Claim by Accident Fund Insurance_Barbara Frondsen r=
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This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this form in full and
attach any additional information that supports your claim.
The claim must be filed with the City Clerk at City Hall, 50 West 13th St., Dubuque, IA 52001. It will then be referred to
the appropriate department for investigation and to the City Attorney's Office. Once that investigation is completed, a
report and recommendation will be submitted to the City Council. You will be provided with a copy of that report and
recommendation.
The final decision on all claims is made by the City Council. No employee of the City of Dubuque has the authority to
make any representation to you as to whether your claim will or will not be paid.
1. Name of Claimant. Accidental Fund Insurance Company a/s/o Barbara Frondsen,.
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2. Address: ~,t ~ _~~ ~~' ~~ r ~.. ~~; _
3. Telephone Number: ' ~ `~~ ~ ~ ~'-~ ~ ~=`
4. Date of Incident:
5. Time of Incident: _ ~ ~-~ `~~
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6. Location of Incident (Be specific): °=-~- a` . ~ J~ ~ ~ '
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7. Describe the accident or occurrence that caused injury or damage. (Give full details upon which you base your
claim. If a City employee was involved, give the employee's name.)
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8. What were weather conditions like? ' ~ ` _ ~ , '~~
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries.)
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12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of
damages or describe basis for ascertaining extent of damage.)
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13. What other damages do you claim, if any? -. <, ~ _'• ., _ ,.. -- , .-
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14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name and
address of insurance company and amount paid.)
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15. What amount do you claim from the City of Dubuque? t - .~ ~
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16. Why do you claim the ClIity of Dubuque is responsible? ~~ ~ ~~~, ~~--<<~~ ~~ ~x~~.~-d,~~~~~a~~
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17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and
address.)
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
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Dated this ~~ day of ~~~~~€~~, ~'~' , 20 ~~ 1 .
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(Signature)
(Print Name)
REQUEST F®R P,4YMENT'
CASE T'AT MENT FR WORKERS' COMPENSATION
Date of Loss: 4/8/2008
Statement sent to :CITY OF DUBUQl1E
Your Claim : AF5016097WC08000002-001 Instructions:
Insured :DAVID W. LEIFKER DBA DAVID Please include TPCS-749245-1144853 on all
W. LEIFKER ATTORNEY AT LAW payments and correspondence to expedite
Policy # :5016097 processing.
Claimant : BARBARA FRANDSEN
ATTENTION:
AMOUNT IS SUBJECT TO CHANGE, PLEASE CONTACT TRANSPAC SOLUTIONS PRIOR TO SETTLEMENT.
Payment Service Dates
Date Start Date End Date Payee Check Number Payment
°r.,,,e• in~n~nntiiTV pavn~FNTS
10/06/2008 09/26/2008 10/02/2008 BARBARA FRANDSEN 7321950 $271.66
10107/2008 10/03/2008 10/09/2008 BARBARA FRANDSEN 7322320 $271.66
10/15/2008 10/1012008 10/1612008 BARBARA FRANDSEN 7324641 $271.66
10/21/2008 10/17/2008 10/23/2008 BARBARA FRANDSEN 7326340 $271.66
10/28/2008 10/24/2008 10/30/2008 BARBARA FRANDSEN 7328400 $271.66
11/04/2008 10/31/2008 11/06/2008 BARBARA FRANDSEN 7330326 $271.66
11/17/2008 11/07/2008 11/13/2008 BARBARA FRANDSEN 7333983 $271.66
11/18/2008 11/14/2008 11/20/2008 BARBARA FRANDSEN 7334355 $271.66
11/21/2008 11/2112008 11/27/2008 BARBARA FRANDSEN 7336328 $271.66
12/02/2008 11/28/2008 12/04/2008 BARBARA FRANDSEN 7338305 $271.66
12/09/2008 12/05/2008 12/11/2008 BARBARA FRANDSEN 7340341 $271.66
12/16/2008 12/12/2008 12/18/2008 BARBARA FRANDSEN 7342370 $271.66
12/19/2008 12/19/2008 12/25/2008 BARBARA FRANDSEN 7344289 $271.66
01/07/2009 12/26/2008 01/01/2009 BARBARA FRANDSEN 7348353 $271.66
01/07/2009 01/02/2009 01/08/2009 BARBARA FRANDSEN 7348354 $271.66
01/13/2009 01/09/2009 01/15/2009 BARBARA FRANDSEN 7349927 $271.66
01/21/2009 01/16/2009 01/22/2009 BARBARA FRANDSEN 7352097 $271.66
01/27/2009 01/23/2009 01/29/2009 BARBARA FRANDSEN 7353637 $271.66
02/03/2009 01/30/2009 02/05/2009 BARBARA FRANDSEN 7355650 $271.66
02/10/2009 02/06/2009 02/1212009 BARBARA FRANDSEN 7357647 $271.66
02/17/2009 02/13/2009 02/19/2009 BARBARA FRANDSEN 7359662 $271.66
02/24/2009 02/20/2009 02/26/2009 BARBARA FRANDSEN 7361665 $271.66
03/03/2009 02/27/2009 03/05/2009 BARBARA FRANDSEN 7363612 $271.66
03/10/2009 03/06/2009 03/12/2009 BARBARA FRANDSEN 7365533 $271.66
03/17/2009 03/13/2009 03/19/2009 BARBARA FRANDSEN 7367475 $271.66
Total Claims Paid for INDEMNITY PAYMENTS
$11490.55
REQU ST ®R PAYMENT
CASE STAT M NT F®R WORKERS' COMPENSATION
Date of Loss: 4/8/2008
Statement sent to :CITY OF DUBUQUE
Your Claim # : AF5016097WC08000002-001 Instructions:
Insured :DAVID W. LEIFKER DBA DAVID Please include TPCS-749245-1144853 on all
W. LEIFKER ATTORNEY AT LAW payments and correspondence to expedite
Policy :5016097 processing.
Claimant :BARBARA FRANDSEN
ATTENTION:
AMOUNT IS SUBJECT TO CHANGE, PLEASE CONTACT TRANSPAC SOLUTIONS PRIOR TO SETTLEMENT.
Payment Service Dates
Date Start Date End Date Payee Check Number Payment
r.,,,o• inin~nnNi-rv ~nvnnFNTS
03/17/2009 03/13/2009 03/1912009 BARBARA FRANDSEN 7367475 $271.66
03/24/2009 03/20/2009 03/26/2009 BARBARA FRANDSEN 7369388 $271.66
03/31/2009 03/27/2009 04/02/2009 BARBARA FRANDSEN 7371227 $271.66
04/07/2009 04/03/2009 04/09/2009 BARBARA FRANDSEN 7373042 $271.66
04/14/2009 04/10/2009 04/16/2009 BARBARA FRANDSEN 7374825 $271.66
04121/2009 04/17/2009 04/2312009 BARBARA FRANDSEN 7376739 $271.66
04/28/2009 04/24/2009 04/30/2009 BARBARA FRANDSEN 7378598 $271.66
05/04/2009 05/01/2009 05/03/2009 BARBARA FRANDSEN 7380130 $116.54
05/12/2009 05/04/2009 05/10/2009 BARBARA FRANDSEN 7382233 $201.07
05/20/2009 05/11/2009 05/17/2009 BARBARA FRANDSEN 7384379 $201.07
05/27/2009 05/18/2009 05/24/2009 BARBARA FRANDSEN 7386182 $201.07
06/08/2009 05/25/2009 06/07/2009 BARBARA FRANDSEN 7389280 $360.91
06/15/2009 06/08/2009 06/14/2009 BARBARA FRANDSEN 7391121 $159.82
06/22/2009 06/15/2009 06/21/2009 BARBARA FRANDSEN 7392941 $159.82
06/26/2009 06/22/2009 06126/2009 BARBARA FRANDSEN 7394490 $159.82
07/06/2009 06/29/2009 07/05/2009 BARBARA FRANDSEN 7396576 $159.82
07/13/2009 07/06/2009 07/12/2009 BARBARA FRANDSEN 7398397 $159.82
07/17/2009 07/13/2009 07/19/2009 BARBARA FRANDSEN 7399934 $159.82
07/27/2009 07/20/2009 07/26/2009 BARBARA FRANDSEN 7402035 $159.82
08/03/2009 07/27/2009 08/02/2009 BARBARA FRANDSEN 7403795 $159.82
08/10/2009 08/03/2009 08/09/2009 BARBARA FRANDSEN 7405543 $159.82
08/13/2009 08/10/2009 08/16/2009 BARBARA FRANDSEN 7406899 $159.82
08/21/2009 08/17/2009 08/23/2009 BARBARA FRANDSEN 7408962 $118.57
Total Claims Paid for INDEMNITY PAYMENTS
T e• MEDICALS
$11490.55
Yp
06/04/2008
05/1212008
05/12/2008
MDM
8796747
$800.00
07/01/2008 05/12/2008 05/12/2008 BARBARA FRANDSEN 8816347 $53.84
Total Claims Paid for MEDICALS
$60888.32
REQUEST F®R PAYMENT
CASE STAT M NT F®R WORKERS' COMPENSATION
Date of Loss: 4/8/2008
Statement sent to :CITY OF DUBUQUE
Your Claim # : AF5016097WC08000002-001 Instructions:
Insured :DAVID W. LEIFKER DBA DAVID Please include TPCS-749245-1144853 on all
W. LEIFKER ATTORNEY AT LAW payments and correspondence to expedite
Policy :5016097 processing.
Claimant :BARBARA FRANDSEN
ATTENTION:
AMOUNT IS SUBJECT TO CHANGE, PLEASE CONTACT TRANSPAC SOLUTIONS PRIOR TO SETTLEMENT.
Payment I Service Dates
Date Start Date End Date Payee Check Number Payment
r.,~,,. nn~nire~ c
y Nom. ~.
07108/2008
04/14/2008
06/19/2008
BARBARA FRANDSEN
8821374
$274.51
07/17/2008 04/11/2008 05/19/2008 THIRD PARTY SOLUTIONS INC 8829567 $58.01
07/17/2008 04/28/2008 06/02/2008 MEDICAL ASSOCIATES CLINIC 8829178 $187.63
07/17/2008 05/08/2008 05/30/2008 MERCY MEDICAL CENTER 8829206 $1189.39
07/17/2008 06/05/2008 06/05/2008 FINLEY HOSPITAL 8829158 $1436.63
07/21/2008 04/08/2008 06/16/2008 MEDICAL ASSOCIATES CLINIC 8831385 $209.49
07/25/2008 06/02/2008 06/02/2008 THIRD PARTY SOLUTIONS 8835463 $4.43
07/25/2008 06/16/2008 06/16/2008 THIRD PARTY SOLUTIONS INC 8835473 $8.86
08/01/2008 06/03/2008 06/24/2008 MERCY HEALTH CENTER DUBU(~ 8839932 $502.15
08/06/2008 08/04/2008 08/04/2008 MAQUOKETA FAMILY CLINIC 8844752 $56.00
08/14/2008 08/06/2008 08/06/2008 IOD INCORPORATED 8852788 $20.00
08/22/2008 07/22/2008 07/22/2008 THIRD PARTY SOLUTIONS 8860606 $8.86
08/2212008 07/17/2008 07/17/2008 MECIAL ASSOCIATES CLINIC 8859942 $248.66
09/1512008 08/21/2008 08/28/2008 BARBARA FRANDSEN 8879614 $65.65
09/17/2008 07/07/2008 07/07/2008 THIRD PARTY SOLUTIONS 8882053 $8.86
09/17/2008 06/19/2008 06/19/2008 TIMOTHY MILLER MD 8881751 $361.41
09/17/2008 06/05/2008 06/05/2008 TIMOTHY MILLER MD 8881752 $445.87
09/19/2008 08/21/2008 08/21/2008 MECIAL ASSOCIATES CLINIC 8883897 $69.22
09/24/2008 08/28/2008 08/28/2008 THIRD PARTY SOLUTIONS 8887708 $27.95
09/26/2008 08121/2008 08/21/2008 THIRD PARTY SOLUTIONS 8890236 $13.97
09/24/2008 08/2812008 08/28/2008 THIRD PARTY SOLUTIONS 8887708 $27.95
09/26/2008 08/21/2008 08/21/2008 THIRD PARTY SOLUTIONS 8890236 $13.97
10106/2008 09/11/2008 09/11/2008 MEDICAL ASSOCIATES 8896329 $69.22
10/09/2008 06/19/2008 06/1912008 FINLEY HOSPITAL 8899954 $1436.63
10/21/2008 09/11/2008 09/11/2008 THIRD PARTY SOLUTIONS 8908147 $88.94
10/21/2008 09/26/2008 09/26/2008 DUBUQUE ANESTHESIA SERV P 8907888 $2160.00
10/29/2008 07/26/2008 08/22/2008 BLUE CROSS/BLUE SHIELD 136993676 $2.00
Total Claims Paid for MEDICALS
$60888.32
REQUEST F®R PAYMENT
CASE STATEMENT F® WORKERS' COMPENSATION
Date of Loss: 4/8/2008
Statement sent to :CITY OF DUBUQUE
Your Claim : AF5016097WC08000002-001 Instructions:
Insured :DAVID W. LEIFKER DBA DAVID Please include TPCS-749245-1144853 on all
W. LEIFKER ATTORNEY AT LAW payments and correspondence to expedite
Policy :5016097 processing.
Claimant :BARBARA FRANDSEN
ATTENTION:
AMOUNT IS SUBJECT TO CHANGE, PLEASE CONTACT TRANSPAC SOLUTIONS PRIOR TO SETTLEMENT.
Payment ~ Service Dates
Date Start Date End Date Payee Check Number Payment
T.,.,e. nnGnire~ c
rr~~ ~•
10/29/2008
07/26/2008
08/22/2008
BLUE CROSS/BLUE SHIELD
187538416
$5.40
10/31/2008 09/2612008 09/2612008 MERCY RADIOLOGISTS OF DUB 8915987 $15.91
10/31/2008 10/03/2008 10/03/2008 THIRD PARTY SOLUTIONS 8916261 $17.72
10/31/2008 09/28/2008 09/28/2008 THIRD PARTY SOLUTIONS 8916248 $17.96
10/31/2008 10/01/2008 10/01/2008 THIRD PARTY SOLUTIONS 8916266 $21.13
10/31/2008 09/26/2008 09/26/2008 MERCY HEALTH CENTER DUBUQ 8916020 $28497.22
11/09/2008 08/2812008 08/28/2008 MEDICAL ASSOCIATES CLINIC 8921504 $49.19
11/09/2008 04/08/2008 04/08/2008 MEDICAL ASSOCIATES CLINIC 8921506 $251.76
11/09/2008 04/11/2008 04/14/2008 MEDICAL ASSOCIATES CLINIC 8921507 $429.86
11/13/2008 10/09/2008 10/09/2008 THIRD PARTY SOLUTIONS 8925771 $43.07
1111312008 09/26/2008 10/09/2008 MEDICAL ASSOCIATES CLINIC 8925657 $7868.20
11/18/2008 10/23/2008 10/23/2008 THIRD PARTY SOLUTIONS 8929242 $5.88
11/18/2008 10/19/2008 10/19/2008 THIRD PARTY SOLUTIONS 8929244 $5.88
11/24/2008 10/13/2008 10/13/2008 THIRD PARTY SOLUTIONS 8932822 $5.88
11/25/2008 09111/2008 10/09/2008 BARBARA FRANDSEN 8933577 $157.95
12105/2008 09/2212008 09122/2008 MEDICAL ASSOCIATES CLINIC 8939604 $24.01
12109/2008 11/12/2008 11/12/2008 MEDICAL ASSOCIATES CLINIC 8941685 $48.85
12/19/2008 09/24/2008 09/24/2008 MEDICAL ASSOCIATES CLINIC 8949057 $49.19
01/06/2009 09/22/2008 11/24/2008 MEDICAL ASSOCIATES CLINIC 8957092 $560.24
01/09/2009 11/12/2008 12/2412008 BARBARA FRANDSEN 8960032 $190.13
01/15/2009 12/1612008 12/16/2008 MERCY RADIOLOGISTS OF DUB 8964658 $329.50
01/26/2009 12/24/2008 12/24/2008 MEDICAL ASSOCIATES CLINIC 8969676 $48.85
01/26/2009 12/16/2008 12/16/2008 MEDICAL ASSOCIATES CLINIC 8969675 $848.25
01/30/2009 11/01/2008 11/28/2008 BLUE CROSS/BLUE SHIELD 159875161 $2.00
01/30/2009 11/01/2008 11/28/2008 BLUE CROSS/BLUE SHIELD 139416671 $19.20
02/11/2009 01/0512009 01/30/2009 BARBARA FRANDSEN $980378 $190.30
02/13/2009 01/19/2009 01/19/2009 MECIAL ASSOCIATES CLINIC 8981891 $108.37
Total Claims Paid for MEDICALS
$60888.32
REQUEST F®R PAYM NT
CASE STAT'EIVIEN`f F®R WORKERS' COMPENSATION
®a4e of Loss: 4/8/2008
T e• MEDICALS
Yp
02/24/2009
09/26/2008
09/26/2008
DUBUQUE ANESTHESIA SERV P
8989571
$31.98
02/26/2009 11/29/2008 12/26/2008 BLUE CROSS/BLUE SHIELD 147140378 $2.00
02/26/2009 11/29/2008 12/26/2008 BLUE CROSS/BLUE SHIELD 176441753 $24.60
03/05/2009 01/05/2009 02/20/2009 PHYSICAL & SPORTS THERAPY 8994919 $1412.59
03/13/2009 02/16/2009 02/16/2009 MERCY RADIOLOGISTS OF DUB 9001001 $234.82
03/19/2009 02/02/2009 02/27/2009 BARBARA FRANDSEN 9005122 $277.20
03/19/2009 02/02/2009 02/27/2009 BARBARA FRANDSEN 9005122 $277.20
03/25/2009 12/27/2008 01/23/2009 BLUE CROSS/BLUE SHIELD 146694863 $1.00
03/25/2009 12/27/2008 01/23/2009 BLUE CROSSIBLUE SHIELD 134315407 $12.30
04/01/2009 02/12/2009 02/12/2009 MEDICAL ASSOCIATES CLINIC 9014340 $69.22
04/03/2009 02/27/2009 03/03/2009 MEDICAL ASSOCIATES CLINIC 9016182 $138.44
04/08/2009 01/05/2009 02/27/2009 BARBARA FRANDSEN 9018296 $29.75
04/12/2009 02/24/2009 03/25/2009 PHYSICAL & SPORTS THERAPY 9019014 $492.24
04/14/2009 03/03/2009 03/24/2009 BARBARA FRANDSEN 9021092 $94.19
04/20/2009 02123/2009 02/23/2009 MEDICAL ASSOCIATES 9024601 $1266.44
04/29/2009 02/21/2009 03/20/2009 BLUE CROSS/BLUE SHIELD 171693832 $2.00
04/29/2009 02/21/2009 03/20/2009 BLUE CROSS/BLUE SHIELD 106447088 $7.00
05/04/2009 04/07/2009 04/07/2009 MEDICAL ASSOCIATES CLINIC 9033242 $69.22
05/14/2009 04/09/2009 04/09/2009 MEDICAL ASSOCIATES CLINIC 9040266 $155.59
05/22/2009 04/01/2009 04/30/2009 BARBARA FRANDSEN 9045388 $226.40
05/26/2009 01/27/2009 01/27/2009 MEDICAL ASSOCIATES CLINIC 9046288 $182.75
05/26/2009 04/01/2009 04/30/2009 PHYSICAL & SPORTS THERAPY 9046297 $656.32
05/28/2009 03/21/2009 04/17/2009 BLUE CROSS/BLUE SHIELD 164977855 $4.00
05/28/2009 03/21/2009 04/17/2009 BLUE CROSS/BLUE SHIELD 190685213 $482.27
06/01/2009 05/04/2009 05128/2009 BARBARA FRANDSEN 9049611 $136.89
06/04/2009 02/16/2009 02/16/2009 MEDICAL ASSOCIATES CLINIC 9051849 $69.22
06/09/2009 02/16/2009 02/16/2009 MEDICAL ASSOCIATES 9054182 $162.31
Total Claims Paid for MEDICALS
$60888.32
REQUEST F®R PAYMENT
CASE STATEN NT F®R WORKERS' COMPENSATION
Date of Loss: 4/8/2008
Statement sent to : CITY OF DUBUQUE
Your Claim : AF5016097WC08000002-001 Instructions:
Insured :DAVID W. LEIFKER DBA DAVID Please include TPCS-749245-1144853 on all
W. LEIFKER ATTORNEY AT LAW payments and correspondence to expedite
Policy # :5016097 processing.
Claimant :BARBARA FRANDSEN
ATTENTION:
AMOUNT IS SUBJECT TO CHANGE, PLEASE CONTACT TRANSPAC SOLUTIONS PRIOR TO SETTLEMENT.
Payment ( Service Dates
Date Start Date End Date Payee Check Number Payment
T e• MEDICALS
Yp
06/11/2009
03/31/2009
03/31/2009
MEDICAL ASSOCIATES CLINIC
9055699
$29.75
06/17/2009 05/0612009 06/09/2009 TRUINE HEALTH GROUP 9058689 $401.50
06/29/2009 05/0412009 05/28/2009 UNIVERSAL SMARTCOMP 9063737 $655.20
06/26/2009 04/18/2009 05/29/2009 BLUE CROSS/BLUE SHIELD 120014232 $3.00
06/26/2009 04/18/2009 05/29/2009 BLUE CROSS/BLUE SHIELD 127256614 $10.50
07/0912009 06/0812009 06/09/2009 MEDICAL ASSOCIATES CLINIC 9070057 $138.44
07122/2009 06/10/2009 07/15/2009 TRUINE HEALTH GROUP 9077403 $496.95
07/22/2009 06/01/2009 06/2912009 UNIVERSAL SMARTCOMP 9077306 $823.94
07/24/2009 06/01/2009 06/29/2009 BARBARA FRANDSEN 9078725 $242.78
07/24/2009 01/24/2009 02/20/2009 BLUE CROSS/BLUE SHIELD 156256259 $3.00
07/24/2009 01/24/2009 02/20/2009 BLUE CROSS/BLUE SHIELD 117029762 $228.50
07/27/2009 05/30/2009 06/26/2009 BLUE CROSS/BLUE SHIELD 107868295 $2.00
07/27/2009 05/30/2009 06/26/2009 BLUE CROSS/BLUE SHIELD 182416636 $274.87
07/31/2009 06/01/2009 06/29/2009 BARBARA FRANDSEN 9081743 $35.10
08!0712009 04/27/2009 04/27/2009 MEDICAL ASSOCIATES CLINIC 9085031 $69.22
08/14/2009 06/27/2009 07/24/2009 BLUE CROSS/BLUE SHIELD 100962144 $3.00
08/14/2009 06/27/2009 07/24/2009 BLUE CROSS/BLUE SHIELD 172978562 $278.37
08/18/2009 07/24/2009 07/24/2009 MEDICAL ASSOCIATES CLINIC 9089489 $38.09
08/18/2009 07/15/2009 07/15/2009 MEDICAL ASSOCIATES CLINIC 9089488 $69.22
08/20/2009 07/01/2009 07/30/2009 BARBARA FRANDSEN 9091227 $303.05
08/2612009 07/17/2009 08/1812009 TRUINE HEALTH GROUP 9094110 $601.90
Total Claims Paid for MEDICALS
$60888.32
Total Claims Paid $72,378.87
Recovered to Date ($0.00)
®utstanding Amount $72,378.87
FootNote:
If an insured's deductible or out-of-pocket expenses are listed, we are requesting payment as
a courtesy to our client's insured.
Client's Claim :AF5016097WC08000002
Christopher Barnes
Licensed in Kentucky
Attorneys at Law
9390 Bunsen Parkway
Louisville, Kentucky 40220
Telephone: (502) 214-5073
Toll Free: (800) 419-8635
Facsimile: (502) 214-1064
ctb@gibson-sharpslaw.com
September 2, 2009
Jeanne Schneider, City Clerk
City of Dubuque
50 West 13t1i Street
Dubuque, IA 52001
RE: Our Client:
Insured Employer:
Injured Employee:
Date of Loss:
Current Claim Amount:
Our File No.:
City Clerl: of the City of Dubuque:
Accident Fund insurance Cornpa~~y
David W. Leiflcer, Attorney at Law
Barbara Frandsen
4/8/2008
72,378.87
TPCS 749275-1144853
This firm is cot~lisel for Accident Fund Insurance Company and its agent for subrogation and recovery services,
TrarisPaC Solutions, with respect to a rennbursement/subrogation claim relating to the above-referenced matter.
Accideni h'u>r? is th:: v,%~rl:ers' co~r~f;elisaiion provider for David 1-~~.:Leifker, Attorney at Law with regard to an
injury that occurred on city property on April 8, 2008. Please accept this as notice of my client's workers'
compensation lien interest. Enclosed please find the city claim form and supporting documents for the claim.
Sincerely,
Chris Barnes