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BERKLEY RISK SERVICES, INC. <br /> DATE: 01/08/96 <br /> • ST. ANTHONY Attn:Finance Dept. -REMIT <br /> PLEASE RE <br /> 3301 SILVER LAKE ROAD <br /> ST. ANTHONY MN 55418 <br /> RE: BRS CLAIM NO 11011866 <br /> TRUST MEMBER: ST. ANTHONY <br /> CLAIMANT: TRI GIA LE <br /> DATE OF LOSS/OCCURRENCE: 05/23/95 <br /> CLAIMS MADE DATE: 12/15/95 <br /> The above claim has been concluded. <br /> This claim occurred when <br /> CLMNT ALLEGES INJURIES FROM ARREST BY CITY POLICE OFFICER <br /> On behalf of your city, we have paid the following to conclude <br /> this claim: <br /> Paid Losses Paid Medical Paid Expenses Total <br /> 2,000 .00 .00 .00 = 2,000.00 <br /> Ded.Recover PRIOR AGGREGATE <br /> This Bill This Claim This Covenant <br /> ( • _ -2,000.00 .00 -1,003.24 <br /> Your city' s deductible is $10,000 per occurrence/ $50,000 annual <br /> aggregate/$1,000 per loss per line of coverage (after aggregate is <br /> exceeded) . This applies under covenant number CMC 15453 effective <br /> 06/01/95 thru 06/01/96. <br /> Accordingly, please prepare a draft made payable to the "LEAGUE OF <br /> MINNESOTA CITIES INSURANCE TRUST" in the amount of $ 2,000.00 <br /> and forward it to Berkley Risk Services,Inc. , 920-2nd Ave. So. <br /> Minneapolis, MN 55402-4023, Attention: Finance Department. <br /> Please include our claim number, as captioned above, with <br /> your remittance to ' insure proper credit. <br /> Should you have any questions relative to the disposition of this <br /> claim, please do not hesitate to contact the BRS examiner who <br /> supervised this claim, JO L. HOOK at 1-800-925-1122, <br /> or locally at 612-281-1284. <br /> Sincerely, <br /> Margo Wecker <br /> Finance Department <br /> �, • Agent of Record: BERKLEY INSURANCE SERVICES <br /> 920 SECOND AVE. S. #700 <br /> MINNEAPOLIS MN 554024 <br /> ACCOUNTING COPY <br />