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City Insurance Claim by A.ZaragozaAdditional information (a) Name and address of the claimant: Nationwide Insurance PO Box 855899 Minneapolis, MN 55485-5899 Contact person: Monique Peebles Phone: 919-881-3443 Email: PEEBLM1cnationwide.com (b) A concise statement of the factual basis of the claim, including the date, time, place, and circumstances of the act, omission, or event complained of: On February 7, 2024, the sewer line broke causing damage to the Nationwide property. (c) A concise statement of the nature and the extent of the injury claimed to have been suffered: Property Damage -See estimate for breakdown of damages (d) A statement of the amount of monetary damages that is being requested: Collision: $ 30,668.56 Deductible: $ 1,000.00 Total: $ 31,668.56 CITY OF SALINA City Clerk's Office Nationwide` Page 1 of 2 Date prepared October 4, 2024 Claim number 513602 -GP Policy number 7215HR000617 Questions? Contact Claims Associate Monique Peebles PEEBLMIrWnationwide.com Phone 919-881-3443 Fax 844-650-0787 CITY OF SALINA City Clerk's Office 300 W ASH ST RM 206 SALINA, KS 67401-2335 u� Dear CITY OF SALINA City Clerk's Office, We're submitting a o claim for damages The intent of this letter is to submit a claim for damages sustained to our 0 insured's, ANDREA ZARAGOZA, property 1921 DOVER DR, SALINA, KS 0 67401-5909. Supporting documents are enclosed. Additional information is 0 0 provided below. a U1 M Claim details N N Insurer: Nationwide Mutual Insurance Company Loss date: February 7, 2024 Our insured: ANDREA ZARAGOZA Our claim number: 513602 -GP Your claim number: unknown Additional information (a) Name and address of the claimant: Nationwide Insurance PO Box 855899 Minneapolis, MN 55485-5899 Contact person: Monique Peebles Phone: 919-881-3443 Email: PEEBLM1cnationwide.com (b) A concise statement of the factual basis of the claim, including the date, time, place, and circumstances of the act, omission, or event complained of: On February 7, 2024, the sewer line broke causing damage to the Nationwide property. (c) A concise statement of the nature and the extent of the injury claimed to have been suffered: Property Damage -See estimate for breakdown of damages (d) A statement of the amount of monetary damages that is being requested: Collision: $ 30,668.56 Deductible: $ 1,000.00 Total: $ 31,668.56 CITY OF SALINA City Clerk's Office Claim tt 513602 -GP Page 2 of 2 (e) Insurance carrier information: Nationwide Mutual Insurance Company Policy: 7215HR000617 Action requested After reviewing the enclosed documents, please contact me at 919-881-3443 to make payment arrangements and include our claim number on any payment or correspondence, ^r Columbus, Ohio 43218-2068 Thank you for your cooperation N N If you have any questions on this matter, please contact me at 0r11 919-881-3443 or PEEBLM1(anationwide.com. 0 0 p Sincerely, 0 o O- Monique Peebles un Nationwide Mutual Insurance Company N Nationwide Recovery P.O. Box 182068 ^r Columbus, Ohio 43218-2068 Nationwide M utual I Insurance Company F_; Thomas Graham Field Cl amsSpeciaist 11, Property Nationwide" PO Box 182068 E-mail: Columbus, OH 43218 0 0 C 785-735-7560 Graht24@nationwide.com Insured: ANDREA ZARAGOZA Home: (785) 827-7206 Property: 1921 DOVER DR Cell: (316) 519-9518 SALINA, KS67401-5909 Home: 1921 DOVER DR SALINA, KS 67401-5909 Claim Rep.: Thomas Graham Business: (785) 735-7560 01 Business: PO Box 182068 E-mail: graht24@nationwide.com 0 0 Columbus, OH 43218-2068 0 CD Estimator: Thomas Graham Business: (785) 735-7560 o Business: PO Box 182068 E-mail: graht24@nationwide.com Columbus, OH 43218-2068 M N N Claim Number: 513602 -GP Policy Number: 7215HR000617 Typeof Loss: WATER NON -WEATHER Date Contacted: 3/7/2024 3:50 PM Date of Loss: 2/7/2024 12:00 AM Date Received: 3/6/2024 1:00 AM Date I nspected: 3/12/2024 12.24 PM Date Entered: 3/8/2024 11.27 AM Date Est. Completed: 5/17/2024 2:48 PM Price List: KSHU8X_MAR24 ' Restorati on/Servi ce'Remodel La= Estimate: ANDREA ZARAGOZAI f Nationwide Mutual Insurance Company Thomas Graham z> Reld Clams Speciaist 11, Property Nationwide' PO Box 182068 Columbus, OH 43218 C 785-735-7560 Graht24@nadionwide.com Dear Val ued Customer, Please refer to the attached itemized esti mate. The estimate contains our Vaal uati on of the damages for the reported I oss and was prepared usi ng usual and customary pri ces f or your geographi c area I f thi s i s a suppl emental or updated esti mate and your pol i cy i ncl udes rept acement cost coverage, pl ease ref er to our communi cati on regardi ng how to make a cl ai m f or any addi ti onal el i gi bl e payment. 10 o PI ease note that i f your mortgage company i s i ncl uded on your cl ad m payment check, contact the mortgage 0 company to di scuss how to handl e the proceeds of thi s payment. 0 0 1 f you choose to hi re a contractor or vendor to make repai rs, pl ease provi de thi s esti mate to them. I f you, your contractor, or vendor determi ne that there are additional building fees and/or permits associated with the esti mated repai rs that are not i ncl uded i n thi s esti mate, pl ease contact me i mmedi ad y so that I may N revi ev and make a deterrni nati on as to the appropri ate payment. N If the esti mate reflects a reduction for Salvage Retention, there are materials estimated for removal that have been identified as having sal vage val ue. The amount ref I ected for Salvage Retention is applied using current vail ues speci f i c to the wei ght and quanti ty of materi al s to be removed and sped f i c to your geographi c regi on. A report i s attached or can be provi ded upon request that provi des a detai I ed summary of the Salvage Retention amount shown on your estimate. This amount should also be reflected on any esti mates or i nvoi ci ng provi ded by your contractor or vendor as a reducti on i n repai r costs. R ease note that the vat ues provi ded are subj ect to change due to market condi ti ons. If you discover any additional damage to your property, pl ease i mmedi atel y contact me, either personally or through your contractor/vendor. We may need to reinspect your property before authorization of supplemental payment. Please do not destroy or discard any of the damaged items until we have had an opportunity to i nspect the damages and have reached an agreement with you on any supplemental cost. Nati onwi de may ad so request to re -i aspect your property, at your conveni ence, as part of our commi tment to quality and customer service. PI ease note your pol i cy may i ncl ude addi ti onal coverages, coverage extensi ons, and/or settl ement provi si ons that may requi re you to noti f us wi thi n certai n ti mes of your i intent to make a cl ai m under those porti ons of the pol i cy. PI ease refer to your pol i cy or contact your cl al m prof essi onal f or more i of ormati on. Thank you f or al I owi ng N ati onwi de M utual I nsurance Company to serve your i nsurance needs. PI ease contact me at the numbers I i sted above if you have any questi ons regardi ng thi s esti mate or any other matter pertai ni ng to your cl al m. ANDREA_ZARAGOZAI 5/17/2024 Page:2 QUANTITY UNIT 1. Durarnx Construction and Roofing Invoice* TAX RCV AGE/LIFE COND. DEP% DEPREC. ACV 1.00 EA 8.785.00 0.00 8,785.00 O/NA Avg. 00/0 (0.00) 8,785.00 access and egress to crawl space repai n ng of f oundati on wal 1. The esti mated amount i n the I i ne item above i s based on the esti mate, i nvoi ce, or bi d i tem for the named vendor. We are i ncl udi ng the stated amount i n our settl ement. Thi s amount covers al I of the esti mated reps r costs f or damages rel aced to the repai rs i nd uded f or thi s esti mate, i nvoi ce, or bi d i tete. Sal es tax i s i ncl uded, if not of herwi se sped f i ed. 2. Phoenix Restoration Estmate* 1.00 EA 11,681.47 0.00 11,681.47 0/NA Avg. 00/0 (0.00) 11,681.47 The esti mated amount i n the I i ne i tem above i s based on the esti mate, i nvoi ce, or bi d i tem f or the named vendor. We are i ncl udi ng the stated amount i n our settl a hent. Thi s amount covers al I of the esti mated reps r costs f or damages rd aced to the repai rs i ncl uded f or thi s esti mate, i nvoi ce, or bi d i tem. Sal es tax i s i ncl uded, i f not otherwi se speci f i ed. Total: ANDREA ZARAGOZAI 0.00 20,466.47 0.00 20,466.47 LineltemTotals: ANDREA_ 0.00 20,466.47 0.00 20,466.47 ZARAGOZAI [%] -Indicates that depredate by percent was used for this item IM] -I ndi cafes that the depreciation percentage was limited by the maxi mum al I owabl a depreciation for this item ANDREA_ZARAGOZAI 5/17/2024 Page:3 Nationwide M utua] Insurance Company Thomas Graham Field CIaimsSpedAist 11, Property Nationwide' PO Box 182068 Columbus, OH 43218 C 785-735-7560 Graiit24@raioiiwide.com ANDREA_ZARAGOZAI ANDREA_ZARAGOZAI QUANTITY UNIT 1. Durarnx Construction and Roofing Invoice* TAX RCV AGE/LIFE COND. DEP% DEPREC. ACV 1.00 EA 8.785.00 0.00 8,785.00 O/NA Avg. 00/0 (0.00) 8,785.00 access and egress to crawl space repai n ng of f oundati on wal 1. The esti mated amount i n the I i ne item above i s based on the esti mate, i nvoi ce, or bi d i tem for the named vendor. We are i ncl udi ng the stated amount i n our settl ement. Thi s amount covers al I of the esti mated reps r costs f or damages rel aced to the repai rs i nd uded f or thi s esti mate, i nvoi ce, or bi d i tete. Sal es tax i s i ncl uded, if not of herwi se sped f i ed. 2. Phoenix Restoration Estmate* 1.00 EA 11,681.47 0.00 11,681.47 0/NA Avg. 00/0 (0.00) 11,681.47 The esti mated amount i n the I i ne i tem above i s based on the esti mate, i nvoi ce, or bi d i tem f or the named vendor. We are i ncl udi ng the stated amount i n our settl a hent. Thi s amount covers al I of the esti mated reps r costs f or damages rd aced to the repai rs i ncl uded f or thi s esti mate, i nvoi ce, or bi d i tem. Sal es tax i s i ncl uded, i f not otherwi se speci f i ed. Total: ANDREA ZARAGOZAI 0.00 20,466.47 0.00 20,466.47 LineltemTotals: ANDREA_ 0.00 20,466.47 0.00 20,466.47 ZARAGOZAI [%] -Indicates that depredate by percent was used for this item IM] -I ndi cafes that the depreciation percentage was limited by the maxi mum al I owabl a depreciation for this item ANDREA_ZARAGOZAI 5/17/2024 Page:3 M u� 0 0 0 0 0 0 o� M N N f 17 Nationwide' Line Item Total Nationwide M utual I nsurance Company Thomas Graham R el d Cl ai ms Special i st 11, Property PO Box 182068 Columbus, OH 43218 C 785-735-7560 Graht24@tiationwide.com Replacement Cost Value Less Deductible Net Claim A N D REA_ZA RAGOZA 1 Summary for Dwelling Thomas Graham 20,466.47 $20,466.47 (1,000.00) $19,466.47 5/17/2024 Page:4 01 0 0 0 0 0 0 01 M N N U., Phoenix Restoration 1805 S Chi o Sal i na, K S 67401 785-493-8080 Please Remit Payment to our Central Office: 1215 N Grand H utchi nson, K S 67501 Insured: Andrea Zaragoza Property: 1921 Dover Dr Sal i na, K S 67401 Esti mator: Chase Swanson Claim Number: Date Contacted: 3/29/202412:00 AM Date of Loss: Date I nspected: 3/29/202412:00 AM Policy Number: Price List: KSHU8X_APR24 Restorati on/Servi celRemodel Estimate: ZARAGOZA-ANDREA-WTR Type of Loss: Water Damage D ate Recei ved. 3/29/202412: 00 AM Date Entered: 5/8/202412:15 PM INSURERS: WE REQUEST DIRECT PAYMENT ASASSIGNED BY CLAIMANT Thisisour final invoice mitigation. Any unpaid amount will be assessed an interest of 1.0% monthly. If thiswork was completed under an insurance claim, client is still responsible to ensure that Phoenix Restoration is paid in full. Thank you for choosing Phoenix Restoration for this remediation and restoration service. If you have any questions, please call 877-662-0108 Rease remit payment to: Phoenix estorahon 1215 N. Grand St Hutchinson, KS 67501 Phoenix Restoration 1805 S Ohi o Sol i na, K S 67401 785-493-8080 Please Remit Payment to our Central Office: 1215 N Grand H utchi nson, K S 67501 ZARAGOZA-ANDREA-WTR General ZARAGOZA-ANDREA-WTR 5/8/2024 Page:2 DESCRIPTION QTY REMOVE REPLACE TAX TOTAL 1. Emergency service call - during 1.00 EA 0.00 181.25 0.00 181.25 r- bus ness hours 0 2. Air mover (per 24 hour period) - No 88.00 EA 0.00 29.25 0.00 2,574.00 0 monitoring 0 8 f ans x 11 days 0 (ONLY CHARGING FOR 11- EQUIPMENT THERE FOR 21 DAYS) 01 3. Dehumidifier 24 hrperiod) 70- 44.00 EA 0.00 83.08 0.00 3,655.52 u� 109 ppd - No monitor. N 4 dehu's x 11 days (actually therefor 21) N 4. Content Manipulation charge- per 3.00 HR 0.00 47.65 0.00 142.95 hour Moved belongingsin closet inside house So could lay floor masking 5. Equipmait decontamination charge- 12.00 EA 0.00 38.10 6.02 463.22 per piece of equipment * * equi pment decontami nati on per pi ece of equi pment* * (CAT 3) (required as to not spread any contaminates or bacteria to other job sites/locations) 6. Add for personal protective 14.00 EA 0.00 12.28 15.90 187.82 +;.{ equipment (hazardous cleanup) n'� 7. Tear out and bag wet insulation in 1.00 SF 3.08 0.00 0.01 3.09 conf i tied space - Cat 3 8. Containment Barrier/Airlock/Devon. 25.00 SF 0.00 1.15 0.37 29.12 Chamber 9. Protect - Cover with plastic 132.00 SF 0.00 0.35 1.59 47.79 10. Hazardous Waste/M old Cleaning 4.00 HR 0.00 74.32 0.00 297.28 Technician - per hour Technician extracted standing areas of sewage/sl udge x 4 hours i n confined space AFTER initial extraction Thistech timewasalso spent spreading Lymeon floor and bagging trash. (could not find chargefor that nut wedid purchase 2 bagsof lyme) 11. Equipment setup, take down, and 21.00 HR 0.00 65.35 0.00 1,372.35 monitoring (hourly charge) ZARAGOZA-ANDREA-WTR 5/8/2024 Page:2 Phoenix Restoration AMC 1805 S Ohio Sal i na, KS 67401 785-493-8080 PI ease Remi t Payment to our Central Off i ce: 1215 N Grand Hutchinson, KS 67501 CONTI NUED - General DESCRIPTION QTY REMOVE REPLACE TAX TOTAL All setup, takedown, monitoring, adjustments done in cat 3 confined space 3/14: 1 tech x 1 hr 3/20: 1 tech x 1 hr 3/29: 1 tech x 2 hr 4/1: 1 tech x 1 hr 4/2: 1 tech x 2 hr 4/9: 2 techs x 1 hr 4/11: 1 tech x 2 hr 4/12: 1 tech x 2 hr 4/15: 1 tech x 2 hr 4/16: 1 tech x 2 hr 4/17: 1 tech x 2 hr 4/18: 1 tech x 2 hr 4/19: 2 techs x 1 hr Total: 21 12. Equi p. setup, take dawn & 2.00 HR 0.00 98.13 0.00 196.26 monitoring - after hrs 4/14: (after hrs) - monitored, moi sture readi ngs, adjustmentsin confined space 1 tech x 2 hours Totals General 23.89 9,150.65 Main Level 24 IT j Crawlspace Height: 3' 284.50 SF Wal Is 560.82 SF Cei I i ng a 845.32 SF Wal I s & Cei I i ng 560.82 SF Floor p 62.31 SY FI oori ng 94.83 LF Floor Perimeter 1 94.83 L F Cei 1. Perimeter DESCRIPTION QTY REMOVE REPLACE TAX TOTAL 13. Water extract from hard surf f I r - 560.82 SF 0.00 1.35 0.00 757.11 Cat 3 wtr - alter hours I niti ai extracti on with truck mount on f i rst day 14. Apply anti -microbial agent to more 1,406.14 SF 0.00 0.32 5.20 455.16 than the f I oor ** Microbanapplied tofloor, ceiling and wails** 15. WATER EXTRACTION & 1.00 EA 0.00 1,445.00 54.80 1,499.80 REMEDIATION See attached i nvoi ce for Reddi I ndustri es - to pump 300 gat Ions f rom crawl space. ZARAGOZA-ANDREA-WTR 5/812024 Page:3 0 0 0 0 0 01 M N N Phoenix Restoration 1805 S Ohio Sal i na, K S 67401 785-493-8080 Please Remit Payment to our Central Office: 1215 N Grand H utchi nson, K S 67501 CONTINUED - Crawlspace DESCRIPTION QTY REMOVE REPLACE TAX TOTAL Totals Crarolspace 60.00 2,712.07 Total: Main Level 60.00 2,712.07 Line Item Totals ZARAGOZA-ANDREA-WTR 83.89 11,862.72 Grand Total Areas: 284.50 SF Wal Is 560.82 SF Floor 0.00 SF Long Wall 560.82 Floor Area 390.00 Exterior Wall Area 0.00 Surf ace A rea 0.00 Total Ridge Length ZARAGOZA-ANDREA-WTR 560.82 SF Cei I i ng 62.31 SY FI oori ng 0.00 SF Short Wail 592.88 Total Area 97.50 Exterior Perimeter of Walls 0.00 Number of Squares 0.00 Total Hip Length 845.32 SF Wal I s and Cei I i ng 94.83 LF Floor Perimeter 94.83 L F Cei I . Peri meter 284.50 Interior Wall Area 0.00 Total Perimeter Length 5/8/2024 Page:4 Phoenix Restoration 1805 S Chi o Sal i na, K S 67401 785-493-8080 Please Remit Payment to our Central Office: 1215 N Grand H utchi nson, K S 67501 Line Item Total Material SaiesTax Replacement Cost Value Net Claim Summary for Dwelling Chase Swanson INSURERS: WE REQUEST DIRECT PAYMENT ASASSIGNED BY CLAIMANT 11, 778.83 83.89 $11,862.72 $11,862.72 This is our f i nal invoice mitigation. Any unpaid amount will be assessed an interest of 1.0% monthly. I f thi s work was completed under an insurance claim, client is sti I I responsible to ensure that Phoenix Restoration is paid in full. Thank you f or choosing Phoenix Restoration for this remediation and restoration service. If you have any questions, please cal l 877-662-0108 PI ease remit payment to: Phoenix Restoration 1215 N. Grand St Hutchinson, KS 67501 ZARAGOZA-ANDREA-WTR 5/8/2024 Page:5 Phoenix Restoration 1805 S Ohio Sal i nA K S 67401 785-493-8080 Please Remit Payment to our Central Office. 1215 N Grand H utchi nson, K S 67501 1 1 -Zaragoza Reddi pump receipt ZARAGOZA-ANDREA-WTR 5/8/2024 Page 6 %V" Date Invoice a 6346 to W 04'1720 891691 avcn�u..a 4446 on.nara�66r..mv Riff M f 156481 Serviw Lwaron 0.52136 Phoenix RaMomflon Phasnlx Restoration ' 215 N Oram at 1921 Dover D., I;arswlle. KS 675Gi S&m!, KS 67901 r N r Tmm. ra.tow Frc�rr eo• air serol fnanw. a,ow.rv..r-a�rr.-n Description _ AmottnI O SERVICES PPROVIDED EE-- NDUSTRLIL 25.E RIDUST RIALSALES �.42G Orr, 0 WORK mE:6C M'j O -cch.X605' 940116 - :OSK Se^: a C8R' N9a'2Z24] Pu= 3DDVA'fwa':Gm t 0vA 6 LL . ON mmo.:nw . attuvcx+i: aOiRmsir-- sue TOTAL 11446.00 M N ear •' , ymLr.Ix�rrw;�e...v-6 c rrum� wn 4: Jte4: r�nu n+. --e.: aarwar i6 tib.nCt4 WR.MY.MT6!W:i!r.Ti N0..4G=MtR"�'P'+W}`Tr'arlq',10L1TNt sALESTAx 0.(10Ir VAwGvr Mn6lC6eYJ:h'•'IE�.R2.t�rn6ltt:.aR.'I ^+:t �.Y..C:..'^Ih,1u<MAP TOTAL $ 1,416.90 1 1 -Zaragoza Reddi pump receipt ZARAGOZA-ANDREA-WTR 5/8/2024 Page 6 Man Level 24' 10" i� CraNlspaoe iV N Main Level ZARAGOZA-ANDREA-VVTR 5/8/2024 Page 7 00 M r r O O O O O tT Ln M N N Pol: 7215HR000617CIaim: 513602-GPlns: ANDREA R ZARAGOZADoL: 02/07/2024St: OpenAdj: Monique Peebles (Claims Claim. 513602 -GP Recovery Services Group 3 Unit 4) Financials: Transactions usium Type Date Amount Exposure Coverage Cost Type Cost Status User I I Category Payment 05/23/2024 $11,681.47 1 Dwelling Indemnity General Submitted Thomas Graham Payment 05/23/2024 $7,785.00 1 Dwelling Indemnity General Submitted Thomas Graham Payment 08/08/2024 $235.00 1 Dwelling Expense General Submitted System User Payment Details Details Exposure Coverage Cost Type Cost Category Payment Type Comments Open Reserves Amount Line Items (1) 1st Party Dwelling - ANDREA R ZARAGOZA Dwelling Indemnity General Partial $11,681.47 Type of Loss Amount Dwelling Unit $11,681.47 Check Details User: Monique Peebles Page 1 Oct 4, 2024 1:27 PM Pol: 7215HR000617CIaim: 513602-GPlns: ANDREA R ZARAGOZADoL: 02/07/2024St: OpenAdj: Monique Peebles (Claims Claim: 513602 -GP Recovery Services Group 3 Unit 4) Payment Details Details Status Cleared (1) 1st Party Dwelling - ANDREA R ZARAGOZA Pay To PHOENIX RESTORATION OF HUTCHINSON LLC Cost Type Net Amount $11,681.47 General Scheduled Send Date 05123/2024 � Issue Date 05/23!2024 Check Number 20422311 O O Bank Account O Date of Service O Payment Method Check O p. Invoice Number LA M Tracking N Status Submitted fV Created By Thomas Graham Created On 05/23/2024 Booking Date 05123/2024 Approval History Payment Details Details Exposure (1) 1st Party Dwelling - ANDREA R ZARAGOZA Coverage Dwelling Cost Type Indemnity Cost Category General Payment Type Partial User: Monique Peebles Page 2 Oct 4, 20241:27 PM Pol: 7215HR000617CIaim: 513602-GPlns: ANDREA R ZARAGOZADoL: 02/07/2024St: OpenAdj: Monique Peebles (Claims Claim: 513602 -GP Recovery Services Group 3 Unit 4) Comments Open Reserves Amount $7,785.00 Line Items Type of Loss Amount Dwelling Unit $7,785.00 Check Details Status Cleared Pay To ANDREA R ZARAGOZA & LYONS FEDERAL BANK, ISAOA/ATIMA Net Amount $7,785.00 Scheduled Send Date 05/23/2024 Issue Date 05/23/2024 Check Number 20422331 Bank Account Date of Service Payment Method Check Invoice Number Tracking Status Submitted Created By Thomas Graham Created On 05/23/2024 Booking Date 05/23/2024 Approval History User: Monique Peebles Page 3 Oct 4, 20241:27 PM Pal: 7215HR000617CIaim: 513602-GPlns: ANDREA R ZARAGOZADoL: 02/07/2024St: OpenAdj: Monique Peebles (Claims Claim: 513602 -GP Recovery Services Group 3 Unit 4) Payment Details N Details r Exposure (1) 1st Party Dwelling - ANDREA R ZARAGOZA O Coverage Dwelling O Cost Type Expense O Cost Category General O O Expense TOL Expert Fees 01 Expense Type In M Payment Type Supplement (V Comments N Open Reserves Amount $235.00 Line Items Type of Loss Amount Not Applicable $235.00 Cleared ACCUSERVE SOLUTIONS INC $235.00 08/08/2024 08/08/2024 45459620 EFT 2 User: Monique Peebles Page 4 Oct 4, 20241:27 PM Check Details Status ` Pay To Net Amount Scheduled Send Date Issue Date Check Number Bank Account Date of Service Payment Method Invoice Number Tracking Cleared ACCUSERVE SOLUTIONS INC $235.00 08/08/2024 08/08/2024 45459620 EFT 2 User: Monique Peebles Page 4 Oct 4, 20241:27 PM Pol: 7215HR000617CIaim: 513602•GPlns: ANDREA R ZARAGOZADoL: 02/07/2024St: OpenAdj: Monique Peebles (Claims Claim: 513602 -GP Recovery Services Group 3 Unit 4) Status Submitted Created By System User Created On 08/08/2024 Booking Date 08108/2024 Approval History User: Monique Peebles Page 5 Oct 4, 2024 1:27 PM ' -+v� •. f ,St -{.ova _ �_ � �� {>> / L'�'y i•�' may' �•r' �� - .. y ' t �� ,�•• r t . l!►r f ri-• .y i+,l -� .y,• '�� - - .. +ice s,t q "`.\. -12 - ,1,c • f1b. hkIw • 4•. i •�-' Q. r 'U �' f►. 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