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Claim Collins, Yvonne Cottinghawww. cb-sisco.com 61 qun x Cottingham & Butler C&B Insurance I SISCO I HealthCorp I Safety Management Established ~887 October 30, 2003 CITY CLERK CITY OF DUBUQUE CITY HALL - 50 W 13ax~ ST DUBUQUE IA 52001 Health Plan: Flexsteel Employee: Yvonne Collins Patient: Yvonne Collins Your Insured: City of Dubuque Date of Accident: October 4, 2003 Dear City Clerk, We represent the Flexsteel self-funded 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 injuries sustained on your clients property. Enclosed for your review is a copy of the portion of the plan, which addresses the right to recovery, as well as a copy 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 granted to the health plan by the patient on the proceeds of any settlement, judgment or other payment received by the patient or any other individual covered under the plan. This includes any non-liability medical payment available. You must receive written approval from the Health Plan prior to any settlement, judgment or other payment made to the patient or their representative. We request that you protect the plan's interest relative to any releases and/or payments made as a result of the above loss. Copies of the charges incurred and payment made under this plan will be forwarded to you upon request. Thank you for your anticipated cooperation in this matter. CD c~ Sincerely, ~,~5- ~-~ ~ ?~ B~bm K. McCoy ~ (D 2c ~ SubrOgation Speci~ist ~ ~ ~ SISCO ~ Ph~563'587-5224 F~563-587-5871 ' ' Enclosure cc: Yvonne Collins - FOR YOUR INFORMATION ONLY (800) 793-5235 (800) 793-5235 (800) 4574726 ~ . Location Where the Znjury Occurred: (City) (State) (Zip) Description of Accident/Incident (Phone) On the lines below, describe the aeeidentYinaident that caused the thjury, including how the injury occurred and ail pertinent details. Attach a second page if necessary. If a specific injury did not occur, please expla~n the reason for seeking medical treatment. Work Related Injury or Cond~ion? __ Yes .~' No If yes, was it reported? Yes __ No Other Injury Informalion 1. Did the injury involve another 2, Did tite injury involve the property of another party? (g ~ 3. Did the injury occur on someone pariy? ~ Yes No Was the vehicle or equlpment involved in the injury owned by else's property (public or private)? someone else0 ~ Yes No /~ Yes No If your answer to any of the above thing questions was "Yes," eomplete the following and continue with the other party's insurance information directly below: (If the injury oceurced on city property-and w~-q not an auto aecident-vro~de..the city attorney's office addre~ if reported to the city.) Name of Other Party: Address, City, State, Zip: Phone No.: Provide the other party's applicable insurance information: Homeowners insurance for an injury that occurred on a person's private property, property liability insurance for a business property, renter's insurance for a rental property, and auto insurance fora motor vehicle accidenL Ifa claim has been made on the other party's insurance, provide the claim number and the insurance representative's name, address, and phone number. Narne of Other Parvj's £nsurance Carr~er: C,- I~-t~ ~.~J~v~ ~.~ ~(~ Phone No.: Policy or Claim No.: Name of your Attorney (if one has been retained for this injury): Address and Phone No.: 1. If the injury involved a motor vehicle (or an illegal act), regardless of fault, complete the following section, AND 2. Attach a copy of the police and/or accident report (if any). Were any citations issued? __Yes __ No If yes, who was charged? For what violation? Name/Address of the Police DepartmenttSher~ff's Office that investigated the accident/incident: Name of Your AUtO Insurance Carrier: O A ddress, City, State, Zip: Phone No.: Policy or Claim No: If a claim has been made on yoUr auto insurmqee, please provide the claim numb~ and the insurance representative's~ame, addressi and phahe number: SUBROGATION This Plan may withhold payment of benefits until such time that liab/lity is legally determined. This Plan does not provide benefits to the extent that there is other coverage under non-group medical payments (including auto) or medical expense type coverage to the extent of that coverage. 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 anyone. This Plan will provide benefits, otherwise payable under this Plan, to or on behalf of the Covered Individual and/or his dependents only on the following terms and conditions: 1. In the event of any payment under this Plan, the Plan shall 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 representatives of the Plan th completing such forms and in giving such information surrounding any accident as the Plan or its representatives deem necessary to fully investigate the incident. 2. The Plan is also granted a right of reimbursement 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 benefits 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 and 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 by any insurance company. b. Any payments or settlements or judgments or arbitration awards paid by an insurance 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. d. Any workers compensation award or settlement. 5. No adult Covered Individual may assign any rights that he 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 incompetent 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. 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, including but not lira/ted 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 Fund Doctrine," "Attorney's Fund 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 k/nd, any mount or share of attorney's fees or other services or expenses incurred by the Covered Individual hi obtaining a judgment, settlement or other payment from a third party. 9. The Plan shall recover the full amount of benefits paid without regard to any claim of fault on the part of the Covered Individual, whether under comparative negligence or otherwise. 10. The benefits under this Plan are secondary to any coverage under no-fault or similar insurance.