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.