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Claim Hingtgen, Craig - TrevorLeisure Services Department 2200 Bunker Hill Road Dubuque, IA 52001 COGHLAN KUKANKOS COOK LLC ATTORNEYS AT LAW (312) ~" ""' November 4, 2003 Attention: Mr. Gil Spence Re: Fund Member: Covered Individual: Date of Accident: CKC File No.: Lien Amount: Craig Hingtgen Trevor, son 08/16/03 IA-3467 $12,439.00 Dear Mr. Spence: The Central States, Southeast and Southwest Areas Health and Welfare Fund (the "Fund") has requested that we assist it regarding proper application of its subrogation and coordination of benefits ("COB") roles to the captioned matter. Our records indicate that on or about August 16, 2003, Fund Covered Individual Trevor Hingtgen sustained injuries as a result of an accident at the Flora Park Pool. We would appreciate it if you would inform our office as to the name of the company with which you had insurance at the time of this accident and forward the enclosed notice of lien to their attention. Please use the space provided below for your response and return this form to our office in the self-addressed, stamped envelope enclosed. If you have any questions regarding this matter, I will be happy to discuss thc~m with you. Yours truly, Coghlan Kukankos Cook LLC MAB/sml Enclosures 1). Name and address of insurance carrier on 8/16/03 2)_ Policy and/or claim number and adjuster's name G:\DOCS\CSS\NOV.03\IA-3467A.MAB x~ COGHLAN KUKANKOS COOK LLC ATTORNEYS AT LAW (312) 357-2312 Leisure Services Depadment Park Administration 2200 Bunker Hill Road Dubuque, IA 52001 Attention: Director November 4, 2003 Re: Fund Member: Covered Individual(s): CKC File No.: Date of Accident: Lien Amount*: Craig Hingtgen Trevor, son IA-3467 08/16/2003 $12,439.00 Ladies and Gentlemen: The Central States, Southeast and Southwest Areas Health and Welfare Fund (the "Fund") has requested that we notify you that the Fund claims a lien and a right of subrogation, to the extent of benefits paid or payable, with respect to rights of recovery a member or other Covered Individual(s) may have arising out of the above-captioned accident. The Fund also claims a lien and a right of subrogation with respect to rights of recovery the captioned member or other Covered Individual(s) may have, Including but not limited to, rights arising from homeowners insurance, third party medical reimbursement insurance, under and uninsured motorist insurance and no fault or personal injury protection (PIP) coverage as otherwise provided by the Fund's plan document. The Fund's Coordination of Benefits ("COB") provisions specify that, with respect to motor vehicle accidents, no fault and personal injury protection (PIP) benefits, as well as third party medical reimbursement coverage, are prime and must be paid before the Fund is obligated to provide benefits. However, if for any reason a primary insurer fails to promptly extend coverage, the Fund may without waiver of any right, provide benefits and then seek reimbursement or contribution from responsible parties. A Notice of Lien describing the Fund's interest in the captioned claim is enclosed. For your protection, please forward this Notice of Lien directly to your insurance company today. If you have any questions about this claim, please feel free to call toll free 1-800-627-3360 to the undersigned. Thank you for your consideration. Sincerely, Coghlan Kukankos Gook~ Michael A. B~s~r MAB:SML Enclosure *The Fund claims a lien to the extent of medical and disability benefits it has paid to date and will pay in the future. Please contact this office and determine the Lien amount before settlement. NOTICE OF LIEN ASSERTED BY TAFT-HARTLEY TRUST/EMPLOYEE BENEFiT PLAN November 4, 2003 Leisure Services Department Park Administration 2200 Bunker Hill Road Dubuque, IA 52001 Attention: Director Fund Member: Covered Individual(s): CKC File No.: Date of Accident: Lien Amount*: Craig Hingtgen Trevor, son IA-3467 08/16/2003 $12,439.00 Ladies and Gentlemen: Please take notice that the above-named Covered Individual(s) is a Fund beneficiary and has received, and may in the future receive, medical and/or loss of time (LOT) benefits provided by the Central States, Southeast and Southwest Areas Health and Welfare Fund (the "Fund") as a result of bodily injury and disability sustained in the captioned accident. The Fund claims a lien and right of subrogation as stated herein and, for that reason, we request that prior to settlement of this case, you contact the undersigned in order to learn and arrange to pay the correct and current amount of the benefits provided by the Fund. The Fund is a Taft-Hartley Trust and Employee Benefit Plan under the protection of the Employee Retirement Income Security Act of 1974, 29 United States Code Section 1001, et se__q. Pursuant to the Fund's Plan Document, it is subrogated to the rights of recovery the captioned member or Covered Individual(s) may have arising from the captioned accident and by mason of homeowners', public liability and group insurance in.eluding, but not limited to, third party medical reimbursement, under and uninsured motorist and no-fault and personal injmy protection (PIP) coverages. For the reasons stated, the Fund asserts a lien to the extent of benefits paid upon claims, demands or causes of action that the captioned member or Covered Individual(s) may have against you arising from the captioned accident. The Fund also asserts its lien to the extent of the present value of future medical expenses the Fund is reasonably certain to be required to provide the Covered Individual(s) as a consequence of the injury in question. __ Coghlan Kukankos Cook 55 West Wacker Drive, Suite 1210 Chicago, Illinois 60601 O12) 357-9200 Toll Free 1~800-627-3360 Central States, Southeast and Southwest Areas ~//~ .~d~tre F~ ,,,,//Michael A. 0a'~ssler One of its Attorueys NOTICE OF SERVICE I certify that I have served the above Notice by mailing a copy of the same by U.S. mail, in a sealed envelope, stamped and addressed to ~/e above-named party, at said address, this November 4, 2003, A.D. *The Fund claims a lien to the extent of medical and disability benefits it has paid to date and will pay in the future. Please contact this office and determine the lien amount before settlement.