x a 0 L p a V) CO Q W Q O W r U a' as = f U X I U) 1� _ 0 <U) y 1- p J V) V) Z J 2 a U •• i-= z O N 0 S I- X Z - U U ,- a a z "' O 0 CD 0 1- a Cl) f - F' V H u`ui X W W Z 0 .i . Y 0 > o W Oo •- < Z/1 N o z — Z_v u W 1 I z CC E 0° m Q N � � Cu.. rn 0 Z O Vi I- < < Y rfl en CY\ - 1- 2Qr a > a 0 a a < Q o O U o co, . H J — u.= y a < W Q X O a N D: - Q z - CV O > O o. V Z Z 0 O 0 2 x W N 0 '- U 0 W H a X H Z � W m� � 0 0 J Z Z V)>- 0 0 } Z d Q O = I- F- I- I- O - - % % G J a c i Lu 0 U a r Z LL c� Y f V w FS LL J O �'O O S < O < W W ¢ W a U U a J a O � I-- CD - a I-° t Q W J • L MC 145 University Avenue West, St. Paul, MN 55103-2044 Phone: (651) 281-1200 • (800) 925-1122 TDD (651) 281-1290 League of Minnesota Cities LMC Fax: (651) 281-1299 • LMCIT Fax: (651) 281-1298 Cities promoting excellence J Web Site: http://www.lmnc.org January 22, 2001 State Farm Insurance Companies 8500 State Farm Way Woodbury, MN 55125-2320 Arden Hills, MN 55112 RE: LMCIT FILE NO:: 11033684 TRUST MEMBER: City of Oak Park Heights YOUR CLAIM#: 23130158 D/OCCURANCE: 12/21/00 YOUR DRIVER: Mr. Balder Dear State Farm: As you may recall, the League of Minnesota Cities Insurance Trust provides coverage to our trust member, the City of Oak Park Heights. I am putting you on notice of our subrogation interest regarding the above-referenced matter. I have finished my investigation regarding the accident between your insured and our insured. My investigation revealed that your driver was the majority at fault for this accident. Our driver had come to a complete stop before being rear-ended by your driver and being pushed into the first vehicle. Enclosed is a copy of the invoices for vehicle repair. This totals $5480.55 to have the vehicle restored to its original condition. On behalf of the City of Oak Park Heights, we are seeking to recover 100% of the money that was spent to repair the vehicle. The City of Oak Park Heights carries a$500 deductible. Please contact me when you receive this letter so we can discuss a settlement. I can be reached at 651-215-4096. When sending payment, please make the check out to the City of Oak Park Heights for their $500 deductible and one made out to LMCIT for $4980.55. Put it to my attention and send it to the above address. I will enclose a copy of the check in my file for my records then forward the check on to the City. Sincer- y Matt Hari ey Claims Adjuster cc: Kelly Robotnik, LMCIT Police Chief Lindy Swanson, City of Oak Park Heights Brian Alm, Landmark Insurance Services AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER DNISSIIN SI ONf10MD)f0V9 03110100 N331:19 Al UIOA • 7 N 0 0. CI DG ..lam G . C''0 .n O ' N 0 —N N .. •'oN \ . ff j goo-if) 1t) 0 N ]%% It ' ':` w e- e- y I.$., Z w Z Z • o w Nw. a C0 •• i�,, Y j ® .:4C. z • Y o• • �n a w m Lt 'o d > 0 o� o .� o 0 2 pp c P.N Q CO .ze � t 0 N r' aI. i CL = F .• 0 a UJ 4 1 i � e; y O ❑ cn o V: o.z x Q cn JiI . q N w O .,... ,,,,, $ e- �;; U G o° �;e- c "' M ©. . 2 On Cl C) * W ❑ O).= � I .* 4frzt J # CD G fit• 0 O = co # •� i11 N t .a• • G l=' ° O s40 in'm * �u y O }X U- a t � ti co Q o v # i y DI- -0 ..,c(/)Z U) 0 J cc a� LLl v2 # a r m U-1 C. r : ZJ wi 0 Ls.] f p # O ❑U fY J a v w *e- Fm O _ :o a N • c Off. V) = Q m * �etN z O W N '# .s # C' g .0 a Ye' : w° * C o aO Q a �.� F z toil # IN3Wf1000 AO 33Vd NO S1lV3ddV 1fOdOd0 N33HO 5238 177915 i OAK PARKS HTS POLICE DEPT *INVOICE* CONTACT PAUL HOPPE 12969 N 60th St. - Stillwater, MN 55082 P. 0. BOX 2007 14168 57TH ST NO 1-800-328-0928 - Fax: (651) 351-9554 STILLWATER, MN 55082 PAGE 1 Ph: (651) 430-2400 HOME: 612-439-4723 BUS: 612-439-4723 SERVICE ADVISOR: 8426 MICHAEL DEAVEY COLOR :YEAR MAKE/MODEL : VIN LICENNSE lVMILEAGE'IN/OUT .. ::>:TAG ;: GREEN 95 FORD CROWN VICTORIA 2FALP71W5SX191817 578LSM 57275/57275 T198 ;DEL DATE :;PROD DATE WARR E tP PROMISED: PO NEJ RATE :P.A,YMENT ' INV'`.poyg;:: >' 010CT1996 23MAY95 16:30 18JAN01 80.00 CASH 18JAN2001 R O OPENED ::.:READY OPTIONS: DLR:09254 09:45 18JAN01 14:21 18JAN01 LINE OPCODE TECH TYPE HOURS LIST NET TOTAL A; "HECK GEAR SHIFT ;OPERATION VERY:::LOOSE 'WHEN PRNDL INDICATOR:!i SHOWS PK. . MAY STILL BE IN REVERSE ii SS SEE STORY ii 8008 C 1.50 120.00 120.00 57.275 R/R S`HEERIN'G COLUMN 'R , LOWER 'STE RING COL MN 'O ACCESS TC TIGHTEN COLUMN BOLTS PER EST * **** :******* *±**** **. t* *t* :o .** *t r:'*:***,* , B** PERFORM MULTIPOINT INSPECTION 9;9 P PERFORM MU TT POINT INSPECTION 8008 ISP 0.10 6. . REPLACE'i A,IR'!;FILTER ,:.. 8008 C 0.10 2.95 2.95 I "ESTZ*:9661 8 ELF" ASY ENG iAIR.CLNR >! ! 10.76 10 '76 :<; 10,76 57275 INSPECTION DONE, REPLACE AIR FILTER, OK'D BY MIKE dr***************:ykdcile***** ;*ak** ,k* * ****k***** F **:.: SHOP SUPPLIES & HAZARDOUS WASTE 12.30 c Q-ef A- i BLS E v V...) momMWONRNXM@WMO -j C f lie 2- ( c 8 IMINgROMMMtMINIUM' ' ,"044, 7j0� � ;.TOTALS YOUR CO rye .TION is 122.95 e . .. -. -- .._ _. ..... ,.., 10.76 implied,including any implied warranty of GAS,OIL, LUBE 0.00 IF YOU HAVE ANY JL Eb TIONS CONTACT merchantability or f iness for a particular prpose. Seller neither assumes nor SUBLET AMOUNT 0.00 authorizes any other person to assume for YOUR SERVICE ADVISOR. it any liability in connection with the sale MISC.CHARGES 12.30 of this item/items. STILLWATER FORD LINCOLN MERCURY TOTAL CHARGES 146.01 ALL PARTS NEW ORIGINAL EQUIPMENT 651-430-2400 UNLESS OTHERWISE SPECIFIED 0.00 SALES TAX 0.70 THANK YOU CUSTOMER SIGNATURE PLEASE PAY THIS AMOUNT `:::::?14t .7,1... <:: ,I CUSTOMER COPY I • • ti's• ` ` •• • 1 , r s'4l-t f$ L ^5L o's y t t i 11' t• ., • .'°P W.Af 'R ,F} ry `'y t° <F '-'440#:1:,Mdt3.4.-?. .t� �1-lte .�d y Ha s _ � seta..;: 1 , L — City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal ,...._ To: ..t-re_ ,-c Y I'e I Fax: From: l i'(.1,-\ 14., Date: / / �l- Re: Gt r'cf G,vT Pages: CC: 0 Urgent For Review 0 Please Comment ❑ Please Reply ❑Please Recycle Nodes: 1-14y 1') cdie CyCIJIc4'1r9nai t,uvI( -rti.c,r L—c, C10tn4 Ba 7 12 C�1/ !n5 re sc-)T CF -tie c,c i'c1en-� 1\ c �clrec� on 7 3 R p� .� S'., .. �K:' .i»iSli}.,R.^uaFblF'uS�',,.s�r �` gx^,^ `fir 01/18/2001 at 11:37 AM Job Number: 35238 (� STILLWATER MOTOR COMPANY it F `�� L5 © CE OW ,�, Federal ID #:410561600 I D i' I j 5900 STILLWATER BLVD NO. I JAN �n0y PO BOX 337 JAN U I Ij STILLWATER, MN 55082 (651)439-4333 Fax: (651)351-5197 PRELIMINARY ESTIMATE Written by: Adjuster: Insured: CITY OF OAK PARK HE Claim # Owner: CITY OF OAK PARK HE Policy # Address: 14168 NO 57TH ST PO BOX 2007 Deductible: OAK PARK HEIGHTS, MN 55082 Date of Loss: Day: Type of Loss: Evening: Point of Impact: 6. Rear Inspect Location: Insurance Company: Days to Repair 1995 FORD CROWN VICTORIA POLICE 8-4.6L-FI 4D SED GREEN Int: VIN: 2FALP71W5SX191817 Lic: 578-LSM MN Prod Date: Odometer: 51266 Air Conditioning Rear Defogger Tilt Wheel Intermittent Wipers Body Side Moldings Dual Mirrors Clear Coat Paint Power Steering Power Brakes Power Windows Power Mirrors Power Trunk Driver Airbag Passenger Airbag 4 Wheel Disc Brakes Cloth Seats Bucket Seats Recline/Lounge Seats NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT 1 REAR BUMPER 2 0/H rear bumper 2.0 3 Repl Cover 1 460.62 Incl. 3.0 4 Add for Clear Coat 1.2 5 Repl Impact pad 1 62.40 Incl. 6 Repl Cover support center 1 46.38 Incl. 7 Repl RT Cover support outer 1 25.97 Incl. 8 Repl LT Cover support outer 1 25.97 Incl. 9 Repl RT Energy absorber 1 53.40 0.3 10 Repl LT Energy absorber 1 53.40 0.3 11 Repl Reinforcement 1 245.70 Incl. 12* Repl Reinforcement 1 3.52 Incl. 13 REAR LAMPS 14 Repl RT Tail lamp assy 1 163.10 0.6 15 Repl LT Tail lamp assy 1 163.10 0.6 16 Repl License lamp 1 27.45 Incl. 17 Repl Reflector panel 1 144.62 0.2 1 01/18/2001 at 11:37 AM Job Number: 35238 PRELIMINARY ESTIMATE 1995 FORD CROWN VICTORIA POLICE 8-4.6L-FI 4D SED GREEN Int: NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT 18* Repl Socket & wire 1 16.27 19 TRUNK LID 20 Repl Trunk lid 1 590.00 1.2 3.0 21 Overlap Major Adj . Panel -0.4 22 Add for Clear Coat 0.5 23 Add for Underside(Complete) 1.5 24* Repl Lock w/o power lock group 1 43.97 Incl. 25* Repl Nameplate Crown Victoria 1 10.72 0.2 26 Repl Nameplate Ford (logo) 1 10.72 0.2 27 Repl Striker plate 1 11.88 28* Rpr RT Hinge 0.6 0.3 29* Rpr LT Hinge 0.5 0.3 30 0 Repl Striker bracket 1 31 Repl Trim panel 1 150.66 Incl. 32 REAR BODY & FLOOR 33 Repl Panel below lid 1 94.49 5.5 1.0 34 Overlap Major Adj . Panel -0.4 35 Add for Clear Coat 0.1 36 Repl Reinforcement 1 59.57 37 Repl RT Support 1 57.07 38 Repl LT Support 1 41.92 39 Repl Mount bracket trunk lid strike 1 40.80 40* Rpr Rear floor pan unleaded 2_0 1.5 41 QUARTER PANEL 42# Subl 4 WHEEL ALIGNMENT 1 79.95 X 43# TINT COLOR 1 0.5 44# CORROSION PROTECTION 1 5.00 X 0.3 45# PULL AND SQUARE 1 4.0 F 46# SETUP 1 1.0 47* Rpr LT Quarter panel 10.0 2.2 48 Overlap Major Adj . Panel -0.4 49 Add for Clear Coat 0.4 50* Rpr RT Quarter panel 6.0 2.2 51 Overlap Major Adj . Panel -0.4 52* Add for Clear Coat 0.4 53# DRILL TIME ON LID 1 0.5 54 REAR DOOR 55 Blnd RT Door shell 1.1 56 Blnd LT Door shell 1.1 57 R&I RT Belt w'strip 0.3 58 R&I LT Belt w'strip 0.3 59 Repl RT Side molding 2" type 1 85.13 0.5 60 Repl LT Side molding 2" type 1 77.72 0.5 61 R&I RT Handle, outside 0.6 62 R&I LT Handle, outside 0.6 63# Repl BRACKET REAR PANEL 1 55.02 Incl. Subtotals =_> 2906.52 38.5 19.0 2 01/18/2001 at 11:37 AM Job Number: 35238 PRELIMINARY ESTIMATE 1995 FORD CROWN VICTORIA POLICE 8-4.6L-FI 4D SED GREEN Int: Parts 2821.57 Body Labor 34.5 hrs @ $ 38.00/hr 1311.00 Paint Labor 19.0 hrs @ $ 38.00/hr 722.00 Frame Labor 4.0 hrs @ $ 55.00/hr 220.00 Paint Supplies 19.0 hrs @ $ 22.00/hr 418.00 Sublet/Misc. 84.95 SUBTOTAL $ 5577.52 Sales Tax $ 2821.57 @ 6.5000% 183.40 GRAND TOTAL $ 5760.92 ADJUSTMENTS: Deductible 0.00 CUSTOMER PAY $ 0.00 INSURANCE PAY $ 5760.92 Estimate based on MOTOR CRASH ESTIMATING GUIDE. Non-asterisk(*) items are derived from the Guide DR2JA92. Database Date 10/2000. Double asterisk(**) items indicate parts supplied by a supplier other than the original equipment manufacturer. Pound sign (#) items indicate manual entries. CAPA items have been certified for fit and finish by the Certified Auto Parts Association. NAGS Part Numbers, Prices and Labor Times are provided from National Auto Glass Specifications, Inc. Pathways - A product of CCC Information Services Inc. 3 • " • • .3 14 ;" ;• -4;14 `44g, s 't' YJ �" Il ..o-,Ff a r i . •T r ♦, •• +'' i City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: '6,11 cfi r're-) Fax: L./ 6 5- (7 6 • • , . • From: K'r11,, Ka Date: • (7 23• 7 /o/ • • Re: Pages: CC: 0 Urgent 0 For Review 0 Please Comment 0 Please Reply 0 Please Recycle Notes: w• LMC 145 University Avenue West St. Paul, MN 55103-2044 Phone: (651) 281-1200 • (800) 925-1122 TDD (651) 281-1290 League of Minnesota Cities LMC Fax: (651) 281-1299 • LMCIT Fax: (651) 281-1298 Cities promoting excellence Web Site: http://www.lmnc.org ACKNOWLEDGMENT OF CLAIM OAK PARK HEIGHTS ATTN: THOMAS MELENA C Q ULI (\ 14168 OAK PARK BLVD. lu P.O. BOX 2007 � � 2 �) STILLWATER MN 55082 Date: 1/08/01 RE: Our File No. : 11033684 LMCIT Member: OAK PARK HEIGHTS Claimant Name: OAK PARK HEIGHTS Occurrence/Loss Date: 12/21/00 Claim Description: INSURED WAS REAR-ENDED & PUSHED INTO VEHICLE IN FRONT OF INSURED Supervisor: KELLY ROBOTNIK Phone No. : (651)281-1288 Fax No. : (651)281-1297 Adjuster: MATT HANLEY Phone No. : (651)215-4096 or 1-800-925-1122(outstate), Extension 4096 Fax No. : (651)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also 1 available to you at any time. LMCIT Claims Department C.C. LANDMARK INSURANCE SERVICES 232 SOUTH LAKE STREET P.O. BOX 188 FOREST LAKE MN 55025 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER • i i a r' a "f 5�4 ; �r� a .. City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: Vc, l i p�'�"5 Fax: 4 6 y— 75 !,6 From: K� Date: 1 P■1 2-Er BUJ Re: eo (Le v J Pages: 6 CC: 0 Urgent 0 For Review ❑ Please Comment ❑ Please Reply ❑Please Recycle Notes: f--) �vv.\ 0,/ �Vl mo��I� re ,✓cllk3 v-Ctcc/61e-17- nCl,,,d 111) ✓e. r oil , "� v St4r,p_, fry:sov'c CPi-,,m ircle,fig qrd C.c r e'I 1'�, �e , 6i r-- Minnesota pa ntof Labor and Industry Workers'Compensation Oi„elan First Report of Injury 443 Lafayette Road North St.Paul.MN 66166-4306 See instructions in folder accompanying forms. 1.OSHA Case. III Jill 15121 295-2432 All dates must be entered in MM/DD/YY format. 11111111 01111 1liii1111 Type or Print. v EMPLOYEE 2.Name(last,first,middle) 3.EMPLOYEE SOCIAL SECURITY NO: Kropidlowski Fred James 283-66-4840 4. Home address(include county and zip) 5.DATE OF CLAIMED INJURY: 2676 Brittany Lane 12-21-00 Do Not Use this Space WOOdbury, MN 55125 - - 6.Sex: X Male 'emale X Washington County - - 7. Marital Status: �frlarm,d Not 8.Occupation: 9.Date of Birth: �'Z1�-/.� Police Officer 10.Date Hired: Jr /jai/ 9.1 11.Regular Dept 12.Home Phone No.INC,No.) Oak Park Heights Police Dept. 651-730-5859 13.Apprentice: X_No Yea r WAGE INFORMATION 15.Rate per hour. 16.Hours per day: 14.Average wage/week $1075.00 $26.86 8 17.Days per week: 5 18.What is the weekly value of MEALS: t (] LODGING: t 0 2nd INCOME: t 0 19.Employment Status: Full time _Part time _Seasonal Volunteer(Attach 26 week wage statement for part lime or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No_ OCCURRENCE 20.PLACE(include dept&full address) 21.Date of first 22.Date employer Z, 6C W/B 1 494 day of lost time: 4_/ / notified of injury: / /_ Wakota Bridge, Newport, MN• 23.Return to work date: / / 24.Date employer notified of lost time: n--� r�� 25.Date of death: _/ / 26.Time of day On employer's premises? L I Yes 11Y No of Injury: o F 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL,BE SPECIF IC 6nciude part(s)of body affected,e.g,amputation of right index finger at 2nd joint,fractured arm,Wad poisori ng) While on duty I was rear ended in a motor vehicle accident causing stiffness in my neck and a headaches 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH OETA LS OF HOW EVENT OCCURRED (include name of other individuals involved,tools,machinery,objects,vapors, chemicals,radiations,unnatural motion of employee) While on duty, I was traveling I494 on the Wakota Bridge when the vehicle in front of me came to a stop, I was able to stop. HOwever, the vehicle behind no was not.trurmirig :into my.,cE 29. PHYSICIAN (full name,title, address and phone number) 30.HOSPITAIJCLINIC(name and address) J Dr. James Ilko 651-501-3000 Allina Medical Clinin Allina Medical Clinic 8675 Valley Creek Rd. Woodbury, MN 55125 31.Witness and photo number Valley Creek Road Tax LL , flu :;127, EMPLOYER 32. Legal name&mailing address incl.zip - 34.Unemploy ID No.: OAK PARK HEIGHTS 33.Date form completed: 22./_22/ 00 14168 57TH STREET, BOX 2007 - n: 35.SIC code Payroll Class Code STILLWATEc R MN 55082-0000 36.Print supervisor's name and phone number: X37.Employer's Representative,print full name,tide and phone number: Lindy Swanson 651-439-4723 1 ICrv1 IYIFI ul4i1llnhylJr4l+�11.Wta2r, chci-U39-4/439 SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM h EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC ■ INSURANCE 38.CARRIER 39. Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF- INSURED 41• Insuran a Class Cods: P• Box 59143 Mpls,, MN 55459-0143 (612) 544-0311 43.Date insurer received notice: 42. CARRIER CLAIM NUMBER 44.Adjuster ID No: 0698639002 02-!: . . ;29 __ u•2032o-o6 t1-921 Original to Berkley Administrators BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division SUPERVISOR'S REPORT OF ACCIDENT (PLEASE READ AND FOLLOW INSTRUCTIONS ON BACK) EVERY ACCIDENT SHOULD BE INVESTIGATED AND THE CAUSES CORRECTED SO THAT MORE ACCIDENTS WILL NOT OCCUR. DO NOT OVERLOOK THE SO-CALLED"UNIMPORTANT"CASES,BECAUSE,EXCEPT FOR"CHANCE"THEY COULD ALSO HAVE BEEN SERIOUS. IT IS ONLY BY THOROUGH INVESTIGATION THAT MANY OF THE REAL CAUSES CAN BE DETERMINED AND CORRECTED. NAME OF EMPLOYEE - N 1424:),(1 ►OI...:st i COMPANY Q/C,^C CAAg alliele 1.1EIc Jrc DEPT. PC,! I CZ DATE OF ACCIDENT 7--Z4 -cc TIME DID EMPLOYEE LOSE TIME FROM WORK? YES 0 NO a. HOURS LOST ON DATE OF ACCIDENT O HAS EMPLOYEE RETURNED TO WORK? YES El NO 0 JOB TITLE 1 I C� Vc c:---■Ce/Z SERVICE WITH THE COMPANY 7 If Z YEARS,IN PRESENT JOB S GIVE US YOUR HONEST COMMENTS ON QUESTIONS BELOW. WE ARE NOT TRYING TO BLAME ANYONE. YOUR OPINION MAY HELP US PREVENT ACCIDENT REPETITION. PLEASE ANSWER THE FOLLOWING: CHECK"YES"OR"NO" 1. WAS INJURED PERSON PROPERLY INSTRUCTED IN SAFE AND EFFICIENT METHODS? YES NO❑ 2. DID INJURED PERSON VIOLATE ANY INSTRUCTIONS? NO&YES ❑ 3. WAS NECESSARY PROTECTIVE EQUIPMENT WORN? (IF APPLICABLE) YES a. NO ❑ 4. DID POOR HOUSEKEEPING CONTRIBUTE TO INJURY? NOOK YES ❑ 5. DID HORSEPLAY CAUSE THE INJURY? NO jit. YES ❑ 6. WAS IT CAUSED BY SOMETHING WHICH NEEDED REPAIRS? NOJ YES ❑ 7. SHOULD A GUARD BE PROVIDED? NOlat-YES ❑ 8. DID ANY BODILY DEFECT CONTRIBUTE TO INJURY? NO Igt.YES ❑ 9. WAS IT CAUSED BY AN UNSAFE ACT? NO YES ❑ 10. DID INJURED REPORT THE INJURY TO YOU, THE SUPERVISOR, IMMEDIATELY? YES 1St NO❑ ACCIDENT. (DESCRIBE WHAT INJURED WAS DOING SAT TIME OF ACCIDENT, WHAT HAPPENED,WHO WAS INVOLVED,NATURE OF INJURY, PART OF BODY AFFECTED.) A r�i(� `W QCAc.7) 'k. • � .i.) (it.• "k--1tA\c. c,— `)..►`,A-S WITNESSES'NAMES UNSAFE ACTS. (WHAT DID THE EMPLOYEE OR ANOTHER PERSON DO INCORRECTLY?) 14/k UNSAFE CONDITIONS. (WHAT UNGUARDED OR UNSAFE CONDITION OF MACHINERY,EQUIPMENT,BUILDING OR PREMISES WAS INVOLVED?) 0 ACTIONS TAKEN. (WHAT DID YOU DO TO CORRECT THE CONDITIONS WHICH CAUSED THIS INJURY?) VA, REMED S.(WHAT SHOULD YOUR ORGANIZATION DO TO PREVENT OTHER INJURIES LIKE THIS?) MEDICAL CARE. DID EMPLOYEE GO TO DOCTOR OR HOSPITAL? YES ❑ NO ELIF YES,COMPLETE THE FOLLOWING NAME OF DOCTOR OR HOSPITAL DATE OF INITIAL VISIT ADDRESS TELEPHONE NUMBER AS SUPERVISOR,DO YOU FEEL THAT THIS INJURY SHOULD BE COVERED UND R WORKERS' COMPENSATION? YESEE NOD REASONS WHY Ii I.) AtQM 4\ ■ .t oN , ' . -7�7 CO REPORT SUBMITTED BY A� ANA ,i ■ _ Ail DATE 17-777-f -60 BA 252 (3/92) n • I 12/22/2000 at 04:03 PM Job Number: • 35238 STILLWATER MOTOR OMPANY , Federal ID ##:410 61600 • • .5931: STILLWATER VD NO. PO HOX 337 . STILLWATER, MN 5082 (6=•1)439-4333 Fax! (6 1)351-5197 PL;ELIMINARY ES MATE I Written by! • Adjuster: Insured: CITY OF OAK P 1R:Z HE laim # Owner: CITY OF OAK PARK HE P licy if Co Address: 14168 NO 57TH S'1 .PO PDX 2007 Deductible: .• OAK PARK HEIGHTS; MN 55082 D to of Loss: ■ a Day: a of Logs: Evening: ' Poin of Impact: 6. Rear I Inspect Location: Insurance Company: Days to Repair 1995 FORD CROWN VICTORIA POLICE 8-4.GL-FI 4D SED GREEN Int: - /E C . Odometer: 51266 VIN: 2FALP71W5SX191817 T :. _.�ic �-LSM MN Prod Date: Air Conditioning Rear Defogger Tilt Wheel Intermittent Wipers Body Side Molding Dual Mirrors Clear Coat Paint Power. Steering Power Brakes Power Windows Powe:_ Mirrors . Power Trunk Driver Airbag • PaestInger Airbag 4 Wheel Disc Brakes Cloth Seats Bucket Seats Recline/Lounge Seats NO_ OP. DESCR.IPT=0N QTY EXT. PRICE LABOR PAINT co 1 REAR PUMPER i 2 0/H rear.' bumper 2.0 3 Repl Cover 1 460.62 Incl. 3.0 4 Add for Claar :`oat 1.2 5 Repl Impact ',ps•i 1 62.40 Incl. 6 Repl Cover Su;,Dort cErnter 1 46.36 incl. , 7 Repl RT Cover suppa_t outer 1 25.97 Incl. 8 Repl LT Cover ,uppo-t outer 1 25.97 Incl. 9 Repl RT Energ; absorber 1 53.40 0.3 I 10 Repl LT Ener_cy absorber 1 53.40 0.3 11 REAR LAMPS 12 Repl RT Tail lamp as3y 1 163-10 0.6 13 Repl LT Tail 9-.1I': al 3y 1 163.10 0.6 14 Repl License L.1 ',2 1 27.45 Inca_ 15 Repl Reflect:i.:+ I r.e._ 1 144.62 0-2 16 TRtJ c :AL. 17 Repl Trunk 1 ` ! 1 590.00 1.2 3.0 1 Id Wti20:b0 000E FE '3aal L6ISZS2TS9 : '0N 3N0Hd 00 '8010W 613115111I1S : WOZIJ m . 12/22/2000 at 04:03 PM 1 Job Number: 35238 • PaSLIMINARX ESTIMATE a 1995 FORD CROWN ''ICTO=!t . POLICE 8-4.6L-FY 4D SED GREEN Int: L 1 NO. OP. C:":St'P.=IoN QTY EXT. PRICE LABOR PAINT 18 Overla3 14aj or Adj . Panel -0.4. 19 Add for Clear ;'oat 0.5 20 Add for Underside(Complete) . 1.5 21 Repl Lock w/o rower lock group i 42.90 I el. • 22 Repl Namepllte C::a4'r. Victoria 1 10.58 0.2 23 Repl Namepl to Ford (logo) 1 10.72 0.2 • 24 Repl Striker : ._:=..te 1 11.88 25* Rpr RT Hinge 00.66 0.3 26* Rpr LT 'lingo r 0_5 0.3 27 REAR :3ODY .i, FLOOR 28 Repl Panel below li..z 1 94.49 5.5 1.0 29 Overlap N'3.jOr Adj- Panel -0.4 30 Add for Clear ::oat 0.1 31 Repl Reinforcetc.E:_nt 1 59.57 32 Repl RT Suppo3:t.: 1 57_07 `7 33 Repl LT Suppc::': 1 41.92 34 Repl Mount bx:: -:,!-:et -runk lid strike 1 40.80 a 3S* Rpr Rear floc:is p.,n un=eaded 2_,0 1.5 36 QUART 2R PANEL 37# Subl 4 WHEEL .'a:...cE^_K:?NT 1 79.95 X 38# TINT COL;:t 1 0.5 39# CORROSXOj'• r-ROTFCiION 1 5.00 X 0.3 40# PULL AND i(JAF:E ! 1 4.0 F 41# SETUP 1 1.0 42* Rpr LT Quar+:.c a: ?Enid 10.0 2_2 43 Overlap " i' or Adj . Panel -0.4 44 Add for ‘Ii-tar :`goat 0.4 45* Rpr RT Quart:.r,r Dart, :r. 66=0 2.2 46 Overlap to _.`o:' :-dj . Panel -0.4 47* Add for ..e.ai: :oat 0.4 48# DRILL T.:':. ON ••.in 1 " 0.5 49* R&I RT Qtr gi ;;1s F:rd 1_0 50* R&I LT Qtr <,-.a.ea F )rd 1.0 51 REAR :.::GOP 52 Blnd RT Door ; :e.11. 1.1 53 Bind LT Door !:. L;. 1.1 . 54 R&I RT Belt .4 ',_2ri a 0.3 SS R&I LT Belt '0'14teip 0.3 9 56 Repl RT Side ; s .d:-.ns- 2" type 3. 85.13 0.5 . 57 Repl LT Side i:'Lii.^.,; 2" type 1 77.72 0.5 a 58 R&I RT Hand .:. . o..t-.idde 0.6 59 R&I LT Hand-f% o.a i.d2 0.6 Subtotals == 2434.14 40.5 19.0 2 Ed Wdb0:b0 000E EZ 'caQ L6TSTScTS9 : 'ON 3NOHd 00 ?O10W d31t3P111I1S : WONA 12/22/2000 t 04=03 PM Job Number: 35238 P:5'L LIMINARY ESTIMATE 1 95 FORD CROWN ' 'C^Tc .IA POLICE 8-4_6L-FI 4D $ED GREEN Int: • 2349.19 ,':i,::dy :Labor 36.5 hrs ® $ 38.00/hr 1387.0 • 2a:I.rxr.: Libor 19.0 hrs ® $ 38.00/hr 722.00 . iFraxn:! Labor 4.0 hrs ® $ 55.00/hr 220.80 ]?ai:n Supplies 19.0 hrs 0 $ 22.00/hr 418.00 • bl:t iMisc. 84.95 • 5181.14 1 .x:,.E. Tax $ 2349.19 @ 6.i15000: 152.70 ^-.RAN TOTAL $ 5333.84 r '_gin;:ZTS'PI�ENTS: . Deductible 0.00 i JS i:.iMl R PAY $ 0.00 7:NS :::ANC E PAY $ 5333.84 Estimate based on MOTOR CRASH xiL_11.-Tnr GUIDE. Won-asterisk(e) items are derived from the Guide nk2SA92. Database Date 10/3000 J;iT1L], asterisk(**) items indicate parts supplied by a supplier other than the original eg1ipr.,.r. . min:1`ac.u.cer. Pound sign (#) items indicate manual entries. CAPA items havt been certifies. :...: L i; and finish by the Certified Auto Parts Association_ NAGS' Part Numbers, Prices and Labor "ines a.-e: provided from National Auto Glass Specifications, Inc_ 0 1 Pathways - ., prc)C ir..t cI' CCC Information Services Inc. a 0 a .3 Ed Wdb0:b0 000E EE '0aa L5 ISETS9 : 'ON ONOHd OD ?IOIOW NA1HM-11IIS : WO?H CITY OF OAK PARK HEIGHTS . 14168 North 57th Street • P.O.Box 2007 • Oak Park Heights, MN 55082-2007 • Phone:651/439-4439 • Fax:651/439-0574 January 25, 2001 Katie Farrel Landmark Ins. Services 232 S. Lake St. Forest Lake, MN 55025 Dear Katie, Enclosed you will find a bill from Frankie's Towing for$175.73. This bill resulted from the vehicle accident that occurred on December 21, 2000. Please let me know if you have any questions. Sincerely, Kimberly Kamper Administrative.Assistant Tree City U.S.A. STATEMENT 264 FRANKIE'S TOWING "► •TI TT P.O. Box 755 LAKELAND, MN 55043-0755 DATE 12/22/2000 ACCOUNT NUMBER (651) 436-9971 24 Oak k Heights Police Department 1416 h 57th Street "Oak P AMOUNT ENCLOSED$ RETURN THIS PORTION WITH PAYMENT } _ AMOUNT DATE CHARGES AND CREDITS 12/22/2000 TWO TOW'S OF FORD CROWN VIC. 165.00 FEDERAL ID#41-1618638 SUBTOTAL 165.00 SALES TAX 10.73 PLEASE PAY THIS AMOUNT 175.73 PAY LAST AMOUNT IN THIS COLUMN FRANKIE'S TOWING THANK YOU FRANKIE'S TOWING Box 755 LAKELAND, MINNESOTA 55043 (651) 436-9971 Not responsible for damage to vehicle while being towed, winched, and stored. Y DATE/1 790 AM REQUESTED Bom- LO ?Cr&OFNC7trt- 9qV Acun4-13R-ibr NAME &NNE 044 011 ADDRESS ZIP MILEAGE SERVICE TIME EXTRA PERSON FINISH FINISH FINISH START START START TOTAL TOTAL TOTAL • • /- • YEAR MAKE/MODE COI,OR DRIVER rz,-)go CRadA.) thL/6-12,d STATE L VEHICLE .NO. 1fliI 5 27( )111 , SPECIAL EQUIPMENT 0 SLING/HOIST TOW 0 FLAT TIRE E SINGLE LINE WINCHING 0 WHEEL LIFT 0 OUT OF GAS 0 DUAL LINE WINCHING 0 SNATCH BLOCKS BED/RAMP WRECK El SCOTCH BLOCKS START 0 RECOVERY 0 DOLLY 0 LOCK OUT El VEHICLE TOWED TO 4412. {IV /A/ PC REMARKS ,,s, vs-) • 1?. g-b47 MiLtsfeGS CHARGE TOWING CH GE /orD, ,-:\ LABOR CHAR STORAGE CHARGE ADMIN. CHARGE STATE TAX 73 OPERATORS SIGNATURE TOTAL /tr.; ) I AUTHORIZED SIGNATURE Road Service 1 3 3 7 5 PRODUCT 613 1 rk______,,N7 LW145 University Avenue West, St. Paul, MN 55103-2044 League of Minnesota Cities Fax: (651) 281-1297 • TDD (651) 281-1290 Cities promoting excellence J Michael Scott Bacock January 08, 2001 9105 Terra Verde Trail Eden Prairie, MN 55347 RE: Employee: Fred J. Kropidlowski Employer: City of Oak Park Heights Date of Injury: 12-21-00 Claim Number: 02-000729-913545 Dear Mr. Bacock, The above employee of our workers' compensation client was injured when the vehicle you were operating, had a collision with the vehicle the employee was operating. As a result of the injury,we will be paying medical expenses or medical and indemnity benefits under the Minnesota Workers' Compensation Law. In accordance with our subrogation rights, we will be requesting reimbursement for our expenses. If you have liability insurance,please turn this letter over to your insurance agent or carrier and Y Y p Y g ask that they contact us. Please send us their names and addresses. If you do not have liability insurance, please call us to arrange for reimbursement of these expenses. Please write the above claim number on all correspondence you send to us, and be sure to have the claim number available, should you call. Sincerely, Harold Roark CST LMC, Phone 1-651-215-4176 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER C @COWE t R--- D JAN - 9 2001 L MC 1\ 1 145 University Avenue West, St. ' u , - League of Minnesota Cities Fax: (651) 281-1297 • I : : - • Cities promoting excellence J 01-08-01 TO: The Employer For your information only. At this time, no action is required from you or the claimant. Harold Roark CST Phone 651-215-4176 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER LNIC145 University Avenue West, St. Paul, MN 55103-2044 League of Minnesota Cities Fax: (651) 281-1297 • TDD (651) 281-1290 Cities promoting excellence City of Oak Park Heights January 04, 2001 14168 57th street, Box 2007 Oak Park Heights, MN 55082-2007 ; � � ' JAN - 5 2001 11 RE: Employee: Fred J. Kropidlowski Date of Injury: 12-21-00 Claim Number: 02-000729-913545 The above employee was involved in an automobile accident, sustaining injuries due to the accident. As a result of this accident, we will pursue subrogation against the other party involved in the accident. In order to proceed,we need for you to obtain a motor vehicle accident report. Please forward this accident report with the name and address of the other driver involved, to the League of Minnesota Cities. Please feel free to give me a call, should you have any questions or concerns regarding this claim or request. Harold Roark 651-215-4176 cc: file AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER • • • • • ,�,�, . 4 r �. . r r si t r. J y City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: r-P_ Fax: L1‘ y ' 75- 6 • • ; From: C • • Date: • • • • Re: �3�-r��-r‘�" Pages: CC: 0 Urgent ❑For Review 0 Please Comment ❑ Please Reply 0 Please Recycle Notes: KcTel �je�e 1 c con, o4 Sre, -Q PC C/ rero:- - oF- "�e.- ac cicf. r rte,o- o cc �e 0 n c -2 .) z 00/. 4.0,4• -� � - )444,4, t * ,,,,,,,4-,1 vr- 4 k.10k • • j + i P �YL..X�AFy��'` +t AiA�� �z'�I €' 7{!�.b rte :l { S t+ ' � x a C s4 x x '0 h :4-„..',F‘,,,..,:-‘,'! � ; r 7 ,:',:' i - ra � f aJ, t- I 47. .& lk ■'•6;grkit r T City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: i-i,„yiJI 120c,vk- Fax: '-)._ 1 - .);,.6) 7 S ' ' From: )4.-ilk,‘ .��4,,,�e/y Date: ' I / 5 / U J Re: �`��en t ge 1Yfi P CC: J ages: 3 ❑Urgerrt 0 For Review ❑ Please Comment ❑ Please Reply 0 Please Recycle NoteLs: 0 — 0 0 0 —),9.1.9 —� 13 / ..° 9 I i 7 7 ',,� re 1,� s z i r 9 r '' � L ' ;rte.t p . . .: u �� °>�-,� "* ? :Ls�,... r ., • 32003-07 STATE OF MINNESOTA-DEPARTMENT OF PUBLIC SAFETY ,� AL CASE NO TRAFFIC ACCIDENT REPORT • 0 "A..7. 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CJG1UPR OAK PARK HEIGHTS POLICE DEPARTMENT DATE 12/22/00 TIME 8 : 10: 33 INITIAL COMPLAINT REPORT 100704198 DATE REPORTED: 12/21/00 TIME REPORTED: 18 : 33:20 DISPATCHER: DDWULFI LOCATION OF INCIDENT: I 494 W WACOUTA BRIDGE NEWPORT MN 55055 GRID: INCIDENT RECEIVED BY: RADIO 396 MUELLNER NAMES ASSOCIATED WITH THIS INCIDENT: FREDERICK KROPIDLOWSKI PHONE: (H) (W) SEX: DOB: ASSOCIATION: COMPLAINANT DAMAGE TO SQUAD CLIFFORD ERVIN BUCHKOSKI 8911 IRONWOOD AVE COTTAGE GROVE MN 55016 PHONE: (H) 651/458-5352 (W) SEX:M DOB: 1/22/1975 ASSOCIATION: OTHER DRIVER OF MN DPZ511 MICHAEL SCOTT BALDER 9105 TEGIA-VERDE TRAIL EDEN PRAIRIE MN 55347 PHONE: (H) 952/914-9825 (W) SEX:M DOB: 2/18/1973 ASSOCIATION: OTHER DRIVER OF MN LIC BHC053 OFFICER COMMENTS: INVOLVED IN MOTOR VEHICLE ACCIDENT/SEE REPORT. 478 12/21/00 ICR 100704198 INV Kropidlowski Date 122100 Time 1750 Hours On 122100 at approx. 1750 hours, while on duty I was traveling W/B I494 . I was crossing the Wakota Bridge when the vehicle in front of me MN lic. BHC053 came to a sudden stop. I had enough distance between my squad and this vehicle to make a complete stop. However, the vehicle behind me MN lic.DPZ511 was not able to stop and ran into the rear of my squad casuing substanial damage to rear of my squad. The impact pushed my squad into MN Lic.BHC053 causing very minor damage to the bumper. State Patrol arrived and wrote the accident (ICR00418967) . He also issued Buchkoski a citation. The squad was towed to Frankies were it was secured inside the building. I filled out the First Report of Injury due to a stiff neck and headache. Minnesota Department of Labor and Indutry worker••ComperraeonOiauon First Report of Injury 443 Lafayette Road North St.Paul,MN 66166-4306 See instructions in folder accompanying forms. 1.OSHA cm.* 1 1/11111 16121 296-2432 All dates must be entered in MM/DD/YY format. Iili Type or Print. EMPLOYEE 2.Name(last,first,middle) 3.EMPLOYEE SOCIAL SECURITY NO: Kropidlowski Fred ' James 283-66-4840 4. Home address (include county and zip) 5.DATE OF CLAIMED INJURY: 2676 Brittany Lane 12-21-00 Do Not Use this Space Woodbury, MN 55125 6.Sex: Male XFemale Not 7,Marital Status: XMarried Washington County - - _ _ 8.Occupation: 9.Date of Birth: 102.1111_611 10.Date Hired: 47 /mil/ C9I Police Officer 11.Regular Dept: 12.Home Phone No (A/C,No.) Oak Park Heights Police Dept. 651-730-5859 13.Apprentice: x_No Yes WAGE INFORMATION 15.Rate per hour: 16.Hours per day: 14.Average wage/week $1075.00 _ $26.86 _ 8 17. Days per week: 5 What is the weekly value of MEALS: $ 0 LODGING: $ n 2nd INCOME: $ 0 19.Employment Status: Full time _Part time _Seasonal _Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.` If employee is a police officer or firefighter: Smoker: Yes_ No_ OCCURRENCE 20. PLACE(include dept&full address) 21.Date of first 22.Date employer day of lost time: _/_/_ notified of injury: _/ /_ Wakota Bridge, Newport, MN 24.Date employer notified 23.Return to work date: _/ / of lost time / / 25.Date of death: _/_/ 26.Time of day On employer's premises) n Yes fR No of injury: 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL,BE SPEOF IC(include piffle)of body affected,e.g.amputation of right index finger at 2nd joint,fractured arm,lead poisoning) While on duty I was rear ended in a motor vehicle accident causing stiffness in my neck and a he-e.che_. 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED (include name of other individuals involved,tools,machinery,objects,vapors. chemicals,radiations,unnatural motions of employee) While on duty, I was traveling 1494 on the Wakota Bridge when the vehicle in front of me came to a stop, I was able to stop. HOwever, the vehicle behind me was not,runniing .into myccnk 29. PHYSICIAN (full name,title, address and phone number) 30.HOSPITAUCLINIC(name and address) Dr. James Ilko 651-501-3000 Allina Medical Clinin Allina Medical Clinic 8675 Valley Creek Rd. Woodbury, MN 55125 31.Witness and phone number. 8675 Valley Creek Road flu 112 - EMPLOYER 32. Legal name&mailing address incl.zip • 34.Unemploy ID No.: OAK PARK HEIGHTS 33.Date form completed: 12./_23(_Q. 14168 57TH STREET, BOX 2007 �� 35.SIC code Payroll Class Code 55 STILLWATER MN 55082-0000 36. Print supervisor's name and phone number: 37.Employer's Representative,print full name,title and phone number: Lindy Swanson 651-439-4723 SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF- INSURED 41.Insurance Class Code: P.O. Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: 42. CARRIER CLAIM NUMBER 44. Adjuster ID No: 0698639002 u-20320-06 tt•ez) Original to Berkley Administrators BA 251 S/I (4/92 Copies to Employer, Employee and Workers' Compensation Division i __ PS-1860-12(8/98) 4.00 as STATE OF MINNESOTA DISTRICI(SrON it` DEPARTMENT OF PUBLIC SAFETY ICR Q, - — TROOP BADGE �. .� STATE PATROL DIVISION -_ C'�wu '! TRAFFIC ACCIDENT INFORMA,, ON"-° AT TIM•F Y',� - THE OFFICIAL POLICE REPORT IS NOT AVAILABLE FOR 14 DAYS FROM THE DATE OF ACCIDENT LOCATION-ON STREET/HIGHW CITY AT INTERSECTION ❑MILES ❑N ❑E WEATHER/ROAD CONDITIONS: PHOTOS? COUN WITH OR: D FEET ❑S ❑W OF: Y❑ N❑ 1 UNIT# VEH.❑ PED.❑ BIKE❑ # VEH.❑ PED.7i..._____ ❑ OIL MBER STATE TCLA S —OIL N B ` STATE CLAS -2-)o if ; 0 b 0 ,t--- I&13 xf .T4--7<(/ - i.-- N T, DDLE,LAST) r-1 / p L NAME(FIRST,MIDDLE,LAST)),y, 6e /Kc ADDRESS / D.O.B. �, ADDRESS ,r D.O.B. 1 J / CITY,S W. ---- ./..--, CITY,S ATIrDE OWNER N. I OWN iiii ■, ADDRE ADDRESS .,./4' ,,,,, -/,(16/07,1er- - r� G - &.J,1�0 V1?-7/7: CITY,STATE,ZIP CODE CITY,ST TE, P Cs E VEH.TYP MAKE/MODEUYEAR COLOR V,Efl.TYPE - A Avm., EAR COLOR INSURANCE TOWED BY: #Of Direction INSURANCE TO Of Di ion _ Occ pants .f" y ! / Occu nts I YEAR STATE D`AM {� / YEAR STATE '1" P( UT# VEH.❑ PED.❑ BIKE❑ U(VIT# VEfj.❑ PED.YBIKE❑ D/L NUMBER STATE CLASS \ D/L MB / CLASS 2 t NAME(FIRST,MI " �J 17 / t NA -. T,MID E,LAST) ADDRESS 3�� �9 /_ ._.B. !' ADDRESS j!± i SSa' /C? . D.O.B. CITY,STATE,ZIP CODE ITY,STW.,,ZI• E OWNER NAME , OWNER NAB` _ re-64,,e_ ST---5 3y ? ADDRESS ' ADD j`�' /15 �l ,)/S----- CITY,STATE,ZIP CODE CI Y;4T ZIP OD f 4j /Cl.-U t ei` VEH.TYPE MAKE/MODEL/YEAR COLOR VEH. Y E/,,./ MAKE/MODEUYEAR C 4. / INSURANCE TOWED BY: #Of Direction INSURANCE TOWED BY: #Of Direction Occupants Of Travel Occupants Of Travel q I YEAR STATE DAMAGE YEAR STATE DAMAGE /..' i--1 n j" �7 PLATE# PLATE# 1 3= ' I TRL: IIRL: 1)// INJURED PASSENGER/WITNESS i COMMENTS: �, . ° t �.. ,- 7 ' �` f%� rL I L f/ /r Minnesota Department of Labor and Industry Workers'Compensation Division First Report of Injury 443 Lafayette Road North St.Paul,MN 66166-4306 See instructions in folder accompanying forms. 1.OSHA Cases J�������111111 11111��,�111 1111 (612)296.2432 All dates must be entered in MM/DD/YY format. Type or Print. EMPLOYEE 2.Name(last,first,middle) 3.EMPLOYEE SOCIAL SECURITY NO: Kropidlowski Fred James 283-66-4840 4. Home address (include county and zip) 5.DATE OF CLAIMED INJURY: 2676 Brittany Lane 12-21-00 Do Not Use this Space Woodbury, MN 55125 X '� 6.Sex: Male 'smalls Washington County - "- 7. Marital Status: X Married Not 8.Occupation: 9.Data of Birth: 112i 1-/tea Police Officer 10.Date Hired: 41.7-/_Q1/_11 1 1. Regular Dept: 12.Home Phone No. (A/C,No.) Oak Park Heights Police Dept. 651-730-5859 13.Apprentice: x_No Yes WAGE INFORMATION 15.Rate per tour. r 16.Hours per day: 14.Average wage/week $1075.00 _ $26.86 _ 8 17.Days per week: 5 18.What is the weekly value of MEALS: $ n LODGING: f () 2nd INCOME: $ 0 19.Employment Status:y.Full time _Part time _Seasonal _Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No OCCURRENCE 20. PLACE(include dept&full address) 21.Date of first 22.Date employer �Z �� day of lost time: o', W B I 494 y _/ / notified of injury: / /_ Wakota Bridge, Newport, MN 23.Return to work date: _/_/ 24.Date employer notified of lost time: / /_ r r� 25.Date of death: / /_ 26.Time of day On employer's premises? l '_ Yes Ill No of injury: o 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL,BE SPECIF IC(include part(s)of body affected,e.g.amputation of right index finger at 2nd joint,fractured arm,lead poisoning) While on duty I was rear ended in a motor vehicle accident causing stiffness in my neck and a headache, 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED (include name of other individuals involved,tools,machinery,objects,vapors, chemicals,radiations,unnettxal motions of employee) While on duty, I was traveling 1494 on the Wakota Bridge when the vehicle in front of me came to a stop, I was able to stop. HOwever, the vehicle behind me was notirunniig .into my..c 29. PHYSICIAN (full name,title, address and phone number) 30.HOSPITALJCLINIC(name and address) .1 Dr. James Ilko 651-501-3000 Allina Medical Clinin Allina Medical Clinic 8675 Valley Creek Rd. Woodbury, MN 55125 8675 Valley Creek Road 31.Witness and phone number, T+L 1,- nu 55 1.2S EMPLOYER, 32. Legal name&mailing address incl.zip • 34.Unemploy ID No.: OAK PARK HEIGHT 33.Date form completed: 12/_21/__01) 14168 57TH STREET, BOX 2007 35.SIC coda Payroll Class Code STILLWATER MN 55082-0000 36. Print supervisor's name and phone number. 37.Employer's Representative,print full name,title and phone number: L i n d y S w a n s o n 651-439-4723 •I Ipin h(1F1 L A I,linrr tta 2L4I , rnSl-U34-q 39 SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 1 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T 0CC INSURANCE 38.CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators 1 SELF- INSURED 41.Insurance Class Code: P.O. Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: 42. CARRIER CLAIM NUMBER 44.Adjuster ID No: 0698639002 u•20320-06 I1-92) Original to Berkley Administrators BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division SUPERVISOR'S REPORT OF ACCIDENT (PLEASE READ AND FOLLOW INSTRUCTIONS ON BACK) EVERY ACCIDENT SHOULD BE INVESTIGATED AND THE CAUSES CORRECTED SO THAT MORE ACCIDENTS WILL NOT OCCUR. DO NOT OVERLOOK THE SO-CALLED"UNIMPORTANT"CASES,BECAUSE,EXCEPT FOR"CHANCE"THEY COULD ALSO HAVE BEEN SERIOUS. IT IS ONLY BY THOROUGH INVESTIGATION THAT MANY OF THE REAL CAUSES CAN BE DETERMINED AND CORRECTED. NAME OF EMPLOYEE 4K l) % 1. c{ /6„..;-sil COMPANY Q(k\-i CC C iAa(249.k ae6er{C DEPT. Pc,i I cam, DATE OF ACCIDENT 17'Z`-O C TIME DID EMPLOYEE LOSE TIME FROM WORK? YES ❑ NO a HOURS LOST ON DATE OF ACCIDENT HAS EMPLOYEE RETURNED TO WORK? YES ❑ NO ❑ JOB TITLE( 1, 1 Ce: Cc c-\C -.--R_ SERVICE WITH THE COMPANY —7 I/Z YEARS, IN PRESENT JOB S GIVE US YOUR HONEST COMMENTS ON QUESTIONS BELOW. WE ARE NOT TRYING TO BLAME ANYONE. YOUR OPINION MAY HELP US PREVENT ACCIDENT REPETITION. PLEASE ANSWER THE FOLLOWING: CHECK"YES" OR "NO" 1. WAS INJURED PERSON PROPERLY INSTRUCTED IN SAFE AND EFFICIENT METHODS? YES NO ❑ 2. DID INJURED PERSON VIOLATE ANY INSTRUCTIONS? NO.0 pLYES ❑ 3. WAS NECESSARY PROTECTIVE EQUIPMENT WORN? (IF APPLICABLE) YES la NO ❑ 4. DID POOR HOUSEKEEPING CONTRIBUTE TO INJURY? NO L YES ❑ 5. DID HORSEPLAY CAUSE THE INJURY? NO ja YES ❑ 6. WAS IT CAUSED BY SOMETHING WHICH NEEDED REPAIRS? NOiSt YES ❑ 7. SHOULD A GUARD BE PROVIDED? NO.2f-YES ❑ 8. DID ANY BODILY DEFECT CONTRIBUTE TO INJURY? NO YES ❑ 9. WAS IT CAUSED BY AN UNSAFE ACT? NO YES ❑ 10. DID INJURED REPORT THE INJURY TO YOU,THE SUPERVISOR, IMMEDIATELY? YES Vit NO❑ • ACCIDENT. (DESCRIBE WHAT INJURED WAS DOING AT TIME OF ACCIDENT, WHAT HAPPENED,WHO WAS INVOLVED, NATURE OF INJURY, PART OF BODY AFFECTED.) {A� (L Ce. ` � "k , r�� its.. ���\.7-V 4-1 C.— ' M'i $ WITNESSES'NAMES UNSAFE ACTS. (WHAT DID THE EMPLOYEE OR ANOTHER PERSON DO INCORRECTLY?) / � UNSAFE CONDITIONS. (WHAT UNGUARDED OR UNSAFE CONDITION OF MACHINERY,EQUIPMENT,BUILDING OR PREMISES WAS INVOLVED?) V UNSAFE. CONDITIONS. TAKEN. (WHAT DID YOU DO TO CORRECT THE CONDITIONS WHICH CAUSED THIS INJURY?) VA... REMED.S. /IE (WHAT SHOULD YOUR ORGANIZATION DO TO PREVENT OTHER INJURIES LIKE THIS?) MEDICAL CARE. DID EMPLOYEE GO TO DOCTOR OR HOSPITAL? YES ❑ NO -IF YES, COMPLETE THE FOLLOWING NAME OF DOCTOR OR HOSPITAL DATE OF INITIAL VISIT ADDRESS TELEPHONE NUMBER AS SUPERVISOR, DO YOU FEEL THAT THIS INJURY SHOULD BE COVERED UND R WORKERS' COMPENSATION? YESg NO❑ REASONS WHY Al t / 14 ._e_Ac)' 4\ I Cks..) l REPORT SUBMITTED BY Ni. D, ,(w 1` DATE 17-777--00 BA 252 (3/92) ' •s34eueq Auep lou 111M 41951!Aq pue uo!u!do ue Apo s!s!41 •sn pal eseeld ')IJOM le Jn000 lou pip AJnfu!eyl 1941 loadsns 01 u0ssoi aA94 '1os!AJedns se noA;! 'JOA9MOH •UO!1BSUQdwo0 ,S10,1JOM Jspun paieAOO s!AJnfu!1241 ')!JOM le a114M peJnfu!s!eoAoldwe 041 1! 'aim 1eJeue6 a sy Zslgaueq uo!lesuadwoo ,519)pOM Japun peJanoo aq Plnoys AJnfu!s!y1 ley1 Iee;noA op '1os!AJedns sv •uogewlo;u!eialdwoo 910W J0;111101 S!41;0 UO11O1dWOO 941 Ae10p IOU OQ •0W!1 s!yl le uMOU)I s!1041 uo!1ewJO;u! 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AJnfui;O lJOdOH 1sJ!j 091 OJO9M 9011;o IeI1uOO ey1 011UOppO2 09111odeJ o1 pasn OSIB s!11 'luap!OOe 041 0108!lsenu!01 s!VIS 94110 esodlnd AJBwpd 941 (VHS) 1N30100V 30 1110d3H .SHOSIAH3df1S HO3 SNOIIOf1li1SNI NOI131dINO0 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST DATE: 05/16/00 D MAY 18 2000 OAK PARK HEIGHTS Ann:Finanoe Dept. ATTN: THOMAS MELENA P.O.BOX 2007 STILLWATER MN 55082 RE: BRS CLAIM NO. : 11029736 TRUST MEMBER: OAK PARK HEIGHTS CLAIMANT: STEVE LOCKWOOD DATE OF LOSS/OCCURRENCE: 01/24/00 CLAIMS MADE DATE: 01/25/00 The above claim has been concluded. This claim occurred when - SEWER BACKUP On behalf of your city, we have paid the following to conclude this claim: Paid Losses Paid Medical Paid Expenses Total 12,290. 36 .00 .00 = 12,290.36 Ded.Recover PRIOR AGGREGATE This Bill ----- This Claim This Covenant - _-. -500.00 .00 .00 Your city' s deductible is $500 per occurrence. This applies under covenant number CMC 19785 effective 07/07/99 thru 07/07/00. Accordingly, please prepare a draft made payable to the "LEAGUE OF MINNESOTA CITIES INSURANCE TRUST" in the amount of $ 500.00 and forward it to Berkley Risk Administrators Company,LLC, 920-2nd Ave.So,Mpls, MN 55402-4023, Attention: Finance Department. Please include our claim number, as captioned above, with your remittance to insure proper credit. Should you have any questions relative to the disposition of this claim, please do not hesitate to contact the BRS examiner who supervised this claim, CURTIS I _ HS TSCHMIDT at 1-800 925-1122, or locally at 651-281-1284. Sincerely, Finance Department Agent of Record: LANDMARK INSURANCE SERVICES 232 SOUTH LAKE STREET P.O. BOX 188 FOREST LAKE MN 55025 LMC 145 University Avenue West, St. Paul, MN 55103-2044 Phone: (651) 281-1200 • (800) 925-1122 TDD (651) 281-1290 League of Minnesota Cities LMC Fax: (651) 281-1299 • LMCIT Fax: (651) 281-1298 Cities promoting excellence Web Site: http://www.lmnc.org ACKNOWLEDGMENT OF CLAIM OAK PARK HEIGHTS ATTN: THOMAS MELENA P.O.BOX 2007 STILLWATER MN 55082 Date: 1/26/00 RE: Our File No. : 11029736 LMCIT Member: OAK PARK HEIGHTS Claimant Name: STEVE LOCKWOOD Occurrence/Loss Date: 1/24/00 Claim Description: SEWER BACKUP Supervisor: CURTIS HEITSCHMIDT Phone No. : (651)281-1284 Fax No. : (651)281-1297 Adjuster: MIKE MUNSON Phone No. : (651)215-4076 or 1-800-925-1122(outstate), Extension 4076 Fax No. : (651)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also available to you at any time. LMCIT Claims Department JAN 2 8 2000 c4 C.C. LANDMARK INSURANCE SERVICES 232 SOUTH LAKE STREET P.O. BOX 188 FOREST LAKE MN 55025 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER • • • • • • r* W/�` ,nx.,�� ',, ,,. J City of Oak Park Heights 14168 North 57'"Street Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: fid-in C / �v S Fax: D '— ) 5 2 • • • • • • • • • • From:K ' Date: / Re: Loc/L(4/bud C_��,'w. Pages: c CC: ❑ Urgent For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle Notes: }/Q is -r1.� erw�y� � l-)c ? rec.levoc/"cis o 1 H o.r Fc,a'.. Es/- 2 I- /:= 74 • Lp�Lwc � irK� DEC.15.1999 1:37PM RE/MAX CROSSROADS IN NO.734 P.2/2 Scenario of Events That Happened at 5564 Osgood Avenue On Sunday November 21, 1999,I came home from work at approximately 11:30 am. I had noticed that the basement carpeting floor was saturated. At first,I thought that our dog had had an accident, but then I beard water and the smell bad become foul. As I came around the corner,I noticed there was water coming up through not one,but two(2)of our floor drains. More so than one(1) wet/dryvac could possibly handle. Panicking, I ran out to the rental place and had rented three(3)industrial wet/dryvac's, due to the gallons of sewage coming through seemingly every 30 seconds. The sewage would not stop from coming into house. At the end of the day it was getting so bad that we bad to suck up fresh clumps of human excrement from everyone in the neighborhood around the clock. This process would continue on for the next 7 hours. I had a plumber come out approximately 2 hours into this mess.He ran a 100 foot snake, and the connecting sewer line was clean. We went out front to look into the manhole North of the house and it was clean. We were stumped. Then be suggested to look at the manhole south of us,and it was full of sewage. The plumber bad told us to call the city ASAP, that it was THEIR problem. It would be approximately 5 hours later when the police and city finally came after hours of phone calls to them that we were in need of assistance,as we were bailing community "excrement's"from our basement residence. At 7:30 PM that night,the City Truck finally showed and bad blasted the sewer system. The sewer manhole, which had been full at this rime,bad suddenly started to drain. Your men then noticed that the water was very black and I told them that this was the very same color and same substance in my basement. It appeared on my walls,flooring, carpeting,furniture and towels. The City said to me it was their fault due to the sewer backing up, and that it bad nothing to do with our houses'plumbing system. I have submitted Bids for cost of damage. Please advise us of the Status of this claim when it may become available to you. Thank you. Sincerely, Steve Lockwood 5564 Osgood Avenue Stillwater,Minnesota 55082 Phone (612) 508.8584 DEC. 9.1999 12:51PM ,RE/MAX CROSSROADS IN NO.601 P.4/4 V I O N7 1U I ui %-i,. A , u� l a s NNJ wv w • ! ,,i -* Jc ..,'I O \N ,,t IP. :::3-:...''''.1 .‘ E k. ..' v2i Z, % 12 6 \/) qii.. 4 \.. ..._ i ist, . v..) ,o) E Pai . " � � � % J v � A C P.1 N ti `Z:1.- N \ ci) (ij -- 'k. . \f1 r M \. o w V • DEC. 9.1999 12:50PM RE/MAX CROSSROADS IN N0.601 P.3/4 B LAKE B UILDERS, I NC. omon6G,M N.86129 (ee1)8o1•5845 OFFICE, (861)501-5647 PAK STEVE LOCKWOOD 5564 OSGOOD AVE. STILLWATER,MN. 55082 PROPOSAL TO FURNISH LABOR AND MATERIALS TO COMPLETE THE FOLLOWING, 1)REMOVE CARPET 2)REMOVE DAMAGED WALLS) 3)BUILD NEW WALL(S) 4)SHEETROCI::AND TEXTURE WALL(S) 5)APPLY NEW TRIM MOLDING AND ENAMEL.AS ORIGINAL 6)RE-PAINT BASEMENT WALL(S) 7)INSTALL.NEW PAL)AND CARPET TOTAL PRICE. . , . . , . . . . , .$8,917.00 ' OP BY: — /1 ,t:/ 77 Phil Soby;' A39./ lake Builders,Inc. • ACCEPTED BY: Steve LOChWood/Homeowner ,. PR 14) DEC. 9. 199 12:50P RE/MAX CROSSROADS I _ No.;, 601 P.2/4 h �p construction o. Mark Phillippi PA O?osAL1112499014 :4., ''' 2892 Hadley Ave. N. SHEET.NO. I ' Oakdale, MN 55128 (651)770-9619 DATE Nov.24, 1999 PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT: 1•9*ES., tiALI Mood, "-.'-e''". ,ii'' '•7,•'`•'; ;.: <f:•.j ; ',1 /ADDJ�E99, ' S5ti4OegobdAve:.N7.'•• 7..., .':, ,-.,,,•,; -,17;^,tip . •+l ..)ii 1( ' t',,,� , °.p B64.Oegood Ave:,N. , Stillwater, MN . ' StillWater,MN 55082 PATE OF PLANS PI.10 '351-7642 ARCHITECT • d ‘ J•("Z ii.' • :.;: eS-_,Id thiNAMI4S' n oh n ssaMVithQI h >t ' e o r � ' :�:f a•= • ;w.. , ''.+Ii 'e '• • tani ecement O 'via It t at dame n Contact en the,cl ; :. 1' .: ,sew,er4,• •• e•1up nick• •sement,t ou•'_)L oar.;• - n in' aceroom:1 ce in u• •s remove a. • .-,; lurid r IaCei<tnent avails In furhac troom whiCh'are a(eo pert of a bedroomend hallway.cAll°A` ',',, • "r'Welt: Nita •• '.WiII hied to to Oil-to match existin, knockdown texture: Securi • ;;I• . ':8,,fetQh ".II 1llee'tieed tOte rewired&ego the facttf at,it le housed ln'the furnace room: Also' • ,. . " ::heted j a ...—j of the 'Q er 5/8"'filling;"�eplecetnent of C pet �d Is also' • 'r :' nose i:aridli I C133.0a6= 0 e'y d f :.careet� _endpad i, a lnc!uld oh'eOWner ll; ' ''' '' ii n: ienal 4rinf lri's "I. , , , i •t - ,..�— • ■ All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifi- cations submitted for above work and completed in a substantial workmanlike manner for the sum of Eight Thousand Seven Hundred dollars Dollars t$ $8700.00 ) with payments to be made as follows. Mark Phlllippi Respectfully submi d Any alteration or devlotlon from above soocificatona Involvtnp eklre cattle will oe executed only upon written order,and will bacoma on axtro charge Per over and above tho estImete,All aoroomenle conlingonl upon elnkos, ac- cldonts,or deleye beyond our control. Note—This proposal may be withdrawn by us if not accepted within 30 days. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authoriz to do the work as specified. Payments will be made as outlined above. Signature . ..7.- . Date /l a` Signature_ 1 Man NC 3818-50 NAPE INuSA Proposal • • • • • . • 6(?, 5-av s—g--6( .. ..... . . .. . ... ... ... . . F4 64-7 - 34-1 - 76 te7.- ti. -2... Gfcl; -" 4v- s e h._ �°_ lost 17 .//e, DEC.15.1999 1:37PM RE/MAX CROSSROADS IN N0.734 P.1i2______________ ______ .___. emk„L:,;i .------------i)��j l', ... . ,i$ !!\ I I I \ i r ifie V. 010444? RE/MAX CROSSROADS INC, WOODBURY,MN FACSIMILE TRANSMISSION / G� FAX (661)735-8246 DATE: I cI LS F I NUMBER OF PAGES INCLUDING COVER SHEET g RECEIVER'S NAME: 4 lb. __Ai ,44 -,r COMPANY: G e• C90.-C_ '- C #e- X FAX NUMBER:,__,__` 4/3 f– 057<7 SENDER'S NAME: ��C.' Y,_.. Lo c_ L ) OO COMMENTS: CONFIDENTIALITY NOTICE: The document(s) accompanying this FAX contain confidential Information which is legally privileged, The information Is intended only for the use of the intended recipient named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or the taking on any action In reliance on the contents on the telecopled information except its direct delivery tp the intended recipient named above is strictly prohibited. If you have received this FAX in error, please notify us Immediately by telephone to arrange for return of the Original documents to us, IF YOU HAVE NOT RECEIVED ALL PAGES OF THIS TRANSMISSION.PLEASE CALL: (651)735.1 ow. . a ".' `�' Steve Lockwood , 4,1t 6-,7, RtALTUR^' i • . 4' 6;,'E ' • S i Mulu•MuUlon Dollar Producer CrOSSfead tt.. 1° y 171 e010h1C1rivlo.Tch1°oNidlnnnily swap 'u g:nii0ivliiidyitiU Oporatod .i 'Pi pi ' 1� N9' . t. �_ t;rllldlr;(012)blI .&iiO4 OHIce.(651)5(5.2'41:1 '� Fax:(651)735.4246 _,' � ilniI'k co;(851)3614442 , DEC. 9.1999 12:50PM RE/MAX CROSSROADS IN NO.6O1 P.1/4 ittpyk '`''S I'4.7 igAt I Of. • RE/MAX CROSSROADS, INC. WOODQURY,MN FACSIMILE TRANSMISSION FAX (e61)736.8246 GATE: /07--lV?" NUMBER OF PAGES INCLUDING COVER SHEET: RECEIVER'S NAME: wy, , COMPANY: /"``,, Cx.� L FAX NUMBER,_ Y 3 9-Q.t'74/ SENDER'S NAME: >< �, kc� C ‘id..s"Or P.r-ry c c-rt ' COMMENTS: CONFIDENTIALITY NOTICE: The document(s) accompanying this FAX contain confidential Information which is legally privileged, The Information Is intended only for the use of the intended recipient named above. If you are not the intended reciplent, you are hereby notified that any disclosure, copying, distribution or the taking on any action in reliance an the contents on the tele.opied information except Its direct delivery to the Intended recipient named above it strictly prohibited. If you have received this FAX In error, please notify us immediately by telephone to arrange for return of the original doCut'nents to us. IF YOU HAVE NOT RECEIVED ALL PAGES OF THIS TRANSMISSION,PLEASE CALL: (E1)735.1350. THANK YOUI t( Crossroads, Inc. 1920 Donegal Drive, Suite 200 Woodbury, MN 55125 Phone: (651)735-1350 Fax:(651) 735.8246 Each 01110e Independently Owned and Operated a `� CITY OF *. r- a = OAK PARK HEIGHTS lt, 14168 North 57th Street • P.O. Box 2007 • Oak Park Heights, MN 55082-2007 • Phone:651/439-4439 • Fax:651/439-0574 ..3i', January 6, 2000 Mr. Mike Munson League of Minnesota Cities 145 University Ave West St. Paul, MN. 55103-2044 Re: Sewer Back-up Lockwood Residence, 5564 Osgood Ave. N. 11/21/99 I have reviewed our existing records from sewer jetting projects in the 1994-1996 time frame. The Osgood sewer line was not jetted during this time frame. The sewer is an 8 inch VCP with a high slope and therefore a high flow velocity which makes it generally self scouring. The downhill manhole was free of residue or build-up indicating that the entering velocity was capable of scouring. Mr. Lockwood contact the Oak Park Heights Police on Sunday afternoon (police report enclosed). Upon receiving the police page I contacted Muncipal/Commercial Sewer Service to jet the line. They arrived on the site at approximately 17:00. We observed the southermost manhole on Osgood Avenue to have 3 to four feet of sewage backed-up. The downhill manhole past Mr. Lockwood's home had a very small flow but was otherwise clear with no signs of build-up or obstruction. The service jetted from north to south hit and cleared an obstruction. The cause of obstruction was not observed as the water velocity in the line was very high and it passed through the manhole unobserved. Conclusion: Pipe obstructed by unknown material caused back-up into Mr. Lockwoods home. If you have any questions please contact me. Jay E. Johnson, PE Public Works Director r. Encl: Police Report Municipal/Commercial Sewer Service Invoice City Sewer Map Tree City U.S.A. CJG1UPR OAK PARK HEIGHTS POLICE DEPARTMENT DATE 1/06/00 TIME 14 : 02 : 58 INITIAL COMPLAINT REPORT 99703939 DATE REPORTED: 11/21/99 TIME REPORTED: 13 : 52 : 52 DISPATCHER: DRKISCH LOCATION OF INCIDENT: 5564 OSGOOD AV N OAK PARK HEIGHTS MN 55082 GRID: INCIDENT RECEIVED BY: DEPUTY OFFICERS ASSIGNED: 482 KISCH NAMES ASSOCIATED WITH THIS INCIDENT: STEVEN MICHAEL LOCKWOOD 5564 OSGOOD AV N OAK PARK HEIGHTS MN 55082 PHONE : (H) 651/351-7642 (W) SEX:M DOB: 5/06/1965 ASSOCIATION: COMPLAINANT COMP. STATED SEWER IS BACK UP SOUTH OF HOUSE ON OSGOOD. CELL PHONE 612-508-8584 OFFICER COMMENTS : SPOKE TO COMP. WHO STATED HIS CITY SEWER IS BACKED UP INTO 482 11/21/99 HIS HOUSE. A PLUMBER CAME TO HIS HOUSE AND TOLD HIM HIS 482 11/21/99 PIPES WERE CLEARED. THEY INVESTIGATED AND FOUND THE SEWER 482 11/21/99 WAS BACKED UP ON OSGOOD TO THE SOUTH OF HIS RESIDENCE. 482 11/21/99 PAGED JAY JOHNSON PUBLIC WORKS TO RESPOND, UNABLE TO REACH 482 11/21/99 JOHNSON ON CELL PHONE OR HOME PHONE. 482 11/21/99 CLEARED. 482 11/21/99 CLASSIFIED AS: PUBLIC ASSIST 9802 • a. /i i iiJ 1' i' 7. t , / / i .... .r._.............. . .... ._ _i ._- ... .. • .N. . '. /''kt / • / 'may`,.... _ .,_. - ---7-_'' -- \ / 4. 0. i .. 7 is � • ,. . ice• a fwG� y ---- •. 4. •fi: i i .'" 30.:141, 4 / ' // / • QD ^' e,e , a pr.......• •••..,.,.,y, ...y.y...■• { t G N. e•, -, z. • Q. y '; r ,c d;^ 6 f • 9 iY 7i N i 4 b 0. JNICIPAL/COMMERCIAL u SEWER SERVICE INVOICE 8 ,\„-z&' 501 W. Maryland Avenue �>a��0'a4'” St. Paul, MN 55117 DATENOVEMBER 22 , 1999 �d�r`?� a2', 489-SI85 ,t ,r. P.O. # o�„>a TERN'S: 10 DAYS • SOLD TO: AT,TN: CITY OF OAK PARK HEIGHTS JAY,, � BCEN _ -- 14168 NO. 57TH STREET -� P.O.BOX 2007 u ' OAK PARK HEIGHTS , MN. 55082-2007` DATE DESCRIPTION AMOUNT 11-21-• • JET SANITARY LINE 5564 OSGOOD 440 . 00 AVENUE Ell” SUNDAY-4 :30 P.M. TO 6 :00 P.M. V ' "7 • r ______Le_c_21" Illn , , r.T i i%� -1. _� r___ _• - ,nce-after 30 Days THANK YOU TOTAL DUE: $ 440 . 00 LANDMARK K I[N 1U[RA\NCE S]ERV][(CES 232 SOUTH LAKE STREET • PO BOX 188 • FOREST LAKE, MN 5512 © E U�E Phone: (651) 464-3333 or(612)427-7473 Fax: (651)464-750,, JAN 18 2000 January 17, 2000 City of Oak Park Heights Thomas M. Melena, City Admin. 14168 N 57th St, Box 2007 Stillwater, MN 55082 RE: Claim of: 1999-11-21 Amount Paid: $7875.5 Claim Number: 11029367 Description: Sewer Backup Dear Mr. Melena, Recently, our agency handled a claim on one of your insurance policies. Our intention is to always give you impeccable service. I want to urge you to contact me personally if we should ever fail to meet your expectations. Could you please take a few moments of your valuable time to complete the attached questionnaire evaluating the service you received from both our agency and the insurance company? This will allow us to reward employees who are doing a good job and correct any deficiencies in our system. We've enclosed a postage paid reply card for your response. Please note the amount shown above may include company expenses - which is why it might be higher than actual bills submitted. Additionally, it is sometimes difficult for us to tell from company documents provided to us if a claim has been closed. If we have sent this letter to you and your claim is not(or should not be) closed, please call Dali at 651-464-3333. Thank you for your help and for the continued opportunity to serve you. Sincerely, Brian Alm, CIC Agency President HI LMC 145 University Avenue 0 , St. ' 103{ 44 Phone: (65 \ $1- Ili :::•925-422 ' j\ TDD (651) 28 - 90 League of Minnesota Cities LMC Fax: (651) 281-1299 ;• LMCIT Fax: ( -1 98 Cities promoting excellence V e-h Site: http://www.lmnc.org ACKNOWLEDGMENT OF CLAIM OAK PARK HEIGHTS ATTN: THOMAS MELENA P.O.BOX 2007 STILLWATER MN 55082 Date: 12/17/99 RE: Our File No. : 11029367 LMCIT Member: OAK PARK HEIGHTS Claimant Name: ;TES LOCKWOOD" Occurrence/Loss Date: 11/21/99 Claim Description: SEWER BACKUP Supervisor: CURTIS HEITSCHMIDT Phone No. : (651)281-1284 Fax No. : (651)281-1297 Adjuster: MIKE MUNSON- Phone No. : (651)215-4076 or 1-800-925-1122(outstate), Extension 4076 Fax No. : (651)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also available to you at any time. LMCIT Claims Department C.C. LANDMARK INSURANCE SERVICES 232 SOUTH LAKE STREET P.O. BOX 188 FOREST LAKE MN 55025 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER 1Launl(d[]rnaurk 1[Iii u[Ir(ance Sery tUC(e S 232 South Lake Street • Forest Lake, MN 55025 617 East Main Street•Anoka,MN 55303 • Phone: (612)464-3332 FAX: (612) 464-7596 Phone: (612)427-7473 FAX: (612)427-1553 Since 1903 September 24 , 1998 • DwE City of Oak Park Heights f� \\\I SEP Thomas M. Melena, City Admin. 14168 N 57th St, Box 2007 _� Stillwater, MN 55082 Dear Mr. Melena, Thank you for promptly reporting the recent claim on your Commercial Package policy. A loss notice has been sent to LMCIT-Berkley Risk Services, I regarding this loss . A copy of this loss notice is enclosed. If the loss requires the services of an adjuster, you should be hearing from one within 3 business days. An appraiser may be used to determine a value for the damaged or lost items, and report this to the company. Both adjusters and appraisers should provide proper identification when contacting you. If the loss is beyond as stated in the report, please inform the adjuster when you are contacted. Additional notices may also be enclosed if required by state law. If you were asked for any additional information at the time you reported this loss, please be sure to call it in as soon as possible . Complete information speeds claim settlement . If your loss involves damaged property and you have a mortgagee, loss payee or lienholder listed on your policy, they may also be named on any claim check. Please discuss this with your adjuster and what options may be available . Please call if you have any questions or if you feel your claim is not being handled properly - we are here to help you. Sincerely, Kate Tipping Customer Service Representative Enclosure IMPORTANT NOTICE: If the item(s) involved in the claim are listed specifically on your policy and are totalled, please call us to remove them. This' will not happen automatically, as we are not normally notified of the- extent of the loss . .; _ 1.05 DATE(MM/DD/YY)OP ID KT ACORD PROPERTY NOTICE 09/23/98 PRODUCER PHONE MISCELLANEOUS INFO(Site& code) DATE OF LOSS AND TIME PREVIOUSLY (A/C No,Ext). 651-4 64-3333 AM REPORTED (�L,N°,Ext): 651-464-7596 07/14/98 I PM YES X NO Landmark Insurance Services POLICY COMPANY AND POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE 232 South Lake Street CO: LMCIT-Berkley Risk Services, I PROP! PO Box 188 HOME Forest Lake MN 55025 POL: CMC17704 07/07/98 07/07/99 Landmark Insurance Services CO: FLOOD CODE: SUB CODE: POL: AGENCY CUSTOMER ID CO: WIND OAKPA-1 POL: INSURED CONTACT J CONTACT INSURED NAME AND ADDRESS NAME AND ADDRESS WHERE TO CONTACT City of Oak Park Heights City of Oak Park Heights Thomas M. Melena, City Admin. Judy 14168 N 57th St, Box 2007 Stillwater MN 55082 WHEN TO CONTACT RESIDENCE PHONE(A/C,No) BUSINESS PHONE(A/C,No,Ext) RESIDENCE PHONE(A/C,No) BUSINESS PHONE(A/C,No,Ext) weekdays 612 439-4439 612 439-4439 LOSS LOCATION West side of the city, near POLICE OR FIRE DEPT TO WHICH REPORTED OF LOSS the High School, water tower FIRE X LIGHTNING FLOOD OTHER KIND (explain) PROBABLE AMOUNT ENTIRE LOSS OF LOSS THEFT HAIL WIND $2493.43 DESCRIPTION OF LOSS&DAMAGE(Use reverse side,if necessary) actual date of loss unknown, damage discovered 7-14-98; damage to power co nverter on outdoor warning siren, W. side of the city, near the H.S. , at t he base of the water tower POLICY INFORMATION MORTGAGEE NO MORTGAGEE HOMEOWNER POLICIES SECTION 1 ONLY(Complete for coverages A,B,C,D&additional coverages.For Homeowners Section II Liability Losses,use ACORD 3.) A.DWELLING B.OTHER STRUCTURES C.PERSONAL PROPERTY D.LOSS OF USE DEDUCTIBLES DESCRIBE ADDITIONAL COVERAGES PROVIDED ON J COVERAGE A.EXCLUDES WIND SUBJECT TO FORMS(Insert form numbers and edition dates,special deductibles) FIRE,ALLIED LINES&MULTI-PERIL POLICIES(Complete only those items Involved in loss) ITEM SUBJECT OF INSURANCE AMOUNT %COINS DEDUCTIBLE COVERAGE AND/OR DESCRIPTION OF PROPERTY INSURED BLDG CNTS BLDG u CNTS BLDG CNTS SUBJECT TO FORMS (Insert form numbers and edition dates, special deductibles) FLOOD BUILDING: _ DEDUCTIBLE: ZONE PRE FIRM DIFF IN ELEV FORM GENERAL — CONDO POLICY CONTENTS: DEDUCTIBLE: POST FIRM TYPE DWELLING WIND BUILDING DEDUCTIBLE CONTENTS ZONE FORM GENERAL CONDO POLICY TYPE DWELLING REMARKS/OTHER INSURANCE(List companies,policy numbers,coverages&policy amounts) CAT# FICO# ADJUSTER# DATE ASSIGNED ADJUSTER ASSIGNED REPORTED BY REPORTED TO SIGNATURE OF PRODUCER OR INSURED Judy Kate Tipping Landmark Insurance Services ACORD 1 (2195) NOTE:IMPORTANT STATE INFORMATION ON ATTACHED PAGE @ACORD CORPORATION 1888 r • t is7 s , i LMC JAN 15 is;: 145 University Avenue'West, St. Paul, MN 55103-2044 League of Minnesota Cities Phone: (651) 281-1200 • (800) 925-1122 Cities promoting excellence Fax: (651)281-1299 • TDD (651)281-1290 J ACKNOWLEDGMENT OF CLAIM OAK PARK HEIGHTS P.O.BOX 2007 STILLWATER MN 55082 Date: 1/13/99 RE: Our File No. : 11025467 LMCIT Member: OAK PARK HEIGHTS Claimant Name: KAREN SCHULTZ Occurrence/Loss Date: 12/04/98 Claim Description: HIT HOLE IN STREET - WB ON 58TH ST. @ HWY 5 Supervisor: KELLY ROBOTNIK Phone No. : (612)281-1288 Fax No. : (612)281-1297 Adjuster: ERIC FAUST Phone No. : (612)215-4096 or 1-800-925-1122(outstate) , Extension 4096 Fax No. : (612)281-1297 We have received this claim at the LMCIT claims office. The assigned claims supervisor and adjuster are listed above. The adjuster is your key contact on this claim. If you have not already been contacted by an adjuster, please call the listed phone number and ask for the specific adjuster assigned to this claim. The claims supervisor is also available to you at any time. LMCIT Claims Department C.C. LANDMARK INSURANCE SERVICES 232 SOUTH LAKE STREET P.O. BOX 188 FOREST LAKE MN 55025 AN EQUAL OPPORTUNITY/AFFIRMATNE ACTION EMPLOYER City of Oak Park Heights W 14168 57`I Street N.•Box 2007.Oak Park Heights,MN 55082•Phone(651)439 4439•Fax 439-0574 Interoffice Memo To: Joe Anderlik, City Engineer From: Public Works Director, Jay Johnson, PE cc: City Administrator, Community Development Director Date: 01/25/99 Re: Kern Center Street Improvements and Pot Hole Insurance Claim Joe Please review the enclosed letter and section from your drawing. The plans do not state that the transition shown on the north side of 58th Street is being built. Based on what I saw the transition shown on your drawings does not currently exist. We need to make sure it is built. Another pothole is developing and will be a maintenance problem on the southside of the street. A transition on the south side should also be considered. I also noticed that there are no traffic signs like lanes merging, intersection ahead, speed limit etc shown on the drawings. Have your traffic engineers determine what signs are appropriate for Kern Center. The City Council has stated that they want speed limit signs on Memorial Drive. Where should they be posted? TREE CITY U.S.A. 4 � qtr City of Oak Park Heights # 14168 57th Street N.•Box 2007•Oak Park Heights,MN 55082•Phone(651)439-4439•Fax 439-0574 Interoffice Memo To: Eric Faust, LMC Insurance Claims From: Public Works Director, Jay Johnson, PE CC: Mayor, City Council, and City Administrator Date: 01/25/99 Re: 58th Street Pot Hole, Claim from Mrs. Karen Schultz I met with Mr. and Mrs. Schultz at 58th Street just west of Highway 5 to locate the pot hole, which Mrs. Schultz claims to have hit. The pot hole located was approximately 2 to 3 inches deep and was at the point in the road where the MNDOT apron from Highway 5 ends and abruptly changes from four lanes to two lanes. This road was installed by Baytown Township and inherited by the City of Oak Park Heights when the area was annexed in June of 1998. Mr. and Mrs. Schultz stated that the hole was 12 to 15 inches deep on Friday December 4th, when she hit it. They originally contacted the City of Stillwater and Washington County about the pot hole and did not contact Oak Park Heights until December 8th. When I investigated on Tuesday December 8th the pot hole was only 2 to 3 inches deep and in my opinion did not poise a significant threat to normal traffic. To the best of my knowledge their call was the only notification that the City had of a pot hole at this location. We have not had any complaints prior to or since their complaint. The City Engineer had reviewed the area for water , sewer and street improvements as part of the annexation process. The improvement project has been approved by the City Council and awarded for construction in the spring of 1999. Originally, this project was scheduled for the fall of 1998 but was delayed in the public hearing process. The enclosed construction drawing shows the area as a normal transition. TREE CITY U.S.A. T p -�►� r J NI-- -. •939:4. : : : • : .939.9' _`' I'•I O `- x i s1TtINOUs 938.3 0 939:6 `_� 0 = N1 xv<�m� -^� --�-I =rnv1 � Z-Ti p m A 9 ,� 1 p I = :938.8 939.4 0 K---I ih M --1-� ®� - ---�� Z tc -, m ri c��z� .rst a �,x •: •938.0 0 939.1 O0mvzi 3r S % SOD i '',.14.fi,. r`-] W coo P O ZDN-I * �h Z Iil C -a,1 N Z cn D 4 K --1-2'- Ross+o- - m r • zE- , • O r_- a1 o 938:2 938.9 M o s ' [- e__--1-__-_ 4 x i, .6 _. o, STILLWATER BLVE � 939.1 " S5_ - 91_ + 938.7 3 v3 s:z O .:.��ir�s� �P�w :. • • 938.5 938.5 T T_= T. `� ti- I _ I. ,,_ _-___ 7T _ ___� T - 938.1 o co 938.2 _ _ _ _ • 938.1 938.; ----- :- _ __ ___ = e: STATE HIGH : a 1, X00 N m • r� z D.crl (TI N i U1NNN0 79�T m I Z * - O I S. cn z 0 m Cm O O 0 X CO 0 )TA I HEREBY CERTIFY THAT THIS PLAN, SPECIFICATION, OR REPORT 4.7'Banestroo WAS PREPARED BY ME OR UNDER MY DIRECT SUPERVISION SURVEY REVISION •.k t AND THAT I AM A DULY REGISTERED PROFESSIONAL ENGINEER DRAWN WAN Rosene UNDER THE LAWS OF THE STATE OF MINNESOTA. G'Ts /1 DESIGNED h,w Anderlik & / �� APPROVED .13.-.-.--..P71; `Associates ^} Engineers 8 Architects _DATE 8 L!A•4 8 _ REG. NO. (047/ DATE _• ,�, , _ .?��j 0 BONESTROO ROSENE. ANOERUK & ASSOCIATES. INC. 1998 -^ •" 1 �f COMM. 55-9a 3398802C07.d.4 6�Z4-96 '- r x City of ,441 Oak Park Heights 14168 57th Street N.•Box 2007.Oak Park Heights,MN 55082•Phone(651)439 4439•Fax 439-0574 Interoffice Memo To: Eric Faust, LMC Insurance Claims From: Public Works Director, Jay Johnson, PE cc: Mayor, City Council, and City Administrator Date: 01/25/99 Re: 58th Street Pot Hole, Claim from Mrs. Karen Schultz I met with Mr. and Mrs. Schultz at 58th Street just west of Highway 5 to locate the pot hole, which Mrs. Schultz claims to have hit. The pot hole located was approximately 2 to 3 inches deep and was at the point in the road where the MNDOT apron from Highway 5 ends and abruptly changes from four lanes to two lanes. This road was installed by Baytown Township and inherited by the City of Oak Park Heights when the area was annexed in June of 1998. Mr. and Mrs. Schultz stated that the hole was 12 to 15 inches deep on Friday December 4th, when she hit it. They originally contacted the City of Stillwater and Washington County about the pot hole and did not contact Oak Park Heights until December 8th. When I investigated on Tuesday December 8th the pot hole was only 2 to 3 inches deep and in my opinion did not poise a significant threat to normal traffic. To the best of my knowledge their call was the only notification that the City had of a pot hole at this location. We have not had any complaints prior to or since their complaint. The City Engineer had reviewed the area for water , sewer and street improvements as part of the annexation process. The improvement project has been approved by the City Council and awarded for construction in the spring of 1999. Originally, this project was scheduled for the fall of 1998 but was delayed in the public hearing process. The enclosed construction drawing shows the area as a normal transition. TREE CITY U.S.A. Q ,� 1 ---�1 , 934.,, / 9•9:4 939:9. -F I 0 I BITUMINOUS . . _- 1 9:8.3 + 939:6 ` ' ( , _-�N1 �---- �>- Z __ d .On - Z0mN b v _N Mr-K-1 'r' --.- I c2K 0) x<O y off m < s°1 0xj mf s►. X 9:8.8 939.4 " EnDDO * c -4. , I _ I N ro � m n UI 1'ti 't s t0 x n?�Zx ..S` y O CI) Zmm l's S' IpF r --7 \ 9.8.0 + 939.1 Oo0N 3.r % s o p r- -] N w 00 ZD�-4 ' 4im C I'2I C-=� 0Dr 4rt `' -4-13 -_u Co r: r_ i 9.8.2 ` :938.9 mo 4 ,,...f.s __ { - _- _=_ 4 STILLWATER BLVD AO I. 932 4 1 �1 ' °919.1 + I 938:7 2 � 5, "1I�. s•.'_ ' 33.6e±..o��:.� O X� eT4'_ !k,c7. ° T T \�i -- - '_ + T IT - 1T e T v — T - _ �X-= I - -- z _ —.9.8.5 938:5 — _ - = 918.1 + 938:2 O - I i --- - - - ---- r- _ --__ --,_ 918.1 938.1 -� s. STATE HIGHW - - -_ lit y_ 1 r:tA7 cr ✓ I m n T N 0 N J X vJ Fl N O N (0jINNN0 -0 o T I : x oZ m- 0 1 . 1 C") -' p_ Z Z 5 I N<W� C) N 0 Re N N _ -P ED °3 a'o Z � oZWI O x X-J --1 , Z O = , V CD i• ''l- R` I HEREBY CERTIFY THAT THIS PLAN, SPECIFICATION, OR REPORT SURVEY t )TA Bonestroo WAS PREPARED BY ME OR UNDER MY DIRECT SUPERVISION +� AND THAT i AM A DULY REGISTERED PROFESSIONAL ENGINEER DRAWN U-'T ,IT• Rosene UNDER THE LAWS OF THE STATE OF MINNESOTA. "- "'ttt''0177 Anderlik s c7","4- DESIGNED KLW vRA. Y APPROVED • ,�•�•. Associates � I � m> DATE 'k•Q 8 REG. NO. i,47/ DATE t' L � Engineers & Architects p BONES-MOO, ROSENE, ANDERUK&ASSOCIATES, INC. 1998 COMM. 55-98-802 559 8aQ2C07.dwq '.11:- 4-9a.;}iM��4. • * 't ' • • s • • • iii yew 1 City of Oak Park Heights 14168 North 57th Street Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 1 facsimile t��nsntransmittal To: Brian Fax: 464-7596 • • • • • From: Roshelle Noeker Date: • 01/07/99 • Re: Insurance Claim Pa es: 3 g CC: ❑ Urgent X For Review 0 Please Comment ❑ Please Reply ❑ Please Recyd Notes: Brian- We are forwarding you a copy of a letter we received for a claim and a copy of the invoice. Please let us know what you decided on it. c r • CITY OF COPY OAK PARK HEIGHTS 14168 N. 57th Street•Box 2007 Oak Park Heights,MN 55082 •Phone: (612) 439-4439 • FAX 439-0574 January 6, 1999 Karen Schultz 13101 Henna Avenue North White Bear Lake, Minnesota 55110 Dear Ms. Schultz: This letter is to serve as acknowledgement of the receipt of your letter regarding a flat tire you received while driving on 58`x' Street on December 4, 1998. Your letter and receipt will be forwarded to the City's insurance company, who will respond to your request. If you have any questions, please do not hesitate to give me a call. 4/IrieUlyryjUTS, a s�o Administrative Assistant Tree City U.S.A. December 15, 1998 —� @ 0\\.7 JAN - 6 CITY OF OAK PARK HEIGHTS 14168 - 57TH STREET N P.O. BOX 2007 OAK PARK HEIGHTS, MN 55082 I was proceeding west on 58th Street crossing 5, where my right front tire hit a hole o the north side the street,th st , adjacent to Stillwater Motors. �� b-�,�-v� �� �3,4``c\c-)Q sl. sovm. The hole was quite deep and blew my tire and affected the alignment of my vehicle. Enclosed are the cost for a tire and alignment. Th k-you 13101 Henna Ave N White Bear Lake, Mn 55110 (651) 426-1684 CASH OR AUTHORIZED CREDIT CARD PURCHASE ONLY 'Is TIME IN PROMISED RESERVE DAIL AM EJAM NMI Like No Other Tire Store DPM 0 PM , ■ INVOICE DATE CUST.NO. ORDER NO. PAGE TIME ORDER TAKEN SOLD DENIS ; ci..Jrz '30 .19108 1 426 PM I TO PHONE MILEAGE YR MAKE MODEL DESCRIPTION 426168-+ SLE LEGACY STORE WhilE BEAR LHKE TIRES PLU 4612 CENTERVILLE RD SHIP TO WHI1E .8EA14: LAKE, 11N 5:5127 (612)653-8711 PURCHASE ORDER NO SALES CONSULTANT MAIN PHONE LICENSE NO INVOICE NO. RYAN PRINSEN Quote ITEM NO. DESCRIPTION QUANTITY F E T. PRICE NET EXTENSION P20714185702 P185/7 0R14 DUNLOP SP40 ALS LW • ' ‘,•< "=4*,. h‘t4.57^1e:, 0.4V, 1 W .11 fIRE RECYCLING rEE . P110409 ShOP SUPPLIES/ IIHE MO OM L.B.LEIC.0 INVOICE SUMMARY Sitk 4 * * uuorE ONLY * Receipt issued at time of payment IFWORK COMPLETED BY DATE t"S s Inv Total : 147..49 WARRANTY YES NO I hereby authorize the above repair work to be done along with the necessary materials. • ••11,•• ilk..• " wL •• •• I- • ••"GPO • :.•••• :a You and your employees may operate above unit for purposes of testing,inspection or TIRE MANUFACTURER MATERIALS&WORKMANSHIP delivery at my risk.An express mechanics'lien is acknowledged on above unit to secure TIRE LIMITED MILEAGE WARRANTY FOR mug the amount of repairs thereto. It is understood that this company assumes no USED TIRE WARRANTY 30 DAYS responsibililty for loss or damage by theft or fire to unit or contents placed with them for PRO liATIED BATTERY WARRANTY FOR MONTHS storage, sate, repair or while testing. Not responsible for loss or damage to cars or ODOXU01140 COMMERCIAL VENOM% CAR REPAIR LIMITED SERVICE WARRANTY articles left in cars in case of fire,theft,or any other cause beyond our control. TPP(TIRE PROTECTION PLAN) I, THE GUEST HAVE BEEN OFFERED THE TIRE DATE PROTECTION PLAN,UNDERSTANDING THE DETAILS, OK'D BY AND HAVE ELECTED NOT TO ACCEPT THE ABOVE WORK AUTHORIZED BY DATE EXPLAINED WARRANTY. INITIALS GUEST COPY -- - December 15, 1998 w =� ' -,/ n JAN - 6 CITY OF OAK PARK HEIGHTS 14168 - 57TH STREET N P.O. BOX 2007 OAK PARK HEIGHTS,MN 55082 I was proceeding west on 58th Street crossing 5, where my right front tire hit a hole oihe north side of the street, adjacent to Stillwater Motors. a-rici� p The hole was quite deep and blew my tire and affected the alignment of my vehicle. Enclosed are the cost for a tire and alignment. Irk-you ar� 13101 Henna Ave N White Bear Lake, Mn 55110 (651) 426-1684 - -- - CASH OR AUTHORIZED CREDIT CARD PURCHASE ONLY TIME IN PFiOMISLD RESERVE l)A I I. 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P41,'AFIr'l f 0IF'F'''' '1,.'," -*,‘,%.**. -f--\':„!.4,.4-'s,-4.„ ,'N'•,.,,',.„,t'..,,, V.', ,,,',.,Ay,'-kB,,s,(‘,.,,, ,4„ ,.,,,, s, s*.s , ...: . , 0"*".- '''''OFF" '"*"..''(,:14,•ou-kt-is-i:vo-..,,,:'kt ,:-:,:,,,94:;‘,,...miict,5',,,,v,:''',5*,.,,:..- !‘„ii:;,‘, ,,;41„...,,,,,, ,,,: ,‘.,,,(44.,„,,,,„ .,:,„,. , ,,r,<4;*:,,,,,,,,,,i.,.:,t,§,---,,,,:.,• ,.-:zy::-. . . , INVOICE,.. , LiiiviAFi,,,,,. , : ,.t ii,,,,,4,,04::: t'-‘stcle's 1.1 .,..-. . . -•,,,,'.,.Ito',:.4.i i' .- :.4j04f4. ',-.=!,1 .,- t ' ' '4'1';" :.:‘.;„',.;.?;,',,,.;,, %,...'.,Al'1''' .KT9 '" 1'' ''('t'',7 , ,'I i• ' z,1,1 i k :, '',,,I' 4-1%-:".. 't t 04;:4,r"''':.":. 4',''',""i'l.' ';:::'--": ''''.i.,'(•;',IVS,.'":` 1,4 F'-;' S'ilf, '"'It,".;' 1 F`it, 's;k 1'"--: WORK COMPLETED BY „.. , . : ;:iii ,4,...,''. !4'1,,,Iti,,,,,1,1:',,,,,'„.: ' 1,":,.:k"1. WARRANTY YES NO I hereby authorize the above repair work to be done along with the necessary materials. ALUMINUM/ALLOY WHEELS LUG NUT RETORQUING POLICY EXPLAINED =11111 You and your employees may operate above unit for purposes of testing,inspection or TIRE MANUFACTURER MATERIALS&WORKMANSHIP IMIIIIIII delivery at my risk.An express mechanics'lien is acknowledged on above unit to s ecure TIRE LIMITED MILEAGE WARRANTY FOR MILES ME= the amount of repairs thereto. It is understood that this company assumes no USED TIRE WARRANTY 30 DAYS 111111=1 responsibility for loss or damage by theft or fire to unit or contents placed with them for cars Or BATTERY WARRANTY FOR MONTHS EXCLUDING CC1M111V,IVAL VEHICLES storage, sale, repair or while testing. Not responsible for loss or damage to c CAR REPAIR LIMITED SERVICE WARRANTY Eimmi articles left in cars in case of fire,theft,or any other cause beyond our control. TPP(TIRE PROTECTION PLAN) MEM I, THE GUEST HAVE BEEN OFFERED THE TIRE DATE x [-4,--1 PROTECTION PLAN,UNDERSTANDING THE DETAILS, OK'D BY AND HAVE ELECTED NOT TO ACCEPT THE ABOVE WORK AUTHORIZED BY DATE EXPLAINED WARRANTY. INITIALS GUEST COPY , _ _ _ _ . , • I CASH OR AUTHORIZED CREDIT CARD PURCHASE ONLY ' . 1 TIME IN PROMISED RESERVE DATE — ---- --11) DAM DAM Like 0 PM 0 PM •, \ I\ \ - ‘\ Like No Other Tire Store - .,. • )J. ........ INVOICE DATE GUST.NO, ORDER NO. PAGE TIME ORDER TAKEN SOLD DEN]:.3 SC(:)TZ 1.2/21'198 3( 1.91E18 1 4 26 PM PHONE MILEAGE YR MAKE MODEL DESCRIPTION 1 ' 4E61.684 93 Si.re3 101::6ACY ' STORE WHITE BEAR,EAKE TIRES PLU 4612 CENTERVILLE RD SHIP TO WHITE BEAR LAKE, MN 55127 (612)653-87:11 1 ' PURCHASE ORDER NO. SALES CONSULTANT MAIN PHONE LICENSE NO. INVOICE NO. RYAN FiRD,SEN k ITEM NO. DESCRIPTION QUANTITY F.E.T. 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INVOICE SUMMARY "":"'"''' :i.k1,1,10,kalie:::::: ::.' ."V::::Mi::;,:;;;;i; ' ., ., ..';%..;',,,,•Kte,:::::AIngai ' . :''',''','',',''';i:.f,4400411'00:':F:::':;:'''' * * OUOTE ONt.Y •.•, -x. . SugaTI51047111: ' :,,,..1:•,'''III-;1111.VAttlit , :II-A.,:,•.',A5,iitinilggi , •::.•,..'''..''.,VViaii*::61111:1FIR:::::;z:::;: 'it'•;:-.'Ill'ItV•glig „, '..',..A.IIII0;,ii.k.Velifk,"::::;:IIIIMP 1..„."*.'''.'7";,,,Ail:,0:,i'fi:::".t.'•,: ,.„ --,•,:;,'-ozgi,t';'01::::::?::•:::,,.. ...'::;!:517io...,.:•.:.,.. Receipt i.1,:.sued at time of payment . ,,,,;;;.,,,,,A.0,A-4,.%,t..(.k.,,,,-.. ,. ..-..:•,,,,,—,s.,.11:,:ov: ••..ril,''',tim.::::;i:iiiiii:':.:',.,:::.! *,''''.Ar..'gttiiN:.".:41:11:::=::::::::,.':::::::::::::::::.::::§,,!''' ,.., ''%*,,,-.1‘%Wre.% , ...:.k',. .. .."0.•k;.1.4t, ....lkso " ' '.',11',..",,i',1,4:01:1:11:01: .."."k'.''..,,t ,AINOREB:::::::."1:.;...,."; 1,1""+"ily,t'X';t11:4''',l'i",'9 "'''.''.''':,::'6'.,,,I,%.'4,::',...r,,,,,,,,...:.:::N , ,, •,:,•,0 A.,..tv:ooze§ .'..•••.•,:,:,s fr:0",..*4 rtam:(.,11111:::r:r:rrurrrrr-r.. ""' '""''''4' ''''''-co,, It', - •''''•''4,,,!,!,41t,,tig.t.:::: ,,,,,,,,,At, so:::or::::::::: .,•-....,:F.4,,,,,.1,,,,,Nme3:::::::::::,,,,,,,.:,. WORK COMPLETED BY DATE --ft 4.';',4z,;:-,54Vk*,444,:;w:•: ",,,::,:':.•Z,t'•:.‘,.!,:t'ii6,...q eUio: ' ,:. 1,:,,,'4.*A.;:troi::::::fe,::::::: ' ''', ,t i:,'',',Altaitimm-Aeig" k '1.,i9 ''i.1.',..,4,4'0.#'''''''.',',0%;: '''.,''''':':.,•i'14',".A'itt,,,,,,NINI ' ' A .A.:':::''''''''"""" ' " - I . •.','''''.',',..0.'.':,...1......,44::; '1,1,* ' ..::.:",..,,,r...,-tkm,.,.-::::•q:..,:d 1 v"v,:::. , •,, ..,,,,,,,,,,,,,,,,,,Avki4. .. - . -,,,,-;i1J,44.1A,::,..,:,*1 --, ••••,:',.-!:',,,i.vvoAtity:ities: ' ,z:,,,.,..,,k.*:p4..,:it ..,..,, ,,,•.::„:„.,,,,., ....::...;,,,,,41,z, •• . •-,. ... ' '''''''':!'*i..'Sn't*ktt50 LiFJP',.',:.'":....,,a'.''''',',,',',k•.,,,:,.410,11 .1.»V 1 t.)t al :: 1 if/.47) -''"'".-.4.''',..%LretliCiVill ---,•:4,!,'.V,4:Atvottiot • WARRANTY YES NO I hereby authorize the above repair work to be done along with the necessary materials. ALUMINUM/ALLOY WHEELS LUG NUT RETORQUING POLICY EXPLAINED 1.111.1.1 You and your employees may operate above unit for purposes of testing,inspection or TIRE MANUFACTURER MATERIALS&WORKMANSHIP INIIIIII• delivery at my risk.An express mechanics'lien is acknowledged on above unit to secure TIRE LIMITED MILEAGE WARRANTY FOR MILES MINIM the amount of repairs thereto. It is understood that this company assumes no USED TIRE WARRANTY 30 DAYS =MI. responsibililty for loss or damage by theft or fire to unit or contents placed with them for , PRO RATED BATTERY WARRANTY FOR MONTHS ExCLUDING COMMERCIAL VEHICLE- IIIIIII. storage, sale, repair or while testing. Not responsible for loss or damage to cars or CAR REPAIR LIMITED SERVICE WARRANTY NM= articles left in cars in case of fire,theft,or any other cause beyond our control. TPP(TIRE PROTECTION PLAN) •r- =WM I, THE GUEST HAVE BEEN OFFERED THE TIRE DATE X PROTECTION PLAN,UNDERSTANDING THE DETAILS, OK'D BY m AND HAVE ELECTED NOT TO ACCEPT THE ABOVE WORK AUTHORIZED BY ' DATE l EXPLAINED WARRANTY. INITIALS ORIGINAL OFFICE .. I t I,MC 145 University Avenue West, St. Paul, MN 55103-2044 Phone: (651) 281-1200 • (800) 925-1122 TDD (651) 281-1290 eague of Minnesota Cities LMC Fax: (651) 281-1299 • LMCIT Fax: (651) 281-1298 Cities promoting excellence J Web Site: littp://www.lmnc.org September 28, 2000 Julie Sorrem, Risk Manager L 0 ( P✓ CI 00'it•\ - Vc(1 7 Washington County Department of Human Resources P. O. Box 6 Stillwater, MN 55082 LMCIT#: 11032349 TRUST MEMBER: CITY OF STILLWATER CLAIMANT: WILLARD & SANDRA COLE D/OCCURRENCE: 8-8-97 Dear Ms. Sorrem: This letter follows up our telephone conversation of September 28. The League of Minnesota Cities Insurance Trust (LMCIT) provides coverage to our trust member, the city of Stillwater. As I indicated, this claim involves a sewer back up to the Coler residence. Our first notice of a claim came from MetLife with their subrogatoin papers requesting reimbursement of$4,277.98 in damages. When I learned of what the Stillwater public works employees found, I contacted the city of Oak Park Heights [of whom we also insure] to determine what they knew about this claim. That's when their sewer operator, Jay Johnson, learned there may have been a Washington County project on Osgood at that time and he called you. Oak Park Heights sewer does run under Osgood. As you can see, Ms. Eidem with MetLife has provided very littieRinformation. Attached is a copy of their letter with documentation of their claim for damages. I've also enclosed my response of September 28, 2000. As of this writing, there has not been a claim against the city of Oak Park Heights, however, I will need to know if there was a county project which resulted in construction debris to get into the Oak Park Heights's sanitary sewer main. I look forward to hearing from you once you have had a chance to look into this. My direct phone line is 651-215-4077. Sincerely, Darlene Boese Senior Claims Adjuster AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER I I `J 1 I OCT - 32..:; _ !L cc: Jay Johnson i City of Oak Park Heights P. O. Box 2007 14168 Oak Park Boulevard Oak Park Heights, MN 55082-2007 Darin Richardson LMCIT Blind note to Jay: Please contact me in the event you receive a claim from MetLife or anyone else relating to this occurrence. Thanks. { . da.4.4- 7-44,(44_549, . ii/301q ' 11 : r / e'YL. CL 0 J � � - let c2 a, _ - -,. i . 1. - , e- CX- r , (-4---Ite td- e'r- e12-. ,..,1&//tei-ee/pot-, ffrl/yl/�}- /q /O 4 It"? C r i ; eti ..e�La�.4� , 1 , , /f. //coy ✓ , i „_,..., „,.,'1,, - . dL,-, -- , c„ } s: CITY ' 40 E ,,. OAK PARK HEIGHTS - -" ` 14168 N. 57th Street •Box 2007 Oak Park Heights,MN 55082 • Phone: (612) 439-4439• FAX 439-0574 - s. May 30, 1997 Kelly Robotnik Claims Technician League of Minnesota Cities Insurance Trust 145 University Ave. West St. Paul, MN 55103-2044 Dear Ms. Robotnik: I am enclosing a check in the amount of$335.91 as reimbursement for claim 11018353 - for accident damages to Police unit 6 `94 Chevrolet Caprice VIN: 1491. Gary Richard Stevens reimbursed the City of Oak Park Heights Police Department the total damage amount of$835.91: Please contact me if you should have any questions or comments. Very truly yours, 42'e /gcce1/74 Judy L. Hoist Deputy Clerk/Finance Director 612-439-4439 jh Tree City U.S.A. 0 0 ; ... . -.- -- • . ..... . . . . . . . • -- - . --- - --- -- • - -,:,,- GARY R. STEVENS, SR. 17'2212 PATRICIA J. STEVENS glo 8233 1262467 S-315-271-738-924 S-315-676-385-415 7980 -71ST STREET SOUTH PH. 612-459-7684 19/7 . COTTAGE GROVE, MN 55016 , _ • OPARYDTEOR on iF E C 1%7 r-...il 00.4 potA yeirlies ;1. 7 II- is a 5- , a i C.-4. eili7,444‘41 ri-4 7 01- el a-4- ' DOLLARS .First Bank Midway q 10 2FsizzltritLo,Atzr.i.fion it __... .__ MEMO 41■Aiamml, .•. .- .. .- . • . .. ... . -.----. .i;',..:,i:::.:.:- •:-;'::::'":':7:"."''- ''''.7•::'"'''''"*''.::•"":''''''': :: 1:09 L0000 221: L 26246. 7134'64011•13 3 o l' :::::::::::::::: :::::::!::::::::::::•:::::::iirii:iii::::*::::::::::4:::::::::„.::::::.::.*::::* :::::: ::::::is::::::::::::::::::::::::::::::::::::*:*:::::::::ii:::i:::i.:::,::::::::::::::::::?;::::;,:::::: :::::.,:::::: :.,.,.:::::::::.*:::::::::::::::::::;::::::::::::::::::::i:::::::::::::::::::::::::: ::::. ,.:- --..:::::...::,::.:::::::::0:::::::::::::.::::::::::::::::i;::::::::::::::::: ::: :::::: : -..iW::: :: :::.:4:::::::::::::::::::•:::::::-::::::::::.::::::::::::::::: :.,:: ::::::::::,;,::::-iy:::::,:, :ii ::::::i:,.:. :-:.::.=::::.:•:.: ii,.::;:.,7:::::,:::. :::::7,:i ::::: ::,,.::::::::.::::::.::.:: -: ... • • N...../ . .. \ R_____\,..7 LW145 University Avenue West, St. Paul, MN 55103-2044 League of Minnesota Cities Phone: (612) 281-1200 • (800) 925-1122 Cities promoting excellence Fax: (612) 281-1299 • TDD (612) 281-1290 May 05, 1997 Q our- ii....../1 Mr. Gary Richard Stevens MAY - 6 1997 1020 Western Ave. No. J St. Paul, MN 55117 RE: BRS Claim#: 11018353 Trust Member: City of Oak Park Heights Responsible Party: Gary Richard Stevens Date of Loss: 04-19-97 Description: Police Unit 6 `94 Chevrolet Caprice VIN: 1491 Dear Mr. Stevens: I represent the the city of Oak Park Heights and the League of Minnesota Cities Insurance Trust(LMCIT)whom the city is insured under and am investigating a claim which has been forwarded to my attention for handling. This incident arose out of damages to the city's squad when the officer had pulled your vehicle over and as he approached your vehicle, your vehicle backed into the front end causing damages in the amount of$835.91. The Oak Park Heights Police Department and the League are seeking recovery of these monies from you or your insurance carrier. I note on the police report filed, you are insured with Illinois Farmers. Please forward this onto your insurance carrier or in the alternative if you do not carry liability automobile insurance, please contact me within 20 days to coordinate payment for these damages sustained to the police squad car. I am enclosing documentation to support our insured's damages in the total amount of$835.91. Checks are to be made payable to the League of Minnesota Cities Insurance Trust and forwarded to my attention at the League of Minnesota Cities Insurance Trust, 145 University Ave. West, St. Paul, MN 55103-2044. Please reference our claim number 11018353. Should you have any questions or comments, please feel free to contact me. My office hours are 7:30 A.M. to 4:00 P.M. Monday thru Friday. Thank you. Sincerely, BERKLEY RISK SERVICES, INC. Kelly Robotnik Claims Technician Direct: 612-281-1288 Claims Dept. Fax: 612-281-1297 1-800-925-1122 KAR:st AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER ifed a • Page Two 11018353 Mr. Gary Richard Stevens 05-05-97 Attn: Police Chief Lindy Swanson City of Oak Park Heights POB 2007 Stillwater, MN 55082-2007 Attn: Mike Robertson City of Oak Park Heights Box 2007 Stillwater, MN 55082-2007 Landmark Insurance Services POB 188 Forest Lake, MN 55025 • . . . . .., . . . . .... . . -.. . , . ,- . , . . . ... 2 < ul -J 03 ct I- 0 (., tu 1— : ..: . ........ -JO co Z ' - ' 2 .9 ' It'g)'`° 11'._J§ ° , ., ..,.... .. 0., ''-'"-,•'..-4.f.--7::':::::. '''',,:•-4--;,:iik.,i'.„:1- . . ..,....,-J.':.iiii:1:-;.,,,,,'''ii,;4;,i'-':',-;;',,,;:';iiiI=i1.1,-i''-iT.''';:',' '''' ',-,', - g',-:'„,', ''''-'- ' ' . -',. 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CHRISTIANS STII.LTEMER MTOR COMPANY FAX 412 439 4425 5900 8TILLWATVR ALVD NO P0337 STILLWATER, 101 55082- (612) 439-4333 Parts 334.75 Body Labor 6.3 units • $34.00 214.20 Paint Labor 5.1 units • $34.00 173.40 Paint/Materials 5.1 units B $18.00 91.80 SUBTOTAL $ 814.15 Tax on $ 334.75 at 6.5000% 21.76 GRANO TOTAL $ 835.91 INSURANCE PAYS $ 835.91 gti+a.t• ma..d m w104 Ci111pg IRmrl:la wan. Ass-aatsciutPI Shama art a.rlved!maths a.La■ . Database Dabs 0/D Doable e.taciaki..1 Lu.sa L.Lia.ta part au pli d!p a aetpiier other than the original ngligentt oraY[aatorwr• k itaa hers baud eamtlllad for It eta fist.*by tie Cart/flat tut.Darts Maeelatjan. Met •A paadaat ea OTC r.ra.eattm aarrisea ma. RECEIVED APB 2 5 ;B37 Pages 2 Monday,April 28, 199712:05:- I Landmark InsKan a/DS) Page 3 of 4 411 • 04/25/97 13:03 CITY OF OAK PARK HEIGHTS 4 612 464 7596 1&.175 D03 WAGE "REPORT OAK PARK 3I8IOHT8 04/22/97 at 12135 D.R. 35238-0000520 41 056 1600 Net: C. CHRISTIANS STILLWATBR MOTOR CQMPAHY FAX: 612 439 4425 5900 STILLWATER BLVD NO P0337 STILLWATER, MN 55082- (612) 439-4333 Owner: POLICE OAK PARK HEIGHTS Day Phone: ( ) 439-4723- Address: Other Ph: ( ) - - DeBuctible: $ N/A Insurance Co. : Phone: Claim No. : j. : 94 CHEV CAPRICE 4DR Vin: 101BL52P5P5RR1491 License: Prod Date: 0/ 0 Odometer: 104000 Clear coat paint • PART NO. OP. DESCRIPTION OF fl31(&O3 QTY COST LABOR PAINT MISC 1* Repl LT FENDER 1 24B_00 3* Repi LT MARKER 1 55.00, 0.0 0.0 3* Repi LT W-O-MLDG 1 33..75 0.3 0.0 4* Rstin SPOT FRWI BUMPER 1 0.00 0.0 2.0 5* Repr LT CORE SUPPORT 1 0.00 1.5, 0.0 Subtotals —. 334.75 6.3 5.1 0.00 RECENED APR 2 5 1' 37 Dap. 1 • • I4 MC 145 University Avenue West, St. Paul, MN 55103-2044 League of Minnesota Cities Phone: (612) 281-1200 • (800) 925-1122 Cities promoting excellence Fax: (612) 281-1299 • TDD (612) 281-1290 J May 01, 1997 - 51997 )` Attn: Mike Robertson 1 City of Oak Park Heights 14168 North 57th St. Box 2007 Stillwater, MN 55082 RE: BRS Claim#: 11018353 Trust Member: City of Oak Park Heights Responsible Party: Gary Richard Stevens Date of Loss: 04-19-97 Description: Squad struck by Stevens vehicle Dear Mr. Robertson: I represent the city of Oak Park Heights and the League of Minnesota Cities Insurance Trust (LMCIT) on a Collision claim which has been turned in and assigned to me for handling. This incident arose out of damages to the above-referenced city's vehicle as the officer pulled over Mr. Stevens and as the officer was approaching the Stevens' vehicle, the Stevens' vehicle proceeded into the rear of the squad. I am in receipt of the estimate from Stillwater Motors in the amount of$835.91'for repairs to the squad due to this incident. The city of Oak Park Heights has coverage under the League of Minnesota Cities Insurance Trust under Covenant CMC 16674 with a term of 07-07-96/97. Your city carries a $500 per occurrence deductible which applies to this incident. I am attaching payment in the amount of$335.91. I have applied your city's $500 per occurrence deductible to this claim. Please feel free to contact me at (612)281-1288, should you have any questions or comments. I am available from 7:30 A.M. to 4:00 P.M. and have voice-mail available. Should the city receive any supplemental repair costs while the vehicle is undergoing any repairs and it is attributed to this incident, please forward to me a copy of the revised supplemental repairs. Thank you. AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER • • Attn: Mike Robertson Page Two 11018353 May 01, 1997 Sincerely, BERKLEY RISK SERVICES, INC. PA-14-41-t-t Kelly Robotnik Claims Technician 612-281-1288 FAX: 612-281-1297 1-800-925-1122 KR:st Landmark Insurance Services POB 188 Forest Lake, MN 55025 DAMAGE REPORT S • OAK PARK HEIGHTS 04/22/97 at 12 :35 D.R. 35238-0000520 41 056 1600 Est: C. CHRISTIANS STILLWATER MOTOR COMPANY FAX: 612 439 4425 5900 STILLWATER BLVD NO P0337 STILLWATER, MN 55082- (612) 439-4333 Parts 334 . 75 Body Labor 6 .3 units @ $34 . 00 214 .20 Paint Labor 5 .1 units @ $34 . 00 173 .40 Paint/Materials 5 .1 units @ $18 . 00 91.80 SUBTOTAL $ 814 .15 Tax on $ 334 .75 at 6 . 5000% 21.76 GRAND TOTAL $ 835 . 91 INSURANCE PAYS $ 835.91 Estimate based on MOTOR CRASH ESTIMATING GUIDE. Non-asterisk(*) items are derived from the Guide . Database Date 0/0 Double asterisk(**) items indicate part supplied by a supplier other than the original equipment manufacturer. CAPA items have been certified for fit and finish by the Certified Auto Parts Association. EZEst - A product of CCC Information Services Inc. Page: 2 DAMAGE REPORT OAK PARK HEIGHTS 04/22/97 at 12 :35 D.R. 35238-0000520 41 056 1600 Est : C. CHRISTIANS STILLWATER MOTOR COMPANY FAX: 612 439 4425 5900 STILLWATER BLVD NO PO337 STILLWATER, MN 55082- (612) 439-4333 Owner: POLICE OAK PARK HEIGHTS Day Phone: ( ) 439-4723- Address : Other Ph: ( ) - - Deductible: $ N/A Insurance Co. : Phone: Claim No. : Adj . : 94 CHEV CAPRICE 4DR Vin: 1G1BL52P5P5RR1491 License: Prod Date: 0/ 0 Odometer: 104000 Clear coat paint PART NO. OP. DESCRIPTION OF DAMAGE QTY COST LABOR PAINT MISC 1* Repl LT FENDER 1 248 . 00 4 . 5 3 . 1 2* Repl LT MARKER 1 55 . 00 0 . 0 0 . 0 3* Repl LT W-O-MLDG 1 31.75 0 .3 0 . 0 4* Ref in SPOT FRONT BUMPER 1 0 . 00 0 . 0 2 . 0 5* Repr LT CORE SUPPORT 1 0 . 00 1.5 0 . 0 Subtotals ===> 334 . 75 6 .3 5 . 1 0 . 00 Page: 1 CITY AI OAK PARK HEIGHTS 14168 N. 57th Street •Box 2007 • Oak Park Heights,MN 55082 •Phone: (612) 439-4439 •FAX 439-0574 Fax Transmittal To: ) c n /NA A Fax #: From: //o f s Date: Subject: Car 14: c Total Number of Pages, including cover sheet: J.• •♦♦••♦•••♦•••.•••♦:••♦•i••♦••♦♦i• • • • •♦•.••♦••► • •♦♦••♦♦4,•♦♦••♦♦ice♦♦••♦••• •(c)./iJ 2 0 _ / Tree City U.S.A. • • AGENDA CITY OF OAK PARK HEIGHTS PARKS COMMISSION Tuesday,April 15, 1997 -6:30 p.m. Oak Park Heights City Hall and Annex Park Area Note: Meet at 6:30 pm at 58th St. and Norell Ave. (behind Wal-Mart) to walk Annex Park followed by meeting at City Hall. Visitors: Comments, Questions, Concerns Council Representative Update: 1. Rainbow Park Dedication Fees - $45,990 2. Beaver Dam Report 3. Valley View Park Restoration Committee 4. Park Walk-Through Reminder: Saturday, May 3, 1997 - 8:30 a.m./Valley View Park Individual Park Walk-through Reports Garden Committee Report Financial Report-Enclosure Approve Minutes: March 11, 1997 -Enclosure Unfinished Business: 1. Review Annex Park Plan- Enclosures 2. Presentation on Purple Loosestrife Management-video New Business: Next Meeting Reminder • MESSAGE CONF I RMAT I ON 04/25/97 13:04 SESSION NO. = 175 ID=CITY OF OAK PARK HEIGHTS DATE TIME 5,R-TIME DISTANT STATION ID MODE PAGES RESULT 04/25 13:02 01'49" 612 464 7596 G3 -S 04 OK 0000 PS-32003-06(1-91) ST.L7E OF MINNESOTA - DEPARTMENT OF PUBLIC SAFETY LOCAL CASE NO. TRAFFIC ACCIDENT REPORT/1k L..„,, ,25/30 `975/0,5-0,:;1. OR POLICE USE ONLY AS REQUIRED BY ST E) PAGE 1 OF I gl HIT-AND-RUN PUB PROP VEHICLES R,LLED .•LURED S MIN MONTH DATE YEAR DAY TIME C fin{ATTENDED /L� y {i a7 7 ].2 AI LJ UNATTENDED '" v / Q 7 1? // IS� �CZ I`\P�'I R7 ROUTE SYSTEM ROUTE NUMBER CR STREEET.NA'.'T ON L S 6 Q ---C .! /1 N 0 INTERSECTION. I OR �G) _ O S Ef CF <i �- _ NIf*H WWW LLJJ �WY COUNTY NO NT ELEM REFERENCE=DINT ROUTE SYS ROUTE STREET.CORP LMIT REF FC NT CR FEATURE crtv TWP �T:1 T.✓ + L';1 / /'.G� 7.) Au. UNIT 2 ®VEH E ❑PEDESTRUAN 0 BICYCLE FACTOR I DRIVER DENSE NUMBER-1 STATE CLASS DRIVER LICENSE NUMBER-2 Tell STATE CLASS FACT:.- /V A/O,) '''' FACTOR 2 NAME(EAST.MIDDLE.LAST) RSTECTNS WTHORWN NAME FIRST.MIDDLE,LAST) SSTRCTNS WTHDP..4°ACTC= CCMPLIEC COMPLIED /(v 4 144 /`44y 4-j, /d ? — N MNUVER ADDRESS DATE OF BATH ADDRESS CATE OF BIRTH ^UVE= 90 //y3 i'0'e 4✓ '/ O 71,2? I4t I I ..; PHYSCL CITY.STATE.ZIP CITY.STATE.ZP .HYS•__ 3 N ,afo o R f , /L1-). 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A) W i t��'s:- -�,,q� J a-4, 1/�41- O .. t .11121 w,4s t J*.q.: !'do 441,�V,0 I/.�-&,J i„ji it... UNIT= ROWORK / �' A/f £7.4 �ar„a.� Aq` / A4-f,'✓.}/jj, P,A _,,- KTRE_ / — rn, .r � 710 ,w,K-4. iv/�-�' ..3 C.)T T,�,.� � �fdo OreaA. / ,J A71r �7`ev to .�..,1n o,-/�� WEAT-_ -/r,C.J 7L Q7 % a.;�i.r,.1 QN/C Rr C4 F,nJ/ / M/!� L,, ,/'J 1 �1 /'� J /� PHOTOS at QC G7 SE/{ W%r( R f G wl J�O A✓44-4-.7,47.0t—,(J, Ai/lam TAKEN. VV I 41,40-4,K. -17 /OUur Uc LUG ,,:r/� igev,dXCIG^'- LIGHT RDSURF / • ;,.r.f ola 0 f,0, k— VE. / 644-k<:427 ,:✓10 9 ROCHAR 1/J i/ L /� 1/' ..�yjjJ± .7WGP.NM V 4 4- a.• V4-h �".'C I�KPY60 ,41� ;IL' /I.M� -c (,�.-.1 414 CAX.„70/ A 4-74;o..) OAf<At/ill• A, .) %I OFFICER RANK.NAME.BADGE s.AND AGENCY .. ._ � - FA-ROL ❑LOCAL 'r A LT 1j/z,v �./ vo y "--ict, SHCRIFF ❑OTHER UNIT MOTOR CARRIER �"r HAZ HAZ MAT'L CLASSIC MAT-CLASS/ID •:T L CLASS 0 SOY TYF MAT PLAC ADDRESS MOTOR CARRIER ID hOC AXLES AXLES TRAILE= . SOURCE DOWN UP H.TCH CITY.STATE.ZIP ICR. I.NSPECTCR. L3:WR CITY OF OAK PARK HEIG Page of 3 • POLICE DEPARTMENT OFFENSE REPORT FOR ALL CRIMES,ATTEMPTS, INVESTIGATIONS AND INCIDENTS OPH CASE NO. 000 CASE NO. O.R.I.NO. COMPLAINT RECD HOW COMPLAINT RECD DATE TIME PHONE RADIO CITIZEN LETTER FOUND 97001141 041997 2045 OFFENSE OR INCIDENT SUBJECT LOCATION OF OCCURRENCE DWIIVRDLJMV Lisa May Wilber 07-29-81 W/B 60th at Oakgreen Accident Prop. Dmg. 1143 7th Av. #1,Newport 55055 INCIDENT/OCCURRENCE OFFICERS ASSIGNED DETECTIVES ASSIGNED REPORT MADE DATE TIME DATE TIME 041997 2045 Croft VICTIM(IF FIRM,NAME OF FIRM&NAME OF PROP.) BUSINESS ADDRESS BUSINESS PHONE HOME ADDRESS HOME PHONE IF VICTIM IS A PERSON - RACE SEX D.O.B. PERSON REPORTING OFFENSE TO POLICE BUSINESS ADDRESS BUSINESS PHONE HOME ADDRESS HOME PHONE moo., Immo ,. 7, ir,Z. ;; ....o.14, Synopsis Observed a vehicle,Minnesota license 383-GIK,pull out of Super America lot without its headlights on. The vehicle made a wide left hand turn from Omaha to west bound 60th Street. I also observed that the vehicle had no headlights on. I got behind the vehicle and observed the vehicle weaving back and forth between the center and fog lines going over both the center and fog lines on more than one occasion. I activated my emergency lights and stopped the vehicle west bound 60th Street at Oakgreen and as I was walking up to the vehicle it started backing up and backed into the marked squad. Female driver was arrested and transported to WC jail by myself. She was issued citations for careless driving, zero tolerance,no Minnesota driver's license. Passenger was issued a citation for allowing illegal operation of a motor vehicle. State patrol wrote the accident report and suspect's vehicle was towed to Frankies Towing. Basis for Stop On 04-19-97 at approximately 2045 hours, I was at Super America gas station. I observed a male and female party get into a GMC Jimmy,Minnesota license 383-GIK. I observed the male get into the passenger side and I observed the female get into the driver's side of the vehicle. I observed the vehicle pull out of Super America lot without its headlights on. It was 2045 hours at night and it was very dark out. I observed the vehicle pull onto Omaha Avenue and then make a very wide left turn from Omaha to west bound 60th Street. I observed that the headlights were still not on at this time. I got into my squad and began following the vehicle west bound 60th Street. I was approximately two cars behind it and observed that the vehicle was traveling over the center line and then back it would correct itself and go back over the fog line. It did this approximately three times between Omaha and Odell Avenue. At this time I activated my emergency lights and attempted to • pull the vehicle over. The vehicle came to a stop at 60th Street and Oakgreen Avenue. I pulled up behind the vehicle,got out of my vehicle and began walking up to the suspect vehicle. CITY OF OAK PARK HEIG Page a of 3 POLICE DEPARTMENT OFFENSE REPORT OPH CASE NO. UI= FOR ALL CRIMES,ATTEMPTS, INVESTIGATIONS AND INCIDENTS Initial Observations As I was approaching the vehicle, the vehicle began to back up. At that time I put my arms out in an attempt to stop the vehicle as I thought it was put into neutral by the driver. The vehicle kept backing up. I was unable to stop the vehicle with my arms. I got out of the way and the vehicle backed into the left front quarter panel of my squad, squad number 41. Again, it should be noted that all my emergency equipment was activated at the time. Once the vehicle came to a stop at the squad I ran up to the drivers side door, opened the door and immediately put the vehicle into park. At this time I noticed that the female driver was sitting on the passenger's lap half way on his lap and half way on the center counsel area. I asked her what she was doing and she stated she wasn't driving. I then explained to her that I observed her get into the vehicle and drive out of the Super America lot and advised her that I was stopping her because she did not have her headlights on. She stated to me again that she had not been driving the vehicle. At this time I noticed the male passenger was sitting in the front passenger seat with a cup of pop from McDonalds in his lap between his legs on the seat. He stated that he was not the driver either and it was clear to me that the female was in fact the driver and was trying to hop into the other seat so that I would not know who was driving. I asked the female driver to step out of the vehicle and walk back to my squad. As I was speaking with her,I noticed a distinct odor of an alcoholic beverage on her breath. I noticed her eyes were very bloodshot and glossy. I placed the driver in the rear of my squad and I called for Sgt. Hoppe to come to the scene of the stop location. Field Sobriety Tests The driver was asked to submit to a PBT test which she did and it showed a yellow light/warn showing that she had alcohol in her system. Identification of Driver The driver was identified by name and date of birth. She stated she did not have a driver's license. She identified herself as: Lisa May Wilber 07-29-81 1143 7th Av. #1 Newport, MN 55055 Mother: Mary Wilber 458-3940 The passenger was identified with a Minnesota driver's license as: Josh Edwin Monette 11-14-75 465 3rd Av. Newport,MN 55055 Officer Kisch administered a PBT to him and he showed a red light or fail. His drivers license status was revoked. I issued him citation SW196582 for allowing illegal operation of a motor vehicle. Vehicle Disposition The-vehicle, a 1989 GMC-Jimmy,Minnesota license 383-GIK,was towed by Frankies Towing. The vehicle was held for registered owner which was neither the passenger nor the driver. ITY OF OAK PARK HEIG Page 3 of`3 POLICE DEPARTMENT OFFENSE REPORT OPH CASE NO. . g7CO ll' FOR ALL CRIMES,ATTEMPTS,INVESTIGATIONS AND INCIDENTS Accident State Patrol SP 104 came and wrote an accident report. See his report for details. State Patrol case number 97405034. Implied Consent Advisory I transported Lisa May Wilber to the WC jail. I read her the Implied Consent Advisory at 2157 hours. Form was completed at 2159 hours and she advised that she would take a breath test. She understood her rights and she did not wish to consult with an attorney. Alcohol Testing The intoxilyzer was administered to the female party by myself at 2202 hours. The instrument was checked to be in good working condition. This is on intoxilyzer test record number 785120 which showed a BAC of.07. Test was started at 2202 hours and ended at 2209 hours. Citations Issued Wilber was issued citation number SW190695 for careless driving, SW190696 for absolute sobriety or driving vehicle with alcohol in her system being under 21 years of age and SW 190697 for no Minnesota drivers license. Citations were all explained to her and copies were given to her at the jail. Questioning At 2215 hours,I read Wilber her miranda rights per the Oak Park Heights Alcohol Influence report. She stated she understood these rights. She did not want to speak with a lawyer. She stated she was operating a motor vehicle. She stated she was taking some pills for bronchitis,however, they did not effect her ability to drive. She stated that she had been drinking. She started drinking around 3:00 and stopped at about 8:00 p.m. She had about 12 cans of Icehouse beer. Evidence The Implied Consent Advisory along with the miranda reading and questioning were all taped. The VHS video tape was placed into evidence at the Oak Heights Police Department. Disposition On 04-19-97 at approximately 2045 hours,I stopped a vehicle for no headlights. The driver was subsequently arrested for careless driving,no Minnesota drivers license and absolute sobriety. She was transported to the WC jail where she was read the Minnesota Implied Consent. She took a breath test showing her to be a .07 BAC. She was issued three citations and released to her father from the WC jail. Vehicle was towed to Frankies Towing. Accident report was filled out by State Patrol due to suspect backing into the Oak Park Heights squad,number 41. Passenger was issued a citation for allowing illegal operation of a motor vehicle. Passenger was released at the scene. Croft 477 O•PARK HEIGHTS POLICE DEPA ltENT INTOXILYZER OPERATOR' S CHECKLIST 7 J� Date : -f -.77 INTOXILYZER TEST RECORD MM# : < 3/`s/-?d OPERATORS " : VZds SUBJECT' S NDM.ME L%s•1 ` 1 k! �,/,'lb r- DOE : 7 2,9 ADDRESS : 1 /ti3 7 t4 Ave At f pe'!.ijoa.,1L /tlIV S s i �. DL # : /V/A STATE: /1/11 YES / NO WAS SUBJECT OBSERVED FOR 15 - 20 MINUTES? WAS SUBJECT' S MOUTH CHFCVED BEFORE AND AF ER TESTING? VV WERF ANY FOREIGN MATERIALS OBSERVED? a°'Yb) IF YES, EXPLAIN: SUBJECT PUT ANYTHING IN THEIR MOUTH DT RING TESTING? IF YES, EXPLAIN: I / WAS SUBJECT COOPERATIVE DURING TESTING? v IF NO, EXPLAIN: DID SUBJECT GIVE TWO GOOD BREATH SAMPLES? IF NO, EXPLAIN: nfi B�o.- ,� Aav- 02`‘ 72-451- DID SUBJECT BURP AT ANY TIME DURING TESTING? IF YES, DID 5 MINUTES ELAPSE BEFORE TESTING CONTINUED? DI D SUBJECT COMPLAIN OF UPSET STOMACH DURING TE STIrG? IF YES, EXPLAIN: DID SUBJECT .COMPLAIN OF ANY PHYSICAL OR MENTAL CdNDITION DURING TESTING? . • k/ IF YES , EXPLAIN: • V/ DOES SUBJECT WEAR FALSE TEETH? 'Acts ADDITIONAL INFORMATION: .543Je.c�` !Acts bi•-•c4ikS ARRESTING OFFICER( S) : jo.Cipt CC_ 44(77 INTOXILYZER OPERATOR: "t . Cei-1(77 • TEST A T 1r1� .y.: - }' 2 :I T- 0 : 3 -i- - , T:37 . :'3: 22: 03 05 AIR 2LANK 0 22: 0 06 CAL. STO. . 107 tee=: 0C AIR ELANK . 300 22: 07 '0'22.2707 i } 22: 37 AIR . 000 22: 09 1 : R2:7-2R7EO VALE . 37 22: 07 I C 785120 INTOXILYZER TEST RECORD Purpose of test jg.Traffic ❑Other Subject: L. I >' WIiAC1' • DOB -+�O /1 2 I p Sex: ❑Male...ER-Female Arresting J / A- ( r Officer: oSe� r4 Arresting 1.1454115 Dept. �a k 1 County -5 Arresting M N 0 / Dept.ORl D • C f Jo SP +� A rO7� Operator: f� t' �J D /� Dept. ( k !��f� T!rl���S (.f�. Sim ator Certificate 4 g ® Solution C0 7, 0 !1 Number 4 Number / Subject has been under observation for 15-20 minutes by v• Record simulator temperature(33.8°-34.2°C) •q .© °C REMARKS: - (A g I R q Rilwq 0— -‘,3 ac . i•- Rfryo✓(C( ) I J jSt fcsf 6c,G c‘ esl OPERATOR'S - • . SIGNATURE: 'i REFERENCE v NUMBER: ... ` FORM PS-50591-02 .. • PART 3 - OFFICERS COPY - so: IMIIED CONSENT ADIORY (Effective January 1 , 1993) `�4jFOFp , Time Started Ig1.57 Location read: �S JJ' /�`'�7`',, COMMERCIAL VEHICLE—BEGIN WITH BOXED AREA L;sQ /17 Wilier 7-2 , I believe you have been driving, (person arrested) operating or controlling a motor vehicle while under the influence of alcohol or a controlled sub- stance "and you have been placed under arrest for this offense," "or you have been involved in a motor ehicle accident resulting in property damage, personal injury, or death." 1. Minnesota law requires you to take a test to determine if you are under the influence (Check) of alcohol or a controlled substance. yes OR (READ ONLY IF PERSON WAS OPERATING A COMMERCIAL VEHICLE) , I believe you have been driving, (operator's name) operating, or controlling a commercial motor vehicle with the presence of alcohol. 1. Minnesota law requires you to take a test to determine the pres- (Check) ence of alcohol. 2. Refusal to take a test is a crime. 3. (READ ONLY IF PROBABLE CAUSE TO BELIEVE VIOLA- (Check) TION OF CRIMINAL VEHICULAR HOMICIDE AND INJURY LAWS) Because I also have probable cause to believe you have violated the criminal vehicular homicide or injury laws, a test will y be taken with or without your consent. 4. Before making your decision about testing, you have the right to g Y g� Y g consult with an attorney. If you wish to do so, a telephone will be made available to you. If you are unable to contact an attorney, you must make the decision on your own. You must make your decision within a reasonable period of time. 4 c Vf test is unreasonably delayed or if you refuse to make a decision, you will be considered to have r9f1 sed the test. Do you understand what I have just explained? re, Do you wish to consult with an attorney? No Ti/me telephone made available: Start: Stopped: twill you take the ,: -- (Blood or Urine) test? Ye (If person refuses:) What is your reason for refusing Time Completed 2/57 io5 t A_ C^°tf Y7 -/ (Printed(Printed name of officer requesting test) Date: • • c 'dd E O a d m C in N N y ai m m Q .c m o O o `m'� , ■ � G'\1. V - E o o �� 1J' R. 1c:m C V/ ° U m W o 3-° m �' m ¢W cc -° °o L ° a z Q¢° c Vm o m E. R rn 0 ± m F W a ° `m aai J il c o 0 3 f d O)- /'•E o E c m d m a WX `�° J Z `To- g 0 .. •° m c o ¢O a m m Z U O 7 d Z o m W N m m rn c O - 3 d 25 3 m o a O? o c m a m Cl) m a m `m m ° m Z¢ in a m m o a 3 3 m o rn c 0 rn 0O c v E c d _ o m ° y in a` 0 v� u-w y co 3 0 c a Z N •_> < . 2 O C m I= Tm C cm C: m m O p F • m V C'O 0 ° Q a'y m 8 0 Q O U) 2 0.� C 8. Z O d a r m m N¢ c a y O Q > F a0¢ > Z oCN rn c c g H C -rn 03 U) N m OW> mOC oo, ¢¢ E ma m p co B m Z Q 0 c°in co p¢pO O og o 0• U))ag a� a c m E • 1 v - U O o• U W ° a� N on. y M C L y Q OO W .c ° Cc m ` m:17 q iii j Ir.'s')• L Q �, m o TO mLr m J m 3 c 0 c m ° m m 0 a. � o y ,a m H a -,6:: t © '7� �o c g m. ° in c W o m r ❑ a C c j Q W (12.J. ,-s m ° c •U o m m V c _ fmh -m e -. m F :�t Z O7 ° 'o m V. m I m r CO CC • m 0 O _ 8 8. o 13 O c o v ° a YW. a O E .0 E N ( m o •E t� j E Z W -0- m m ?NO ai 'O U r.c. 7 a°� r O ii` r �, U v Z Q z m :° EE O r a m E.D. a) °V (CIO) cn N ° 8 U V m❑ c . i E 1 m y aAo _a W o o y . c ° O i m C Q-,D C ° ma pQ ►� g m V v, m m C • p r, m o o ; E C. c c g�� . .2 Li m m U �. J� m • o a E y o. a. . m ❑ c ) c 0 EOv E O. o 0 c m co V y o of m c 3 0 0'� o co ¢ U in W W r0 'C L m O m c - m o f� 1 V -1 cn m m m T > E v L •c N m i Q F- E c o m -6 m 5 •o c, m $ . a m X 0 Z m 4E, c m m e m c a o > > •• O m W E '° c 3 § ,,,,� U c0 ; m ; U a co m m `m $gg O us �, O U C a C L C L co m a m >U L� V m I_ U ' m 0a) 1 Q m m 0 Ei 3 L CC ° V m 0 V T L ,_ E ° 0 D iii o. co IM co ly, y - > c}� a > Y ° a r d ° o c ° ro m W J c ❑ i = 3 ccad o $q' ° m c o ti E� m o 8 y o c ¢o To °m N aa c 3 y m r IM o -5 m � v d U o m? a V 'C ° " m a ro • V ° co OL m V C C p T C m a C N C y N O d Q U .-U) 03• a3 C C L A E\ C m U m N m 'O N N -W E C � 7 v O • p m c Z- o > Q a aa O x p w ° m o o ¢ a a m a L c LO o £ �'^ Q //1•►1 ❑! ' ' m- a t _ m � , F o H 0 • ° 2 m 't.---$ m v d a � y U m ri Ti ui c N.: ai c E °' E E-0-1 ?n w d v > >Z m v aZ ° 3 LL Q p U 0 s .c X pne or more OAK PARK HEIGHTS ICR # ` Driver „Accident •OLICE DE P ART M EOT ;;e sting ❑ Pedestrian ❑ Violation sJ pk A C,*y ❑ Passenger ❑ Other Alcohol Influence Report Date //-,(f p 7 Name, Last /j First Middle Time/0J� h/', L7Sq /1/6V D.O.S. Location of Drivers St to 7'� '1 Arrest w18 60'k a� 0 erg Lic. # 1v�i4 /10 Actions of driver prior to stop, "X" all that apply Picture D/L ❑ Yes N0 l. , .-Turning with wide radius 10. ❑ Turning abruptly or illegally 2. ❑ traddling center or fog line 11. ❑, Accelerating or decelerating rapidly 3. eaving 12 eadlights off 4. ❑ Stopping (without cause) in 13. Q Almost striking object or vehicle traffic lane 14.* Swerving 5. ❑ Following to closely 15. ❑ Drifting 6. ❑ Driving into opposing or 16. Involved in any accident crossing traffic 17. 0 Other (explain on r verse side) 7. ❑ Signaling inconsistent with 18. Type of road Two way driving actions ❑ Divided 8. ❑ Slow response to traffic signals Road/Shoulder surface 9. ❑ Stopping inappropriately Pte/ Pw�a(ell. �f' Weather conditions: ❑ Daylight ❑ Dark ❑ Clear S ❑ Cloudy Road conditions Pry YOUR MIRANDA WARNING (Time ) 1. You have the right to remain silent 2. Anything you say can and will be used against you in a court of law. 3. You have the right to talk to a lawyer and have a lawyer present with you while your are being questioned. 4. If you cannot afford to hire a lawyer, one will be appointed to represent you before any questioning, if you wish. 5. You can decide at any time to exercise these rights and not answer y questions or make any statements. DO YOU UNDERSTAND THESE RIGHTS? YES ❑ NO 1. Having these rights in mind, do you wish to answer my questions at this time? es 0 no 2. Were' you driving or operating a ' 3. What type vehicle a t ,, motor vehicle? `(€S - you operating? CJ")'"/"lt/ 4. Are you unde a doctor or dentist's care? 5. If so, what is doptor's name. trS 2.ecn�A 4 S.ee>cc,n...e.-. 6. Are you taking any medication? I7A What kin ?7 ,, 48. Date/Time 4/'/8- '? 9. Quantity Sa„1c iX�c 6 P%1JS ? Vani (k,,o��etev,cA; 's last taken 17°°4rsI 10. Do you have diabetes? 11. What medication do. 12. Date/Time itA, you take? last taken 13. Do you have any physical disability? 14. Descri your disability. D 15. Do you have any speech difficulty? 16. Describe your difficulity. Ai 17. Have you been in an accident? �/ u 18. Did you get any injury? //�� res, / 5,+0,-cc' /vO 19. What time s,..t? Actual time ' 20. Where are you now? /� / �/� /Of lS (01.6 14/asit,% ,4)-� Co *y L!t x io.�c �!1� 21. Have you been es drinking? 22. What did you drink? 23. Where did you rink? tf lce� 4.s.c .,,,k�,is 1.f 11:;s�. 24. When did you have your 25. When did you have your 26. How many drinks? first drink? 3c 00 II last drink? gi:© ' P-17 . 12 27. Have you had anything to drink 28. What did you have? since the accident or arrest? o 29. Do you feel the effects of what 30. Do you feel that what you had to drink has effected our ability to drive? you have had to drink? t (per( G��t _,,1-9-\ y y _51., ,,v Mitt/call) k,,1 o • FIELD SOBRIETY TESTS Subject wearing contacts? •es 0-No PBT Test": 10 ❑ Fail • Count down test: , ❑ Pass ❑ Fail Alphabet Test: ❑ Pass ❑ Fail Finger to nose test: n aig ;,,a.; ALA•4r+ci. One-leg stand test Nystagmus - 0 1 2 3 4 5 6 ❑ Sways while balancing ❑ Uses arms to balance 0 ' C3 Hopping ,� t safe ❑ Puts foot down 1 \ pimmil P Incorrect counting w C3 Incorrect y0 ❑ Cannot do test (puts foot down o 2 three or more times) w 3 VW / Total score (Decision Point: 2) ai 4 A. 64 ...im ____ HORIZONTAL GAZE NYSTAGMUS TEST w 5 e 6 Left, Right ,a 7 Eye does not pursue x smoothly b 8 3 ' Distinct nystagmus at 9 maximum diviation Nystagmus onset before Decision Table 45 degrees Total score (Decision Pt:2) Walk & turn test: ❑ Cannot keep balance while ❑ Loses balance (falls off line) listening to instructions ❑ Loses balance while turning • ❑ Starts before instructions -• ❑ Incorrect number of steps are completed ❑ Cannot do test (steps off line three ❑ Stops while walking to steady self or more times) ❑ Does not touch heel to toe ❑ Uses arms for balance Total score (Decision Point: 2) Indication of Alcoholic Speech: Beverage on Br the ❑ Good C3 Slurred Eyes: (3 None Moderate ❑ Normal ❑ Staring ❑ Fair ❑ Incoherent ❑ Faint ❑ Strong IA�_ lu.r red 0 Confused Watery ❑ Glassy ""\ odshot Pupils: Reaction to Balance: Walk: ❑ Normal Light n;lated E3 None C3 Good C3 Wobbling CD Sure ❑ Uncertain. ❑ Contracted Poor it C3 Falling Fair ❑ Falling ❑ Fair ❑ Swaying ❑ Cannot ❑ Swaying ❑ Staggerir stand Clothing: Color of Face: Ability to Understand Observed Reactions: ❑ Neat ❑ Normal instructions: ❑ Average ❑ Slow 0 Excited Average lushed ❑ Poor ❑ Indignant ❑ Reserved ❑ Messy C3 Pale "- E it Talkative ❑ Fighting ❑ Good ..Belligerent ❑ Other Conclusion: Effects - ,- ...1 Remarks: ❑ None ❑ Slight Obvious 1 t • • 202 MAYOR AND COUNCILMEN SALARIES WORKMAN' S COMPENSATION AN ORDINANCE PROVIDING FOR WORKMAN' S 5 COMP �NS TIO N BENEFITS AND ESTABLISHING THE SALARIES OF THE MAYOR AND COUNCILMEN OF THE CITY OF OAK PARK HEIGHTS, WASHINGTON COUNTY, MINNESOTA. THE CITY COUNCIL OF THE CITY OF OAK PARK HEIGHTS, WASHINGTON COUNTY, MINNESOTA DOES ORDAIN: 202 .01 Workman' s Compensation. The Mayor and Councilmen of the City of Oak Park Heights are hereby entitled to receive compensation from the City in accordance with the provisions of the Workman' s Compensation Law of the State of Minnesota. If the Mayor or any Councilman sustains an injury or illness, covered by law, not caused by his intoxication or willful misconduct and not intentionally self- inflicted, which with or without negligence is proximately caused by and arises out of and in the course of performance of his duties as such Mayor or Councilman, he or his dependents shall be entitled to the maximum benefits provided under the compensation law upon the date of such injury or illness. 202.02 Salaries. Commencing on the first business day of January, 1987, the salary of the Mayor of the City of Oak Park Heights shall be Two Hundred Twenty Five ($225. 00) Dollars per month, and the salaries of Council members shall be One Hundred Seventy Five ($175. 00) Dollars per month. 202.03 Effective Date. This ordinance shall be in full force and effect from and after its passage and publication as provided by law. Clerk Mayor Passed by the City Council: November 10, 1986 • Published: November 18, 1986 City Ordinance Reference No. 68 O b b b w n ' H o o O W rH .1ln,W H 0 Hy o,MWNLJX to 0L1 W.1 aO,o r 'Co to n7JLJ7Vn Lx otd MOP N NOMVH to 0000 x • 0 * ` H O x n y cCi gH bd9 + y N i ..t0 t' x'+u xl'4 tt+� [ 0 QV OT' LI H"MH HZ Vto x %m P z m t'� �H Oto � 0 00 On N ' H 0 O L7 y 'X,0 OH W.l '. 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" (Employee,family,etc.) PURPOSE PERMISSION? EMPLOYEE OF USE Police Car X YES NO ESTIMATE AMOUNT WHERE CAN WHEN CAN VEH BE SEEN? OTHER INSURANCE ON VEHICLE DESCRIBE VEHICLE DAMAGE fender/bumper BE SEEN? PROPERTY DAMAGED OMPANY OR DESCRIBE PROPERTY 1989 GMC Jimmy - Plate 383GIK OTHER VEH/PROPINS?I AGENCY NAME: Illinois Farmers (If auto,year,make, — model,plate#) X YES ri NO POLICY#: OWNER'S Gary Richard Stevens (EC,No): PHONE NAME& ADDRESS 1020 Western Ave N St. Paul MN 55117 BUSINESS PHONE (A/C,No,Ext): OTHER NAME&ADDRESS Lisa May Wilber A//C,No)CE PHONE —1(Chk if BUSINESS PHONE same ec as owner) 1143 7th Ave. #1 Newport MN 55055 (A/C,No,Ext): DESCRIBE Unknown ESTIMATE AMOUNT WHERE CAN DAMAGE DAMAGE BE SEEN? INJURED NAME&ADDRESS PHONE(A/C,No) PED VEH VEH AGE EXTENT OF INJURY WITNESSES OR PASSENGERS INS VEH OTHER(Specify) NAME&ADDRESS PHONE(A/C,No) VEH VEH REMARKS(Include See attached police report adjuster assigned) REPORTED BY REPORTED TO SIGNATURE OF PRODUCER OR INSURED Insured Tracey Lund Landmark Insurance Services ACORD 2(2/95) NOTE:IMPORTANT STATE INFORMATION ON ATTACHED PAGE ©ACORD CORPORATION 1988 . • 00000000 H 00 00000000 Z 00 00000000 0 t�l 00000000 did FH+hHH HHIHI- 0 bbd 00000000 Cpl W.DWWwwww * \ 00 0 00 00 00 00 00 00 0 .30 H CO 00000000 H '3' 00 7C 7C 7C 7C 7C 7C707C CO i 0 rorororororororo E \ro ri 55555555 v IQ H H H H H H H H Hq HHHHH1 H 3 0 F m xp R n o n o O M N ro ( 3 ( ] ] ] f] r 0 N 0 H H H H H 0 H H &ONNHOO W (0 N 0O\000ONN.4. 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NJ tl rrin vl O warn a ah a W r r N N in Ch O O O a 0 0 0 0 0 0 0 CO Enclosure F LI I 145 University Avenue West League of Minnesota Cities St. Paul, MN 55103-2044 r ebruary 23, 1996 Ms. Mary Lach 930 Eagle Ridge Place Stillwater, MN 55082 Re: BRS File No.: 11012527 Trust Member: City of Oak Park Heights Claimant: Mary Lach D/Occurrence: 01/29/96 Dear Ms. Lach: As you know, our office handled the investigation of the motor vehicle accident in which you were involved on 01/29/96 on behalf of the city of Oak Park Heights. Our investigation has been completed at this time. Our investigation into this incident reveals that a collision occurred between a 1995 GMC conversion van driven by yourself and a 1995 Chevrolet police squad vehicle operated by Mr. Joseph Croft, an employee of the city of Oak Park Heights. Mr. Croft was traveling eastbound on 60th as you attempted to turn right from Oldfield onto 60th Street. Mr. Croft clearly maintained the right of way on 60th as you proceeded from a stop sign at the intersection of Oldfield and 60th. The collision occurred as you pulled into the path of the eastbound Oak Park Heights Police squad vehicle. Based on our investigation it is our determination that you did not exercise sufficient care and caution when proceeding from your stopped position on Oldfield onto 60th Street. Minnesota traffic regulations state that after coming to a stop at a stop sign, the driver must yield to vehicles not obliged to stop which are within or approaching the intersection. We conclude that you proceeded into the intersection without appropriately yielding to the approaching police squad vehicle. The responsibility for this incident is thus established on your part, and we will therefore be unable to recommend any payment be made to you on behalf of the city of Oak Park Heights. You should contact your own insurance carrier regarding the damages sustained to your vehicle. You may provide them with a copy of this letter if necessary. Sincerely, Eric Faust Claims Adjuster EF:dlm/12527.L AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER (612)281-1200 (800)925-1122 TDD(612)281-1290 Fax(612)281-1299 f • 0 00000 H 00000 0 d N 00000 O c4 a C2 0 CD 00000 70 C 1 HHHHH HHHHH taC] 4 DO W OD co CO OD OD wD WWW 0 HO 00000 H gggg N N a rororororo 030 oLn qHHHHH 1 o �OH0O 0 0o. 0 K ....., 1-+N477WN W w w 0 0 0 H 4wH o b C+1 0 a�ok ow UW 00000 .4.4.4_J.4 \\\\ 00000 ar■44oa r 0 N3 0. 0 00 C m[" M o 0 O OH OH W M v g°1 \ H H t0"10) b X31 H w N o 0 CO w 02 q CO rn lFzp3 000wo 8 V H 0 K 0 VI z co hiyy H J O .3 0000H LL��17 N • -" Q co d f\� 00000 O 9. tki V V O n"r0 .\ 00000 Pci IL 1 or • xa gi � z > z >05 J N H W H O y �• � �� b � rc � 0 o � rcJ � 0�� � roo�� o � �ro t t t tt t t t H02H C1Hy\y\ HC�1H ,3iH �s7C,Jy\yz �+Ht�1N HHpCH \y\ \�f .3O �DgRKH ROH gt�1H •�i}H Na.p0y HO �le gH ��ylO1 Nay ,t�1 CmmzmmumJ..< umm GGL+1''=1+1pm.< Uzmy ummzqL+1'�u1+1K ��vb2 W'1mm0 C] k > > Cl) 05 4 >>.3M00i .0 A .Ctdy.3y.3tdf02 t' < w•• • -• • bW 0.o • 5.\G: � h7• [0200 • -': td ts7. 0000 0 CO • NO — wo '.-NO yy HO 00 1 N O HO WO MOKH HOH �Jozm H0WOH br.CgH HHH �C H JUI J 02 HO. 0.40.7Ui00 r O 00.40.4W03 001 0�\\o\05 Ma. \\....0\W r rn ,n\....\0\w tjJ N H NON O t1 J NOr CO MN NON 00 �f Cl) 00.J0 oJw 0 Acv. 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O 0. , O U0 cn tO 0 >;J O Oro 0 o H o o 0 0 0 .. I r w w 0 0 01 01 V+ 0 N I•+ -7 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 CO 0 0 0 CO 0 • • Dy G I No b0 co ro 0 to• il tn�Qy1 ml�A Wy CA N .. �J 0 0 O 0 0 y to 0 c t=l0 0 •• 0 g O O 0 'd h1WH .3 Am \ON N �s# roa rH H 0 k n Iyyy q \y��Cl7 0 HWHc'IL'c DCO t(al g CO E y Ly+fOm 4• • •I N IA 0 A)-1 0 0 W CO i to 0 ON CO J 0 0 N00oh 1,1 Minnesota Department of Labor and Industry first Report of Injury Workers'Comberrshoo Division St.Paul,MN 616 4306 See ctions in folder accompanying forms. 1.osH 11111111 41111 TIM I11I 4t. Laf,MN 66166, rth (612)29e-2432 All d s must be entered in MM/DD/YY format. Type or Print. EMPLOYEE 2.Name(last first,middle) 3. EMPLOYEE SOCIAL SECURITY NO: Buckley, Stanley Leo 476-62-2154 4.Home address (include county and zip) 5.DATE OF CLAIMED INJURY: 14448 N. 55th St. , Oak Park Heights,MN 12/26/94 Do Not Use this Space 55082 6.Sex: X Male _Female 7. Marital Status: x-Married Not 8. Occupation: 9.Date of Birth: 07 / 14/ 52 Police Officer 10.Date Hired: 01 /01 /85 11.Regular Dept 12. Home Phone No. (A/C,No.) 13.Apprentice: Yes POLICE 612-439-9176 WAGE INFORMATION 115. Rate per hour. I 16. Hours per day: 14.Average wage/week $896 $20.69 1 8 17.Days per week: 5 18.What is the weekly value of MEALS: $ 0 LODGING: 3 0 2nd INCOME: 1 0 19.Employment Status: XFull time _Part time _Seasonal Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_x No_ OCCURRENCE 20. PLACE(include dept&full address) 21.Date of first 22.Date employer Parking lot: K-Mart day of lost time: _I_/_ notified of injury: 12 / 26/94 St. Croix Mall 24.Date employer notified 5909 Omaha Ave.N. 23. Return to work date: _/�!_ of lost time: _/ I_ Oak Park Heights, MN. 55082 25. Data of death: _/_/_ 26.Time of day 3:45 AM of injury: 1 On employer's premises? L Yes fi No ) PM 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL,BE SPECF IC(include partial of body affected,e.g.amputation of light irdax finger at 2nd joint,fractured arm,lead poisoning) Scratched cornea, left eye. 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED (include name of otlw individuals involved,tools,machinery,objects,vapors, chemicals,radiations,tnrr,eturaf motions of employee) Officer was removing suspected stolen property from a motor vehicle. A piece of the property got caught on vehicle interior then let loose sending a loose pin into the nffirers left. eye. 29. PHYSICIAN (full name,title, address and phone number) 30. HOSPITAL/CLINIC (name and address) Lakeview Hospital 927 West Churchill St. , Stillwater,Mn. 55082 31.Witness and phone number. N/A EMPLOYER 32.Legal name&mailing address incl.zip 34.Unemploy ID No.: OAK PARK HEIGHTS 33. Date form completed: 1 2/ 27/ 94 14168 57TH STREET, BOX 2007 STILLWATER MN 5508E 35.SIC code Payroll Class Code 36.Print supervisor's name and phone number. 37.Employer's Representative,print full name,title and phone number. t Lindy M. Swanson 612-439-4724 MirhRel Rnhertsnn. City Admin. . 439-4439 SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.CARRIER 39. Insurer ID No: 40.ADJUSTER N/A Berkley Administrators 41. Insurance Class Code: S ELF-I N S lJ R E D P.O. Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: 42.CARRIER CLAIM NUMBER 02-000729 44.Adjuster ID No: 0698639002 LI.20320-06(1-e2) Original to Berkley Administrators BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division •PERVISOR'S REPORT OF ACCIOT (PLEASE READ AND FOLLOW INSTRUCT IONS ON BACK) EVERY ACCIDENT SHOULD BE INVESTIGATED AND THE CAUSES CORRECTED SO THAT MORE ACCIDENTS WILL NOT OCCUR. DO NOT OVERLOOK THE SO-CALLED"UNIMPORTANT"CASES,BECAUSE,EXCEPT FOR"CHANCE"THEY COULD ALSO HAVE BEEN SERIOUS. IT IS ONLY BY THOROUGH INVESTIGATION THAT MANY OF THE REAL CAUSES CAN BE DETERMINED AND CORRECTED. NAMEOFEMPLOYEE Stanley Leo Buckley COMPANYCity of Oak Park HeightsoEPT. Police DATE OF ACCIDENT 12/26/94 TIME 1545 DID EMPLOYEE LOSE TIME FROM WORK? YES ❑ NO ❑ HOURS LOST ON DATE OF ACCIDENT 0 HAS EMPLOYEE RETURNED TO WORK? YES NO ❑ JOB TITLE Police Officer SERVICE WITH THE COMPANY 10 YEARS, IN PRESENT JOB 10 GIVE US YOUR HONEST COMMENTS ON QUESTIONS BELOW. WE ARE NOT TRYING TO BLAME ANYONE. YOUR OPINION MAY HELP US PREVENT ACCIDENT REPETITION. PLEASE ANSWER THE FOLLOWING: CHECK "YES" OR "NO" 1. WAS INJURED PERSON PROPERLY INSTRUCTED IN SAFE AND EFFICIENT METHODS? YES Iig- NO ❑ 2. DID INJURED PERSON VIOLATE ANY INSTRUCTIONS? NO LA'YES ❑ 3. WAS NECESSARY PROTECTIVE EQUIPMENT WORN? (IF APPLICABLE) YES NO ❑ 4. DID POOR HOUSEKEEPING CONTRIBUTE TO INJURY? NO • YES ❑ _ 5. DID HORSEPLAY CAUSE THE INJURY? NO Q YES ❑ 6. WAS IT CAUSED BY SOMETHING WHICH NEEDED REPAIRS? NO t -YES ❑ 7. SHOULD A GUARD BE PROVIDED? NO 13 YES ❑ 8. DID ANY BODILY DEFECT CONTRIBUTE TO INJURY? NO L YES ❑ 9. WAS IT CAUSED BY AN UNSAFE ACT? NO a YES ❑ 10. DID INJURED REPORT THE INJURY TO YOU,THE SUPERVISOR, IMMEDIATELY? YES El-- NO ❑ ACCIDENT. (DESCRIBE WHAT INJURED WAS DOING AT TIME OF ACCIDENT, WHAT HAPPENED,WHO WAS INVOLVED, NATURE OF INJURY, PART OF BODY AFFECTED.) Removing property from a vehicle when a piece of the property hooked on h- -hi le seat. A .in flew from the .ro.ert and hit the officer in the e e. WITNESSES'NAMES UNSAFE ACTS. (WHAT DID THE EMPLOYEE OR ANOTHER PERSON DO INCORRECTLY?) UNSAFE CONDITIONS. (WHAT UNGUARDED OR UNSAFE CONDITION OF MACHINERY,EQUIPMENT,BUILDING OR PREMISES WAS INVOLVED?) ACTIONS TAKEN. (WHAT DID YOU DO TO CORRECT THE CONDITIONS WHICH CAUSED THIS INJURY?) REMEDIES. (WHAT SHOULD YOUR ORGANIZATION DO TO PREVENT OTHER INJURIES LIKE THIS?) MEDICAL CARE. DID EMPLOYEE GO TO DOCTOR OR HOSPITAL? YES C1 NO ❑ IF YES,COMPLETE THE FOLLOWING NAME OF DOCTOR OR HOSPITAL Lakeview Hospital DATE OF INITIAL VISIT 12/26/94 ADDRESS 927 West Churchill St. , Stillwater, Mn. 55082 TELEPHONE NUMBER 439-5330 AS SUPERVISOR, DO YOU FEEL THAT THIS INJURY SHOULD BE COVERED UNDER WORKERS' COMPENSATION? YES NO REASONSWHY The officer was conducting a vehicle .ro.ert inventor and W. -II. ' Ig .- -d stolen propert from the vehicle. Officer was performing the duties of his position. REPORT SUBMITTED BY �O,JV Lindy Swanson. Chief of Pn1i@caTE 12/27/94 BA 252 (3/92) • 0 A >1 • A• z o WOx w x Ei O Uzw H H H = O a U H z z 1 a H W 4 H w W � H CO a g 4aA x E-iwax El fs cnUx A o aA4 z o • z4 � o GHQ' 0 e H W w• zE-1H D4W HHu) W D 0 I cn W I-1 x zoHO O H H A W g WAOE-I x x 4a � i I o, awag rcl va 0 CV • El� I UMU3W HE-IH � � O cnc) W , _ El 4Hx v. OHa' Uz v. � W cnoxHa°log w E- O�W W 12P C7 Al w 11 O-1 zx c n O U H E- w ° a+ x O U E-4 Z O 2 g xx HwQUEa t 3 zEixwz o �+ � H 8 = a � WWWO cS Y x t wAx w a - cc o as z 1 a HaaA 2 I ¢ Ci a ° $ • ,,co,. ABRASIONS.LACERATIONS STRAIN$. PRAINS.CONTUSIONS:FRACTURES %a�- N,` ,❑ Change original dressing after 48 hours. ❑ ;:Elevate the extremity:Weararm sling if prescribed;;When`resting � , ;: or sleeping, p 0 Keep the wound and dressing clean and dry. p g,place two pillows under the injured extremity ., r 2 z M ❑ Cleanse wound daily with hydrogen peroxide on cotton-tipped 0 'Ice bag to area as often as possible for thefirat 48 hours Protect ,,w- applicator. Reapply thin film of Bacitracin ointment. Apply clean rJ"skin from direct contact source of cold; 14•-- k,st! , W dressing. k Wigglefingers/toes frequently Make sure they are"pink in color, o FOR SIGNS OF INFECTION, such as redness ocred warm,and not numb ortingling Pinchfinger/toe often;pin kcolor .,, :,, Q c i ' streaks:swelling, increasing pain, heat at the sight of the injury,��t ��should return to nail beds quickly � �r �:�,. .t '', *w as r g P 9 ',❑ No`weight bearing on affected side'USE'CRUTCHESThe 3 r cv; fever, foul-smelling discharge from the wound. IF SIGNS OF {'' point gait pattern is useful'fora one sided,injun4of'arlower INFECTION DEVELOP,SEE YOUR PHYSICIAN IMMEDIATELY w" '' z extremity.'` ,� ?�`,�y j�t, � � F- ❑ In days,see your physician for a wound check.. ,,, 1 ) Place both crutches ahead,the distance of a normal step,' r F. 1 N ❑ In days,see your physician for suture removal.. p 2.)'Step forward with affected side parallel to the crutch.r>� • �� k ' I .. ❑ Elevate the extremity to avoid throbbing and swelling..., 3.),Stepthroughwithunaffectedsideandplaoeitaheadofthecrutches " i' ¢a4cerestreutchesareprorearmsed'Avoidlearnngoncrutches ❑ Ice bag to area Protect skin from direct contact with source of m` ,�' �� • ;use-the atrength"of,-your forearms , F'+t �,,� 3 ` ; ' ; J cold. Keep sutures dry. 3 , , , y Bear weight as tolerated. _ ,- a. ,-. Yx Q ❑ Wash hair today gently, but then avoid soaking wound until ! $ t"`� `aft CC .CJ:Heat to the area a ski ro urns ' ,, sutures are removed.„ 'f ,i. 1 ` -„��`r ,, ,, Protect th n f m b ,� � - � ' �❑N Bed rest. 's ..`. , �"ir«�.� i�a 7�:r,,�,�rM 3.,�� t �d , 0, ' ' ❑ Rinse mouth wounds with a i:1 mixture of hydrogen peroxide and�` T*D`,Plaster,splints/casts do not dry completely for 48 hours.Protect (f) water after meals and at bedtime Eat soft foods. , '$ :e lie'rg°froQ7pressure,as this may cause circularity�,impairment 0 ❑-Allow paper tapes to remain in place for as long as possible Avoid , ” getting the tapes wet. "► r t{ FEVER x . '�' 7g`��• • VII" ''' ❑ booster given.Please record this information. I:' [3u Acejamir�opl e,nlinapprpropre dose for age,as directed,i ,, C7�,Aspirin,rf in adult;,rn appropriate dose.‘ -� ��',��� � k�; � a� HEAD INJURY rb1Drink extra liquids.Avoid warm beverages,No alcohol,v.,!.(1.,,,,,1- -,` W After a head injury, it is normal for you: '•'• 'O4.Avoid heavy,warm garments.Use a light blanket only 4a ', f y r ,-',.• 0.iiSponge baths with cool water.Allow the water to evaporate form the ,:� • to have a headache. •-. . skin;but avoid.drafts. cool W • to have mild nausea and one or two episodes of vomiting Apply packs to underarm/groin areas. <. • to be mildly dizzy or drowsy. EYE INJURIES ::* r~ d 11, :. 0 You may take Tylenol ever 4 hours for pain. DO NOT take any 10 rWeareye patch until seen by your own physician Do not drive stronger medications.No aspirin or Ibuprofen.` TO Wear eye patch ` • Do not,dri e q Elevate on two pillows. require �' ❑ Do not drink any alcoholic beverages for 24 hours , � P Apply ice bag , ° is ❑ Have someone wake you up every hours for 24 -o ,Rest your eyes Avoid reading and activities which regwre close Q hours and check you for complications(see below) + visual attention „� b ��: � SPECIFIC INSTRUCTIONS FOR CHILDREN. ' : ' � i �,� ,;,x �MEDICATIONS� ` ' • '��, r., �, � ��z�n��, O ❑ Awaken child every 2 hours for 24 hours;make sure child can Walk; ','G:,ATake Aspirin;.Tylenol or Advil for relief of discomfort..i, .-•c•-,, , r,••,1 and talk. O Take medications exactly as`prescribed.y Be sure to bring the.'.?., + V ❑ DO NOT give child any pain medications.If headache~is severeedications with you when you see your physician ?^ z W bring the child back to the emergency department. j, ,;` `� ❑ may cause drowsiness Be aware 4 'of•this with regard to your activities 3n N x :- x ' I',..' C CALL YOUR DOCTOR OR RETURN TO THE EMERGENCYIDE j o Do'not drink alcohol or drive., `� PARTMENT /A�* t❑ '•Take with food' ' '1) Pupils which are unequal in size. ' 't°�P,* *,�, ,.... . NTIB�O A 71CINST w R C Li U TIO 2) Persistent headache,particularly if worse when up and Itut744ir," NS ` i `n F ' rve ' You have been given an antibiotic to fight infection Please observe 0 $) Increased frequency of vomiting('more than ,, the,fo lbwing instructions about your medication s` r" , a >r Ct 4) Inability to arouse easily from sleep. �� " ,� ; 5) Visual disturbances. „ ,•, Take the antibiotic as directed until it is all gone regardless of V 6) Staggering walk. , �t" how you feel. a''€ ,,,. �� . �� ,, ‘,34,..;:i',;,,11 k, Z 7) Slurred or incoherent speech. ., c£E, DO NOT give the antibiotic to any person for whom`it has Hotly,, 8) Increased irritability. °"r '.been prescribed. ;5k . x1 ' ,� � It is advisable to check the patient every few hours after a head injury`i ,,s,;Observe for any reaction to the r antibiotic, sucharashr x= Until the patient's condition improves,give clear liquids only����"` , , , wheezing,etc. ,, ,4'i„^▪`•,-' -• '• -,i`g ",";( _, F ; CC h Many antibiotics cause nausea,vomiting,or.diarrhea as a side & ,; W X-RAY EXAMINATION "z y 't effect but this should not be considered an allergy to the drug`and;' ,C ❑ Your initial x-ray reading is a preliminary T ,� you should not become alarmed unless these symptoms be , P ry interpretation T e,r ` cOmeseve.re. _.:. ''''' y4+9 �i r1 p, -, - ',,b?.,` LU Radiologist will make a final reading,and if there is any differences ,• Please notify your physician if there is not improvement in your• from the preliminary reading, you and/or your physician will be 44,';;'"6,"';'condition`after completion of your antibiotic treatment or if any notified. Your physician will receive a copy of the Radiologist's :,signs of allergic reaction develop or your infection seems worse.., ,, final report., ' , ' "Theantibioticyouhavebeenprescribedistohelpyourbodyfight ''''infection.It is NOT a pain pill.Please take it as prescribed.''''''', The examination and treatment which you have received has been on an emergency basis only g Y y and has not been intended to be a substitute for complete medical care.Follow-up care by your physician'complements the treatment received here. r F Ft Follow-up care by a physician usually is a requisite for injuries sustained on the job.If you do not have a personal physician,'you will be given'' a physician you are welcome to follow up with. Upon Y P pon making a follow up appointment you should rnform the office that ou were seen at ',� F,,,the Emergency Department and are now to see the doctor for subsequent care., ti ,,k 2 DISPOSITION TIME . �"'-__ r .-., . CONDITION �., r=« o sc. ADDITIONAL INSTRUCTIONS; i " " ° f td?�� s'r WITH WHO f P I tea.a,a^rt rr arty r��5dntSi)K > m Lf-ii°I i0t"t Cif C1l.S 106496440,k t,t ❑ADDITIONAL PRIVATE PHYSICIAN IN'` "'' ,,t j ,:'''',!;A,.5,0„4' e irs 1 ¢ ' ' DAYS FOR FOLLOW UP CARE'w Rrkhi.Ir t i - ; >,.pYOUHAVEBEEIVREFERREDTODR. r 4" � � '� � . 'E °'PHONE# FOR FOLLOW UP CARE SE INS "DAYS ❑CALL PHYSICIANf1FTER 48 HOURS FgR�Y,OUR CULTURE Ei,,,,,,,04,4'),� '4„ '. r,I, " r,,,. OTHER ' *- J IR, ' ,'`'"'""' `'i`1- `.'.° ��j aDtCATION INFORMATION GI BEN ' �}h''.?",°4'''',' �} 5 ' --' ' q a 7 ' , ) 6 t, `ba L"� +�23` 6 t �+� ,; +'f.IF YOUR CONDITION DOES NOT IMPROVE, NOTIFY YOUR PHYSICIAN CI' OR RTURN,TO+THE'EMERGENCY,DEPARTMENTFA CORYtOF4NOUR COEMERGENCY DEPARTMENTRECOR WILL BE SENT TO,YOUR PI X iCIAN ttn t :tt< ,.yt •tt x x t; Ihereby acknowledge receipt of verbal a dwritte r-care ins c d s I,understandthatonl eme gen tree entwasrende Lid.. 1 a e � . from the Emergency Department befog al of my ical pro e sure k ownror treatedy .',"'," t 1#" i �@ IE f Date ( ',,;,! •,,)',1% •;. 2ar P I �.3 ^^"4 { PATIENT OR E}?RESENTATIVE(RELATIONSHIP) ��f..✓// DR'S SIGNATURE l' t^ ,, --E ,,.. .. .0.i ')Y • ". fr . .� �w qa li < i • ' aii 4�G+ ii ��, i rty t{, dZl� t,i i =GENERA'L'1NSTRUCTION �A IENTS° w s' . CcBu)i1Al `d&11111' UYR l: wI tflt '1 YOtb.HA F.nF3EC/cl .EQtEME�iGENG�Y<T' '�� ' r Y `this!&ttn�o intended to be a substitute for gran,effort to provide, � "[". ..... RijdVl S A x 1 xA,'e•+�1rM". l,. 1 } { t r 1 T� ,� com let fidicaLcare i our prwate;doGtors jd a �e X maykrequest a copy of your records. It is important that you report' 'xto�fairirf6ffri 1 SCr�fistth`attg°rf5e't�oro �t� ,fffrove"frarthislproblem,because it is impossible to recognize and . � treat A e = 'j�}nt •' heaf(th h a sing}ee"Ei1= ge ;;Department-visit. — T' 'Y.t� t"u' .y `n: rj Y '�'"' .,;: f at.. Y •y %., ti a �t,� ,i 4£S. 7.„,F4 �C*, �2 i IF$X-RAYS,,: E E TAKEN ou may ha``ve been ated fort;thg•basis of the Emergency Department physician's initial • interpretation on1 a Wlll`tse °e'Iewe`d`fa =' . a*Physicran•Radiologist for final interpretation. If his impression differs T s.. «, ; .,.... r, r ' si�'"nrfi .8 loi.'�f o s- . er en /��a�part t • i n' g rog I contact our ph sici rcenc he will contact you''fn any case,if f ' a � i'1 ytJ fYV r�` r�� � l}1 "t 1`�t,: �::V�11 ` t ,1 y J ha 17 , e t a m e "Y b y r. L�U]call your'physician.`""'` ,+u� ��f� J t�+ ou es i0�.{n'y�.�I.oC�yrQblem re(a`fe�fo�f7 �y a e area o �shoul kid, 4 }. }�u�,/1V�17`� , ..L (..✓�1�__,.V,",hiit�{: E:�i:: GLLltii IS V).. v %', ,..s rt _ fit,; ! r-ii.7, ; �f,1 4 a ik , �� 3 Y � ' niz` ds ent will;be •r •: • • soon . .t •,�,o �"� v���eo'fi s• 'i�r5#of your Emergency Department visit. Because of the ' '" �" ti�g�,�$.q�ipment`and,�support� �ple�involved mergency_care,the fees for Emergency Department ! Ida a week ��� tr trig• t understandably higherth i„1.,7,r rea ment lnxa doctor' offfce.This is primarily due to 24-hour, y rte • r a _.• w • eT• Q Wate'phVSi sin gltarns rnll �iII Ot7 separately 1._...,1„,11. ,..,...' a� trL �uU u yL U M 21� �� t cgi+� ..�... � x t�' �7 Ef 1. lF SLIfMO)C"rll 401 .-:ll(A�` x ' • sa' #9bbo,3jUFf3klj�pit ' I.�t{ ia{ i t x ;,'•�c){it�.r �. �t t�,-itii 2d6U `r! S + f ai. . .a tJ 4 e i,,3,-,,-,,,,lc...J ii ai.1 ` 4p?�4Tt?jd1123Ct rructt IIR• 56 , ,,, ',i{ t 6 ?'1{a, 4 2.' 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'?"` =:--- �'�.r.�` ,.' � pro} z r u 'a i t:.�..• `� ► ) u �a,J c <.�r C' i istljr; iii L..,;{'. 4W q ° #` E — IiEWO ° EMERGENCY DEPARTMENT t . ` „ ? $ '' 1.tf?+.,, Iy J LI , p(1y,,,,S) fi� Jba .Y >4 i tk I c>>,t! , , .jO UCr" ;Cit bli-;.;i !OL St icl �1. .ix1CjE5t�'; 1 OI'TT-9701,4 �t �- k , �J ��wwa., , r r 1�..t ti 1;a r, -._ FiCi i! d'�•i;; �tQiU 1�{LU2' b. + `R#' i) .209$i MbriU 1I1 , r r S_ 1 C1;: O !. i g } t takeviev ,Hospital b`' � w •t � '�i KP iY R l ,�.i't t,� 11 I 1 1 K4'+? � xir fq � a'9 ,"{ Z .y a,.,... Y.a s p� '�` ;927 West C,hurCil lill �t ,� t ' , � '• t[pFs �� • 1).' +creot'2l ItJ L0W gli cr:coutecr,Mttp nL c}' Stillwater ' ' ,55082 r �'d t e , '' ,`at�'tflC.il cif Ult), IJi.Lll4•..U•J2. rs° �a � ew} toos�ittc�pplu�'suq r8lir � i t j ,. r 1`>t �l(is7 1 i " � .° :�J f ru't3 fsG"3 f v 1E3"t 'P tv�.f1 C.1C3i, 4 " a tr , •8f1rr','�d'ee'''5X4.I3�.II�2ic i tot.211jt1,' ,0'ii�o/1J r,. c r r r. as [ ,:,4, d, rR) ;fit} t.t.M`Yt r .';l i..xi,- 0 . e l'IG'r• s l g, s r:R ,.. 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Gt:^.i'iCiitU !.>i7CO 1Mli✓tiiOM2 iiai�6L ji,16 G7�11LFq©Xti8t:1J1j)i', . . .• ro !� 9U.`' ' f0(ll.� 1s, ��11(1 r x i• t 7- t)M lE'rox tfitSJl 1' E9i,L30L1?iltldt k719 11 eu-ie s1•,fi ''a°�• ■ ► t "r r i �+r ° +may} �yy}�--rip �,(,,-Jr-/''� /�t Thy I-6a`■��y,•�� *-' •'" 4➢1 * • d 7fl l.xi("�[�Y, irs fix) M A'Yj ! �C.k VIi� ....7sblt. ��Y 11. �./�..)i.�i+l 1•VAi11lJ � .� ? y 4 Workers'-Cci ncenestionDivision s u.7I. IIGpvI I. WI III4era 443 Lafayette Rued North St-r. La)1. See instructions in folder accompanying forms. 1.OSHA Casa/ MN MN 65166-4306 r I 11 I I 16121 296-243f All must be entered in MM/DD/YY format. T Print. • EMPLOYEE 2.Name (last,first,middle) 3,EMPLOYEE SOCIAL SECURITY NO: Benson, Roger G. 470-34-4435 4,Home address(include county and zip) 5.DATE OF CLAIMED INJURY: 9154 Fairy Falls Rd. August 17, 1994 Do Not Use this Space Stillwater, 'MN 55082 Washington County 6.Sex: }Male Female 7, Marital Status: X Married Not 8. Occupation: 9.Data of Birth: 02/ 13,36 10.Date Hired: 1�/?41 77 Director of Public Works 11.Regular Depttt_bliC Works 1 2.Home Phone No. (A/C,No.) 13.Apprentice: XNo Yes I tLl , (612) 439-2522 : WAGE INFORMATION 15.Rate per hour. 16. Hours per day: 14.Average wage/week $833 $20.82 I 8 17. Days per week: 5 18.What is the weekly value of MEALS: $ LODGING: 5 2nd INCOME: S 19.Employment Status: X FuII time _Part time _Seasonal _Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No_ OCCURRENCE 20. PLACE(include dept&full address) 21.Date of first 22. Data employer day of lost time: 08 /18/94 notified of injury: 08 18 04 City of Oak Park Heights 15021 N. 60th St. 23.Return to work date: / / 24. Date employer notified Oak Park Heights, MN 55082 - of lost time: 08 / 18/,94 25. Data of death: -/ / 26.Time of day ❑ AM ��11 I I of injury: 1:30 Rx PM Yes r-� No On employer's premises? RI 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL,BE SPECIFIC(Include partlsl of body affected,s.o.amputation of right index finger at 2nd joint,fractured arm,lead poisorvngl Slipped on grassy bank, southside of Hwy. 36 / across from Club Tara 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HCW EVENT OCCURRED (include name of other individuals involved,tools,machinery.objects,vapors. chemical.,radiations,unnatural motions of employee) Looking for a water main valve 29. PHYSICIAN (full name,title, address and phone number) 30.HOSPITAL/CLINIC(name and address) 31.Witness and phone number. EMPLOYER 32.Legal name&mailing address inc l.zip 34.Unemploy ID No.: OAK PARK HEIGHTS 33.Data form completed: 8 /18/ 94 14168 57TH STREET, BOX 2007 STILLWATER MN 5508E 35.SIC code Payroll Class Code 36.Print supervisor's name and phone number: 37. Employer's Representative,print full name,title and phone number. La Vonne Wilson - 612-439-4439 Same (Administrator/Treasurer) SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE T11I5 SPACE N P S T OCC INSURANCE 38.CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF I N S tJ R E D 41.Insurance Class Code: P.O. Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: 42. CARRIER CLAIM NUMBER 02-000729 44.Adjuster ID No: 0698639002 T LI-20720-06(1-921 Original to Berkley Administrators BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division Minnesota` srtmssi of Lab and Industry ,tionOlvisien or. First Report of Injury 44 Lafayette Road -4306 ructions in folder accompanying forms. 1.Wee* I (81 1 29 -2 66166 4306 11111111(I'II'liii!fill Ill liii (8121 Pouf,MN 6 A dates must bei entered in MMlDD/YY format. Type or Print. ,EMPLOYEE 2.Name past,first,middle) 3.EMPLOYEE SOCIAL SECURITY NO: T3 iCJS>A/ RRGL ' G_ LI 70-34- 411135 4.Home address(include county and zip) 5.DATE OF CLAIMED INJURY: 9/5 L/ rA//C y FALL J?0- 8-i 7.9'41 Do Not Use this Spate -(L1"W A/fR1 Ha 5S'cy - 6.Sex: "K_Male _Female WA,;t'/A G-TOA/ CO_ 7.Marital Status:X Married Not 8. Occupation: 9.Date of Birth: / l b I Jf/ 7 7 aR. OF PE) W�S 10.Date Hired: 0! 11.Regular Dept /- 1 2.Home Phone No.IA/C,No.) 3Q-a 13.13.Apprentice: ,No _Yes WAGE INFORMATION 15.Rate per houu�r. Q✓� 16.Hours per day: 9 14.Average wage/week ■Q' V ^ �+ 17.Days per week: 18.What is the weekly value of MEALS: $ LODGING: $ 2nd INCOME: S 19.Employment Status: XeFull time Part time _Seasonal Volunteer(Attach 26 week wage statement for part lime or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No_ ,OCCURRENCE 20. PLACE(include dept&full address) 21.Date of first p p 22.Date employer p p cal T day of lost time: Q ! le, 7y notified of injury: Q f 18( 74 23. Return to work date: _/!!_ 24.Date employer notifi of lost time: /.13.f_.2k* 25. Date of death: / / 26.Time of day I 3 AM Yes n of injury: / s�3 O �PM On employer's premises? 1 1 No 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL.BE SPECIE IC(include partial of body affected,e.g.amputation of right index finger at 2nd joint,fractured atm,lead poisorinpl ACJ40.5 3'' Frc'Ml SL I PE,D ©n/ -/RAssy l34A))( S007-1/5/ o/.'ivy 34 c40,8 7-48,4, 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED (include name of other individuals involved,tools,machinery,objects,vapors, chemicals,radiations,unnatural motion.of empleyeel LOOK i null- FD2 A WA-TE/> MA1/V V4-1-s' 29. PHYSICIAN (full name,title,address and phone number) 30.HOSPITAL/CLINIC(name and address) 31.Witness and phone number. EMPLOYER 32.Legal name&mailing address incl.zip 34.Unemploy ID No.: AK PARK HEIGHTS 33.Date form completed: _/ /_ 14168 57TH STREET, BOX 2007 STILLWATER MN 55082 35.SIC code Payroll Class Code 36. Print supervisor's name and phone number. 37.Employer's Representative,print full name,title and phone number. SEND REPORT IMMEDIATELY - DO NOT WAFT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T 0CC INSURANCE 38.CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF-INSURED MpI 41. Insurance Class Code: Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Data insurer received notice: 42.CARRIER CLAIM NUMBER 02-000729 44.Adjuster ID No: 0698639002 1.1-20320.06 11-92) Original to Berkley Administrators BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division „..,,,h4. ,t- mac. • 74 NIC-OFFICE 0050-01 00001 PRIMARY INSURANCE FORM C IENT FORM I: PRI OMMBM FAPPRO0B NO.0938-000O 08 HEALTH INSURANCE CLAIM FORM MN 99999 (CHECK APPLICABLE PROGRAM BLOCK %%H) 1300 O (MEDICARE CARE NO.) 71 MEDICA D NO.) a SPONSOR'S SSN) ` ' VA FIILEVNO.) Q (SSN)BLACK LUNG ® CE T FICATE SSN( PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1. PATIENTS NAME(LAST NAME.FIRST NAME,MIDDLE INITIAL) 2. PATIENTS DATE OF BIRTH 3. INSURED'S NAME(LAST NAME.FIRST NAME.MIDDLE INITIAL) ANDERSON, KEN R 021 11 1 66 ANDERSON, KENNETH 4. PATIENTS ADDRESS(STREET.CITY.STATE.ZIP CODE) 5. PATIENTS SEX 6. INSURED'S I.D.NO(FOR PROGRAM CHECKED ABOVE.INCLUDE ALL LETTERS) MALE X I I 1 FEMALE 14055 54TH ST NO J I STILLWATER M N 55082 7. PATIENT'S RELATIONSHIP TO INSURED 8. INSURED'S GROUP NO.(OR GROUP NAME OR FECA CLAIM NO.) SELF SPOUSE CHILD OTHER INSURED IS EMPLOYED AND COVERED BY EMPLOYER TELEPHONE NO. 430-2823 ® HEALTH PLAN 9. OTHER HEALTH INSURANCE COVERAGE(ENTER NAME OF POLICYHOLDER 10. WAS CONDITION RELATED TO 11. INSURED'S ADDRESS(STREET.CITY.STATE.ZIP CODE) AND PLAN NAME AND ADDRESS AND POLICY OR MEDICAL ASSISTANCE NUMBER) A. PATIENT'S EMPLOY NT 14055 54TH ST NO YES Li NO STILLWATER MN 55082 NO OTHER INSURANCE TELEPHONE NO. 430-2823 B. ACCIDENT 11.0. �-1 CHAMPUS SPONSOR'S: AUTO n n OTHER ( ' 1 ACTIVE El DECEASED BRANCH OF SERVICE STATUS I 1 1 DUTY 1 n RETIRED 1 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE(READ BACK BEFORE SIGNING) 13. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM.I ALSO REQUEST PAYMENT PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW. OF GOVERNMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. SIGNED DATE SIGNED(INSURED OR AUTHORIZED PERSON) PHYSICIAN OR SUPPLIER INFORMATION 14. DATE OF ILLNESS(FIRST SYMPTOM)OR INJURY 15. DATE FIRST CONSULTED YOU FOR THIS 16. IF PATIENT HAS HAD SAME OR 16.0,IF EMERGENCY (ACCIDENT)OR PREGNANCY(LMP) CONDITION SIMILAR ILLNESS OR INJURY,GIVE DATES CHECK HERE 17. DATE PATIENT ABLE TO 18. DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY RETURN TO WORK FROM I THROUGH FROM I THROUGH 19. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE(e.g.PUBLIC HEALTH AGENCY) 20. FOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION DATES ADMITTED I DISCHARGED 21.S4111 I I.NL8W7AE1SEF ACIC NMNE151C ES IIM EMDERED(IF OTHER THAN HOME OR OFFICE) 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? STILLWATER MN 55082 YES❑® NO CHARGES: 0 . 00 23. A.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE NUMBERS 1.2.3. B. ETC.OR DX CODE 1. 71947 JOINT PAIN-ANKLE EPSDT YES �No 2. FAMILY PLANNING YES NO 3. 4. PRIOR AUTHORIZATION NO. 24. A. B.* C. FULLY DESCRIBE PROCEDURES.MEDICAL SERVICES OR SUPPLIES F. H.LEAVE BLANK DATE OF SERVICE PLACE FURNISHED FOR EACH DATE GIVEN D. DAYS Ip�(�ppjy�pSl$� MC E OR GA FROM TO SERVICE ?AQB r EJEODE (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) �m/F'J-C�•�[;HARGES UNITS T.O.S. DEFT��Y' `1 DR J STRATTE MD 04/28/94 LEVEL 3 EST. PT. 3 99213 _ 71947 4650 1 1 04/28/94 X-ANKLE 3 73610 71947 55100 1 4 04/28/94 ANKLE WRAP 3 A4570 71947 825 1 9 I 25. SIGNATURE OF PHYSICIAN OR SUPPLIER(INCLUDING DEGREES OR 26. ACCEPT ASSIGNMENT(GOVERNMENT 27. TOTAL CHARGE 28. AMOUNT PAID 29. BALANCE DUE CREDENTIALS)(I CERTIFY THAT THE STATEMENTS ON THE REVERSE APPLY TO CLAIMS ONLY)(SEE BACK) THIS BILL AND ARE MADE A PART THEREOF) $$��$$1ddP0991,7$5N�0j1 i 000 109.75 YES Q O NO 31. AND ICIAFL OIfI 01(1C 1 A 4(J 7 OU1 y ADDRESS.ZIP CODE 30. YOUR SOCIAL SECURITY NO. 1 L J J STILLWATER CLINIC STILLWATER CLINIC, P.A. DATE: 05/07/94 1500 CURVE CREST BLVD 32. YOUR PATIENTS ACCOUNT NO 900012525A 33. YOUR EMPLOYER I.D.NO I.D.N�STILLWATER MN 55082 MED. CHART 3347 41-1683126 411683126 REMARKS:F SERVICE AND TYPE OF SERVICE(T.O.S.)CODES ON THE BACK PAGE p ON MEDICAL AMA G COUNBCK5/0 7/cf4rm HCFA-1500 (C-2)(1.84) Form OWCP-1500 P 3' Form CHAMPUS-501 Form RRB-1500 " I • BECA HIS FORM IS USED BY VARIOUS GOVERNMENT PRIVATE HEALTH PROGRAMS,SEE SEPARATE RUCTIONS ISSUED BY APPLICABLE PROGRAM. REFERS TO GOVERNMENT PROGRAMS ONLY MEDICARE AND CHAMPUS PAYMENTS: A patient's signature fiscal intermediary if this is less than the charge submitted. CHAMPUS requests that payment be made and authorizes release of medical is not a health insurance program and renders payment for health ben- information necessary to pay the claim. If item 9 is completed, the efits provided through membership and affiliation with the Uniformed patient's signature authorizes releasing of the information to the insurer Services. Information on the patient's sponsor should be provided in or agency shown. In Medicare assigned or CHAMPUS participation those items captioned "Insured"; i.e., items 3,6,7, 8, 9 and 11. cases, the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge, BLACK LUNG AND FECA CLAIMS: The provider agrees to accept the and the patient is responsible only for the deductible, coinsurance, amount paid by the Government as payment in full. See Black and noncovered services. Coinsurance and the deductible are based Lung FECA instructions regarding required procedure and diagnosis upon the charge determination of the Medicare carrier or CHAMPUS coding systems. SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE,CHAMPUS, FECA AND BLACK LUNG) I certify that the services shown on this form were medically indicated although incidental part of a covered physician's service, 3) they must and necessary for the health of the patient and were personally be of kinds commonly furnished in physician's offices, and 4) the rendered by me or were rendered incident to my professional service services of nonphysicians must be included on the physician's bills. by my employee under immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUS regulations. For CHAMPUS claims, I further certify that neither I nor any employee who rendered the services are employees or members of the Uniformed For services to be considered a"incident"to a physician's professional Services (refer to 5 USC 5536). For Black Lung claims, I further certify service, 1) they must be rendered under the physician's immediate that the services performed were for a Black Lung related disorder. personal supervision by his/her employee, 2)they must be an integral, No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations (20 CFR 422 510). NOTICE: Any one who misrepresents or falsifies essential information to receive payment from Federal funds requested by this form may upon conviction be subject to fine and imprisonment under applicable Federal laws. NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE, CHAMPUS, FECA, AND BLACK LUNG INFORMATION. We are authorized by HCFA, CHAMPUS and OWCP to ask you for tions or Federal agencies as necessary to administer these programs. information needed in the administration of the Medicare, CHAMPUS, For example, it may be necessary to disclose information about the FECA, and BLACK LUNG programs. Authority to collect information benefits you have used to a hospital or doctor. is in section 205(a), 1872 and 1875 of the Social Security Act as With the one exception discussed below, there are no penalties under amended and 44 USC 3101, 41 CFR 101 et seq and 10 USC 1079 these programs for refusing to supply information. However, failure and 1086; 5 USC 8101 et seq;and 30 USC 901 et seq. to furnish information regarding the medical services rendered or the amount charged would prevent payment of claims under these pro- The information we obtain to complete claims under these programs grams. Failure to furnish any other information, such as name or claim is used to identify you and to determine your eligibility. It is also used number, would delay payment of the claim. to decide if the services and supplies you received are covered by these programs and to insure that proper payment is made. It is mandatory that you tell us if you are being treated for a work re- lated injury so we can determine whether workers' compensation will The information may also be given to other providers of services, pay for treatment. Section 1877 (a) (3) of the Social Security Act pro- carriers, intermediaries, medical review boards and other organiza- vides criminal penalties for withholding this information. MEDICAID PAYMENTS (PROVIDER CERTIFICATION) I hereby agree to keep such records as are necessary to disclose fully SIGNATURE OF PHYSICIAN (OR SUPPLIER): I certify that the the extent of services provided to individuals under the State's Title services listed above were medically indicated and necessary to the XIX plan and to furnish information regarding any payments claimed health of this patient and were personally rendered by me or my for providing such services as the State Agency or Dept. of Health and employee under my personal direction. Human Services may request. I further agree to accept, as payment in full, the amount paid by the Medicaid program for those claims NOTICE: This is to certify that the foregoing information is true, submitted for payment under that program, with the exception of accurate and complete. authorized deductibles and coinsurance. I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws. PLACE OF SERVICE CODES: TYPE OF SERVICE CODES: 1 - (IH) -Inpatient Hospital 1 -Medical Care 2 - (OH) -Outpatient Hospital 2 -Surgery 3 - (0) -Doctor's Office 3 -Consultation 4 - (H) - Patient's Home 4 -Diagnostic X-Ray 5 - - Day Care Facility(PSY) 5 -Diagnostic Laboratory 6 - - Night Care Facility(PSY) 6 -Radiation Therapy 7 - (NH) - Nursing Home 7 -Anesthesia 8 - (SNF) -Skilled Nursing Facility 8 -Assistance at Surgery 9 - -Ambulance 9 -Other Medical Service 0 - (OL) -Other Locations 0 - Blood or Packed Red Cells A - (IL) -Independent Laboratory A - Used DME B - (ASC) -Ambulatory Surgical Center F -Ambulatory Surgical Center C -(RTC) -Residential Treatment Center H -Hospice D - (STF) -Specialized Treatment Facility L -Renal Supplies in the Home E - (COR) -Comprehensive Outpatient M -Alternate Payment Rehabilitation Facility for Maintenance Dialysis F - (KDC) -Independent Kidney Disease N - Kidney Donor Treatment Center V - Pneumococcal Vaccine Y -Second Opinion on Elective Surgery Z -Third Opinion on Elective Surgery -Fnrnitiioa Span*eittortiaoor moue�ry Worker'Compensation First Report of Injury y-2- 9 - t3.a.,'- 1+-• /C,Lefyette Road North St,Paul,MN 66166.4306 S Instructions in folder accompanying forms. 1 0 ACwef 11111111111111 I�I�I��'1'�I��II(812)2sa-2432 tes must be entered in MM/DD/YY or Print. . .- EMPLOYEE 2.Name past,first.middle) 3.EMPLOYEE SOCIAL SECURITY NO: Anderson Kenneth Ray 470 96 1003 4.Home address (Include county and zip) 5.DATE OF CLAIMED INJURY: 14055 N. 54th St. , 04/28/94 Do Not Use this Space Oak Park -Heights, MN 55082 6.Sex: X Male Female 7.Marital Status:X Married Not 8.Occupation: 9.Date of Birth: 02 /11/ 6 6 10.Data Hired: 01 / 01/ 9 O Police Officer 11.Regular Dept 12.Home Phone No.(A/C.No.) 13.Apprentice: X No _Yes Police Department 612-430-2823 WAGE INFORMATION 15..Rate per hour: 16.Hours per day: 14.Average wage/week weekly= $853. 00 $21. 3 2 8 17.Days per week: 5 18.What is the weekly value of MEALS: $ 0 LODGING: $ 0 2nd INCOME: f 0 19.Employment Status: >Full time _Part time _Seasonal _Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) 1 If employee is a police officer or firefighter: Smoker: Yes_ No OCCURRENCE 20. PLACE(include dept&full address) 21.Date of first N/A 22.Date employer day of lost time: /-I_ notified of injury: 04 /28 /94 Mens restroom Oak Park Heights Police Dept. N/A 24.Data employer notified g P 23.Return to work date: / 14168 N. 57th St. of lost time:N/A -/ / Oak Park Heights, MN 55082 N/p, 26.Time of day ❑ AM �-1 25.Date of death: 1 _/ / On employer's premises? 1 Yes 1_i No , of injury: 2 :2 0 PM 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL,BE SPECIF IC(include penis)of body affected,e.g.amputation of right index finger at 2nd joint,fractured arm,lead poisoning) Employee slipped on wet bathroom floor causing injury to left ankle. 2B.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED 'include name of other individuals involved,tools,machinery,objects,vapors, chemicals,radiations,unnatural motions of employes) Subject was preparing to use the toilet and slipped on wet floor in front of the toilet_. 29.PHYSICIAN (full name,title, address and phone number) 30.HOSPITAUCLINIC(name and address) Stillwater Clinic Dr. STratte • 1500 Curvecrest Blvd. , Stillwater,MN 55082 31.Witness and phone number. NONE EMPLOYER 32.Legal name&mailing address incl.zip 34.Unemploy ID No.: C Aj�. pARIt. HEIGHTS 33.Date form completed: 0 4/ 2 9 94 14168 57TH STREET. BOX 2007 STILLWATER MN 55082 35.SIC code Payroll Class Code 36.Print supervisor's name and phone number: 37.Employer's Representative,print full name,title and phone number: Chief Lindy M. Swanson 439-4723 Lavonne Wilson, Administrator 439-4439 ,SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT • CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T 0CC • INSURANCE 38.CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF- I N S lJ R E D 41.Insurance Class Code: P.O. Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Data insurer received notice: 42.CARRIER CLAIM NUMBER 02-000729 44.Adjuster ID No: 0698639002 LI-20320.0611-e2) Original to Berkley Administrators BA 251 VI (4/92) Copies to Employer, Employee and Workers' Compensation Division SUPERVISOR'S REPORT OF ACCIDENT ■ (PLEASE READ AND FOLLOW INSTRUCTIONS ON BACK) EVERY ACCIDENT SHOULD BE INVESTIGATOD THE CAUSES CORRECTED SO THAT MORE ENTS WILL NOT OCCUR. DO NOT OVERLOOK THE SO-CALLED "UNIMPORTANT" CASE CAUSE. EXCEPT FOR "CHANCE" THEY COU SO HAVE BEEN SERIOUS. IT IS ONLY BY THOROUGH INVESTIGATION THAT MANY OF THE REAL CAUSES CAN BE DETERMINED AND CORRECTED. NAME OF EMPLOYEE Kenneth Ray Anderson COMPANY City of Oak Park Ilts Police DATE OF ACCIDENT 04/28/94 TIME 2:20 p•mDID EMPOYEE LOSE TIME FROM WORK?YES NO }:X HOURS LOST DATE OF ACCIDENT 0000000 HAS EMPLOYEE RETURNED TO WORK? YES NO JOB TITLE Police Officer SERVICE WITH THE COMPANY4 YEARS, IN PRESENT JOB 1 GIVE US YOUR HONEST COMMENTS ON QUESTIONS BELOW. WE ARE NOT TRYING TO BLAME ANYONE. YOUR OPINION MAY HELP US TO PREVENT REPETITION. PLEASE ANSWER THE FOLLOWING: CHECK"YES" OR"NO" 1. WAS INJURED PERSON PROPERLY INSTRUCTED IN SAFE AND EFFICIENT METHOD? .1411- YES ❑ NO ❑ 2. DID INJURED PERSON VIOLATE ANY INSTRUCTIONS? NO R YES ❑ 3. WAS NECESSARY PROTECTIVE EQUIPMENT WORN? (IF APPLICABLE) t'.4 4- YES 0 NO ❑ 4. DID POOR HOUSEKEEPING CONTRIBUTE TO ACCIDENT? NO % YES ❑ 5. DID HORSEPLAY CAUSE THE ACCIDENT? NO ' YES ❑ 6. WAS IT CAUSED BY SOMETHING WHICH NEEDED REPAIRS? NO,iii`" YES ❑ 7. SHOULD A GUARD BE PROVIDED? NO YES ❑ 8. DID ANY BODILY DEFECT CONTRIBUTE TO ACCIDENT? NO & YES ❑ 9. WAS IT CAUSED BY AN UNSAFE ACT? NO ❑ YES 10. DID INJURED REPORT THE INJURY TO YOU,THE SUPERVISOR,IMMEDIATELY? YES R.-. NO ❑ ACCIDENT. (DESCRIBE WHAT INJURED WAS DOING AT TIME OF ACCIDENT, WHAT HAPPENED, WHO WAS INVOLVED, NATURE OF INJURY, PART OF BODY AFFECTED.) ETtployee Anderson entered the restroan located off of the Police Training ng roc: The maint. dept. had wet mopped the restroan floor and failed to place a warning placard warning of a wet floor. Anderson entered the restroan and slipped on the wet floor injuring his left ankle. s to sprained. NUMBER OF EMPLOYEES AT WORK SITE WITNESSES'NAMES 0 UNSAFE ACT. (WHAT DID THE EMPLOYEE OR ANOTHER PERSON DO INCORRECTLY?) Did not place a warning placard indicating that the restroan floor was wet due to recently being wet mopped. UNSAFE CONDITIONS. (WHAT UNGUARDED OR UNSAFE CONDITION OF MACHINERY, EQUIPMENT, BUILDING OR PREMISES WAS INVOLVED?) Wet floor-no caution placard placed. REMEDY. (WHAT SHOULD BE DONE TO PREVENT OTHER ACCIDENTS LIKE THIS?) - •.• .r •• • •! ! - .- t• 4• ! 8.7 put in place any tine maint. is done on the floors. ACTION TAKEN. (WHAT HAS BEEN DONE TO CORRECT THE CONDITIONS WHICH CAUSED THIS ACCIDENT?) Maint. Dept. notified immediately of failure to use warning placards. MEDICAL CARE. DID EMPLOYEE GO TO DOCTOR OR HOSPITAL?YES X NO IF YES'COMPLETE THE FOLLOWING NAME OF DOCTOR OR HOSPITAL Dr. Stratte DATE OF INITIAL VISIT 04/28/94 ADDRESS Stillwater Clinic, 1500 Curbecrest Blvd.,StilIwater. NUMBER 439-1233 AS SUPERVISOR, DO YOU FEEL THAT THIS INJURY SHOULD BE COVERED UNDER WORKERS' COMPENSATION BENEFITS?: RkYES ❑ NO REASONS WHY Maint. Dept. was negligent in placing a warning placard indicating that the floor was wet. Lindy M. Swanson, Chief of Police 04/29/94 REPORT SUBMITTED BY DATE BA 252 (6/83) • I • • xJ 01 01:4 o 0 a c.D IA Hw H Z H a Cfl E.-4 f:4 Z 0 W xg H0 til o Z . H w W .8 a H H oH x oN 3 • . o a H z lwo W Aa H E' Z .a a a • H H "'M o . co iHa �I O1 � 4W � Gy PI H 'd' ■0 H E E >4 0Hxci] 54441 ° . 0 A a 0 •• ' ' 74 I OCx- Ax ril () H 0 0 W . H V. P: 4 o Z wHb 0 ri4 . : . o w �aHwH4 x3Aw 3 0 A H W �a 3 i z x r a H Y A 1 1 a H A �] Ha+ H t awHa! v 8 Minnesota Department of Labor end Industry Workan:Compensation Division First Report of Injury 443 Lafayette Road North instructions in folder accompanying forms. 1. cases 11111111 111111111111111 Ill 1111 St.Paul,MN 66166306 (8121 298-2432 All dates must be entered in MM/DD/YY format. Type or Print. EMPLOYEE 2.Name (last,first,middle) 3.EMPLOYEE SOCIAL SECURITY NO: Staberg, Rolland Jerome 474-46-2959 4.Home address(include county and zip) 5.DATE OF CLAIMED INJURY: 1418 Stagecoach Tr. Do Not Use this Space Afton MN 55001 1-6-94 6.Sex: Male _Female 7. Marital Status: Married X Not 8.Occupation: 9.Date of Birth: ,�3Q/ 5 20 88 Public Works Dept. Employee 10.Date Hired: / /_ 11.Regular Dept 12.Home Phone No. (A/C,No.) Smite 13.Apprentice: X_No _Yes 612-4'16-RS1R WAGE INFORMATION 15.Rate per hour. 16.Hours per day: 14.Average wage/week 14.29 8 17.Days per week: 5 18.What is the weekly value of MEALS: $ LODGING: S 2nd INCOME: $ 19.Employment Status: Full time _Part time _Seasonal Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No_ •OCCURRENCE 20. PLACE(include dept&full address) 21.Date of first 22.Date employer day of lost time: /_/ notified of injury: 1_07 / 94. Brekke Park Ice Rink 23.Return to work date: _/_/_ 24.Date employer notified of lost time: / / 26.Time of day 11:00 Id AM {{��'� ^ 25.Date of death: _/ / of injury: ❑ PM 6 On employer's premises? 1i1 Yes I-1 No 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL,BE SPECIF IC(include partial of body affected,•.g.amputation of right index finger at 2nd joint,fractured arm,lead poisoning( Slipped on ice - hurt lower back and tail bone 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED (include name of other individuals involved,tools,machinery,objects,vapors, chemicals,radiations,unnatural motions of employee) Moving Snowblower Backwards - Slipped on ice. 29. PHYSICIAN (full name,title, address and phone number) 30.HOSPITAL/CLINIC(name and address) 31.Witness and phone number. Jeff Kellogg - 439-0550 EMPLOYER 32.Legal name&mailing address incl.zip 1 7 94 34.Unemploy ID No.: AK PARK HEIGHTS 33.Date form completed: / / 14168 57TH STREET:, BOX 2007 STILLWATER MN 55082 35.SIC code Payroll Class Code 36. Print supervisor's name and phone number. 37.Employer's Representative,print full name,tide and phone number. Roger Benson - 439-4439 SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T 0CC INSURANCE 38.CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF- INSURED 41.Insurance Class Code: P.O. Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: - 42. CARRIER CLAIM NUMBER 02--000729 44.Adjuster ID No: 0698639002 • LI.20320-06(1-921 Original to Berkley Administrators BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division Minnesota Department of Labor and Industry 443 Lafayette ette Road North Division First Report of Injury St. Lafayette Road North a instructions in folder accompanying forms. A Case/ I 111111111 VIII 1111 III II > St.Paul,MN 66166-4306 (812)296-2432 All dates must be entered in MM/DD/YY format. Type or Print. EMPLOYEE 2.Name (last,first,middle) 3.EMPLOYEE SOCIAL SECURITY NO: 'CL k/g-N1 _ �-- / / 7A (� 5/4 -, 9 / �17i-trite P -/'"7 lam-'" .�a5 9 s"S D 4. Home address linErlude county and zip) 5.DATE OF CLAIMED INJURY: ` �'S �,7Z6' (7d%n 'C'' �'/; Do Not Use this Space �) ��� 6.Sex: Male Female /�( /� e 4/1 // s'.� / - 7. Marital Status: _Married Not 8. Occupation: !(��L/t/ 9. Date of Birth: LA, 9g 10. Date Hired: / /_ 11.Regular D 12.Home Phone No. (A/C No Z`/ / � "7 � (f/ ')/ ✓ 1/I j was jq 13.Apprentice: No _Yes WAGE INF RMATION 15. Rate per hour. 16.Hours per day: 14.Average age/week /4s' ;'4 1,04J- , z9 17.Days per week: c 7A 8.What is the weekly value of MEALS: $ LODGING: 3 2nd INCOME: f 19.Employment Status: /`Full time _Part time _Seasonal _Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No OCCURRENCE 20. PLACE(include dept&full address) 21. Date of first 22. Date employer t day of lost time: _/i/ notified of injury: _/ /_ /6 e 7/l i Y f - - ,. A,...�=_ 24. Date employer notified 23.Return to work date: /_/_ of lost time: / / r-I 25.Date of death: / / 26.Time of day y / c... I-1 I 1 No of injury: X // ❑ PM On employer's premises? I l Yes - , 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL,.BE SPECIF IC(include part(s)of body affected,•.g.amputation of right index finger at 2nd joint,fractured arm,lead poisoning) 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCC/BRED WITH DETAILS OF HOW EVENT OCCURRED (include name of other individuals involved,tools,machinery,objects,vapors, chemicals,radiations,unnatural motions of employee) 5z,,,,eyed „iii le H .1 it....... )9,1e71/4/ z 29.PHYSICIAN (full name,title, address and phone number) 30. HOSPITAL/CLINIC(name and address) 31.Witness and phone number i��=�! //��� . �� EMPLOYER 32. Legal name&mailing address incl.zip ... 34.Unle/mploy ID Nki.d 33.Date form completed: / /l7/ ' OAK PARK HEIGHTS S 14168 57TH c TEE- , BOX 2007 35.SIC code Payroll Class Code STIL.LWA i ER MN 5500E-0000 36. Print supervisor's supervisor's name and phone number: 37. Employer''ss Represe tative,print full n me,title and hone number: fp 1/' fig ir(-51&e (, A SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAMS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF INSURED 41.Insurance Class Cade: Mpls.,Box 59143 pls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: 42. CARRIER CLAIM NUMBER 44.Adjuster ID No: 0698639002 02-000729 LI-20320-06(1-921 Original to Berkley Administrators BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division Workers'ers'•Department Division Labor and InduW First Report of Injury Worker'Compensation Division (81 Lafayette Road North _ I IIIIIII 111111 11111 1111 III IIII St.Paul,MN 661661306 instructions in folder accompanying forms. I. Canal (81 Lafayette 286-2432 1 ates must be entered in MM/DD/YY format. 1 •.e or Print. . EMPLOYEE 2.Name(last,first,midd ) 3.EMPLOYEE SOCIAL SECURITY NO: 4.Home address(inclu ••unty and zip) 5.DATE OF CLAIMED INJURY: f , , e-1--44-141 �il / 2-/0- 473 Do Not Use this Space e 41retv, me,ve 6.Sex: Male _Female � 7. Marital Status: Married Not 8. Occupation: 9.Date of Birth: d lirF � 10.Date Hired11i6�/ �r e;r e 11.RegularAp 12.Home Phone N C No.) pa-Ali r eq ,i 4w / ,/s ,+„ ,+„ i° I ,°C 13. Apprentice: No _Yes WAGE INFORMATION f / 115 atee per hour: i+'`e+/, 16.Hours per day: 14.Average wage/week i 5"7 , -/ 4;4, 2 90 6 17. Days per week: C 18.What is the weekly value of MEALS: $ LODGING: S 2nd INCOME: $ 19.Employment Status: Z(Full time Part time _Seasonal Volunteer IAttar1.'a° statement for part time or irregularly scheduled employee.) If employee is a police officer or fire_fighter: Smoker: Yes 1"-1' •OCCURRENCE 20. PLArc'° 22.Date employer 019r 0 _/- notified of injury: I / /Si 1/3 /��qc, #1C 24.Date employer notified Sii i l O /lV i _ of lost time: -/_/- /G L 26.Time of day 0 AM + -/- of injury: PM On emolo 27.DESCRII f�; , "�. .rj L / ) ,' ndex finger at 2nd joint,fractured arm,lead poisons-1W ha-, 4 ��/�,,Z ( l _ �, ' -22 21 r- 1 1 28.DESCRIBE % ,,// It that individuals involved,tools,machinery,objects,vapor, ! chemicals,redi ,.C'( ('''. -. s-4-tiy ( '24-'2- - te7/117,- 29. PHYSICIAI ✓" ` J. i v ls) 1 ui2,eut--y- ---e-z-E4'--"-) EMPLOYER !t ''`'' '''/ 34.Unemploy ID No.: C c(.-ri' 14168 57 /Y� / Payroll Class Code STILLWATI %*� /f '" i, ` t//// ,e. zz/ 36.Print supervisor ��2'mot' ` // ame,title and p ne number: 1 k .,,t-g- ./6- 6j72)-e-- v Her �`s X3 -'yV39 SEND REPORT `�4J, AINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HEF l� N Z �GC ��Z.� OCC INSURANCE 38. /{'.I �,' JSTER � , p �n r°e Berkley Administrators ArL fi--h - '' Box 14 1 SELF 59 3 I �Ipis., MN 55459-0143 . ► .., il2) 544-0311 42. CARRIER CLAIM NUI %LiJ?9/L % � ID No: 0698639002 ).6ebtid /, /(3/93 L-20320-06(1-92) /r Z BA 251 S/I (4192)5.. - i i Minnesota Department of Labor and Industry Workers'Compensation Division First Report of Injury 443 Lafayette Road North •ACaSa 'St.Paul,MN 66166-4306 a instructions in folder accompanying forms. ' 11111111 111111 11111 III!Ill lilt 1812)298-2432 All dates must be entered in MM/DD/YY format. Type or Print. EMPLOYEE 2.Name (last,first,middle) 3. EMPLOYEE SOCIAL SECURITY NO: Staberg, Rolland Jerome 474-46-2959 4.Home address(include county and zip) 5.DATE OF CLAIMED INJURY: 1418 Stagecoach Trl. 12-10-93 Do Not Use this Space Afton, MN 55001 - Washington County 6.Sex:XX Male _Female 7. Marital Status: Married XX Not 8. Occupation: 9.Date of Birth: 03 / 30/42 10. Date Hired: 05 / 20/88 City Worker - Oak Park Heights 1 1. Regular Dept: Public Works (41 )1 me 436 Phone-85 No.38(A/C,No.) 13. Apprentice; X No Yes WAGE INFORMATION 15.Rate per hour. 16. Hours per day: 14.Average wage/week $575.00 $14.29 8.0 17. Days per week: 5 18.What is the weekly value of MEALS: $ 0 LODGING: $ 0 2nd INCOME: $ 0 19.Employment Status: XFull time _Part time _Seasonal _Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No_ OCCURRENCE 20. PLACE(include dept&full address) 21. Date of first 22.Date employer Oak Park Heights day of lost time: NONE /-/- notified of injury: 12 / 13/ 93 14168 N. 57th St. , PO Box 2007 24.Date employer notified Oak Park Heights, MN 55082 23.Return to work date: / ! of lost time: _/ /i 25.Date of death: / / 26.Time of day El AM of injury: IS PM On employer's premises? pLI Yes ri No 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL.BE SPECIF IC(include part's)of body affected,e.g.amputation of right index finger at 2nd joint,fractured arm,lead poisoning) Back 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED 'include name of other individuals involved,tools,machinery,objects,vapors, chemicals,radiations,unnatural motions of employee) Tool: Crowbar Removing manhole covers with Jeff Kellogg 29.PHYSICIAN (full name,title, address and phone number) 30. HOSPITAL/CLINIC(name and address) 31.Witness and phone number. Jeff Kellogg (612) 439-0550 EMPLOYER 32. Legal name&mailing address incl.zip 34.Unemploy ID No.: PARK I ) r 33.Date form completed: 12 /14 /93 5_ARK OAK "1E I GHT>S 14168 rn- { STREET, Et h 2007 35.SIC code Payroll Class Code ST I LLWATER MN 55082-0000 36. Print supervisor's name and phone number. 37.Employer's Representative,print full name,title and phone number. Roger Benson (612) 439-2522 City of Oak Park Heights (612) 439-4439 SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.CARRIER 39. Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF INSURED 41.Insurance Class Code: P•0. Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: 42. CARRIER CLAIM NUMBER 44.Adjuster ID No: 0698639002 LI.20320.06(1-92) Original to Berkley Administrators BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division Minnesota Department of Lobos' Indutry First Report of Injury Workers'Compensation Division 443 Lefayilt• North 1 A Case` Paul,MN B5155156-4305 = instructions in folder accompanying forms. 16121 298-2432 •ates must be entered in MM/DD/YY format. I •.e or Print. EMPLOYEE 2.Name past.first,midd I 3.EMPLOYEE SOCIAL SECURITY NO: KELLOG-& 7'E F PAUL. _IV, 70 ° 113 4.Home address(include county and zip) 5.DATE OF CLAIMED INJURY: 70 a Mt E1-14 57- S T iL.L WATER 0.1/0/13 Do Not Use this Space 1 Ac H r�6--rg� g5/1 Q 9 6.Sex://AMale _Female 7. Marital Status: Married Not (T I ..7 if QO/�► 8. Occupation: PARKS -5 Up./V!5O 9.Date of Birth: 4-g--1111/-2V" 10.Date Hired: 7 /06/77 1 1.Regular Dept PI A(i&TE NA Alc-E 12.Home Phone No. (A/C,No.) 13.Apprentice: XNo Yes ( /a) 1+39 - Osso WAGE INFORMATION 15.Rate per hour. 16.Hours per day: 14.Average wage/week 7.15 00 // TI rc • //A?+ 17.Days per week: sr 18.What is the weekly value of MEALS: $ LODGING: $ 2nd INCOME: $ 19.Employment Status: X"FuII time _Part time _Seasonal Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No_ e , OCCURRENCE 20. PLACE(include dept&full address) 21.Date of first 22.Date employer t day of lost time: / / notified of injury: 4 1.//3/ 413 t'/i of l cf6-tfT S `� 23.Return to work date: / _/ 24.Date employer notified of lost time: / / 1 25.Date of death: / / 26.Time of day I:1 AM On employer's premises? Yes I No --- of Injury: ik PM 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL.BE SPECIF IC(include pan(s)of body affected,s.g.amputation of right index finger at 2nd joint,fractured arm,lead poisoning) M r A) Z& LOW6g• IMO< ) (IAN T 5 7AND & ! T 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED J(include name of other individuals involved,tools,machinery,objects,vapors, chemicals,radiat ions,unnatural motions,of employee), v 'A S PO/"/'/N6- /t91��v#G'4E C 0 VET $ r fy Q It Ea< ch/ui/Tyei?y c '6kSq .met Ti`/ ke4,4 ;`5 �"'rft jEeX6- �, t/t.1 -r I* f P4xe7-10tf4ty 1‘•-v l el te0 Gi✓ AA Az / 777/E'v Cr /1/36 7-ive' )!-if 1/lAAl. •`✓c` A"�i. Q -'"' (.7J /Nr- 29.PHYSICIAN (full name,title, address and phone number) 30.HOSPITAL/CLINIC(name and address) 71 71r"1 C L e-4 At ft 31.Witness and phone number' e"-L-I E srAtr347'Z R &r 93( - 0. 3 EMPLOYER 32.Legal name&mailing address incl. 34.Unemploy ID No.: 33.Date form completed: /4111/ OAK PARK HEIGHTS 14168 57TH STREET, BOX 2007 35.SIC code Payroll Class Code STILL WATER MN 5508P-0000 36. Print supervjsor's name and phone number. 37.Employer's Representative,print full name,title and phone number. kin 6-E-k 4ENsort; 4137- .:25a - C/ TT" 0, 4.14k' PA kW /f6-7-c. Y3?` `/Mf. cj rSEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.CARRIER 39. Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF- INSURED 41.Insurance Class Code: p•�• Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: - 42.CARRIER CLAIM NUMBER 44.Adjuster ID No: 0698639002 fl_PS1i7!t c L LI•20320-06(1 42) Original to Berkley Administrators BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division Minnesota Department of Labor and Industry WorkerstCompartment Division First Report of Injury s St. Lafayette Paul,MN Road North a instructions in folder accompanying forms. A Casa/ 11111111 II�I�I 11111 I��I 1111111 St.Paul,MN 66166-4306 1812)2e8-2432 All dates must be entered in MM/DD/YY format. Type or Print. EMPLOYEE 2.Name(last,first,middle) 3. EMPLOYEE SOCIAL SECURITY NO: Kellogg, Jeff Paul 469-72-2193 4.Home address(include county and zip) 5.DATE OF CLAIMED INJURY: 706 W. Elm St. 12/10/93 Do Not Use this Space Stillwater, MN 55082 - Washington County 6.Sex: X Male Female 7. Marital Status: X Married Not 8. Occupation: 9.Date of Birth: 12 /03 / 56 10.Date Hired: 09 103 !77 Parks Supervisor 11.Regular Dept: 12. Home Phone No. IA/C,No.) Maintenance (612) 439-0550 13. Apprentice: XX No _Yes WAGE INFORMATION 15. Rate per hour. 16.Hours per day: 14.Average wage/week $72. 5.00 $16.91 8.0 17.Days per week: 5 18.What is the weekly value of MEALS: $ 0 LODGING: $ 0 2nd INCOME: $ 0 19.Employment Status: XFull time _Part time _Seasonal _Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No_ •OCCURRENCE 20. PLACE(include dept&full address) 21. Date of first 22.Date employer day of lost time: NONE !-/ notified of injury: 12 /13 /93 Oak Park Heights City Hall 14168 N. 57th St. , PO Box 2007 24.Date employer notified 23.Return to work date: -/-!- of lost time: /-/ Oak Park Heights, MN 55082 - - r-� 25.Date of death: / / 26.Time of day ❑ AM On employer's premises? Yes I I No --- of injury: XX PM 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL,BE SPECIF IC(include part(s)of body affected,e.g.amputation of right index finger at 2nd joint,fractured arm,lead poisoning) Pain in lower back. Am unable to stand erect. 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED (include name of other individuals involved,tools,machinery,objects,vapors, chemicals,radiations,unnatural motions of employee) Was popping manhole covers to check sanitary sewers with Rollie Staberg. Lift them partially with crowbar, then grab them with hand and swing them clear. 29.PHYSICIAN (full name,title, address and phone number) 30.HOSPITAL/CLINIC(name and address) 31.Witness and phone number. Rollie Staberg (612) 439-8538 EMPLOYER 32. Legal name&mailing address incl.zip 34.Unemploy ID No.: 33.Date form completed: 12 /14/ 93 Oft)< PARK HEIGHTS 14168 57TH STREET, BOX 2007 35.SIC code Payroll Class Code ST I L.LWATER MN 55082-0000 f 36. Print supervisor's name and phone number. 37.Employer's Representative,print full name,title and phone number. Roger Benson (612) 439-2522 City of Oak Park Heights (612) 439-4439 SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF- INSURED 41. Insurance Class Code: P.O. Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: 42. CARRIER CLAIM NUMBER 44.Adjuster ID No: 6P-0007P9 0698639002 L1 20320-06(1-921 Original to Berkley Administrators BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division Minnesota Department of Labor and Industry Workers_CotnpensationDivision First Report of Injury 443 Lafayette Road North 'instructions in folder accompanying forms, 1• I I�'II�'j��Il�1'�'I������+�'�� St.Paul,MN 66166-4306 I 111 11(6121 296-2432 ates must be entered in MM/DD/YY format.or Print. EMPLOYEE 2.Name(last,first,middle) 3.EMPLOYEE SOCIAL SECURITY NO: �,J) r nrupictiet,>5r.'s., Fit- 'n A1-✓.E °�8,�- c,c, • (42) t0 �. c�<,. ,I CJ ,•, raj 4.Home address(include county and zip) 5.DATE OF CLAIMED INJURY: c9C, /10 N LN /�L' O}�� Do Not Use this Space f:A3CC-l'Obc.3r MN SS/a'S t .9"- 9 �> 6.Sex:&Male _Female �JAS h,v- }o 7. Marital Status: Married Not I 8.O c c�u j a t i o n: 9.Date of Birth: / // / l�0 1- z`,I k: �� 10.Date Hired: C�!al / fl 3, 11.Regular Dept Al 12.Home Phone No. (AIC,No.) 13.Apprentice: No Yes o PY1-?-ic ;-ce)�h-f-, Co I a-- 'The> ?S'7 WAGE INFORMATION 15.Rate per hour. 16. Hours per day: 14.Average wage/week //S 7 e 8 17.Days per week: S' 18.What is the weekly value of MEALS: $ G) LODGING: $ d 2nd INCOME: f d 19.Employment Status: XFull time Part time _Seasonal _Volun ear(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No OCCURRENCE 20. PLACE(include dept&full address) 21.Date of first n 22.Date employer )3 �+ day of lost time: (-f/ O'fi/ 5 3 notified of injury: 01 iO(1 93 • " 1.x _ - ss J r 24.Data employer notified dh r/ 'A 4177] A14/ 23.Return to work date: Ott /617/ r/ Cj f( r`� �'1 /� y of lost time: d / 9 t-1 / ��,,11 25.Date of death: / / 26.Time of day Q!. AM On employer's premises? 1 1 Yes yV No of in jury: 0 13o 0 PM 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL,BE SPECIF IC(include part(*)of body affected,e.g,amputation of right index finger at 2nd joint,fractured arm,lead poisoningl 5 CMN'et11P r13" GrAVI.Q 29.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED (include name of other individuals involved,tool*,machinery,objects,vapors. chemicals,radiat ions,unnatural motion.of employsel If/1 ‘5,21.-ii CIA- faVike.>v' `.fit-�1 t�J,p re a� 4 11"'-'c4(0-c,,,� G o, -1- (.vas 2)0.4 I r, �L-t hdv uz -Cc. Coy-•'G c k '-e "'el by\ate S ry.i s,...,:.,1 '.e.t -ice 2 s)s�) Co,A n pN -Sco Srot.p C� vw` a1�, re sc.?1)1.� lP. q .P,r-y>ro� canACk Cr., 1,c) 29. PHYSICIAN (full name,title, address and phone number) 30.HOSPITAL/CLINIC(name and address) J - or' Cea( , AMM E/Ul'�r c.a�r ( G14«.P 0/64,4) /YlE/HOr/)4-1 1-ez r 31.Witness and phone number: gr44'J c--tcy(o_c� 4-01-9( 1(0 EMPLOYER 32. Legal name&mailing address incl.zip 34.Unemploy ID No.: 33.Date form completed: 05/0// OAK PARK HEIGHTS 1416B 57TH STREET, BOX 2007 35.SIC code Payroll Class Code ST I LLWATER MN 55052-0000 36. Print supervisor's name and phone number: 37.Employer's Representative,print full name,title and phone number: v GA: -L.;,rr4iy soda.,vsr v his -fir-17.z3 _ L.. v.,r>ti 4).'had Ai&. G/a. - 7,31 SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC 1 INSURANCE 38.CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF-I Iv S U R E D 41.Insurance Class Code: P.O. Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: 42. CARRIER CLAIM NUMBER 44.Adjuster ID No: 0698639002 02-000729 ll-20320-06 f1-921 Original to Berkley Administrators BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division • • ]o rni N H rn 1 rgl DO NI 2 8 -N , ■ mi 5J . .. .. mn . z 8 N > N 'O Z - iM3MR g VII 1, Mellit,r, r/23R ::: 0 .. 1 ° Igigtgogl . iwil . I IcilMRq 11M P0F — z Milt 113 (1 g 8 ti_11 cy, 1 I A gN gM8 tzi 2 t V -) @ _ gN t4g t§ imhd ri ?ici PNr-cnvci sg H n a30-0 M g8q 8 igg t N mg I tri D i � v n �• 'AD ,�� t2i 5 3 l 'a'r!U' = i n aw 21 O A) E yy Q, m N5 O m eg 1 1 fig ., 0 - 0 x -4 33 • k i H PI i , \\1 ,,, • ',„, ‘u., I � 'r l% 5 1 S S--c r G m " '"d C l 4;py, •1 o r- f"r ► CH) rs . Q cP 50-4V►-cO'k-ti J S, —i- LL.Q S v Jae 0i'' p (..,1/4.)0 '�o/� cetiA c 01-4 'tq • • 111 ...:71 „..,:,...4.5 -,/,..„-ki--, 4._..y, „;,..-,0".3 ( 11 2 ) 119-5:130 ) -SOO- 421-721 2 M I S S I N G I N F O R M A T I O N S H E E T DATE: 9/10/93 PATIENT NAME: Fred Kropidlowski DATE OF SERVICE: 9/4/93 _-_ As a service' to our patients , wo process lnsnr'nnre claims on your . behalf . Please send or call us with the following lnformni. tnn : Social Securi ty Number of Patient : Neat t.h Insurance Company : • Address of Insurance company : City t,y and S t a t e : _ - - - Z i p ID No . or SS# of Policy Holder : Group No . _---- --- - --- _ . _ - Policy Holder Name' : Relationship to Policy Holder : - Claims to he paid by : _ Automobile or Worker ' s romp . Policy Holder ' s Name : ed J. Kropidlowski Relationship : _ _ Insurance Company Name _Fr Berkley Administrators Insurance Address : P._9.._,.0x_59.1,.4-3-- ---------__--. City & State : Minneapolis, MN 55459-0143 _ 7.i P ___._._ _. . . Agent or Employer ' s Name : ._.. City of O k_Park Heights —____ .._ .._ ... Worker ' s Comp . Claim 1 : _ 02-000729 Automobile Policy # : We ne'r'd the indieat.erl information to process this claim for vote . Please fill out and rettern f n I.AvrfIF'W MF'MfIiAI, 7105PITA1, wit )rirn r•, date . Please use the e'nc 1 o^n'd ,1 t nmt'.'cl envelope or rn 1 1 11" n l I 'en 4515 . 1 f wr have no f heard from rote w i t h i n 5 days , I I w i l l t+.• xour responsibility In pay yonr ncr•n11nI in full within 21 days and fi t ,- your own i nsteranrr' . • -RECAPITULATION BY QUAR - - 410 EMPLOYEE RECORD DEDUCTIONS FED STATE DISH- NAME_J_L .� ___ _ ' y /v EXEMPTIONS__ n- OTR. EARNINGS F.I.C.A. I NET PAID - WHLDG. WHLDG. BILTY p ADDRESS /1f_ C'�A/// QU PHONE__ __—_ __ .I-IT 1st j II S. S. ACCT NO.—_ .6,4 �_yQ.-/_O-—. -_SEX_� SINGLE 2nd I � i I I I �(/n =' MARRIED i CLOCK NO. _-_POSITION__L -- -. ___. _-- DATE BORN ?/4/4). ant a..a.!C¢,;....4 HRS. PER DAY__ PER WEEK .__..__DATE EMPLOYED7/</93TERMINATED____- dth I II p'- O/#-yrD_ - REMARKS �__ /� F _ _- TOT. RATE OF PAY DATE SIP PER 1!j— DATE 07 S-1Y .I PER '7.. 1/1 Boorum & Pease W 152 FIRST QUARTER - 19_9, .(51L•L� it I! REGULAR `' j NON ! 11 PAYROLL I, OVERTIME1I W--� # ,? TIME TOTAL lTA XABuEII AM'T DEDUCTIONS NET EARNINGS s w__-_ ; I PERIOD `I iEARNINGS _ #I TAXABLE -€ -#' ii TIMEORATE HRS RATE I SICETCPAYE 1# F 1 C A 1 FED. I STATE DISA i AMOUNT DATE II II WHLDG. 1 WHLDG SILTY 1 FAIR 1 � ,r!j X1.8' - �c�y f.JY37 s', i_ . '��5O :;D /36/7._ -�� �I 33�i.�93 ; � .rS F �� �.�5' /5� S8' 31A� [3/t # - ifI j 8�0 1 11:'7, ..47. /6 4 4/ I t,.E I , t I 3 E 1 i II 1 f 11 i 11- I 1 I I I I I I 11 1 I ft itil r4 11 j { w. TOTAL ' - ' ' I ' )$ � 1ST R. f ^ I i 1 1 i _„._341.1.2.0o..._.. I4_ 3 SECOND QUARTER - 19 2.3 3 { I IREGU LA RI NON- ';OVERTIME; I PAYROLL 1 TIME I TOTAL A ITAXABLEI; M'T D E D U C T I O N S NET EARNINGS — -4— _. !. PERIOD ) 1 1 EARNINGS i SICK PAYE TAXABLE I i — I I _ .t € DATE ii ! ITIME RA7E#I HRS_tRATEI ,i ETC I1 F I C.A.t FED. STATE # DISA- PAID # # ( I II 1 WHLDG. iWHLDG.1 BILTY q9E ...�1 D AMOUNT —_ I=_ 1 i . I '15i Y,/4 — iI �� r ' . 3/y ts.�.51 *y.3118.051 .114.3c �:3'It''i-- yya __I g3_I Gag ,_ 3yb`� ?0.a3 y).0(-11.2.57.. __ S I E _A/.? S°'' - `i t , I . / ,= II ,I % I 03 Q.,18.4..-3 ;! 11 S.;*1. g',"111 SY.dtil 6.• j {� /_ I 1 {l......... .._........._.14 : �.,J ' .I . ........._ ....jf.7LY-.-.3-97 .._..... ! .7,23Ti 11 ii # #I i II 1 I _ ..., it ! 14 ,,* 1 i : 1 it .t. 4 ...: „ 1 ii_ , .. I I I Ij I 41 I , It , , - ii i 3 ,, , , ,, ,, P i TOTAL 11 �/f x' } ...., .�,.. ._.._......_...7._._, 4 .--w-- 1 2ND OTR. ii21 0 h°7 t I ( C b 3'� 50'3& l`t�.l-i 3�. _. ' .e l ._ TOTAL it !I 2-8 °J ' { 1 (0'3 - 1_5.0.3 8' 230 81 H1R3 z Q$ " #I • [E © F27 1 11 - 6 1993 Di Berkley Risk Services, Inc. DATE: August 4, 1993 RE: League of Minnesota Cities Insurance Trust Detail Claims Report - Property/Casualty Program • City of Oak Park Heights Enclosed please find your Property/Casualty claims' report for the League of Minnesota Cities Insurance Trust Program. Please review this report, should you find any discrepancies, notify Joanne Chambers at (612) 376-4272 of our office. Berkley Risk Services, Inc. • 3/18/93 LMCIT26 920 Second Avenue South,Suite 700 •Minneapolis,Minnesota 55402-4023•(612)376-4200 • Fax(612)376-4299 A Member of Berkley Risk Management Services Group • • 0 m m O Lfl O Olf1 O O 000 000 0 O H O O , 0 0 . . . . . . 0 N O O O N O O 0800000 O N O O N O O Or-- 00N00 0 0 0 0 0 0 0 0000000 H H H .-1 0 .-I H 0 L11 Ln N N N N O M M 0 0 07 41 OM Ln M m N a H .-I 0 H H wj . . a . . a . . . . . m • H � WEz+ZO �,NjEz Zp . 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Ey N 0 LL W N s W O .-I .`4 co N S rMi or E F z a N O O N Z H Vi < Q Q w 'i' O 0 0 op, QwrWZOQWQ m 0 N •• FZ W F-� HFOUZ r1 X . W " nu Co'Jwn �D .-1 H H H H H H m H 0 0 N 0 � ayFU w 1 N O w a H 0 0 fa W 0 0, w > > >+ >+ W . m g U U U U fPx 00 m0 H P 2 H ,tay;,i` -,y,fr. desy.;. ,Ar4$,k w r •.✓ ""i ',risk", �1o`s•}*±.a4c ,6 ..i',4.7 "`' ..< xh 'q..i74,:4 ,,.y„ t`tf "t''7,,',. '''f p ' a n `.t Sate of Minnesota• FIRST REPORT OF INJUR Department of Labor and Industry '' Workers'Compensation Division (See Instructions on Reverse Side. Type or Print) „ 443 Lafayette Road }, St.Paul,Minnesota 55101 ��++ //���}``},, EMPLOYEE BENEFIT ADMINISTRATION CO. 612-296-6107 (EBA) A Member of the Berkley Risk Management Services Group 8441 Wayzata Blvd.,Suite 200 • P.O.Box 59143 Minneapolis,MN 55459-0143 1. Administrator's Claim Number Phone(612)544-0311 2 Employee's Social Security Number 'J`3 k0 - EI° Official the Only 3. Date of Claimed.Injury .$ Employee's Name(Last,First,Middle) T ' Phone(Include Area Code) Sex Male - .. .forger)3ot1• ltchir'ti_ Arlen (612) 439- 73494 ❑ Female 5. Address(Street,Route,P.O.Box) Date of Birth Marital . Married . e!(1 j6 itch.;:Isree11,.' r!`w'':#i l s N. 12/15/41 Status ❑ Not Married' 6. City,State,Zip Job Title t (( Type of Work Program :!t.i 1-L>74,!f?).') :X,'J 5. tJ'JG g)r)2 1.0 e spt. ❑APPrenticesh)p Employment Status �-{ ❑Other(Specify) ], Lt'Full time 0 Part time ❑Seasonal ❑Volunteer. ❑Other (Specify,irregularly scheduled,etc.) . Straight Rate Per Hour Hours Per Day Days Per Week Overtime Rate Per Hour Average Hours Per Week Average Gross 8. Time le If Paid la. Weekly Wage► 22..51.) i 5 33.75 ,' 975.E If part time or irregularly shceduled worker,indicate total amount Amount Earned Total Days Worked Total Weeks Worked 9. earned,total days worked,and total weeks worked in last 26 weeks. If furnished in addition Meals Lodging Other Did employee have Hours/Week Weekly Wages I U. to wages,state the other regular ❑Yes.If yes,where? o. weekly value of • $ $. $ employment? ❑No Did claimed injury cause 1 iY First day of lost time Did the employee lose time from work Hours lost 11, loss of time from work? ,,,,,,,Yes'❑ If yes ► on the day of claimed•injury) ❑Yes.If yes• 'LT y No . 'tli No Has employee YYomr��s-- Date Were full or artial wa es aid ' 12• tom•Yes.If es ► P 9 P $Paid Hrs.Worked returned.to work? - y Yes.If yes► for first day of lost time. y[� ��••yy�� t� ❑ No Ij. 4—%., ❑No 1.95x00 8 Employer(If subsidiary,also specify parent's name and address) Phone(Include Area.Code) Type Ype of Ownership ❑Individual 0 Corporation 1. `''??L,t 'lt 3 y 43'1)-443 )t at5 { 0 Z I'41 fT � ❑Partnership 'C:7 GoVernmeot Department Phone(Include Area Code) 14. 'oiicr. 'it:,Ep,3t t (612) 439-4723 Sc i I I 15 employer's Street Address Name and title of Supervisor who first received notice of claimed injury 14168 N. 57 !A `.1t. -° PO 110K 20107 1,1111y 3''i n: ro:'l, T}c .1.i it Chhie 16. City State,Zip Date when notice received Time of day that A.M C i3 t)t. r: 't ii. J "' r 't i. t ( 43 injury ocourted Q P.M. t 7 Location where injury occurred(identify job.site)(identify city,zip) Did injury occur.on ❑Yes employer's premises? y� 3�i.).5 .`il ,( x!)3'2 t'2 . , (,),1,,,,,,.., park" :42(.f3i) ,da r' 5 `..)ti? �7 No.If no,where? Total number of employees at the work location where. C p, ••I1 •y Park .S i., 17a. the claimed injury occurred -`,J, ,i-'51V e i,1 r.'o i"c .i j. f Oa . Park 1�?iP,,e;t'r9S 18. Name of treating doctor or practitioner(Specify MD,DO,DC,etc.) Phone(Include Area Code) If treated at a hospital or hospitalized,name of hospital 19.• Address Hospital Address 20.....:City,State,Zip - City,State,Zip 21 Describe claimed injury or occupational illness in detail Lower i)a'."-; , 11r1 la' i)a.L 1 " lei? ?t;t iChei: 3o liC r«3.,')O "(: 22. Part of body affected Name of object(machine,tool,etc(or substance(chemical,etc)involved .1 t{,{Cj• .3;'ll L -0 A 23 Nature of injury(cut,sprain,burn,etc), Type of accident(fall,struck by,etc:) What action has taken to prevent reoccurrence? '' 24 P Complete this section only if claimed injury or ilMass rewltsd in death. ,'•;,�(l t`a. Name of next-of-kin Relationship -':Date of death 25. Names of co-employees who may have witnessed claimed injury Address City,State,Zip 26 Name of workers'compensation insurer,if not on form ;it';ien Abcr t� Signed by(include official title and phone) 27. Dated L)-- I,- ''.! Sign Here ► MUST NOT BE SIGNED BY INJURED EMPLOYEE } EBA-251 S I(8/90).. White Canary—to EBA Green-Employee Blue-Employer ! IMPORTANT NOTICE The filing of this report is not an admission of liability. It should be filed with your insurance carrier when- ever anyone believes a work-related injury or illness has occurred. In many cases (see general instructions), the prompt filing of this form with your insurance carrier and the Department of Labor and Industry is required by law. Failure to do so may subject you to penalties. The best procedure is to file this report immediately with your insurer. This will allow your insurer as much time as possible to investigate the claim. Even if the claim is questionable, it is important that you report it promptly to your insurer, so that it may adequately repres'nt you. If you question the claim, you should attach any additional information to this report. GENERAL INSTRUCTIONS 1. Death or serious injury arising from employment must be reported to the Department of Labor and Industry, Workers' Compensation Division, within 48 hours of the occurrence. Either may be reported initially by telephone (612-296-4893), telegraph or personal notice within 48 hours, but this notice must be followed by the filing of the First Report of Injury with your insurer within seven days of the occurrence. 2. Any other injury which totally or partially prevents the employee from working for more than three cal- endar days or which causes permanent disability must be reported to your insurer within 10 days. The insurer or self-insured employer must report the injury to the Workers' Compensation Division within 14 days of the occurrence. When a reported injury subsequently results in death, a report of the death must be made to the Division within 48 hours of when you are notified of the death. 3. Any injury initially not reported because it resulted in three or fewer. calendar days of disability and no permanent disability must be reported if it later results in one of those conditions. 4. If the employee has a physical or mental disability which may have contributed to the claimed injury or illness, you should be sure to notify your insurer or your workers' compensation claims office of the disability and whether the employee is registered under the second injury (subsequent disability) provi- sions of the Workers' Compensation Law. 5. Any report of injury or illness must be made on this form,must include all information requested on this form, and must be signed and dated by a company official. Send the original and one copy* of this report to: EMPLOYEE BENEFIT ADMINISTRATION CO. A Member of the Berkley Risk Management Services Group 8441 Wayzata Boulevard, Suite 200•P.O. Box 59143 Minneapolis, MN 55459-0143 Phone (612) 544-0311 *The original of this report must be sent to the Workers' Compensation Division by insurance carrier. See distribution code on the bottom of the front of this form. • . * o o I m r 8 x. '� -a m G, m D pCp O -< m r r< O N n ---Im ma Z a O D z C 0 v) ►-+ °w C) - Z r (n 3 v O cn -i m n ..< f-r n K -1 z = i • Z rrnm m ~ xis ° m m v • 3 • 2c, < O rz rn7C3m O m • zmc ° v)_.1 O ��c D3mz -Dim ono �r N 70 73 ° o < C 7C C = ..1 zr -� o -1vrng � go z � __A xxi -4xi rxn'' °- a z w m ``) -1 ./N M D = w Z al Z • r D >- Cl)c C) ril 1 7Cvc° co W m 70 Q 4 O , N C Z Co K c--) O_ DOIr ° � vX ('- x v -I `� Zv °v373 D5 m7° �-'] n )-.xm ° ° 33 = . 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N W Co 0o X0 D0 C)JJ U1 X Z ZO 1 J 0 0 -CV m 0 N 0 m a m 0 • 0 0 a rn o o -n 0 -4 rn 1 0 I A m Cl) r Dm 3 3 A A 0< 3 Cm 01 O 0 0 0 Z Z p -i r -I D O 0 0 0 N N m G) Z0• OrD A — D. m Z .-•Co Cl) 0 3• m m N X A 0 CO A < CDWC mm <tn Z W m U)> 0 1 Z O 0 0 0 mo - CD O• 0 0 0 Z N -4 N O m ZA -I A 0 m -1.. Cl) CO D Z r • C .. 0 0O O 0 3 0 m A W 0 0 0 Z O N -I D Or A A O 0 0 0 C C 0 O• 0 0 0 m0 3 Z A D m 3 C- r) m O -100 '0 • CO 0<m D • N 0 A C m• C U) a <A A3 O 0 0 0 m — rn N CO a CO (D 0 A 0 O 0 0 00 P CO M m O W • O • • FOCIEDWE u Berkley Risk Services, Inc. 3 WE • Date: 8-14-92 Re: League of Minnesota Cities Insurance Trust Detail Claims Report - Property/Casualty Program 2ci % , . Enclosed please find your Property/Casualty claims' report for the League of Minnesota Cities Insurance Trust Program. Please review this report, should you find any discrepancies, notify your local GAB office, as GAB has provided this report for us. Berkley Risk Services, Inc. 4/92 920 Second Avenue South.Suite 700• Minneapolis,Minnesota 56402-i023 •(612)376-4200• Fax(612)376-4299 A Member u(Berkley Risk\I:iretr niern Services Grip f GAB • CLAIMS MANAGEMENT REPORTING SYSTEM FORM 892A(11 90 Type of Accident Codes CLAIM CODES CAUSE.CODE 10 Workers'Compensation (Refer to-Workers'Compensation injury Codes-Booklet(Form 1949)for Cause Codes.) 11 General Liability 001 Struck by hand tool or machine in use 032 Sunstroke or heat exhaustion 002 Struck by falling or flying object 033 Explosion or flareback 003 Struck by moving object (tipping,sliding.rolling) 034 Bites into a foreign substance 30 Products Liability 004 Struck by object handled by other person 035 Contact with irritating or corrosive substance 006.Strain in lifting 036 Breathing dangerous gases,vapors,fumes,dusts 007 Strain in using tool or machine 037 Swallowing injurious substance 008 Strain in pushing or pulling 038 Reaction to chemicals(rash,skin,burn,loss of hair) 009 Strain in holding or carrying 039 Drowning 010 Strain in reaching 040 Contact with electric current 012 Fall on same level 042 Stepping on sharp object 013 Fall to or from different level(stairs,docks, 043 Kneeling on sharp object ramps,platforms,scaffolds,ladders,etc.) 044 Foreign body in eye 014 Fall—Slip 045 Splinter 015 Fall—Trip 046 Animal bites or scratches 017 Striking against objects being handled 047 Escalator 018 Bumping into stationary objects 048 Motor vehicle accident(lift truck,tow motor) 019 Striking against moving parts of machine 049 Faulty equipment (saws,grinders,etc.) 050 Personal injury 020 Striking against another person 051 Collapse of building 022 Caught in,on or between machine or machine parts 052 Heart attack 023 Caught in.,on or between moving object and 053 Alleged damage to property of others stationary object 054 Observing foreign object(nausea) 024 Caught in,on or between two moving objects 055 Elevator 025 Cave is 101 Hospital professional 027 Contact with steam or other fluids(burns,scalds) 102 Physicians,Surgeons,Dentists,professional 028 Contact with welding flash 103 Misc.Medical professional 029 Contact with fire or flame 030 Contact with hot or molten metal 031 Frostbite 50 Property Damage 056 Fire and Lightning 080 Collision with bicycle 55 Automobile Physical Damage 057 Wind and hail 081 Collision with train or bus 058 Explosion 082 Collision with animal TRANSPORTATION 059 Riot and Civil Commotion 083 Collision with fixed object 060 Smoke 084 Collision with other object 60 Property on Insureds Premises 061 Aircraft and vehicles 085 Upset or vehicle(overturned,jackknifed,ran off roadway 062 Electrical breakdown 086 Damage in loading or unloading 61 Property on Premises 063 Sprinkler leakage 087 Equipment failure Other Than Insureds 064 Earthquake 088 Fire damage to vehicle 065 Water damage 089 Theft-entire vehicle 62 Railroad Shipments 066 Burglary and theft 090 Theft-parts or contents of vehicle 067 Vandalism&Malicious Mischief 091 Glass breakage 63 Railway Express-Mail Service 068 Sonic Shock Wave 092 Riot and Civil Commotion 070 Non-delivery or Mysterious Disappearance 093 Malicious Mischief and Vandalism 64 Truck or Automobile Shipments 078 Collision with motor vehicle 094 Wind,Hail,Explosion,Water Damage 079 Collision with pedestrian 095 Flood and rising waters 65 Aircraft Shipments(Mail, Express Freight) 66 Waterborne Shipments 67 Person 70 Burglary and Fidelity 071 Shortage in accounts 072 Dishonesty of employee 073 Disappearance of funds 074 Fraud 075 Burglary on premises 076 Robbery of interior 077 Theft in transit 80 Automobile Liability 078 Collision with motor vehicle 079 Collision with pedestrian 080 Collision with bicycle 081 Collision with train or bus 87 Automobile No Fault 082 Collision with animal 083 Collision with fixed object 084 Collision with other object 76 Public Officials 085 Upset of vehicle(overturned,jackknifed,ran off roadway) 086 Damage in loading or unloading 75 Umbrella 087 Equipment failure 096 Garage Liability 097 Garagekeeper's Legal Liability 601 Police Liability 602 Land Use Liability 603 Employment Practices Liability 604 Emergency Care Liability 605 Fire Fighter Liability All Claim Description 099 Unclassified 0 0 • O 1 1 • M W <t 0 0 • N . 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I- I- • • I ••• Ha J Uaa V)D0 0 0 0 • a W F- U OJJZaU F- F- F- • W ar in aUU ■-■ Ua • 03 CO W•-.., a W • XC0 CO a N 0 O • OOOZw W N 0 Z Z 0 • Z Da CO N 0 0 LCW ZZ > M M > H +- 21- 0 I- 7 0 Z 0 F- LU H V)H > Z I H H < Ln F- W F- 0M N < J 0 a 0 4 H H w V -J 0 0 OZOUJ < J in 0 a J MD W O O J H a 1 I I • O a a J a 0 w in 1 • J07;,. �Z,��.. ,Y,Syd, :' j7�".,. « +,. -�:.+rrMn - ,ay Stateroffulinnesota FIRST REPORT .CIF::INJURE Deparllhent of Labor and Industry Workers'Compensation Division (See Instructions on Reverse Side. Type or Print) `..443 Lafayette Road'. St.Paul Minnesota 55101 '/r EMPLOYEE BENEFIT ADMINISTRATION CO. 612.286-61.07 CEBA� A Member of the Berkley Risk Management Services Group 8441 Wayzata Blvd.,Suite 200 • P.O.Box 59143 Minneapolis,MN 55459-0143 1 Administrator's Claim Number Phone(612)544-0311. 2. Employee's Social Security Number SELF-INSURED vfflcal use only 3. Date of Claimed Injury' February 5,1992 j 4. Employee's Name(Last,First,Middle) Phone(Include Area Code) Sex Male HINNUNI Koehler, Michael Al/n 612 430-0403 ❑ Female ' 5. Address(Street,Route,P.O.Box) Date of Birth Marital at Married 14033 54th St. No. 7/24/53 Status 0 Not Married 6 City,State,Zip Job Title Type of Work Program Oak Park Heights MN. 55082 Building Off ical ❑Apprenticeship ❑Other(Specify).. Employment Status ys,Full time CI Part time Seasonal ❑Volunteer ❑Other (Specify,irregularly T t�. scheduled,etc.) , Straight Rate Per Hour Hours Per Day Days Per Week Overtime Rate Per Hour Average Hours Per Week Average Gross ~�' 8. Time If Paid► Weekly Wage► 16.25 8 5 If part time or irregularly shceduled worker,indicate total amount Amount Earned Total Days Worked Total Weeks Worked 9. earned,total days worked,and total weeks worked in last 26 weeks. If furnished in addition Meals Lodging Other Didemployee have Hours/Week 'Weekly Wages 1 0. to wages,state.the other.regular Yes.If yes,where? ► weekly value of ► $ $ $ employment? ❑.No - ` Did claimed injury cause First day of lost time 'Did the employee lose time from work Hours lost 1 1. loss of time from work? Yes.If yes-la .Ir., on the day of claimed injury? ❑Yes.If yes 11" • Has employee r's. Date Were full or partial wages paid r-p $Paid` Hrs.Worked �- Yes.If es ► i�Yes.If yes► 12. returned to work? Y J /92 for first day of lost time? CI No 13. Employer(If subsidiary,also specify parent's name and address) Phone(Include Area Code) Type of Ownership City of Oak Park Heights (612) 439-4439 ❑Partn rshi 0 Government t Department Phone(Include Area Code) I: 14. Building Department SIC 15. Employer's Street Address ! Name and title of Supervisor who first received notice of claimed injury 14168 57th St. No. LaVonne. Wilson City Administrator City,State,Zip r Date when notice received Time of day that A.m 16. inju Oak Park. Heights MN. 55082 2/5/92 � :: ❑P,M- Location where injury occurred(identify job site)(identify city,zip) Did injury occur on ❑yes 1 5904 Odell Ave N• employer's premises? :®No.If no,where? Total number of employees at the work location where While I was on a inspect ion. 17d, tThe claimed injury Occurred 15. Name of treating doctor or practitioner(Specify MD,DO,DC,etc.) Phone(Include Area Code) If treated at a hospital or hospitalized,name of hospital. L. 19. Address Hospital Address ZO. City,State,Zip City,State,Zip 21. Describe claimed injury or occupational illness in detail Very sore neck 22. Part of body affected Name of object(Machine,tool,etc or substance(chemical,etc.)involved Neck icef gnaw conditions 23. Nature of injury(cut,sprain,bum,etc), Type of accident(fall.struck by.etc I sprain fall 24. What action has been taken to prevent reoccurrence' Complete this section only if claimed injury or illnessresulted in death. Name of next-of-kin Relationship Clete of death 25. Names of co-employees who may have witnessed claimed injury none Address City,Stale,Zip 26. Name of workers'compensation insurer,if not on form Signed by(include official title and phone) 27. Dated / 2/6 9 2 Sign Here I°. MOST NOT BE SIGNED BY INJURED EMPLOYEE EBA-251 S I(8/90) White.Canary-to EBA Green—Employee Blue—Employer IMPORTANT NOTICE The filing of this report is not an admission of liability. It should be filed with your insurance carrier when- ever anyone believes a work-related injury or illness has occurred. In many cases (see general instructions), the prompt filing of this form with your insurance carrier and the Department of Labor and Industry is required by law. Failure to do so may subject you to penalties. The best procedure is to file this report immediately with your insurer. This will allow your insurer as much time as possible to investigate the claim. Even if the claim is questionable, it is important that you report it promptly to your insurer, so that it may adequately repres'nt you. If you question the claim, you should attach any additional information to this report. GENERAL INSTRUCTIONS 1. Death or serious injury arising from employment must be reported to the Department of Labor and Industry, Workers' Compensation Division, within 48 hours of the occurrence. Either may be reported initially by telephone (612-296-4893), telegraph or personal notice within 48 hours, but this notice must be followed by the filing of the First Report of Injury with your insurer within seven days of the occurrence. 2. Any other injury which totally or partially prevents the employee from working for more than three cal- endar days or which causes permanent disability must be reported to our insurer within 10 days. The Y Y insurer or self-insured employer must report the injury to the Workers' Compensation Division within 14 days of the occurrence. When a reported injury subsequently results in death, a report of the death must be made to the Division within 48 hours of when you are notified of the death. 3. Any injury initially not reported because it resulted in three or fewer. calendar days of disability and no permanent disability must be reported if it later results in one of those conditions. 4. If the employee has a physical or mental disability which may have contributed to the claimed injury or illness, you should be sure to notify your insurer or your workers' compensation claims office of the disability and whether the employee is registered under the second injury (subsequent disability) provi- sions of the Workers' Compensation Law. 5. Any report of injury or illness must be made on this form,must include all information requested on this form, and must be signed and dated by a company official. Send the original and one copy* of this report to: EMPLOYEE BENEFIT ADMINISTRATION CO. A Member of the Berkley Risk Management Services Group 8441 Wayzata Boulevard, Suite 200•P.O. Box 59143 Minneapolis, MN 55459-0143 Phone (612) 544-0311 *The original of this report must be sent to the Workers' Compensation Division by insurance carrier. See distribution code on the bottom of the front of this form. UPERVISOR'S REPORT OF ACCIDENT ♦ ASE READ AND FOLLOW INSTRUCTIONS 0 CK) 'EVERY ACCIDENT SHOULD BE INVESTIGA AND THE CAUSES CORRECTED SO THAT MORE DENTS WILL NOT OCCUR. DO NOT OVERLOOK THE SO-CALLED "UNIMPORTANT" CASES, BECAUSE, EXCEPT FOR "CHANCE" THEY COULD ALSO HAVE BEEN SERIOUS. IT IS ONLY BY THOROUGH INVESTIGATION THAT MANY OF THE REAL CAUSES CAN BE DETERMINED AND CORRECTED. NAME OF EMPLOYEE Al Q . 715.4464.4.-, COMPANY_' EPT. DATE OF ACCIDENT 2-13-/P- TIME/.4D44a.DID EMPOYEE LOSE TIME FROM WORK? YES NO,� • HOURS LOST DATE OF ACCIDENT - a HAS EMPLOYEE RETURNED TO WORK?YES X NO JOB TITLE ,dam Q SERVICE WITH THE COMPANY / YEARS, IN PRESENT JOB 1 GIVE US YOUR HO ST COMMENTS ON QUESTIONS BELOW. WE ARE NOT TRYING TO BLAME ANYONE. YOUR OPINION MAY HELP US TO PREVENT REPETITION. PLEASE ANSWER THE FOLLOWING: CHECK "YES" OR"NO" 1. WAS INJURED PERSON PROPERLY INSTRUCTED IN SAFE AND EFFICIENT METHOD? YES Lr NO ❑ 2. DID INJURED PERSON VIOLATE ANY INSTRUCTIONS? NO E4ro. YES ❑ 3. WAS NECESSARY PROTECTIVE EQUIPMENT WORN? IF APPLICABLE) YES ❑ NO ❑ 4. DID POOR HOUSEKEEPING CONTRIBUTE TO ACCIDENT? NO C.• YES ❑ 5. DID HORSEPLAY CAUSE THE ACCIDENT? NO YES ❑ 6. WAS IT CAUSED BY SOMETHING WHICH NEEDED REPAIRS? NO e YES ❑ 7. SHOULD A GUARD BE PROVIDED? NO C!le. YES ❑ 8. DID ANY BODILY DEFECT CONTRIBUTE TO ACCIDENT? NO [Ir. YES ❑ 9. WAS IT CAUSED BY AN UNSAFE ACT? NO L° YES El 10. DID INJURED REPORT THE INJURY TO YOU,THE SUPERVISOR,IMMEDIATELY? YES Qo"°— NO ❑ ACCIDENT. (DESCRIBE WHAT INJURED WAS DOING AT TIME OF ACCIDENT, WHAT HAPPENED, WHO WAS INVOLVED, NATURE OF INJURY, PART OF BODY AFFECTED.) -/ ,.i,. —— N UMBER OF EMPLOYEES AT WORK SITE —O `WITNESSES'NAMES 4 UNSAFE ACT. (WHAT DID THE EMPLOYEE OR ANOTHER PERSON DO INCORRECTLY?) UNSAFE CONDITIONS. (WHAT UNGUARDED OR UNSAFE CONDITION OF MACHINERY, EQUIPMENT, BUILDING OR PREMISES WAS INVOLVED?) REMEDY. (WHAT SHOULD BE DONE TO PREVENT OTHER ACCIDENTS LIKE THIS?) ALA-4a- 0 ACTION TAKEN. (WHAT HAS BEEN DONE TO CORRECT THE CONDITIONS WHICH CAUSED THIS ACCIDENT?) . MEDICAL CARE. DID EMPLOYEE GO TO DOCTOR OR HOSPITAL?YES NO1 IF YES'COMPLETE THE FOLLOWING NAME OF DOCTOR OR HOSPITAL DATE OF INITIAL VISIT ADDRESS TELEPHONE NUMBER AS SUPERVISOR, DO YOU FEEL THAT THIS INJURY SHOULD BE COVERED UNDER WORKERS' COMPENSATION BENEFITS?: YES ❑ NO REASONS WHY Ah 46.4JLo• / . .4A4 -.K/ REPORT SUBMITTED BY mow. 4--L -. DATE 2A )►L BA 252 (6/83) • 1I • tS North Star Risk Services, Inc. Date: August 13, 1990 Re: League of Minnesota Cities Insurance Trust Detail Claims Report - Property/Casualty Program The City of Oak Park Heights Enclosed please find your Property/Casualty claims' report for the League of Minnesota Cities Insurance Trust Program. Please note that the format of this report has changed slightly from the last claim report you received. Please review this report, should you find any discrepancies, notify your local GAB office, as GAB has provided this report for us. North Star Risk Services, Inc. 1401 West 76th Street, Suite 550 • Minneapolis, Minnesota 55423 • (612) 861-8600 • TELEX 9102401598 G1 13 CLAIMS MANAGEMENT REPORTING SYSTEM • Type of Accident Codes CLAM COD. CAUSE CODE JO Worker,'Compensation 001 Struck by hand tool or maehln•In use 032 Sunstroke or heat eshausUon 002 Struck by falling or flying object 033 Explosion or flareb•ek 003 Struck by moving object(tipping.sliding.rotting) 034 Bites Into •foreign substance 11 General Liability 004 Struck by oheiet handled by other person 036 Contact with Irritating or corrode,n,b,t•nce 006 Strain In fitting 03G flreatking dangerous lase..vapors.fume,.dual, 007 Strain In using tool or m•ehlns 037 Swallowing Injurious substance 008 Strain in pushing or puUtng 038 Reaction to chemicals(rub.skin.burn.leas of hair) 30 Products LiabUlty 000 Strain in holding or carrying 039 Drowning 010 Strain in reaching 040 Contact with electric current 012 Fall on sans.level 042 Stepping on,harp object 013 Fall to or from different level(stairs,docks. 043 Kneeling on sharp object ramps.platforms.seaflolds,ladders,etc.) 044 Foreign body In eye 014 Fall—Slip 045 Splinter 016 Fall—Trip 040 Animal bites or'crotches 017 Striking against objects being handled • 047 Escalator • 018 ilumpint into stationary obleet, 048 Motor vehicle accident(lift truck.tow motor) 019 Striking against moving part,of machine 049 Faulty equipment (saws,grinders.etc.) 060 Personal Injury 020 Striking against another person 001 Collapse of building 022 Caught In.on or between machine or maehln•parts 062 heart attack 023 Caught in,on or between moving object and 003 Alleged damage to properly of others stationary object 064 Observing foreign object(nausea) 024 Caught in,on or between two moving objects 066 Fle•alor 025 Cave In 101 hospital professional 027 Contact with steam or other fluid,(bums,scalds) 102 Physicians.Surgeons,Dentists,profeulonal 028 Contact with welding flash 103 Misc.Medical protesajonal 020 Contact with fire or flame 104 United States Longshoremen and harbor Workers 030 Contact with hot or molten metal • 106 Jones Act 031 Frostbite 106 Premises Medical Payment • 60 Property Damage 066 Fire and Lightning 080 Collision with bicycle 56 Automobile Physical Dam ate 057 Wind and hall 081 Collision with train or bus 068 Explosion 082 Collision with animal TRANSPORTATION 060 Idol and Clvll Commotion 083 Collision with fixed object • 060 Smoke 084 Collision with other object GO Property on Insureds Premises 061 Aircraft and vehicles 085 Upset or vehlelq(overtumed.Jackknifed.ran off roadway) 062 Electrical breakdown 080 Damage in loading or unloading 61 Property on Premises 063 Sprinkler leakage 087 Equipment failure Other Than Insureds 064 Earthquake 088 Fire damage to vehicle 065 Water damage 089 Theft•entire vehicle 62 Railroad Shipment, 066 hurgiary and theft 000 Theft•parts or contents of vehicle 067 Vandalism& Malicious Mischief 091 Glass breakage G3 hallway Express•Mall Service 068 Sonic Shock Wave 092 Riot and CI•ll Commotion 070 Non-delivery or Mysterious Dls•ppsaanee 093 Malicious Mischief and Vandalism 64 Truck or AutomobUe Shipments 078 Collision with motor vehicle 094 Wind,hall,Explosion,Water Damage 079 CoUision with pedestraln 096 Flood and rising waters 65 Aircraft Shipments(Mall. Express Freight) 66 Waterborne Shipments • • 67 Person 70 Uurgfary and Fidelity Oil Shortage In account, 072 Dishonesty of employee • 073 Disappearance of fund, • 074 Fraud 075 Mimicry on premises • 070 Robbery of Intellbr 077 Theft In transit • 80 Automobile Liability 078 Collision with motor vehicle 079 Collision with pedestrJn 080 Collision with bicycle • 081 Collision with train or bus 67 Automobile No Fault 082 CO11100n with animal 083 Collision with fixed object 084 Collision with other object • 086 Upset of vehicle(overturned.l•ekknifed•tun off roadway) 086 Damage In loading or unloading 76 Public Officials 087 Equipment(allure 096 G Liability 007 Gar■gekeeper'a Legal Liability 75 Umbrella 601 Police Liability 602 Land Use Liability 603 Employment Practices Liability 604 Emergency Care Liability Ali Claim DescripUon UU090Unclufll(eliilt.�` LTdDftlty FORM 892A (5181) • • I cn T C)v..r A A 0 _ 1 CO 1-1 r00mC3 C) O r DrC)OZVI ✓ A m I-1►+DC 0) D N 30-1 ml0 H 1 Z <H of 1-1 01 3 0 C -I 013.4. 1.0 3 <Z Z m to C) I0 CO 7)C Z• 0 O m m3a)C• O N A CO(03• m D -gym 00 W• 4*C)1^4 C)C)4, to JA m• -I C)D Z r r C) O 1-) CO A• O C)CVID DC) V Dr. v 1 • • -1 1-1 VI C s 1••1 IH m 1 r 0 > OmA330 z Cm -n D1.0 r m mD m o 1-I XCOAA 1 2C)OZ3Z O CO• C I -l0 1D1 m A-W Z O m A Z m 0 1.4 A •O m .+D > 17 -4 7C N D 0--..<3v-I D < t0-4 • C)0)mmIm 1-. = m A O A -4 O C) m - 1-I N c m r O I-+ v......tn 01 < 0 o -I 0 v1 0 m I o 1•+ Z 0 0 A -i o o D 0 o D v) • z 3 > G) O i m 0 -I m O 1 1 0 m 0 1 1 J 0 0 0 C— r 0 0 m 2NN v (0 0) mAO > O m A m 1-I A O - co co A X O (0(0 A -4 I A J m -I CO C A Co N O • N O m O J ►+ r- J D 0) 2 0) 1 G) > m • O ►•1 N C) A A m 1-1 VI r 3 D m 3 .~ 3 A 0 Z 0 < 3 > C m 0 1 • o Z r -z1 D 0 Z 0 0 r • U) m C) Z C) • OrT A -I D• m Z 1-+CO v) 0 3• m m () O 0 -0< 0)03C mm <(n v) v D 0rz m3 �0m O (0 C)(n N N C 0 D U) A A Z 1 -I 1-1 v) O m Z A N 1 A 0 m N N 11-1 v) 0) 0) D Z r A O 0 C 1-+ 0 0 3 A C O m O 0 CO O 0 Z 1 U) 1 D or v O 0 D C C) O 0 m CO D o 2 Z A D m 2 G C) m o 1 o O 17 • CO o<m D • m0 0 • Z O A C m• C 444. cl 2W -4-‹ 1 J 0 O m 1-I to(n m It CO -4 0 0 0 Cor NN• 0 O Am w• . 0• • • 4 S 1 ■ 0) O) 1-1 rOOmC3 '0 0 to UI r D r o O Z In O r A A m Iti1-+DC 0) r D N N 3C)-Im1UI M N I 1 Z .<1.401..102 0 3 C 1 0 1 3- < 0 O 3 <ZZ mm Z 0 m OO CO m 3 CID C 0- O O -4 UI U COtD3 rn > > -- mooW DAI-+AC) D >01.00> o CO A rn -4 -I ADZr1C) C) C)>Zr1C) C) -A -n 0 A O o CCW > >C) I- 0 C0DD0 r /. .4 �-+ I • 1 -i IM to C I-1 1--1 I-1 0 1-+N C I-+I-I 1-4 0 1 r O• D D 0m73330 N 0m33330 N Cm a D►+0 ✓ r m m> m m m m D m m on C 7C C13 A A 1 1 ZC)OZ3Z 0 ZOOZ3Z 0 -4 CO• C I t 10 1D1 10 1D-1 0 -0+COZ 0 m 73 Z m O O m A Z m O r A• • 0 M .4 D D m 1•+D D -0 I-1 7C N D 0^<3O-I 0^< 30-1 D D (.0 -I C)Omm >m C)Ommam .+ CO I m A -)A -I A -)A -I 0 I-I m M CO = m 1-+ CO = m r r "I -0..6 -13v6 01 I-I G) CJ () -I CA -I N 0 -I I CO Co 1-+ Z CO I-I Z N -< -1 U) UI 0 D to 0 a 0 0 U) Z 3 • Z 3 D 1 m CO 0 I m 0 -I O O I I -I 0 m 0 0 1 1 I I O -4 I--I \ 1-I0 X0- 00 Z-•-- r 0 ZO .4 -,-, r0 ON + < A or Z\\ 3r A\■ \ Ar IZ10 1r O-4 j D Z 0 mX <\\ DX \\ m►+ c A 0\ - CO CO r\ -0 Co CO X0 C 3 O(O r3 D000O 13 A -1 CO O 0 m O C m-I -< CO 0 A 0 Z 0 m O r 0 U)0 • • 7C A Z • in xi m0 -I O m 1-I 0 0 D 0) 0 0< U) 0 < < 0 -I rn in m m I-4= II z 1--1 -4 C) 0 r m A C) m r 0 N c- m -I 3 3 X) C) N D 0 < 3 0 CM 01 O 0 O 0 m 0 Z Z D • 0 -1r -1D O 0 A 0 0 0 mr O O m 0 0 0 C r m 0 O A Z A• H 0 r D -I Z Tl H D• A 0 m Z 1-+m C N 03• N F A XA 0y co O A < 0)CO C m m m \<V) N N Z co F-4 1 ox. or Z 0 0 0 mm \o m O 1O C)!n N 0 0 0 C 0 D N A 0 0 0 Z 1 --1 H(n 0 2 A < H 1 C) 0 m N -i I-+ N O) D 2 - r C) CO Cu) Cu) C 1-I cn to 0 3 A CZ to ) o m O 0 0 0 CO -4 -4 -4 0 Z 1 N --1 > 0r -0 O 0 0 0 0 D C O . 0 0 0 1W A O 0 0 0 m A D 0 3 Z A D m 3 C C) m o 1 0 0 -0• W O< m D• m O G)• Z 0 Xi C m• C D< 0 A 3 1 -I J 3 07 O 0 0 0 m r. 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Date: Re: League of Minnesota Cities Insurance Trust Detail Claims Report - Property/Casualty Program Enclosed please find your Property/Casualty claims' report for the League of Minnesota Cities Insurance Trust Program. Please note that the format of this report has changed slightly from the last claim report you received. Please review this report, should you find any discrepancies, notify your local GAB office, as GAB has provided this report for us. North Star Risk Services, Inc. 1401 West 76th Street, Suite 550 • Minneapolis, Minnesota 55423 • (612) 861-8600 • TELEX 9102401598 • s ( CLAIMS MANAGEMENT REPORTING SYSTEM Y"�� • Type of Accident Codes CLAIM COD: CAUSE CODS 10 Workers'Compensation 001 Struck by hand tool or machine in use 032 Sunstroke or heat eshausUon 002 Struck by falling or flying oblect 033 Explosion or fiarrback 003 Struck by moving oblect(tipping.sliding,rolling) 034 Dues Into•foreign sub.tane• 11 General LI•bllitl 004 Struck by Owlet handled by other person 035 Contact with Irritating or eorroJ•e n,bstance 006 Str•In In lilting 036 ilreathing dangerous sum vapo».fumes,dusts 001 Strain In using tool or m•chb,a 037 Swallowing Injurious substance 008 Strain In pushing or pulling 038 Reaction to chemicals(rub.akin,burn,low of hair) 30 Produeta Lt•bUlty 000 Strain In holding or carrying 039 Drowning 010 Strain in reaching 040 Contact with electric current 012 Fall on wane level 042 Stepping on sharp oblect 013 Fail to or from different level Weirs.docks. 043 Kneeling on sharp object ramps,platforms.scaffolds.ladders,etc.) 044 Forden body in eye 014 Fall—Slip 045 Splinter 015 Fail—Trip 04G Animal bites or scratches 017 Striking against objects being handled 047 Escalator • 018 !lumping into stationary objects 048 Motor,chie(.aeeldenl(IUt truck.tow motor) 019 Striking against moving puts of machine 049 Faulty equipment (saws,grinders.etc.) 060 Personal Injury 020 Striking against another person 051 Collapse of building 022 Caught In,on or between machine or machine parts 062 heart attack 023 Caught in,on or between moving object and 053 Alleged damage to prnperty of others stationary object 054 Observing foreign object(nausea) 024 Caught In,on or between two moving objects 066 Elevator 025 Cave in 301 Hospital professional 027 Contact with.te•m or ether fluids(burns,scalds) 102 Physicians.Surgeon,.Dentists,prefeastona.I 028 Contact with welding flash • 303 Mise,Medical professional 029 Contact with fire or flame 104 United States Longshoremen and(tarbor Workers 030 Contact with hot or molten metal . 106 Jones Act 031 Frostbite 106 Premises Medical Payment 60 Property D•m•ge 056 Fire and Lightning 080 Collision with bicycle 55 Automobile Physical Darn age 057 Wind and hall 081 Collision with train or bus 058 Explosion 082 Collision with animal TRANSPORTATION 057 Riot and Civil Commotion 083 Collision with flied object • • 0(70 Smoke 084 Collision with other object GO Properly on insureds Premises Or.i Aircraft and vehicles 085 Upset or vehlelq(overturned.l.ekknifed,ran off roadway 002 Electrical breakdown 056 Damage In loading or urdoading 61 Properly on Premises 063 Sprinkler leakage 087 Equipment failure Other Than Insureds 064 Earthquake 058 Fire damage to vehicle 065 Water d•maee 050 Theft•entire vehicle 62 Railroad Shipments OGG /tutelary and theft 090 Thctt-parts or contents of vehicle 0117 Vandalism& Malicious Mischief 001 Glass breakage G3 Railway Express•Mall Service (1.4 Sonic Shock Wave 092 Riot and Civil Commotion 070 Non-delivery or Mysterious Disappearance 093 Malicious Mischief and Vandalism 64 Truck or Automobile Shipments 078 Collision with motor vehicle 094 Wind,Nall.Leptodon,Water Damage 079 Collision with pedestraln 005 Flood and rising waters G5 Aircraft Shipments(Mall, Express Freight) 66 Waterborne Shipments 67 Person • 70 !Juicier" and Fidelity 071 Shortage in accounts 072 Dishonesty of employee • 073 Disappearance of funds 074 Fraud 076 (tutelary on premises • 07G Robbery of Wefts' 077 Theft In transit 80 Automobile Liability 078 Collision with motor vehicle • 079 Collision with pedestraln 080 Collision with bicycle • 081 Collision with train or bus • 87 Automobile No Fault 082 Collision with animal 053 Collision with fixed object 054 Collision with other object 086 Upset of vehicle(overturned,jackknifed,ran off roadway) 081, Damage in loading or unloading 76 Public Officials 087 Equipment failure 096 Garage Liability 7 5 Umbrella 007 G•ragekeeper's f.egal Liability 601 Police Liability 602 Land Use Liability 603 Employment Practices Liability 604 Emergency Care Liability . 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DM Z O 0 0 0 O X:1 C ) O 0 0 0 C D O 0 0 0 Z C/) 1 D 0 r A O O OO 0 DC 0 00 0 0 0 m CO a O 3 z M D m C.C- O m o 1 0 0 v • W 0 < m n • M O O• Z D M C m• C -<-1 U13 W O 0 0 0 m .-. OO Q) m at CO M0M O 0 0 0 COr Cn N• O 0 0 0 .o m C• • 0 . • • '� • North Star Risk Services, Inc. Date: July 29, 1988 Re: League of Minnesota Cities Insurance Trust Detail Claims Report - Property/Casualty Program • City of Oak Park Heights Enclosed please find your Property/Casualty claims' report for the League of Minnesota Cities Insurance Trust Program. Please note that the format of this report has changed slightly from the last claim report you received. Please review this report, should you find any discrepancies, notify your local GAB office, as GAB has provided this report for us. North Star Risk Services, Inc. 1401 West 76th Street, Suite 550 01 Minneapolis, Minnesota 55423 111 (612) 861-8600 ■ TELEX 9102401598 GAD k •LA1MS MANAGEMENT REPORTING TEM l""��� Type of Accident Codes CLAIM CODE CAUSE CODE 10 Workers'Compensation 001 Struck by hand tool or machine In use 031 Sunstroke or heat exhaustion 002 Struck by falling or flying object 033 Explosion or flareb•ck 003 Struck by moving object(tipping.sliding,rolling) 034 Bites Into•foreign substance 11 General Liability 004 Struck by obeIct handled by other person 036 Contact with irritating or corrosive substance 006 Strain in lifting 036 Breathing dangerous gases,vapors,fumes,dusts 007 Strain in using tool or machine 037 Swallowing injurious substance 008 Strain In pushing or pulling 038 Ite•ction to chemicals(rub,skin,burn,loss of h•tr) 30 Products Liability 009 Strain In holding or carrying 039 Drowning 010 Strain in reaching 040 Contact with electric current 012 Fall on snore level 042 Stepping on sharp object 013 Fall to or from different level(stairs,docks. 043 Kneeling on sharp object ramps,platforms,scaffolds,ladders,etc.) 044 Forcicis body In eye 014 Fall—Slip 045 Splinter 016 I'all—Trip 046 Animal bites or scratches 017 Striking against objects being handled 047 Escalator 018 Bumping Into stationery objects • 048 Motor vehicle accident(lift truck,tow motor) 019 Striking against moving Darts of machine 049 Faulty equipment (saws,grinders,etc.) 060 Personal Injury 020 Striking against another person 051 Collapse of building 022 Caught In,on or between machine or machine parts 002 Heart attack 023 Caught In,on or between moving object and 003 Alleged damage to property of others stationary object 064 Observing foreign object(nause•) 024 Caught in,on or between two moving objects 005 Elevator 025 Cave In 101 Hospital professional 027 Contact with steam or other fluids(burns,scalds) 102 Physicians,Surgeons,Dentists,professional 028 Contact with welding flash 103 Misc.Medical professional 029 Contact with fire or flame • 104 United States Longshoremen and Harbor Workers 030 Contact with hot or molten metal . 106 Jones Act 031 Frostbite 106 Premises Medical Payment 60 Property Damage 050 Eire and Lightning ORO Collision with bicycle 55 Automobile Physical Damage 1)57 Wind and hail 081 Collision with train or bus 058 Explosion 082 Collision with animal TRANSPORTATION 0611 Riot and Civil Commotion 083 Collision with fixed object 000 Smoke 084 Collision with other object GO Property on Insureds Premises 061 Aircraft and vehicles 086 Upset or vehiclq(overturned,jackknifed,ran off roadway) 062 Electrical breakdown 086 Damage In loading or unloading 61 Property on Premises 063 Sprinkler leakage 087 Equipment failure Other Than Insureds 064 Earthquake ORR Fire damage to vehicle 005 Water damage 089 Theft•entire vehicle 62 Railroad Shipments 066 Burglary and theft 090 Theft-parts or contents of vehicle 067 Vandalism& Malicious Mischief 091 Glass breakage G3 Railway Express-Mall Service 008 Sonic Shock Wave 092 :dot and Civil Commotion 070 Non-delivery or Mysterious Disappearance 093 Malicious Mischief and Vandalism 64 Truck or Automobile Shipments 078 Collision with motor vehicle 094 Wind,hall,Explosion,Water Damage 079 Collision with pedestraIn 096 Flood and rising waters 65 Aircraft Shipments(Mall, Express Freight) • 66 Waterborne Shipments • 67 Person 70 burglary and Fidelity 071 Shortage In accounts 072 Dishonesty of employee 073 Disappearance of funds 074 Fraud 075 Burglary on premises • 076 Robbery of inte ibr 077 Theft In transit 80 Automobile Liability 078 Collision with motor vehicle 079 Collision with pedestraln 080 Collision with bicycle • • 081 Collision with train or bus 87 Automobile No Fault 082 Collision with animal 083 Collision with fixed object 084 Collision with other object 085 Upset of vehicle(overturned,jackknifed,rut off roadway) 086 Damage In loading or unloading 76 Public Officials 087 Equipment failure 096 Garage Liability 7 PJ Umbrella 097 Geregekeeper's Legal Liability 601 Police Liability 602 Land Use Liability 603 Employment Practices Liability 604 Emergency Care Liability All Claim Description J g r D 099 Unc asst(e FORM 892A(5181) • 1 roomcC 4 01 71 A C) 1n r DrC)OZZ O r A rn M N D C r > N 301m10 • 1 3 0 3 <ZZ1mm • 0 a CO A C Z Z O 0 0 m 1.) 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RE: League of Minnesota Cities Insurance Trust Detail Claims Report - Property/Casualty Program City of: 03/3 Enclosed please find your Property/Casualty claims' report for the League of Minnesota Cities Insurance Trust program. Please note that the format of this report has changed slightly from the last claim report you received. Please review this report, should you find any discrepancies, notify your local GAB office, as GAB has provided this report for us. North Star Risk Services, Inc. • • CLAIMS MANAGEMENT REPORTIYSTEM Type of Accident Codes CLAM CODE CAUsscons 10 Workers'Compensation 001 Struck by band tool or machine In use 031 Sunstroke or beat ashaurio. 002 Struck by falling or firths*bleat 033 Explosion or Bareback 003 Struck by moving object(Upping.OLding,rolling) 034 Bites Into a tor.tgn substance 11 General 004 Struck by obJet handled by other person 036 Costae!with!flitting or corrosive substance 006 Strain in i tt ag 036 Breathing dangerous goer.74po4.fuw.e,dust. 007 Strain In using tool or machine 037 Swallowing injurious substance SO Product Ll.bilit7 00$Strain in pushing or pulling 038 Reaction to chemicals(rash.akin,burn,toes of hag 001 Strain in holding or carrying 081 Drowning 010 Strain In na•king • 040 Contact with.1.ettla current 012 Pall on same level 042 Stepping on sharp object 013 Pall to or from different level(stairs docks. 043 Kneeling os sharp obl..t tamp.,platforms.scaffolds,ladders....) 044 Foreign body In 014 Pail—Slip 046 Splinter 016 Far—Tr* 044 Animal bites or scratches • 017 Striking againe°blests being bandLd 047 Escalator 011 lumping into stationary oldoet, 043 Motor vehici.accident(lift truck,tow motor) 011 Striking against moving parts of machine 041 faulty.puipmest (sews,grinders,.ta.) 060 Pasoncl in jury 020 linking against another person 061 Collap.a of building 022 Caught in,on or betwsii machine or machine part. 042 Heart attack 023 Caught inn,on or between moving of i.et and 048 Alleged damage to property of othan stationary obl.+t • 064 Observing foreign object(onus..) • 024 Caught In,on or between two moving objects 068 Elevator 026 Caw to 101 Hospital profesdonal • 027 Contact with steam of other Guide(urns,scalds) 102 Phy/elan,Surgeons,Dentists,professional 023 Contact with welding lads • 103 Misc.Medical professional 029 Contact with are or flame 104 Dotal States Longshoremen and Harbor Workers 030 Contact with hot or molten metal 106 Jonas Aft 031 ProetbtM 104 Premise.Medical Payment • 00 Property Damao 066 Pin and Lightning 040 Coilido.with bicycle • Si Automobile thrice'Damage 067 Wind and had 041 Coltidon with Soaks or bus 064 2xpioion 043 Collision with TRANSPORTATION 069 Riot and Civil Commotion . ON Collidos with fixed animal • 040 Smoke 044 Coilidos with ether object 00 Provosts M Insureds Premises 041 Aircraft and vehicles 046 Vent or vehichi(overtum.d.laekkait.d,ran off roadwa 042 Electrical breakdown 044 Damage In leading or uabading 01 Property.s Prom('., 043 Sprinkler leakage 017 Equipment tailor. 0th.,Than ta.unde 044 Larthpwk. Oil sin dampe to vehicle 046 water damage 044 Theft•entire valet 0S Railroad Shipment 064 luzglary and theft 090 Theft•parts or.o.tents of v hlds 047 vandalism•Malicious MIse lei 001 Olaes breakage OS Railway!spree•Mail S.M.. 044 Solis Shook Ware 092 Riot and Civil Commotion 070 Nondelivery or Mysterious Disappears*** 093 Malicious Mischief sod Vandalism 44!Wok or Automobile Shipments 074 Collision with motor wall. 094 Wind,Hai Explosion.Wave Damage 079 Collision with p.deetrsls 004 Flood and!Wag waters 00 Abeatt Ship...h(Mail. Raps.Tod 00 N Wsfarbors.Shipments 0T tar,.. TO Surgery ad Iid.11ty 071 Skortags is amounts •71 Dishonesty of employee 013 Disappears*,of turd. 074 fund 016 Stuyiary on promises 076 Robbery of intim 077 Theft is trawl! SO Aut...bcce Ualnn, 07$Cation with solos v.hMN 079 CaWon with p.d..tnla. 040 Midas with blush IT Automobile N.Inuit 0041 ColWon with animal boo 043 Collision with lied objet 044 Ciliates with*dui:West 048 Upset of vehicle(overturned,)ackkalf.d,tar off roadway) 044 Damage is loading or*nlo.dLg 047 Equipment failure 094 Ouage Liability 007 Oarag•k.eper's Logs)Liability • • Al Claim Des..iptiom 099 Vnclaads.d • • FORM lilA(9/41) • V. . • 0 • ►+ r 0 0 m C C . . A cr. r >4--0 O Z Z r . r A m .•.•a C O'V a N 3 A-1 m-I O A 0.. I Z <.. N.. D DI.r..3 C <ZZ-< mm •.AA N 03 13 C Z 0 <0 N m m300 C Z 0 .) A W 70 3 <m a m 0) CO -10 + A m -4 •DO Cl AD0r -IT . >r-i ACDOO D .. • r . a ..N•. ..N < r 0330 0 -.0 I . r 0rn30m Cm 0•v•• OI-- -4 1 1 m D m O N 0 N < I I I Z A Z Z m• -� -i O-I -4 rA . C4 -4 O N < O O 4).. • \ Om 0 'n UIOc m ZD 0 ..n) . 0) J N,-.D -i D ZAO -3 A 0 3 m .. C > . 77 aim 0 C 7; w(J r . A .. 0-1 < 'v -1 N 0 - D .. N . A 000 Z 7: 0 a0 0 000 I 0 -1 I 000 I 0 m 4o m -I C) m>>(11 -A M 3 x0 a N A-I mn) m.. 0- x0 w Co -0 . a v 0-4 m-I 7002 001 000 C-u rn 0 m0 v p a 000- n 00 m 0 r -i 3 2 3 A m 0 . N Z am < D 0 < 2rr- C m m Z Z A 000 0 -I r0 0ra 000 0 N O3 N 0 m mw m �< N W mm 0r X A \0 < CO A m m -7 D Z -I N D or m 3 0 000 0 0 Z 000 0- Zi -4 0 -I ■• D Z r A C D 0 3 70 000 O Om CO 000 0 Z 000 0 --I 0 -ID Or Oz D m 17 C- -4 C) AO m O O co 000 0 < AZ 000 0 z aC 000 0 < X33 > Zm 0D 70 m3 m• O • 10• • 4) A A N N .)0) N-) O 0) 0 Date/Time: 4/01/2003 0:25:54 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST : WORKERS' COMP Program: BUCC750 Years Selected: 1/01/50 To 3/31/03 As Of Report Date 3/31/03 Page Number 913 ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS CLAIMS REPORT FOR OAK PARK HEIGHTS, CITY OF ACCOUNT *: 490729 POLICY YEAR 7/07/2001 TO 7/07/2002 CLAIM DAYS LOSS PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD DATE MEDICAL INDEMNITY EXPENSE RESERVE COST ST M 00917089 KELLOGG, JEFF P SPRAINS, STRAINS 0 9/28/01 .00 .00 .00 . .00 C C4 00917905 JOHNSON, JAY MULTIPLE INJ BOTH PHY & PSYC 9 12/14/01 1,835.29 1,350.00 .00 3,185.29 C M9 00918861 BUCKLEY, STANLE HEART ATTACK,MYOCARDIAL INFRCT 0 1/09/02 .00 .00 104.31 396. 500.31 D T4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS POLICY YEAR # CLMS OPEN---CLOSED OPEN----CLOSED NO PAY OF TTD 3 1 0 0 1 1 9 MEDICAL INDEMNITY EXPENSE TOTAL Amount Paid ... 1,835.29 1,350.00 104.31 3,289.60 Recovered ... .00 .00 .00 .00 Reserves ... .00 .00 396.00 396.00 Total Cost ... 1,835.29 1,350.00 500.31 3,685.60 l/P/tP940:ni, /X' ; 44119p We (Sep 28 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1007 CLAIMS REPORT FOR OAK PARK HEIGHTS, CI DATE OF REPORT 10/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1998 TO 07/07/1999 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 905341 KISCH, DAVID R Cut, laceration, puncture FINGER(S) 0 12/28/98 0.00 0.00 0.00 0.00 0.00 C G1 906425 DEROSIEL, BRIAN STRAINS Groin 0 04/06/99 0.00 0.00 0.00 0.00 0.00 C G1 906424 ANDERSON, KENNE Puncture HAND 0 04/07/99 175.88 0.00 0.00 624.12 800.00 0 C4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 3 1 0 0 0 2 0 175.88 0.00 0.00 DISTRIBUTION OF RESERVES -> 574.12 0.00 50.00 624.12 800.00 I 8 (t:I r EU co 0 g J (Sep 28 DATA FILES) W O R K E R S, C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1008 CLAIMS REPORT FOR OAK PARK HEIGHTS, CI DATE OF REPORT 10/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/2000 TO 07/07/2001 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 911833 KISCH, DAVID R CONTUSION,CRUSHING,BRUISE Thumb 0 08/01/00 0.00 0.00 0.00 0.00 0.00 C Z1 912851 NELSON, RAYMOND Puncture FINGER(S) 10 10/23/00 1183.56 720.00 0.00 0.00 1903.56 C M9 913474 HULTMAN, JULIE STRAINS MULTIPLE PARTS 0 12/06/00 0.00 0.00 0.00 0.00 0.00 C Z1 913545 KROPIDLOWSKI, F MULTIPLE INJURIES MULTIPLE PARTS 0 12/21/00 0.00 0.00 0.00 0.00 0.00 C C4 914606 STABERG, ROLLAN STRAINS LOW BACK AREA - LUMBAR AND LU 0 03/12/01 365.30 0.00 0.00 0.00 365.30 C C4 915064 CRAFT, JOSEPH A Cut, laceration, puncture FINGER(S) 0 04/23/01 0.00 0.00 0.00 0.00 0.00 C C4 915428 ANDERSON, KENNE MULTIPLE INJURIES Thumb 0 05/31/01 0.00 0.00 0.00 0.00 0.00 C C4 915559 KROPIDLOWSKI, F STRAINS LOW BACK AREA - LUMBAR AND LU 0 06/11/01 254.22 0.00 0.00 345.78 600.00 0 C4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 8 1 1 0 1 5 10 1803.08 720.00 0.00 DISTRIBUTION OF RESERVES -> 245.78 0.00 100.00 345.78 2868.86 (Aug 31 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 999 CLAIMS REPORT FOR OAK PARK HEIGHTS, CI DATE OF REPORT 09/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1998 TO 07/07/1999 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 905341 KISCH, DAVID R Cut, laceration, puncture FINGER(S) 0 12/28/98 0.00 0.00 0.00 0.00 0.00 C G1 906425 DEROSIEL, BRIAN STRAINS Groin 0 04/06/99 0.00 0.00 0.00 0.00 0.00 C G1 906424 ANDERSON, KENNE Puncture HAND 0 04/07/99 175.88 0.00 0.00 624.12 800.00 0 C4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 3 1 0 0 0 2 0 175.88 0.00 0.00 DISTRIBUTION OF RESERVES -> 574.12 0.00 50.00 624.12 800.00 in Ei-gm2 L---------_._._J \,1 \, E *-1 1 iidi\=. 1 , , (Aug 31 DATA FILES) WORKERS' COMP ENSATI ON CLAIMS REPORT MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1000 CLAIMS REPORT FOR OAK PARK HEIGHTS CI DATE OF REPORT 09/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/2000 TO 07/07/2001 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 911833 KISCH, DAVID R CONTUSION,CRUSHING,BRUISE Thumb 0 08/01/00 0.00 0.00 0.00 0.00 0.00 C Z1 912851 NELSON, RAYMOND Puncture FINGER(S) 10 10/23/00 1183.56 720.00 0.00 0.00 1903.56 C M9 913474 HULTMAN, JULIE STRAINS MULTIPLE PARTS 0 12/06/00 0.00 0.00 0.00 0.00 0.00 C Z1 913545 KROPIDLOWSKI, F MULTIPLE INJURIES MULTIPLE PARTS 0 12/21/00 0.00 0.00 0.00 0.00 0.00 C C4 914606 STABERG, ROLLAN STRAINS LOW BACK AREA - LUMBAR AND LU 0 03/12/01 365.30 0.00 0.00 0.00 365.30 C C4 915064 CRAFT, JOSEPH A Cut, laceration, puncture FINGER(S) 0 04/23/01 0.00 0.00 0.00 0.00 0.00 C C4 915428 ANDERSON, KENNE MULTIPLE INJURIES Thumb 0 05/31/01 0.00 0.00 0.00 0.00 0.00 C C4 915559 KROPIDLOWSKI, F STRAINS LOW BACK AREA - LUMBAR AND LU 0 06/11/01 254.22 0.00 0.00 345.78 600.00 0 C4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 8 1 1 0 1 5 10 1803.08 720.00 0.00 DISTRIBUTION OF RESERVES -> 245.78 0.00 100.00 345.78 2868.86 (Jul 31 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 993 CLAIMS REPORT FOR OAK PARK HEIGHTS, CI DATE OF REPORT 08/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1998 TO 07/07/1999 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 905341 KISCH, DAVID R Cut, laceration, puncture FINGER(S) 0 12/28/98 0.00 0.00 0.00 0.00 0.00 C G1 906425 DEROSIEL, BRIAN STRAINS Groin 0 04/06/99 0.00 0.00 0.00 0.00 0.00 C G1 906424 ANDERSON, KENNE Puncture HAND 0 04/07/99 175.88 0.00 0.00 624.12 800.00 0 C4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 3 1 0 0 0 2 0 175.88 0.00 0.00 DISTRIBUTION OF RESERVES -> 574.12 0.00 50.00 624.12 800.00 (Jul 31 DATA FILES) W O R K E R S, C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 994 CLAIMS REPORT FOR OAK PARK HEIGHTS, CI DATE OF REPORT 08/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/2000 TO 07/07/2001 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 911833 KISCH, DAVID R CONTUSION,CRUSHI'NG,BRUISE Thumb 0 08/01/00 0.00 0.00 0.00 0.00 0.00 C Z1 912851 NELSON, RAYMOND Puncture FINGER(S) 10 10/23/00 1183.56 720.00 0.00 0.00 1903.56 C M9 913474 HULTMAN, JULIE STRAINS MULTIPLE PARTS 0 12/06/00 0.00 0.00 0.00 0.00 0.00 C Z1 913545 KROPIDLOWSKI, F MULTIPLE INJURIES MULTIPLE PARTS 0 12/21/00 0.00 0.00 0.00 0.00 0.00 C C4 914606 STABERG, ROLLAN STRAINS LOW BACK AREA - LUMBAR AND LU 0 03/12/01 365.30 0.00 0.00 0.00 365.30 C C4 915064 CRAFT, JOSEPH A Cut, laceration, puncture FINGER(S) 0 04/23/01 0.00 0.00 0.00 0.00 0.00 C C4 915428 ANDERSON, KENNE MULTIPLE INJURIES Thumb 0 05/31/01 0.00 0.00 0.00 0.00 0.00 C C4 915559 KROPIDLOWSKI, F STRAINS LOW BACK AREA - LUMBAR AND LU 0 06/11/01 212.36 0.00 0.00 387.64 600.00 0 C4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 8 1 1 0 1 5 10 1761.22 720.00 0.00 DISTRIBUTION OF RESERVES -> 287.64 0.00 100.00 387.64 2868.86 r ■ (Jun 29 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 962 CLAIMS REPORT FOR OAK PARK HEIGHTS, CI DATE OF REPORT 07/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1998 TO 07/07/1999 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 905341 KISCH, DAVID R Cut, laceration, puncture FINGER(S) 0 12/28/98 0.00 0.00 0.00 0.00 0.00 C G1 906425 DEROSIEL, BRIAN STRAINS Groin 0 04/06/99 0.00 0.00 0.00 0.00 0.00 C G1 906424 ANDERSON, KENNE Puncture HAND 0 04/07/99 175.88 0.00 0.00 624.12 800.00 0 C4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 3 1 0 0 0 2 0 175.88 0.00 0.00 PISTRIBUTION OF RESERVES -> 574.12 0.00 50.00 624.12 800.00 M (Jun 29 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 963 CLAIMS REPORT FOR OAK PARK HEIGHTS, CI DATE OF REPORT 07/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/2000 TO 07/07/2001 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 911833 KISCH, DAVID R CONTUSION,CRUSHING,BRUISE Thumb 0 08/01/00 0.00 0.00 0.00 0.00 0.00 C Z1 912851 NELSON, RAYMOND Puncture FINGER(S) 10 10/23/00 1183.56 720.00 0.00 0.00 1903.56 C M9 913474 HULTMAN, JULIE STRAINS MULTIPLE PARTS 0 12/06/00 0.00 0.00 0.00 0.00 0.00 C Z1 913545 KROPIDLOWSKI, F MULTIPLE INJURIES MULTIPLE PARTS 0 12/21/00 0.00 0.00 0.00 0.00 0.00 C C4 914606 STABERG, ROLLAN STRAINS LOW BACK AREA - LUMBAR AND LU 0 03/12/01 365.30 0.00 0.00 0.00 365.30 C C4 915064 CRAFT, JOSEPH A Cut, laceration, puncture FINGER(S) 0 04/23/01 0.00 0.00 0.00 0.00 0.00 C C4 915428 ANDERSON, KENNE MULTIPLE INJURIES Thumb 0 05/31/01 0.00 0.00 0.00 0.00 0.00 C C4 915559 KROPIDLOWSKI, F STRAINS LOW BACK AREA - LUMBAR AND LU 0 06/11/01 0.00 0.00 0.00 600.00 600.00 0 C4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 8 1 1 0 1 5 10 1548.86 720.00 0.00 DISTRIBUTION OF RESERVES -> 500.00 0.00 100.00 600.00 2868.86 odd=\ \\✓ (Apr 30 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 958 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 05/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1998 TO 07/07/1999 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 905341 KISCH, DAVID R Cut, laceration, puncture FINGER(S) 0 12/28/98 0.00 0.00 0.00 0.00 0.00 C G1 906425 DEROSIEL, BRIAN STRAINS Groin 0 04/06/99 0.00 0.00 0.00 0.00 0.00 C G1 906424 ANDERSON, KENNE Puncture HAND 0 04/07/99 175.88 0.00 0.00 624.12 800.00 0 C4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 3 1 0 0 0 2 0 175.88 0.00 0.00 DISTRIBUTION OF RESERVES -> 574.12 0.00 50.00 624.12 800.00 1 1[E © _ � 4! MAY 1 4 2001 \,,_\ i el (Apr 30 DATA FILES) W O R K E R S, C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 959 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 05/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/2000 TO 07/07/2001 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 911833 KISCH, DAVID R CONTUSION,CRUSHING,BRUISE Thumb 0 08/01/00 0.00 0.00 0.00 0.00 0.00 C Z1 912851 NELSON, RAYMOND Puncture FINGER(S) 10 10/23/00 1183.56 720.00 0.00 0.00 1903.56 C M9 913474 HULTMAN, JULIE STRAINS MULTIPLE PARTS 0 12/06/00 0.00 0.00 0.00 0.00 0.00 C Z1 913545 KROPIDLOWSKI, F MULTIPLE INJURIES MULTIPLE PARTS 0 12/21/00 0.00 0.00 0.00 600.00 600.00 0 C4 914606 STABERG, ROLLAN STRAINS LOW BACK AREA - LUMBAR AND LU 0 03/12/01 365.30 0.00 0.00 209.70 575.00 0 C4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 5 2 0 0 1 2 10 1548.86 720.00 0.00 DISTRIBUTION OF RESERVES -> 734.70 0.00 75.00 809.70 3078.56 ii (Mar 30 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 999 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 04/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1998 TO 07/07/1999 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 905341 KISCH, DAVID R Cut, laceration, puncture FINGER(S) 0 12/28/98 0.00 0.00 0.00 0.00 0.00 C G1 906425 DEROSIEL, BRIAN STRAINS Groin 0 04/06/99 0.00 0.00 0.00 0.00 0.00 C G1 906424 ANDERSON, KENNE Puncture HAND 0 04/07/99 175.88 0.00 0.00 624.12 800.00 0 C4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 3 1 0 0 0 2 0 175.88 0.00 0.00 DISTRIBUTION OF RESERVES -> 574.12 0.00 50.00 624.12 800.00 -T © C OWE -r APR - 6200 (Mar 30 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1000 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 04/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/2000 TO 07/07/2001 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 911833 KISCH, DAVID R CONTUSION,CRUSHING,BRUISE Thumb 0 08/01/00 0.00 0.00 0.00 0.00 0.00 C Z1 912851 NELSON, RAYMOND Puncture FINGER(S) 10 10/23/00 1183.56 720.00 0.00 0.00 1903.56 C M9 913474 HULTMAN, JULIE STRAINS MULTIPLE PARTS 0 12/06/00 0.00 0.00 0.00 500.00 500.00 0 Z1 913545 KROPIDLOWSKI, F MULTIPLE INJURIES MULTIPLE PARTS 0 12/21/00 0.00 0.00 0.00 600.00 600.00 0 C4 914606 STABERG, ROLLAN STRAINS LOW BACK AREA - LUMBAR AND LU 0 03/12/01 0.00 0.00 0.00 575.00 575.00 0 C4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 5 3 0 0 1 1 10 1183.56 720.00 0.00 DISTRIBUTION OF RESERVES -> 1600.00 0.00 75.00 1675.00 3578.56 • (Jan 31 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1006 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 02/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1998 TO 07/07/1999 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 905341 KISCH, DAVID R Cut, laceration, puncture FINGER(S) 0 12/28/98 0.00 0.00 0.00 0.00 0.00 C G1 906425 DEROSIEL, BRIAN STRAINS Groin 0 04/06/99 0.00 0.00 0.00 0.00 ,: 0.00 C G1 906424 ANDERSON, KENNE Puncture HAND 0 04/07/99 175.88 0.00 0.00 624.12 800.00 0 Z1 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 3 1 0 0 0 2 0 175.88 0.00 0.00 DISTRIBUTION OF RESERVES -> 574.12 0.00 50.00 624.12 800.00 i, JJ7 (Jan 31 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1007 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 02/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1999 TO 07/07/2000 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 907750 HAUSKEN, MICHAE Cut, laceration, puncture FINGER(S) 0 07/26/99 0.00 0.00 0.00 0.00 0.00 C G1 910412 KROPIDLOWSKI, F Cut, laceration, puncture FINGER(S) 0 03/29/00 291.50 0.00 0.00 0.00 291.50 C Z1 910530 STABERG, ROLLAN STRAINS LOW BACK AREA - LUMBAR AND LU 0 03/31/00 197.73 0.00 0.00 0.00 197.73 C Zi 911406 BUCKLEY, STANLE Myocardial Infarction Heart 0 04/04/00 0.00 0.00 153.71 46.29 200.00 D T4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 4 1 2 0 0 1 0 489.23 0.00 153.71 DISTRIBUTION OF RESERVES -> 0.00 0.00 46.29 46.29 689.23 (Jan 31 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1008 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 02/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/2000 TO 07/07/2001 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 911833 KISCH, DAVID R CONTUSION,CRUSHING,BRUISE Thumb 0 08/01/00 0.00 0.00 0.00 0.00 0.00 C Z1 912851 NELSON, RAYMOND Puncture FINGER(S) 10 10/23/00 1183.56 720.00 0.00 0.00 1903.56 C M9 913474 HULTMAN, JULIE STRAINS MULTIPLE PARTS 0 12/06/00 0.00 0.00 0.00 500.00 500.00 0 Z1 913545 KROPIDLOWSKI, F MULTIPLE INJURIES MULTIPLE PARTS 0 12/21/00 0.00 0.00 0.00 600.00 600.00 0 Z1 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 4 2 0 0 1 1 10 1183.56 720.00 0.00 DISTRIBUTION OF RESERVES -> 1100.00 0.00 0.00 1100.00 3003.56 (Dec 29 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 952 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 01/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1998 TO 07/07/1999 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 905341 KISCH, DAVID R Cut, laceration, puncture FINGER(S) 0 12/28/98 0.00 0.00 0.00 0.00 0.00 C G1 906425 DEROSIEL, BRIAN STRAINS Groin 0 04/06/99 0.00 0.00 0.00 0.00 0.00 C G1 906424 ANDERSON, KENNE Puncture HAND 0 04/07/99 175.88 0.00 0.00 624.12 . 800.00 0 Zl TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 3 1 0 0 0 2 0 175.88 0.00 0.00 DISTRIBUTION OF RESERVES -> 574.12 0.00 50.00 624.12 800.00 D 92001 (Dec 29 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCL S 953 L ABRIDGED ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 01/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1999 TO 07/07/2000 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 907750 HAUSKEN, MICHAE Cut, laceration, puncture FINGER(S) 0 07/26/99 0.00 0.00 0.00 0.00 0.00 C G1 910412 KROPIDLOWSKI, F Cut, laceration, puncture FINGER(S) 0 03/29/00 291.50 0.00 0.00 0.00 291.50 C Z1 910530 STABERG, ROLLAN STRAINS LOW BACK AREA - LUMBAR AND LU 0 03/31/00 197.73 0.00 0.00 0.00 197.73 C Z1 911406 BUCKLEY, STANLE Myocardial Infarction Heart 0 04/04/00 0.00 0.00 154.21 45.79 200.00 D T4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 4 1 2 0 0 1 0 489.23 0.00 154.21 DISTRIBUTION OF RESERVES -> 0.00 0.00 45.79 45.79 689.23 (Dec 29 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 954 CLAIMS REPORT FOR OAR PARR HEIGHTS DATE OF REPORT 01/01/01 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/2000 TO 07/07/2001 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 911833 KISCH, DAVID R CONTUSION,CRUSHING,BRUISE Thumb 0 08/01/00 0.00 0.00 0.00 0.00 0.00 C Z1 912851 NELSON, RAYMOND Puncture FINGER(S) 10 10/23/00 1678.24 720.00 0.00 3100.76 5499.00 0 Z1 913474 HULTMAN, JULIE STRAINS MULTIPLE PARTS 0 12/06/00 0.00 0.00 0.00 500.00 500.00 0 Z1 913545 KROPIDLOWSKI, F MULTIPLE INJURIES MULTIPLE PARTS 0 12/21/00 0.00 0.00 0.00 0.00 0.00 X Z1 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 4 2 0 1 0 1 10 1678.24 720.00 0.00 DISTRIBUTION OF RESERVES -> 2000.76 1500.00 100.00 3600.76 5999.00 (Oct 31 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1061 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 11/01/00 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1998 TO 07/07/1999 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 905341 KISCH, DAVID R Cut, laceration, puncture FINGER(S) 0 12/28/98 0.00 0.00 0.00 0.00 0.00 C G1 906425 DEROSIEL, BRIAN STRAINS Groin 0 04/06/99 0.00 0.00 0.00 0.00 0.00 C G1 906424 ANDERSON, KENNE Puncture HAND 0 04/07/99 175.88 0.00 0.00 624.12 800.00 0 Z1 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 3 1 0 0 0 2 0 175.88 0.00 0.00 DISTRIBUTION OF RESERVES -> 574.12 0.00 50.00 624.12 800.00 (Oct 31 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1062 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 11/01/00 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1999 TO 07/07/2000 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 907750 HAUSKEN, MICHAE Cut, laceration, puncture FINGER(S) 0 07/26/99 0.00 0.00 0.00 0.00 0.00 C G1 910412 KROPIDLOWSKI, F Cut, laceration, puncture FINGER(S) 0 03/29/00 291.50 0.00 0.00 108.50 400.00 0 Zl 910530 STABERG, ROLLAN STRAINS LOW BACK AREA - LUMBAR AND LU 0 03/31/00 197.73 0.00 0.00 0.00 197.73 C Z1 911406 BUCKLEY, STANLE Myocardial Infarction Heart 0 04/04/00 0.00 0.00 154.21 45.79 200.00 D T4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 4 2 1 0 0 1 0 489.23 0.00 154.21 DISTRIBUTION OF RESERVES -> 108.50 0.00 45.79 154.29 797.73 (Oct 31 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1063 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 11/01/00 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/2000 TO 07/07/2001 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 911833 KISCH, DAVID R CONTUSION,CRUSHING,BRUISE Thumb 0 08/01/00 0.00 0.00 0.00 0.00 0.00 C Z1 912851 NELSON, RAYMOND Puncture FINGER(S) 0 10/23/00 0.00 0.00 0.00 300.00 300.00 0 Z1 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 2 1 0 0 0 1 0 0.00 0.00 0.00 DISTRIBUTION OF RESERVES -> 300.00 0.00 0.00 300.00 300.00 (Sep 29 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1077 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 10/01/00 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1998 TO 07/07/1999 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 905341 KISCH, DAVID R Cut, laceration, puncture FINGER(S) 0 12/28/98 0.00 0.00 0.00 0.00 0.00 C G1 906425 DEROSIEL, BRIAN STRAINS Groin 0 04/06/99 0.00 0.00 0.00 0.00 0.00 C G1 906424 ANDERSON, KENNE Puncture HAND 0 04/07/99 175.88 0.00 0.00 624.12 800.00 0 Z1 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 3 1 0 0 0 2 0 175.88 0.00 0.00 DISTRIBUTION OF RESERVES -> 574.12 0.00 50.00 624.12 800.00 (Sep 29 DATA FILES) W O R K E R S, C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1078 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 10/01/00 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1999 TO 07/07/2000 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 907750 HAUSKEN, MICHAE Cut, laceration, puncture FINGER(S) 0 07/26/99 0.00 0.00 0.00 0.00 0.00 C G1 910412 KROPIDLOWSKI, F Cut, laceration, puncture FINGER(S) 0 03/29/00 291.50 0.00 0.00 108.50 400.00 0 Z1 910530 STABERG, ROLLAN STRAINS LOW BACK AREA - LUMBAR AND LU 0 03/31/00 197.73 0.00 0.00 402.27 600.00 0 Z1 911406 BUCKLEY, STANLE Myocardial Infarction Heart 0 04/04/00 0.00 0.00 108.60 91.40 200.00 D T4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 4 3 0 0 0 1 0 489.23 0.00 108.60 DISTRIBUTION OF RESERVES -> 510.77 0.00 91.40 602.17 1200.00 (Aug 31 DATA FILES) W O R K E R S' COMPENSATION C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1072 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 09/01/00 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1998 TO 07/07/1999 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 905341 KISCH, DAVID R Cut, laceration, puncture FINGER(S) 0 12/28/98 0.00 0.00 0.00 0.00 0.00 C G1 906425 DEROSIEL, BRIAN STRAINS Groin 0 04/06/99 0.00 0.00 0.00 0.00 0.00 C Gl 906424 ANDERSON, KENNE Puncture HAND 0 04/07/99 175.88 0.00 0.00 624.12 800.00 0 21 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 3 1 0 0 0 2 0 175.88 0.00 0.00 DISTRIBUTION OF RESERVES -> 574.12 0.00 50.00 624.12 800.00 i i fUJ (Aug 31 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1073 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 09/01/00 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1999 TO 07/07/2000 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 907750 HAUSKEN, MICHAE Cut, laceration, puncture FINGER(S) 0 07/26/99 0.00 0.00 0.00 0.00 0.00 C G1 910412 KROPIDLOWSKI, F Cut, laceration, puncture FINGER(S) 0 03/29/00 291.50 0.00 0.00 108.50 400.00 0 Z1 910530 STABERG, ROLLAN STRAINS LOW BACK AREA - LUMBAR AND LU 0 03/31/00 197.73 0.00 0.00 402.27 600.00 0 Z1 911406 BUCKLEY, STANLE Myocardial Infarction Heart 0 04/04/00 0.00 0.00 0.00 200.00 200.00 D T4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 4 3 0 0 0 1 0 489.23 0.00 0.00 DISTRIBUTION OF RESERVES -> 510.77 0.00 200.00 710.77 1200.00 I (Aug 1 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1047 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 08/01/00 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1998 TO 07/07/1999 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 905341 KISCH, DAVID R Cut, laceration, puncture FINGER(S) 0 12/28/98 0.00 0.00 0.00 0.00 0.00 C G1 906425 DEROSIEL, BRIAN STRAINS Groin 0 04/06/99 0.00 0.00 0.00 0.00 0.00 C G1 906424 ANDERSON, KENNE Puncture HAND 0 04/07/99 175.88 0.00 0.00 624.12 800.00 0 Z1 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 3 1 0 0 0 2 0 175.88 0.00 0.00 DISTRIBUTION OF RESERVES -> 574.12 0.00 50.00 624.12 800.00 I@ g O V E AUG _ 4 2000 1 1 1 (Aug 1 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1048 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 08/01/00 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1999 TO 07/07/2000 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 907750 HAUSKEN, MICHAE Cut, laceration, puncture FINGER(S) 0 07/26/99 0.00 0.00 0.00 0.00 0.00 C G1 910412 KROPIDLOWSKI, F Cut, laceration, puncture FINGER(S) 0 03/29/00 291.50 0.00 0.00 108.50 400.00 0 Z1 910530 STABERG, ROLLAN STRAINS LOW BACK AREA - LUMBAR AND LU 0 03/31/00 197.73 0.00 0.00 402.27 600.00 0 Z1 911406 BUCKLEY, STANLE Myocardial Infarction Heart 0 04/04/00 0.00 0.00 0.00 200.00 200.00 D T4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 4 3 0 0 0 1 0 489.23 0.00 0.00 DISTRIBUTION OF RESERVES -> 510.77 0.00 200.00 710.77 1200.00 AUG IECIEOWEB - 4 2000 (Jul 3 DATA FILES) W O R K E R S' COMPENSATION C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1007 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 07/01/00 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1998 TO 07/07/1999 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 905341 KISCH, DAVID R Cut, laceration, puncture FINGER(S) 0 12/28/98 0.00 0.00 0.00 0.00 0.00 C G1 906425 DEROSIEL, BRIAN STRAINS Groin 0 04/06/99 0.00 0.00 0.00 0.00 0.00 C G1 906424 ANDERSON, KENNE Puncture HAND 0 04/07/99 175.88 0.00 0.00 624.12 800.00 0 Z1 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 3 1 0 0 0 2 0 175.88 0.00 0.00 DISTRIBUTION OF RESERVES -> 574.12 0.00 50.00 624.12 800.00 (Jul 3 DATA FILES) W O R K E R S' COMPENSATION C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1008 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 07/01/00 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1999 TO 07/07/2000 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 907750 HAUSKEN, MICHAE Cut, laceration, puncture FINGER(S) 0 07/26/99 0.00 0.00 0.00 0.00 0.00 C G1 910412 KROPIDLOWSKI, F Cut, laceration, puncture FINGER(S) 0 03/29/00 247.30 0.00 0.00 152.70 400.00 0 Z1 910530 STABERG, ROLLAN STRAINS LOW BACK AREA - LUMBAR AND LU 0 03/31/00 155.43 0.00 0.00 444.57 600.00 0 Z1 911406 BUCKLEY, STANLE Myocardial Infarction Heart 0 04/04/00 0.00 0.00 0.00 200.00 200.00 D T4 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 4 3 0 0 0 1 0 402.73 0.00 0.00 DISTRIBUTION OF RESERVES -> 597.27 0.00 200.00 797.27 1200.00 (Apr 1 DATA FILES) W O R K E R S' COMPENSATION C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1002 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 04/01/00 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1998 TO 07/07/1999 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 905341 KISCH, DAVID R Cut, laceration, puncture FINGER(S) 0 12/28/98 0.00 0.00 0.00 0.00 0.00 C G1 906425 DEROSIEL, BRIAN STRAINS Groin 0 04/06/99 0.00 0.00 0.00 0.00 0.00 C G1 906424 ANDERSON, KENNE Puncture HAND 0 04/07/99 175.88 0.00 0.00 624.12 800.00 0 G1 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 3 1 0 0 0 2 0 175.88 0.00 0.00 DISTRIBUTION OF RESERVES -> 574.12 0.00 50.00 624.12 800.00 • t B i : N 3 ......_ i � (Apr 1 DATA FILES) W O R K E R S' C O M P E N S A T I O N C L A I M S R E P O R T MTHCLLS ABRIDGED : ALL CLAIM DETAIL FOR POLICY YEARS WITH OPEN CLAIMS 1003 CLAIMS REPORT FOR OAK PARK HEIGHTS DATE OF REPORT 04/01/00 GROUP NO. 02 ACCT # 000729 POLICY YR. 07/07/1999 TO 07/07/2000 CLAIM DAYS DATE OF PAID TO DATE TOTAL CL A NUMBER CLAIMANT INJURY DESCRIPTION OF TTD LOSS MEDICAL INDEM. EXPENSE RESERVE COST ST M 907750 HAUSKEN, MICHAE Cut, laceration, puncture FINGER(S) 0 07/26/99 0.00 0.00 0.00 0.00 0.00 C G1 910412 KROPIDLOWSKI, F Cut, laceration, puncture FINGER(S) 0 03/29/00 0.00 0.00 0.00 0.00 0.00 X Z1 TOTALS THIS TOTAL MED ONLY CLMS INDEM CLMS CLOSED DAYS PAID PAID PAID TOTAL TOTAL POLICY YEAR # CLMS OPEN---CLSD OPEN---CLSD NO PAY OF TTD MEDICAL INDEMNITY EXPENSE RESERVE COST 2 1 0 0 0 1 0 0.00 0.00 0.00 DISTRIBUTION OF RESERVES -> 0.00 0.00 0.00 0.00 0.00 III Complete Numerical List of Payroll Rates Code Description Code Description Code Description 7423 Aircraft Operations 7380-2 First Responders(Not 8868 Professional,Teachers& 7421 Aircraft Operations—Flying Volunteer) Clerical Crew 7381-1 First Responders(Volunteer) 8835 Public Health Nursing- 7380-1 Ambulance Service(Not 9403 Garbage or Refuse Collection Traveling Volunteer) 7590 Garbage Works—Reduction 9101-1 Public Library or Museum— 7381 Ambulance Service or Incineration All Other Employees (Volunteer) 7502 Gas Company 8810-3 Public Utilities Clerical 4511 Analytical Chemist 6319 Gas Mains or Connection 7610 Radio or Television 8831 Animal Control Construction Broadcasting Station—All 8810-5 Attorney—All Employees& 5506-1 General Maintenance Employees Clerical 5462 Glaziers 8264 Recycling&Drivers 9411-1 Boards and Commissions 9040 Hospital—All Other 9083 Restaurant—Fast Food 7090 Boat Livery Employees 9082 Restaurant—NOC 9410-1 Book Mobile Drivers 8833 Hospital—Professional 5551 Roofing—All Kinds 9093 Bowling Lanes Employees 8742 Salespersons 9015 Building Maintenance& 8810-1 Hospital Clerical 4000 Sand or Gravel Digging Repair 9033 Housing Authority—All 9101 School—All Other 5703 Building Raising or Moving Employees Employees 9014 Buildings—Operation by 8810-6 HRA Clerical 7580 Sewage Disposal Plant Contractor 9015-2 HRA Maintenance 6306 Sewer Construction 8385 Bus Company—Garage 5479 Insulation Work 5538 Sheet Metal Work-Erection Employees 5057 Iron or Steel Erection 9016 Skating Rink Operation 7382 Bus Drivers 6229 Irrigation or Drainage System 9180 Ski Lift Operation 7600-1 Cable TV Company Construction 8033 Store/Grocery Retail NOC 9054 Campground Operation 0042 Landscaping 5506 Street Construction& 5403 Carpentry 8810-2 Library or Museum— Maintenance 5437 Carpentry—Installation of Professional&Clerical 9015-1 Swimming Pool or Beach Cabinets/Interior Trim 6826F Marina—Coverage Under Operations 9220 Cemetery Operation Federal Act 7370 Taxicab Company 8017-1 Charitable Gambling 6836 Marina—Coverage Under 7600 Telephone Company—All 9182 City Arena—All Employees State Act Only Other Employees 9156 City Band 5022 Masonry 8901 Telephone Company—Office 8227 City Shop&Yard 3724 Millwright Work or Exchange 8810 Clerical 9410 Municipal Employees 7601 Telephone Line Construction 9060 Club—Country/Golf 8830 Nursing Home—Non- 9154 Theater—All Other 9061 Club-NOC Professional Employees Employees 9063 Community Centers—All 8829 Nursing Home—Professional 9052 Tourist Court or Cabins Employees and Clerical Employees 0106 Tree Trimming 5213 Concrete Construction 8810-4 Nursing Home Clerical 9534 Truck Crane Operation 5221 Concrete/Flat&Drivers 8017 Off Sale Liquor Store 7228 Trucking—Local Hauling 6325 Conduit Construction 5191 Office Machine Repair Only 9101-2 Crossing Guards 9084 On Sale Liquor Store 7229 Trucking—Long Distance 7380 Drivers&Helpers 5474 Painting or Paper Hanging Hauling 9102-1 Dumpster Helper 5192 Parking Meter Readers 7520 Waterworks 9411 Elected or Appointed 9102 Parks Officials 8832 Physician&Clerical 7538 Electric—Power Line (Clinics) Construction 6003 Pile Driving 7539 Electric&Steam Plant 5480 Plastering 5190 Electric Wiring—within 5183 Plumbing buildings 7720 Police 6217 Excavation 7721 Police—Non Smoking 6400 Fence Construction-Metal 8868-1 Police Chaplains 7716 Firefighters—Non Smoking 7722 Police Reserves (Not Volunteer) 7723 Police Reserves—Non 7718 Firefighters—Non Smoking Smoking (Volunteer) 4299 Printing 7706 Firefighters(Not Volunteer) 7708 Firefighters(Volunteer) MAY-28-2002 0 01 04022002 P.01/03 9 LMC145 University Avenue West, St. Paul, MN 55103-2044 L.oy •of M;nn,.oto Ca;,, Fax: (651) 281-1297 • TDD (651) 281-1290 C;,; .promoting cro,)tano, Fax Transmission 05/28/02 To: Judy From: Barb Meyer City of Oak Park Hgts Title: PST Fax*: 651-439-0574 Phone#: (651)215-4173 No. of pages including this one: 3 If you have difficulty receiving this communication, please contact me at(651)215-4173. Message: Judy, Here is a copy of last year's information page and notice of premium options sheet. Thanks, Barb Notice of Confidentiality Information contained in this fax is strictly confidential and may be subject to legal privileges.It is for the sole use of the individual or entity named above. If the reader of this message is not the intended recipient,you are hereby notified that any use, duplication or dissemination of this communication or its contents is strictly prohibited. If you have received this transmission in error,please notify us immediately by telephone and return the original to us at our expense.Thank you. LM 4070(11/98) MAY-28-2002 09:01 04022002 P.02/03 League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 Phone (651) 215-4173 Information Page RENEWAL 1. The"City" Agreement No. 02-000729-15 OAK PARK HEIGHTS, CITY OF "City"is: x City PO BOX 2007 Joint Powers Entity OAK PARK HEIGHT MN 55082-2007 Other(describe) 2. The Agreement period is from 12:01 a.m. 07/07/2001 to 12:01 a.m. 07/0772002 at the"City's"address. 3. A. Workers'Compensation Coverage: Part One of the Agreement applies to the Workers'Compensation Law of any state of the United States of America and the District of Columbia. B. Employers Liability Coverage: Part Two of the Agreement applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury-Each Occurrence$1,000,000. Bodily Injury by Disease-Agreement Limit$1,000,000. C. Part Three of the Agreement applies to Infectious Disease Diagnostic Testing. D. Part Four of the Agreement applies to Peace Officers' Posttraumatic Stress Syndrome Benefit, E. This Agreement includes these amendments and schedules: 4. Retro-rating option selected? NOT APPLICABLE 5. Elected Officials Covered? YES Boards and Commissions Covered (List) EDA 6. The premium for this Agreement will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. PREMIUM BASIS RATES ENTRIES IN THIS ITEM.EXCEPT AS SPECIFICALLY PROVIDED ESTIMATED ESTIMATED TOTAL PER$100 OF CODE ELSEWHERE IN THIS AGREEMENT; DO NOT MODIFY ANY OF THE ANNUAL ANNUAL REMUNERATION REMUNERATION NO• OTHER PROVISIONS OF THIS AGREEMENT. PREMIUM 194458. 4.11 5506 GENERAL MAINTENANCE 7992. 610608. 2.81 7720 POLICE 17158. 407370. 0.40 8810 CLERICAL 1629. 19544. 2.44 9102 PARKS 477. 126706. 1.00 9410 MUNICIPAL EMPLOYEES 1267. 26000. 0.37 9411 ELECTED OR APPOINTED OFFICIALS 96. MPrt R� gay 1 �01N�OR 0. DO Manual Premium 28619. Experience Modification 0.74 Standard Premium 21178. Managed Care Credit 0% 0. AGENT Deductible Credit 0% 0. F-411709883 393.00 Premium Discount 1537. LANDMARK INS SERVICE Discounted Standard Premium 19641. 232 S LK ST BOX 188 LIIC Insurance Trust Discount U% O. FOREST LAKE MN 55025 Ncat Deposit Premium 19641. 1= DATE_ LM 4670(12/9 05/23/2001 MAY-28-2002 09:02 04022002 P.03/03 League of Minnesota Cities Insurance Trust G rouV Sal insured'Nork4rs:tompenstion Plan 145 UniversityAYnee West Sty�aul,IA N,5103-?�� : tione(651) 21 5-4173 Notice of Premium Options The "City" greementNo.: 02-000729-14 OAK PARK HEIGHTS Agreement Period: From: 07/07/2000 PO BOX 2007 To: 07/07/200! OAK PARK HEIGHT MN 55082•-2007 Enclosed is aquotationforworkers'compensation d epositpremium.Deductible options are now available in returnfor a premium credit applied to your estimated standard premium of$ 200133.. The deductible will apply peroccurrenceto paid medical costs only.There is no aggregate limit. Please indicat e b elowthe premium option you wish to select. You may chooseonly one and you cannotchangeoptions duringthe agreementperiod. °0 C `i NET DEPOSIT PREMIUM OPTIONS GX� 1)(1 Np� P Ps 1 X RegularPremiumOption (8650. Deductible Premium Credit per Occurrence Credit Amount 2 0 $250 3% 602. 18048. 3 ❑ 500 4.5% 304. 17746. 4 ❑ 1,000 6% .1205. 17445. 5 ❑ 2,500 10% 2008. 16642. 6 ❑ 5,000 13.5% 2711 . 15939. 7 ❑ 10,000 18% 3615. 15035. This shouldbesignedby an authorizedrepresentative ofthe city requesting coverage. One ofthe above options must be selected. Please return a signed copy of this notice to us with payment and make checks payable to the LMCIT. --,��---, N,"\rNiN,.----.� ---4,-.;;;:f_. City Administrator 9/14/00 Signature Title Date For more information on the premium options thatapplyto your city,referto theenclosed brochure. LM4501(8/99) TOTAL P.03 Leagu of Minnesota Cities Insura Trust GrouVelf-Insu red Workers' Compensating Plan 145 University Avenue West St.Paul,MN 55103-2044 Phone(651)215-4173 Notice of Premium Options The "City" Agreement No.: 02-000729-14 OAK PARK HEIGHTS ' Agreement Period: FO BOX 2007 From: 07/07/2000 OAK PARK HEIGHT MN 55082-2007 To: 07/07/2001 Enclosed is a quotationforworkers'compensation depositpremium.Deductible options are now available inreturnfora premium credit applied to your estimated standard premium of$ 200j83.. The deductible will apply 1 Y per occurrence to paid medical costs only.There is no aggregate limit. Please indicate below the premium optionyouwishtoselect. You may choose onl one you Y change options duringthe agreementperiod. OPTIONS NET DEPOSIT PREMIUM 1 Regular Premium Option 18650. Deductible Premium Credit per Occurrence Credit Amount 2 ❑ $250 3% 602. 18048. 3 ❑ 500 4.5% 904. 17746, 4 ❑ 1,000 6% 1205. 17445. 5 ❑ 2,500 10% 2008. 16642. 6 ❑ 5,000 13.5% 2711. 15939. 7 ❑ 10,000 18% 3615. 15035 J_..ice. This should besigned by an authorized repres entative ofthe city requesting coverage. One ofthe above options must be selected.Please return asigned copy ofthis notice to us with payment and make checks payable to the LMCIT. ql - City Administrator 9/14/00 Signature Title Date For more information on the premium options that apply to your city,referto the enclosed brochure. LM4501 (8/99) w w CcCCaYE � LMC 1 1 2000 5EP , R I�:�'145 University Avenue We ' i t ► !_ _144 League of Minnesota Cities Phone: (651) 215-4173 Cities promoting excellence Fax: (651) 281-1297 • TDD (651) 281-1290 Enclosed is your: ❑ Coverage Document for Minnesota Workers' Compensation Please carefully review your Policy or Agreement, the Information Page and any Endorsements to ensure that the coverages you want or need are included and that they are accurately prepared. If you have one, your agent will also receive copies of your Information Page and any Endorsements. Please communicate with your agent or the League of Minnesota Cities Insurance Trust if there are errors or if changes are necessary. Also included for your review are the forms and instructions you need to report all workers' compensation claims to the League of Minnesota Cities Insurance Trust. ® Minnesota Workers' Compensation Renewal Document Please carefully review your renewal Policy or Agreement, the Information Page and any Endorsements to ensure that the coverages you want or need are included and that they are accurately prepared. ❑ New supply of First Report of Injury forms and/or the other information you requested. Mandatory Fraud Notice A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. Minnesota Statute 60A.955. You must maintain an adequate supply of First Report of Injury forms. They should be kept where they are accessible to the person who is responsible for completing the form and sending it to the League of Minnesota Cities Insurance Trust. If you have run out of forms or can't find your supply, please complete the form below and return it to the League of Minnesota Cities Insurance Trust. We will gladly send you a supply of forms and provide any other information you request. Please do it today because you never know when an injury might be reported by one of your employees. 02-.00072 Please send the following information to the attention of: OAK PARK HEIGHTS F'0 SOX 2007 OAK PARK HEIGHT l•Ihd 55082-2007 at the address at left. ❑ First Report of Injury forms ❑ Supervisor's Report of Accident forms ❑ Minnesota Workers' Compensation booklet Clip and mail to: ❑ Employer's Injury Management Guide ❑ Employer's Loss Control booklet League of Minnesota Cities Insurance Trust ❑ Deductible information 145 University Avenue West St. Paul, MN 55103-2044 LM 3111 (8/99) N 10)..4 10)..4 10)..4 c c @.I. .0 a) •Q - .1144.14 al) 4311) al) c WIMNI = CA V:!.,P/ ' •- I J Cti tiMal Cf:j �� i O CC! 0 • i C o _ #7/: G) C CZ (iOn 1111) .7� E L'�� i ) � a: I _II. - _ �V . a)CA = wein. 4 1,., , t .. ' & -'-' .... CI o at . 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(D CD 0 Q' ^ v• ° CD m '�] LliH G cD 0 o e1 co ccD D eC P� = O" y I 4! trt ` (� co K A .. 0, 0 o v� o'O 5 .-1 p °0 5n yo k-, fa, i I HI. O P e�•h �7 C ►0�.. A c m o a cD ob ►°"i 1�.,� & 0.1 4 i w �' ,.... 0 P V rA al 1� V o 'i CT P R']t o ° co rn o Q� 1 �r J 5� tM CD 1 .4:7", ., .. ."" �._°to WORKERS' COMPENSATION DIVISION RESOURCE GUIDE Location Phone # Appeals to Court of Appeals Docket 296-3536 Apportionment A & C 296-2432 Assessments paid to Special Fund S.C. F. 296-2117 Attorney Fees A & C 296-2432 Awards J.S. 297-3663 Benefits (weekly or permanent partial) A & C 296-2432 Brochures or written information R & E 297-4595 Change of Physicians A & C 296-2432 Claims Files (to review or copy) Records 296-7959 Claim Petition Forms Docket 296-3536 Claim Questions A & C 296-2432 Compensation Rates A & C 296-2432 Complaints about Health Care Providers S.C.F. 296-8213 Coverage A & C 296-2432 Data Privacy A & C 296-2432 Denial of Benefits A & C 296-2432 Discontinuance of Benefits A & C 296-2432 Forms: • How to Complete or What to Use (not A & C 296-2432 reimbursement forms) • Special Compensation Fund S.C.F. 296-2117 Reimbursement Forms Independent Contractors: • Insurance Coverage S.C.F. 296-4358 • Other Questions A & C 296-2432 Insurance Verification S.C.F. 296-2170 -or- 296-2117 Mediation Mediation 296-4534 Medical Conference Request Forms DRS 297-2636 Medical Fee Schedule Copy MN BookStore 297-3000 Questions A & C 296-2432 or 1-800- 342-5354 Medical Problems DRS 297-2636 Medical Services Review Board S.C.F. 296-8213 Motions J.S. 297-3663 Notice of Intention to Discontinue Benefits A & C 297-2636 Objection to Discontinuance Forms Docket 296-3536 Objection to Penalty Assessment Forms Docket 296-3536 Orders J.S. 297-3663 Penalties A & C 296-2432 Permanent Partial Disability: MN Book Store • Schedule A & C 297-3000 • General Questions 296-2432 Petition Forms Docket 296-3536 Posters IMS 296-4893 Qualified Rehabiltation Consultant (QRC) DRS 297-2636 QRC Registration and Training S.C.F. 297-2727 Rehabilitation Review Panel S.C.F. 296-8213 Rehabilitation: • Forms & General Questions DRS 297-2636 • Rules S.C.F. 297-3970 Reopening Benefits A & C 296-2432 Request for Formal Hearing Docket 296-3536 Return to Work A & C 296-2432 Rules Legal 296-8184 Second Injury Reimbursements S.C.F. 296-2117 Seminars R & E 297-4599 Settlement Conferences J.S. 297-3663 Speakers for Meetings Assistant to Commissioner 296-2492 Statistics R & E 297-4595 Statute Book MN Book Store 297-3000 Stipulations J.S. 297-3663 Subpoena Forms , Docket 296-3536 Suitable Job A & C 296-2432 Subrogation Claim Orders Legal 296-8184 Supplementary Benefits Reimbursement S.C.F. 296-2117 Time Limitations: Reporting, Paying Benefits, Objecting, Requesting a Conference A & C 296-2432 Uninsured Claims S.C.F. 296-2117 KEY TO SECTIONS Section Abbreviation Assistance & Compliance A & C Dispute Resolution DRS Docket Docket Information Management Unit IMS Mediation Mediation Legal Services Legal Records Records Research & Education R & E Special Compensation Fund S.C.F. Judicial Services J.S MM/kh 7/95 STATE OF MINNESOTA Department of Labor and Industry Apprenticeship Division Information 296-2371 Labor Standards and Prevailing Wage Division Information 296-2282 Research and Education Unit Information 297-4595 Occupational Safety and Health Consultation 297-2393 Information Occupational Safety and Health Enforcement Division Information 296-2116 Complaints 296-4017 Legal Services Information 296-8184 Workers' Compensation Division Assistance and Compliance Section - Claims 296-2432 or Assistance Information 1-800-342-5354 MM/kh 7/95 t 0 , o Statute Description Effective Date a) ARTICLE 1 Subject Page 1 79.50 Rate Regulation - Purpose 2 January 1, 1996 2 79.51, Subd. 1 Rate Regulation - Rules 2 January 1, 1996 3 79.51, Subd. 3 Rate Regulation - Rules 2 January 1, 1996 4 79.53, Subd. 1 Rate Regulation - Method of Calculation 4 January 1, 1996 5 79.55, Subd. 2 Rate Regulation - Excessiveness 4 I January 1, 1996 6 79.55, Subd. 5 Rate Regulation - Discounts 5 I January 1, 1996 .7 79.55, Subd. 6 Rate Regulation - Rating Factors 5 January 1, 199 9 9 I ry 1996 8 79.55, Subd. 7 Rate Regulation - External Factors 6 I January 1, 1996 9 79.56, Subd. 1 Rate Regulation - Prefiling Rates 6 January 1, 1996 10 79.56, Subd. 3 Rate Regulation - Penalties 7 January 1, 1996 11 79.561 Rate Regulation - Disapproval 7 January 1, 1996 12 175.16, Subd. 2 Fraud Unit 9 July 1, 1995 * 13 176.011, Subd 25 Maximum Medical Improvement 9 October 1, 1995 doi 14 176.021, Subd. 3 PPD 2-Tier Elimination 10 I October 1, 1995 doi 15 176.021, Subd. 3a PPD Lump Sum Elimination 12 I October 1, 1995 doi 16 176.061, Subd. 10 PPD 2-Tier Technical 12 I October 1, 1995 doi 17 176.101, Subd. 1 TTD - Maximum & Minimum comp; cessation October 1, 1995 doi and recommencement 13 18 176.101, Subd. 2 PPD 2-Tier Technical 16 I October 1, 1995 doi 19 176.101, Subd. 2a PPD Compensation Schedule 17 October 1, 1995 doi 20 176.101, Subd. 4 Retirement PresumptionPTD 65% Minimum 18 October 1,1995 doi 21 176.101, Subd. 5 PTD Definition 17/15/13 Percent 19 October 1, 1995 doi 22 176.101, Subd. 6 PPD 2-Tier Technical 20 October 1, 1995 doi 23 176.101, Subd. 8 TTD Retirement Presumption 20 I October 1, 1995 24 176.105, Subd. 4 PPD Schedule - Technical Actuarial 21 1 October 1, 1995 Pace 1 of 6 25 176.178 Fraud - Forms 23 July 1, 1995 * 26 176.179 Credits - PPD - 2 Tier Technical 24 October 1, 1995 27 176.221, Subd. 6a PPD 2-Tier Technical 25 October 1, 1995 28 176.645 Cost of Living Adjustment 25 October 1, 1995 doi 29 176.66, Subd. 11 Occupational Disease - Supp. Benefit 26 I October 1, 1995 doi 30 176.82 Refusal to Hire 27 October 1, 1995 doi 31 176.861 Fraud - Insurer Disclosure of Information 28 I July 1, 1995 * 32 268.08, Subd. 3 TPD - Reemployment Benefits-Offset 28 October 1, 1995 doi 33 Appropriation Commerce 30 July 1, 1995 * 34 I Appropriation La bor and Industry ry 30 Jul y 1, 19 95 • 35 Repealer Supplementary Benefits 30 October 1, 1995 doi • 36 Repealer a) Old Insurance Provisions January 1, 1996 b) 2-Tier Elimination October 1, 1995 c) 176.86 - Fraud Unit July 1, 1995 d) Logger Safety Sunset 30 July 1, 1995 37 Effective dates 30 * Effective date is not specified in the Act, but governed by: Igr Minn. Stat. §645.02: For Acts containing appropriation items, the effective date is July 1, unless the Act specifies otherwise. Minn. Stat. §176.1321: Workers' Compensation benefit changes are effective October 1, unless the Act specifies otherwise. Pace 2of6 c 0 iti) Statute Description Effective Date ARTICLE 2 Subject Page Effective Date 1 13.69, Subd.1 Fraud-Data 31 July 1, 1995 * 2 13.82, Subd.1 Fraud-Data 31 July 1, 1995 ' 3 79.074, Subd. 2 Insurance Dividends - Technical 31 ( July 1, 1995 * 4 79.085 Insurer Safety Consultation 32 October 1, 1995 5 79.211, Subd. 1 Insurance Rate Wage Base 32 October 1, 1995 6 . 79.251, Subd. 2 ARP Premium Discount 33 July 1, 1995 * 7 79.251, Subd. 8 ARP Dissolution System 34 July 1, 1995 * 8 79.253, Subd. 2a Safety Grants 34 July 1, 1995 * 9 79.34, Subd. 2 WCRA Retention Limit 35 January 1, 1996 10 79.35 WCRA Retention Limit 38 January 1, 1996 11 79.52, Subd. 17 Rate Review- Rating Association 40 January 1, 1996 12 79.52, Subd. 18 Rate Review - Rate Oversight Commission 40 January 1, 1996 13 79.55, Subd. 8 Rate Review -Annual Filings 41 ( January 1, 1996 14 79.55, Subd. 9 Rate Review - Rate Oversight Commission 41 ( January 1, 1996 15 79.55, Subd. 10 Rate Review - Duties of Commissioner 41 January 1, 1996 16 79.60, Subd. 1 Rate Review - Insurer Reporting 43 January 1, 1996 17 79A.01, Subd. 1 Self-Insurers Technical 43 July 1, 1995 * 18 79A.01, Subd. 4 Self-Insurers Technical - Insolvency 43 July 1, 1995 • 19 79A.Q1, Subd. 10 Self Insurers - Common Claims Fund 43 July 1, 1995 • 20 79A.02, Subd. 1 Self-Insurers -Advisory Committee 43 ( July 1, 1995 * ■ 21 79A.02, Subd. 2 Self-Insurers - Advice to Commissioner 44 ( July 1, 1995 22 79A.02, Subd. 4 Self-Insurers Solvency 44 July 1, 1995 • 23 79A.03, Subd. 4a Self-Insurance Solvency 45 July 1, 1995 * 24 79A.04, Subd. 2 Self-Insurers Technical 45 ( July 1, 1995 25 79A.04, Subd. 9 Self-Insurers Technical 47 I July 1, 1995 * Pace 3 of 6 126 79A.09, Subd. 4 Self-Insurers Technical 48 July 1, 1995 * 27 79A.15 Self-Insurers Technical 48 ' July 1, 1995 * 28 79A.19 Group Self-Insurance 54 August 1, 1995 29 79A.20 Group Self-Insurance 55 I August 1, 1995 30 79A.21 Group Self-Insurance 55 August 1, 1995 31 79A.22 Group Self-Insurance 58 August 1, 1995 32 79A.23 Group Self-Insurance 62 August 1, 1995 33 79A.24 Group Self-Insurance 65 August 1, 1995 34 79A.25 Group Self-Insurance 68 August 1, 1995 35 79A.26 Group Self-Insurance 69 August 1, 1995 36 79A.27 Group Self-insurance 74 August 1, 1995 37 79A.28 Group Self-Insurance 75 August 1, 1995 38 79A.29 Group Self-Insurance 75 August 1, 1995 • 39 79A.30 Group Self-Insurance 75 August 1, 1995 40 79A.31 Group Self-Insurance 75 August 1, 1995 41 79A.32 Group Self-Insurance 76 August 1, 1995 42 168.012 Fraud - Unmarked Vehicles 77 July 1, 1995 * 43 175.16 Dispute Resolution - Delegation 79 May 26, 1995 44 176.011, Subd. 16 2 Tier-Technical 80 October 1,1995(doi*) 45 176.081, Subd. 1 Attorney Fees 80 October 1, 1995 46 176.081, Subd. 7 Penalty Increase -Attorney Fees 84 October 1, 1995 47 176.081, Subd. 7a Attorney Fees 85 October 1, 1995 48 176.081, Subd. 9 Attorney Retainer Agreement 85 July 1, 1995 * 49 176.081, Subd. 12 Attorney - Sanctions 86 July 1, 1995 50 176.102, Subd. 3a Penalty Increase - QRC 86 July 1, 1995 * 51 176.102, Subd. 11 Retraining Timelines; Penalty 87 October 1, 1995 doi 52 176.103, Subd. 2 Medical Services Review Board July 1, 1995 * 53 176.103, Subd. 3 I Medical Services Review Board 90 I July 1,1995 54 176.104, Subd.1 DOLL -Vocational Rehabilitation Unit 91 I July 1, 1995 * 55 176.106 Administrative Conferences - $1,500 92 July 1, 1 995 56 176.107 I Teleconferences 94 I July 1, 1995 * 57 176.108 Light Duty - Work Pools 94 October 1, 1 995 Pace 4 of 6 58 ( 176.129, Subd. 9 ( Special Compensation Fund - Settlements 94 ( May 26, 1995 59 ( 176.129, Subd. 10 Penalty Increase 95 ( July 1, 1995 * 60 ( 176.130, Subd. 9 Penalty Increase 95 July 1, 1995 * 61 176.135, Subd. 1 Attorney Fee 96 October 1, 1995 * 62 ( 176.1351, Subd. 1 ( Managed Care Application Fee 97 July 1, 1995 * 63 ( 176.1351, Subd. 5 Managed Care - Penalties 98 J May 26, 1995 64 ( 176.136, Subd. 1a Medical Fee Schedule -Adjustments 100 July 1, 1995 * 65 ( 176.136, Subd. 1 b Maximum Liability for Medical Charges 102 ( July 1, 1995 * 66 176.136, Subd. 2 Excessive Medical Fees - Burden of Proof 102 ( July 1, 1995 * 67 ( 176.138 Penalty Increase -Technical 103 July 1, 1995 * 68 176.139, Subd. 2 Penalty Increase 104 July 1, 1 995 * 69 176.181, Subd. 7 Penalty Increase 104 July 1, 1995 * 70 176.181, Subd. 8 Fraud-Data 105 July 1, 1995 * 71 1 176.1812 Collective Bargaining Agreements 105 July 1, 1995 * 72 ( 176.182 Penalty Increase 109 July 1, 1995 * 73 176.183, Subd. 1 Petitions - Uninsured Employers 109 ( July 1, 1995 * 74 ( 176.183, Subd. 2 Tech - Penalty - Special Comp. Fund 110 ( July 1, 1995 * 75 ( 176.185, Subd. 5a Penalty Increase 111 July 1, 1 995 * 76 ( 176.191, Subd. 1 Temporary Orders- Special Comp. Fund 111 July 1, 1995 * 77 ( 176.191, Subd. 1 a Equitable Apportionment 112 July 1,1995 78 ( 176.191, Subd. 5 Apportionment-Arbitration 113 July 1, 1995 79 176.191, Subd. 8 Attorney Fees - Technical 114 - ,. 80 176.194, Subd. 4 ( Penalty Increase 114 July 1,1995 * 81 ( 176.215, Subd. la ( Contractor Liens 115 July 1, 1995 * 82 ( 176.221, Subd. 1 Pay w/o Prejudice - Extension of Time 116 October 1, 1995 83 ( 176.221, Subd. 3 Penalty Increase 117 October 1, 1995 84 176.221, Subd. 3a ( Penalty Increase 117 October 1, 1995 85 ( 176.221, Subd. 7 ( Interest rate 118 ( October 1, 1995 86 ( 176.223 ( Prompt Payment Report 118 ( October 1. 1995 87 ( 176.225, Subd. 1 ( Penalty Increase - Definition of Frivolous 119 I October 1, 1995 88 ( 176.225, Subd. 5 ( Penalty Increase 119 ( October 1, 1995 89 ` 176.231, Subd. 10 Penalty Increase ( October 1, 1995 Pace 5 of 6 90 176.238, Subd. 6 Expedited Hearings - Discontinuances 120 October 1, 1995 91 176.238, Subd. 10 Penalty Increase 121 October 1, 1995 92 176.261 Settle claims - DOLI Effort October 1, 1995 93 176.2615, Subd. 7 Small Claims Court 122 July 1, 1995 * 94 [ 176.275, Subd. 1 Refuse Incomplete Documents 123 October 1, 1995 95 176.281 Technical-Imaging 123 July 1, 1995 * 96 176.285 Technical-Imaging hn' - in ec ical g 124 July 1, 1995 * 97 1 176.291 Claim Petitions - Signature 125 July 1,1995 * 98 176.305, Subd 1a Small Claims Court 126 ( July 1, 1995 99 176.83, Subd. 5 Technical -Treatment Rules 127 July 1,1995 * 100 176.84, Subd. 2 Penalty Increase 128 July 1, 1995 * 101 182.676 Safety Committees 128 July 1,1995 * 102 L'94,C625 A5 S7 24 Hour Coverage 129 July 1,199 * 103 Small Business Injury Prevention Project 130 July 1,1995 * Pilot 104 Small Business Health Services Survey Q * Safety and Heath Se es y 130 July 1, 19„5 Survey 105 Auditor Assigned Risk Plan Evaluation 131 July 1,1995 * 106 Appropriation Small Business Survey - $150,000 131 I July 1,1995 * 107 Appropriation Small Business Safety Pilot Project $200,000131 ( July 1, 1995 * 108 Appropriation Department of Labor and Industry $960,000 132 ( July 1,1995 * 109 ( Appropriation Inconsistent Laws Superseded 132 ( May 26, 1995 110 Repealer Various Provisions Governing Insurance July 1, 1995 Attorney Fees; Medical Services Review Board; and July 1, 1995 Supplementary Benefits October 1, 1995(doo* 111 I Effective Dates Insurance Rate Regulation; Transition 132 I 112 Effective Dates Various provisions 132 * Effective date is not specified in the Act, but governed by: car Minn. 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LICENSES OR CERTIFICATIONS NEEDED EDUCATION/EXPERIENCE/SKILLS REQUIRED TO PERFORM THE JOB: IS THE JOB: FULL TIME PART TIME :P/T HRS PER WEEKS REGULAR TEMPORARY (LENGTH OF JOB) HOURS: DAYS OF WORK PER WEEK SALARY OR PAY RANGE COMMISSION VACATION PHYSICAL DRUG TESTS BENEFITS: YES/NO HEALTH DENTAL _._ TESTS REQUIRED: TYPING/WPM OTHER HOW DO YOU WANT APPLICANTS REFERRED: JOB SERVICE CALL RESUME APPLY IN PERSON APPLICANT CALL JOB SERVICE 2098 11TH AVENUE NORTH ST. PAUL, MN 55109 For your hiring needs contact the Job Service. We will be happy to take your job listings and refer qualified candidates. To list a job,call our job order telephone at 779-5671 or send the information by fax: 779-5646. In Stillwater please call 297-2440. If you prefer, call one of our staff to list your job opening. Y p Y J Dave Dahlke Employer Relations 779-5649 Annette Geisbauer Employer Relations 779-5670 Judy Novotny Employer Relations 779-5403 Ray Robertson Employer Relations 779-5405 Roger Bosman Veterans Employment 779-5647 George Francis Veterans Employment 779-5662 Mark Smith Veterans Employment 779-5407 Larry Meyer Counseling/Testing 779-5420 Gene Heuer Applicant Services 779-5669 Cheryl Beaumier Applicant Services 779-5645 Ray Newby Applicant Services 779-5421 Rick Casperson Supervisor 779-5653 Sue Meredith Manager 779-5650 JOB SERVICE 14900 61ST ST. NO. STILLWATER, MN 55082 Elaine Krueger Stillwater Office 297-2440 0 II. WORKERS' COMPENSATION A. CHAPTER 231 -SUMMARY OF 1995 LAWS OF MINNESOTA -AN ACT RELATING TO WORKERS' COMPENSATION Article 1 Section 1 amends Minn. Stat § 79.50 - Purpose - Insurance This section regarding the purposes of chapter 79 is amended in reference to rate regulation by deleting provisions relating to promotion of price competition. Section 2 amends Minn. Stat §79.51, subdivision 1 -Technical This section is amended by deleting the portion dealing with the adoption of rules after May 1, 1982. These rules dealt with the shift to competitive market conditions. Section 3 amends Minn. Stat §79.51, subdivision 3 - Prior Approval Rate Regulation This subdivision deals with subject matter of rules. The subdivision is amended to include consideration of rating manuals adopted by licensed data service organizations. The subdivision deletes provisions that state that the rules shall provide for competition in workers' compensation rates, deletes t s provision for monitoring the effectiveness of competition and deletes other reference to competition in premium rates. The Commissioner of Commerce in issuing rules shall also consider the supporting data and information required in filings under section 79.56, including but not limited q 9 � 9 to, the experience of the filing insurer and the extent to which the filing insurer relies upon data service organization loss information, descriptions of the actuarial and statistical methods employed in setting rates, and the filing insurers interpretation of any statistical data relied upon. Legislative Update 1 Leg p 1995 17 Section 4 amends Minn. Stat. §79.53, subdivision 1 - Prior Approval Rate Regulation This subdivision amends the method of calculation of premium by an insurer. The base premium may be increased or decreased up to 25 percent (by various methods or factors previously provided) if the increase or decrease is not unfairly discriminatory. Section 5 amends Minn. Stat. §79.55, subdivision 2 - Prior Approval Rate Regulation This subdivision regarding excessiveness is amended to delete provision that no premium is excessive in a competitive market. This subdivision now defines when rates and rating plans are excessive and places the burden on the insurer to establish that profit is not unreasonably high. Section 6 amends Minn. Stat. §79.55, subdivision 5 - Prior Approval Rate Regulation This subdivision permitting discounts on premiums is amended to provide that an insurer may offer a scheduled credit or debit to a manual premium of up to 25 percent. The amendment deletes language which did not allow the Commissioner of Commerce to prohibit premium discounts or credits greater than a certain percentage of premium. Section 7 amends Minn. Stat. §79.55 - Prior Approval Rate Regulation This section adds a subdivision regarding rating factors. The subdivision gives a comprehensive list of factors to consider in determining whether a rate filing complies with this section. Consideration must be given to: 1. past and prospective loss experience within this state and outside this state as needed for credible rates; 2. dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members, or subscribers; 3. reasonable allowance for expense and profit. Reasonableness of profit and expense allowance is also further defined according to specified criteria. Legislative Update 1995 18 Section 8 amends Minn. Stat. § 79.55 - Prior Approval Rate Regulation A subdivision 7 is added regarding external factors which shall not cause the rate or rating plan to be considered excessive, inadequate or unfairly discriminatory. These include various assessments and state mandated surcharges. Section 9 amends Minn. Stat. § 79.56, subd. 1 - Prefiling of Rates This section provides for pre-filing of rates by companies at least 60 days prior to its effective date along with supporting data. The Commissioner of Commerce is to advise the insurer within 30 days of the filing, which may be extended by 30 days. Longer filing and review periods are given for filings from August 1, 1995 to December 31, 1995. If not disapproved within the review period, the rate or rate filing plan may be implemented. Section 10 amends Minn. Stat. § 79.56, subd. 3 - Rates not Subject to Disapproval The amended section provides that employers generating $500,000 per year in workers'compensation premiums, before accounting for large deductibles, may be written by insurers using filed rates which are not subject to disapproval. The $500,000 threshold is to be adjusted annually. Section 11 - New Law: Minn. Stat. § 79.561, subds. 1 - 3 - Disapproval of Rates or Rating Plans This section provides that the Commissioner of Commerce can disapprove a rate or rating plan. If the commissioner disapproves a rating plan the commissioner shall advise the filing insurer what rate would be in compliance. An insurer is not allowed to implement a plan which has been disapproved. An insurer whose filing has been disapproved can continue its current rate and rating plan. An insurer may request a contested case hearing under the Administrative Procedures Act when and if disapproved. The Commissioner of Commerce may retain such consulting actuaries or other experts as necessary for the purposes of Chapter 79. Section 12 amends Minn. Stat. § 175.16 - Fraud This section adds a new subdivision 2 to the section which establishes the Department of Labor and Industry. The new subdivision provides that DOL1 shall contain a Fraud Investigation Unit and describes in general terms its duties and purposes. DOLL fraud investigators are specifically granted the Legislative Update 1995 19 inspection authority of the commissioner under Minn. Stat. § 182.659 which describes the inspection powers for occupational safety and health matters. Section 13 amends Minn. Stat. § 176.011, subd. 25 - MMI Amends the definition of maximum medical improvement to provide that once MMi has been reached, no further periods of MMI are permitted except where an employee is medically unable to continue working. Removes subjective complaints of pain from the definition of MMI, and provides that worsening of the condition does not render MMI ineffective. Section 14 amends Minn. Stat. § 176.021, subd. 3 -Technical Technical changes are made to this statute to reflect the change from two types (IC and ERC) to one type of permanent partial disability. Section 15 amends Minn. Stat. § 176.021, subd. 3a - Periodic payment of Permanent Partial Disability This amendment changes payment of permanent partial disability benefits from lump sum to periodic, at the same intervals as temporary total disability compensation was made. Section 16 amends Minn. Stat. § 176.061, subd. 10 -Technical This is a technical amendment to conform to the change from two types to one type of permanent partial disability. Section 17 amends Minn. Stat. § 176.101, subd. 1 - Temporary Total Disability (b) Commencing on October 1, 1995 the maximum weekly compensation payable is $615 per week, replacing the previous maximum rate of 105 percent of the statewide average weekly wage. The Workers' Compensation Advisory Council is to consider adjustment increases and make recommendations to the legislature. (c) The minimum compensation is changed from 20 percent of the statewide average weekly wage to $104 a week, or the actual weekly wage, whichever is less. (e) Provides that temporary total disability stops when the employee returns to work, and may be recommenced if: (1) the employee is laid off within one year, prior to payment of 104 weeks of temporary total Legislative Update 1995 20 disability and prior to MM!; or (2) if the employee is medically unable to continue at a job, in which case a new period of MMI begins, subject to the maximum of 104 weeks. The employee must be working at the time the employee becomes medically unable to work in order for benefits to recommence. (f) Provides that temporary total disability stops when the employee withdraws from the labor market, and may be recommenced only if employee returns to the labor market prior to 90 days after the employee reached MMI and prior to payment of 104 weeks. (g) Provides that temporary total disability stops when the employee fails to diligently search for appropriate work within the employee's physical restrictions, and can be recommenced if the employee begins searching for work prior to 90 days after MM1 and prior to payment of 104 weeks. (h) Provides that temporary total disability stops when the employee is released to work without any physical restrictions. (i) Provides that temporary total disability stops if the employee refuses work that is consistent with a rehabilitation plan and within the employee's physical restrictions, in which case temporary total disability may not be recommenced. (j) Provides that temporary total disability stops 90 days after the employee reaches MM! except during retraining. The 90 days begin to run on the earlier of the dates the employee receives a written MMi report or the date the report is served on the employee and the employee's attorney. It may be recommenced only if the employee returns to work and then is medically unable to continue working. (k) Provides that temporary total disability stops when 104 weeks of benefits have been paid, except during retraining. All periods of initial and recommenced temporary total disability combined are subject to the 104 weeks. (I) Provides that there may be other bases under law to suspend or discontinue temporary total disability - the list is not exhaustive (i.e. Legislative Update 1995 21 other statutory provisions may apply such as the retirement provision or failure to cooperate with rehabilitation provision). Section 18 amends Minn. Stat. § 176.101, subd. 2 -Technical Technical amendments are made to conform to the repeal of Minn. Stat. § 176.101, subd. 3a through 3t and to new language in this bill. Section 19 adds Minn. Stat. § 176.101, subd. 2a - Impairment - PPD This section reinstates the table for impairment compensation benefit as the schedule for all permanent partial disability compensation. It gives the percent disability to the body as a whole and dollar amounts by which the percent is to be multiplied to determine the benefit amount. The benefit is limited to 100 percent disability of the whole body. Paragraph (b) provides for payment of the permanent partial disability benefit in periodic installments when temporary total disability is no longer being paid. Section 20 amends Minn. Stat. § 176.101, subd. 4 - 65% of SAWW is Minimum PTD The minimum compensation rate for permanent total disability p is set at 65 percent of the SAWW. Permanent total disability benefits end at retirement which is presumed at age 67. The presumption is rebuttable by the employee. The employee's subjective statement is not sufficient to rebut the presumption in itself, but may be a factor. Section 21 amends Minn. Stat. § 176.101, subd. 5 - 17/15/13% PTD Definition The definition of permanent total disability under clause (2) of this subdivision is limited to injuries that result in a disability rating as follows: • A 17% permanent partial disability rating ■ A 15% permanent partial disability rating and the employee is at least 50 years old a e . • A 13/o permanent partial disability rating and the employe., is at least 55 years old at the time of injury and has not completed high school. Other factors such as age, education, training and experience may only be considered after the employee meets the threshold criteria. Legislative Update 1995 22 Section 22 amends Minn. Stat. § 176.101, subd. 6 - Technical A technical change is made to conform to the change from two types to one type of permanent partial disability. Section 23 amends Minn. Stat § 176.101, subd. 8 - Cessation of Benefits It is detailed that it is receipt of social security old age and survivors insurance retirement benefits under the Social Security Act, P. L. #98-21 that creates the presumption of retirement for temporary total disability benefits. Section 24 amends Minn. Stat. 105. 176 § subd. 4 - Technical This eliminates the requirement that the aggregate total of impairment q P compensation and economic recovery compensation under the permanent partial disability schedule be equal to payment for permanent partial disability under 176.101, subd. 3. Technical changes to paragraph numbering are made. Section 25 adds a new subdivision 2 to Minn. Stat. §176. 178 - Fraud A new subdivision 2 is added to require that all forms prescribed by the commissioner for claims or responses to claims for workers' compensation benefits include the text of the substantive portion of the fraud statute. The new subdivision also states that the absence of the notice is not a defense. Section 26 amends Minn. Stat. §176.179 - Technical This amendment provides that compensation benefits mistakenly paid may be taken as a partial credit against future "periodic" (substituted for "lump sum" and "weekly") benefits, and adds permanent partial disability benefits to the list of benefits against which the credit may be taken. Section 27 amends Minn. Stat. §176.221, subdivision 6a - Technical This penalty section is amended to substitute the term "permanent partial disability" for the terms "economic recovery compensation" and "impairment compensation," which are proposed to be repealed in another section. Section 28 amends Minn. Stat. § 175.645, subdivisions 1 and 2 - COLA This section amends subdivision 1 of the statute on cost of living adjustments to provide that for injuries on or after October 1, 1995 cost of living adjustments are limited to two percent a year. The Workers' Compensation Advisory Council may recommend future increases to the legislature. Legislative Update 1995 23 Subd. 2 is amended to provide that for dates of injury on or after October 1, 1995 the initial adjustment is deferred until the fourth anniversary of the date of injury, and is the adjustment of the last year. Section 29 amends Minn. Stat. § 176.66, subd. 11 - Supplementary Benefits This amendment removes cross references to supplementary benefits for occupational disease injuries because the entire law regarding supplementary benefits is repealed in this bill. Section 30 amends Minn. Stat. § 176.82 by adding a new subdivision 2 - Refusal to Rehire A new subdivision 2 is added entitled "refusal to offer continued employment". The new subdivision provides that an employer with more than 15 full-time employees is liable in a civil action for failure to rehire without reasonable cause an employee subsequent to the employee's injury, provided there is a job available within that employee's restrictions. The employer is liable for a maximum of one year's wages for the employee up to a maximum of$15,000. The liability is not to be covered by contracts of insurance. In determining whether employment is available, the court is required to consider the continuance in business of the employer. Also, written rules of the employer with respect to seniority and the provisions of any collective bargaining agreement are to govern. Section 31 - New Law: Minn. Stat. § 176.861, subds. 1 -4 Disclosure of Information; Fraud This new section provides the commissioner of Labor and Industry with the power to require insurance companies to release any or all relevant information which the commissioner deems important to a workers' compensation claim or the investigation of the claim including statements or other evidence relevant to the investigation. Insurance companies are to report suspicious or fraudulent claims to the commissioner of Labor and Industry. An insurance company who does so in good faith is provided with immunity from civil and criminal liability for making such a report. The section applies to self-insurers and the Assigned Risk Plan as well. Legislative Update 1995 24 Section 32 amends Minn. Stat § 268.08, subd. 3 - Coordination with reemployment benefits This section deletes a provision allowing concurrent temporary partial disability and reemployment benefits. Section 33 - Appropriation This section appropriates $900,000 from the Special Compensation Fund to the Department of Commerce to increase the complement by 13 positions for the purposes of rate regulation. Section 34 -Appropriation $110,000 is appropriated from the Special Compensation Fund to the Department of Labor and Industry for purposes of this Act. Section 35 - Repealer Repeals section 176.132, the supplementary benefits provision. Section 36 - Repealer Repeals provision in chapter 79 related to premium calculation, standards for rates, rate filing and disapproval of rates, provisions related to the two-tier permanent partial disability system and repeals the original provision establishing the fraud unit, which is replaced by section 12. Repeals the sunset provision on the Special Fund for the logging industry, thus reinstating the program. Section 37 - Effective date. This is the effective date section. The primary effective date for benefit changes is for dates of injury after October 1, 1995. The effective date for the insurance rate regulation provisions is January 1, 1996. Legislative Update 1995 25 Article 2 Section 1 amends Minn. Stat. § 13.69 - Fraud This section allows Public Safety to share social security numbers with DOLL. Section 2 amends Minn. Stat. § 13.82, subd. 1 - Fraud This section adds DOLI's Fraud Investigation Unit to the list of agencies governed by the portion of the government data practices act regarding comprehensive law enforcement data. Section 3 amends Minn. Stat. § 79.074, subdivision 2 - Technical This section amends the subdivision regarding dividends. It is a technical change which deletes reference to section 79.20, a section which had been repealed by prior law. Section 4 amends Minn. Stat. § 79.085 - Safety This section regarding safety programs adds language about occupational health loss control consultation as well as the safety consultation services already available. The amendment provides for annual notification to policyholders by insurers of their right to such consulting services. The amendment also sets out what must be included in the services. Section 5 amends Minn. Stat. § 79.211, subdivision 1 -Wage Base Shift This section amends the subdivision on ratemaking to change the wage base for purposes of calculating workers' compensation premiums. The amendment provides that wages paid for vacation, holiday or sick leave shall be included in determining the premium. Previously, this subdivision had excluded these wages from the premium calculation. The licensed data service organization and insurers are to amend their charged rate premium schedule to reflect this change. Section 6 amends Minn. Stat. §79.251, subdivision 2 -Merit Rating Plan This section requires a credit of 33% for nonexperience rated employers (premiums under $3,000 annually) with no lost time claims for the past three policy years. Experience rated employers may receive a debit or credit of up to 10% of annual premium. Legislative Update 1995 26 Section 7 amends Minn. Stat. § 79.251, new subdivision 8 - Upon Dissolution of Assigned Risk Plan This new subdivision is added to establish procedures to settle the final affairs of the Plan upon its dissolution. Section 8 amends Minn. Stat. § 79.253 - Safety Grants and Loans This new subdivision clarifies eligibility and qualifications for assigned risk safety grants and loans. Section 9 amends Minn. Stat. § 79.34, subdivision 2 -WCRA This subdivision deals with the reinsurance association retention limits. The amendment changes the amount of the retention limits to a choice of three: low, high, or super, at the option of the member. The amendment explains how the three limits are calculated. Section 10 amends Minn. Stat. § 79.35 -WCRA This section deals with duties, responsibilities and powers of the reinsurance association. Amendment is made to the paragraph describing how premiums are calculated and charged to members. The amendment deletes language about the prior retention limits and replaces it with references to the new low, high or super retention limits created in Minn. Stat. § 79.34, subdivision 2 (above). Section 11 amends Minn. Stat. §79.52 - Technical This definition section is amended by adding at subdivision 17 a definition cf "Association" or "Rating Association" to mean the Minnesota Workers' Compensation Insurers Association, Inc. Section 12 also amends Minn. Stat. §79.52 - Rate Review/Rate Oversight A subdivision 18 defining "Rate Oversight Commission" is added to mean the workers' compensation advisory council established in chapter 175. Section 13 amends Minn. Stat. § 79.55 - Rate Review/Rate Oversight A new subdivision 8 is added describing what information needs to be included in annual filings by the rating association to the Commissioner of Commerce and the rate oversight commission. The information is information used and related to the calculation and cost of workers" compensation insurance premiums. Legislative Update 1995 27 • Section 14 amends Minn. Stat. § 79.55 - Rate Review/Rate Oversight A subdivision is added providing that the rate oversight commission may submit an annual report to the Commissioner of Commerce. The report concerns the completeness of the filing and the compliance of the filing with the standards for excessiveness, inadequacy and unfair discrimination set forth in this chapter. Section 15 amends Minn. Stat § 79.55 by adding a new subdivision 10 - Rate Review/Rate Oversight The new subdivision adds a duty of the Commissioner of Commerce to issue a report by January 1 of each year comparing average rates charged by workers' compensation carriers, as reviewed by the rate oversight commission. Also provides that the rate oversight commission shall review the Commerce Commissioner's report and recommend legislative changes if the rate experience has not reasonably reflected the changes in pure premiums. Section 16 amends Minn. Stat. § 79.60, subd. 1 - Rate ReviewlRate Oversight Mandates some additional activities upon workers' compensation insurers including providing sufficient information to the rating association and the rate oversight commission with the rate filings. Also requires insurers to pay the rating association the insurer's actual share of costs of preparing filings for submission to the Commissioner of Commerce and the rate oversight commission. Section 17 amends Minn. Stat. § 79A.01, subdivision 1 - Technical This section is amended to allow definitions to be used throughout the chapter. Section 18 amends Minn. Stat § 79A.01, subd. 4 - Insolvent Self-Insurer Adds a new clause describing a new class of"insolvent self-insurers" to the definition section in self insurance. A member or self-insurer who has failed to pay an assessment required by Section 79A.12, subd. 2 or who has been issued a certificate of default by the Commerce Commissioner or whose security deposit has been called by the commissioner of commerce are all included in the definition of "insolvent self-insurer". Legislative Update 1995 28 Section 19 amends Minn. Stat. § 79A.01 - Technical This section adds a definition for"common claims fund" which was included in prior statute but never defined. Section 20 amends Minn. Stat. § 79A.02, subd. 1 - Self-Insurer's Advisory Committee This subdivision regarding the membership of the Workers' Compensation Self-Insurers' Advisory Committee is amended to provide that three alternates are to be elected by the Self Insurers' Security Fund Board of Trustees and that two alternates shall be appointed by the Commissioner of Commerce. Section 21 amends Minn. Stat. § 79A.02, subd. 2 - Self-Insurer Advisory Council - Conflict of Interest This subdivision regarding advice to the commissioner is amended to provide that the Commerce Commissioner shall furnish the Workers' Compensation Self-Insurers' Advisory Committee with information and financial data, but that any member of the Advisory Committee who has a potential conflict of interest in reviewing the financial data will not have access to it. The section also provides that the financial data is non-public data. Section 22 amends Minn. Stat. § 79A.02, subdivision 4 - Financial Re- Evaluation/Group Self Insurance Establishes level of funding that must be maintained to retain authority to group self-insure. Section 23 amends Minn. Stat. § 79A.03, subdivision 4a - Financial Re- Evaluation Establishes exceptions to section 22, allowing continued self-insurance authority according to specified criteria. Section 24 amends Minn. Stat. 79A.04, subd. 2 -Self-Insurer-Security ty Deposit This sections amends the subdivision regarding the minimum deposit of private self-insurers' estimated future liability to provide that unpaid assessments as required by section 79A.12 may also be secured by up to ten percent of the deposit. This section also provides that non-group members total deposit required may be determined by an actuary more often than every two years, but shall be done at least every two years. Also in e islative Update 7 L g p 1995 29 addition to the current conditions for granting or renewing a Certificate of Self-Insurance this section provides that Commissioner of Commerce may require any amount of additional security that the commissioner considers sufficient to insure payment of all workers' compensation claims. Section 25 amends Minn. Stat. § 79A.04, subd. 9 - Self-Insurer Insolvency - Utilization of Security Deposit This subdivision regarding insolvency bankruptcy, default or utilization of the security deposit is amended to provide that the Commissioner of Commerce may call the security deposit if a self-insurer has failed to pay an assessment to the Self-Insurers' Security Fund when due. This is in addition to the other bases upon which the Security Fund can be invaded already in law. Section 26 amends Minn. Stat §79A.09,subd.4-Self-Insurer-Security Deposit Provides that private data submitted to the Self-Insurers' Security Fund becomes public upon its receipt by the Security Fund. Section 27 amends Minn. Stat § 79A.15 - Self-Insurer's Surety Bond This section which sets forth the surety bond form for self-insurance is amended to provide that bond proceeds can be used to satisfy unpaid assessments when a surety exercises its option to administer claims. SECTIONS 28 - 41 GROUP SELF-INSURANCE (All New Law) Section 28 - Minn. Stat. § 79A.19, subdivision 1 - 8 - Group Self- Insurance Definitions: Adds new definitions to 79A as follows: Accountant, Actuary, Common Claims Fund, Member, and Commercial Self-Insurance Group Security Fund which establishes a separate security fund for these new groups, and Trustee. Section 29 Minn. Stat. § 79A.20, subds 1 & 2 Group Self-Insurance Establishes eligibility for commercial group membership. Allows any two employers to form a group. Prohibits groups from forming a "business trust." Legislative Update 1995 30 Section 30 - Minn. Stat. § 79A.21, subds. 1 -3 - Group Self-Insurance Establishes application and approval criteria. Amends Chapter 79A to require some additional items for new groups including: detailed business plan; rating plan; a schedule of operating expenses with at least 65% of revenues available for the loss fund to pay claims; indemnity agreement from each member; security deposit; minimum annual premium $500,000 (vs $300,000); and financial statements - 75% reviewed or audited and 25% complied. Section 31- Minn. Stat. § 79A.22, subds. 1 - 12 - Group Self-Insurance Establishes operating requirements: Board of Directors (No Third Party Administrators allowed). Rating plan and premium volume for commercial groups. New members - 50% of annual premium security deposit. Commerce reviews member financial statement if premium over 20% of group. Establishes requirements for common claims fund, fiscal agent and joint and several liability. Establishes guidelines for marketing and administration. Mandates specific stop loss at lower limit with Workers' Compensation Reinsurance Association (WCRA). Section 32 - Minn. Stat. § 79A.23, subds. 1 -4 - Group Self-Insurance Establishes required reporting to the Commissioner of Commerce: Quarterly internal financial statements of group. Federal and state income tax returns. Combined compiled statement from CPA (no member statements). Audited group statements of the common claim fund. Any member over 25% of total premium must be sent to commerce. Establishes operational audit procedures. Mandates loss information to be sent to Minnesota Workers' Compensation Insurance Association (MWCIA). Section 33 - Minn. Stat. § 79A.24, subds. 1 - 4 - Group Self-Insurance Requires members to post a combined total security deposit in the forms of letters of credit, bond, or cash and securities (to be drawn on in the event of a group failure to pay claims of injured workers). Minimum is 150% of the workers' compensation liability (110% for groups with 100% reviewed or audited statements). Allows members to post proportionate share through their bank or financial institution. Legislative Update 1995 31 Section 34 - Minn. Stat. § 79A.25, subds. 1 - 3 - Group Self-Insurance Insolvency and Revocation: Establishes conditions under which the security deposit is utilized to pay claims. Provides conditions under which a group self-insurer could lose its authority (for good cause) to self-insure. Allows group to request hearing. Section 35 - Minn. Stat. § 79A.26, subds. 1 - 16 - Group Self-Insurance Creates Commercial Self-Insurance Group Security Fund, a new fund to provide a "safety net"for potential commercial group failures. Creates Board of Trustees and allows assessments of members. Section 36 - Minn. Stat. § 79A.27 - Group Self-Insurance Individual and Proportional Indemnity Agreement: Establishes a new form rm which provides for joint and several liability. Any collection for failed members of groups would be assessed on an individual and proportional basis (pro-rata based on premium size of member). Section 37 Minn. Stat. § 79A.28 - Group Self-Insurance Provides that the security fund and its board of trustees are not subject to: (1) the open meeting law (2) the open appointment law P privacy the data P Y law (4) and except as specifically set forth, the administrative procedure act. Section 38 - Minn. Stat. § 79A.29 - Group Self-Insurance Allows the Commerce Commissioner to adopt, amend, and repeal rules as necessary. Section 39 - Minn. Stat. § 79A.30 - Group Self-Insurance Provides that if there is any inconsistency between rul es o r previous ious statute, this law shall govern with respect to commercial self-insurance groups. Section 40 - Minn. Stat. § 79A.31, subds. 1- 4 - Group Self-Insurance Provides for the transfer of existing groups to the new commercial group security fund. Existing groups as of August 1, 1995 will have until January 1, 1996 to transfer. Transfers liabilities to new fund and relieves the relocated group from assessments from old security fund. Legislative Update 1995 32 Section 41 - Minn. Stat. § 79A.32, subds. 1 - 3 - Group Self-Insurance Requires that all self-insurers report individual loss experience and payrolls to the Minnesota Workers' Compensation insurance Association or a licensed data service organization. Delayed effective date for existing self- insurers until January 1, 1998. Section 42 amends Minn. Stat. § 168.012 - Fraud Provides that DOLI's fraud unit is treated the same way as the Department of Revenue's law enforcement personnel with regard to use of unmarked vehicles. Section 43 amends Minn. Stat. § 175.16 - DOLI - Duties Provides that not withstanding any other law to the contrary the commissioner shall delegate dispute resolution functions and personnel to implement funding and statutory obligations. Section 44 amends Minn. Stat. § 176.011, subdivision 16 -Technical The definition section defining "personal injury" is amended to remove the word "such" and some other minor grammatical non-substantive changes. Section 45 amends Minn. Stat. § 176.081, subd. 1 - Attorney Fee Limitations These are modifications to the attorney fee provisions. The contingent fee is presumed adequate to cover recovery of medical and rehabilitation benefits. Where the contingent fee is inadequate the employer/insurer is liable for attorney fees based on the contingent formula using the dollar amounts of disputed medical and rehabilitation benefits obtained. A maximum fee of$500 for obtaining non-quantifiable rehabilitation or medical benefits is set. An attorney must concurrently file all outstanding disputes. Total fees are included in the $13,000 limit. Withholding from employee benefits for attorney fees is modified to provide notice of the withholding to the employee on the checks. The definition of dispute for attorney fee purposes is modified including that no fee can be charged after June 1, 1996 until the Department certifies that a dispute on a medical or rehabilitation issue still exists after the Department has been consulted, except where other litigation is already pending. Legislative Update 1995 33 The provisions for objection to the statement of attorney fees and for claiming excess fees are deleted. Section 46 amends Minn. Stat. § 176.081, subd. 7 - Penalty The partial reimbursement of attorney fees to the employee where benefits are unsuccessfully disputed by employer/insurer is increased from 25 to 30 percent of p t o a fee over $250. Section 47 amends Minn. Stat. § 176.081, subd. 7a -Attorney Fees Language concerning adjustments to the partial reimbursement of attorney fees, where there has been a settlement offer, is repealed. Section 48 amends Minn. 6.0 1 mends M nn. Stat § 1 8 , subd. 9 -Attorney Fee Notice A notice about the maximum attorney fee is set out in this section and required to be included in the retainer agreement. Section 49 amends Minn. Stat. § 176.081 - Unprepared Sanction A new subdivision is added providing a penalty for failure of a party or party's attorney to appear, prepare for, or participate in a conference or hearing without justification. Expenses of the other party can be awarded. Rules for additional sanctions are authorized. Section 50 amends Minn. Stat. § 176.102, subd. 3a - Penalty The maximum per violation penalty for discipline of qualified rehabilitation consultants and vendors is raised from $1,000 to $3,000. Section 51 amends Minn. Stat. § 176.102, subdivision 11 - Retraining This section is amended to add a paragraph (c), which provides that a request for retraining must be filed before 104 weeks of any combination of temporary total disability or temporary partial disability has been paid. Requires the insurer to give prior notice to the employee, before 80 weeks of benefits have been paid, of the time limitation, subject to sanctions and an extension of time to fill the retraining request. Section 52 amends Minn. Stat § 176.103, subdivision 2 - Medical Services Review Board This section modifies the statute on medical healthcare review by amending the subdivision regarding the scope of the commissioner's duties to eliminate the requirement that the commissioner report specific cases to the Medical Legislative Update 1995 34 Services Review Board and that the Medical Services Review Board review each of these cases and make a determination regarding inappropriate, unnecessary excessive treatment; eliminating the provision that determination of the Medical Services Review Board is not subject to the contested case provisions of Chapter 14 and eliminating the requirement that the Board report its findings and conclusions to the commissioner. The purpose of these changes is to eliminate the two-track system of cases before the Medical Services Review Board and to provide that cases of suspected unnecessary and excessive treatment are handled procedurally in the same fashion as other complaints against health care providers in the workers' compensation system and that these cases be heard by an administrative law judge OAH as the other complaints are, with the Medical Services Review Board deciding the penalty. Section 53 amends Minn. Stat. § 176.103, subdivision 3 - Medical Services Review Board This section amends the subdivision of the Medical Services Review Board statute to provide that certain restrictions on treatments or warnings could be issued in addition to the issuance of penalties already allowed in law. All the penalties and sanctions now also apply where there has been a pattern of or a single egregious case of inappropriate, unnecessary excessive treatment by the provider. Section 54 amends Minn. Stat§ 176.104, subdivision 1 - Housekeeping This section amends the statute regarding rehabilitation services prior to a determination of liability in a workers' compensation case. The subdivision of the statute regarding disputes over medical causation or injury in or out of the course and scope of employment is amended to provide that an employee who is otherwise eligible for rehabilitation services under section 176.102 shall be referred to the Department's Vocational Rehabilitation Unit prior to the determination of liability, eliminating the prior qualification requirement that the disability shall have lasted for the requisite time under section 176.102, subdivision 4. Section 55 amends Minn. Stat. §176.106, subds. 1, 3, 4, 5, 6 and 7 - Rehab and Medical Disputes Subdivisions 1, 3, 4 and 5 are amended to provide that rehabilitation and medical determinations made under this section be made by the commissioner's designee. Subd. 6 is amended to provide that the Legislative Update 1995 35 commissioner's designee may levy a penalty. Subd. 7 of this section is amended to require that Requests for Formal Hearing, filed by persons aggrieved by the decision of the commissioner's designee, must be served on all parties. Requires the commissioner, rather than the Office of Administrative Hearings, to review a decision of the commissioner's designee where the claim is for medical benefits of $1,500.00 or less. In such cases, the commissioner's decision is final. Other issues referred to the Office of Administrative Hearings involving liability for past treatment or services that do not affect entitlement to ongoing or further rehabilitation or medical services are not subject to the expedited hearing procedures at OAH. This change allows cases involving ongoing treatment or future treatment to remain as "fast track". Section 56 - New Law: Minn. Stat. §176.107 -Teleconferences This new section allows the Department of Labor and Industry, Office of Administrative Hearings and Court of Appeals to conduct mediation sessions, administrative conferences, settlement conferences and hearings under Chapter 176 in person, by telephone or by visual or audio teleconferencing methods. Section 57 - New Law: Minn. Stat §176.108 - Light-Duty Pools This new section allows employers to form light-duty work pools to encourage the return to work of injured employees, and allows the commissioner to adopt emergency and permanent rules to implement this section. Section 58 amends Minn. Stat. §176.129, subd. 9 - Special Compensation Fund - Technical This section is amended to clarify that a settlement agreement may provide that the Special Compensation Fund partially or totally denies liability for payment of benefits and that in such cases the determination of employer insurance status and liability required by 176.183, subd. 2 is not required. Section 59 amends Minn. Stat. §176.129, subd. 10 - Penalty Increases the maximum enal payable to the assigned risk safety tYpY g tY account from $500.00 to $1,000.00 where special compensation fund assessments are not paid by employers and insurers as required. Legislative Update 1995 36 Section 60 amends Minn. Stat. §176.130, subd. 9 - Penalty The penalty for making a false report to avoid an assessment or reimbursement with respect to the targeted industry logging fund is increased from 50% to 75% of the amount of the assessment. Section 61 amends Minn. Stat. §176.135, subd. 1 -Attorney Fee -Hourly Charge This amendment removes the requirement that attorney fees for recovery of medical benefits be determined on an hourly basis according to the criteria in section 176.081, subd. 5 (repealed in Section 109). Section 62 amends Minn. Stat. §176.1351, subd. 1 -Technical This amendment states that the application fee for certification as a workers' compensation managed care plan is to be deposited in the special compensation fund. Section 63 amends Minn. Stat. §176.1351, subd. 5 - Managed Care Organization - Penalty This amendment allows the commissioner to assess a penalty against a certified managed care plan, in lieu of or in addition to the existing suspension or revocation authority, for noncompliance with the managed care plan as certified or for violation of a statute or rule applicable to a managed care plan. The penalty is payable to the special compensation fund in an amount up to $25,000.00 for each violation. The amendment sets forth factors to consider in determining the amount of the penalty, including the number of injured workers affected, the effect on workers health, workers' compensation benefits, access to health services, or understanding of rights and obligations; whether the violation is part of a pattern and any economic benefit derived by the managed care plan from the violation. The commissioner may also issue a cease and desist order. The managed care plan may request a hearing at the Office of Administrative Hearings on the penalty or the cease and desist order. The amendment also allows the commissioner to call an informal conference with the managed care plan to correct or prevent the violation and enter into stipulated agreements. A person acting on behalf of a managed care plan who violates or knowingly submits false information in any report required to be found is guilty of a misdemeanor. Legislative Update 1995 37 Section 64 amends Minn. Stat. §176.136, subd. 1a - Housekeeping This amends the statute requiring adoption of a workers' compensation relative value fee schedule. The amendment requires the commissioner to annually give notice in the State Register, in lieu of the rulemaking procedures in Chapter 14, of any additional relative value units or changes to the relative value units or service codes adopted by the federal Medicare ro ram. p g (Notice of the annual adjustment of the conversion factor is already required.) Statistical adjustments necessary to adapt the federal relative value units to workers' compensation may be made in the same manner as the adjustments were made to the original relative fee schedule. Section 65 amends Minn. Stat. §176.136, subd. lb - Housekeeping This amendment allows the commissioner to establish by rule the reasonable value of a medical service, article or supply that is not included in the relative fee schedule. The reasonable value established by rule is in lieu of the existing requirement that services, articles or supplies that are not included in the relative value fee schedule be paid at 85% of the provider's usual and customary charge or 85% of the prevailing charge. Section 66 amends Minn. Stat. §176.136, subdivision 2 - Excessive Medical Charges This amendment eliminates the requirement that the employer and insurer have the burden of proving that a medical service or charge is excessive, where a health care provider has filed a claim for payment of medical charges. Section 67 amends Minn. Stat. §176.138 - Penalty The amendment to paragraph (c) of this statute increases the penalty from $200 to $600 for a person who does not timely release existing medical data related to a current claim for compensation within the time frames specified to the employee, employer, insurer or the Department of Labor and Industry. There is a technical amendment to paragraph (d). The existing law allows workers' compensation insurers to share medical billing data with health insurers solely to discover duplicate billing, and provides that a person who improperly uses the medical billing data for any other purpose may be sued for actual and punitive damages. The amendment clarifies that the action for actual and punitive damages applies only to violations of this paragraph (d), not to other provisions of Minn. Stat. 176.138. Legislative Update 1995 38 Section 68 amends Minn. Stat. §176.139, subd. 2 - Penalty This amendment increases the penalty from $300 to $500 when an employer does not post the required notice to employees, informing them of their rights and obligations under the workers' compensation law, the assistance available to them and the name of the workers' compensation insurer (or self-insurer if applicable). Section 69 amends Minn. Stat. §176.181, subd. 7 - Penalty This increases the civil penalty from $5,000.00 to $10,000.00 for self-insured employers who violate laws or rules related to self-insurance. Section 70 amends Minn. Stat. §176.181, subd. 8 - Fraud This amendment adds the Departments of Human Services, Agriculture and Transportation to the list of agencies authorized to share information regarding employment status and payroll and income tax information. The amendment also allows for the exchange of data regarding the status of businesses, including general contractors, intermediate contractors, and subcontractors. The amendment requires the data to be requested in writing and provided within 30 days. Section 71 - New Law: Minn. Stat. § 176.1812 - "Bechtel" - Collective Bargaining Agreements This section authorizes certain employers and employee representatives to agree to vary non-benefits aspects of workers' compensation through a collective bargaining agreement. Subdivision 1. Requirements. Collective bargaining provisions permitted by this section must be recognized as valid and enforceable. Within the construction industry a qualified employer is a private employer developing or projecting an annual workers' compensation premium of $250,000 or more or an employer who is responsible for the first $100,000 or more of any claim. The agreement may include: a) an alternative dispute resolution system, to supplement, modify or replace the provisions of chapter 176; if arbitration is chosen it must be subject to review by the Workers' Compensation Court Legislative Update 1995 9 P 39 of Appeals, the Office of Administrative Hearings, the District Court, the Minnesota Court of Appeals or the Supreme Court; b) an exclusive list of medical provides that is not subject to managed care certification; c) a limited list of impartial physicians to conduct independent medical examinations; d) a light-duty, modified job, or return-to-work program; e) a limited list of individuals and companies for establishment of vocational rehabilitation or retraining programs, which list is not subject to the regular rehabilitation provisions; f) the establishment of safety committees and procedures; and g) 24-hour and health care coverage, if a pilot project is authorized by law. Subd 2. Filing and review. Agreements must be filed with the commissioner. The commissioner must recommend modifications to bring the agreement into compliance with this section within 21 days. The agreement must provide for reporting to the commissioner service cost and utilization information to enable annual reports to the legislature. The aggregate data includes: person hours covered by agreements; number of claims filed; average cost per claim; number of litigated claims, number submitted to arbitration, and appealed; projected and actual incurred costs of claims; employer's safety history; number of vocational rehabilitation and light-duty participants. Subd. 3. Refusal to recognize. This subdivision allows initiation of a contested case proceeding under the administrative procedure act (chapter 14) or an appeal to the Workers' Compensation Court of Appeals by a person injured by a refusal to recognize the agreement filed under subdivision 2. The request for a contested case hearing must be made within 30 days of the commissioner's decision. Legislative Update 1995 40 Subd. 4. Void agreements. This subdivision prohibits and voids any agreement to reduce benefits. Subd. 5. Notice to insurance carrier. This subdivision requires the employer to give notice of the agreement to the insurer and prohibits recognition of the validity of the agreement unless notice is given in the manner provided in the insurance contract. Subd. 6. Pilot program. This subdivision permits a short-term pilot program, ending December 31, 2001, for up to ten private and ten public employers. The agreement must be collectively bargained with the employee's exclusive bargaining representative. Dollar insurance premium limitations do not apply to the pilot program. Subd.7. Rules. This subdivision permits emergency or permanent rules to implement this section. Section 72 amends Minn. Stat. §176.182 - Penalty This amendment increases the penalty from $1000 to $2000 to be assessed against an employer that fails to accurately report to a licensing agency acceptable evidence of workers' compensation insurance coverage. Section 73 amends Minn. Stat. §176.183, subdivision 1 - Special Compensation Fund - Uninsured Employers This amendment provides that a petition for benefits under Chapter 176 that names a corporation that is not insured for workers' compensation shall be considered to also name the owners or officers as defendants. Service of the petition on the corporation constitutes service on the owners or officers. Section 74 amends Minn. Stat. §176.183, subdivision 2 - Special Compensation Fund - Uninsured Employers This amendment provides that when ordering the Special Compensation Fund to pay benefits for an uninsured employer, the compensation judge need only make a finding that the employer is uninsured and is liable for benefits if a hearing has been held. This amendment is a companion amendment to section 59, which permits the Special Compensation Fund to enter into settlements without a specific finding of liability. Legislative Update 1995 41 This subdivision is also amended to require the compensation judge to order the employer to pay reasonable costs and disbursements expended by the Special Compensation Fund in uninsured cases. The penalty assessed against an uninsured employer is increased from 60% to 65% of the benefits ordered by the judge. Section 75 amends Minn. Stat. §176.185, subdivision 5a - Penalty This increases the penalty from 200% to 400% of the amount charged to an employee where the employer has illegally required the employee to pay part of the employer's workers' compensation insurance. The portion of the penalty payable to the employee is increased from 50% to 60%. Section 76 amends Minn. Stat. §176.191, subdivision 1 - Special Compensation Fund This subdivision is amended to provide that where there is a dispute between two employers or insurers regarding liability for workers' compensation benefits, the Special Compensation Fund may be ordered to make payment only if it is alleged that one or more of the employers in uninsured. Section 77 - New Law: Minn. Stat. §176.191, subdivision 1a - Apportionment This new subdivision prohibits equitable apportionment and actions for contribution or reimbursement among employers and insurers, except by settlement agreement or by arbitration. Apportionment is prohibited whether the injury is the result of cumulative trauma or a specific injury. Apportionment for occupational disease and preexisting permanent partial disability is still permitted as provided under other existing statutes. The commissioner may develop rules governing arbitrator selection and presumptive apportionment to be used in the arbitration proceeding. Section 78 amends Minn Stat. §176.191, subdivision 5 -Apportionment by Arbitration. This amendment permits an employer or insurer to require arbitration of apportionment disputes if the employer or insurer requests arbitration within one year of its payment of more than $10,000 in medical or 52 weeks of indemnity benefits. The arbitrator's decision is conclusive on the issue of apportionment between the employers and insurers, but is not binding on the employee in any other proceeding. Legislative Update 1995 42 Section 79 amends §176.191, subdivision 8 -Technical This amendment deletes reference to a subdivision in the attorney fee section that is repealed. Section 80 amends §176.194, subdivision 4 - Penalty This section increases the penalties for prohibited insurer practices by 20%. Section 81 amends Minn. Stat. §176.215 - General Contractor Liability for Subcontractor- Liens This section amends the statute regarding the failure of subcontractors to comply with workers' compensation by adding a new subdivision which would provide that the order of a compensation judge directing a contractor, intermediate contractor, or subcontractor to pay compensation benefits results in an award which is a lien for government services under section 514.67 against all the property of the contractor, intermediate contractor, or subcontractor and the order is also subject to the provisions of the revenue recapture act. The section further provides that the Special Compensation Fund may enforce the terms of such an award in the same way as a district court judgement. Section 82 amends Minn. Stat. §176.221, subdivision 1 - Payment without Prejudice This amendment changes certain time frames in this subdivision. it allows an employer or insurer who has commenced payment of benefits to terminate payment by filing a notice of denial within 60 days of notice of the injury, where the insurer has determined that the disability is not the result of an injury for which it is liable. After the 60 days, payment may be terminated only by filing a Notice of Intention to Discontinue benefits under Minn. Stat. 176.239. The current law has a 30-day time frame. This subdivision is also amended to require that a notice of denial of liability must state in detail the facts forming the basis for the denial. Section 83 amends Minn. Stat. §176.221, subdivision 3 - Penalty This section increases by 5% the penalties to be assessed against an employer or insurer for failure to begin payment of benefits within the required time frames. The maximum dollar amounts of the penalties are also increased. Legislative Update 1995 43 Section 84 amends §176.221, subdivision 3a - Penalty The penalty is increased from $1000 to $2000 against an employer or insurer that does not pay benefits or file a notice of denial of liability within the required time frames. Section 85 amends Minn. Stat. §176.221, subdivision 7 - Interest Rate The interest rate for late payment of benefits is set at the rate established by Minn. Stat. 549.09, the rate for judgements in district court actions, (eliminating the previous provision that interest is the greater of section 549.09 or eight percent). Section 86 New Law: Minn. Stat §176.223 - Prompt Payment Report This new provision requires the Department of Labor and Industry to publish an annual report on the promptness of insurers and self-insurers in making first payments of compensation according to specified criteria. Section 87 amends §176.225, subdivision 1 - Penalty This amendment requires the compensation judge (previously permissive) to award the employee a penalty of 30% (increased from 25%) of compensation awarded where the employer or insurer has frivolously or unreasonably delayed or neglected to pay compensation. A new basis for the penalty has been added, where the employer or insurer has frivolously denied a claim. The amendment defines "frivolously" to mean without a good faith investigation of the facts, or on a basis that is contrary to fact or law. Section 88 amends Minn. Stat. § 176.225, subd. 5 - Penalty The penalty for inexcusable delay in making workers' compensation payments is increased from a 10 percent surcharge on the amount of delayed payment to a surcharge of 25 percent of the amount of delayed payment. Section 89 amends Minn. Stat. § 176.231, subd. 10 - Penalty The penalty which may be levied against an employer, insurer, physician, chiropractor or other health care provider who fails to provide a required medical report to the commissioner is increased from $200 to $500 for each failure. Legislative Update 1995 44 Section 90 amends Minn. Stat. § 176.238, subd. 6 - OAH Hearing The time for an expedited hearing at the Office of Hearing Examiners for objections to discontinuance of benefits and for petitions to discontinue benefits is increased to 60 days from 30 days. Section 91 amends Minn. Stat. § 176.238, subd. 10 - Penalty The potential fine for violation of the requirements regarding notices of intent to discontinue for violations committed by the employer is increased from $500 to $1,000 for each violation, payable to the Special Compensation Fund. Section 92 amends Minn. Stat § 176.261 - Housekeeping This section regarding employees of DOLT acting for or advising parties is amended to specify that the obligation to try to settle problems exists whether or not a formal claim has been filed. Section 93 amends Minn. Stat § 176.2615, subdivision 7-Small Claims Court This section amends the subdivision in the small claims court statute regarding determinations to clarify that there is no appeal or request for a formal de novo hearing from an order arising out of the small claims court. The small claims decisions are res judicata in subsequent proceedings concerning the issues determined in the small claims action. The section provides clarification to the previous law which appeared to contain a mistake regarding the res judicata nature of the small claims court decisions. Section 94 amends Minn. Stat§ 176.275, subdivision 1 - Housekeeping - Filing Documents The subdivision of the statute on filing and proof of service dealing specifically with filing is amended to provide that DOLT can refuse to file forms or documents lacking sufficient information such as date of injury, name of employee or employer and employee's social security number. It also provides that, in cases where the employee has had fewer than three days of lost time from work, whoever submits the document for filing must attach a copy of the first report of injury to the document. Section 95 amends Minn. Stat § 176.281 - Digitized Signatures This section amends the existing section on filing and service of orders, decisions, and awards to provide that signatures of the commissioner, the Legislative Update 1995 45 compensation judges, or the judges of the Workers' Compensation Court of Appeals may be digitized and reproduced electronically and have the same force and effect as the original signature. Section 96 amends Minn. State. § 176.285 - Digitized Signatures This section amends the statute regarding service of papers and notices to provide that where service to the Workers' Compensation Division, the Department, the Office of Administrative Hearings or the Workers' Compensation Court of Appeals is by electronic filing, digitized signatures may be used. It also provides that electronic filing of a document with the Department marks the start of a prescribed period for another party to respond, the prescribed time shall be lengthened by two days when service to the other party was by mail. Section 97 amends Minn. Stat. § 176.291 - Technical - Claim Petitions This section amends the statute regarding claim petitions to provide that a claim petition need not be notarized but that the petition must be signed by the petitioner. This is a technical change. Section 98 amends Minn. Stat § 176.305, subdivision la -Small Claims Court This subdivision of the statute on claim petitions filed with the workers' compensation division and regarding settlement and pre-trial conferences and summary decisions is amended to clarify the provision that the summary decisions in small claims court are final and not subject to appeal or de novo proceedings. This section provides further clarification of the issue dealt with in section 93. Section 99 amends Minn. Stat § 176.83, subdivision 5 -Housekeeping - Treatment Standards The section on treatment standards is amended to clarify that treatment outside the scope of the treatment standards in the rules is excessive and unnecessary and inappropriate under section 175.135, subdivision 1. The amended section also clarifies that the commissioner or compensation judge at a hearing or administrative conference is to determine whether the level, frequency, or cost of treatment was excessive under the rules. A repealed provision in section 176.103 is deleted. Legislative Update 1995 46 Section 100 amends Minn. Stat. § 176.84, subd. 2 - Penalty The penalty for violation of Minn. Stat. § 176.84, subd. 1, regarding the specific bases for notices of discontinuance and denials of liability, is increased from $300 for each violation to $500 for each violation. Section 101 - New Law: Minn. Stat. § 182.676 - Safety Committees The law on safety committees is moved from Chapter 176 to Chapter 182 and amended. Every public or private employer of more than 25 employees is required to establish and administer a joint labor management safety committee. Employers with 25 or fewer employees are also to established and administer safety committees if the employers had lost work day cases ranking in the top 10 percent of other employers in the same industry or if the experience rating of the employer is in the top 25 percent of rates for all classes. The safety committees must hold regular meetings and the employee members must be selected by the employees of the company. Failure to comply is a serious OSHA violation. Section 102 amends laws 1994 Chapter 625, Art. 5, Section 7 - 24-Hour Coverage Clarification This session law is the one regarding a 24-hour coverage plan. The law is amended to add the Commissioner of Commerce to the group of commissioners, including Health and Labor and Industry, who are to develop a 24-hour coverage plan. The 24-hour coverage plan to be developed is to be developed on a pilot project basis. The health component of workers' compensation is to be coordinated with health care coverage offered by Integrated Service Networks as well as other medical coverage providers including HMOs and standard fee-for-service health insurance providers. The plan for a pilot project program is to be provided to the legislature by January, 1996. Section 103- Pilot Injury Prevention Pilot Project This section requires the Commissioner of Commerce to contract with the University School of Public Health, Division of Environmental and Occupational Health, for a pilot injury-prevention project. The consultation is to provide assistance about ergonomic problems to small employers (less than 500 employees) insured by the state Assigned Risk Plan. Legislative Update 1995 47 Section 104 - Small Business Injury and Illness Prevention Survey Requires the University School of Public Health, Division of Environmental and Occupational Health, to evaluate injury and illness prevention activities of small business by surveying them to assess their assistance needs and resources. Section 105 -Assigned Risk Evaluation This law requests the legislative audit commission to direct the legislative auditor to conduct an evaluation of the safety practices of unsafe employers, and the assigned risk plan's organization, operations, claims auditing and reserving practices, to develop a plan for transfer of the assigned risk plan to State Fund Mutual Insurance Company, and develop alternative insurance techniques for small employers to reduce premiums. Section 106-Appropriation - Commerce This section appropriates $150,000 from the assigned risk safety account in the Special Compensation Fund to the Commissioner of Commerce to participate in the development of the small business injury and illness prevention survey. Section 107 -Appropriation - Survey This section appropriates $200,000 from the assigned risk safety account in the Special Compensation Fund to the Commissioner of Commerce for the pilot project in section 103. Section 108 -Appropriation - DOLI $ This section provides a $960,000 appropriation from the Special Compensation Fund to the Department of Labor and Industry for the biennium ending June 30, 1997 for the purposes of this Act. Section 109 - Inconsistent Laws Superseded This section provides that notwithstanding the order of final enactment, the amendments to Minn. Stat. § 175.16 supersede any conflicting law enacted by the 1995 legislature. Section 110 - Repealer This section contains the repealers in the bill including various insurance provisions, certain attorney fee provisions, supplementary benefits and provisions amended by other sections. Legislative Update 1995 48 Section 111 - Effective Dates and Transitions The sections regarding prior approval rate regulation and rate oversight are effective January 1, 1996 but this section provides a transition for rating plans to be filed after that time. Section 112 Effective dates Various effective dates for the rest of the bill are included in this section. Legislative Update 1995 49 Date: 01/07/98 04:21 PM Estimate ID: 404 Committed Profile ID: MSP/SUBURBAN AMERICAN GENERAL ADJUSTING 1397 GENEVA AVENUE SUITE 202 OAKDALE,MN 55128 (612)731-1891 Fax: (612)731-1151 "Specialists in Claim Adjustments for the Industry" Damage Assessed By: DAVID LIVINGSTON Appraised For: DAR BOESE � © a n/]� �4' Type of Loss: Collision Arrival Date: 1/02/98 JAN - 9 1998 Accident Date: 12/27/97 Deductible: UNKNOWN I Policy No: NA Claim Number: 11021209 Insured: CITY OF OAK PARK HGTS Address: 14168 NO 57TH STREET STILLINATER,MN 55082 Mitchell Service: 917620 Description: 1997 Ford Crown Victoria Vehicle Production Date: /97 Body Style: 4D Sed Drive Train: 4.6L In)8 Cyl AO VIN: 2FALP71W9VX167061 License: POLICE MN Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 700032 BDY REMOVE/REPLACE FRT BUMPER COVER **Qual Repl Part 396.00* 0.2 # 2 AUTO REF REFINISH FRT BUMPER COVER C 2.8 3 700033 BDY REMOVE/REPLACE FRT BUMPER COVER MLDG F5AZ 17C829 A 53.70 0.1 # 4 700039 BDY REPAIR FRT BUMPER REINFORCEMENT Existing 2.0* 5 700040 BDY REMOVE/REPLACE R FRT BUMPER IMPACT ABSORBER F5AZ 17754 A 136.93 0.2 # 6 700041 BDY REMOVE/REPLACE L FRT BUMPER IMPACT ABSORBER F5AZ 17755 A 136.93 0.2 # 7 700042 BDY REMOVE/REPLACE FRT BUMPER LICENSE FRAME F5AZ 17A385 A 5.60 INC # 8 700044 BDY REMOVE/REPLACE GRILLE F5AZ 8200 A 218.75 INC # 9 700045 BDY REMOVE/REPLACE GRILLE HEADER PANEL F5AZ 8190 A 222.07 2.0 # 10 AUTO REF REFINISH HEADER PANEL C 1.8 11 AUTO REF REFINISH HEADER PANEL EDGE C 0.5 12 AUTO BDY CHECK/ADJUST HEADLAMPS 0.4 13 701570 BDY REMOVE/REPLACE GRILLE PANEL ORNAMENT E2GZ 8A223 B 12.93 INC # 14 700052 BOY REPAIR HOOD PANEL Existing 2.5* 15 AUTO REF REFINISH HOOD OUTSIDE C 2.8 16 700090 BDY REMOVE/REPLACE L FENDER PANEL F6AZ 16006 AA 295.65 3.5 # 17 AUTO REF REFINISH L FENDER OUTSIDE C 2.1 18 AUTO REF REFINISH L FENDER EDGE C 0.5 19 700563 BDY REMOVE/REPLACE L FENDER ADHESIVE MOULDING ORDER FROM DEALER 25.44 0.1 20 700261 BDY REPAIR L FRT DOOR SHELL Existing 3.0*# 21 AUTO REF REFINISH L FRT DOOR OUTSIDE C 2.0 22 712760 BDY REMOVE/INSTALL L FRT REAR VIEW MIRROR INC # 23 700741 BDY REMOVE/INSTALL L FRT OTR BELT WEATHERSTRIP 0.4 # 24 712870 BDY REMOVE/REPLACE L FRT DOOR ADHESIVE MOULDING ORDER FROM DEALER 83.03 0.2 25 713234 BDY REMOVE/INSTALL L FRT OTR DOOR HANDLE 0.7 # 26 900500 BDY* REMOVE/REPLACE FT PUSH BAR ASSY-BY POLICE DEPT New 0.0* 27 900500 BDY* REMOVE/REPLACE DECAL SET BY POLICE DEPT. New 0.0* ESTIMATE RECALL NUMBER: 1/07/98 16:21:16 404 UltraMate is a Trademark of Mitchell International Mitchell Data Version: DEC_97 A Copyright(C)1994, 1995 Mitchell International Page 1 of 2 All Rights Reserved • • Date: 01/07/98 04:21 PM Estimate ID: 404 Committed Profile ID: MSP/SUBURBAN 28 900500 BDY* CHECK/ADJUST ALIGN FT.END Sublet 49.95' 0.0* 29 AUTO REF ADD'L OPR TWO TONE 1.7 30 AUTO REF ADD'L OPR CLEAR COAT 3.1" 31 933004 BDY ADD'L OPR UNDERCOATING 8.00* 0.3* 32 933005 BDY ADD'L OPR RESTORE CORROSION PROTECTION 0.4* 33 933006 FRM ADD'L OPR FRAME/RACK SET UP 4.5" 34 933008 REF ADD'L OPR CHIP RESISTANT MATERIAL APPLICATION 7.00* 35 AUTO ADD'L COST PAINT/MATERIALS 311.40" 36 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 3.00* *-Judgement Item #-Labor Note Applies C -Included in Two Tone/Clear Coat Calc • Add'I Labor Sublet I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount Body 16.2 35.00 8.00 49.95 624.95 T Taxable Parts 1,587.03 Refinish 17.3 35.00 7.00 0.00 612.50 T Sales Tax @ 6.500% 103.16 Frame 4.5 52.00 0.00 0.00 234.00 T Total Replacement Parts Amount 1,690.19 Taxable Labor 1,471.45 Labor Summary 38.0 1,471.45 III. Additional Costs Amount IV. Adjustments Amount Non-Taxable Costs 314.40 Customer Responsibility 0.00 Total Additional Costs 314.40 I. Total Labor: 1,471.45 II. Total Replacement Parts: 1,690.19 III. Total Additional Costs: 314.40 Gross Total: 3,476.04 IV. Total Adjustments: 0.00 Net Total: 3,476.04 Insurance Co: LEAGUE OF MN CITIES Address: 145 UNIVERSITY AVE WEST ST PAUL,MN 55103-2044 Telephone: (612)281-1200 Fax Phone: (612)281-1297 Body Shop: TEDS BODY SHOP Address: 1430 MANNING AVE.SO. WOODBURY,MN 55125 Telephone: (612)738-1287 Federal ID Number 41-0997843 ESTIMATE RECALL NUMBER: 1/07/98 16:21:16 404 UltraMate is a Trademark of Mitchell International Mitchell Data Version: DEC_97 A Copyright(C)1994, 1995 Mitchell International Page 2 of 2 All Rights Reserved • . EsTimAT • TED'S AUTO B4p3Y REPAIR 1430 MANNING AVE. SOUTH, WOODBURY. MN. 55125 436-6566 NAME ADDRESS DATE PHONE ` z<- r ,, • C. 7tz,..1. r _t >J ` d YEAR MA E MODEL LICENSE NO. SPEEDOMETER INS. Co. `�t 1 .Para eAdo reN„ S1 s�a sat INS. ADJ. Part No. Repair Replace Material Labor V ii/ i rr Mr J f I V ..60r lo. & 4 A E.., , _ _____ of _ �+7J�' .) I s �11., r ‘) =N 2, ' e / f e la 3. . ,. : -_ A. 1 ' t 1 Mil I ill -- rrr ALL DEDUCTIBLE PORTIONS I U __. PAID IN CASH BEFORE DELIVERY i- i AMOUNT , , � ■ I 1____21. :4-1 PARTS PRICES SUBJECT TO CHANGE WITHOUT NOTICE. GRAND TOTAL T'_•e shove I.an estimate based upon our inspection and do...not cover any additional parts or labor which mar be re- ` anirrct alter the work has been opened up. Occasionally after the work has started.worn pasta are discovered which are not evident on the first inspection.Because of this the above prices are not guaranteed. 1 7•ti.-inte made by-- �'�L' -i-si' C_41t1 Landmark Insuranceervices M 0 Page 1 PO Box 188 ACCOUNT NO. OP DATE Forest Lake,MN 55025 OAKPA-1 HJ 01/02/98 Phone: 612-464-3333 Support: 612-464-7596 POLICY INFORMATION POLICY VI CMC17704 TYPE EFFECTIVE EXPIRATION. CAU 07/07/97 07/07/98 City of Oak Park Heights Mike Robertson,City Admin. 14168 N 57th St, Box 2007 Stillwater,MN 55082 Judy, Re: Auto Claim Below please find detailed information about your 12-27-97 auto claim: The adjuster is Dar Boese, and her phone # is 215-4077 . The claim # is 11021209 Please contact our office with any further questions . Thank you. Heather Jonason lS L.5 0 l! 15 )1 JAN - 5 19, 98 - J . +_ CITY Oki t. g ,; OAK PARK HEIGHTS ,trauo sa yr '' 14168 N. 57th Street•Box 2007 •Oak Park Heights,MN 55082 • Phone: (612) 439-4439 • FAX 439-0574 s, Fax Transmittal To: 'DcL-r 0 e s -( Fax #: From: t.LaL.1 Ho (s fi Date: / - 2— 2 Subject: //0 21 2O Total Number of Pages, including cover sheet: 2 Tree City U.S.A. • • FOR YOUR INFORMATION To: Oak Park Heights Police Dept. 9 P Company: Fax number: +1 (612)439-3639 Business phone: From: Patrick W. Ferguson Fax number. +1 (612)434-1740 Home phone: Business phone: Date&Time: 1/1/98 5:09:29 PM Pages sent 2 Re: Estimate ! • Estimate DATE ESTIMATE NO. 12/30/97 27 NAME/ADDRESS Oak Park Heights PD Attn:Chief Swanson 14168 North 57th St. Oak Park Heights,MN 55082 PROJECT Squad#71 ITEM DESCRIPTION QTY RATE TOTAL Labor Labor Charges(m hours) 3 40.00 120.00 Squad#71 A2-PAR36 PAR-36 Rubber Lights(pair) 39.95 39.95T Misc Lactic Lights Push Bumpers 167.00 167.00T � P MN Sales Tax 6.50% 13.45 Please feel free to call us at 413-0664 if should have any questions Total $340.40 Landmark Insurance Services M M () r��� PO Box 188 m vm.xr no. or • uxr F.FpresE Lake, MN 55025 OAK P A-i 11.1 111(02/98 Phone; 612-464-3333 Support:612-464-7596 Pt,.it•i• in•I°RASA i ion POLICY r (WIC MN 'I'M KPrLcuvK EXPu$. MIN CA U 07/07/97 07'07198 City of Oak Park Heights Mike Robertson,City Admin, 14168 N 57tIt Si, Buz 2D1)7 Stillwater_MN 55082 Judy, Re; Auto Claun . e1ow please find detailed information about your 12 -27-9 / aut..o claim The adjuster is Dar Boese, and her phone # Is 215-4077. The claim # is 11 21209 Please contact our office with any further quef.t.ions . Thar,:{ you, Heather JunHsoii cwt 01 a ■ iz t E� CITY OF • -,.. N OAK PARK HEIGHTS -, 14168 N. 57th Street•Box 2007 •Oak Park Heights,IVIN 55082 •Phone: (612) 439-4439 • FAX 439-0574 Fax Transmittal To: i /'4 c, x Fax #: From: k _ Date: 12.. - 6) -- •7 Subject: Total Number of Pages, including cover sheet: ♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦•♦♦•♦♦♦♦•♦♦♦•♦♦♦•♦♦�•♦♦♦♦♦♦i•♦♦•♦♦♦•O♦♦•♦♦♦♦♦♦♦♦♦♦♦♦•♦♦i•♦♦♦♦♦♦♦•♦♦♦•♦♦♦•♦♦♦♦♦♦♦•♦♦••• ♦ • ♦ • ♦ • ♦ • ♦ • ♦ ♦ • ♦ • ♦ • ♦ • ♦ • ♦ • ♦ ♦ • ♦ • ♦ • ♦ • ♦ • ♦ • ♦ • ♦ • ♦ • ♦ • ♦ • ♦ • ♦ S - ) .•c. r►'1 t o no k,1 w 1 n 4.J •e, C C4. n .j I h.` , .:1S'VL7 Tree City U.S.A. CITY OF OAK PARK HEIGHTS Page 1 of POLICE DEPARTME OFFENSE REPORT FOR ALL CRIMES,ATTEMPTS,INVESTIGATIONS AND INCIDENTS COMPLAINT HOW OPH CASE NO. OOD CASE NO. O.R.I.NO. DATE REC'D TIME PHONE RADIO COMPLAINT RECD LETTER FOL 97004257 12-27-97 2307 OFFENSE OR INCIDENT SUBJECT LOCATION OF OCCURRENCE I 1 0-50 Osgood Ave at Hwy 36 INCIDENT/OCCURRENCE OFFICERS ASSIGNED DETECTIVES ASSIGNED REPORT MADE DATE TIME DATE TIME 12-27-97 23Q7 Hoppe / State Patrol #374 VICTIM(IF FIRM,NAME OF FIRM&NAME OF PROP.) BUSINESS ADDRESS BUSINESS PHONE HOME ADDRESS HOME PHONE IF VICTIM IS A PERSON 1110- RACE SEX D.O.B. PERSON REPORTING OFFENSE TO POLICE BUSINESS ADDRESS BUSINESS PHONE HOME ADDRESS HOME PHONE On 12-27T-97 at 2307 hours I was at the intersection of 60th St and Osgood Ave when I received a request to respond to a male/female damestic at 14806 N 58th St in Oak Park Heights. I activated the rotating red lights, flashing red lights and the white wig wag intersection lights prior to approaching the Hwy 36 intersection. The lights are located on the exterior light bar mounted on the roof of squad 471. I stopped breifly at the intersection of South bound Osgood Ave and Be_ 36 with the lights activated. The traffic for West bound Hwy 36 was stopped along with several Vehicles in the left turn lane of East bound Hwy 36 and also a vehicle stopped in the right lane of East bound Hwy 36. I began to proceed through the intersection on a red light with the squad lights activated. I did not see the vehicle traveling East bound Hwy 36 approaching Osgood Ave prior to entering the intersection. As I proceeded through the intersection with due caution I struck a vehicle traveling East bound Hwy 36 in the left lane at a speed estimated near the 50 mph speed limit. The front push bumpers of squad #71 struck the other vehicle in the left rear corner panel. Both vehicle pulled onto the shoulder of Hwy 36 after the accident. The two occupants of the other vehicle quickly exitted and walked back towrds my squad. I checked for injuries and non were indicated. I called for a Minnesota State Patrol Trooper to investigate and write the accident. Trooper 374 arrived on scene and conducted the investigation speaking witl- drivers and witnesses. Prior to clearing the accident, the driver of the other vehicle was indicating sogsness in his Imee and the passenger soloness in his lower back. Both refused medica_ attention. ether vehicle was towed by Stillwater Towing, and passengers given a ride Home. Vehicle INfO: Vehicle #1 Vehicle #2 Sqaud Raymond John Sparks 9-14-54 Paul Gregory Hoppe 04-10-69 110 S. Main St #3 14168 N 57th St Stillwater, MN 55082 Oak Park Heights,MN 55082 S-162-730-429-714 H-100-676-288-280 MN plate 576KPC 97 Cram Victoria 87 Chev Nova Gray Front Damage Left Rear damage No Tow Pass: David Anthony Sparks 4-14-82 No passengers Reference: 'State Patrol Case # 974-16135 MSP 24UU ILL :b11-((9-592b 11ec ou - r 1D ;LJ IVO .u.0 r .u., • • • • . • Veh. 2 was en route a domestic and was traveling southbound on Osgood. Veh. 2 came to the intersection of Osgood and MNTH 36. Veh.2 had the red light. Veh.2 had the emergency lights activated(veh.2 is a fully marked squad) . Veh. 2 stopped and then proceeded across MNTH 36. Veh. 2 came to the eastbound lanes of MNTH 36, and started across. Veh.2 collided with veh.l. Veh.1 was eastbound MNTH 36 traveling in the left lane, when the crash occurred. Drv. 2 said that there was a vehicle stopped in the left turn lane from eastbound MNTH 36 to northbound Osgood, which blocked his line of sight. Which caused Drv. 2 not seeing veh.i . Drv.1 said that he was e as tbound MNTH 36 traveling in the left lane, when he was crashed in the intersection. Drv.l said he was doing the speed limit and never saw the squad. The witness said that the squad was southbound Osgood, and hesitated before across MNTH 36 lanes. That the squad had its emergency lights on. Veh.l was eastbound MNTH 36 and didn't slow down entering the intersection and the vehicles • . crashed.. • • •• . . • • . Contributing factors:Drv.2 sight pictured. was obscured by • . the vehicle stopped in the left turn lane of MNTH 36. . Drv.1- failed to slow for the intersection, and didn't see the • squad with the emergency- lights activated. • Drv.I should' of been aware of the squad traveling across MNTH 36 with the good sight picture approaching the intersection. • • • • • MS-' 24UU ILL :b1Z-(( -by2 UeC ou ' r iD •cJ Ivu .l).3u r .V '5-W1( MA/a I1-M II v•••.r v. ..•.•• • • u• • • •••••.n•r.•• v. • • uuv%WV 1..• II ,LGBEND• TRAFFIC ACCIDENT REPO 22 -' ,2 ; • - - 4��'' (�POLICE USE ONLY AS PEcw 0 BY ) � / of Si a '„ INI Id o /z idleA NM PAM ROUTE Mow •• FMI NaER Oil STREET NAME �^-aTTEa 111 OR OM ON CIE oP W oN/1JliV 3� wR►� 0 FT 0 a A W rC COINITV NO CITY � PIT ELEM REFERENCE POINT - ROUTE GYP ROUTE.,BTREEL CORP ULLtt.REF IMF OR maim • 3vl O'MOP> /L L..L(/47 "2- [ 2 03 + C_c• /A" 45 456-ODiO • • •L�N UNIT RLLE 0 PEOEITNAN a aYjYaE FALL 1.ORIWER uCENSE NII.Y2ER-1 `cIIB'E C.ASS ' y-.•.,a IXZNSE R-x Vol E CLAES -FACTOR 1 : /3 5 .2 a - �,v c �. ' ' 1 r4.4/ 3 FACTOR2 NAME(FIRST,NIXIE.LAST) RSTTIDTNS M•:IIp1AYM NAME/FRST.MOLE.LAST) RETRCTFL4 WII.pRWI FACTOR COMPLIED CCNPLIED 1 £r e.±1n o..Sici_ .- 4/E /17.4 , ea4 6,¢Li6 I.72Y /51/1/1. /i1 MNLR¢R ADORES$ DATE OF BRTH ,.ADDRESS OATS OF BIRTH DMINER_• /ic 's .1/-L/ 577L- ---f VY L Y f i.� 7iw ...- /�� ley 7U NOW. CITY,SWE.DP / ••G�Y.SDCTE.DP FNMECL Id /_frm, ... ..6.17.T.20- 'RCOMNO AOORESB SEX EJECT-MURKY aLLCOD TOHOSIP TSPNSOC.1 I4001It$S SEX FELT RETRNT INICOO•TOLKI,K"1 4F0(L) ROOMS;7 • YE/M ,dER MwLF OWNER NAME ■�YENTYP A, iii/ 1TYAry RI DIRECT ad.)._ L MODEL SNAKE Of EEL MAKE MODEL YEAR COLOR BEQUEICE OF SAWS DMOOGL — • i, A - f? " / 1 - I - I - l-g MWE ,PURE• DM YEAR RBIIIMICE DIFDBEV .3 Of A . 1 �� /cE - 7 y .ryl.f/ .C+E✓9Gd, ...7 I4iUTE' • NDERHYRTLEasEa --- -----. 10ND01• i. /D ' , NirK....LIECT . . t/ : %i D 10 73"- •- jiiiimisi ? 4v.a p Q G • S 0 011111 III .4 p .. STw /M 82_ . Damn lit. :- _-OF OMM • •• f;"•: T •^,now=- oFINAANCE St-RF CELSI AFI1IOR BTAIE AMeIAM IZ RUN li& t I$) •....,._ _ �Ip F)mDSI 7 Iill !•1■■itiOt■ i atAS� ■�1i■■■�� ... * i-^._,.� •I. ..<--.-- Rr rA��l /:t� 1� i�� .....1_I of CNAROEYIEAD•q,AAD•'• � •' ;DEMpE . 1 �� rll ra■ '. .. . ��Itti riy.%vvR ' M•�IZGE.•!�y vE,yicaE R/FS�1?�v / tit``aH181� i •k*i I li_.,_ �■■O■ o srn __.. _ .-- WORRRG ' EY iuJ��ait■n�■ UU■ i■■.i.Ii RAI --_ l lit �r./mueoCFtiii11 'siimiiiti�it • - I sYEo Il��aaLVIEa■■1t■it■■ Nn di ��. - Sp •I I PWROR Y ROCIDN .-, • ' -,' .. • - .. �•:..- • -•- I E500 Q//C/11 n/ 911 Ac4.• OFFICER'm'" '• .:n:•' 0. • - 'r -15binaW- 0 LOCAL. . .. c . . ,44-4- -T. O LL e.carr 0 OTHER •'-MOTOO CAM1EA 04A2 w11.CLAStI4'• 'ILMit CLA29/O MATt CL/,SEND -BOY TYP - IAI1Ty 7 I I I 1 Mid ADORERS mLT;OR GOMYERD SOINICE ppWIL 1/I LS MP r CaTI•SVAC.LP - - LLR• 'PlWEC10R• coma ■ l -J "''''''"":"'''""""""'''"-K"*""'"''''''"'"*'""""''''''''""""""""""""""'''''''""""'"'""'"""""'"'""*'"*""'"'"""""'""""""""'"'"""""""'-'• • I e NOERTIFIO DATE(MM/DDAM /2/03/97 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PAULET/SLATER INC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 2610 UNIVERSITY AVE, STE 200 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ST PAUL MN 55114 COMPANIES AFFORDING COVERAGE COMPANY A NORTHLAND INS COMPANY INSURED COMPANY STILLWATER TOWING INC 1855 S GREELEY COMPANY STILLWATER MN 55082 C 4 997 COMPANY COVERAQES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND ONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICY EFFECTIVE POLICY EXPIRATION um TYPE OF INSURANCE POLICY NUMPEP. umrrs DATE (MMIDDMY) DATE (MM/DDNY) GENERAL LIABILITY GENERAL AGGREGATE COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGO CLAIMS MADE OCCUR PERSONAL&ADV INJURY OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE FIRE DAMAGE(Any one fire) S MED EXP(Any one person) A AUTOMOBILE LIABILITY RENEWAL OF 12/01/97 12/01/98 COMBINED SINGLE LIMIT S 750,000 ANY AUTO TN223368 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE GARAGE LIABILITY AUTO ONLY-EA ACCIDENT OTHER THAN AUTO ONLY: ANY AUTO S S EACH OCCURRENCE EXCESS LIABILITY UMBRELLA FORM AGGREGATE OTHER THAN UMBRELLA FORM TvgySITItTlii 041- WORKERS COMPENSATION AND EMPLOYERS'LIABILITY _EL EACH ACCIDENT $ THE PROPRIETORI INCL EL DISEASE-POLICY LIMIT PARTNERS/EXECUTIVE OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS PROVIDES EVIDENCE OF INSURANCE. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE CITY OF OAK PARK HEIGHTS EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 14168 N 57TH ST 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, OAK PARK MN 55082 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPAN A ' TS OR REPRESENTATIVES. AUTHORIZED REPRESENT 1:.r • :Li',