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Claim Cottingham, J. Kaiserwww. cb-$isco.corll / Assurex Cottingham & Butler C&B Insurance I SISCO [ HeakhCorp ] Safety Management Established I887 Mai-ch 21, 2001 MS JEANNE SCHNEIDER CITY CLERK DUBUQUE CITY HALL 50 WEST 13z~ STREET DUBUQUE IA 52001 Health Plan: Flexsteel Induslries Employee/Patient: Judy Kaiser Your Insured: C'fcy of Dubuque Date of Accident: Febmary 6, 2001 Dear Ms. Sclmdd~, We represent the Flexsteel Industries self-landed employee benefit plan, which covers the above- mentioned patient. This ERISA based health plan includes a provision which permits full recovery of medical and/or disability benefits paid as a result of the injuries sustained on your insureds property. Enclosed for your review is a copy of the portion of the plan, which addresses the right to recovery, as well as a cccpy of the accident/incident report. Please accept this letter as formal notification of the plan's lien against any recovery for the above loss. A lien, for injury related benefits, was graraed to the health plan by the patient on the proceeds of any settlemeat, judgment or other paymem received by the patient or any other individual covered under the plan. We request that you protect the plan's irr~erest relative to any releases and/or paymcmts made as a result of the above loss. Copies of the charges incurred and payment made under this plan wSll be forwarded to you upon request, Thank you for your anticipated cooperation in tgfis matter. Sincerely, 319-587-5224 Endosure cc: Judy Kaiser - FOR YOUR INFORMATION ONLY .Mar, 9, 2001 9:43AM Barry A, Lindahl, Eaq. Corporation Counsel 196 Dubuque Building (3~9) 5~3-4na (31 ~') ~-~ogo tAX BARRY A LINPAHL, ESQ No,2868 P. 1/5 MZ, Barb McCoy Flexsteel ~ealth Plan P,O. BOX 389 Dub%u~ue, Iowa 62004-0389 March 9, 2801 Faxed 587-5871 RE: Subrogation Claim against the City of Dubuque Dear Ms, McCoy: If you wish to file a subrogation claim against the City of Dubuque fo~ d~ages for personal injuries your insured; Judith Kaiser, sustained as a result, of a f~ll on an i0e-cover~d street, we wo=ld ask that you fill out the enclosed Claim Form and mmil it to the City Clark's Office at the £ollowin~ address: Ms. Jeara'l~ Schneider, City Clerk Dubuque City Hall 60 West 13th Street Dubuque, Iowa 52001 Once the Clai~ has been o~ff~ially date-stamped in by the City Clerk, it w£11 be sent to the Legal Departmen~ for processing. I am also enclosing a copy of the Dubuque Police Department Incident Report concerning this aedident, which you requested by telephone thi~ morning. cc - M~. Sin~erely, Carol A. Gulick Legal Department Don Vogt, Operations & Maintenance Manager John ~loetermann, Street\Sewer Maintenance Supervisor SISCO INJURY REPORT All claim payments will be made ia accordcmce with your Health Plan booklet and will be subject to the subrogation/right of reimbursement language of your plan. ~ in its AND SIGN AT THE BOTTOM Employer Name: Number: Work Related Inju~y~s (~clrcie O' ri'e)' If~S: Was it reported? i) Yes () NO ' L~fio}~ Where ~e Acqide~qident 9ccu~red: ~ ¢~ ~/~ C~'~ ~ ~ ~ ~ ~a T (S~eet Address) det~ts (attach ~o~er pag, Name of Property or Car Owner: Complete Address: Phone Nmnber: Name of other Party's Homeowner or Auto Insurance Carrier: Complete Address: Phone Number: Policy,. Name of your Attorney (if you are working with one on this injury): Complete Address and Phone Number: Were any citations issued? Yes No N/A If yes, who was charged?. For what violation? A~ach a copy of the police report and/or accident report (if any). Name and complete address of the Police Department or Sheriffs' Office who investigated this accident: Name, complete address, and phone number of your Auto Insurance Carrier. I have tmswered all questions trttthfally card to the best of my knowledge. I tmderstand my cltdtn cannot be processed unless the plan receives complete informaU'on attd benefit payments are subject to the [imitations and guideli,,tes found in the Summary Plat~ Document. Signature: Print Name: Date: ~tSUflAHCE ~A~tEfl ADO~ESS !. .Mar. 9, 2O01 9:~3AM BARRY A LINDAHL, N0,2863 P, 2/5 CLAIM AGAINST THE CITY OF DUBUQUE This w~itten re~ort constitutes your claim against the City of Dubuque, Iowa~ You should c~mplete this form in full and attach The Claim must he filed with the City Clerk at City ~all, 50 West l~t~ Street, Dubuque, Iowa 52001-486~. It will then be referred by the City Council to the appropriate Department for investigation. Once that investigation is sompteted, a ~egert and recc~mnendation will be submitted to the City Council. ?ouwi11 be provided with a copy o£ that report a~d re0ommenda~ion. THE FINAL DECISION ON ALL CLAIMS IS MADE BY T~E CITY COUNCIL. NO EMPLOYE~ OF T~{E CITY OF DUBUQL~ HAS TI{E ~.%~THORITY TO REPRES~ATION TO ~U AS TO ~ETHER YO~ C~IM ~LL OR WILL N~ BE PAID · 7. DESCKI~E 'ACCID~' O~ OCC~ENCE T~T (~i=e full ~etails ugou which you base your ~laim. If a City 9. ~ive =~e and address of any witnesses. Did police investigate? (If so, ~ive names of of~ioer~.) WaS amyo~e i~J~red? (~£ so, ~iYe ~ame, address and extant injuries.) .Mar. 9. 2001 9:43AM BARRYA LJNDAHL, ESQ No.2888 P, 3/5 i2. Wa¢ any damage done to property? (If so, describe property ibe basi~ for ascertaining extent of ~e. ) 13. 14. What other damages do you claim, if any? ~/ave you been compensated for a~%y part or ell of your claim by insurance c~p~y and ~o~t paid,) 15. wh~.t amount do you claim f~om the City of DubuqUe? 16. Why do you claim the City o~ Dubuqu~ is reeponsibl~? 17. Have you mad.e any ~ieim again,~ anyon~ else If yes, give If the answer to Question 17 im ye~, have you r~c¢ived any payment from that SOurce, and if sg, i~. what amo~ult? 2001 · CE' r "l .E',..t~./Name ) (EIGHTH AMENDMENT - FLEXSTEEL INDUSTRIES, INC. PLAN 506 - PAGE 5) This Plan will be reimbursed for all benefit payments made as the result of Injuries or Illnesses which are caused by the actions of a third party and which give rise to a court ordered financial award or out-of-court settlement to a Covered Individual from a third party tort-feasor, person or entity. This Plan will provide benefits, otherwise payable under tl~ Plar~ to or on behalf of the Covered Individual only od the following terms and conditions: 1. In the evem of any payment under this Plan, the Plan slmll be subrogated to all of the Covered Individual's rights of recovery against any person or organization and the Covered Individual shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights. The Covered Individual shall do nothing after loss to prejudice such rights. The Covered Individual shall agree to cooperate with the Plan and/or any represematives of the Plan in completing such forms and in giving such information surrounding any accident as the Plan or ks representatives deem necessary to fully investigate the incident. 2. The Plan is also granted a right of rehnbursement from the proceeds of any settlement, judgment or other payment obtained by the Covered Individual. This right of reimbursement is cumulative with and not exclusive of the subrogation right granted in 1 above, but only to the extent of the benefits paid by the Plan. 3. The Plan, by payment of any proceeds, is granted a lien on the proceeds of any settlement, judgment or other payment received by the Covered Individual, and the Covered Individual consents to said lien and agrees to take whatever steps are necessary to help the Plan Administrator secure such lien. 4. The subrogation and reimbursement rights mad liens apply to any recoveries made by the Covered Individual as a result of the Injuries sustained or Illness suffered, including but not limited to the following: a. Payments made directly by the third party tort-feasor or any insurance company on behalf of the third party tort-feasor or any other payments on behalf of the third party tort-feasor. b. Any payments or settlements or judgments or arbitration awards paid by an inmrance company under an uninsured or underinsured motorist coverage, whether on behalf of the Covered Individual or other person. c. Any other payments from any source designed or intended to compensate a Covered Individual for Injuries sustained or Illness suffered as the result of negligence or alleged negligence of a third party. d. Any workers compensation award or settlement. 5. No adult Covered Individual may assign any rights that it may have to recover medical expenses from any tort-feasor or other person or entity to any minor child or children of said adult Covered Individual without the express prior written consent of the Plan. The Plan's right to recover (whether by subrogation or reimbursement) shall apply to decedent's, minor's and incompetem or disabled person's settlements or recoveries. 6. No Covered Individual shall make any settlement which specifically excludes or attempts to exclude the medical expenses paid by the Plan. (EIGHTH AMENDMENT - FLEXSTEEL INDUSTRI]]S, INC. PLAN 506 - PAGE 6) 7. The proceeds of any settlement, judgment or other payment recovered by or on behalf of the Covered Individual shall be allocated first to full reimbursement of the Plan and, after the Plan has been fully reimbursed, then to expenses and compensation of the Covered Individual, notwithstanding any so-called "Made-Whole Doctrine", "Rimes Doctrine" or any other law which would compensate the Covered Individual, in whole or in part, before reimbursing a subrogee. 8. No Covered Individual shall incur any expenses on behalf of the Plan, inclnding but not limited to court costs or attorney's fees, without the prior express written consent of the Plan. The Plan's rights to full reimbursement shall not be reduced because of any so-called "Fund Doctrine", "Common Fulld Doctrine", or any other law which implies the Plan's agreement or otherwise requires the Plan to pay, or to accept as a reimbursement in kind, any mount or share of attorney's fees or other services or expenses incurred by the Covered Individual in obtaining a judgment, settlement or other payment from a third party,' The Plan shall recover the full mount of benefits paid without regard to any claim of fault on the part of the Covered Individual, whether under comparative negligence or otJlerwise. 10. The benefits under this Plan are secondary to any coverage under no-fault or similar insurance. ' 9) Page 35, the definition of "Actively at Work" shall be deleted and replaced as follows: "ACTIVELY AT WORK/ACTIVE WORK An Employee is considered to be Actively at Work when performing, in the customary manner, all of the regular duties of his occupation with the Company, either at one of the Company's regular places of business, or at some location to which the Company's business requires an Employee to travel to perform his regular duties. An Employee shall be deemed Actively at Work on each day of a regular paid vacation, on each day he is absent due to illness or injury or on a regular non-working day on which he is not Totally Disabled, provided he was Actively at Work on the last preceding regular workh~g day." 10) Page 38, the definition of "Eligible Retiree" shall have the following added: "Effective November 1,1998, an employee who notifies the Company in writing by April 30, 1999, of their intentions to retire and whose retirement is effective not later than Octoberl, 1999, will be considered an eligible retiree if he has attained the age of fifty-five (55) and has at least thirty (30) years of continuous service with the Company prior to retirement. Health care coverage will be provided until the retiree reaches Medicare eligibility but no later than the age of sixty-five (65)." 11 ) Page 42, the definition of "Pre-Existing Condition' shall be deleted and replaced as follows: "PRE-EXISTING CONDmON An injury, disease or illness of a Covered Individual for which the Covered Individual has been under the care of a licensed physician or has received medical care, services or supplies within the six (6) month period immediately preceding his effective date of coverage or enrollment date, whichever is applicable. Medical care, services, or supplies shall include, but shall not be limited to, medication, therapy, x-ray or lab tests, counseling, or any other treatment recommended by a licensed provider of medical care or services."