Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
Expenditures made on account of accident or Injury: (Date - Item) (Amount) Name and address of Witnesses, Doctors and Hospitals:
READ CAREFULLY
For all accident claims place on following diagram names of streets, including North, East. South, and West: indicate place of accident by "X'' and by showing house numbers or distances to street corners.
If City Vehicle was Involved, designate by letter"A" location of City vehicle when you first saw it, and by "B" location of yourself or your vehicle when you first saw City vehicle; location of City vehicle at time of accident by "A-1" and location of yourself or your vehicle at the time of accident by "8 1" and the point of Impact by "X." NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
FOR OTHER ACCIDENTS
I declare, under penalty of perjury, that the foregoing, including any attachments, is true and correct.
Typed/Printed Name: Signature of Claimant or person filing on his/her behalf, giving relationship to Claimant:
Date:
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CAL.
PEN. CODE SEC. 72). CLAIMS MUST BE FILED WITH CITY CLERK (GOV.CODE SEC. 915a). STATE LAW PROVIDES THAT IF YOU ARE NOT NOTIFIED OF ANY ACTION BY THE CITY OF THIS CLAIM WITHIN 45 DAYS OF FILING THEN THE CLAIM IS DEEMED DENIED (SEE GOV. CODE SEC. 911.6 & 912.4) Rev. 8/4/16 ture of Claimant or person filing
nship to Claimant:
Medical treatment was paid under her Work Comp Carrier United Heartland $5,193.95
See attached
Barbara Gossom, Agent for
United Heartland aka SubroIQ
5/14/25
Our Claim
Number: UHC230733100
Instructions:
Please include on all payments and correspondence to expedite 02783828 processing.
Coverage Type: WC Medical
Claimant Name: BEDELID
GUERRERO
From: Contact Information:
SubroIQ Email: [email protected]
PO Box 6228
Hermitage, PA 16148-0923
Taxpayer ID: 25-1753655
May 14, 2025
REQUEST FOR PAYMENT
Date of Loss: 06/24/2024
ATTENTION:
AMOUNT IS SUBJECT TO CHANGE, PLEASE CONTACT SUBROIQ PRIOR TO SETTLEMENT.
Check
Number Amount
2284881 $306.72
2467068 $100.24
2467068 $100.24
2467068 $74.19
2467068 $100.24
2467068 $100.24
2467068 $74.19
2467068 $100.24
2467171 $339.35
2479028 $104.19
2479028 $104.19
2479028 $104.19
2479028 $166.49
2479028 $163.21
$1,691.44
2511956 $107.47
2511956 $104.19
2511956 $163.21
2511956 $107.47
2511956 $98.19
2511956 $107.47
2057740 $151.01
2027528 $111.35
Total Paid: $5,193.95
Payments Received: $0.00
Deductible: $0.00
Salvage: $0.00
Balance: $5,193.95
$111.35
$151.01
$111.35
$151.01
$111.35
$151.01
$161.25
$151.01
$156.61
$111.35
$111.35
$156.61
$151.01
$156.61
$236.93
$111.35
$14.51
Total Paid: $0.00
Payments Received: $0.00
Deductible: $0.00
Salvage: $0.00
Balance: $0.00
Our Claim
Number: Instructions:
Please include on all payments and correspondence to expedite processing.
Coverage Type: WC Indemnity
Claimant Name: Bedelid
Guerrero
From: Contact Information:
SubroIQ Email: [email protected]
PO Box 6228
Hermitage, PA 16148-0923
Taxpayer ID: 25-1753655
May 14, 2025
REQUEST FOR PAYMENT
Date of Loss: 06/24/2024
ATTENTION:
AMOUNT IS SUBJECT TO CHANGE, PLEASE CONTACT SUBROIQ PRIOR TO SETTLEMENT.