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HomeMy WebLinkAboutRFP - P1158 INUSRANCE (2)City of Financial Services F6rt Purchasing Division 215 N. Mason St. 2 Floor Collins PO Box 580 Fort Collins, CO 80522 Purchasing 970.221.6775 970.221.6707 fcgov. com/pu rchasing ADDENDUM No. 3 Property and Liability Insurance Specifications for City of Fort Collins and Poudre Fire Authority (P1158) SPECIFICATIONS AND CONTRACT DOCUMENTS OPENING DATE: 3:00 P.M. (Our Clock) March 20, 2009 To all prospective bidders under the specifications and contract documents described above, the following changes are hereby made. Deadline for Questions concerning this RFP P1158 Insurance is March 9, 2009. QUESTIONS AND ANSWERS: 1. In reviewing the 2007 CAFR introductory section it says the City's Financial department prepares separate financials for the Poudre Fire Authority. Please provide a copy of their most recent financial statement. Please use this link to obtain the 2007 Annual Report for Poudre Fire Authority and the 2008 Annual Budget. httL3:llwww.L)oiidre-fire.org/aboutlreports.htm 2. What is the City's intent as far as coverage design as it relates to the following requested parties as named insureds? 1. City of Fort Collins, Colorado 2. Poudre Fire Authority 3. Poudre Valley Fire Protection District 4. City of Loveland; City of Fort Collins, DBA Fort Collins - Loveland Municipal Airport - Entities 1, 2, and 3 are presently covered under the City's program for essentially all coverage lines, except that 2 and 3 maintain their own coverage for workers' compensation through Pinnacol Assurance. - Entity 4 needs to be included for property coverage only. 2008 Payroll by WC Code 5506 $1,169,509.00 $1,259,330.00 2,428,839.00 2,494,417.65 6325 $87,340.00 $90,775.00 178,115.00 182,924.11 7380 $9,315.00 $11,146.00 20,461.00 21,013.45 7382 $1,308,009.00 $1,337,072.00 2,645,081.00 2,716,498.19 7520 $1,278,919.00 $1,644,270.00 2,923,189.00 3,002,115.10 7539 $2,220,824.00 $2,538,804.00 4,759,628.00 4,888,137.96 7580 $1,898,945.00 $2,019,047.00 3,917,992.00 4,023,777.78 7610 $26,264.00 $68,327.00 94,591.00 97,144.96 7720 $7,219,394.00 $7,284,993.00 14,504,387.00 14,896,005.45 8227 $458,160.00 $468,589.00 926,749.00 951,771.22 8385 $82,763.00 $86,774.00 169,537.00 174,114.50 8742 $87,087.00 $83,386.00 170,473.00 175,075.77 8810 $10,714,510.00 $14,457,023.00 25,171,533.00 25,851,164.39 8811 $29,220.00 $23,700.00 52,920.00 54,348.84 8820 $455,475.00 $459,262.00 914,737.00 939,434.90 9015 $1,818,908.00 $2,183,728.00 4,002,636.00 4,110,707.17 9060 $250,643.00 $306,245.00 556,888.00 571,923.98 9102 $2,242,809.00 $2,498,644.00 4,741,453.00 4,869,472.23 9154 $150,186.00 $177,926.00 328,112.00 336,971.02 9220 $51,813.00 $67,181.00 118,994.00 122,206.84 9410 $3,237,556.00 $3,637,738.00 6,875,294.00 7,060,926.94 Sum: i 1 75,501,609.00 77,540,152.44 City of Fort Collins - Employee Count by Location in 2007 2009 # of Location City State County Notes Employees 281 N College Ft. Collins CO Larimer 98 321 Maple (Budget) Ft. Collins CO Larimer 0 300 Laporte (City Hall) Ft. Collins CO Larimer Includes 7 city council members 46 411 S Bryan (CPN Golf) Ft. Collins CO Larimer Plus Seasonals 3 215 N Mason Ft. Collins CO Larimer -' 178 Municipal Court Parking Services - 12. Also sometimes a booth attendant or the lead booth attendant will work here, and the number at those times would be 14. Those two are included in the count below for 120 N Mason. Human Resources Risk Management Purchasing Finance Mgmt. Information Services GIS Recreation 3800 S Lemay (Collindale Golf) Ft. Collins CO Larimer 4 250 N Mason (Transit Center) Ft. Collins CO Larimer 14 CSU Transit Center Ft. Collins CO Larimer 2 1801 Riverside (EPIC) Ft. Collins CO Larimer Mostly part-time employees 121 117 N Mason (Facilities) Ft. Collins CO Larimer Half are field workers 24 5216 Poudre Canyon (Gateway Park) Ft. Collins CO Larimer 1 1900 W Mountain (Grandview Cemetary) Ft. Collins CO Larimer 6 600 N Sherwood (Farm) Ft. Collins CO Larimer 5 417 W Magnolia (Lincoln Center) Ft. Collins CO Larimer 30 on typical day work at facility on non-event days. Others are called as needed. 124 424 S Sherwood (Mulberry Pool) Ft. Collins CO Larimer Mostly part time employees 88 200 Matthews (Museum) Ft. Collins CO Larimer Mostly part-time/hourly 28 1745 Hoffman Miller Road (NIX) Ft. Collins CO Larimer Most are field workers 34 112 E Willow (Northside) Ft. Collins CO Larimer Most part-time/hourly. Typically less than 10 in building. 120 200 W Mountain Ft. Collins CO Larimer 13 415 S Bryan Street Ft. Collins ICO Larimer Includes Parks maintenance & forestry workers - most work in field and seasonal. 288 220 N Howes (Parks Maintenance) Ft. Collins CO Larimer Field workers. 19 2718 E Mulberry (Roselawn) Ft. Collins CO Larimer 1 1200 Raintree (Senior Center) Ft. Collins CO Larimer Mostly part time 147 6090 S Lemay (Southridge Golf) Ft. Collins CO Larimer 16 625 Ninth Street (Streets) Ft. Collins CO Larimer 20 Office staff - others field 65 6570 Portner Road (Transfort) Ft. Collins CO Larimer 75% are bus drivers in field 93 330 S College (Utility Building) Ft. Collins CO Larimer 40 3036 E Drake (Pollution Control Lab) Ft. Collins CO Larimer 10 3036 E Drake (Waterwater Treatment) Ft. Collins CO Larimer 38 4316 LaPorte (WTP) Ft. Collins CO Larimer 33 4316 LaPorte (Water Quality Lab) Ft. Collins CO Larimer 8 415 E Monroe (YAC) Ft. Collins CO Larimer 0 626 Linden Drive (Traffic) Ft. Collins CO Larimer 70% field 19 5833 S Lemay (Parks South) Ft. Collins CO Larimer Field maintenance workers mostly. 15 3036 Drake (Fleet) Ft. Collins CO Larimer 16 700 Wood (Utility Service Center) Ft. Collins CO Larimer Approx. 1/3 are field workers 249 Old Town Square (Police) Ft. Collins CO Larimer 1 civilian employee & officers mostly in the field 6 221 S. Timberline Rd. (Police) Ft. Collins CO Larimer civilian employees and officers mostly in the field 241 2544 Midpoint Drive (Police) Ft. Collins CO Larimer 1 5824 Wright Avenue (Police) Ft. Collins CO Larimer 1 civilian & officers mostly in the field 9 1801 Riverside (Aquatics Staff) Ft. Collins CO Larimer Same employees from 424 Sherwood 424 S Sherwood (Aquatics Staff) Ft. Collins CO Larimer Same employees from 424 Sherwood 1200 Raintree (Aquatics Staff) Ft. Collins CO Larimer Same employees from 424 Sherwood 120 N Mason (Parking Attendants) Ft. Collins CO Larimer 18 102 Remington (Parking Attendants) Ft. Collins CO Larimer 2 garages used - rotate shifts Employees at this location are included in the count above for 120 N Mason. Interpreters Ft. Collins CO Larimer No specified work location 7 2145 S Centre Avenue Ft. Collins ICO IlLarimer 6 City Park Pool - Bryan St. Ft. Collins ICO Larimer Same employees from 424 Sherwood N/A 700 Wood St. Utility Srvc Center Ft. Collins ICO I Larimer 50% Field Personnel 256 IVIAL ADW Poudre Fire Authority Employees by Worksite Worksite Code Worksite Description 523 FIRE TRAINING CTR - BLDG A 524 PFA HEADQUARTERS 510 FIRE STATIONS St. 1 St. 2 St. 3 St. 4 St. 5 St. 6 St. 7 St. 8 St. 9 St. 10 St. 11 St. 12 St. 14 Address 3400 W. Vine 102 Remington Locations: 505 Peterson St 415 S. Bryan Ave 2000 Matthews St 2030 Devonshire Dr 4615 Hogan Dr. 2511 Donella Ct. 2817 N. Overland Tr. 4104 Main St. 4914 Shoreline Dr. 2067 Vermont Dr. 16248 N. County Rd 25E 321 Country Club Rd 2109 Westchase Rd Count 18 26 135 PINN/I COL Standard Loss Run Report ASSURANCE Gross Claims Loss History Report Requested for Policy Periods with Coverage between 01/01/2004 and 01/01/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2004 thru 01/01/2005 Claim Accident' Report j Worker. �" Closed ', EzpePaeas. , 'Me !Ilnde !Date Received, Number Named Injury Cause��. Date In' ry Pald . Paid _Reserve_ Incurrtal ed 01/01/2004 01/02/2004 3064462 LONG, GARY W 03/01/2004 BURN -CONTACT HOT OBJECT $0.00 $0.00 $0.00 $0.00 $0.00 Nature cf 04 BURN FodX7 35 HAND ide: Left njury: art: OPENING FIRE ALARM PANEL IN FURANCE ROOM OF A RESIDENCE AT 1425 HOPPLEWHITE CT. WHEN THE BACK OF MY LEFT HAND BUMPED A HOT FLUE PIPE CAUSING A MINOR ccldenE;�i: DeSCr[� ; BURN TO MY LEFT HAND N/A OPENING FIRE PANEL N/A 01/06/2004 01/07/2004 3065018 PIETRANGELO, JIM H 03/04/2004 FALL ON ICE OR SNOW $0.00 $1,492.92 $0.00 $0.00 $1,492.92 Nature of Injury: -= 52 STRAIN Body7 53 KNEE art: :: 'WASLOOKING FOR THE TRAINING CENTER WATER METER WHEN I SLIPPED ON THE SNOW AND FELL DIRECTLY ON MY RIGHT KNEE, HITTING ide. ,; Right THE FROZEN GROUND WALKING ccident Descr: :..-°": WALKING NONE 01/07/2004 01/08/2004 3065357 GILLESPIE, JEFFREY 03/08/2004 FALL ON ICE OR SNOW $0.00 $0.00 $0.00 $0.00 $0.00 Natureof Injury: 52 STRAIN ody .,. 32 ELBOW ide: Right iPart.. WALKING DOWN OUTSIDE CEMENT STEPS WITH MY BOND ON THE RAILING SLIPPED ON THE ICE AND LANDED ON MY RIGHT ELBOW, BUTT AND BACK. WALKING DOWN WALKING ' ccidenCV Descr:' i;lI DOWN NONE 01/08/2004 01/09/2004 3065498 RAY, DON 12/16/2004 STRAIN-HOLDING,CARRYING $72.60 $3,990.61 $32,084.66 $0.00 $36,147.87 Nature of 52 STRAIN Body 7 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide: Injury: MOVING PATIENT FROM HOUSE TO AMBULANCE rt: Pa ON A COT INJURED MY BACK CARRYING COTT DOWN STEPS TO THE GARAGE. STEVE FLEMING & BRUCE PERRY WERE PRESENT. ccident,:. Descr:., -:IJ MOVING PATIENT MOVING PATIENT NONE 01/14/2004 01/15/2004 3066505 LOVE, PATRICK 03/15/2004 STRAIN -LIFTING $0.00 $0.00 $0.00 $0.00 $0.00 Nature of njury: 52 STRAIN Body .- 44 CHEST (INCL RIBS, STERNUM, SOFT TISS) ide: _ Right Part: I was part of outside crew at fire. At time of injury I was carrying a ppv fan up and down stairs. Try to navigate hoselines. CARRYING A PPV FAN UP AND DOWN STAIRS CARRYING A PPV FAN UP ccident' Descr::.:---- AND DOWN STAIRS PPV FAN 01/18/2004 04/07/2004 3079553 LEHMAN, DAVID 06/07/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $127.04 $0,00 $0.00 $127.04 Nature of 73CONTAGIOUS DISEASE Botly. a 48 INTERNAL ORGANS Side Injury: -' EXPOSURE TO PATIENT WITH TB ON A MEDICAL art: CALL. EMT EMT N/A Accidenr,. t Descr: : 01/18/2004 05/06/2004 3083872 CLOSE, KELLY 07/06/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $142.02 $0.00 $0.00 $142.02 INJURY Natureof 59ALLOTHER ody,'+ 48 INTERNALORGANS njury:,,,' art: Accident-:,. ASSISTED WITH PATIENT ASSESSMENT AND ASSISTED PARAMEDICA UPON THEIR ARRIVE. WAS WEARING LATEX GLOVES & FULL EYE PROTECTION DURING CONTACT WITH escr: -:- PATIENT. FIRE FIGHTER/EMT FIRE FIGHTER/EMT N/A 01/19/2004 01/20/2004 3067230 JOHNSON, TOM 03/19/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY ature of 59ALL OTHER Injury ody - 61 ABDOMEN INCLUDING GROIN arty Side. ': Right ccident.- Right lower abdominal and back pain approx 7:30 while Op duty at station 1 NOT PROVIDED Fire Fighter NOT PROVIDED Descr:, = Page 1 01=00908'45 AM MCIS UW651R PINNACOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01101/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2004 thru 01/01/2005 Claim AccidentReport `+,.. Claim Injured Worker , • ;Closed ,, .;,,. Expenses ,. Medical Indemnity Current.Total ; 'Number 'Date In'u Cause Pald - Date •' Received Paid' - ry °Paid' Paid Reserve, Incurred 01/20/2004 01/21/2004 3067305 MAYNARD, JIMMIE D 03/17/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature_of 73 CONTAGIOUS DISEASE ody",.-. 18 OTHER FACIAL SOFT TISSUE ides- Injury: art: ccident:r. Responding to unconcious female, female had multiple lac to scalp. Patient head cradled on left shoulder blood contact to left side neck and jaw. NOT PROVIDED Fire Fighter EMT NOT PROVIDED escr: 01/30/2004 02/02/2004 3069146 KRISTINE, BRAMAH 03/19/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59 ALL OTHER Barty '.. 66 NO PHYSICAL INJURY itle:' Injury: ccident.. Exposure to influenza A,B due to providing medical care. NA Fire Fighter/Driver Operator NA Descr.i 01/30/2004 02/02/2004 3069141 RANDY, CALLAHAN 03/19/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59 ALL OTHER ody, 66 NO PHYSICAL INJURY „ ide:.:, Injury:. Part. ccident •: Crew was exposed to a known hepatitis C patient who was vomiting blood. all precaustions were taken. NA Fire Fighter/EMT NA Descr. . F, 01/30/2004 02/02/2004 3069140 ENGLAND, GARNET 03/19/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59ALL OTHER ody. -. 66 NO PHYSICAL INJURY Side: Injul Part ccident Patient with Hetatitis C vomiting blood. NA EMT/Diner Operator NA Descr. 01/30/2004 02/02/2004 3069135 WRIGHT, ELLEN E 03/19/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 ature of 59ALL OTHER ody• ,.: 66 NO PHYSICAL INJURY Kide: Injury: Part Accident .'- On run 874 @ 533 Crestmore we were on scene with patient who has been diagnosed with Hetatitis C and was vomiting Blood. N/A EMT N/A Descr:.' -: 01/30/2004 02/02/2004 3069176 MYERS, CHAD 03/19/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59 ALL OTHER :i 66 NO PHYSICAL INJURY Injury: aorty ccident,Exposure to influenza A,B due to providing medical care. NA Fire Fighter NA Descri, 01/30/2004 02/02/2004 3069178 CUPP, DOUG 03/19/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59 ALL OTHER Baorty ,$ 66 NO PHYSICAL INJURY ide> njury: ccident.«. Exposure to influenza A & B due to medical call NA EMT NA Descr:': 02/04/2004 02/11/2004 3070944 BRANDON, GARCIA 03/19/2004 CUT BROKEN GLASS $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 40LACERATION Body 35 HAND ide; Left ryr' a ' I'u rt...: n1 ccident .: Performing search on working structure fire cleaning out glass on window cut through fire glove cut on left knuckle. CLEANING OUT GLASS Fire Fighter (Search & Rescue NOT PROVIDED Desccda:•� Page 01=0090845 AM MCIS UW651R PII VN/I COL Data as of:01/23/2009 Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01101/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Period: 01/01/2004 thru 01/01/2005 PROTECTION DISTRICT Claim ent Expenses r Injured Worker Closed Medical Indemnity. CurrentTotal DatedClaim Received NmbeName Date -'Paid Injury Cause Paid Paid" •. Res Incurred 02/04/2004 02/05/2004 3069946 RAY, DON W 02/28/2005 BURN -FIRE, FLAME $342.80 $3.828.21 $60,000.00 $0.00 $14,111,11 Natureof 54ASPHYXIATION Body 60 LUNG ide: " Injury::. Part: At structure fire and smoke affected my reactive airway disease making it difficult to breath. NA Fire Figher (Pumping on a Fire) NA ccident,: Descr:"� 02/04/2004 02/09/2004 3070442 WEBER, BRETT 03/25/2004 FALL ON ICE OR SNOW $0.00 $0.00 $0.00 $0.00 $0.00 Nature of Injury ' 52 STRAIN ody ' 42 LOW BACK (LUMBAR 8 LUMBO-SACRAL) art: . Shoveling snow @ PFA 10 slipped on ice and landed on right hip had no pain until friday around noon. Pain in in right lower back. SHOVELING SNOW Shoveling de: Snow NOT PROVIDED cc!dent esccl=-.-' 02/12/2004 04/07/2004 3079535 KLASSEN, JAY 06/07/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $114.97 $0.00 $0.00 $114.97 INJURY Nature of 73 CONTAGIOUS DISEASE ody 66 NO PHYSICAL INJURY ide::... Injury: -�� Part: Accident EXPOSED TO PATIENT WITH TB ON A MEDICAL EMT/COMPANY OFFICER EMT/COMPANY OFFICER NOT PROVIDED Descrl:-- 02/12/2004 04/07/2004 3079545 POTTLE, MICHAEL 06/07/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $114.97 $0.00 $0.00 $114.97 Nature of 73 CONTAGIOUS DISEASE Body.__; 48 INTERNAL ORGANS Injury ,`; art: � EXPOSED TO PATIENT WITH TB ON A MEDICAL CALL FIRE FIGHTER/EMT FIRE FIGHTER/EMT N/A ccident bescr(i - 02/12/2004 04/07/2004 3079528 GILLESPIE, JEFFREY 06/07/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $141.13 $0.00 $0.00 $141.13 INJURY Nature of 73CONTAGIOUS DISEASE Body :. 66 NO PHYSICAL INJURY Injury: ccident.: EXPOSED TO PATIENT WITH TB ON A MEDICAL EMT EMT NOT PROVIDED Descr: 02/16/2004 02/17/2004 307.1821 LESSER, MILTON 03/24/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE Body ,, 60 LUNG Injury' ` Part:. ccident .: Treat patient in an enclosed room - Possible TB TREATING PATIENT Fire Fighter / EMT NOT PROVIDED Descr: 02/16/2004 02/17/2004 3071818 JAQUES, MICHAL 04/19/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE Body 60 LUNG ide: � Injury: f Part ccident Attend to patient who paramedics though could have tuberculosis based on her signs and described symptoms. ATTENDING PATIENT Fire Fighter/EMT NOT PROVIDED Descr: =�,:... Page 01/23I200908'45 AM MCIs UW651R PINNAA COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01/01/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2004 thru 01/01/2005 Claim..'. Accident Report "Claim -'Injured Worker - 'Closed' .. -- Expenses Medical .'Indemnity.; Current - Total "Date Received 'Number ;.Name Date .Injury Cause''. '; .; y_ Paid - Paid. Paid:. Reserve, Incurred. 02/16/2004 02/17/2004 3071820 MCGRAW, WALTER 03/24/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 aWre of 73 CONTAGIOUS DISEASE INJURY Body 60 LUNG ide: Injury:",;. Part: ccident Attended to patient who was though to have tuberculosis. Based on PVH medics determinations. ATTENDING PATIENT Fire Fighter / EMT NOT PROVIDED " Descr: ' 02/20/2004 02/20/2004 3072419 CAPE, RICHARD 03/09/2004 MISCELLANEOUS STRAIN OR INJURY $0.00 $504.18 $0.00 $0.00 $504.18 Natureof 52STRAIN Body- 42 LOW BACK (LUMBAR & LUMBO-SACRAL) .ide: njury; art: ccident,,; While pulling up bunker pants and twisting slightly, I felt a pop in my lower back resulting in significant pain. NA Company Officer NA Descr:: , 02/24/2004 02/25/2004 3073062 HERRINGTON, JAMES 03/26/2004 STRAIN -LIFTING $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 52STRAIN Body 142 LOW BACK (LUMBAR & LUMBOSACRAL) ide: Injury: '. Part: _ %ccident WAS MOVING BUNKER GEAR LIFING AND TWISTING AND BACK BEGAN TO SPASM. LIFTING BUNKER GEAR LIFTING BUNKER GEAR NOT PROVIDED Descr: 03/19/2004 03/19/2004 3076741 STRAUSS II, ARNOLD D 06/08/2004 STRAIN -REACHING - $35.93 $0.00 $0.00 $0.00 $35.93 ature of 52STRAIN ody, ,.. 42 LOW BACK (LUMBAR & LUMBO-SACRAL) nlury: Bart: ccident > WAS ON FOOT END OF FLAT COT, CARRING LARGE PATIENT DOWN STEEP STAIRS, HAD TO REACH AROUND TO OPEN DOOR WHILE ON STAIRS, STRAINED LOWER BACK AND NECK Descr.: EMT EMT NOT PROVIDED 03/23/2004 04/22/2004 3081709 PARSON, NOLAN 04/27/2004 STRUCK BY -FALLING OBJECT $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 1000NTUSION Body;. 34 WRIST ide: �. �,,: Left Injury:,, r.. Part: Accident WAS RAISING LADDER AND HOLYGARD BROKE AND LANDED ON MY LEFT WRIST. LADDER FELL 1 TO 1/1/2 FEET. VOLUNTEER VOLUNTEER LADDER Descr:;:?+'., 04/02/2004 04/04/2005 3137677 SAXBURY, LYNDEL 05/10/2005 STRIKE -LIFTED OBJECT $0.00 $567.32 $0.00 $0.00 $567.32 Nature of 1000NTUSION P ody7 36 FINGER(S) Injury:" Part: ccident I HAD LIFTED HOOD INSIDE ENGINE TO CHECK OIL WHEN I LET IT DOWN, IT CAME DOWN FAST AND HIT MY FINGER. FIRE FIGHTER/DRIVER OPERATOR FIRE FIGHTER/DRIVER )escr:.- I OPERATOR N/A 04/03/2004 04/06/2004 3079247 JONES, SEAN E 06/29/2004 STRAIN-HOLDING,CARRYING $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 52STRAIN ody, ._ 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Injury: ccident WHILE ASSISTING IN CARRY A PATIENT DOWN STAIRS, ONE END OF COT WAS DROPPED BY OTHER. TRYING TO ADD WEIGHT EXTRA STRESS PLACED ON BACK. FIRE FIGHTER FIRE escrrr- .: FIGHTER NOT PROVIDED 04/14/2004 04/15/2004 3080808 FINK, ALBERT 08/30/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $92.40 $6,786.72 $0.00 $0.00 $6,879.12 INJURY Nature of 03 ANGINA PECTORIS ody :^. 44 CHEST (INCL RIBS, STERNUM, SOFT TISS) ider Injury: :' art: ccident EXERCISE, SHORTENING OF BREATH CHEST TIGHTNESS DURING REQUIRED FITNESS TESTING FITNESS TEST FITNESS TEST NOT PROVIDED Descc.'P' Page 01=0090645AM PWCIS UW651R PINN/ICOL Standard Loss Run Report ASSURANCE Requested Claims Loss History Report Requested for Policy Periods with Coverage between 01/01/2004 and 01/01/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2004 thru 01/01/2005 Claim:.,;.. Accident Report Claim Injured Worker. Closed -• ': _ p Medical Ex enses' M Indemnity Current y Total Date Received Number Name, ' , ,- _, , {,. _ -, Date InjuryCause . Paid:' Paid Paid Reserve Incurred,,. 04/18/2004 04/22/2004 3081689 STACHURSKI, JUDY 05/18/2004 STRAIN OR INJURY BY TWISTING $0.00 $0.00 $0.00 $0.00 $0.00 ature of Injury 52 STRAIN PULLING CHARGED 2 1/2 HOSELINE ON UNEVEN ody: 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Side: Part: GROUND, STEPPED ON STICK, ROLLED UNER FOOT - WRENCHED BACK TRYING TO REGAIN BALANCE FIRE FIGHTER FIRE FIGHTER Accident'] Der. NOT PROVIDED 05/04/2004 05/13/2004 3084940 DELANEY, DEAN 06/29/2004 CAUGHT -MACHINERY $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 1000NTUSION Body, 53 KNEE ide: Left Injuryr'. Fart: ' PUTTING HARD SUCTION IN PUMP PIT AND LUG ON SECTION CAUGHT KNEE RON SIMMS WAS HELPING LIFE HOSE IN. FIRE FIGHTER/PUMP TESTING FIRE FIGHTER/PUMP TESTING cci dent,,,,„ Descr: : NOT PROVIDED 05/08/2004 05/12/2004 3084778 BERNUM, RICHARD 06/21/2004 FALL MISCELLANEOUS $0.00 $568.98 $0.00 $0.00 $568.98 Natureof Injury 52STRAIN ody .:32 ELBOW ide: Right art: , GOT OUT OF BED RAPIDLY TO GO TO BATHROOM. WHILE USING URINAL BECAME LIGHT HEADED & HAD A SYNCOPAL EPISODE & FELL TO FLOOR INJURING MY RIGHT ELBOW. N/A ccident. Descr::-1 :._ OTHER N/A 05/08/2004 05/10/2004 3084304 LEHMAN, MICHAEL 07/09/2004 BURN TEMP. EXTREMES $0.00 $0.00 $0.00 $0.00 $0.00 ature of Injury: `. 04 BURN ody;] 34 WRIST IPart ; ON STRUCTURE FIRE. BURNING INSOATION WENT DOWN INTO MY SLEEVE AND I RECEIVED SUPERFICIAL BURNS ON MY WRIST. FIRE FIGHTER FIRE FIGHTER N/A cciden, escr: 05/11/2004 05/12/2004 3084717 MORAN, JOHN 07/08/2004 STRAIN -LIFTING $0.00 $342.82 $0.00 $0.00 $342.82 Nature of 52 STRAIN Pody, ; 42 LOW BACK (LUMBAR & LUMBO-SACRAL) idei< nlury Part: ; INJURED BACK WHILE PLACING EQUIPMENT ON APPARATUS FIRE FIGHTER FIRE FIGHTER NOT PROVIDED ccident:..f. r. Desc 05/16/2004 05/18/2004 3085642 JOHNSON, THOMAS 06/29/2004 STRAIN -LIFTING $20.53 $0.00 $0.00 $0.00 $20.53 ature of njury: 1 49SPRAIN ody, ,,: 53 KNEE art: KNEE INJURY WHILE WEIGHTLIFTING. FIRE FIGHTER FIRE FIGHTER N/A ide: .;, Left Accident] Descry: 05/17/2004 05/18/2004 3085692 LIPPERT, JOHN C 07/12/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 73 CONTAGIOUS DISEASE ody -¢ 66 NO PHYSICAL INJURY ide: Injury.;.' art.. RESPONDED TO A HOMELESS PERSON IN THE ALLEY. WAS SUPERVISING SCENE W/ PARAMEDICS ARRIVED. PARAMEDICS FOUND CARD IN WALLET ' FROM WELD CO. PT WAS ccidentc: escr: , POSITIVE FOR TB. DISCOVERED AFTER PARA. CALLED. FIREFIGHTER/COMPANY OFFICER FIREFIGHTER/COMPANY OFFICER N/A 05/17/2004 05/18/2004 3085681 MACARTHUR, JOHN D 07/1212004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 73 CONTAGIOUS DISEASE ody, 66 NO PHYSICAL INJURY 1de: Injury RESPONDED TO A HOMELESS MAN IN AN ALLEY. r PT RESPONDED TO OUR ARRIVAL ON SCENE. PARAMEDICS ARRIVED. FOUND WELD COUNTY TB CARD IN PT'S WALLET. ccident{" escr: :'.I FIREFIGHTER/EMT FIREFIGHTERIEMT NIA Page 5 01MII 08:45 AM MCIS UW651R Data as of:01/23/2009 PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01/01/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Period: 01/01/2004 thru 01/01/2005 PROTECTION DISTRICT Claim :. .:.. Accident Report Claim Injured Worker' Closed - Expenses., . Medical .. � -Indemnity � Current Totst, .... - :, ,Paid .,,„ Date,.%. ':; „:'. ,"; 1. rY ,,,,, Received. Numbere,Name (Date In'u Cause,>. Paid:.-. Paid Reserve ,.. ,,, Incurred'.' 05/17/2004 05/18/2004 3085667 SHEESLEY, DREW W 06/30/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 73 CONTAGIOUS DISEASE _P_od­y7 66 NO PHYSICAL INJURY Side: Injury: Accident FOUND HOMELESS MAN ASLEEP IN ALLEYWAY. HE RESPONDED TO CONTACT & WAS ASSESSED. PARAMEDICS HANDLED PT'S WALLET & FOUND EVIDENCE -PT IS POSITIVE FOR TB. escr:. NO OBVIOUS SIGNS OR SYMPTOMS TO INDICATE THIS. FF/EMT FF/EMT N/A 05/25/2004 05/27/2004 3087143 GARCIA, BRANDON J 06/30/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE Pod_y7 66 NO PHYSICAL INJURY InInjury:. ! art: ccident a EXPOSED TO POSSIBLE MENINGITIS ON A MEDICAL CALL, CALL 94497 EMT EMT PROTECTIVE GEAR Descr: �.. 05/25/2004 05/27/2004 3087155 WILSON, MICHAEL P 06/30/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature.of 73 CONTAGIOUS DISEASE ody.,., 66 NO PHYSICAL INJURY Sidef i 'njury;....,;. Part: Accident WHILE RESPONDING ON AN EMS CALL, I WAS IN CONTACT WITH APT EXHIBITING MENINGITIS -LIKE SYMPTOMS. EMT EMT PROTECTIVE GEAR Descr: 05/25/2004 05/26/2004 3086946 FOWLER, MARK W 06/30/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY atute of 73 CONTAGIOUS DISEASE Body' 66 NO PHYSICAL INJURY ides. Injury: �j rt: Pa Accident; CONTACT WITH PATIENT THAT HAD SYMPTOMS LIKE MENINGITIS. ALL PROTECTIVE GEAR UTILIZED. COMPANY OFFICER COMPANY OFFICER NOT PROVIDED Descr: 05/26/2004 05/27/2004 3087161 NUCKOLS, GARY L 06/30/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59ALL OTHER Body 66 NO PHYSICAL INJURY itle_. ojury:." -, art: ccident' WAS STAGED ON SCENE AT A HAZ MAT CALL. VAPORS FROM A CHEMICAL RELEASE DRIFTED INTO THE GREEN SAFE ZONE. WE DID NOT HAVE ON RESPIRATORY PROTECTION. Descr.- - GREEN ZONE ESTABLISHED PRIOR TO OUR ARRIVAL. HAZ MAT RESPONSE HAZ MAT RESPONSE TURNOUT GEAR & SCBA--DURING RESCUE STANDBY ONLY 05/26/2004 05/27/2004 3087193 SALMON, WILLIAM A 06/30/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY aturerof 59ALL OTHER Body 66 NO PHYSICAL INJURY idei; Injury: art: ccident WHILE WORKING AT A HAZMAT SCENE, I WAS EXPOSED TO VAPORS FROM A CHEMICAL REACTION OF PLASTIC EPDXY RESINS. THE WIND SHIFTED AND CAUSED THE VAPORS TO pescr:;I REACH OUR LOCATION. HAZMAT RESPONSE HAZMAT RESPONSE TURNOUT GEAR & SCBA 05/26/2004 05/27/2004 3087180 LEMAN, MIKE D 06/30/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $2.20 $0.00 $0.00 $0.00 $2.20 INJURY Nature of 59ALL OTHER Body; . 66 NO PHYSICAL INJURY itle { njury: art: ccident4 WHILE WORKING AT A HAZMAT SCENE, I WAS EXPOSED TO VAPORS FROM A CHEMICAL REACTION OF PLASTICEPDXY RESINS. THE WIND SHIFTED AND CAUSED THE VAPORS TO Descr.'1.. REACH OUR LOCATION. HAZMAT RESPONSE HAZMAT RESPONSE TURNOUT GEAR & SCBA Page 6 01n3J200908:45 AM awcis ❑W651R 3. What is the relationship between the above stated parties and/or reasons for combining them for certain coverages. - Although the City and the fire entities are governed separately, they do share services including risk management and have been combined for insurance purposes. The City has representatives on the Board of the fire entities, but the fire entities are governed separately. 4. Please provide the full legal names of the benefit plans to be covered under CFC's plan — including the sponsor, for example "City of Fort Collins GERP" or "Poudre Valley Fire District GERP." - Poudre Fire Authority Old Hire Money Purchase Pension Plan and Trust - Poudre Fire Authority New Hire Money Purchase Pension Plan and Trust - Ci{y, of FC General Employee Retirement Plan (GERP) - City of FC Money Purchase Plan - City of FC Retirement Health Savings Plan 5. CFC is the sponsor for which plans and who participates? Are Poudre employees eligible to participate in all of CFC's plans? - Answered above in #3 - No, PFA employees do not participate in City plans and City employees do not participate in PFA plans. 6. If any of the plans are defined benefit (GERP, Money Purchase Plan) we need a copy of the plan actuarial reports. - Only the GERP is a defined benefit plan. - Retirement plans (including GERP) can be viewed at: htty://fcgov. com/cityclerk/retirement. php 7. Please provide the following Workers' Compensation rating Information for Poudre Fire Authority: • E-mod work sheet for the past three years • Payroll by class code • Concentration of risk by location • Cost containment certification if applicable • 5-Years Audited Premium from Carrier • 5-years Detailed Large Loss Report on Claims over $25,000 • Details on any loss sensitive plan in force • 5 yrs Auto liability and Physical damage • 5 yrs Property IM, Crime, Boiler & Machinery • 5 yrs Public Liability to include GL, EPLI, POL, E&O • 5 year detail report on large losses over 25,000 Data as of:01/23/2009 PINNAA COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01/01/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Period: 01/01/2004 thru 01/01/2005 PROTECTION DISTRICT ' Clajm'y ., Accident' Report 'Claim .Injured Worker Closed Expe Me nses decal ' Indemnity Current Inde ty Total ,I I ry ,, Date, • Received Number Name Date „� ;. , n'u Cause Paid:. .Paid Paid Reserve 'Incuned ' 05/26/2004 05/27/2004 3087192 JAQUES, MICHAL 06/30/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59ALL OTHER Body -,: 66 NO PHYSICAL INJURY Vida. Injury!.IPart. ccident WHILE WORKING AT A HAZMAT SCENE, MICHAL JAQUES WAS EXPOSED TO VAPORS FROM A CHEMICAL REACTION OF PLASTIC EPOCY RESINS. THEWIND SHIFTED AND ALLOWED Descr:!: , I THE VAPORS TO REACH OUR LOCATION. HAZMAT RESPONSE HAZMAT RESPONSE TURNOUT GEAR & SCBA 05/26/2004 05/27/2004 3087159 WILSON, MICHAEL P 06/30/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59ALL OTHER Body. 66 NO PHYSICAL INJURY Side: In1urY:� i' art: ccident, WHILE STAGED IN COMMAND AREA OF HAZMAT RESPONSE, SMOKE FROM A HAZMAT RELEASE DRIFTED INTO OUR AREA. THIS AREA WAS DESIGNATED AS A SAFE AREA PRIOR TO Descr.=;,.. OUR ARRIVAL. HAZMAT RESPONSE HAZMAT RESPONSE TURN -OUT GEAR AND SCBA 05/26/2004 05/27/2004 3087177 ROSEN, ANDREW 06/30/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY . Nature of 59 ALL OTHER P-o-d771 66 NO PHYSICAL INJURY Side:: Injury: Part.•.`, ccident WHILE WORKING AT A HAZMAT INCIDENT, CASE #4534, 1 WAS EXPOSED TO VAPORS FROM A CHEMICAL REACTION OF PLASTIC EPDXY RESINS. HAZMAT RESPONSE HAZMAT Descr:>;.. RESPONSE TURNOUT GEAR & SCBA 05/26/2004 05/27/2004 3087166 GILLESPIE, JEFFREY A 06/30/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY ature of 59 ALL OTHER ody V_' 66 NO PHYSICAL INJURY Sde: Injury.- ::' art ' ' ccident WHILE STAGED IN COMMAND AREA OF A HAZMAT RESPONSE, VAPORS/SMOKE FROM A HAZMAT RELEASE DRIFTED INTO OUR AREA. TIS AREA WAS DESIGNATED AS A SAFE ZONE Descr. `_. : PRIOR TO OUR ARRIVAL. HAZMAT RESPONSE HAZMAT RESPONSE TURNOUT GEAR & SCBA-DURING STANDBY ONLY 06/14/2004 06/25/2004 3092015 DRAGAN, ANTHONY 06/29/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59ALL OTHER Body 7... 66 NO PHYSICAL INJURY Injury: ' = Part: s, EN-2 RESPONDED TO A CALL WITH A PATIENT WHO HAD BECOME SICK WITH THE NOROVIRUS WHILE WORKING @ TEXAS ROADHOUSE. BECAME SICK TILES IN THE AM MEDICAL ccident escr.:':P'11, CARE/EMT MEDICAL CARE/EMT N/A 06/14/2004 06/25/2004 3092018 GILLAN, RAY 08/24/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Nature of injury: 59ALL OTHER Body.'. 66 NO PHYSICAL INJURY Part: E-2 RESPONDED TO A PATIENT THAT WAS SICK FROM TEXAS ROAD HOUSE OUTBREAK. NORO VIRUS. I BECAME SICK ON TUESDAY NIGHT, HEAD ACHE, THROWING UP, STOMACH ccident:4 escr::'=-.. PAIN. EMT EMT EMT 06/14/2004 06/25/2004 3092022 CALLAHAN, RANDY 06/29/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 ature of Injury:: - 59ALL OTHER ody 66 NO PHYSICAL INJURY art: <. RESPONDED TO PATIENT THAT WAS SICK FROM TEXAS ROAD HOUSE OUTBREAK. NORO VIRUS, I BECAME AWARE OF VIRUS AFTER RETURNED Ide: � , T WORK FROM SICK LEAVE. ccident':.: escr:• - COMPANY OFFICER/EMT COMPANY OFFICER/EMT N/A O6/16/2004 06/17/2004 3090652 LINDHOLM, LEONARD E 07/12/2004 STRAIN -LIFTING $0.00 $1,542.15 $0.00 $0.00 $1,542.15 ature of 52 STRAIN Body ' 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Sidei-;, njury art:, PUTTING DOORS BACK INTO VEHICLE AFTER EXTRICATION TRAINING. SOMETHING POPPED IN BACK. GOT TO HURTING AFTER. TRAINING TRAINING DOOR ccident;;:;, Descr:2`':- Page 7 01=0090845 AM MCIS ❑W651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/0112004 and 01101/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PRr)TFCTIAN DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2004 thru 01/01/2005 Claim - - Report Claim Worker Expenses Medical - Ex 'Psis Indemnity - Current Total {' -Incurred Datedent-', Received, Number;; Named ,/. Injury -, l ,.'- „' „paid Date. Inju Cause,, Paid .-, . Reserve O6/23/2004 06/24/2004 3091736 DEBAERE, DUSTIN 08/20/2004 STRAIN -LIFTING $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 52STRAIN od 38 SHOULDER(S) Y ide: Leff Injury: Part: ccldent WHILE LIFTING WATS (BENCH PRESS) FELT A POP AND PAIN IN LEFT SHOULDER AND PECTORAL AREA FIRE FIGHTER FIRE FIGHTER N/A escr: . 06/23/2004 06/25/2004 3091867 PONCELOW, ROBERT 08/24/2004 CUT -TOOL, NOT POWERED $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 40 LACERATION Fo-d-y7 37 THUMB itle: Left 6jury: art: Accident :"' WHILE DOING A REPAIR JOB @ MY OFFICE I SLICED THE END OFF MY THUMB WITH A RAZOR KNIFE. FIRE FIGHTER FIRE FIGHTER N/A escr: 06/29/2004 06/30/2004 3092676 LEMAN, MIKE 08/02/2004 STRAIN -LIFTING $5.13 $561.40 $0.00 $0.00 $566.53 Nature of 52STRAIN Pody.-= 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide:... Injury:' -'- Part: ccident - WHILE ASSISTING AT THE SCENE OF AN ACCIDENT, I LIFTED THE PATIENT AND BACKBOARD SO THAT ROSEN COULD TAPE THE PATIENTS HEAD DOWN. FIRE FIGHTER/EMT FIRE DescrFIGHTER/EMT NOT PROVIDED 07/14/2004 07/19/2004 3095653 MONTOYA, KEN 09/14/2004 MISCELLANEOUS STRAIN OR INJURY $0.00 $1,549.51 $0.00 $0.00 $1,549.61 atureof 52STRAIN Body. 56 FOOT ide: Left Injury.!.,, Part: ccident; : PHYSICAL FITNESS TEST. WHILE ON TREADMILL EXPERIENCED BURNING IN RIGHT HEEL, PAIN FORCED ME TO STOP. FIRE FIGHTER FIRE FIGHTER TREADMILL Descr:, 07/14/2004 07/19/2004 3095785 GILLESPIE, JEFFREY A 08/18/2004 FALL, ON STAIRS $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 10 CONTUSION Body 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide:; Left Injury:,. ::. art: ccident:;::i CARRYING GAS CAN UP STAIRS AND TRIPPED OVER A BROOM THAT FELL ON THE STAIRS. FIRE FIGHTING WORK. FIRE FIGHTING WORK. NOT PROVIDED Descry 07/17/2004 07/29/2004 3097701 ENGLAND, TIMOTHY 08/17/2004 MISCELLANEOUS STRIKING AGAINST OR $0.00 $0.00 $0.00 $0.00 $0.00 STEPPING ON Natureof 49SPRAIN ody;; : 53 KNEE ide::_.- Left Injury:, art: Accident +t. STEPPING DOWN OFF EN 3 AFTER CLEANING WINDSHIELD LOST FOOTING AND TWISTED -STRAINED LEFT KNEE FIRE. FIGHTER FIRE FIGHTER N/A Descr. 07/24/2004 07/27/2004 3097182 FINK, ALBERT 09/15/2004 CUMULATIVE (ALL OTHER) $0.00 $1,043.55 $0.00 $0.00 $1,043.55 Nature of 52 STRAIN Body.; . 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Pide. Injury: ', Part:. ccident.•: OPERATING ON SCENE OF A PLANE CRASH FROM 120 TO 6PM SORE BACK IN THE MORNING OF 25TH. IT BECAME STIFF AND SORE DURING THE 25TH. CAME IN ON MONDAY TO Descr.:i,= HAVE IT CHECKED. FIRE FIGHTER FIRE FIGHTER N/A 08/11/2004 08/20/2004 3101401 MILLER, GREGG 09/24/2004 STRUCK BY -OBJECT BY OTHR $0.00 $0.00 $0.00 $0.00 $0.00 ature of 10 CONTUSION Bdy _ o19 FACIAL BONES ide: Injury::''. art: ccident. LOADING 2 1/2" HOSE ONTO ENGINE 4 AFTER TRAINING DRILL. STANDING ON TAIL BOARD HOSE COUPLING SLIPPED AND STRUCK ME ON FOREHEAD. LOADING HOSES LAODING Descr: - ' < HOSES NOT PROVIDED ' Page 8 PI@3I200908:45 AM MCIS UW651R P/NN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01/01/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data asof:01/23/2009 Policy Period: 01/01/2004 thru 01/01/2005 calm 'Accident 'Report - .'Claim : Injured Worker. - Closed. - :-'Expenses : _,Medical ­11•.: -bate. Indemnity.. Current Total ' ' Date' '' ,Received Number Name - .Injury Cause •.;,.,, .Pails - _,Paid - PaidReserve . Incurred . 08/13/2004 08/16/2004 3100502 LOVE, PATRICK 09/30/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY ature of 73 CONTAGIOUS DISEASE od� 66 NO PHYSICAL INJURY ide: Injury: Part: ccident-r TB EXPOSURE MEDICAL TREATMENT WHEN EXPOSURE OCCURRED. HAD PRIOR KNOWLEDGE SO BSI PRECAUSTIONS WERE MADE. FIRE FIGHTER EMT ACTING CO FIRE FIGHTER escr:, - EMT ACTING CO NOT PROVIDED 08/13/2004 08/16/2004 3100532 SHEESLEY, DREW 09/30/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 73 CONTAGIOUS DISEASE Body 66 NO PHYSICAL INJURY ide: Injury:.." Part .. AccidentRESPONDED TO PATIENT WITH TB. PRECAUSTIONS WERE TAKEN, MASK, GLOVES AND EYE PROTECTION. FIRE FIGHTER/EMT FIRE FIGHTER/EMT FIRE FIGHTER/EMT es6r, 08/13/2004 08/16/2004 3100533 MACARTHUR, JOHN 10/15/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 - $0.00 $0.00 $0.00 atureof 59ALL OTHER Body--] 48 INTERNAL ORGANS - Injury: EVALUATION MEDICAL PATIENT EXPOSURE TO TB. Part: ' WORE PROTECTIONS, SAFETY GLASSES, GLOVES, MAST AND NON RE BREATHER FOR PATIENT. FIRE FIGHTER/EMT FIRE Accident Descr:',1. FIGHTER/EMT N/A 08/14/2004 08/20/2004 3101371 JOHNSON, THOMAS 10/18/2004 OBJECT BEING LIFTED OR HANDLED $0.00 $0.00 $0,00 $0.00 $0.00 atureof Injury::: 59ALLOTHER A CONNECTION TO FILL HIGH PRESSURE AIR BOTTLE Body; - 13 EAR(S) IPart:' BROKE UNDER PRESSURE. HOSE HIT IN LEG RESULTING IN MINOR BRUISE, NOISE CAUSED Side: Both RINGING IN EARS. FIRE FIGHTER ccident:'ri- Descr. FIRE FIGHTER NOT PROVIDED 08/14/2004 08/20/2004 3101380 HOUSLEY, MATT 09/30/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE FBody-7 66 NO PHYSICAL INJURY ide: I Injury. 'I'.. Part: Accident _ EXPOSURE TO PATIENT WITH TB. PATIENT WAS LATER IDENTIFIED AS HAVING TB BY MED UNIT CREW. NORMAL BSI PRECASUTION TAKEN. FIRE FIGHTER/EMT FIRE FIGHTER/EMT Descr:, ;,. NOT PROVIDED 08/14/2004 08/16/2004 3100492 DURRE, HOLGER 10/08/2004 FALL - MISCELLANEOUS $0.00 $0.00 $0.00 $0.00 $0.00 Nature"of Injury: 1000NTUSION Body: 19 FACIALBONES Part: BECAME LIGHTHEADED WHILE GETTING BLOOD DRAWN. WHILE WALKING TO RESTROOM FELL INTO OFFICE PARTITION STRIKING HEAD & RIGHT Sidei.', SIDE OF BODY. FIRE FIGHTER FIRE ccident;,. Descr.,J',;," FIGHTER NOT PROVIDED 08/18/2004 08/20/2004 3101385 DEBAERE, DUSTIN 10/18/2004 STRAIN -LIFTING $0.00 $0.00 $0.00 $0.00 $0.00 ature of 52 STRAIN ody ,1 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Side: Injury: LIFTING LARGE PATIENT OFF GROUND TO PLACE PATIENT ON COT PATIENT WEIGHT SHIFTED CAUTING PATIENT TO ROLL AWAY FROM ME. AWKARD POSITION INJURED LOWER ccident-. Descri' BACK. FIRE FIGHTER FIRE FIGHTER NOT PROVIDED 08/19/2004 08/20/2004 3101485 STRAUSS, SANDY 09127/2004 FALL OR SLIP FROM LIQUID OR GREASE $0.00 $0.00 $0.00 $0.00 $0.00 SPILLS Nature of 10 CONTUSION Body • 32 ELBOW ide: • I Left Injury:. Part.. Accident SLIPPED ON WET BETAL STRIP ON SIDEWALK IN FRONT OF TRAINING BLDG A. FELL & LANDED ON ELBOW AND SHOULDER HIP ON LEFT SIDE. SECRETARY SECRETARY NOT escr: PROVIDED - Page 9 01/28/200908:45 AM PWCIS UW651R PINNACOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 0110112006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2004 thru 01/01/2005 Claim •'Accident Report Claim Injured Worker` Closed _ _. Expenses: Medical .Indemnity Current -Total Date Received,. Number Name 1 Date Injury Cause Paid Paid Paid .Reserve Incurred 09/03/2004 09/10/2004 3105044 MILLER, GREGG 10/14/2004 OBJECT BEING LIFTED OR HANDLED $0.00 $179.18 $0.00 $0.00 $179.18 Nature of 40 LACERATION ody 52 UPPER LEG ide: Left Injury:' art: ccident WHILE FIGHTING GRASS FIRE IN DARK, WALKED INTO BARBED WIRE FENCE. RECEIVED TWO SMALL LACERATIONS ON LEFT THIGH. COMPANY OFFICE COMPANY OFFICE (FIRE De"'. FIGHTER NONE 09/08/2004 09/10/2004 3105047 HATFIELD, TOM 11/29/2004 OTHER $0.00 $1,663.10 $0.00 $0.00 $1,663.10 Nature of 59 ALL OTHER eody 44 CHEST (INCL RIBS, STERNUM, SOFT TISS) Side: Injury: Part: Accident TREADMILL STRESS TEST (HEART ARRHYTHMIAS) STRESS TEST STRESS TEST NONE Descr: 09/10/2004 09/10/2004 3105038 BERNUM, RICHARD 10/15/2004 STRAIN OR INJURY BY TWISTING $0.00 $1,161.32 $0.00 $0.00 $1,161.32 Natureof 49SPRAIN Body 53 KNEE ide: Left : nluryi� Accident STEPPED OFF EN 12 @ PUMP PIT AND INTO A HOLE TWISTING MY LEFT KNEE. FIRE FIGHTER FIRE FIGHTER PUMP Descr: 09/12/2004 09/13/2004 3105173 FISHER III, GILBERT 10/07/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY ature of 73 CONTAGIOUS DISEASE ody' .. 66 NO PHYSICAL INJURY .ide: Injury: art: ccldentr EXPOSURE TO POSSIBLE INFECTIOUS DISEASE. DURING A MEDICAL CALL AT 301 LEEWARD DO TO PHYSICAL CONTACT WITH PATIENT. FIRE FIGHTER/EMT FIRE FIGHTER/EMT N/A Descr: 09/12/2004 09/13/2004 3105180 GREENWOOD, WILLIAM 10/07/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE FBody7 66 NO PHYSICAL INJURY ide: ecident . EXPOSURE DUE TO MEDICAL CALL AT 301 LEEWARD. EXPOSURE TO POSIBLE INFECTION DISEAS. DUE TO PHYSICAL CONTACT WITH PATIENT. FIRE FIGHTER/EMT FIRE Descr: FIGHTER/EMT N/A 09/12/2004 09/13/2004 3105132 GUTIERREZ, JOSEPH 10/07/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 73 CONTAGIOUS DISEASE Body y 66 NO PHYSICAL INJURY ide: Injury: Part: Accident MEDICAL CALL. POSSIBLE EXPOSURE TO POSSIBLE INFECTIOUS DISEASE AT 301 LEEWARD. DUE TO PHYSICAL CONTACT WITH PATIENT. FIRE FIGHTER FIRE FIGHTER N/A Descr. . 09/14/2004 09/15/2004 3105743 STEPHEN, SAILING 10120/2004 OTHER $0.00 $883.30 $0.00 $0.00 $883.30 Natureof 40 LACERATION ody_ ] 54 LOWER LEG id Left Injuy: art:-. ccident .� RUNNING STAIR DURING PHYSICAL FITNESS ACTIVITY FOR FIRE ACADEMY. FIRE FIGHTER RECUIT FIRE FIGHTER RECUIT NONE Descr:. ` 09/15/2004 09/17/2004 3106263 PONCELOW, ROBERT 10/20/2004 STRIKE -STATIONARY OBJECT $0.00 $756.13 $0.00 $0.00 $756.13 Nature of 52 STRAIN Body, , 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide: Injury: WHILE EXITING THE SHOWER ROOM AND WALKING TO THE STIAR I RAN INTO THE EXIT SIGN WHICH WAS BURNED OUT NOT VISIBLE IN DARK. WHEN HIT LIGHT BACK POPPED OUT. ccident Descr: EXITING THE SHOWER ROOM B/C NONE Page 10 01n3120090845 AM MCis UW651R PINN/I COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01/0112006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data asof:01/23/2009 Policy Period: 01/0112004 thru 01/01/2005 Claim 'I Worker ;Closed . Accident Report: Claim Injured Wo Ex enses'I Me - •, � P �-lodePaid Date Received Number Name n ry 'Date Injury Cause ' _ Paid ,Paa .Reserve Incurred /2004 3106512 GILLESPIE, JEFFREY 10/26/2004 STRUCK BY -TOOL, MACHINE $0.00 $ o.00 $o 00 $0.00 $0.00 Nature o0f41000 Bod 51 HIP ide Left Injury: 7:. Part: DOING FORCIBLE ENTRY TRAINING. WAS HOLDING HALLIGAN BAR TO DOOR JAB AND PERSON WAS SUPPOSE TO DRIVE HOLLIGAN INTO DOOR. PERSON MISSED HIT ME IN LEFT Accident Descr: HIP. TRAINING TRAINING FIRE FIGHTER 09/18/2004 09/20/2004 3106515 SIMMS, RONALD 09/24/2004 STRIKE-STEP,SHARP OBJECT $0.00 $415.16 $0.00 $0.00 $415.16 Nature of Injury:..,. 43 PUNCTURE Body: 35 HAND ides' Right art: MOVING PATIENT TO BACKBOARD WITH CRED. RUBBER GLOVED HAND DOWN LEFT LEG FELT POKE. MOVE PATIENT & LATER SAW PATIENT GLUCOMETER SITTING WHERE ccident- Descr � �'. RECEIVED THE POKE. FIRE FIGHER/EMT FIRE FIGHER/EMT N/A 10/11/2004 10/14/2004 3110577 MILLER, STEVEN 12/03/2004 OTHER $0.00 $248.32 73 CONTAGIOUS DISEASE b-od-y-1 66 NO PHYSICAL INJURY $000 $0.00 ide: 1 $248.32 Nature of Injury: ,,;, art: , BLOOD TEST CONDUCTED AS PART OF EMPLOYER PHYSICAL RESULTED IN POSITIVE HEP C READING UNKNOWN WHEN EXPOSURE OCCURED. ASSIGNED TO OFFICE JOB LAST 6 Accident Descr:. YEARS. UNKNOWN UNKNOWN NONE 10/15/2004 11/16/2004 3115902 STACHURSKI, JUDY 01/25/2005 STRAIN-HOLDING,CARRYING $0.00 $0.00 52 STRAIN Body ,_ 42 LOW BACK (LUMBAR & LUMBO-SACRAL) $0.00 $0.00 $0.00 Nature of Injury:-, MOVING EMPTY COT OUT OF AMBULANCE,LEGS OF COT CAME DOWN BUT DID NOT LOCK, SO WHEN WHEELS LEFT FLOOR OF AMBULANCE, COT FELL TO GROUND. FIRE FIGHTER ccident Descr.::. FIRE FIGHTER N/A 10/19/2004 10/20/2004 3111693 RICHARDSON, BRIAN S 01/03/2005 CAUGHT -OBJECT HANDLED $77.73 $5,725.75 $5 68583 $0.00 $11,489.31 Natured 49SPRAIN b-o-dy-1 37 THUMB ide: Injury: I art:_ ": PERFORMING LADDER DRILLS WHEN MY THUMB GOT CAUGHT BETWEEN THE RUNGS OF THE LADDER AND GOT BENT BACK. DRILLS DRILLS YES Accident Descr`. 10/19/2004 10/28/2004 3112916 ZIMMERMAN, ALLEN R 12/03/2004 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature'of 59ALL OTHER ;Body _ 44 CHEST (INCL RIBS, STERNUM, SOFT TISS) ide:.- : Injury: art. ccident° PHYSICAL FITNESS TEST AT CSU, DURING THE STRESS TEST THE DOCTOR NOTICED TO LON OF A STANCE BETWEEN ST ST WAVES ON EKG. STOPPED ACTIVITY UNTIL Descr CARDIOLOGIST CLEARS ME FOR DUTY. FIRE FIGHTER FIRE FIGHTER N/A 10/19/2004 10/19/2004 3111438 ENGLAND, GARNET 12/08/2004 STRAIN -LIFTING $0.00 $0.00 $0.00 $0.00 52 STRAIN ody ;; 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide: Part . MOVING ITEMS IN STATION FOR REMODEE, BACK (LOWER) BEGAN TO HURT AND THEN BEGAN TO TIGHTEN UP. MOVING ITEMS MOVING ITEMS FOR REMODEL NONE $0.00 atureof njury:: ccident. Descr: , 11/05/2004 11/08/2004 3114677 SAXBURY, LYNDEL 11/10/2004 OTHER $12.10 $0.00 03 ANGINA PECTORIS Body 44 CHEST (INCL RIBS, STERNUM, SOFT TISS) $0.00 $0.00 $12.10 Nature of Injury:;..... , Part:,. ] CO SAXBURY EXPERIENCES SUDDEN ONSET ILLNESS WHITE @STATION. SYMPTOMS WERE CONSISTENT WITH POSSIBLE CARDIAC EVENT. TRANSPORTED TO PVH EKG &CAT ccident Descr.:? NEGATIVE SUSPECTED INNER EAR INFECTION, FIRE FIGHTER FIRE FIGHTER NONE Page 11 01R31200906.45 AM MCIS UW651R PINNAA COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01/01/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PR(1TFCTICIN nlRTRICT Data as of:01/23/2009 Policy Period: 01/01/2004 thru 01/01/2005 Claim Accident: Report Claim^ ',Injured,Worker -Closed - Expenses". Medical :. Indemnity ., ','Current; 'Total - Date Received'. Number Name. Date 'Injury Cause Paid' . 'Paid Paid. • Reserve Incurred 11/06/2004 11/08/2004 3114687 VANGORDER, JIM 11/10/2004 FALL OR SLIP FROM DIFFERENT LEVEL $0.00 $0.00 $0.00 $0.00 $0.00 Nature 7of 49 SPRAIN Body 51 HIP ide: Right Injury:;: ccident- USING TENDER 12 AS PLATFORM TO PROVIDE HEIGHT TO ACCESS FLUORSCENT FIXTURES @ CEILING LEVEL CHANGE OUT LAMP. FOOT SLIPPED AND FELL TO CONCRETE FLOOR. Descr: . FIRE FIGHTER FIRE FIGHTER LIGHT 11/24/2004 11/30/2004 3117877 ROBERTS, NANCY 12/30/2004 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59ALL OTHER Body 66 NO PHYSICAL INJURY idea. Injury: Part: Accident- " WHILE RESPONDING TO MEDICAL CALLA EXTINGUISHER FELL OFF THE CAB WALL AND DISCHARGED WHEN IT HIT THE FLOOR. FIRE FIGHTER FIRE FIGHTER N/A Descr:' 11/24/2004 12/01/2004 3118163 HATFIELD, RANDALL 12/30/2004 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59ALL OTHER ody . 66 NO PHYSICAL INJURY ide: Injury:..; Part:,, .: ccident WHILE RESPONDING TO CALL A SMALL FIRE EXTINGUISHER FELL OFF OF CABWALL HITTING THE CAB FLOOR DISCHARGING. FIRE FIGHTER FIRE FIGHTER N/A Descr: 11/24/2004 12/01/2004 3118177 HERGENREDER, TERI 12/06/2004 OTHER $0.00 $0.00 $000 $0.00 $0.00 Nature7of 59ALL OTHER Body7 65 INSUFFICIENT INFO TO PROPERLY IDENTIFY -UNCLASSIFIED ide:_ Injury:,; art: ._ ccident + WHILE RESPONDING TO A CALL A SMALL FIRE EXTINGUISHER FELL OF THE CUB WALL, HITTING THE CAB FLOOR AND DISCHARGING. FIRE FIGHTER/DRIVER FIRE FIGHTER/DRIVER Descr."' NONE 12/14/2004 12/20/2004 3121101 NEWBERRY, DOUGLAS 02/14/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $126.96 $0.00 $0.00 $126.96 INJURY Nature of 59ALL OTHER Body f; 66 NO PHYSICAL INJURY ide: Injury:--_'. Part:: ccident ON FRIDAY 17 OF DEC WAS NOTIFID BY PFA ADMIN THAT I WAS EXPOSED TO PATIENT WITH NENINGITIS. EXPOSURE WAS 3 DAYS PRIOT TO NOTIFICATION. WENT TO OHS WAS 'Sc', GIVEN ANTIOBIOTICS. EMT ON PFA ENGINE 5 EMT ON PFA ENGINE 5 N/A 12/14/2004 12/28/2004 3122216 MORAN, JOHN 01/10/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $126.96 $0.00 $0.00 $126.96 INJURY ature of 73 CONTAGIOUS DISEASE ody 66 NO PHYSICAL INJURY Side:: Injury:, -.. art: ccident. MENINGITIS EXPOSURE FIRE FIGHTER FIRE FIGHTER NOT PROVIDED Descr. 12/17/2004 12/20/2004 3121111 LONG, GARY 02/11/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $239.93 $0.00 $0.00 $239.93 INJURY Natureof 59ALL OTHER ody : �. 66 NO PHYSICAL INJURY ide: -: Injury: art: Accident RESPONDED TO MEDICAL CALL RECEIVED NOTIFICATION IN AFTERNOON 12-17 THAT PATIENT HAD MENANGINITIS AND WENT TO OHS WAS GIVEN TREATMENT. FIRE FIGHTER/EMT escr.: FIRE FIGHTER/EMT N/A 12/19/2004 12/20/2004 3121115 KETTLE, RALPH 02/18/2005 CUT TOOL, NOT POWERED $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 40 LACERATION ody 37 THUMB ide: ; Injury:.. Pad: SHARPENING KITCHEN KNIVES, LACERATED THE THUMB ON RIGHT HAND. LACERATION IS APPROX 3/8" IN LENGTH ON LEFT SIDE OF THUMB PDXIMAL TO THE NAILBED. FIRE rccident Descr FIGHTER FIRE FIGHTER N/A Page 12 01/231200903:45AM PWCis UW651R PINN/I Standard Loss Run Report COL Data as of 01/23/2009 Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01/01/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Period: 01/01/2004 thru 01/01/2005 PROTECTION DISTRICT Policy Period Totals: Total Claims: 94 $661.42 $34,944.61 $97,770.49 $0.00 $133,376.52 Open: 0 Open: $0.00 $0.00 $0.00 $0.00 Closed: 94 Closed: $661.42 $34,944.61 $97,770.49 $133,376.52 Average: $7.04 $371.75 $1,040.11 $1,418.90 Minimum: $0.00 $0.00 . $0.00 $0.00 Maximum: $342.80 $6.786.72 $60,000.00 $64,171.01 Page 13 012X200908:45 AM alaas UW651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01/01/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2005 thru 01/01/2006 Claim.'. ..Accident Report Claim Injured Worker _ _- Closed -' Expenses Medical 'Indemnity. Current Total Date Received. _ Number Name _ Date Injury Cause Paid Paid Paid Reserve Incurred .. 01/06/2005 01/06/2006 3182252 DELANEY, DEAN M 01/1712006 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $0.00 $0.00 $0.00 $0.00 PATIENT Natureof 73 CONTAGIOUS DISEASE Body 15 NOSE itle: '. Injury: art:, ccident PATIENT WAS COUGHING & SPITTING WHILE THEY GAVE EMS, LATER TOLD HE MAY HAVE TB FIRE FIGHTER/EMT FIRE FIGHTER/EMT NONE Descr: 01/19/2005 01/19/2005 3125832 RUSSELL, ANDREW 03/22/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73CONTAGIOUS DISEASE Body 66 NO PHYSICAL INJURY ide:- Injury: Part: ccident.. PERFORMING ON UNRESPONSIVE PATIENT BODY FLUID & URINE ALL OVER BED TOLD AS LEAVING PATIENT HAD HEPATITIS C. EXPOSED ENTIRE CALL. FIRE FIGHTER/EMT FIRE Descr: I FIGHTER/EMT N/A 01/19/2005 01/19/2005 3125847 HANSON, BRYAN 08/23/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $6.67 $0.00 $0.00 $0.00 $6.67 INJURY Nature of 73 CONTAGIOUS DISEASE Body ,. 66 NO PHYSICAL INJURY ide: Injury: Part: Accident PATIENT HAD BODY FLUIDS URINE & BLOOD ON HIMSELF AND BED. LIFTING PATIENT TO BOARD TOUCHED ARM AND CHEST. WIFE TOLD HE HAD HEP C AS THEY WERE LEAVING. escr: FIRE FIGHTER/EMT FIRE FIGHTER/EMT N/A 01/31/2005 02/01/2005 3127719 EWY, LEONARD 04/04/2005 CAUGHT -OBJECT HANDLED $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 49 SPRAIN Body '. 35 HAND ide: Right Injury: Part:' ccident • IN PROCESS OF DEPLOYING HOSELNE ON STRUCTURE FIRE SOMEHOW JAMBED MIDDLE FINGER ON RIGHT HAND. REALIZED IT WHEN FIRE WAS OUT. FIRE FIGHTER FIRE FIGHTER Descr:a HOSE 02/02/2005 02/02/2005 3128017 BERG, SHARON 0311712005 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $193.64 $0.00 $0.00 $193.64 PATIENT ature of 73 CONTAGIOUS DISEASE Body 48 INTERNAL ORGANS Side: ` Injury: �, Part:. ccident EXPOSED TO PATIENT WITH WHOPPING COUGH, PATIENT CARE PATIENT CARE NONE Descr." 02/02/2005 02/02/2005 3128021 STAUFFER, LYNN 03/17/2005 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $0.00 $0.00 $0.00 $0.00 PATIENT Nature of 73CONTAGIOUS DISEASE Body : 48 INTERNAL ORGANS ide: Injury: Part. Accident EXPOSED TO PATIENT WITH WHOOPING COUGH. FIRE FIGHTER/EMT FIRE FIGHTER/EMT NONE escri 02/02/2005 02/02/2005 3128041 MCGAFFIN,SHAWN 03/17/2005 OTHER $0.00 $0.00 $000 $0.00 $0.00 Nature of 73 CONTAGIOUS DISEASE Body - 48 INTERNAL ORGANS Injury: f part: EXPOSED TO PATIENT WITH WHOOPING COUGH, FIRE FIGHTER FIRE FIGHTER NONE ccident Descr: Page14 Cla320090845AM MCIS UW651R PINN/I\COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01101/2004 and 01/01/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data asof:01/23/2009 Policy Period: 01/01/2005 thru 01/01/2006 Claim:.- '. - Accident Report- Claim .Injured Worker _ ;, �. .Closed' , t Expenses, -. ,Medical Indemnity �;.: - "Current - Total Date .Received Number Name .. Date - Injury - <. .i : Paid 9 Paid Paitl ',�Reserve . Incurred ' 02/21/2005 02/22/2005 3131271 RICE, SPENCER 03/23/2005 STRIKE-STEP,SHARP OBJECT $0.00 $144.41 $0.00 $0.00 $144.41 atureof 43PUNCTURE Body,:" 56 FOOT ide: Right njury: art: WE WERE DISSAMBELING PALLETS TO BURN IN BURN HOUSE. STEPPPED ON PALLET & NAIL PENETRATED THROUGH RIGHT SHOE AND INTO FOOT. ACADEMY ACADEMY NONE ccident, Descry.. I' 03/01/2005 03/03/2005 3132893 STANCZYK, QUENTIN 05/02/2005 STRAIN -REACHING $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 49SPRAIN B dy. 51 .HIP ide: Left Injury:.. ,, part: REACHED ACROSS TAILGATE TO GET SCBA FELT A TWINGE IN THE LEFT HIP SCIATIC AREA. WORKING OUT LATER AT THE # 1 MUCH BIGGER TWINGE. FIRE FIGHTER/INVESTIGATE ccident' Descr...-.1I FIREFIGHTER/INVESTIGATE NONE - 03/01/2005 03/01/2005 3132401 STANCZY, CLIENT 0311712005 STRAIN -REACHING $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 49SPRAIN ody 51 HIPSid Injury: -. EMPLOYEE STATES, "REACHED ACROSS TAILGATE Part: TO GET SCBA, FELT TWINGE IN THE LEFT HIP, SCIATIC AREA. WORKING OUT LATER AT STATION 1, MUCH BIGGER TWINGE. ccident Descc�:z-..:: -. UNLOADING TRUCK AND WORKING OUT UNLOADING TRUCK AND WORKING OUT UNKNOWN 03/03/2005 03/04/2005 3132959 WILSON, MICHAEL 09/20/2005 MISCELLANEOUS STRAIN OR INJURY $102.00 $5,403.01 $7,507.64 $0.00 $13,012.65 atureof Injury: -. 49SPRAIN SQUATTED DWON STOOD BACK UP, FELT SLIGHT : ody _ 53 KNEE Pa rt POP AND SHARP PAIN IN RIGHT KNEE 30 SEC TO RE -STRAIGHTEN LEFT POP WITH PAIN EACH "ide:: Right STEP PAIN SEVER 2-3 MORE TIMES Accidents:,.: Descri , %d FIRE FIGHTER FIRE FIGHTER N/A " 03/03/2005 03/03/2005 3132900 LINDERHOLM, KRISTINE 12/28/2006 FALL -SLIP, NO FALL $341.96 $20,794.92 $9,009.33 $0.00 $30,146.21 Nature of 49SPRAIN ody 1 52 UPPER LEG Side:. Injury: ::. E STEPPING BACKWARDS OFF ENGINE FROM THE _ Part: JUMP SEAT & MISSED THE LOWER STEP, LANDED ON MY RIGHT FOOT, WRENCHING KNEE & FALLING TO THE GROUND. FIRE ccident:: Descr;; �_'J FIGHTER FIRE FIGHTER NONE 03/17/2005 03/18/2005 3135213 HERGENREDER, TERI R 04/29/2005 STRAIN -PUSH ING, PULLING $0.00 $0.00 $0.00 $0.00 $0.00 atureof 52STRAIN Body 38 SHOULDER($) ide:' I njury� EMPLOYEE PULLING DUMMY THROUGH WINDOW DURING TRAINING STRAINED SHOULDER TRAINING EVOLUTION TRAINING EVOLUTION UNKNOWN - ccident Descr:-'•- 03/20/2005 03/22/2005 3135688 BOWLES, HEATHER 05/27/2005 STRIKE -STATIONARY OBJECT $0.00 $946.48 $0.00 $0.00 $946.48 Nature :of 1000NTUSION g ody 36 FINGER(S) nj ury:... =' WHILE GETTING INTO THE FIRE ENGINE I -BANGED �art: MY MIDDLE FINGER FIRE FIGHTER FIRE FIGHTER N/A ccident:-. Descr. 03/28/2005 03/30/2005 3136983 KOBIELUSZ, BRAD 05/10/2005 STRAIN -LIFTING $0.00 $71.37 $0.00 $0.00 $71.37 ature of Injury: rr 52 STRAIN ody 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Part: ': : TAKE A HEAVY PATIENT AND COT DOWN AN AWKWARD STAIR AREA. STRAIN TO LEFT SIDE BACK THRU AREA OF BACK. FIRE FIGHTER FRE FIGHTER ide: N/A Accident escri " Page 15 o123noo9a6:45AM Rwcis UW651R PINNAA COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01/01/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2005 thru 01/01/2006 Claim Accident'. Report Claim., . Injured Worker Closed -- - !Expenses ", "Medical Indemnity Current Total Date.., Received'. Number' -Name <.. 'Date In•u Cause. Paid.. _. Injury .,�r ',,::; Paid' Reserve Incurred'; Paid 04/03/2005 04/04/2005 3137689 DELANEY, DEAM 05/27/2005 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 59ALL OTHER Body 48 INTERNAL ORGANS ide: Injury: Part: AAccident. INHALATION OF FUMES FROM AIRPLANE FUEL FIRE FIRE FIGHTER FIRE FIGHTER N/A Descr: 04/18/2005 04/20/2005 3140342 DEBAERE, DUSTIN 05/19/2005 FALL OR SLIP FROM LIQUID OR GREASE $0.00 $362.30 $0.00 $0.00 $362.30 SPILLS Nature of 10 CONTUSION Body. �,. 44 CHEST (INCL RIBS, STERNUM, SOFT TISS) Left Injury:.. Part: -' "ide:. ccident " FELL WHILE RUNNING DURING PHYSICAL TRAINING LANDING ON MY LEFT SIDE INJURING MY RIBS IN THE FRONT & SIDE OF RIBCASE. FELL DUE TO WET GRASS. TRAINING TRAINING Descr:-,.,.�.. NOT PROVIDED 04/19/2005 04/21/2005 3140534 RICE, SPENCER 06/08/2005 STRAIN -LIFTING $0.00 $739.26 $0.00 $0.00 $739.26 Natureof 52 STRAIN ody • 42 LOW BACK (LUMBAR & LUMBO-SACRAL) .ide: Injury: '.. art: Accident PRAICING FIREFIGHTER RESUCE TRIED TO LIFT AND FELT POP IN LOWER BACK. COMPLETED DRILL BEGAN TO DO DIFFERENT STRETCHES AFTERWARDS. FIRE FIGHTER RECRUIT Descr:[. `'�' FIRE FICTGHTER RECRUIT NOT PROVIDED 04/27/2005 05/02/2005 3141985 PIERTRANGELO, JIM 05/24/2005 FALL OR SLIP FROM LADDER OR $0.00 $0.00 $0.00 $0.00 $0.00 SCAFFOLDING Nature of] 10 CONTUSION Body 62 BUTTOCKS ide:.. Right Injury: ccident.- INSTRUCTING STUDENT ON LADDER PLACEMENT. FELL INTO WINDOW WELL LANDING ON RIGHTBUTTOCK HIT METAL EDTE. FELL APPROX 3 FEET. TRAINING OFFICER TRAINING Descr:' OFFICER NOT PROVIDED 04/29/2005 05/02/2005 3142002 BARELA, TYSON R 06/24/2005 STRAIN -LIFTING $0.00 $2,342.34 $0.00 $0.00 $2,342.34 Nature of 52STRAIN Body :, 38 SHOULDER(S) Injury: ccident:. • PULLING HOSE EXPERIENCED PAIN THROUGH BACK SHOULDERS & ARMS - NUMBNESS IN EXTREMITIES FOLLOWED PAIN. FIRE FIGHTER TRAINING FIRE FIGHTER TRAINING NOT Descr.;'#, ,s PROVIDED 05/17/2005 05/18/2005 3144645 JONES, SEAN 06/27/2005 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 atureof 59ALL OTHER ody ', 66 NO PHYSICAL INJURY Injury: '. Part: Yide: ccident:::,; WHILE TREATING A PATIENT (WHO HAD FARILY AGGRESSIVE STAFT INFECTION ON ARMS) PATIENT MADE DIRECT SKIN TO SKIN CONTACT WITH ME. FIRE FIGHTER/EMT FIRE Descr:; :: FIGHTER/EMT N/A 05/17/2005 05/18/2005 3144661 MILLER, GREGG 06/27/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59ALL OTHER Body 66 NO PHYSICAL INJURY ide: ;.., Injury: ` _�,: Part ccident. • WHILE TREATING A PATIENT WITH A FAIRLY AGGRESSIVE STAPH INFECTION ON HER ARMS, DIRECT CONTACT WAS MADE BETWEEN AND MYSELF. FIRE FIGHTER FIRE FIGHTER N/A Descr... 05/17/2005 05/18/2005 3144659 ANDUSS, MURRAY 06/27/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY atureof 59ALL OTHER ody _ 66 NO PHYSICAL INJURY Injury:, j art:; ; "idei AccidentWHILE TREATING A PATIENT WITH A FAIRLY AGGRESSIVE STAFF INFECTION ON HER ARM, DIRECT CONTACT BETWEEN THE PATIENT AND MYSELF WAS MADE. FIRE FIGHTER/EMT Descr. ," FIRE FIGHTER/EMT N/A Page 16 01n3rz0090845 AM wads UW651R See Addendum Attachments - Cost Containment Certification Obtained from DOL Dec. 5, 2001 provides for 5% discount. Details on loss sensitive plan include an existing grandfathered dividend plan. - 5 Year audited premiums: ■ 2008 - $285, 679 ■ 2007 - $247,906 ■ 2006 - $257, 711 ■ 2005 — $262, 837 • 2004 - $253, 983 8. Please confirm that the attached 2008 Payroll by Class Code are the payrolls you want to use as estimated payrolls for the 2009 renewal. - An attachment has been added to this addendum providing 2009 estimated payroll with an increase of 2.7% 9. The Retained Limit Coverage Application lists 96 Misc. Autos. Can you describe what these autos are? - An attachment has been added to this addendum to more closely detail each auto classification category and total vehicles. The Munich Retained Limit Coverage application, Section III Auto Liability Coverage should be changed to reflect the current addendum attachment "Vehicles by Category Combined". 10. How many miles of streets and roads do the City of Fort Collins serve? - 504 center lane miles and 1,779 total lane miles. 11. The Retained Limits Coverage application list one Psychologist. Can you explain the role of this employee and if any other medical staff is employed by the City? - The Psychologist listed is an employee of Fort Collins Police Services (FCPS) and utilizes his psychologist credentials within the FCPS department only. He does not provide professional services to any other organizations either within or outside the City of Fort Collins. - The City of Fort Collins employs no other medical staff. This includes Nurses. PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01/01/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2005 thru 01/01/2006 `.. Claim ;Accident Report- .. Claim .Injured Worker 1 ', Closed :,,.. ,.Expenses :Medical �Indemnity �. Current _ �. Total •'Date '•' Received Number Name Date. In'/ ury Cause, Paid:: Paid Paid. Reserve. Incurred 05/24/2005 05/25/2005 3145755 TENNYSON, GREG W 06/29/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59 ALL OTHER Body,. 66 NO PHYSICAL INJURY ide: Injury:•,+ Part: ccident- ODOR INVESTIGATION - POSSIBLE EXPOSURE TO UNKNOWN ORGANIC SUBSTANCE. FIRE FIGHTER FIRE FIGHTER N/A Descr) 05/24/2005 05/25/2005 3145762 ROOT, ROBERT C 06/29/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59ALL OTHER Body 66 NO PHYSICAL INJURY ide: Injury: Part:. ; ccident±r;: ODOR INVESTIGATION -POSSIBLE EXPOUSRE TO UKNOWN ORGANIC SUBSTANCE FIRE FIGHTER FIRE FIGHTER NA/ Descr. ' 05/24/2005 05/25/2005 3145753 LIPPERT, JOHN C 06/29/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 59ALL OTHER Vod-Tj 66 NO PHYSICAL INJURY Injury:,: Part: ccidenf� RESPONDED TO ODOR WITH PERSON ILL, INITIALLY TO CHECK FOR LOCATION OR PROBLEM FOUND IN BASEMENT, EXPOSURE UNKNOWN OF CHEMICAL SPILLED ON SHELF FIRE Descr: , FIGHTER FIRE FIGHTER N/A 05/25/2005 05/25/2005 3145818 GALLEGOS, ARTURO 06/29/2005 CUMULATIVE (ALL OTHER) $0.00 $822.55 $0.00 $0.00 $822.55 ature-of 52 STRAIN 9;dy. 54 LOWER LEG _Pkd­a-.__j Left Injury:.: art: INJURY OCCURED WHILE RUNNING ON GRASS. FELT PAIN STOPPED AND LAYED ON GROUND. PHYSICAL TRAINING. PHYSICAL TRAINING PHYSICAL TRAINING N/A ccident, Descr: , 06/06/2005 06/08/2005 3147967 ARNOLD, STRAUSS 06/30/2005 MISCELLANEOUS STRIKING AGAINST OR $0.00 $252.25 $0.00 $0.00 $252.25 STEPPING ON ature.of 52STRAIN ody- : 38 SHOULDER(S) Side:- Left njury. Accident :'..: DISMOUNTING FROM BED OF PICKUP STAKEBED, MY FOOT SLIPPED CAUSING BODY TO ROTATE ON LEFT ARM STRAINING A CURRENT INJURY FIRE FIGHTER FIRE FIGHTER N/A Descr: 06/10/2005 06/16/2005 3149207 VANGORDER, JIM 08/09/2005 MISCELLANEOUS STRAIN OR INJURY $0.00 $2,951.82 $0.00 $0.00 $2,951.82 Nature.of 52 STRAIN Body. 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Side: Injury: -'' DURING A FIREFIGHTER RESCUE DRILL JIM FELT art:. A SLIGHT DISCOMFORT IN HIS LOWER BACK. OVER THE NEXT FEW DAYS THE PAIN GOT WORSE RESCUE TRAINING RESCUE Accident. Descr..;, TRAINING N/A 06/14/2005 06/15/2005 3148970 WEBER, BRETT M 07/05/2005 MISCELLANEOUS MOTOR VEHICLE $0.00 $1,340.68 $0.00 $0.00 $1,340.68 Natureof 49 SPRAIN Body 1.. 37 THUMB ide. njury; ,!:; . RESPONDING TO EMERGENCY CALL IN VEHICLE iPart: ACCIDENT RESPONDING TO CALL RESPONDING TO CALL NONE ccident: Descr. 06/14/2005 06/15/2005 3148965 ALBRANDT, CHARLES H 07/12/2005 MISCELLANEOUS MOTOR VEHICLE $25.83 $1,198.85 $0.00 $0.00 $1,224.68 Natureof 49SPRAIN Body.," 21 NECKVERTEBRAE 1de:, Injury: i.. Part : IN VEHICLE ACCIDENT ON ROUTE TO EMERGENCY RESPONSE FIRE FIGHTER (COMPANY OFFICER) FIRE FIGHTER (COMPANY OFFICER) NONE Accident Descr. Page 17 012MM906:45 AM nwcis UW651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01101/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2005 thru 01/01/2006 Claim Accident Report Claiim Injured Worker Closed' .. %'Expenses. 'Medical �. .Indemnity Current Total 'Date Received l. Number Name. < Date ,;_ Injury Cause,.} : - Paid Paid •,. Paid _ Reserve Incurred . 06/1512 005 06/16/2005 3149211 KETTLE, RALPH 06/15/ 08/04/2005 MISCELLANEOUS'STRAIN OR INJURY $0.00 $582.23 $0.00 $0.00 $582.23 of 52 STRAIN ody 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide: r Inj ury: Part: ccident) I WAS PRACTING AFIRE FIGHTER RESUCE DRILL PICKED UP LEGS OF DOWN FIRE FIGHTER TO HELP MOVE HIM UPSTAIRS. FELT A POP IN LOWER RIGHT BACK FOLLOWED UP BY Descr:.. SLIGHT PAIN. RESCUE TRAINING RESCUE TRAINING N/A 06/17/2005 06/20/2005 3149785 GILLESPIE, JEFFREY 06/22/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE 'body 66 NO PHYSICAL INJURY ide:, Injury:".: IPart: Accident ":' WHILE PERFORMING CPR ON PATIENT BECAME EXPOSED TO BLOOD AND OTEHR FLUIDS. PERSONAL PROTECTION EQUIPMENT IN PLACE. VICTIM HAD HEPATITIS C. EMS/CPR Descry" EMS/CPR NONE 06/17/2005 06/20/2005 3149780 MACCARINI, GENE F 06/22/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE ody . 17 MOUTH Side:: Injury: .,Fait: ccident':; WHILE PERFORMING CPR ON PATIENT WE BECAME EXPOSED TO BLOOD & OTHER BOD FLUIDS. PERSONAL PROTECTION EQUIPMENT WERE IN PLACE. VICTIM WAS FOUND TO HAVE Descr:i, HEPATITIS C. EMT EMT NONE 06/17/2005 06/20/2005 3149782 CAPE, RICHARD 06/22/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY atuie of 73 CONTAGIOUS DISEASE ody . 66 NO PHYSICAL INJURY ide: Injury:... art: ccitlent -I: WHILE PERFORMING CPR ON PATIENT WE BECAME EXPOSED TO BLOOD AND BODY FLUIDS. BARRIER PRECAUTIONS WERE IN PLACE. VICTIM HAD HEPATITIS C. OFFICER ER Descr:'; - `� OFFICER ER NONE 06/25/2005 06/27/2005 3151016 LOVE, PATRICK S 08/26/2005 CUT- MISCELLANEOUS $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 40 LACERATION go-dy7, 36 FINGER(S) ide: Injury:- art: ccident. I WAS SLICING TOMATOES FOR DINNER WHEN THE KNIFE SLIPPED AND CUT OFF 1/4" DIAMETER TIP OF INDEZ FINGER ON LEFT HAND. CO CO NONE Des.cr:;,t. 07/01/2005 07/01/2005 3152079 PIETRANGELO, JIM H 03/30/2006 STRUCK OR INJURED BY FELLOW WORKER, $120.51 $673.95 $0.00 $0.00 $794.46 PATIENT Natureof 52STRAIN Body •. 33 LOWER ARM ide:. Right Injury:, Part:. Accident + : HAD SURGERY ON RIGHT SHOULDER 2 WEEKS AGO. IN SLING & SWATH. TURNED AROUND AN OFFICE PARTITION & CAUGHT SLING ON PARTITION AND IT YANKED RIGHT ARM. OUT baser: OF SLING 8 INCHES.I WAS ON LIGHT DUTY. LIGHT DUTY IN TRAINING ROOM LIGHT DUTY IN TRAINING ROOM NONE 07/15/2005 07/18/2005 3154653 HORNING, WILLIAM C 09/08/2005 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 52STRAIN ody-•'+ 52 UPPER LEG Left Injury: ` :. art: Accident IN CLASS STOOD UP FOR BREAK THERE WAS CRAMPING AND TIGTNESS IN LEFT HAMSTRING TRAINING TRAINING NONE Descr:, 07/19/2005 07/20/2005 3155029 JONES, SEAN E 08/30/2005 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59 ALL OTHER Body 56 FOOT Injury::,, WEARING LEATHER WILD LAND BOOTS WHICH Part: CAUSED LARGE BLISTERS ON BOTH HEELS. ON GRASS FIRE FIRE FIGHTER FIRE FIGHTER N/A Accident D"cr. Page 18 0123nM90845 AM Pwcis UW651R PINN//\COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01/01/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2005 thru 01/01/2006 . :Claim'.- -. :. -'. -. , Worker -( s Me ExpePald,_ In ` 'Current .Total . Date Received Received Number Named ,De Date `:InjuryCause,` '. _ . ' :- „', Pad Pald` : Reserve ;Incurred 07/31/2006 08/01/2005 3157022 CHAMBERS, TERRY L 09/28/2005 FOREIGN BODY IN EYE $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 25 FOREIGN BODY Body 14 EYE(S) ides- Right Injury: WAS LOADING SPARE SCOTT PACKS TO TOP SHELVES Part: OF SQUAD PIECE OF DEBRIS LANDED IN MY RIGHT TYE & IMMEDIATELY HUT TREADY BY PARAMEDICS WITH WATER & IV Accident escr: SOLUTION TO WASH DEBRIS FROM EYE PICKING UP SPARE PACKS PICKING UP SPARE PACKS N/A 07/31/2005 08/01/2005 3157017 LEMAN, LEMAN 09/08/2005 STRAIN -PUSH ING, PULLING $0.00 $0.00 $0.00 $0.60 $0.00 Natureof 52STRAIN Body 38 SHOULDER(S) P'id;77 Left Injury. J Part LEMAN WAS PULLING LADDERS OFF OF ENGINE 4 TO CONDUCT VENT ENTER SEARCH FIRE OPERATIONS WHEN HE INJURED HIS LEFT SHOULDER FIRE FIGHTER FIRE FIGHTER N/A ccident, Descry 08/03/2005 08/04/2005 3157874 LYNXWILER, JAMES R 09/08/2005 STRIKE-STEP,SHARP OBJECT $0.00 $0.00 $0.00 $0.00 $0.00 Nature of Injury: 43PUNCTURE Body 33 LOWER ARM Part:. SUSTAINED PUNCTURE WOUND TO LEFT FOREARM AS RESULT OF PAIR OF SCISSORS. BREAKING DOWN A CARDBOARD BOX WHEN SOMEHOW Side: ! Left SLIPPED AND JABBED MYSELF IN ccident_= Descr: - I THE ARM. FIRE FIGHTER FIRE FIGHTER N/A 08/08/2005 08/09/2005 3158508 MACCARINI, GENE F 09/28/2005 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Natureof Injury:'. ',. 49 SPRAIN ATTEMPTED TO OPEN STAND PIPE VALVE THAT Body-] 35 HAND art: WAS FROZEN SHUT. SOMETHING POPPED IN MY HAND. TRAINING TRAINING N/A ide: - Right Accident-. Descr.. 08/18/2005 08/19/2005 3160527 LEVY, GLENN M 09/29/2005 MOTOR VEH-COLLNEHICLE $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 52 STRAIN Body 21 NECK VERTEBRAE ide:fi nj6ry: art: I WAS DRIVING PFA VEHICLE STOPPED @ SB SHIELDS @ MOUNTAIN. WAS GOING TO TURN LEFT. LIGHT TURNED GREEN AND I WAS REAR ENDED BATTALION CHIEF BATTALION ccident.-- Desic,'- -> CHIEF N/A 08/24/2005 08/26/2005 3161845 GARNER, ROBERT 10/06/2005 MISCELLANEOUS STRIKE OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 40 LACERATION - ody ^.» 36 FINGER(S) ide: Injury:.'; REMOVING PAPER TOWEL FROM DISPENSER FINGER art: WAS PULLED INTO DISPENSER KNOB CAUSING SMALL AVULSION ON LEFT INDEX FINGER CLEANING CLEANING N/A ccident,-. Descr: 09/02/2005 09/14/2005 3164873 GUTIERREZ, JOSEPH 10/25/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY ature of 73 CONTAGIOUS DISEASE ody 66 NO PHYSICAL INJURY Side: Injury: Part: �` ccident:'a'. DEPLOYED AS A RESCUE WORKER TO HURRICANE KATRINA. I WORKED GETTING EVACUEES OUT OF THE WATER IN NEW ORLEANS RESCUE SPECIALIST RESCUE SPECIALIST N/A escr: 09/08/2005 09/09/2005 3164031 BENNETT, JASON S 09/12/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE Body 90 MULTIPLE BODY PARTS i de: Injury: ' Part: : Accident CHECKING MEDICAL KIT ON ENGINE DURING SHIFT CHANGE NOTICED DRIED BLOOD ON FEW ITEMS INDSIDE BAG. NO MEDICAL GLOVES USED. FIRE FIGHTER/EMT FIRE escr. FIGHTER/EMT NONE Page 19 01n3I2W908:45 AM mcis UW651R PINN/I COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01/0112006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2005 thru 01/01/2006 Claim .. .. Accident Report Claim ' Injured',Worker Closed -, Expenses Medical i Indemnity Current Total ^u :. Date ' ` Received. 'Number 'Name' - •. Date `.Injury Cause_ - Paid - " Paid Paid. Reserve - Incurred ' 09/08/2005 09/09/2005 3164034 WILSON, MICHAEL P 09/12/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 73 CONTAGIOUS DISEASE Body 90 MULTIPLE BODY PARTS ide,;,l- „ Injury: art: ccident ON CALL IN PROCESS OF PUTTING EQUIPMENT BACK IN BAG, MY HANDS CAME IN CONTACT WITH BLOOD ON OUR GEAR FROM A PREVIOUS CALL. FIRE FIGHTER FIRE FIGHTER escr: I NONW 09/09/2005 09/12/2005 3164386 CALLAHAN, RANDY 11/11/2005 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 04 BURN Body 7 54 LOWERLEG idea: Both - Injury:. - Part: Accident OPERATING PUMP PIT. HOSE RAPIDLY EXPANDED AGAINST LEGS. NO OBVIOUS INJURY AT TIME. BUT 24 TO 36 HOURS LATER DEVELOPED INTO A BURN INJURY TO BOTH LEGS. Descr:. MORE SEVERE TO LEFT LEG. CAPTAIN OF ENGINE COMPANY/FIRE FIGHTER CAPTAIN OF ENGINE COMPANY/FIRE FIGHTER N/A 09/21/2005 09/22/2005 3166226 DELANEY, DEAN M 11/02/2005 STRAIN -LIFTING $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 52STRAIN Body 38 SHOULDER(S) ide:, Right Injury: Part: ccidentb,z WAS LOADING 5 GALLON BUCKETS OF MICROBLAZE FOAM INTO TRUCK TO TAKE TO A HAZMAT CALL AT THE DODGE DEALER WHILE LOADING RIGHT SHOULDER GOT A SHARP PAIN Descr:.:; �,. '_..! IN IT. FIRE FIGHTER FIRE FIGHTER NOT PROVIDED 09/21/2005 09/22/2005 3166245 DINI, CHRISTOPHER 10/19/2005 STRAIN -LIFTING $0.00 $661.08 $0.00 $0.00 $661.08 Natureof 49SPRAIN :Body 34 WRIST 'Part: Side: Injury:.- -, ccident., PULLING UP A 2 112 INCH HOSE UP 4 STORIES VERTICALLY ON A ROPE FELT OVEREXTENSION OF WRIST NO DIRECT PAIN, SLIGHT TENDERNESS & RESISTANCE WHEN MOVING D6scr:', . ^ I THUMB. RECRUIT FIREFIGHTER RECRUIT FIREFIGHTER ROPE 09/22/2005 09/23/2005 3166489 ENGLAND, TIM 11/04/2005 FALL -SLIP, NO FALL $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 49SPRAIN Body 53 KNEE bide: '_ Injury:, art: ccident:. WHEN STEPPING OUT OF VAN AT DEPLOYED STAGING SITE FOR HURRICANE RITA ASSIGNMENT TIM TWISTED AND STRAINED HIS KNEE. USAR DEPLOYMENT USAR DEPLOYMENT Descr.'• NONE 09/22/2005 09/23/2005 3166496 BLOIS, STEPHEN 11/04/2005 FALL -MISCELLANEOUS $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 49SPRAIN g ody 51 HIP Side:; Left njury;.., Part: ccident:,.`. WHILE DEMOBILIZING @ SCENE OF TRENCH COLLAPSE WAS REPLACING EQUIP USED AT SCENE. WAS CARRYING STRONGBACK FORM WHEN TRIPPED WHILE WALKING BACKWARD Descrc , �1 FELL TO GROUND AND EQUIPMENT FELL ON ME FIREFIGHTER SUPERVISOR FIREFIGHTER SUPERVISOR NONE 09/26/2005 09/28/2005 3167256 WILSON, KEVINM 06/14/2006 FALL -MISCELLANEOUS $0.00 $1,877.76 $456.39 $0.00 $2,334.15 Natureof 28 FRACTURE ody: 32 ELBOW ide: Injury: Part: ccident:,: TRIPPED & FELL IN PARKING LOT HIT LEFT ELBOW SAMS, FORT COLLINS CO ON OFFICIAL BUSINESS REPORT FROM DOCTOR BROKEN ELBOW WALKING WALKING NONE Descr: 09/30/2005 09/30/2005 3167673 BUTLER, GEOFFREY 06/30/2006 STRAIN -LIFTING $199.17 $9,517.24 $4 563.94 $0.00 $14,280.35 Nature of 71 ALL OTHER OCCUPATIONAL DISEASE Pody 38 SHOULDER(S) ide` Injury: art: ccident FIRE TRAINING EXERCISE, CARRYING BACKPACK, USING TOOLS, LIFTING LOADS LED TO THIS. FIRE FIGHTER FIRE FIGHTER NONE Descr: Page 20 01=0090845 AM RWas UW651R PINNncOLStandard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01/01/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2005 thru 01/01/2006 . Claim.. Accident .Report Claim, ..Injured Worker , .Closed ,•. - EzpenseS• Medical Indemnity, Current Total Date =Received Number .Name Date ;InjuryCause - _" 'Paid 'Paid _ •Paid' ' Reserve - Incurred 10/05/2005 10/07/2005 3168952 DURRE, HOLGER 12/06/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 71 ALL OTHER OCCUPATIONAL DISEASE ody, 60 LUNG Injury: �'.'', Part: Accident INVESTIGATING FIRE, BUILDING WAS VENTILATED EXPOSED TO REMAINING PRODUCTS OF COMBUSTION. EXPERIENCED CHEST CONGESTION AND COUGHING N/A FIRE escr: - INVESTIGATOR N/A 10/08/2005 10/10/2005 3169089 WRIGHT, RANDALL 11/21/2005 STRAIN -LIFTING $0.00 $0.00 52 STRAIN ody 42 LOW BACK (LUMBAR & LUMBO-SACRAL) $0.00 $0.00 ide: $0.00 Natura of Injury:..,.., art: . CARRIED 300 LB CODE BLOCK OUT OF HOME ON BACK BOARD DECEASED PERSON LOCATED IN BACK BEDROOM TURN THRU CORNER HALLWAY THRU FAMILY ROOM. MID LEVEL ccitlent:.: Descr: a,. ''. BACK PAIN APPEARED OVER NIGHT. COMPANY OFFICER COMPANY OFFICER NONE - 10/10/2005 10/11/2005 3169292 GARNER, ROBERTL 11/30/2005 STRAIN-PUSHING,PULLING $0.00 $0.00 $0.00 $0.00 52STRAIN (Body„ 38 SHOULDER(S) ide: :., Left Part WE WERE PLAYING WATER POLO FOR PHYSICAL -TRAINING OPPONENT AND I GOING FOR BALL BOTH PUSHED AT BALL OPPOSITE DIRECTIONS FORCE CAUSED PAIN IN LEFT $0.00 Nature of Injury:. -•. ecidenti'+. Descr.:• .:"'I SHOULDER. PHYSICAL TRAINING PHYSICAL TRAINING NONE 10/17/2005 10/19/2005 3170804 ROOT, ROBERT C 12/19/2005 BURN -STEAM, HOT FLUIDS $0.00 $0.00 04 BURN Body ,. 33 LOWER ARM Part: SPRAY CAN OF MOLY LUBE LUBRICANT EXPLODED WHEN OPENING COMPARTMENT DOOR. MOLY LUBE SPRAYED OVER RIGHT HAND AND ARM $0.00 $0.00 side: -'.- Right COVERING ENTIRE ARM. OPENING $0.00 Nature of Injury:. ccident-". escr 11= COMPARTMENT DOOR OPENING COMPARTMENT DOOR NA 10/21/2005 10/25/2005 3171557 MCKEON, JONATHAN 11110/2005 MISCELLANEOUS STRAIN OR INJURY $0.00 $278.16 49SPRAIN g ody 7 53 KNEE $0.00 $0.00 Side:._ Left $278.16 atureof Injury: Yart:- r-. KNEE WAS IRRITATED WHILE CRAWLING, KNEELING DURING SCENARIOS. KNEE BECAME SWOLLEN. N/A TRAINING DRILLS N/A ccident Descr:." 11/09/2005 11/14/2005 3174704 PIETRANGELO, JIM H 12/14/2005 STRAIN -LIFTING - $0.00 $0.00 52STRAIN Body-] 38 SHOULDER(S) Part -• ; RESPONDED TO MVA REMOVED CHILD FELT SHARP PAIN IN SHOULDER AREA N/A FIRE FIGHTER N/A $0.00 $0.00 ide: Right $0.00 Natureof Injury:'- Accident escr: 11/09/2005 02/09/2006 3187800 PIETRANGELO, JAMES H 08/02/2006 STRAIN -LIFTING $308.45 $1,071.11 $0.00 $0.00 $1,379.56 Natureof Injury::' 52STRAIN Body 38 SHOULDER(S) Part: . : RESPONDED TO MVA (CAR WRECK) NEAR TRAINING DIVISION. I WAS INSIDE THE CAR WITH PATIENT CHILD WHO WAS BADLY INJURED I HAD TO ide: Right REMOVE CHILD & IN PROCESS FELT ccident Descr:- SHARP BURNING PAIN IN RIGHT SHOULDER AREA N/A TRAINING CAPTAIN/FIRE FIGHTER N/A 11/11/2005 11/14/2005 3174676 GUTIERREZ, JOSEPH 12/14/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE Body 17 MOUTH ide: ,: Injury: art: Accident:: CPR MOUTH TO MOUTH CONTACT NO MEDICAL PROTECTION N/A FIRE FIGHTER N/A escr: Page21 01n31200906:45AM PWCiS UW651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 0110112006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2005 thru 01/01/2006 Claim Accident Report Report Claim -;'Injured Worker,. '. Closed. Expenses 'Medical 'Indemnity Current- Total` Date Received Number Name .`.. :Date InjuryyCause ',Paid Paid Paid' - - Reserve incurred 11/15/2005 11/16/2005 3175223 ROSEN, ANDREW 12/19/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 59 ALL OTHER INJURY Body 7 66 NO PHYSICAL INJURY Injury:; ccldent INHALATION EXPOSURE TO VOMITING OVER WALL OF AMBULANCE N/A EMT N/A Descr: 11/16/2005 11/16/2005 3175225 GALLEGOS. ARTURO 12/15/2005 MISC, OTHER THAN PHYSICAL CAUSE OF $2.50 $0.00 $0.00 $0.00 $2.50 INJURY Natureof 59ALL OTHER Body .�, 66 NO PHYSICAL INJURY ,ide: Injury:, Part: Accident AIRBORNE DIRECT CONTACT VOMIT EXPOSURE ON LEFT THIGH N/A EMT/FIRE FIGHTER N/A Descr: 11/18/2005 11/21/2005 3175873 ROBERTS, NANCY L 01/20/2006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 49SPRAIN Body „ 55 ANKLE We: Right Injury: , Part: , ccident. LEADED OVER TO PICK UP STOKES BASKET AND FELT A POP IN RIGHT ANKLE. FIRE FIGHTER FIRE FIGHTER NONE Descr: 11/28/2005 11/29/2005 3176702 LEMAN, MIKE D 01/24/2006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE Podj7 19 FACIAL BONES ide: Injury:. iPart., ccident APPLYING COLLAR TO PATIENT BLOOD FROM PATIENTS HEAD SPLASHED UP AND GOT ON LEMANS FACE. WAS WEARING SAFETY GLASSES NO EXPOSED CUTS OR WOUNDS. N/A Descr: FIRE FIGHTER N/A 12/10/2005 07/23/2007 3278099 REINKING, KRISTINE E 07/24/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59 ALL OTHER ody 66 NO PHYSICAL INJURY ide: Injury: Part: Accident . Crews were inside structure removing wat from sprinkler break. At time we were not aware of any hazards. In June 07 an asbestos removal was done and it is possible crews were exposed in 2005 FIRE Descr: FIGHTER Fire Fighter NO 12/10/2005 07/23/2007 3278094 FOWLER, MARK W 07/24/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59 ALL OTHER Body,] 66 NO PHYSICAL INJURY ide: Injury:,"' ; Part: ccident Recently determine there is asbestos material in building on South College. On 12-10-05 Eng 3 respond to sprinkler system. Bldg materials with asbestos were distribute throughout structure with water Descr: FIRE FIGHTER/CAPTAIN Fire Fighter/Captain NO 12/14/2005 12/15/2005 3179607 GONZALES, SHAWN K 0211312006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 59 ALL OTHER Body, 14 EYE(S) ide: Both Injury:,;' , Part: ccident FUMES FROM ROOFING CONSTRUCTION CAUSED EYES TO BURN & TEAR FOR APPROX 20 MIN. LEFT BUILDING FOR LUNCH RETURNED WITH NO PROBLEM SECRETARIAL Descr:. SECRETARIAL NOT PROVIDED Page 22 01/2312200908:45 AM PWCis UW651R PINNn, COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2004 and 01/01/2006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2005 thru 01/01/2006 ,. Claim....,:, ,,,. ' '...,, .• .. , ,', �. 'Accident:Report.. Claim .:1: InjurediWorker Closed !Expenses •' Indemnity Current :Total Date '`. Received Number Name r IDa4e injury Cause ". -' " Paid-: 'Paitl .. •• Pahl Reserve, Incurred., 12/28/2005 12/29/2005 3181298 FISHER, GILBERT W 02/24/2006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 73 CONTAGIOUS DISEASE Body 66 NO PHYSICAL INJURY Injury: Part:, Party ccidenP l ASSISTING PARAMEDICS TREATMENT OF PATIENT. PATIENTS FATHETER STATED DIAGNOSED WITH SPINAL MENANGITIS APPROX 5 DAYS AGO. EXPOSURE TO PATIENT AND TO escri . �.j DISEASE. N/A FIREFIGHTER/EMT N/A 12/29/2005 12/30/2005 3181555 MCGAFFIN, SHAWN 02/28/2006 FOREIGN BODY IN EYE $0.00 $0.00 25 FOREIGN BODY ody 14 EYE(S) $0.00 $0.00 ide: $0.00 ature of Injury:.. art: WHILE ON FIRE SOMETHING GOT INTO MY EYE WAS WEARING PROPER PPE. OBJECT CAME OUT AND CONTINUED WORKING LATER IT BECAME IRRITATED WOKE UP IN MORNING cciden6:: Deser. 4 EYE WAS SWOLLEN. N/A FIRE FIGHTER N/A 12/29/2005 12/30/2005 3181466 MONTOYA, KENNETH J 02/24/2006 STRAIN PUSHING,PULLING $0.00 $0.00 $0.00 $0.00 49SPRAIN - Body _ 53 KNEE -ide:., Right Part: -:'. 2 1/2: HOSE BEING DRUG PINNED RIGHT KNEE TO BLITZ FIRE NOZZLE FOR SHORT TIME UNTIL I COULD PULL IT FREE I THEN STOOD UP TO MOVE THE HOSE OVER THE BLITZ FIRE $0.00 Natureof Injury. ceident Descr.) x-?. AND NOTICED PAIN IN MY RIGHT KNEE N/A FIRE FIGHTER N/A 12/31/2005 01/03/2006 3181764 MORAN, JOHN H 03/06/2006 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 52 STRAIN FBo_d­j7 32 ELBOW ide:. Injury Part: I INJURED @ RIGHT ELBOW WHILE DOING PULL UPS AS PART OF REQUIRED P.T. PULL UPS CO ENGINE 2 (FIRE FIGHTER) NONE ,, Accident, Descr:, 12/31/2005 01/03/2006 3181761 SAMBUR, JEFF M 03/06/2006 BURN -ACID CHEMICALS $0.00 $0.00 $0.00 $0.00 $0.00 ature of 65 RESPIRATORY DISORDERS igody. .160 LUNG Side. njury: EXPOSURE TO ATMOSPHERE OF VAPORIZED BATERY ACID FIRE ENGINE MALFUNCTIONED ELECTRICAL SYSTEM BOILED A BATTERY ENGINE COMPANY EXPOSURE OVER SEVERAL hcitlentr-. escr. :=. k HOURSE BEFORE FINDING PROBLEM FIRE FIGHTER FIRE FIGHTER UNKNOWN 12/31/2005 01/03/2006 3181710 BLOIS, STEPHEN E 03/06/2006 BURN - DUST, GAS, FUME, VAPOR $0.00 $0.00 $0.00 $0.00 $0.00 atureof 66POISONING-CHEMICAL Body - 60 LUNG Sitle:- Injury: _. Part EXPOSURE TO ATMOSPHER OF VAPORIZED BATTERY ACID FIRE ENGINE MALFUNCTION ELECTRICAL SYSTEM BOILED BATTERY COMPANY EXPOSURE OVER SEVERAL HOURS Accident,;: Descr:• BEFORE FINDING PROBLEM FIRE FIGHTING FIRE FIGHTER FIRE FIGHTER - CO 12/31/2005 01/03/2006 3181755 ROGERS, BREN D 03/06/2006 BURN -ACID CHEMICALS $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 65RESPIRATORY DISORDERS Body : 60 LUNG Side: Injury ., -s Plan: - n EXPOSURE TO ATMOSPHERE VAPORIZED BATTERY ACID, ENGINE MALFUCTIONED ELECTRICAL SYSTEM BOILED BATTERY. ENGINE COMPANY EXPOSURE OVER SEVERAL HOURS ccident:- Descr:: r BEFORE FINDING PROBLEM. FIRE FIGHTER FIRE FIGHTER UNKNOWN Policy Period Totals: Total Claims: 77 $1,107.09 $52,225.41 $21,537.30 $0.00 $74,869.80 Open: 0 Open: $0.00 1 $0.00 $0.00 $0.00 Closed: 77 Closed: $1,107.09 $52,225.41 $21,537.30 $74,869.80 Average: $14.38 $678.25 $279.71 $972.34 Minimum: $0.00 $0.00 $0.00 $0.00 Maximum: $341.96 $20,794.92 $9,009.33 $30,146.21 Page 23 01@3I20090845 AM PWCIS UW651R PI VI AA COL Data asof:01/23/2009 Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 0110112004 and 01/0112006 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Total Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE Total Claims: 171 $1,768.51 S87,170.02 $119,307.79 $0.00 $208,246.32 VALLEY FIRE Open: 0 Open: $0.00 $0.00 $119,307.79 $0.00 ' Closed: 171 Closed: $1,768.51 $87,170.02 $119,307.79 $208,246.32 Average: $10.34 $509.77 $697.71 $1,217.81 Minimum: $0.00 $0.00 $0.00 $0.00 Maximum: $342.80 $20,794.92 $60,000.00 $64,171.01 Page 24 01Q312009 o6:a5 AM MCS uw651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01101/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2006 thru 01/01/2007 Claim 'Accident Report Claim - Injured Worker Closed --" - Expenses. Medical .Indemnity Current, TotaU:, Date _ Received Number Name , .' :Date 'Injury' Cause ;, . - Paid. '.Paid Paid Reserve Incurred 01/06/2006 01/06/2006 3182273 CHRISTEN, STEVE A 02/06/2006 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $0.00 $0.00 $0.00 $0.00 PATIENT Nature of 73 CONTAGIOUS DISEASE Body ��,:. 66 NO PHYSICAL INJURY Injury:': 'i Part. ccident: PATIENT WAS COUGHING & SPITTING WHILE THEY GAVE EMS, LATER TOLD HE MAY HAVE TB FIRE FIGHTER/EMT FIRE FIGHTER/EMT NONE Descr: 01/06/2006 01/06/2006 3182255 MORAN, JOHN - 01/13/2006 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $0.00 $0.00 $0.00 $0.00 PATIENT ature of 73 CONTAGIOUS DISEASE Body 66 NO PHYSICAL INJURY ide: njury: : Part:„ ccident) ` PATIENT WAS COUGHING & SPITTING WHILE THEY GAVE EMS, LATER TOLD HE MAY HAVE TB FIRE FIGHTER/EMT FIRE FIGHTER/EMT NONE escr:,.. 01/06/2006 01/06/2006 3182265 JAQUES, MICHAL J 02/06/2006 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $0.00 $0.00 $0.00 $0.00 PATIENT Nature of 73 CONTAGIOUS DISEASE Body 66 NO PHYSICAL INJURY Injury: '. Part: ccident -. PATIENT WAS COUGHING & SPITTING WHILE THEY GAVE EMS, LATER TOLD HE MAY HAVE TB FIRE FIGHTER/EMT FIRE FIGHTERIEMT NONE 01/13/2006 01/13/2006 3183411 GALLEGOS, ARTURO 03/14/2006 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $152.86 $0.00 $0.00 $152.86 PATIENT ature of 73 CONTAGIOUS DISEASE Body 66 NO PHYSICAL INJURY Injury:. I''! Part: . Accldent : ATTENDING MEDICAL CALL & ASSISTING PARAMEDICS THE PATIENT BLEW BLOOD OUT OF HIS NOSE. I'M CONCERNED ABOUT BEING EXPOSED TO MATERIALS IN THE AEROLIZED Descr.,;.,;I AND AIRBORN BLOOD. FIRE FIGHTER/EMT FIRE FIGHTER/EMT NONE 01/13/2006 01/13/2006 3183390 ROSEN, ANDREW 03/14/2006 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $466.02 $0.00 $0.00 $466.02 PATIENT Nature of 73 CONTAGIOUS DISEASE ody 66 NO PHYSICAL INJURY ide: Injury: ccident, .. RESPONDED TO CALL @ PROSPECT & SHIELDS FOR MAN WITH CHECK PAIN. PATIENT UNDER INFLUENCE OF ETDH & OR DRUGS. WHILE RESTRAINED PATIENT BLEW BLOOD FROM Descr: - f HIS NOSE OVER US. CSU PD & FCPD WERE THERE FIRE FIGHTER/EMT FIRE FIGHTER/EMT NONE 01/13/2006 01/13/2006 3183416 PIETRANGELO, JIM H 03/14/2006 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $130.85 $0.00 $600 $130.85 PATIENT Nature of 73 CONTAGIOUS DISEASE Body • 66 NO PHYSICAL INJURY Ide: Injury Part: Accident RESPONDED TO MEDICAL CALL, WHILE ASSISTING PVH PERSONEL WITH PATIENT, PATIENT BLEW BLOOD OUT OF HIS NOSE AT EVERYONE NEAR HIM, INCLUDING MYSELF. Descr: ,CONCERNED ABOUT BEING EXPOSED TO AERSOLIZED BLOOD FIREFIGHTER/EMT FIREFIGHTER/EMT NONE 01/16/2006 01/17/2006 3183894 BEARD, JEFFREY 03/15/2006 MISCELLANEOUS STRAIN OR INJURY $0.00 $679.17 $0.00 $0.00 $679.17 Nature of Injury: 52 STRAIN ody 44 CHEST (INCL RIBS, STERNUM, SOFT TISS) art: HAD CHEST PAIN WHILE AT WORK. UNKNOWN CAUSE AT THIS TIME. MUSCLE INJURY ON LEFT SIDE OF THE CHEST. FIREFIGHTER FIRE FIGHTER P ide: Left NONE ccidenNr.:. Descr.'.;- Page 01M/20090851 AM PWCIS UW651R PINNACOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2006 thru 01/01/2007 ..: Claim - Accident Report Claim Injured Worker. - Closed Expenses ,Medical. Indemnity Current Total :Date .Received, Number Name Date -Injury "Cause. - - Paid Paid Paid:: Reserve Incurred 01/20/2006 01/20/2006 3184639 GRESS, MICHAEL M 03/23/2006 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Nt 52STRAIN Body 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ' 1de. . In'uryeof Part: .. ccldent LIFTING EMS STRETCHER ON MEDICAL RESPONSE WHILE GOING DOWN STEPS FELT TWINGE OF MUSCLE SPASM LOWER BACK. LIFTING STRETCHER LIFTING STRETCHER Descr: STRETCHER 01/21/2006 01/23/2006 3184719 GUTHRIE, JAL J 02/07/2006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $324.52 $0.00 $0.00 $324.52 INJURY Nature of 73 CONTAGIOUS DISEASE Body, ,. 60 LUNG ide: Injury:' Part: cclde- RESPONDED TO 20 Y/O FEMALE W/ FLUE LIKE SYMPTOMS PPE INCLUDED BUNKER PANTS, RUBBER GLOVES, HEPA MEDICAL MASK & UNIFORM SHIRT. DIRECT CONTACT W/AMY Descr: -nt.NIELSON (PATIENT) OCCURED WHILE CARRYING HER TO COT. FIRE FIGHTER/EMT-B FIRE FIGHTER/EMT-B UNKNOWN 01/21/2006 01/23/2006 3184705 STANCZYK, QUENTIN C 02/02/2006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $329.65 $0.00 $0.00 $329.65 INJURY Natureof 73 CONTAGIOUS DISEASE (Body 60 LUNG ide: Injury::. „ Part: ccident -., WE WERE ON A MEDICAL WITH A 20 YEAR OLD FEMALE PATIENT WITH "FLU LIKE" SUMPTOMS. PATIENT WAS AGITATED & UNCONSCIOUS WE MAY HAVE HAVE BEEN EXPOSED TO AN Descr:' '' UNKNOWN MEDICAL PROBLEM. CAPTAIN ENGINE 2 MEDICAL EMERGENCY CAPTAIN ENGINE 2 MEDICAL EMERGENCY UNKNOWN 01/21/2006 01/23/2006 3184716 STEWART, ROBERT L 03/2712006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $324.52 $0.00 $0.00 $324.52 INJURY Natureof 73CONTAGIOUS DISEASE Body �, 60 LUNG ide: Injury: ccident POSSIBLE INHALATION - WE WERE MASKED UP MEDICAL WITH FAMALE PATIENT WITH FLUE LIKE STYMPTOMS FIRE FIGHTER/EMT FIRE FIGHTER/EMT NONE Descr.' 01/25/2006 01/26/2006 3185409 MCGRAW, WALTER D 03/24/2006 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $195.74 $0.00 $0.00 $195.74 PATIENT Nature of 73 CONTAGIOUS DISEASE ody 66 NO PHYSICAL INJURY Side: 71 Injury:., Part: Accident-•' RESPONDED TO PATIENT WHO HAD FALLEN 8 FEET HIT HIS HEAD. WHILE ON SCENE TREATING PATIENT MY FACE EXPOSED TO PATIENTS BLOOD ATTEMPTING TO REPLACE MASK Descr: : ON PATIENT STRAP SNAPED & BLOOD ON LEFT SIDE FACE FIRE FIGHTER/EMT FIRE FIGHTER/EMT NONE 01/26/2006 01/27/2006 3185577 GALLEGOS, ARTURO 03/02/2006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $366.70 $0.00 $0.00 $366.70 INJURY atureof 59 ALL OTHER Body - 66 NO PHYSICAL INJURY- njuryi" ^ Part: Accident- : -. RESPONDED TO MEDICAL @ SPRING CREEK. ENERING PATIENT ROOM WITH GLOVED & SAETY GLASSES PATIENT WAS COUGHING FORECEFULLY. PUT RESPATORY MASK ON Descr..' OURSELVES. PATIENT IS A KNOWN CARRIER OF TB. N/A FIRE FIGHTER N/A 01/26/2006 01/27/2006 3185606 DINT, CHRISTOPHER 03/28/2006 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 49 SPRAIN ody, 37 THUMB $0.00 $0.00 ide:'. Right $0.00 Nature of Injury:, rarty, SPRAINED THUMB DURING PFA TRAINING EXERCISE @ PFA TRAINING CENTER TRAINING DUMMY FELL ON THUMB. N/A FIRE FIGHTER N/A ccident�b Descr. : Page 2 0123/ 009 08 51 AM PWCIS UW651R AIRCRAFT Aircraft type typically chartered. - Single engine, general aviation Is the pilot listed (Russell Reed) the one who would usually be flying or would aircraft be chartered with pilot? - Yes, Russell Reed is a FC police officer and the only pilot used for business purposes Under what circumstances will aircraft be chartered? - On rare occasion (2-3 times a year) Officer Reed is used to provide aerial surveillance for unique assignment or when cost effective, provides air transportation to training classes outside the immediate area for 2-3 other officers. ATTACHMENTS: • 1C 5 Year PFA Only AL Loss Run • 2C 5 Year PFA Only GL Loss Run • 3C 2008 FPA Payroll Report • 4C 2008 City Actual Payroll By Code W est 2009 • 5C Employee Concentration Info 2009 • 6C Copy of PFA Employee Count by Location • 7C PFA 2004-2006 WC Loss Runs • 8C PFA 2006-2009 WC Loss Runs • 9C PFA Premium Comparison • 10C Vehicles by Category Combined Please contact Lance Murray, Project Manager at (970) 221-6807 with any questions regarding this addendum. RECEIPT OF THIS ADDENDUM MUST BE ACKNOWLEDGED BY A WRITTEN STATEMENT ENCLOSED WITH THE BID/QUOTE STATING THAT THIS ADDENDUM HAS BEEN RECEIVED. PINN/I\COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01101/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2006 thru 01/01/2007 Claim.,:. } .. Accident Reportr. ,Claim ,, Injured Worker, i, I Closed Expenses'', 'Medical rl Indemnity Current Total';' !(Date Date' .Received Number Name. �. :Irijury,Cause ;;. ;:� I,.,, ,;,; ,, ,. ".. . „. -, Paid' Paid Paid,, :Reserve Incurred,:;,, 01/26/2006 01/27/2006 3185598 SIMMS, RONALD S 03/24/2006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59 ALL OTHER -p-od-y-I 66 NO PHYSICAL INJURY Side: Injury: part: Accident ON MEDICAL CALL @ SPRING CREEK. WALKED INTO PATIENTS ROOM IMMEDIATELY PUT ON FACE MASKS. THE PATIENT IS ATE; CARRIER, N/A FIRE FIGHTER/MEDICAL CALL N/A Descr. 01/26/2006 01/27/2006 3185610 STRAUSS, AD 03/22/2006 MISCELLANEOUS STRAIN OR INJURY $0.00 $295.61 $0.00 $0.00 $295.61 Nature of 25 FOREIGN BODY Fo-d-y-1 48 INTERNAL ORGANS ide: Injury: Part: PICKING UP FIRE HOSE & BREATHED IN DEBRIS THAT WAS BLOWING AROUND BECAUSE OF HIGH WINDS THIS IS A TRAINING EXERCISE AT FIRE DEPT TRAINING BURN BUILDING. N/A 'ccident Des --. FIRE FIGHTER N/A 01/26/2006 01/27/2006 3185592 PIETRANGELO, JIM H 02/22/2006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $335.17 $0.00 $0.00 $335.17 INJURY Nature of 59ALL OTHER Body, tde: 66 NO PHYSICAL INJURY Injury` - Part: Accident RESPONDED TO MEDICAL @ SPRING CREEK HEALTH CARE ENTERED PATIENTS ROOM WITH GLOVES & GLASSES, PATIENT WAS COUGHING FORCEFULY IMMEDIATELY PUT Descr„ RESPIRATOR MASKS ON PATIENT IS KNOWN CARRIES OF TB. N/A FIRE FIGHTER/CAPTAIN N/A 02/08/2006 02/09/2006 3187695 PIETRANGELO, JAMES H 03/15/2006 FALL OR SLIP FROM DIFFERENT LEVEL $0.00 $0.00 $0.00 $0.00 $0.00 ature of 49 SPRAIN ody 7 51 HIP gi-dT7 Left ^jury '• Part: IN THE PROCESS REMOVING VICTIM FROM HOUSE FIRE TRAINING SCENARIO & ON THE WAY DOWN FLIGHT OF STAIRS WITH 175 SLB VICTIM LOST FOOTING & FELL ABOUT 5 FT & HIT Accident: D escr: - FLOOR ON LEFT HIP WITH VICTIM ON TOP OF ME N/A FIRE FIGHTER N/A 02/10/2006 02/10/2006 3188079 LOVE, PATRICK S 03/30/2006 STRAIN OR INJURY BY TWISTING $0.00 $0.00 $0.00 $0.00 $0.00 ature;of Injury..'- 49SPRAIN ody-; 53 KNEE Side:,: Right IPart:.` ::,,: @ TRAINING SITE ACQUIRED SINGLE FAMILY DWELLING. DURING EXERCISE ON HOSELINE MOVING DOWN STAIRS TO BASEMENT IN ZERO VISIBILITY. REPOSITION MYSELF DUE TO ceident Descri �a: - HOSE BLOCK ROUTE. TURNED TWISTED RIGHT KNEE FIRE FIGHTER FIRE FIGHTER NONE 02/10/2006 02/13/2006 3188177 SALISBURY, JOHN F 04/14/2006 STRAIN OR INJURY BY CONTINUAL NOISE $0.00 $D.00 $0.00 $0.00 $0.00 ature of 59ALL OTHER ody: 13 EAR(S) Side:. Injury:- art:' , STANDING APPROX 10- IN FRONT OF ENGINE TALKING WHEN CAPT OF E-12 TRIED TO SIGNAL TO BACK UP WITH HORN BUTTON ON TAIL BORD. AIR HORN WENT OFF. N/A FIRE ccident.. Descr. CAPTAIN N/A 02/21/2006 02/21/2006 3189525 CAPE, RICHARD 03/30/2006 OTHER $0.00 $0.00 $000 $0.00 $0.00 Nature of 73 CONTAGIOUS DISEASE ody' 15 NOSE Injury:,.:.. EXPOSED TO BODY FLUIDS WHILE ASSISTING A PATIENT BACK INTO BED FIRE FIGHTER / COMPANY OFFICER FIRE FIGHTER / COMPANY OFFICER NONE Accident, escr: 02/21/2006 02/21/2006 3189518 RICE, SPENCER 03/30/2006 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $0.00 $0.00 $0.00 $0.00 PATIENT Nature of 73 CONTAGIOUS DISEASE Body -: 66 NO PHYSICAL INJURY Injury: :' Part ccident CALLED TO LIFT ASSIST PATIENT WAS HEPITITUS COT BODILY FLUIDS EXPOSED. BLOOD ON PATIENT FULL FACE FULL DIAPER.GOT SEVERE ITCH ON NOSE, USED BAKESIDE OF MY Descr:: ,- HADN TO SCRATCH IT. FIRE FIGHTER/EMT FIRE FIGHTER/EMT NONE Page 3 0123 W906:51 AM PWCIS UW651R PINNACOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/0112006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2006 thru 01/01/2007 Claim, Accident. Report. 3 Claim-:Injured,Worker 'Closed ,, .., . Expenses;'. Wedical +Indemnity Current Total p�' Date. Received: Number '.Name- Date InjuryCause- -' Paid Paid Paid. •- Reserve Incurred'" 02/21/2006 02/21/2006 3189529 PERRY, BRUCE E 03/30/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 of Nature 71 ALL OTHER OCCUPATIONAL DISEASE ody 15 NOSE Side: Injury: art: ccldent PATIENT WAS HEPATITIS C HAD VARIOUS BADLY FLUIDS EXPOSED CALLED TO LIFT ASSIST BLOOD ON PATIENT FACE & HANDS & CHEST FULL DIAPER. HELP LIFTED PATIENT NOSE Descr: TOUCHED PATIENT & GLOVE HAND BRIEFLY. FIRE FIGHTER/EMT FIRE FIGHTER/EMT NONE 02/23/2006 02/24/2006 3190143 DELANEY, DEAN M 04/27/2006 REPETITIVE MOTION $0.00 $901.27 $0.00 $0.00 $901.27 Natureof 52STRAIN Body 38 SHOULDER(S) Ide: Right Injury: Part: ccident TRAINING DOING BENCH DRILLS TRAINING TRAINING NONE Descr. - 04/02/2006 04/03/2006 3196007 GILLAN, RAY D 06/21/2006 FALL SLIP, NO FALL $0.00 $1,682.20 $0.00 $0.00 $1,682.20 Nature.of 49SPRAIN Body-7.L 53 KNEE Pide.7, Right Injury;:' Part . Accident WALKING DOWN A DIRT DRIVEWAY & STEPPED IN A TIRE RUT, FEELING KNEE TWIST TO THE SIDE. PAIN STARTED RIGHT AWAY AT BOTTOM OF KNEE CAP & INSIDE REAR. FIRE Descr: FIGHTER FIRE FIGHTER NONE 04/07/2006 04/10/2006 3197048 CHAVEZ, MICHAEL A 06/01/2006 FALL, ON STAIRS $0.00 1000NTUSION ody � ] 10 MULTIPLE HEAD INJURY $0.00 $0.00 $0.00 bide: Right $0.00 Nature of Injury:,. Part: WHILE CLIMBING INTO ENGINE 7 SLIPPED ON STEP STRIKING HEAD ON FLASHLIGHT WHICH WAS IN FLASHLIGHT HOLDER. -BUMP THE SIZE OF QUARTER APPEARED ON RIGHT ccident-'. Descr:: : EYEBROW. SKIN WAS NOT BROKEN NO BLOOD WAS INVOLVED FIRE FIGHTER RESPONDING TO MEDICAL EMERGENCY FIRE FIGHTER RESPONDING TO MEDICAL EMERGENCY NONE 04/10/2006 04/12/2006 3197603 RAYNOR, DICK 06/01/2006 ANIMAL OR INSECT $0.00 $0.00 $0.00 $0.00 $0.00 atureof 40 LACERATION Body.'., 35 HAND Injury: Part:. ccident- BOARD MEMBER VISITNG TRAINING CENTER PERSONNEL DOGS IN OFFICE BEHIND BARRIER. DICK REACHED IN TO PET DOGS AND WAS BITTEN BY DOG ON HAND .WOUND WAS Descr.,•' .:I CLEANED AND BAND AIDS APPLIED BOARD MEMBER TOURING STATION BOARD MEMBER TOURING STATION NONE 04/24/2006 04/24/2006 3199267 VANGORDER, JOHN 05/15/2006 CUT - MISCELLANEOUS $0.00 $910.84 $0.00 $0.00 $910.84 Natureof 40LACERATION Eody;... 37 THUMB ide: Injury: 'Part: cctdent CUT LENGTH OF THUMB WITH BOX KNIFE WHILE CUTTING DOWN CARDBOARD BOXES. CUTTING CARDBOARD BOXES WAREHOUSE CUTTING CARDBOARD BOXES Descr: 05/04/2006 05/05/2006 3201039 BARELA, TYSON R 06/01/2006 MISCELLANEOUS STRIKE OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 40 LACERATION oily,.,, 15 NOSE Ides' Right Injury:-... • Part: . Accident HIT IN NOSE WITH WATER CHUTE EXTENSION (TENDER) RIGHT SIDE OF NOSE CUT & BLEEDING. FIRE FIGHTER TRAINING FIRE FIGHTER TRAINING WATER CHUTE EXTENSION Descr. 05/08/2006 05/09/2006 3201485 HOUSLEY, KEVIN M 05/1012006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $113.57 $0.00 $0.00 $113.57 INJURY Nature of 73CONTAGIOUS DISEASE Body . 31 UPPER ARM (INCL. CLAVICLE & SCAPULA) Side: Right Injury: ccldent - PATIENT PROJECTILE VOMITED ON HOUSLEY. HOUSLEY WAS APPROX 10 FT AWAY FROM PATIENT WHEN HE BEGAN TO VOMIT. VOMIT HIT HOUSLEY ON RIGHT ARM AND SHOULDER. Descr:.. MED 11 AND FM2 ALSO ON SCENE. FIRE FIGHTE EMT FIRE FIGHTER EMT N/A Page 4 OV2,V2009 08:51 AM awcis UW651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2006 thru 01/01/2007 .. .Claim.. ,... .. Accident Report-. Claim'. Injured'.Worker' Closed' _ Expenses Metlical indemnity, Current .Total Date. Received ,Number Name. ; . .Date jri'u Cause - ' '. 1 ry Paitl',. _ , :Paid _ Paid _ Reserve ' ,Incurred l' 05/10/2006 05/12/2006 3202015 HORNING, WILLIAM C 06/16/2006 STRAIN -LIFTING $0.00 $147.47 $0.00 $0.00 $147.47 Nature cf Injury: 52 STRAIN Body 31 UPPER ARM (INCL. CLAVICLE & SCAPULA) PHYSICAL TRAINING WHILE LIFTING HURT RIGHT BICEP FIRE FIGHTER TRAINING FIRE FIGHTER TRAINING UNKNOWN ide: Right ccldent escr: 05/10/2006 05/10/2006 3201621 EWY, LEONARD K 06/29/2006 STRAIN-HOLDING,CARRYING $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 52 STRAIN Body 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Injury:,ide::.. ?" ;:. art: I WAS CARRYING BACK HALF OF AMBULANCE STAIR CHAIR WITH 210 POUND PATIENT DOWN 3 STORIES OF A NARROW STAIRWELL. POSITION REQUIRED FOR LIFTING WAS ccident:, escr: -._"] AWKWARD DUE TO STEEPNESS OF STAIRWELL. FIRE FIGHTER EMT FIRE FIGHTER EMT STAIR CHAIR 05/12/2006 05/15/2006 3202244 PONCELOW, ROBERT 06/01/2006 FALL - SAME LEVEL $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 52 STRAIN ody 44 CHEST (INCL RIBS, STERNUM, SOFT TISS) ide: Left Injury -• Part: 1 ':. SHOOTING BASKETS AS PART OF PT IN REAR OF STATION 1 WHILE CHASING BASKETBALL I TRIPPED OVER A ROUGH PIECE OF ASPHALT AND FELL. FELT SHARP PAIN IN LEFT ccldent Descr: _-: PECTORAL AROUND SIDE AND UNDERARM FIRE FIGHTER B/C FIRE FIGHTER B/C NO 05/14/2006 05/15/2006 3202299 GUTHRIE, JAL J 06/29/2006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $579.59 $0.00 $0.00 $579.59 INJURY atureof 73 CONTAGIOUS DISEASE ody ,` 19 FACIAL BONES ide:.. .jury:.;.; art: ccidenti:-: DISPATCHED TO PERSON HAVING SEIZURE PATIENT TRANSPORTED TO PVH I ATTENDED ENROUTE PATIENT BEGAN TO VOMIT ARRIVE IN ER W/PATIENT BECAME COMBATIVE I WAS Descr: -.I HOLDING PATIENT FOR ER HE SPIT VOMIT IN MY FACE FIRE FIGHTER/EMT FIRE FIGHTER/EMT NO 05/25/2006 05/26/2006 3204310 CUPP, DOUG L 06/29/2006 FALL -SLIP, NO FALL $0.00 $0.00 $0.00 $0.00 $0.00 Natureof Injury- - 49SPRAIN ody rc. 55 ANKLE Part: FIRE FIGHTER CUPP SLIPPED AND ROLLED HIS RIGHT ANKLE WHILE PLAYING BASKET BALL FIRE FIGHTER FIRE FIGHTER N/A ide:". Right ccident`I escr:,- -.-:,: 05/26/2006 05/26/2006 3204438 MOINESTER, JUSTIN M 06/29/2006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE Body 90 MULTIPLE BODY PARTS Injury: Accident?,_; HOSING DOWN SCENE OF ACCIDENT AND BLOOD SLASHED BACK ON HIM. FIRE FIGHTER FIRE FIGHTER HOSE Desc',.. 06/06/2006 06/07/2006 3205799 PIETRANGELO, JIM H 06/14/2006 STRUCK BY -OBJECT BY OTHR $0.00 $0.00 $0.00 $0.00 $0.00 Natureof Inlury: ,, 59ALLOTHER ody•;` 38 SHOULDER(S) Ide:., Right art: A CO-WORKER STRUCK MY RIGHT SHOULDER WITH HIS HAND AS A FRIENDLY GESTURE AND FORGOT ABOUT MY RECENT SURGERY ON THIS SHOULDER. MODIFIED INJURY Accident;'-: Descr. '.:I MODIFIED INJURY N/A 06/15/2006 06/15/2006 3207524 HERRINGTON, JAMES R 06/23/2006 STRAIN-HOLDING,CARRYING $0.00 $0.00 $0.00 $0.00 $0.00 ature of 52 STRAIN Body 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Side: Injury:-','. art: ; BENT OVER TO CARRY EQUIPMENT AROUND OBSTRUCTIONS FELT SHARP TWINGE IN LOWER. BACK BACK NOW STIFF AND SORE. N/A FIRE FIGHTER ' C-SHIFT TRUCK N/A ccident;, Descr. - Page 01231200908.51 AM MCIs UW651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2006 thru 01/01/2007 claim -I! WWorker ; '- CDaotseed. ExPennseds,.:.. Medical ,', _ Indemnity „ Currente Total Dccident. RReport eceived Number "Named Injury Cause '' , ;Paid Paid Reserve Incuired 06/29/2006 06/30/2006 3210041 LYNXWILER, JAMES 08/22/2006 STRAIN -LIFTING $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 52 STRAIN I ody 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide: Injury: Part. ccident : INJURED LOWER BACK DURING CARRYOUT RESCUE OF MAN WHO FELL OFF HORSETOOTH MTN. STRAINED BACK WHILE LIFTING AND CARRYING THE LITTER OVER STEEP ROCKY Descr: - :! TERRAIN WHILE PROVIDING RESCUE EMS/RESCUE EMS/RESCUE NO 06/29/2006 06/29/2006 3209972 CUPP, DOUG L 06/30/2006 CUT -TOOL, NOT POWERED $0.00 $174.31 $0.00 $0.00 $174.31 Natureof 43PUNCTURE Fd-y7 37 THUMB ider..,. Left Injury: '; art: Accident WHILE CLEANING TOOLS A SCREWDRIVER SLIPPED AND PUNCTURED MY LEFT THUMB. FIRE FIGHTER FIRE FIGHTER NO Descr: 07/06/2006 07/06/2006 3210655 HERRINGTON, JAMES R 08/31/2006 STRAIN OR INJURY BY CONTINUAL NOISE $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 59 ALL OTHER _ ody 13 EAR(S) ide_ Both Injury:.:.. art: ccr:_ INVESTIGATING HIGH PITCHED ALARM FROM DIALER FOR STATION 5. FIRE ALARM SYSTEM. NOW HAVE RINGING IN EARS. N/A FIRE FIGHTER/CAPTAIN -TR 5 N/A Descr:r. . 07/15/2006 07/17/2006 3215534 HORNING, WILLIAM C 09/07/2006 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 atureof 52 STRAIN Sody 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide: Injury: art: ccident=: AFTER RETURNING FROM A CALL, I WAS GETTING OUT OF THE ENGINE AND FELT A SHARP PAIN IN MY LOWER BACK. FIRE FIGHTER FIRE FIGHTER NONE Descr.' 07/27/2006 07/28/2006 3217680 ROGERS, BREN D 08/22/2006 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 25 FOREIGN BODY Fo-d-y7 14 EYE(S) Side: _. Injury:_ Part: Accident.' CUPP & MYSELF WERE UNDERNEATH THE MANUFACTURED HOME PULLING INSULATION WE WERE WEARING HELMETS, EYE PROTECTION, INSULATION & OTHER PARTICLES STILL Descr. - GOT IN MY EYES AND AROUND NOSE & MOUTH. N/A FIRE FIGHTER N/A 07/27/2006 07/28/2006 3217668 CUPP, DOUGLAS L 09/11/2006 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59 ALL OTHER Body 46 INTERNAL ORGANS ide:., „ Injury: Part: , ccident':, FIREFIGHTER ROGERS & MYSELF WERE UNDERNEATH THE MANUFACTURE HOME PULLING INSULATION ROGERS & I WERE WEARING EYE PROTECTION & PAPER RESPITORY Descr. I MASKS. INSULATION PARTICLES STILL FOUND WAY TO EYE & MOUTH N/A FIRE FIGHTER N/A 07/27/2006 07/28/2006 3217657 STRAUSS, A. DAVID 09/11/2006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature.of 59 ALL OTHER Body 7 48 INTERNAL ORGANS Side: Injury::..; Part: ccident,.: TRAILER FIRE UNDER TRAILER, WHILE PULLING SKIRTING TO INVESTIGATE SMOKE AND DEBRIS PUSHED OUT & I INADVERTANTLY INHALED. WAS IN CLEAN AIR, OUTDOOR Descr. ` '41 ENVIRONMENT. N/A FIRE FIGHTER N/A 08/01/2006 08/02/2006 3218396 MILLER, GREGG E 05/17/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $796.80 $0.00 $0.00 $796.80 INJURY Natureof 59 ALL OTHER ody - 13 EAR(S) Side: Right Injury: art: ccident•-; WHILE REMOVING A CEILING MOUNTED SMOKE DETECTOR THE UNIT ALARMED, SOUNDED, NEXT TO RIGHT EAR. IMMEDIATELY AFTER THERE IS RINGING SOUND IN EAR THAT HAS Descra? .":I':. PERSISTED, STILL RINGING (7 HRS LATER) REMOVING SMOKE DETECTOR FIRE FIGHTER/CAPTAIN/E-14 NOT SPECIFIED Page 6 0123200908'51 AM MCIS UW651R PINNAA COL Data as of 01/23/2009 Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Period: 01/01/2006 thru 01/01/2007 PROTECTION DISTRICT ..., ... Claim. -.. .'. ., .: ..� .,.. -..... _ :. ,. ... Accident Report Claim' _ Injured Worker , „. Closed .';-, ..,-.. , . Expenses Medical Indemnity ; Current -,.Total . ', ,,Date, Received Number', Name �, ,,, Date ',Injury, Cause-„ . - , �. Paid .Paid!, Paid •;,., Reserve ',Incurred' ; 08/02/2006 08/02/2006 3218563 MCKEON, JONATHAN 08/22/2006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59 ALL OTHER Body 13 EAR(S) ide: ': Both Injury:,.'. Part: 'ccident- WHILE CLAMPING NATURAL GAS LINE EXPOSED TO HIGH AUDIOLOGIC AGENT, FOR APPROX 15 MINUTES. FIRE FIGHTER FIRE FIGHTER NOT SPECIFIED escris 08/02/2006 08/02/2006 3218561 BERNUM, RICHARD A 08/22/2006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $30.76 $0.00 $0.00 $30.76 INJURY Nature of 59ALL OTHER $ody - . 13 EAR(S) ide: Both Injury:' ;,... Part. Accidently".: WHILE CLAMPING NATURAL GAS LINE EXPOSED TO HIGH AU DIOLOGIC AGENT FOR APPROX 15 MINUTES. FIRE FIGHTER FIRE FIGHTER/CAPTAIN NOT SPECIFIED Descr.`:.'. 08/16/2006 08/17/2006 3221220 LEVY, GLENN M 11/21/2006 MISCELLANEOUS STRAIN OR INJURY $0.00 $1,633.17 $0.00 $0.00 $1,633.17 Nature of 52 STRAIN ody.:; 41 UPPER BACK AREA Injury: - art: Was moving rescue dummys at burn building & felt something pull in upper back & right knee both sore this morning FIRE FIGHTER TRAINING Fire Fighter Training NOT SPECIFIED cciden, Descr: 08/19/2006 08/21/2006 3221715 ROOT, ROBERT C 10/23/2006 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 52 STRAIN ody ,, 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide: Injury: ccident- I pulled cooler full of water out of engine # 1. As 1 pulled the cooler out, I twisted to the left injuring my lower back FIRE FIGHTER fire fighter NOT SPECIFIED Descr:',^ - 08/22/2006 08/22/2006 3221894 VANGORDER, JAMES 10/31/2006 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Nature of Injury: f 52 STRAIN I started to lift cot to raised position for movement to ody ,, 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide: Part: med unit. I immediately realized that the load was to heavy paramedic assisted with lifting head end of col. Back was tweaked in initial lift. FIRE ccident.;: Descr. `'. FIGHTER Fire Fighter NOT SPECIFIED 08/30/2006 08/31/2006 3223564 MIROWSKI, RANDY K -37 09/25/2006 ANIMAL OR INSECT $0.00 $0.00 $0.00 $0.00 $0.00 Nature of Injury INFLAMMATION Received some type of bite on right arm during the night Body,._ ;, 33 LOWER ARM art::.. realized this - small red bumps starting to swell @ approx 1100 hours on 8-30-06. FIRE FIGHTER/BATTALION ide:. - Right CHIEF Fire Fighter/Battalion ccident_ Descr. Chief NO 09/04/2006 09/05/2006 3224114 GILIOTTI, TYLER C 09/26/2006 OBJECT BEING LIFTED OR HANDLED $0.00 $833.93 $0.00 $0.00 $833.93 Nature of Injury: 40 LACERATION Body,, 36 FINGER(S) i7 de: Right Part: Matt & I were forcing a door a miss communication put my right index finger in the way of a kallagen flat head axe & @ point of impact on finger was in way and was cut open 2 inches to blunt trauma N/A ccident.•.. Descr')' volunteer fire fighter N/A 09/05/2006 09/05/2006 3224109 SAXBURY, LYNDEL D 09/13/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59ALL OTHER ody,. 66 NO PHYSICAL INJURY ide: Injury: :s Lyndel became ill w/dizzyness nausea vomiting. He had inability to move without becoming sick, occurred during an out of district deployment to Dubois Wyoming area, Lyndel was taken by ambulance ccident Descr. r•It. N/A Fire Fighter/Crew Boss N/A Page 012320090851 AM MCIS UW651n PINNAA COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PRATFCTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2006 thru 01/01/2007 . Claim Accident 'Report . Claim Injured Worker. - Closed + - +.: ,- Expenses 'Medical Indemnity, Current .Total :,Date, ., Received: Number'::Name - Date Injury Cause - -`.. - ',. Paid '..,Paid Paid '.; ReserveIncurred' 09/07/2006 09/08/2006 3224750 LEE, DOUG B 12/06/2006 OBJECT BEING LIFTED OR HANDLED $0.00 $2,126.95 $0.00 $0.00 $2,126.95 Natureof 52STRAIN Body- r 38 SHOULDER(S) ides, �,, Left Injury:` Part: ccident I was performing an incline bench press exercise with 135 pounds on a Smith Machine during one of the reps I experienced a sharp pain in my left shoulder. N/A Fire Fighter/Assistant Fire Marshal N/A escr: DI 09/11/2006 09/12/2006 3225219 GARCIA, SANTOS 07/02/2007 STRAIN -LIFTING $286.46 $15,653.90 $74,305.73 $0.00 $90,246.09 Natureof 52 STRAIN ody. 41 UPPER BACK AREA Side: Injury;'',;, Part: Accident ,;.; I was lifting a med cot into the up position with patient on it. Then lifted cot into med unit with patient on it. Patient was a large person FIRE FIGHTING Fire Fighter COT Descr:!" , 09/13/2006 09/14/2006 3225671 BOWLES, HEATHER M 11/09/2006 BURN -TEMP. EXTREMES $0.00 $1,781.04 $0.00 $0.00 $1,781.04 Natureof 04 BURN Body 19 FACIAL BONES ide: ;, Injury: ' Part: Accident.'. Entry into a high heat environment while fighting a structure fire. FIRE FIGHTING Fire Fighting NOT SPECIFIED Descr. 09/14/2006 09/15/2006 3225919 WIGGINS, FORREST W 11/10/2006 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 49SPRAIN Body7 53 KNEE ide: Left Injury: Part: ccidenta-: Was practicing firefighter rescue technique in bay station 5. Was suspended in air rope attached to decending friction device. Released device to quickly & came down with leg underneath me to ground Descr.!-- - FIRE FIGHTER Fire Fighter AIR ROPE 09/15/2006 09/15/2006 3225951 LYON, KEVIN R 11/10/2006 MISCELLANEOUS STRAIN OR INJURY $0.00 $1,783.75 $0.00 $0.00 $1,783.75 Natureof 52STRAIN Body 21 NECK VERTEBRAE Side: Injury: Part: Accident y Training for search & rescue & ran head first into concrete block wall. I was crawling @ the time, was in full personnel protection equipment with helmut on, was also holding halligan tool. SEARCH & Descrij'I:,.. `" RESCUE Search & Rescue NOT SPECIFIED 09/18/2006 09/18/2006 3226212 FIELDS, KEVIN W 09/29/2006 FALL, ON STAIRS $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 49 SPRAIN Body, ;'. 55 ANKLE ide: Right Injury: , Part: . ccident".. I was coming down a set of stairs holding a fire extinguisher. I missed the last step & rolled my right ankle and landed on my left hand. N/A Recruit Firefighter N/A Descr. - 10/01/2006 10/02/2006 3228419 RICE, SPENCER L 12/01/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 40 LACERATION Body' 52 UPPER LEG Right njury:' . art: ,ide:.., ccident.t: I WAS ASSISTING THE PARAMEDICS IN ROUTE TO PVH WITH A PATIENT. I KNELT DOWN IN THE AMBULANCE TO TAKE A BLOOD PRESSURE. IN THE PROCESS !CUT/SCRATCHED MY Descr::`!. -- RIGHT LEG ON THE COT YOLK. N/A Firefighter/EMT N/A 10/11/2006 10/16/2006 3230473 STARCHURSKI, JUDY L 05/22/2007 OBJECT BEING LIFTED OR HANDLED $33.54 $3,777.91 52STRAINody 38 SHOULDER(S) $0.00 $0.00 $3,811.45 Ides Right Natureof njury: , r art: Right shoulder pain from starting chain saw and tossing plywood N/A Starting chain saw and tossing plywood Chain saw Accident- Descr:': Page 8 01=W908'51 AM MCIS UW651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data asof:01/23/2009 Policy Period: 01/01/2006 thru 01/01/2007 Claim , Accident Report ,Claim.- Injured Worker- Closed ,... =� ".: - - ' Expenses Medical Indemriityr Current .Tbtal- Date. :;Received 'Number Name - Date ..,,jury, ., ,,' Injury Cause Paid'. ;.,,. - Paid Paid" Reserve Incurred 10/13/2006 10/16/2006 3230492 DELANEY, DEAN M 52 STRAIN 12/08/2006 OBJECT BEING LIFTED OR HANDLED Body J 42 LOW BACK (LUMBAR & LUMBO-SACRAL) $0.00 $0.00 $0.00 $0.00 $0.00 Nature.of Injury: : " Changing ceiling sprinkler head twisted back N/A CHANGING Part: SPRINKLER HEAD N/A ccident escr. - 10/15/2006 10/16/2006 3230476 SHALBERG, LORI L 1000NTUSION 11/16/2006 OTHER Body 713 EAR(S) $0.00 $490.35 $0.00 Side: $0.00 S490.35 Natureof In/ury.:.,`... Part: .. = ,. Rolled out of bed and hit head and ear N/A getting out of bed N/A Accident Descr: 10/26/2006 11/09/2006 3234823 DRAGAN, ANTHONY R 59 ALL OTHER 1111412006 OTHER $ody.. 66 NO PHYSICAL INJURY $0.00 $0.00 $0.00 ide: $0.00 $0.00 Nature of ntury: -:. , Asbesto Exposure @Structure Fire N/A Fire Fighter N/A art: ccident=: Descr:_:-.-_-` 10/26/2006 11/07/2006 3234369 REINKING, KRISTINE 59 ALL OTHER 11/14/2006 OTHER Body 7, 66 NO PHYSICAL INJURY $0.00 $0.00 $0.00 ide: $0.00 $0.00 Nature of Injury: Asbestos Exposure @ Structure Fire N/A Fire Fighter N/A Part: Accident lrr Descr: .- 10/26/2006 11/07/2006 3234399 THOMAS, RYAN 11/14/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 ature-of 59ALLOTHER #6d-y7 66 NO PHYSICAL INJURY njury` Asbestos Exposure @ Structure Fire N/A Fire Fighter N/A art: , ccidentr: escr: 10/26/2006 11/07/2006 3234374 RICE, SPENCER L 59 ALL OTHER 11/14/2006 OTHER FB-od-y-1 66 NO PHYSICAL INJURY $0.00 $0.00 $0.00 ide: $0.00 $0.00 Nature of njury: Asbestos Exposure @ Structure Fire N/A Fire Fighter N/A ccident-:- 10/26/2006 11/07/2006 3234328 GUTIERREZ, JOSEPH A 11/14/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59ALL OTHER ody 66 NO PHYSICAL INJURY Side: Injury' - art: Asbestos Exposure From Structure Fire N/A Fire Fighter N/A ccident] Descr: 10/26/2006 11/07/2006 3234326 DEBAERE, DUSTIN D 59ALL OTHER 11/14/2006 OTHER Vody7166 NO PHYSICAL INJURY $0.00 $0.00 $0.00 $0.00 $0.00 ature of njury Asbestos Exposure N/A Fire Fighter N/A art._,: ccidenb': Descr:'.: Page 9 011231200908:51 AM MCIS UW651R PINNACOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2006 thru 01/01/2007 . Claim. Accident' Report Claim: '' Injured Worker ,' Closed;_ . ' . - ..,,. ,Expenses . Medical Indemnity Current Total ' `; Date .. Received. Number. _:Name Date Injury Cause jury Paid' � Paid Paid` - Reserve Incurr,66 10/26/2006 11/07/2006 3234325 MANTAS, JASON W 11/14/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59 ALL OTHER Body, ' 66 NO PHYSICAL INJURY ide: Injury:. Part:' ccident Fighting Fire in building later to be determined to contain asbestos N/A Firefighting N/A Descr: 10/26/2006 11/07/2006 3234324 TENNYSON, GREG W 11/14/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 59ALL OTHER (Body 66 NO PHYSICAL INJURY ide: Injury:, Accident, Asbestos Exposure N/A Fire Fighter N/A Descrc 10/26/200+6 11/07/2006 3234323 DURRE, HOLGER 11/14/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59 ALL OTHER Body 66 NO PHYSICAL INJURY Sider Injury:.. art:., Accident Fighting Fire inside buiding later to be found to contain asbestos N/A Fire Fighting N/A Descr:' 10/26/2006 11/07/2006 3234321 LIPPERT, JOHN C 11/14/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59 ALL OTHER Body 66 NO PHYSICAL INJURY ide: Injury:.,, Part: ccident Asbestos Exposure N/A Fire Fighter N/A Descr., 10/26/2006 11/07/2006 3234320 ALBRANDT, CHARLES H 11/14/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 Nature:of 59ALL OTHER Body 66 NO PHYSICAL INJURY njury:-; : Part:.. Accident -:' Asbestos Exposure. N/A Fire Fighter N/A Descr: 10/26/2006 11/07/2006 3234317 HANSON, BRYAN K 11/14/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59 ALL OTHER ody: _ 66 NO PHYSICAL INJURY Injury:',= art: ccident Asbestos Exposure N/A Fire Fighter N/A escr. ; . 10/26/2006 11/07/2006 3234314 GREENWOOD, WILLIAM J 11/14/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 o f 59 ALL OTHER Body 66 NO PHYSICAL INJURY Side: Injury: ccidentll Asbestos Exposure N/A Fire Fighter N/A Descr:;:'..' 10/26/2006 11/15/2006 3235711 LEE, DOUGLAS B 11/30/2006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $154A4 $0.00 $0.00 $154.44 INJURY ature of 59 ALL OTHER ody 66 NO PHYSICAL INJURY njury:;. ` art: ccident>° Possible asbestos exposure in apartment buildng which had structure fire. May have been exposed during the investigation. ASST FIRE MARSHALL Asst Fire Marshall NOT SPECIFIED Descr Page 10 011231200908:51 AM MCis UW651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data asof:01/23/2009 Policy Period: 01/01/2006 thru 01/01/2007 ClaimAcci.. ' dent Report ,, ;, Claim , Injured Worker. Closed. .. .(,� .,' . Expenses. Medical Ind eImnity Current. DateReceived', Number Name Date inju cause. ;,ry __ Paid. ?'Paid ., ,,.+ Paid _ Reserve ,•Total Incurred ;'a. 10/26/200 11/07/2006 3234364 HOUSLEY, KEVIN M 59 ALL OTHER 11/14/2006 OTHER ody 66 NO PHYSICAL INJURY $0.00 $0.00 $0.00 ides. $0.00 $0.00 Nature of6 r Injury:. j Asbestos Exposure @ Structure Fire N/A Fire Fighter N/A Pan. Tccldent,.. Descr: 10/26/2006 11/07/2006 3234361 FOWLER, MARK W 11/14/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 NatureoT 59ALLOTHER Body I,! 66 NO PHYSICAL INJURY Injury:: Asbestos Exposure @ Structure Fire N/A Fire Fighter N/A Part ccidentr- Descr: 10/26/2006 11/07/2006 3234358 RUSSELL, ANDREW M 11/14/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 ature of 59 ALL OTHER -B-od-v----1 66 NO PHYSICAL INJURY Side:. ^jury;' i'. Asbestos Exposure @ Structure Fire N/A Fire Fighter NIA art DccidenE Descr: 10/26/2006 11/07/2006 3234353 REINKING, ROSS G 11/14/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 Nature cf 59 ALL OTHER Body . 66 NO PHYSICAL INJURY ide Injury: , Part: LLLj ccident, Asbestos Exposure @ Structure Fire N/A Fire Fighter N/A _ Descr.` 10/26/2006 11/07/2006 3234347 SAXBURY, LYNDEL D 11/14/2006 OTHER $0.00 $0.00 $0.00 $0.01) $0.00 Nature of 59 ALL OTHER ody, 66 NO PHYSICAL INJURY ide:" Injury:. Asbestos Exposure @ Structure Fire N/A Fire Fighter N/A art..', ccident:.=: Descr.' 10/26/2006 11/07/2006 3234339 LINDHOLM, LEN E 11/14/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 ature of] 59 ALL OTHER ody , 66 NO PHYSICAL INJURY Side; Injury:, r:;: Asbestos Exposure on Structure Fire N/A Fire Fighter N/A Part. , ccident Descr:-, 10/26/2006 11/07/2006 3234333 KELLN, DAVID L 11/1412006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59ALL OTHER Body : 66 NO PHYSICAL INJURY ide: d ^jury Part: >; Exposure to Asbestos on structure fire N/A Fire Fighter N/A ccident escr;.' 10/26/2006 11/13/2006 3235179 STANCZYK, OUENTIN 11/15/2006 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY aof 59 ALL OTHER ody 66 NO PHYSICAL INJURY idea Injury: "- art . ccldenb__- Asbestos Exposure @ Structure Fire FIRE INVESTIGATOR Fire Investigator NOT SPECIFIED Descr. < Page 11 01=W9 08:51A weas UW651R PINN/I COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2006 thru 01101/2007 Worker amber Closi, ExpePaaids: 'Medical- Indemnity Date ReceClaim ,`..Dateed Received"NuReport ived 'Named Injury Cause aid Reserve' Incurred'"' 10/26/2006 11/07/2006 3234330 DINT, CHRISTOPHER M 11/07/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 N,ut re of 59 ALL OTHER Paorty 66 NO PHYSICAL INJURY ide: ln' ccldent Asbestos Exposure at structure fire N/A Fire Fighter N/A _ escr: 11/05/2006 11/06/2006 3234142 DINI, CHRISTOPHER M 12/27/2006 STRIKE -STATIONARY OBJECT $0.00 $0.00 $0.00 $0.00 $0.00 aWre of 40 LACERATION Body' 19 FACIAL BONES Injury: art: ccident': While cleaning waterway on truck 5, hit head on nozzle of extended ladder/aerial. Aerial was not mount app not on. No operations were taking place. N/A Fire Fighter N/A Des". 11/08/2006 11/09/2006 3234700 GARNER, ROBERT L 12/27/2006 OBJECT BEING LIFTED OR HANDLED $0.00 $275.85 $0.00 $0.00 $275.85 ature of 25 FOREIGN BODY ody 60 LUNG ide: Injury:. ,, Part: Accident_ I was inside of car that was upside down attending to patient . Glass from windows was falling around me & on top of me. Some glass entered my respiratory tract and throat causing minor pain. N/A Fire escr: -.I fighter Extraction Yes 11/08/2006 11/09/2006 3234828 HORNING, WILLIAM C 12/2712006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 25 FOREIGN BODY ody ] 60 LUNG Side: Injury: . . - art:. Accident ... Breathed in dust and particulate during a breaching exercise at the training house. N/A Fire Fighter N/A Descr: , 11/09/2006 11/09/2006 3234831 CHAMPLIN, TIM J 12/27/2006 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 49 SPRAIN Body-, 35 HAND ide:'. Left njury; art:. ccidebt : During firefighter bail out drill my left hand got caught under the rope on the windowsill. N/A firefighter training N/A Descr. , 11/09/2006 11/13/2006 3235198 MCNEIL, SHARON M 12/27/2006 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 52 STRAIN Body ,- 90 MULTIPLE BODY PARTS Injury:' i 1part:�: ccident. Practicing bail out @ training house Back up safety line not released system jammed causing jolt on body after jumping head first out window. Back up line caught back of helmet & jammed on face FIRE Descr: FIGHTER TRAINING Fire Fighter Training NOT SPECIFIED 11/10/2006 11/13/2006 3235159 WILSON, MICHAEL P 12/27/2006 MISCELLANEOUS STRIKE OR INJURY $D.00 $0.00 $0.00 $0.00 $0.00 Nature of 1000NTUSION ody I.., 19 FACIAL BONES ide: 1, injury: ., art: ccident.. I was using a chainsaw to cut through metal roof during training evaluation. A piece of roof was thrown by saw & the piece hit me just above upper lip. ACTING CAPTAIN FIREFIGHTER Acting Captain Descr: Firefighter SAW 11/12/2006 11/14/2006 3235473 MAKRIS, MARY E 02/18/2007 STRAIN -LIFTING $0.00 $1,461.35 $0.00 $0.00 $1,461.35 Natureof 52 STRAIN 'ody. 138 SHOULDER(S) Ide: Right Injury art" ccident.'., Reached into vehicle across back of front seat, picked up computer case @ full extension & with right arm. As lifted there was loud pop & burning pain under scapula radiating to neck. Muscle spasms. Descr.i EMS COORDINATOR EMS Coordinator COMPUTER CASE Page 12 01rz31200e 0e:51 AM Rwcis UW651R Date Of Loss Covg Location2 Name Department Name Status Total Paid Reserve Total Incurred Init Report Summary 1/27/2004 AL POUDRE FIRE AUTHORITY( PFA) POUDRE FIRE AUTHORITY Academy, Seven Oaks Closed S862.00 $0.00 $862.00 (PFA) 8/31/2004 AL POUDRE FIRE AUTHORITY (PFA) POUDRE FIRE AUTHORITY Cotter, Pete Closed $545.37 $0.00 . $545.37 (PFA) 11/30/2004 AL POUDRE FIRE AUTHORITY (PFA) POUDRE FIRE AUTHORITY Larson, Jessica Closed $2,680.28 $0.00 $2,680.28 (PFA) 1/16/2005 AL POUDRE FIRE AUTHORITY (PFA) POUDRE FIRE AUTHORITY Leroy, Wayne Closed $1,648.42 $0,00 $1,648.42 (PFA) 11/302005 AL POUDRE FIRE AUTHORITY (PFA) POUDRE FIRE AUTHORITY Dearing, David Closed $41.65 $0.00 $41.65 (PFA) 6/122006 AL POUDRE FIRE AUTHORITY (PFA) POUDRE FIRE AUTHORITY Montana, Eduardo Rodr Closed $436.23 $0.00 $436,23 (PFA) 1122008 AL POUDRE FIRE AUTHORITY (PFA) POUDRE FIRE AUTHORITY Kiesling, Craig Closed $1,329.96 S0.00 $1,329.96 (PFA) PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/0112010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data asof:01/23/2009 Policy Period: 01/01/2006 thru 01/01/2007 Accident Reported Claim Injured Worker `'Closed ,Expenses, Medical' .Indemnity, .Current Total Date Received Number"Name ," „, . Date- j ry �', '' ,. `. In'u Cause„ }j ,,. ,:, Paid., Paid .' II, Paid, Reserve Incurred 11/16/2006 01/05/2007 3242901 GILIOTTI, TYLER 01/18/2007 BURN - DUST, GAS, FUME, VAPOR $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 66 POISONING -CHEMICAL Body,:,; 60 LUNG ide: Both Injury: Part: Working in old house for 45 days. 100 Year old dust. TEMPORARY WORK @ HOUSE Temporary work @ house NO Accident Descr: 11/17/2006 01/05/2007 3242907 HEGSTROM, TIMOTHY 02/15/2007 BURN - DUST, GAS, FUME, VAPOR $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 66 POISON ING-CHEMICAL ody :_ 60 LUNG ide: Injury: Walking through old house for 45 days during set up period Part breathing 100 year old dust. TEMP WORK @ 3 F HOUSE temp work @ 3 F House NO ccident. escc 11/21/2006 11/22/2006 3236738 MYERS, CHAD A 11/22/2006 ELECTRIC SHOCK -CONTACT W/ ELECTRIC $25.88 $1,388.28 $0.00 $0.00 $1,414.16 CURRENT Nature of 19 ELECTRIG SHOCK IBody _ 54 LOWER LEG ide: Left Injury:- . Part ,., Accident.; Received electrical shock from live wire while fighting a fire. N/A Fire Fighter N/A Descii;. , 11/23/2006 11/27/2006 3237077 WIGGINS, SCOTT 52STRAIN 12108/2006 STRAIN -LIFTING $0.00 $0.00 Body . 38 SHOULDER(S) $0.00 Side: ,., Right $0.00 $0.00 Natute:of Injury:, Part I was working out & during one of the exercises I felt a pull or strain at the right shoulder. I had to guard or tighten this area while carrying the mod kit to illiminate pulling of the arm. FIRE FIGHTER/ ccident Des cr: DRIVER/OPERATOR Fire Fighter/ Driver/Operator NO 11/30/2006 12/04/2006 3238317 WIGGINS, SCOTT 07/17/2007 MISCELLANEOUS STRIKING AGAINST OR $87.21 $13,127.12 $2,826.97 $0.00 $16,041.30 STEPPING ON Natureof 52STRAIN Injury. � = Body 38 SHOULDER(S) ide: Right Part: ccident. We were looking for an open window or door at a home with a waterleak in the garage. I slipped on a plexy glass cover over a window well. It was covered with snow. N/A Fire Fighter Acting Captain N/A Descr. 12/03/2006 12/04/2006 3238280 LINDHOLM, LEN E 52 STRAIN 03/21/2008 FALL ON ICE OR SNOW $237.75 $13,434.51 Body,- 42 LOW BACK (LUMBAR & LUMBO-SACRAL)„- $8,009.75 $0.00 $21,682.01 Nature of Injury: Part: Getting out of truck to fight fire stepped on ice slipped twisted back. N/A Fire Fighter N/A ccidenY;fs Descr 12/07/2006 12/11/2006 3239576 SHALBERG, LORI 52STRAIN 01/09/2007 FALL - SAME LEVEL $0.00 $763.74 ody 42 LOW BACK (LUMBAR & LUMBO-SACRAL) $0.00 bider $0.00 $763.74 Nature of Injury:- Slip and Fall FIRE FIGHTER Fire Fighter NO art f. . ccident Descr: 12/08/2006 12/15/2006 3240382 VANGORDER, JOHN 03/15/2007 MISCELLANEOUS MOTOR VEHICLE $59.42 $1,493.72 52 STRAIN Body 21 NECK VERTEBRAE Part: Backed truck into tree when pulling into warehouse. Sudden stop whiplashed my neck and shoulders backwards. N/A Fire Fighter/Warehouse Dir N/A $0.00 ide: $0.00 $1,553.14 Nature of Injury: `1 Accident Descr: Page13 01=00908:51AM Pwas uw651R PINNn, COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/0112006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2006 thru 01/01/2007 Claim'; Accident ..; . '.Injured'.Worker' ,. - -'Closed, -- - ', ..;. *':Expenses +Medical Report.Claim Indemnity {Current -.Total'' Date, Received",; Number '.Name .Date In'u Cause,. Paid,' _:Paid', _ j, ry Paid }: Reserve Incurred!- 12/18/2006 12/18/2006 3240667 JOHNSON, THOMAS A 02/16/2007 FALL -MISCELLANEOUS $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 52STRAIN Body 38 SHOULDER(S) ide: " Right Injury: .Part. Accident During a structure fire fell straining my shoulder. N/A firefighter N/A Descr: 12/18/2006 12/19/2006 3240751 LYNXWILER, JAMES R 02/19/2007 MISCELLANEOUS STRIKE OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 10 CONTUSION ody . ,_ 44 CHEST (INCL RIBS, STERNUM, SOFT TISS) Side: Injury:, art. f Accldent Ice rescue training & acting as victim in an ice hole. Injury to ribs occurred when I was pulled out of hole by rescuer. Chest was pulled aginst ice shelf causing the injury. N/A Fire Fighter N/A Descr: 12/22/2006 12/27/2006 3241436 MORAN, JOHN 02/15/2007 MISCELLANEOUS STRAIN OR INJURY $0.00 $654.08 $0.00 $0.00 S654.08 ature of 52 STRAIN ody,.. 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Side: Injury:. art:_,. ccidenl.:. AFTM running station 7 snow blown for 6 hours I strained my back, cleaning out the chute on the snow blower. FIREFIGHTER CAPTAIN STATION 7 FireFighter Captain Station 7 SNOW BLOWER Descr:. 12/23/2006 12/27/2006 3241444 ANDUSS, MURRAY 02/15/2007 FALL ON ICE OR SNOW $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 10 CONTUSION Body 41 UPPER BACK AREA ide: Injury: part:,' While repairing the tire chains on the fire engine,l slipped on the ice and landed on my back and right shoulder FIRE FIGHTER Fire Fighter NOT SPECIFIED ccident escr, Policy Period Totals: Total Claims: 106 $730.26 $69,771.71 $85,142.45 $0.00 $155,644.42 Open: 0 Open: $0.00 $0.00 $0.00 $0.00 Closed: 106 Closed: $730.26 $69,771.71 $85,142.45 $155,644.42 Average: $6.89 $658.22 $803.23 $1,468.34 Minimum: $0.00 $0.00 $0.00 $0.00 Maximum: $286.46 $15,653.90 $74,305.73 $90,246.09 Page 14 01=0090831 AM awns UW651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01101/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data asof:01/23/2009 Policy Period: 01/01/2007 thru 01/01/2008 claim Worker Expenses Medical Current TotalAcciII Datedert Received . , Nu:CIamber Name,lniur�ed 'ury Dated Inj Cause ,'', . Paitl.+• :Paid �,�Indemnity Paid Reserve incurred " 01/04/2007 01/04/2007 3242535 KOBIELUSZ, BRAD C 12/20/2007 FALL ON ICE OR SNOW $10.54 $18,581.89 $8,009.75 $0.00 $26,602.18 ature of 52 STRAIN -Body 33 LOWER ARM ide: Right njury:, Part:' , Removing chain saw from back of vehicle when I slipped on ice. As I fell the weight of the chainsaw hyperextended my right arm/shoulder. FIRE FIGHTER TRAINING CAPTAIN Fire Fighter Training Accident, Descr: ' Captain NO 01/05/2007 01/10/2007 3243768 STOUFFER, LYNN E 02/15/2007 OBJECT BEING LIFTED OR HANDLED $0.00 $0.00 $0.00 $0.00 $0.00 Natureof Injury: 40LACERATION Raising flag from 112 mast haluard guard on pole fell Botly, 15 NOSE art: off, striking me between eyes, 1" non suchereable on right side of nose. N/A Fire Fighter N/A :der Right Accident 01/11/2007 01/11/2007 3244062 BERNUM, RICHARD A 09/11/2007 OBJECT BEING LIFTED OR HANDLED $124.59 $8,388.96 $0.00 $0.00 $8,513.55 Natureof In/ury , 49SPRAIN Body 37 THUMB Part: : Slammed right thumb in engine door. N/A Fire Fighter N/A ide: Right _ccident escr. 01/21/2007 01/22/2008 3308601 DINT, CHRISTOPHER M 01/29/2008 FALL ON ICE OR SNOW $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 1000NTUSION otly 53 KNEE ide: ;. Lek Injury,: `.. Morning chores. It was snowy outside took out trash art.. ,€. and slipped on ice. Right knee shin left knee instantly bruised. FIREFIGHTER FireFighter NONE _ ccident:'I 01/30/2007 01/31/2007 3250186 VANGORDER, JAMES D 05/1712007 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 52 STRAIN otly-._+ 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide: njury:. art: Carried cot loaded with patient from house to med unit. Only person lifting the foot end of cot. Head end caught on brackets on floor. Felt minor twinge to lower back, possible injury. N/A Fire Fighter N/A ccident.. Descri 02/04/2007 02/12/2007 3252418 BREWSTER, WAYNE 03/13/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 73 CONTAGIOUS DISEASE Body : 66 NO PHYSICAL INJURY Injury::. Part: ccident. Responded to patient with breathing problems. While attending to patient facility staff stated about 10 minutes into patient care that patient was MRSA. All EMS crew put face mask on at that time. FIRE Descr: ',I FIGHTER Fire Fighter NO 02/04/2007 02/20/2007 3253832 LONG, GARY W 02/27/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE • Body 66 NO PHYSICAL INJURY In/ury: •; ccident. Exposure to patient with MRSA was not aware of patients condition until well into the call. Notified by A CO Brewster to submit this report on 2-12-07. FIRE FIGHTER/ EMT Fire Fighter/ EMT Descr. '. UNKNOWN 02/04/2007 02/12/2007 3252415 GUTHRIE, JAL J 03/21/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73CONTAGIOUS DISEASE otly 66 NO PHYSICAL INJURY Injury:.'9, Part: ccident.-.: Responded to patient with difficulty breathing. Arrived & began pliant assessment & treatment. After moving patient to cot nurse notified crew that he had MRSA. FIRE FIGHTER/ EMT Fire Fighter/ EMT escr:, - ; NO Page 15 01=00906:51 AM awns UW651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2007 thru 01/01/2008 . ,Claim Accident" Report,.,Claim ' Clnjured Worker 'Closed Expenses.! 'Medical . Indemnity: • Current Total' "1ncurred Date. Received.'. Number. Name, ." Date injury Cause -� Paid:„ Paid Paid Reserve' 02/06/2007 02/07/2007 3251539 LEVY, GLENN M 04/09/2007 OBJECT BEING LIFTED OR HANDLED $0.00 $35.55 $0.00 $0.00 $35.55 atureof 1000NTUSION - gody. 36 FINGER(S) Side: Injury: , art: ccident WAS MOVING LARGE METAL DRAFTING TABLE WHEN LID FELL AND SMASHED LEFT 1ST FINGER. N/A Fire Fighter / Chief of Training N/A Descr. '11 02/13/2007 02/13/2007 3252639 MIROWSKI, JAMES A 04/19/2007 STRAIN -LIFTING $0.00 $480.70 $0.00 $0.00 $480.70 Nature of 52 STRAIN Fo-d-y7 36 FINGER(S) ide: Left Injury:. art:. ccident Was carrying hub - rotor assembly off left front of engine 3 to parks washer when something popped at the base of my finger on my left hand. FLEET MAINTENANCE TECH Fleet Maintenance tech NO Descr: 02/16/2007 02/20/2007 3253829 MCKEON, JONATHAN 03/23/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $334.43 $0.00 $0.00 $334.43 INJURY Nature of 73 CONTAGIOUS DISEASE Body , ; 66 NO PHYSICAL INJURY ide:: Injury: Part: ccident While acting as EMT on medical call, exposed to copious amounts of mouse feces in patient vehicle. No injuries. Just exposure. N/A Fire Fighter/EMT N/A Descr: 02/22/2007 02/23/2007 3254325 HORNING, WILLIAM C 05/17/2007 STRIKE -STATIONARY OBJECT $0.00 $542.51 $0.00 $0.00 $542.51 Natureof 1000NTUSION Body ..,' 32 ELBOW Sider Injury: -•1 Part Accident : While exercising doing cardio by going upstairs to the loft & back down stairs I hit my right elbow on the 2 x 4 handrail causing sharp pain in elblow -possibly chipped. N/A Fire Fighter N/A Des,r:,' 03/12/2007 03/13/2007 3257152 TAYLOR, SCOTT G 05/14/2007 MISCELLANEOUS STRIKE OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 atureof 40LACERATION § ody'. 15 NOSE Side: Injury: art: ccident Performing a search and rescue drill & I crawled head first into the wall. The brim of my helmut came down & took out a chunk of skin on the bridge of my nose. FIRE FIGHTER/SEARCH & RESCUE Fire Descr:'r;i:, ;,I, Fighter/Search & Rescue NOT SPECIFIED 03/19/2007 03/20/2007 3258316 FALBO, TONY J 05/17/2007 MISCELLANEOUS STRIKE OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 atureof 49SPRAIN Body!'. 53 KNEE ide: Both njury: art: ccident Opened WYE gate under pressure and struck my knees. Pressure was approx 225 PSI. FIRE FIGHTER Fire Fighter NO - escr:. 03/21/2007 03/22/2007 3258717 HANSON, BRYAN K 03/31/2008 STRAIN -LIFTING $3B2.39 $19,021.53 $45,891 28 $0.00 $65,295.20 Natureof 52 STRAIN Body, 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide: Right Injuryi ccident Was lifting PVH Cot with very large female, lifted to hold legs down felt sting in lower right side of back. FIRE FIGHTER/EMT Fire Fighter/EMT NO Descr. 03/21/2007 03/22/2007 3258750 HOUSLEY, KEVIN M 06/21/2007 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 52 STRAIN ody _, 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide: Injury: `: Part: ccident - We got dispatched to MVA & as I was puling my bunker pants on & pulling up my boots my lower left back began to hurt. The injury occurred during the pulling motion. Twinge in lower back. BREAKING Descr: UP FIGHT BREAKING UP FIGHT NOT SPECIFIE Page 16 0120200908'51 AM Rwcis UW651R PINNncOLStandard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2007 thru 01/01/2008 .'Claim.:, Accident .Report, Claim Injured Worker. Closed ---" - Expenses, ; 7Medical Indemnity. Current Total Date. Received Number Name ,...:Date ,. .. ,Injury Cause - - - -. . , ", Paid 'Paid '_ -Paid c Reserve "Incurred 03/30/2007 04/02/2007 3260246 GREAVES, GREGORY S 04/06/2007 FALL - SAME LEVEL $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 1000NTUSION Body 1 34 WRIST ide ,! Left Injury: -,,' Part: Walking outside of PFA HQ Bldng @ 102 Remington @ the SE comer of Mountain & Remington tripped on raised concrete surrounding manhole cover on sidewalk. Was walking to lunch. POLICY AND ccident Descr.. PERSONNEL WALKING NONE 04/13/2007 04/16/2007 3262248 CONTRERAS, KEVIN H 06/15/2007 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $0.00 $0.00 $0.00 $0.00 atureot 73 CONTAGIOUS DISEASE ody- 19 FACIAL BONES Injury: . Blood exposure to face from intubation tube strap N/A Rescue N/A Accident . Descr:' 04/27/2007 04/27/2007 3264234 RICE, SPENCER 06/21/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 59ALL OTHER ody 7] 66 NO PHYSICAL INJURY Side: ; Injury: ' art: ccident - Performed CPR on 24 y of that was in arrest. Full BSI was used including gloves glasses as well as an airway barrier. Parents informed us patient had been diagnosed with a virus the day before. FIRE Descr: .: FIGHTER/EMT Fire Fighter/EMT NOT SPECIFIED 04/27/2007 04/27/2007 3264238 DEBAERE, DUSTIN D 05/08/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE Body 66 NO PHYSICAL INJURY ide: Injury. -:: Part. ' Accident t: Performed CPR on a 22 Y of using complete BSI & eye protection. Parent of patient stated that she had been diagnosed with a virus the previous day. FIREFIGHTER/CAPTAIN Firefighter/Captain NOT Descri.,, SPECIFIED 04/27/2007 04/27/2007 3264252 DRAGAN, ANTHONY R 05/08/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY ature of 73 CONTAGIOUS DISEASE Body 66 NO PHYSICAL INJURY Side: Injury: _ Part:. " -. ccidenta Responded to 22 Year old female patient in arrest. Was wearing full PPE including eye glasses safety gloves & boots & bunker pants. Performed CPR on the patient for approx 5-10 min. FIRE Des&::, 'I FIGHTER Fire Fighter NOT SPECIFIED 05/12/2007 05/14/2007 3266688 GARCIA, BRANDON J 06/18/2007 STRAIN-PUSHING,PULLING $0.00 $292.34 $0.00 $0.00 $292.34 Natureof 52 STRAIN Body,;, 38 SHOULDER(S) ide: Left Injury: Part: Doing truck check was putting circular saw back in compartment. Had saw in left hand and pulled saw away from body and something happened in left shoulder. FIRE FIGHTER Fire Fighter NO ccident:= Descr: 05/12/2007 08/28/2007 3284859 ONIGKEIT, BRIAN A 03/10/2008 MISCELLANEOUS STRAIN OR INJURY $298.04 $6,837.32 $0.00 $0.00 $7,135.36 Natureof 49SPRAIN ody, 1 53 KNEE -Side: Left Injury: '- During academy in confined space training injured left art: knee reported injury @ that time didn't think was severe & did not seek medical attention. Injury has increased in severity since that time. N/A Fire Accidents. Des'cr`.'I -w"d: Academy N/A 05/15/2007 05/16/2007 3267062 HOUSLEY, MATT J 05/24/2007 STRUCK BY -FALLING OBJECT $0.00 $634.37 $0.00 $0.00 $634.37 Nature of 40 LACERATION ody, 11 SKULL ide, njury:_:. art: ` - While conducting annual fire sprinkler. inspection @ 305 E Elizabeth, the Flow switch cover box fell from 10 feet and hit me in the left side of my head above the eye. FIRE FIGHTER Fire Fighter NOT ccident escr:" SPECIFIED Page 17 011231200908:51 AM MOM ❑W651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2007 thru 01/01/2008 'Claim:, _ ... .... Accident' Report ,Claim. Injured Worker .Closed. _. _ Expenses, _ .Medical Indemnity. Current' :. Total .Date,Receive0 Number Name' Date ;Injury Cause, - Paid -Paid Pain- Reserve 'Incurred' 05/17/2007 05/18/2007 3267583 SANTILLANES, DANIEL L 06/21/2007 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 wetu-re of 52STRAIN Wod-Y-7 62 BUTTOCKS ide: Left Injury:. art: • ccident- Performing high angle rope rescue off of 5th floor tower. I was repelling over side of building and my feet stayed up rolling in harness and hitting my tail bone on the building hard. HIGH ANGLE RESCUE Descr: TRAINING High Angle Rescue Training NOT SPECIFIED 05/20/2007 05/23/2007 3268248 SHEESLEY, DREW W 07/13/2007 MISCELLANEOUS STRIKING AGAINST OR $0.00 $519.96 $0.00 $0.00 $519.96 STEPPING ON Nature of 1000NTUSION ody - 35 HAND Side: _ Right Injury: Part: ccident Conducting swift water training exercising in Poudre river, possibly contacted rock with right hand. FIREFIGHTER TRAINING FIREFIGHTER TRAINING NO Descr:'. 05/21/2007 05/22/2007 3268037 HORNING, WILLIAM C 06/11/2007 STRAIN -LIFTING $0.00 $424.83 $0.00 $0.00 $424.83 Nature of 52 STRAIN Fod-y7 44 CHEST (INCL RIBS, STERNUM, SOFT TISS) . ide - Right Injury: Part: Accident .. I was working out doing presses and had felt a cramp pull in my right chest - shoulder and neck. FIRE FIGHTER Fire Fighter NO Descr: 05/25/2007 05/25/2007 3268689 ROBERTS, NANCY L 06/27/2007 STRUCK OR INJURED BY FELLOW WORKER, $28.00 $537.78 $0.00 $0.00 $565.78 PATIENT Nature of 73 CONTAGIOUS DISEASE Body .,, 66 NO PHYSICAL INJURY ide:• Injury::.:°.. Part: ccident Treating a.combative head wound patient who repeatedly scratched me with his bloody hands and fingernails. FIRE FIGHTERIEMT Fire Fighter/EMT NOT SPECIFIED Descr e� 05/29/2007 05/30/2007 3269154 PIETRANGELO, JAMES H 03/21/2008 STRAIN-PUSHINGRULLING $239.59 $22,857.67 $4.240.45 $0.00 $27,337.71 Natureof 52STRAIN ody. 38 SHOULDER(S) IPart: ide: Left njury:... _= ccident. I hurt my left shoulder pulling hose and using axe and halligan during a fire in a structure. N/A Captain/Fire Fighter N/A Descr. O6/01/2007 06/01/2007 3269621 MAKRIS, MARY E 06/27/2007 FALL OR SLIP FROM LIQUID OR GREASE $0.00 $0.00 $0.00 $0.00 $0.00 SPILLS Natured 1000NTUSION Body _I 51 HIP rde: Injury: Part: Accident Walking out of classroom carpet was wet once on linoleum, wet soles of shoes lost balance and slipped and fell on hip. N/A EMS Coordinator/Training N/A Descr: 06/01/2007 06/01/2007 3269618 GRESS, MIKE 06/27/2007 FALL OR SLIP FROM LIQUID OR GREASE $0.00 $0.00 $0.00 $0.00 $0.00 SPILLS Natureeof 49SPRAIN Bo­dT_j 55 ANKLE ide. -.. Right Injury: Part: ccideComing off wet carpet slipped on the floor - twisting right ankle. NIA Division Chief N/A Descr. O6/04/2007 06/05/2007 3270012 LYNXWILER, JAMES 08/06/2007 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 52STRAIN ody ', 52 UPPERLEG $0.00 ide:•,t Left $0.00 $0.00 Natureof njury: , art: I was exercising with the fire fighter recruit academy when I pulled a muscle during a run. FIRE FIGHTER Fire Fighter NOT SPECIFIED ccident. escr: Page18 01/23/2009 08:51 AM awns UW651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/0112010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data asof:01/23/2009 Policy Period: 01/01/2007 thru 01/01/2008 ,_. Claim:. Accident Report Claim Injured Worker. .'. Closed ` Expenses Medical Indemni ,Current ' ,_ Date Received . Number Name ', Date ^.Injury, Cause', Paid- Paid Paid :'' ,.Reserve Incur�ed'". 06/08/2007 06/11/2007 3270977 WILSON, MICHAEL P 08/10/2007 CUT -TOOL, NOT POWERED $0.00 $0.00 $0.00 $0.00 $0.00 ature of 40 LACERATION od 36 FINGERS ( ) ide: Left nitureury: :, Part' Installed electric medical suction unit on reserve engine. Used scissors to cut through plastic zip tie. When scissors cut through zip tie, closed on left index finger injury & exposure resulted. N/A Fire Accident,` Descr: Fighter N/A 06/08/2007 06/11/2007 3270980 GILLAN, RAY D 03/21/2008 MISCELLANEOUS STRIKING AGAINST OR $12.46 $9,339.38 $8,952.07 $0.00 $18,303.91 STEPPING ON Natureof 49SPRAIN ody•. 53 KNEE njury: art: ide; Right ccident : - After backing out E-24 I stepped out of the cab onto the grass and unlevel ground twisting my right knee. Falling to the ground. N/A Training fire N/A Descr: 06/10/2007 06/11/2007 3271021 PEARSON, MATT 08/01/2007 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $620.51 $0.00 $0.00 $620.51 ature of 40 LACERATION ody ' , 61 ABDOMEN INCLUDING GROIN Side: njury:� s Part: Matt Pearson was sittin on front of E-9 & went to push off engine to stand upon ground in front of engine. Clip to gear compartment was up & caught scrotum & created a laceration on Matts Scrotum Accident escr: •' N/A Volunteer Fire Fighter N/A 06/13/2007 06/14/2007 3271717 MURPHY, TIM R 08/13/2007 MISCELLANEOUS STRIKING AGAINST OR $0.00 $0.00 $0.00 $0.00 $0.00 STEPPING ON Nature of 52 STRAIN ody- .- 52 UPPER LEG Injury:..:. art: 1 Side:^t•, Right ccident€zs. Running for PT. Pulled right hamstring strain. FIRE FIGHTER Fire Fighter NO Descr: 06/15/2007 06/18/2007 3272229 GAUCHER, PAUL R 08/16/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59ALL OTHER Eody • - 14 EYE(S) Injury:' Part: Vide-7 r,� : ccident.=s Swimming in pond looking for drowning victim. N/A Fire Fighter N/A Descr. .`- 06/15/2007 06/18/2007 3272234 BUTLER, GEOFF 08/16/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY atureof 59 ALL OTHER ody;-;_ 48 INTERNAL ORGANS Injury:' ccident•a: Searching in pond for drowning victim. N/A Fire Fighter N/A Descr.,`. - )6/15/2007 06/18/2007 3272245 RAISLEY, BRIAN D 08/16/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59ALL OTHER Body, ,, 14 EYE(S) Injury: i Part:' ccident Swimming in pond searching for a drowning victim N/A Fire Fighter N/A escr:;,,.:-, Page 19 OlaM00908:51 AM wads UW651R Data asof:01/23/2009 PINNAA COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE DDnT9=rTIr)KI INCTR ICT Policy Period: 01/01/2007 thru 01/01/2008 Claim Claim, d Worker. ExpensesPaid ,Me ical - Indernrifty Current " Total Datedentl Received'I Number'.NameReport DatCloed In'u Cause. ' Pad Paid.' 'Reserve, `incurred O611812007 06/19/2007 3272539 JONES, SEAN E 08/16/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 Nature7of 59ALLOTHER INJURY Body ,,,:, 66 NO PHYSICAL INJURY ide: ,. Injury:, Part Accident Responded to single car rollover with possible code black. Deceased is pinned under car & moderate amount of blood is at scene. Patient is reported to possible Hepatitis C. FIRE FIGHTER Fire Fighter Descr: NOT SPECIFIED 06/18/2007 06/19/2007 3272546 HORNING, WILLIAM C 08/17/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $125.51 $0.00 $0.00 $125.51 ature of 73CONTAGIOUS DISEASE INJURY Body 66 NO PHYSICAL INJURY Side: njury:.., Part: - ccident,-. Patient was code black & pinned uner car. There was a pool of blood around vehicle and patient. Patient deceased reported to have Hepatitis C. FIRE FIGHTER Fire Fighter NOT SPECIFIED Descrr- 06/18/2007 06/19/2007 3272563 GUTIERREZ, JOSEPH A 08/16/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 ature of 59 ALL OTHER INJURY Body 66 NO PHYSICAL INJURY ide: njury: Part: ccident:.. Single rollover vehicle. Patient trapped. Was assigned to extricate patient from car. Patient had lot of blood on street had some exposure getting patient out of vehicle. N/A Fire Fighter NA Descr:CC, O6/18/2007 06/19/2007 3272536 LESSER, MILTON 08/16/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59ALL OTHER INJURY ody-, . 66 NO PHYSICAL INJURY Injury:,,, Part. ccident; _. Responded to a single car rollover with code Black. Body recovery operation - body was surrounded by blood. Victime may have Hepatitis C. FIRE FIGHTING Fire Fighter NOT SPECIFIED Descr... O6/18/2007 06/19/2007 3272564 THOMAS, RYAN 08/16/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 ature of 59ALL OTHER INJURY Body- - 66 NO PHYSICAL INJURY Side _. njury: . art: ccident':"_: Rollover accident, deceased victim with hugh amount of blood from wound blood contact from victim removal. N/A Fire Fighter/Extrication N/A f]escr. O6/18/2007 06/19/2007 3272568 LIPPERT, JOHN C 07/03/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 59 ALL OTHER INJURY (Body , ; 66 NO PHYSICAL INJURY Ide: Injury: ,.." art. ccident_ •. Rollover accident had to extricate deceased from under vehicle. Patient had severe head trama & a large amount of blood was on ground had exposure to blood on PPE & boots. N/A Fire Descr:.'"`;' Fighter/Supervisor N/A O6/1812007 06/19/2007 3272566 TENNYSON, GREG W 08/16/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 are of 59ALL OTHER tu INJURY ody- 66 NO PHYSICAL INJURY Slde: Injury: > Part: Accident Assigned to extricating trapped male from single car rollover. Significant amount of blood on road & we had some exposure getting patient out of vehicle N/A Fire Fighter N/A escr. Page20 0123I 908:51AM Rwcis M651R PINNAcOLStandard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/0112010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data asof:01/23/2009 Policy Period: 01/01/2007 thru 01/01/2008 Claim ., Accident..Report Claim. Injured Worker Closed Expenses Medical ;Indemnity .Current _ Total '. Date .Received Number Nae mm Date- - _._ Injury Cause _ _ _ Paid _ Paid 'Paid:" , Reserve Incurred 06/19/2007 06/20/2007 3272703 HETTINGER, MARK 07/16/2007 OBJECT BEING LIFTED OR HANDLED $0.00 $292.34 $0.00 $0.00 $292.34 Nature'bf 52 STRAIN Bod ;. 38 SHOULDER(S) Left n u' I was unloading hose from the engine to the north stair well on a structure fire. N/A Fire Fighter N/A ,ide:ECT Accident Descr: ` O6/20/2007 06/21/2007 3272906 LESSER, MILTON 09/28/2007 MISCELLANEOUS STRAIN OR INJURY $0.00 $975.99 $0.00 $0.00 $975.99 atureof Li M- 52STRAIN New Exercise N/A Fire Fighter N/A P ody •a 52 UPPER LEG art: ide: Right ccident'r-_ escr:: 06/21/2007 06/21/2007 3272901 BEARD, JEFFREY 08/16/2007 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $0.00 $0.00 $0.00 $0.00 PATIENT atureof 52 STRAIN Injury: P ody - _: 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Part: _ 'ccident: MM LIFT ASSIST OF 77 YEAR OLD MALE PATIENT WAS SITTING NEXT TO HIS BED. AREAD HAD LIMITED ACCESS. PATIENT WEIGHT ABOUT 300 LBS. N/A Fire Fighter N/A Descr: 06/25/2007 07/02/2007 3274540 MAKRIS, MARY E 08/16/2007 CUMULATIVE (ALL OTHER) $0.00 $1,125.18 $0.00 $0.00 $1,125A8 ature of 80 ALL OTHER CUMULATIVE INJURIES Body, 7 38 SHOULDER(S) ide: Right njury: J Part: - Was moving equipment packing med bags typing & pain began in right shoulder radiation to neck back and arm. Over few days became worse with numbness tingling and muscle spasms. MOVING ccldent.. Descr: EQUIPMENT & PACKING KITS Moving equipment & packing kits NO 07/08/2007 07/09/2007 3275687 LINDHOLM, LEN E 03/10/2008 CUMULATIVE (ALL OTHER) $248.21 $13,071.52 $4,931.89 $0.00 $18,251.62 ature of Injury:, , 80 ALL OTHER CUMULATIVE INJURIES ody. ; 38 SHOULDER(S) Part: Digging Digging a trench to put in sprinkler line FIRE FIGHTER Fire Fighter NO Srde: _ Right Accident Descr: 07/18/2007 07/23/2007 3278088 GARCIA, BRANDON J 07/24/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature.of 73 CONTAGIOUS DISEASE njury:' ody : 35 HAND art: ;' Side:_ , Right ccWont:. Extracting patient & came in contact with patients bodily Fluid. I had extrication gloves & did not have medical gloves on. Blood soaked through & exposed right hand. FIRE FIGHTERNICTIM REMOVAL Descr. ,':�Fire RghterNictim Removal NO 07/27/2007 07/30/2007 3279380 LYNXWILER, JAMES R 09/12/2007 STRAIN -USING TOOL/MACHINE $0.00 $0.00 $0.00 $0.00 $0.00 Nature of Injury: 52 STRAIN I was exercising on a stair master when I felt a "pop" Body, 56 FOOT - Part: on the middle top of my left foot. FIRE FIGHTER Fire Fighter NO ide: Left Accident :: Descr.;;, - 08/13/2007 08/14/2007 3282136 CHAVEZ, MICHAEL A 09/07/2007 FALL-SAMELEVEL $0.00 $186.46 $0.00 $0,01 11116,46 ture aof Injury: , 52STRAIN Help deploy blitz fire personnel portable monitor on a ] od 36 FINGER(S) Side: Left part:,,.'; grassy slope. While climbing grassy slope I slipped on wet grass landing my left hand jamming left finger onto the FIRE FIGHTER ccitlent'%'. Descr: " Fire Fighter PORTABLE MONITOR pinkie ground. Page 21 01=00908:51 AM Rwcis UW551R Data as of:01/23/2009 PINN/I COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01101/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Period: 01/01/2007 thru 01/01/2008 DPnTFCTIAW r11CTRICT Claim - Accident Report; Claim Injured Worker ' . ClosedExpenses 'Medical Indemnity Current - Total--, .' Date Received: Number. Name Date Injury Cause _ - - - Paid Paid Paid Reserve Incurred 08/18/2007 08/22/2007 3283763 HERRINGTON, JAMES 10/30/2007 STRAIN -LIFTING $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 52 STRAIN Body 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Injury: art: ccldertt. Lifting heavy tool - felt "twinge" in lower back became painful following day and worsening painful to stand up on 8-20. N/A Fire Fighter/Equipment Check N/A Descr: 08/28/2007 08/29/2007 3285128 RICE, SPENCER 09/12/2007 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 73 CONTAGIOUS DISEASE PATIENT Body , 19 FACIAL BONES Injury: Part: ccident Patient was very combative & had to be restrained. While holding patient down he pinched/scratched me causing small skin break & bruising. Patient also spit on me twice. EMT-8 EMT-8 NONE Descry 08/29/2007 08/30/2007 3285396 HERGENREDER, TERESA 12/11/2008 MISCELLANEOUS STRAIN OR INJURY $116.92 $3,595.34 $0.00 $0.00 $3,712.26 Natureof 49 SPRAIN ody , 51 HIP ide: - Left Injury: Part: -. ccident -: Stepped out of the engine wrong and felt pain in my left hip and down left leg. FIRE FIGHTER Fire Fighter NONE escr: 08/31/2007 09/04/2007 3285915 LYONS, CURTIS P 11/26/2007 MISCELLANEOUS STRIKING AGAINST OR $0.00 $543.90 $0.00 $0.00 $543.90 ature of 49SPRAIN Injury: STEPPING ON Body 53 KNEE ide:- _ Left Part: ccident. Knees sore causing slight limp while walking and running. Mostly left knee issue. FIRE ACADEMY Fire Academy NO Descr: 08/31/2007 08/31/2007 3285643 VANDER VLIET, JOHN A 09/12/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $239.00 $0.00 $0.00 $239.00 Natureof 59ALL OTHER INJURY Bodge. 66 NO PHYSICAL INJURY Injury:, Part: cscident d While escorting patient to ambulance I was being held on to by patient. Patient had blood on her hand and blood was transfered to my arm. FIRE FIGHTER Fire Fighter NOT SPECIFIED Decr?^ 09/09/2007 09/10/2007 3286960 GILLESPIE, JEFFREY A 10/19/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59 ALL OTHER Body 7 66 NO PHYSICAL INJURY Injury:: Part: ccident = Investigating & ventilating gas that leaked from furnace that exploded which was wrapped in asbestos causing asbestos fibers to become airborne. N/A Fire FighterNentilating Basement N/A Descr.,.:.. �. 09/09/2007 09/10/2007 3286954 HOUSLEY, MATT 11/09/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 ature of 59ALL OTHER INJURY Pody. 66 NO PHYSICAL INJURY ide: Injury:. art: ccident 1 Investigating gas leak in basement likely exposed to asbestos fibers that became airborne due to small explosion in old furnace that most likely wrapped in asbestos insulation. N/A Fire Fighter N/A Descr. Page 22 [MaWW908:51 AM wwcis Uw651R Date Of Loss Covg Locatlon2 Name Department Name Status Total Paid Vulbwrlullig Reserve Total Incurred Init Report Summary 5/8/2004 GL POUDRE FIRE AUTHORITY (PFA) POUDRE FIRE AUTHORITY Rennal, Harry Closed $750.00 $0.00 $750.00 (PFA) 324/2005 GL POUDRE FIRE AUTHORITY (PFA) POUDRE FIRE AUTHORITY Boyd, Clinton Closed $506.77 $0,00 $506.77 (PFA) 324/2005 GL POUDRE FIRE AUTHORITY (PFA) POUDRE FIRE AUTHORITY Gutcher, William Closed $2,290.61 $0.00 $2.290.61 (PFA) 2/1/2007 GL POUDRE FIRE AUTHORITY (PFA) POUDRE FIRE AUTHORITY Guucher, Clam Closed $1,675.42 $0.00 $1,675.42 PFA vehicle damaged gutter on Clara Gauchefs home. Please (PFA) send check to Complete Carpentry Inc. 3005 Parkview Court Fort Collins, CO 80525 ASAP This is an in house claim. P/NN/ICOL Standard Loss Run Report ASSURANCE Gross Claims Loss History Report Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY 8r POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2007 thru 01/01/2008 .Claim Accident Report Claim Injured Worker. Closed .. Expenses - ' - Medical. . Current, -Total Date Received L. -, <Number, Name Date njuryCause',: rPaid: Paid;.,, ,Indemnity ` Paid . Reserve Incurred:. 09/09/2007 09/10/2007 3286973 POTTLE, MICHAEL C 11/09/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59ALL OTHER IEody 66 NO PHYSICAL INJURY Injury:. art: ,de: Accident Possible exposure to asbestos dust. I was acting as fire fighter on truck 1 responding to 911 call where boiler in basement ruptured. Boiler was covered with insulation that likely contained asbestos N/A escc Fire Fighter N/A 09/09/2007 09/10/2007 3286915 MCKEON, JONATHAN 11/09/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 59ALL OTHER Body - 66 NO PHYSICAL INJURY ide: Injury:. Part: ccident Possible exposure to asbestos dust from old boiler in basement during recovery for basement fire. N/A Fire Fighter N/A Descis' " 09/09/2007 09/10/2007 3286921 KLASSEN, JAY S 11/09/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59 ALL OTHER Body 66 NO PHYSICAL INJURY Injury ' „ art: ,, Accident : Possible exposure to asbestos dust from old boiler in basement during recon for a reported fire in the basement. N/A Fire Fighter/Captain N/A escc. 09/09/2007 09/10/2007 3286925 DRECKMAN, FRANK W 11/09/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59 ALL OTHER Body . 66 NO PHYSICAL INJURY ide_.. Injury: ' Part: ccident. �. Investigating & ventilating a house with a possible boiler explosion we discovered asbestos had been disturbed surrounding the boiler and pipes. N/A Fire Fighter/Captain N/A escr::' 09/10/2007 09/11/2007 3287203 EDELMON, TRENTON C 10/24/2007 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $000 $0.00 $0.00 Nature of Injury:,-. 52 STRAIN ody 1 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Part. ide: -. ccident. Working in search maze. Lower back muscle strain. N/A Fire Fighter Training N/A Descr 09/13/2007 09/14/2007 3287807 ECKLUND, MATT P 11/13/2007 STRAIN -LIFTING $0.00 $0.00 $0.00 $0.00 $0.00 Natureof Injury,;Z 49SPRAIN Body' j. 37 THUMB art. Employee reported while lifting a ladder he hyper -extended his right thumb. TRAINING Training Ladder ide: Right - ccident Deser: 09/14/2007 09/21/2007 3289064 DARION, MICHAEL W 11/29/2007 STRAIN -LIFTING $0.00 $0.00 $0.00 $0.00 $0.00 atureof Injury: . 52 STRAIN ody 42 LOW BACK (LUMBAR & LUMBO-SACRAL) art: Physical test simulated dead lift pulling up with legs & arms on platform with chain & bar. Test measures leg strength. Strained lower back. FIRE FIGHTER Fire Fighter &de: CHAIN/BAR ccidentr,;l: Descr:' Page 23 01n31200908,51 AM PWcis UW651R Data as of:01/23/2009 P1NN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Policy Period: 01/01/2007 thru 01/01/2008 ClaimAcci. Report, Claim In ured Worker _ :. Closed ExpensesMedical Indemnity Current. c Total Accident ,Received Number„- Name...;- " / ry ,Date,"Inu Cause ,, ",,,.. • �_,«„ _ !Paid - - Paid Paid Reserve Inpuned 09/14/2007 09/14/2007 3287795 RICHARDSON, BRIAN S 09/17/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 73 CONTAGIOUS DISEASE INJURY Fo_dy7 66 NO PHYSICAL INJURY ide: Injury:., Part: ccident Employee reported a patient who was cut with a knife and had a severe arterial bleed exposed him to blood when dressings were applied to help control bleeding RESPONDING TO AN EMERGENCY Descr:. Responding to an emergency Hands and dressings 09/14/2007 09/14/2007 3287798 MCGAFFIN, SHAWN D 09/17/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 73 CONTAGIOUS DISEASE INJURY F,-dy7 66 NO PHYSICAL INJURY Sitlei Injury: art: ccident.. Employee reported he was exposed to large amounts of blood on a call. He had blood on his L. forearm and shirt. RESPONDING TO AN EMERGENCY Responding to an emergency Gloves, hands, Descr:. and dressings 09/18/2007 09/26/2007 3289720 LYNXWILER, JAMES R 07/25/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $1,769.29 $0.00 $0.00 $1,769.29 Nature of 59ALL OTHER INJURY Body 66 NO PHYSICAL INJURY 'Side Inju:...,, ry Part: ccident ,was exposed to a lot of smoke on wildland fire w/no symptoms after exposure. Later started feeling short of breath & coughing. Coughing slowly went away been having problem catch breath ever Descr:. since. WILDLAND FIREFIGHTER Wildland Firefighter NO 09/21/2007 09/25/2007 3289588 LYONS, CURTIS P 09/28/2007 ANIMAL OR INSECT $0.00 $151.33 $0.00 $0.00 $151.33 Natureof 43PUNCTURE iBody 55 ANKLE ide: Right njury: . Part: Accident Insect bite on right ankle found after being dismissed @ 8:00 PM I was at facility from 6:00 AM to 8:00 PM hours and did not have a bite prior to reporting to work. RECRUIT ACADEMY Recruit Academy Descr: NONE 09/23/2007 09/24/2007 3289278 TAYLOR, SCOTT G 10/18/2007 STRAIN -JUMPING $0.00 $286.02 $0.00 $0.00 $286.02 Natureof 49SPRAlN Body 51 HIP Side: Left Injury: IPart: ccident.. While exercising (doing base jumps) I went to jump up & as I did I felt a pop in the back part of my hip. It became tight and is tender with certain movements. FIRE FIGHTER Fire Fighter NO Descr: 09/27/2007 09/28/2007 3290323 ECKLUND, MATTHEW P 11/27/2007 CUT - MISCELLANEOUS $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 40LACERATION ,ody, 36 FINGER(S) Injury: part: ' ccjdent Cut finger while donning SCBA FIRE FIGHTER TRAINING Fire Fighter Training NOT SPECIFIED Descr:, 10/04/2007 10/09/2007 3292030 HILL, CHRISTOPHER M 11/29/2007 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 371NFLAMMATION INJURY Pody,. 56 FOOT Side: Both njury: art: Accident New shoes "wild - land" blisters on both right and left heels. WILD LAND FIREFIGHTER wild land firefighter NONE Descr: 10/05/2007 10/05/2007 3291544 GAVIN, MIKE G 11/29/2007 CUT- MISCELLANEOUS $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 40 LACERATION Body. 7 37 THUMB ide: ,,. Right Injury:• I IPart:. cident ] Smashed hand moving fire computers - small cut on right thumb. FIRE FIGHTER/OEM Fire Fighter/OEM NONE rc Descr. Page24 01/2312009 08:51 AM PWCis UW551R PINN/ICOL Standard Loss Run Report ASSURANCE Gross Claims Loss History Report Requested for Policy Periods with Coverage between 01/01/2006 and 01/0112010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2007 thru 01/01/2008 Claim Report .Inured Worker CI Me Expensesni ., Inde y ` Current; Total� Date, Received Number Name Datead Injury Cause . Paid' Paid Reserve Incurred 10/08/2007 10/09/2007 3292012 LYONS, CURTIS 10/1212007 CUT MISCELLANEOUS $0.00 $0.00 40LACERATION Body .fit 36 FINGER(S) Part `. Finger got caught on SCBA strap, buckle and began to bleed from a cut or tear. FIREFIGHTER RECRUIT Firefighter Recruit SCBA STRAP $0.00 ide: $"00 $0.00 Natureof- Injury.. ccldenf Descr: 10/10/2007 11/13/2007 3297696 STANCZYK, QUENTIN C 11/29/2007 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $0.00 $0.00 $0.00 $0.00 PATIENT Nature of 52 STRAIN ody, 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Injury:,_j art IS ide: . ccidenf -.: Lifting large patient patient is difficult to move not flexavle & cannot walk. Patient falls often & we are called to left from laying position to wheelchair. N/A Firefighter D/O EMT N/A Descr:, 10/11/2007 10/12/2007 3292795 ECKLUND, MATTHEW P 01/04/2008 FALL SAME LEVEL $0.00 $451.31 $0.00 $0.00 $451.31 atureof njury:; 10 CONTUSION Body-__, 38 -SHOULDERS) art �= Tripped going into structure fell on left shoulder while pulling hose. FIRE FIGHTER RECRUIT Fire Fighter Recruit HOSE ide: Left ccidenf' escr.. - 10/11/2007 10/12/2007 3292742 EDELMON, TRENT 1012912007 STRAIN OR INJURY BY TWISTING $0.00 $1,593.55 $0.00 $0.00 $1,593.55 Natureof 52STRAIN ody, 52 UPPER LEG ide: ,, During recruit training tripped over hose on the ground and fell backwards twisting leg. TRAINING Training HOSE Fe-eld-ent7 escr:. 10/11/2007 10/11/2007 3292567 SWIHART, MARKS 11/29/2007 STRUCK BY -MOVING PARTS $0.00 $0.00 1000NTUSION Body „., 35 HAND $0.00 ide: Left $0.00 $0.00 Nature ,of njury:- Part Releasing pressure on a 2 1/2" hose line under pressure at a gated eye. Hose kicked back & fully opened hose & hit me in left hand. Small amount of swelling. I I. was wearing gloves. FIRE FIGHTER Fire ccident:�>+ Descr...` Fighter FIRE HOSE 10/17/2007 10/18/2007 3293693 GILLESPIE, JEFFREY 10/19/2007 OBJECT BEING LIFTED OR HANDLED $0.00 $0.00 $0 00 $0.00 $0.00 Natureof Injury:,`''; 52STRAIN Body, 138 SHOULDER(S) Part: While practicing taking a LaCrosse helmet off a mannequin my right shoulder popped. I was above the head on the mannequin while spreading the helmet to remove ide: '. Right it. N/A EMS Training N/A ccidenf.. Descrt+ 10/19/2007 10/19/2007 3293925 ECKLUND, MATT P 10/30/2007 STRAIN-HOLDING,CARRYING $0.00 $0.00 $0.00 $0.00 $0.00 ature o f Injury 52STRAIN ody -, 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Part: . . While do live fire training the SCBA Matt was wearing had the bottle come off. FIRE FIGHTER Fire Fighter SCBA ide.. ccident Descr..., i;.,,1;, 10/23/2007 10/25/2007 3294679 FIGHTMASTER, BRADLEY D 11/13/2007 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 atureof 49SPRAIN ody 53 KNEE ide: Left Injury: �� _ art: While slowing down from a run my foot slipped on slick leaves and grass. My leg went out in front and I hyperexlended my knee. N/A Fire Fighter N/A Accident Descr.:..; Page25 012W200808'.51AM PwCis uw651R PINNAA COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/0112010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PRf)TFCTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2007 thru 01/01/2008 CAccident: Claim ' • '. :. Report., Claim •'Injured,Worker Closed • Expenses Medical :Indemnity Current ` Total . Date. Received :• ' Number -Name - Date '.Injury Cause 'Paid -Paid Paid Reserve Incurred 10/25/2007 10/25/2007- 3294833 ABBOTT, LOUISE A 11/06/2007 MISCELLANEOUS STRIKING AGAINST OR $0.00 $470.34 $0.00 $0.00 $470.34 Natureof 28FRACTURE STEPPING ON Body - 34 WRIST Side: Right Injury: art: ccident Abbot was performing a search drill when her right hand holding a halligan tool, contacted the wall forcefully, causing the injury. Possible fractue on the right 3rd metacarpal. FIRE FIGHTER SEARCH Descr: DRILL Fire Fighter Search Drill HALOGEN TOOL 10/31/2007 11/01/2007 3295960 KETTLE, RALPH L 11/29/2007 STRAIN -LIFTING $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 52 STRAIN Fo__d_y7 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide: Injury: .Part: ccWant'r,: While doing the PFA fitness test, supervised by CSU personnel. I strained my back during the isometric lifting. FIRE FIGHTER FITNESS TEST Fire Fighter Fitness Test NOT SPECIFIED Descry 11/02/2007 11/02/2007 3296172 HILL, CHRISTOPHER M 11/29/2007 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 49SPRAIN Body,^. 53 KNEE injury;. ider. Right 1; art: ccident•:. Right knee, swollen blister fire attack search and rescue "Burn Week" FIRE FIGHTER RECRUIT BURN WEEK Fire Fighter Recruit Burn Week NOT SPECIFIED Descr, 11/07/2007 11/09/2007 3297230 HORNING, CRAIG W 1210612007 ANIMAL OR INSECT $0.00 $0.00 $0.00 $0.00 $0.00 ature of 43 PUNCTURE Body :( 36 FINGER(S) ide: _„ Injury:' Part: ccident A cat bit my left index finger though a firefighter glove while trying to take the cat from a structure fire. FIRE FIGHTER Fire Fighter NO Descr::,. " 11/07/2007 11/09/2007 3297232 SHEESLEY, DREW 12/20/2007 ANIMAL OR INSECT $3.83 $0.00 $0.00 $0.00 $3.83 atureof 43PUNCTURE ody, , 36 FINGER(S) Side:. Right Injury:, Part: ccident... During search and rescue operation at fire trying to remove cat the cat bit through my structured firefighting gloves & into the tip of my right index finger. SEARCH & RESCUE DURING FIREFIGHTING Descr. Search & Rescue during Firefighting NO 11/08/2007 11/09/2007 3297237 ECKLUND, MATTHEW P 11/29/2007 STRAIN -USING TOOUMACHINE $0.00 $0.00 $0.00 $0.00 $0.00 atureof 52STRAIN Pody 38 SHOULDER(S) ide: Injury..,.: Part: , ' ccident. Shoveling a trench when between the shoulder and clavick popped and is sore. SIMULATED HAZMAT Simulated Hazmat NO Descr.: 11/10/2007 11/14/2007 3297983 DINI, CHRISTOPHER M 11/29/2007 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $0.00 $0.00 $0.00 $0.00 PATIENT Nature of 52 STRAIN Body 742 LOW BACK (LUMBAR & LUMBO-SACRAL) Injury: '.I Part: ccident t. Lihing extrememly heavy patient and patient is seen repeatedly by PFA ES. Back Soreness/tenders after moving patient. N/A Fire Fighter N/A Descr. 11/12/2007 11/13/2007 3297701 HILL, CHRISTOPHER M 11/29/2007 CUMULATIVE (ALL OTHER) $0.00 $379.95 $0.00 $0.00 $379.95 Nature of 80ALL OTHER CUMULATIVE INJURIES Pody . 34 WRIST ide: Right Injury. art: Accident Hurt wrist sharp pain - after doing pushups right side. N/A Fire Fighter - Recruit Training N/A Descry:., Page 26 012=0090851 AM PWCIS UW651R PINNACOLStandard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01101/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2007 thru 01/01/2008 'Claim ReportAcci dent Claim Injured Worker Closed - - Ex enses Me decal p Indemnity H Current Total' DateReceived Number Name. - Date - , ,., Injury Cause;;, .... j ry -Paid Paidl „� Paid I;'. ,' Reserve :Incurred 11/15/2007 11/16/2007 3298266 MORAN, JOHN 12/20/2007 STRAIN -REACHING $0.00 $463.25 52 STRAIN ody 42 LOW BACK (LUMBAR & LUMBO-SACRAL) - Part: 1 was placing board under a patient under car lower back strain. N/A FireFighter/Captain N/A $000 Side: $0.00 $463.25 Nature of Injury:. ccident Descr. 11/19/2007 11/20/2007 3298866 HANSON, BRYAN K 12/17/2007 FALL OR SLIP FROM DIFFERENT LEVEL $0.00 $0.00 1000NTUSION BodyF;dy7 42 LOW BACK (LUMBAR & LUMBO-SACRAL) $0.00 Side: $0.00 $0.00 Nature of ^jury art: Was being transported in back of county ranger pickup to patient who fell off horse. Ranger driving ran over rock pile bound me out of truck. I landed on my tail bone - lower back. Continued to rescue ccidente=+. Descr.3" EMT/FIREFIGHTER EMT/Firefighter NONE 11/23/2007 11/26/2007 3299432 MACARTHUR, JOHN D 12/20/2007 CUT -MISCELLANEOUS $0.00 $309.03 40 LACERATION Body :.: 37 THUMB art:. Opening a can of black beans. Lacerated right thumb removing lid. FIREFIGHTER FireFighter NO $000 ide:. Right $0.00 $309.03 Natureof Injury: ", ccident.:. Descr:=1;: 11/26/2007 11/27/2007 3299485 RUSSELL, ANDREW M 12/20/2007 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Nature of Injury: I! 52 STRAIN gocly7, 21 NECK VERTEBRAE .Part: While doing exercises in the weightroom my neck popped while bringing the weight up and it has been hurting since. FIRE FIGHTER PHYSICAL FITNESS Fire Fighter ide: ,. LL_, Physical Fitness NO ccident. Descr.- 11/28/2007 11/28/2007 3299869 SHEESLEY, DREW W 11/29/2007 FALL OR SLIP FROM LADDER OR $0.00 $0.00 $0.00 $0,00 $0.00 SCAFFOLDING Nature of 52 STRAIN Body 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Injury:.,.;;: Part:. < Side: - ,Accident . Working on ladder doing over haul on chimney chase. Coming down ladder foot slipped off rung, fell backwards approx 10 feet, leg was caught in ladder rungs Rod SCBA air FIGHTING FIRE Descr.- Fighting Fire NO pack on. 12/07/2007 12/07/2007 3301488 LYONS, CURTIS P 02/05/2008 MISCELLANEOUS STRIKING AGAINST OR $0.00 $0.00 $0.00 $0.00 $0.00 STEPPING ON Natureof 1000NTUSION b-od-y.-I 53 KNEE ide: Left Injury: L.,. Part. , ,, Accident Repeated crawling on concrete causing knee soreness. PFA ACADEMY PFA Academy NONE Descr.- 12/10/2007 12/13/2007 3302418 SAXBURY, LYNDEL D 01/08/2008 CUT MISCELLANEOUS $0.00 $713.63 $0.00 $0.00 $713.63 Natureof 40LACERATION Pbdy,. 34 WRIST ide:,_ Left njury: - - art:. . Working on exhaust pipe on engine. Part I was adjusting slipped off and my wrist hit a sharp part of the pipe. FIRE FIGHTER/MECHANIC Fire Fighter/Mechanic PIPE Accidentl Descr:' 12/12/2007 12/17/2007 3303201 GAUCHER, PAUL R 02/15/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59ALL OTHER P-ody 7 13 EAR(S) . Injury: art: - ide, Left ccident:i9 Ear ringing after being fitted for new ear piece foam and silicone injection. Left Ear. FIRE FIGHTER Fire Fighter NO escr. Page 27 91n31209908:51 AM PWras UW651R Data as of:01/23/2009 PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01101/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Period: 01/01/2007 thru 01101/2008 PROTECTION DISTRICT Claim Date ^ Received? Number"Name" :,,Date. "•.Injury Cause ?. ,Paid:. d aid Indemnity - Current Total Accident Report, Claim, Injured Worker Closed. Expenses Me l' ^ >JPaid Paid ,Reserve OIncurred, 12/13/ 0 43 PUNCTURE y L OR INSECT $0.00 $0.00 $0.00 $0.00 $0.00 art: 35 HAND ide: Right Injury: /2007 12/14/2007 3302814 GALLEGOS, ARTURO OZ1 Z2006 ANIMAL ccident I was positioning blanked on rescued dog. The dog ran & I restrained him by the collar. The dog turned and bit my hand , he released his bite quickly. FIRE FIGHTER ICE RESCUE Fire Fighter Ice Descr:, I Rescue NONE Policy Period Totals: Total Claims: 101 $1,464.57 $116,192.67 Open: 0 Open: $0.00 $0.00 Closed: 101 Closed: $1,464.57 $116,192.67 Average: $14.50 $1,150.42 Minimum: $0.00 $0.00 Maximum: $382.39 $22,857.67 $72,025.44 S0.00 $189,682.68 $0.00 $0.00 $72,025.44 $189,682.68 $713.12 $1,878.05 $0.00 $0.00 $45,891.28 $65,295.20 Page28 0112312o90e51AM Rwcis uw651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY 8r POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2008 thru 01/01/2009 '!Claim!:' ' AcciReport Claim ExpePaleds iDate Indemnity Datedent Received Number Name r Name `'Me Pi tll: .-'Injury Cause, ,'., Date Date Paid ReserveIncurred, ., 01/02/2008 01/04/2008 3305519 BOYD, GUY A 03/04/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 71 ALL OTHER OCCUPATIONAL DISEASE Body_-60 LUNG ide: Injury Part: ccident. An antique fire extinguisher with carbon tetrachloride was accidently broken at our Administrative office. I was exposed to the fumes resulting in taste in mouth and felt in lungs. NOT SPECIFIED Director Descr:. Admin Services NONE 01/02/2008 01/03/2008 3305413 NUCKOLS, GARY L 03/03/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59ALL OTHER ody 66 NO PHYSICAL INJURY ide: Injury;. Part: -. ccideht `-. Antique fire extinguisher with carbon tetrachloride was accidentally broken at our administration office. I was exposed to the fumes. N/A Battalion Chief N/A Descr: 01/02/2008 01/03/2008 3305403 MIROWSKI, RANDY K 03/03/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $aoo $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59 ALL OTHER __� 66 NO PHYSICAL INJURY Bodyrt Side: njury: a. z, ccitlent.,r. An antique flre extinguisher containing carbon tetrachloride was broken during a move. The fumes were spread at the north section of 2nd floor near our offices. N/A Battalion Chief Admin N/A Desc:' 01/02/2008 01/03/2008 3305399 GILLAN, RAY D 02/18/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $799.67 $0.00 $0.00 $799.67 INJURY Nature'.of 59 ALL OTHER Body 66 NO PHYSICAL INJURY ide: - nlury. art:IL-Li c=nts Dropped a carbon tetrachloride antique fire extinguisher broke and then used a shop vac to pick up chamical and put fumes in air. N/A FireFighter N/A D. 01/02/2008 01/03/2008 3305398 LOVE, PATRICK S 02/13/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $852.27 $0.00 $0.00 $852.27 INJURY ature:of 59ALL OTHER Body 48 INTERNAL ORGANS ide � Injury: , ' art: ccdents:. An antique fire extinguisher containing carbon tetrachloride was broke on the floor of Admin building. The fumes spread throughout the 2nd floor and was only about 10 feet from my office. N/A Firefighter Descr: ' I Administration N/A 01/08/2008 01/09/2008 3306293 GILLESPIE, JEFFREY A 01/30/2008 CUT -MISCELLANEOUS $0.00 $720.32 $000 $0.00 $720.32 Nature of Intury. ,;; 40LACERATION ody , 34 WRIST Part: , While on the roof with an 1 3/4 hoseline I put the nozzle in the rafters to extinguish the fire and caught my wrist on a nail or piece of metal and cut my wrist. FIER ide: Left FIGHTER Fire Fighter NO cc'itlent Descr. 01/09/2008 01/09/2008 3306312 GILLESPIE, JEFFREY 01/16/2008 CUT- MISCELLANEOUS $0.00 $42.00 $0.00 $0,011 $42,00 Natur c-f 43 PUNCTURE Body 34 WRIST :. - ideLeft Injury.. While on the roof with an 1 3/4 hoseline I put the nozzle in the rafters to extinguish the fire and caught my wrist on a nail or piece of metal and cut my wrist. FIREFIGHTER Fire Fighter NO ccident:ca: Descr: Page29 0123=0908:51AM nwcis UW651R P/NN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PRATFCTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2008 thru 01/01/2009 Claim Accident Worker d�. ClosedExpePaid nses Jnjury IndemnityeseCurrrve Total ReP Number Named ., Date,ive , Cause : ,. _ Me DatePad Paid' Rrve Incurred 01/12/2008 01/14/2008 3307210 GARNER, ROBERT L 03114/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $886.13 $0.00 $0.00 $886.13 Natureof 59ALL OTHER INJURY ody _ 66 NO PHYSICAL INJURY ide: Injury:• Part: ccident Potential exposure to blood borne pathogen due to blood entering gloved during CPR. N/A Fire Fighter EMS -CPR N/A Descr:. 01/16/2008 01/16/2009 3363928 KOBIELUSZ, BRAD OPEN MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 73 CONTAGIOUS DISEASE INJURY @ody 90. MULTIPLE BODY PARTS Side: Injury:', art: ccident Employee stated that constant exposure to recruit academy individuals who had a major staph IMRA outbreak. Skin Infection/MRSA Check. FIRE FIGHTER TRAINING CAPTAIN Fire Fighter Training Descr, I Captain UNKNOWN 01/20/2008 01/21/2009 3364483 ALBRANDT, CHARLES H OPEN MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 71 ALL OTHER OCCUPATIONAL DISEASE Sody �;.. 60 LUNG Side' Injury:. ccident Smoke exposure from treated fence when wind shifted SMOKE EXPOSURE SMOKE EXPOSURE N/A Descr. 01/20/2008 01/21/2009 3364479 MERKEY, THOMAS J OPEN MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 71 ALL OTHER OCCUPATIONAL DISEASE Body, 1,. 60 LUNG Sitle: Injury: - art: ccident. Smoke exposure from treated fence when wind shifted. FIRE FIGHTER/EXTINGUISHMENT Fire Fighter/Extinguishment NIA Descr:. 01/23/2008 01/24/2008 3309126 CHAMPLIN, TIM J 03120/2008 STRAIN -LIFTING $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 52 STRAIN Body 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide; Injury:. Part: ccident. , Patient handling while trying to remove them from a structure. FIRE FIGHTER TRAINING Fire Fighter Training NONE Descr:' - 01/23/2008 01/24/2008 3309115 FISHER, GILBERT W 03/20/2008 STRUCK BY -LIFTED OBJECT $0.00 $0.00 $0.00 $0.00 $0.00 ature of 1000NTUSION P ody 11 SKULL ide: njury:-r+., art: ccident: Doing AED Training in copy room at station # 1 & a bulletin board fell from wall on to the back of head. Bruised and bandaide was applied. FIRE FIGHTER OPERATIONS CAPTAIN Fire Fighter Descr. ' Operations Captain NONE 01/26/2008 01/28/2008 3309744 TREMAINE,LAURAJ 01/30/2008 STRAIN -LIFTING $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 52 STRAIN ody, .:: 42 LOW BACK (LUMBAR & LUMBO-SACRAL) itle: njury.. art: ccident- �. I was working at a structure fire at the time of picking up the hose to reload on the engine, I felt pain and tightness in my lower back. FIRE FIGHTER Fire Fighter NO Descr., 01/27/2008 01/28/2008 3309737 DINT, CHRISTOPHER M 02/04/2008 ANIMAL OR INSECT $0.00 $944.69 $0.00 $0.00 $944.69 ature. of 43 PUNCTURE Body ^.� 19 FACIAL BONES Injury:' . Part. ccident Chris Dini was performing an ice rescue to retrieve a canine from a hole in the ice. Chris attempted to rescue the canine when it bit him in the face and hand. FIRE FIGHTER/RESCUE Fire Descr:" Fighter/Rescue NO Page30 012MG09 08:51 AM MCIS UW651R P►NN/I COL Data as of:01/23/2009 Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Period: 01/01/2008 thru 01/01/2009 PROTECTION DISTRICT Claim .. Accident Report. Claim Injured Worker .Closed "' ,' : '. 'Expenses . Medical Indemnity, Current 1„ Total Date Received Number Name _ Date -'Injury Cause-, 'Paid- -'Paid` Paid Reserve 'Incurred '- 01/30/200 8 01/31/2008 3310419 CHAMPLIN, TIMOTHY 02/04/2008 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 re Natuof 52 STRAIN Body- ] 54 LOWER LEG ide: Left Injury: ] ry Part: While exercising -running, Pulled my left hamstring. FIREFIGHTER/NORMAL DUTY EXERCISING FireFighter/normal duty exercising NO Accident- Descr:• 02/09/2008 02/12/2008 3312226 VANDER VLIET, JOHN 02/29/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $11.50 $0.00 $0.00 $0.00 $11.50 INJURY Nature of 59ALL OTHER 48 INTERNAL ORGANS Injury: j iPartY .. Accident Possible Kidney Stone FIRE FIGHTER Fire Fighter NONE Descr. 02/11/2008 02/14/2008 3312668 RICHARDSON, BRIAN S 02/29/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $239.04 $0.00 $0.00 $239.04 INJURY Nature of 59ALL OTHER P ody- 66 NO PHYSICAL INJURY Side: Injury:..:, Part: ccident .: WHILE RESPONDING TO A MEDICAL EMERGENCY, HE WAS EXPOSED TO INFLUENZA B. RESPONDING TO A MEDICAL EMERGENCY RESPONDING TO A MEDICAL EMERGENCY NONE Descr: 02/11/2008 02/13/2008 3312623 NEWBERRY, DOUGLAS B 02/29/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $240.04 $0.00 $0.00 $240.04 INJURY Nature of 73 CONTAGIOUS DISEASE Injury: "ry -Body-1 66 NO PHYSICAL INJURY Part. ider ccident. : RESPONDING TO MEDICAL EMERGENCY AND WAS EXPOSED TO INFLUENZA 8 FROM A PATIENT WHO LATER DIED. MEDICAL EMERGENCY RESPONSE MEDICAL EMERGENCY Descr. ;. : RESPONSE NONE 02/11/2008 02/14/2008 3312653 WEBER, BRETT M 02/29/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $202.84 $0.00 $0.00 $202.84 INJURY Nature 7of 73 CONTAGIOUS DISEASE W ody 66 NO PHYSICAL INJURY Injury: ._: Part:'. '; LLLj ccident WHILE RESPONDING TO A MEDICAL EMERGENCY, HE WAS EXPOSED TO INFLUENZA B VIRUS. RESPONDING TO MEDICAL EMERGENCY RESPONDING TO MEDICAL EMERGENCY NONE Descr< 02/11/2008 02/14/2008 3312656 VIGIL, ANDREW K 02/29/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $239.04 $0.00 $0.00 $239.04 INJURY Nature :of 73CONTAGIOUS DISEASE Body 66 NO PHYSICAL INJURY ide: Injury:.-. Part: cr. en, WHILE RESPONDING TO A MEDICAL EMERGENCY, HE WAS EXPOSED TO INFLUENZA B. RESPONDING TO A MEDICAL EMERGENCY RESPONDING TO A MEDICAL EMERGENCY NONE Dcri.:. es 02/14/2008 02/15/2008 3312893 STEWART, ROBERT L 02/29/2008 STRAIN LIFTING $0.00 $302.62 $0.00 $0.00 $302.62 Nature of Injury:.:;; 52STRAIN ody ,; 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Part: = Assist crew in lifting cot into the amulance with a very heavy female patient approximately 300 plus pounds. FIRE FIGHTER EMT Fire Fighter EMT NONE ide: Right ccident. Descc �,,,., Page 31 01231200908:51 AM awcis uw651R Data as of:01/23/2009 PINN/I\COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PRnTFCTInN ❑IRTRICT Policy Period: 01/01/2008 thru 01/01/2009 . . Claim - ical' AcciClod Report - ExPePaid', "'- " `lode Current Total Datedent Date -Me Paid ryturfed Received: Number. Name Date , Injury Cause Paid Reserve In 02/20/2008 02/21/2008 3313918 PROCHASKA, MARK 03/20/2008 MISCELLANEOUS STRIKING AGAINST OR $0.00 $0.00 $0.00 $0.00 $0.00 STEPPING ON Natureof 1000NTUSION P7o-dy7 36 FINGER(S) ide: Injury: Part: ccident Driving engine # 3. Turning NB Remington from WB Prospect, jambed left middle finger on a post of engine 3. FIREFIGHTER/DO Fire fghter/DO NO Descr:' 02/26/2008 02/27/2008 3314685 CAPE, RICHARD W 10/02/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $3,442.36 $1,377.32 $6,685.55 $0.00 $11,505.23 INJURY ature of 31 HEARING LOSS Body - 13 EAR(S) ide: Both Injury: Part: Accident :I Numerous instances loud noise exposure over 30 year career long cumulative impact. Fire alarms, gas leaks, loud radios, sirens & air horns my hearing is damaged to point of impacting quality of life Descr..,;' FIRE FIGHTER/COMPANY OFFICER Fire Fighter/Company Officer NONE 03/01/2008 03/03/2008 3315284 STACHURSKI, JUDY L 05/02/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE Body 66 NO PHYSICAL INJURY Side:_ Injury: -,- Part: ccident- Emergent response to 15 year old with breathing difficulties. Possible contagious disease exposure. Patient also scratched her arm. FIRE FIGHTER Fire Fighter NOTSPECIFIED escr:� 03/01/2008 03/03/2008 3315279 ZIMMERMAN, ALLEN R 05/02/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE ody ,, 66 NO PHYSICAL INJURY Side: Injury: Part: ccident Assisted PVH paramedics treat a 15 year old female with possible meningitis. Had medical masks, gloves, & eye protection on. Possible exposure report due to severity of patient. FIRE FIGHTER Fire Descr ', ': Fighter NOT SPECIFIED 03/12/2008 03/13/2008 3317171 VANGORDER, JIM D 12/10/2008 MISCELLANEOUS STRIKING AGAINST OR $75.71 $9,117.92 $7,397.83 $0.00 $16,591.46 STEPPING ON Natureof 49SPRAIN Body -. 53 KNEE _ide:, Right Injury:, - Part: Accident'] While reloading hose on EN12 & climbing up steps on back of engine I noticed a pop in right knee. Felt tightness in knee as worked through shift. Woke up after midnight found knee very tight & swollen bescr:,IcL,'J FIRE FIGHTER Fire Fighter NO 03/13/2008 03/19/2008 3318129 BREWSTER, WAYNE T 04/04/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $529.38 $0.00 $0.00 S529.38 INJURY -- — --- - - - -- - - Natureof 59 ALL OTHER Body;: 66 NO PHYSICAL INJURY - - - - Injury: tart: ccident„;, Stopped to assist MVA with patient down. Found patient not breathing with head trauma and C-spine trauma. Did not have latex gloves when assisting patient. Blood did come in contact with both Descr. hands. N/A FireFighter Off Duty N/A 03/14/2008 03/17/2008 3317602 LYNXWILER, JAMES R 05/07/2008 FALL, ON STAIRS $0.00 $983.99 $0.00 $0.00 $983.99 Mature of 10 CONTUSION Body ., 53 KNEE bide::•' Left Injury: '- Part: , ,` I was headed up the stairs at the PFA training center and tripped on the last step and fell on my left knee. N/A FireFighter N/A rcident. cr.::.;:: ;' Page 32 011231200908:51 AM PWCIS UW651R i.4115707 CITY OF FORT COLLINS 2/242009 161038 Workers Compensation Report for Risk Management Page- 1 Workers Comp 5506 Alpha Name Description Job Ty, Description Total Dollar for Period Premium Adjustment Premium Once of the Fire Marshall 2043 CODE INSPECTOR 35140 0 35140 Total Home Business Unit 35140 Total For Workers Comp Code 5506 Workers Comp 7704 Fife Suppression 9615 FIREFIGHTER INTRO-56 HR/WK 36128.04 1561.6 0 Fire Suppression 9615 FIREFIGHTER INTRO- 5611 N 358W 27 1422.52 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 65158.6 1122,01 0 Fire Suppression 9675 COMPANY OFFICER I - 40 HRANK 9119L52 5444.77 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 73727.25 1665.13 0 Fire Suppression 9640 FIREFIGHTER II-56 HRAVK U633.85 6645,31 0 Fire Suppression 9640 FIREFIGHTER II - 56 HRM 65796.1 6447.1 0 Fire Suppression 9640 FIREFIGHTER II - 56 HR/WK 7760D.99 3682.22 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 107373,28 13700.55 0 Fire Suppression 9640 FIREFIGHTER II - 56 HR/WK 75384.19 2557.04 0 Fire Suppression 9670 COMPANY OFFICER I-56 HR/WK 91582.92 6640.66 0 Fire Suppression 9640 FIREFIGHTER II .56 HR/WK 84072,09 6133.15 0 Fire Suppression 9640 FIREFIGHTER II - 56 HR/WK 89328,01 8381.19 0 Fire Suppression 9640 FIREFIGHTER II .56 HR/WK 79525.72 4686.14 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 81816.28 2130.47 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 70657.6 2453.92 0 Fire Suppression 9645 FIREFIGHTER II-40 HR/WK 71424.86 2114.91 0 Fire Suppression 9655 FIRE INSPECT COORD - 56 HRNdK 789504 3956.04 0 Fire Suppression 9655 FIRE INSPECT COORD-56 HR/WK 78533.22 3670A 0 Fire Suppression 9640 FIREFIGHTER It - 56 HRIWK 75986.88 3807.86 0 Fire Suppression 9640 FIREFIGHTER II - 56 HR 73068.31 2161.75 0 Fire Suppression 9655 FIRE INSPECT COORD- 56 HRAVK 83644.59 5186.57 0 Fire Suppression 9640 FIREFIGHTER II - 56 HRANK 85121.63 6657.59 0 Fire Suppression 9640 FIREFIGHTER II - 56 HRMK 97478.51 1096905 0 Fire Suppression 9E,,10 FIREFIGHTER II - 56 HRNJK 9396647 9518.83 0 Fire Suppression 9640 FIREFIGHTER II - 56 HRNJK 79877.22 5548,15 0 Fire Suppression 9640 FIREFIGHTER II - 56 HRANK 74484 3217.32 0 Fire Suppression 9640 FIREFIGHTER II-56 HRAVK 74513.41 294505 0 Fire Suppression 9640 FIREFIGHTER II - 56 HRAVK 88667.16 7736.57 0 Fire Suppression 9640 FIREFIGHTER II-56 HRANK 75172.97 4131,78 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 72727,09 2679.36 0 Fire Suppression 9640 FIREFIGHTER II-56 HRANK 75160,13 3578.78 0 Fire Suppression 9640 FIREFIGHTER II-56 HRIWK 72255.67 3339,25 0 Fire Suppression 9640 FIREFIGHTER II - 56 HRANK 72977 05 4093,39 0 Fire Suppression 9640 FIREFIGHTER II - 56 HR WK 73943.92 3612.07 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 75683.49 4456,72 0 Fire Suppression 9640 FIREFIGHTER II-55 HRANK 75352.72 4463,42 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 74140.65 3892.39 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 76640.3 5045.5 0 Fire Suppression 9640 FIREFIGHTER II - 56 HRAVK 70853,22 3550.15 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 68888.72 3072.38 0 Fire Suppression 9640 FIREFIGHTER It - 56 HRANK 71066.33 4069.85 0 Fire Suppression 9640 FIREFIGHTER II - 56 HRfWK 77571.76 5199.54 0 Fire Suppression 9640 FIREFIGHTER II - 56 HR(WK 72220.25 4622.23 0 Fire Suppression 9625 FIREFIGHTER 1- 56 HR/WK 66149.53 2452.19 0 Fire Suppression 9625 FIREFIGHTER 1- 56 HR/WK 66872.43 3303.61 0 Fire Suppression 9625 FIREFIGHTER I - 56 HR/WK 67421.39 3569,74 0 Fire Suppression 9615 FIREFIGHTER INTRO-56 HRIWK 12458.59 488,59 0 Fire Suppression 9615 FIREFIGHTER INTRO -S6 HRIWK 3871375 1874,48 0 Fire Suppression 9625 FIREFIGHTER I - 56 HR/WK 676964 4617.54 0 Fire Suppression 9625 FIREFIGHTER 1- 56 HR/WK 71091.61 5790.13 0 Fire Suppression 9625 FIREFIGHTER I - 56 HR/WK 71047.69 5565.01 0 Fire Suppression 9625 FIREFIGHTER I - 56 HRNYK 66442.13 3466.07 0 Fire Suppression 9625 FIREFIGHTER I - 56 HRAWt 64560.52 2340.6 0 Fire Suppression 9625 FIREFIGHTER I - 56 HRAMC 5498368 3189,08 0 Fire Suppression 9625 FIREFIGHTER I - 56 HR/WK 53666.17 3045 0 Fire Suppression 9670 COMPANY OFFICER I - %HRNJK 84470.36 3985.26 0 Fire Suppression 9640 FIREFIGHTER 11- 56 HR WK 76522A6 3532.39 0 Fire Suppression 9640 FIREFIGHTER II - 56 HRANK 70523.97 1804.92 0 Fire Suppression 9670 COMPANY OFFICER I - 56 11 W 101323.22 9798.25 0 Fire Suppression 9670 COMPANY OFFICER 1- 56 HR=K 86989.83 5251.33 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 75347.62 3012.45 0 Fire Suppression 9715 BATTALIONCHIEFI-56HR/WK 104814,26 1636.26 0 Fire Suppression 9715 BATTALION CHIEF I-56 HR/WK 904352 3614.3 0 Fire Suppression 9725 BATTALION CHIEF II - 40 HR,WK 1275064 5160.4 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 80337.63 5274.56 0 Fire Suppression 9640 FIREFIGHTER It-56 HR/WK 74797.28 2854.26 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 78984.25 471867 0 Fire Suppression 9670 COMPANY OFFICER 1- 56 HR WK 94916.38 6961.73 0 Fire Suppression 9640 FIREFIGHTER II - 56 HR/WK 77104.68 3528.94 0 Fire Suppression 9640 FIREFIGHTER II-56 HRfWK 78989.61 507907 0 Fire Suppression 9670 COMPANY OFFICER I-56 HR/WK 85053.49 4052.77 0 Fire Suppression 9670 COMPANY OFFICER I-56 HR/WK 82186.8 3312.9 0 Fire Suppression %70 COMPANY OFFICER I-56 HRfWK 82560.11 2081,38 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 32905.61 1342.33 0 Fire Suppression 9670 COMPANY OFFICER 1. 56 HRANK 85770.34 5189.25 0 Fire Suppression 9640 FIREFIGHTER 11-56 HRWK 78584A3 3941.18 0 Fire Suppression 9640 FIREFIGHTER 11- 56 HRM/K 82093.87 4636.31 0 Fire Suppression M70 COMPANY OFFICER I - 56 HRAVK 84363.27 4384.17 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 89383.2 7692.85 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 78505,82 4665.76 0 Fire Suppression 9640 FIREFIGHTER II-56 HR7WK 77122.49 3054.26 0 Fire Suppression 9670 COMPANY OFFICER 1- 56 HR/WK 106123,25 11472.86 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 78289.36 3817.39 0 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 83592.61 597067 0 Fire Suppression %55 FIRE INSPECT COORD-56 HRANK 85314.71 544962 0 Fire Suppression 9670 COMPANY OFFICER 1- 56 HR WK 82819.63 3863.71 0 Fire Suppression 9640 FIREFIGHTER It - 56 HRfWK 73877.29 2106.99 0 Fire Suppression 9670 COMPANY OFFICER I-56 HR/WK 95918.82 6514,84 0 PINNncOLStandard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/0112010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2008 thru 01/01/2009 Clairn I Worker' W Closed Expenses Me Indemnity,. went Total! Date Received Rece ved Number Name, _ Date,'Injury Cause Pad j ry 4- _. Paid Reserve _.. _ Incurred 03/18/2008 03/19/2008 3317966 POTTLE, MICHAEL C 05/19/2008 FALL, ON STAIRS $0.00 $0.00 $0.00 $0.00 $0,10 Natureof Injury: 49SPRAIN During training exercise @ timberline training site, I was A_0dT7 55 ANKLE art: in process of descending front porch stairs with hoseline missed step right ankle rolled and I fell to the ground. Sider Right Ankle soreness. N/A FireFighter ccldent Descr:t"" N/A 03/18/2008 03/19/2008 3318039 GILLESPIE, JEFFREY A 03/20/200B STRIKE -LIFTED OBJECT $0.00 $202.36 $0.00 $0.00 $202.36 Natureof Injury:_ ,,. 40LACERATION Practicing forcible entry on metal door was struck on left ody- 35 HAND Part hand with Flat head of axe. Had halligan against door frame door force open. Instructed Len to strike halligan ide: Left with axe missed hit hand. N/A Accident escr::_ FireFighter N/A 03/21/2008 03/24/2008 3318673 BREDEHOFT, BRANDON A 05/23/2008 MISCELLANEOUS STRIKING AGAINST OR $0.00 $0.00 $0.00 $0.00 $0.00 STEPPING ON atureof 40LACERATION ody 36 FINGER(S) Side: Left Injury:: art: ! _ ccident•'i Replaced OSB board pushed up into hole middle finger (left) got pinched and cut. FIREFIGHTER FIX VENT ROOF FireFighter fix vent roof NONE Descr: 04/14/2008 06/09/2008 3330395 PHILLIPS, KERRY D 06/12/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 59ALL OTHER ody 66 NO PHYSICAL INJURY ide: Injury: : art: Accident,,s Exposed to active TB on medical emergency FIRE FIGHTER Fire Fighter N/A Descr:' 04/14/2008 06/09/2008 3330389 BERNUM, RICHARD A 06/12/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59 ALL OTHER Body (, 66 NO PHYSICAL INJURY ide: Injury' I Part: _: ccident: _. Responded to report of male in severe respiratory distress. Arrived on scene provided BLS until PVHAS arrived on scene transfered patient care to them. Notified on June 7 of exposure to active TB pt. Descr.'- FIRE FIGHTER CAPTAIN Fire Fighter Captain N/A 04/14/2008 06/09/2008 3330392 MAYNARD, JIMMIE D 06/18/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59 ALL OTHER Injury::'" Body 66 NO PHYSICAL INJURY Part: ide: ccldent. Exposed to active TB case on medical emergency. FIRE FIGHTER Fire Fighter N/A Descr.. 04/14/2008 04/15/2008 3321914 MCGRAW, WALTER 05/21/2008 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $0.00 $0.00 $0.00 $0.00 PATIENT Nature of 1000NTUSION ody 1: 19 FACIAL BONES Side: Injury:, - Part: ccident _- Escorting patient to the cot. He struck me in the face with his right hand. Witnesses were present. FIRE FIGHTER Fire Fighter NONE Descr :: Page 33 01=W908:51 AM Rwcis UW651R Data as of:01/23/2009 PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01101/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE I3PnTFrTlr1N r11STR1rT Policy Period: 01/01/2008 thru 01/01/2009 , Accident Worker InjuredReserve ExpePaid Medical .Indemnity Current - Total DateReceived �' , Number Name Date Injury Cause Paid Reserve Incurred 04/16/2008 04/17/2008 3322520 BISCHOFF, TAYLOR D 05/21/2008 BURN -TEMP. EXTREMES $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 04BURN Body _ 53 KNEE ide: Both njury: art: ccident ,: I was making fire attack with the nozzle in the burn building when my knees got extremely hot. I had to leave the building due to burns on both knees. FIRE ATTACK Fire Attack NOZZLE Descr: 04/19/2008 04/21/2008 3322921 MACCARINI, GENE F 04/22/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59 ALL OTHER (Body- 66 NO PHYSICAL INJURY ide: Injury: Part: ccident Blood from patients mouth splattered on Gene's left arm. Gene did not appear to have an open skin wound. NIA Firefighter NIA Descr:,' 05/01/2008 05/02/2008 3324886 WIGGINS, FOREST W 07/01/2008 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 ature of 52 STRAIN ody 54 LOWER LEG Side: - Right Injury:, . Part: ccident While running on the treadmill at Fire Station 12 my right hamstring tightened up and continued to cramp for about 20 to 30 minutes after stopping. FIRE FIGHTER/PHYSICAL FITNESS Fire Descr. Fighter/Physical Fitness NONE 05/02/2008 05/06/2008 3325203 DRECKMAN, FRANK W OPEN MISC, OTHER THAN PHYSICAL CAUSE OF $13,764.93 $383.98 $0.00 $2,927.58 $17,076.49 Nature of 71 ALL OTHER OCCUPATIONAL DISEASE INJURY P ody 48 INTERNAL ORGANS Side: Injury: art: ccident. a Firefighting caused prostate cancer. For almost 30 years I have been exposed to vapors, chemicals, Haz-mat, smoke etc. Culminating in Cancer. FIRE FIGHTER Fire Fighter N/A Descr:' 05/05/2008 05/06/2008 3325197 LEHMAN, DOUG C 05/20/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature'of 61 ASBESTOSIS Body: 60 LUNG Sitle: ^ Both Injury: art: ccident: •. Fighting a house fire - possible asbestos exposure. Proper PPE was worn. FIRE FIGHTER Fire Fighter NONE Descr: 05/05/2008 05/06/2008 3325207 DAIRON, MICHAEL W 05/20/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 61 ASBESTOSIS Body < 60 LUNG ide: Both Injuryi _. ..Part:---.._.. Accident Possible exposure to asbestos during fire at 1313 Emigh Street, Fort Collins Colorado FIRE FIGHTER ENGINE 1 Fire Fighter Engine 1 NONE Desch: 05/05/2008 05/06/2008 3325211 SIMMS, RONALD S 05120/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 61 ASBESTOSIS ody 60 LUNG ,ide: Both Injury:-,. , Part:, ::. ccident Possible exposure to asbestos while fighting a fire at 1313 Emigh St. run # 08-4991, FIRE FIGHTER Fire Fighter N/A Descr: Page34 0112312009 08:51 AM Pwcis M651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2008 thru 01/01/2009 Claim • , Alcci-,t ExpePaeds' MediCaadl ,Inde Total ;i Date Received "'Number, Namenjbre Date - Dateclosed Injury Cause• '. Date - P Paid ._. _ Reserve ... Incurred . 05/05/2008 05/06/2008 3325215 SIMMS, RONALD S 05/20/2008 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 52 STRAIN Injury:.. r Body 38 SHOULDER(S) Part:' ide: Right ccltlent " I fell to the ground while fully bunkered up with SCBA while exiting the structure fire. I landed on my hands & knees & felt a slight pain in right shoulder. It has tightened up. FIRE FIGHTER Fire Fighter Descr: N/A 05/05/2008 05/06/2008 3325223 MCKEON, JONATHAN M 05/20/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 61 ASBESTOSIS Body .lt 60 LUNG ide: r,.,. Both Injury:" - Part: Accident `?. Possible exposure to asbestos during fire structure at 1313 emigh street. FIRE FIGHTER ENGINE 1 Fire Fighter Engine 1 N/A escr: 05/05/2008 05/06/2008 3325226 MYERS, CHAD A 05/20/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY atureof 61 ASBESTOSIS ody 60 LUNG ide:_• Both njury: art:, ccitlent:.:; Possible exposure to Asbestos during fire at 1313 Emigh Street. FIRE FIGHTER Fire Fighter N/A Descr. ' 05/05/2008 05/06/2008 3325230 HORNING, WILLIAM C 05/20/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY atureof 61ASBESTOSIS Body,� 60 LUNG ide:.-. Both Injury" ' Part:' ccident1 Possible exposure to Asbestos at a house fire at 1313 Emigh Street FIRE FIGHTER Fire Fighter N/A Descr. 05/05/2008 05/06/2008 3325313 JAQUES, MICHAL J 07/07/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 61 ASBESTOSIS Injury: _ Body ; 60 LUNG Part: ide: Both LLLj Accident While descending down a ladder from the roof, I missed the last step & twisted my right knee, I felt a pop underneath the patella (right knee) FIRE FIGHTER Fire Fighter N/A ` Des r: 05/05/2008 05/06/2008 3325315 JAQUES, MICHAL J 07/07/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 61 ASBESTOSIS Fo-d-j7 60 LUNG itlei' Both njury: ; - art: ccident..- Possible exposure to asbestos while fighting a structure fire & overhauling post -fire. Asbestos remains on gear when returning to station and decontaminating. FIRE FIGHTER Fire Fighter N/A Descr:..,'Y' 05/05/2008 05/06/2008 3325318 HERGENREDER, TERESA 07/07/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY atureof 61 ASBESTOSIS ,$ody 60 LUNG Side: Both Injury: art:. ccident:..: Fighting fire in a residential with a strong possibility it contains asbestos. FIRE FIGHTER Fire Fighter N/A Descr Page35 01=00908:51AM MCis UW651R PINN/I COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01101/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PRf)TFCTIt7N DISTRICT Data asof:01/23/2009 Policy Period: 01/01/2008 thru 01/01/2009 Claim ;.. .. 'Accident,. Report , claim .InjuredlNorker .Closed °� Expenses) Medical Indemnity Current. ''"Total':' '. Date, Received 'Number Name Date Injury Cause : - Paid Paid Paid Reserve Incurred' 05/05/2008 05/06/2008 3325320 GUTHRIE, JAL J 07/07/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature_of 61 ASBESTOSIS ody... 60 LUNG ides, Both Injury:- Part: ccident Performing fire ground operations & were notified of possibility that Asbestos may have been present in home that was on fire. I may have obtained lung exposure. FIRE FIGHTER Fire Fighter N/A Descr. 05/05/2008 05/06/2008 3325321 WRIGHT, RANDALL K 07/07/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 61 ASBESTOSIS Body 60 LUNG ide: Both Injury: Part: ccident :. Fire fighting in a residential with a strong possibility it contains asbestos. FIRE FIGHTER Fire Fighter N/A Descr.;: 05/05/2008 05/06/2008 3325325 CUPP, DOUG L 07/07/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 61 ASBESTOSIS Body 60 LUNG Side:_ Bath Injuryi Part: ccident.'. Asbestos may have been present in a house that was on fire. Engine 2 was assigned to suppress the fire. FIRE FIGHTER Fire Fighter N/A Descr:'. 05/05/2008 05/06/2008 3325332 SALISBURY, JAMES B 07/07/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 61 ASBESTOSIS Body ,: 60 LUNG Side: Both Injury:;: Part: ccident Possible asbestos exposure FIRE FIGHTER Fire Fighter NIA escr: 05/05/2008 05/06/2008 3325335 SWIHART, MARK S 07/07/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 61 ASBESTOS IS Body 7.. 60 LUNG ide::3. Both Injury: art: ccident.. Manning two outline at house fire. Moved hose line twice in & out of front living room where E 10 was pulling down fire to fire in atic. Preleminary report asbestos in attic. Wearing full PPE & SCBA FIRE escr:,, . FIGHTER Fire Fighter N/A 05/05/2008 05/06/2008 3325336 BISCHOFF, TAYLOR D 07/07/2008 STRUCK BY -LIFTED OBJECT $0.00 $0.00 $0.00 $0.00 $0.00 atureof 1000NTUSION ody 36 FINGER(S) ide:- Left Injury:... art: ccident. Hit in left middle finger with axe. Blunt Injury. FIRE FIGHTER TRAINING Fire Fighter Training AXE Descr:,, ". 05/05/2008 05/06/2008 3325248 DURRE, HOLGER H 05/20/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY ature of 61 ASBESTOSIS Fo-d-y7 60 LUNG ide:. Both Injury:, A art: ,: ccident•;: Conducting fire investigation when potentially exposed to Asbestos in home built in 1960's. Contractor on scene reported potential due to home of age in neighborhood having same problems. SCBA Descr:� worn. FIRE INVESTIGATION Fire Investigation N/A Page 36 Cln3200908:51 AM MCis UW651R PINN/ICOL Standard Loss Run Report ASSURANCE Gross Claims Loss History Report Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2008 thru 01/01/2009 claim .... ... ....,. . ,. ,.. Accident Report Claim. .Injured Worker Closed -:" Expennsseds-: McPad Indemnity -Current Total,. Date injury Cause,, ... Received Number Name ;l Date j ry id . Reserve .;,Incurred;, 05/05/200805/06/2008 3325251 STACHURSKI, JUDY 05/20/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 61 ASBESTOSIS ody 60 LUNG Injury: ,;': Part: Side: , Both ccident Opened ceiling during fire fight / potential asbestos exposure. FIRE FIGHTER Fire Fighter N/A Descr: 05/05/2008 05/06/2008 3325252 CLOSE, KELLY R 05/20/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY ature of 61 ASBESTOSIS Body 60 LUNG ide: Both Injury:! r, Part . tl ccident `. Possible exposure to asbestos while fighting a house fire. Proper PPE was worn for fire fighting work. FIRE FIGHTER/CAPTAIN Fire Fighter/Captain NIA Descr:, 05/05/2008 05/06/2008 3325256 HOUSLEY, MATTHEW J 05/20/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 61 ASBESTOSIS ody -., 60 LUNG Side: Both Injury:, C Part +' I.. ccident=:+ Helping crews clean up from house fire. After begining clean up advised by BC via conference call that likely asbestos exposure eng 1 was first & if asbestos was '---. present then exposed. FIRE FIGHTER Descr> Fire Fighter N/A 05/05/2008 05/06/2008 3325259 BENNETT, JASON S OS/20/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY ature of 61 ASBESTOSIS #Ody 60 LUNG Injury:, Fide: Both ccident:-.'-_: Exposure to asbestos particles as we were overhauling the house. Breathing apparatus was used at all times inside the structure. The address of the incident was 1313 Emigh Street. FIRE FIGHTER Descr: Fire Fighter N/A 05/05/2008 05/06/2008 3325245 BRANN, SHAWN 05/20/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY ature of 61 ASBESTOSIS ody 7 60 LUNG Injury:_ - art: ider Both ccident. Conducting fire investigation when potentially exposed to Asbestos in home built in 1960's. Contractor on scene reported potential due to home of age in neighborhood having same problems. SCBA Descr. -- worn. FIRE INVESTIGATION Fire Investigation N/A 05/05/2008 05/06/2008 3325262 GALLEGOS, ARTURO 05/20/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 61 ASBESTOSIS ody - 60 LUNG Injury: =. art: Ide:'l. Both Accidentaia Possible exposure to Asbestos while fighting a fire at 1313 Emigh Street. Run # 08-4991. FIRE FIGHTER Fire Fighter N/A Descr:. 05/05/2008 05/06/2008 3325265 FIELDS, KEVIN W 05/20/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 61 ASBESTOSIS - Body ,-. 60 LUNG Injury:. ''. Part Ide: Both ccident, Asbestos exposure may have occured while engaged in interior firefighting at a structure fire. FIRE FIGHTER Fire Fighter N/A Descr.; Page 37 01n3n009 08:51 Ann Pwas Uw651R Data as of:01/23/2009 PINN/I COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Policy Period: 01/01/2008 thru 01/01/2009 Claim _ Worker Expenses Accident. Report Claim Injured Wo 'Medical .. Indemnity. Current Total• ,, Data `-In'u Cause` ,. Date Received' NumberiName.�; ., j ry , Paid, ':Paid Paid` 'Reserve tlncurred . 05/05/2008 05/06/2008 3325266 DINT, CHRISTOPHER M 07/07/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 61 ASBESTOSIS Body 60 LUNG ide;, Both Injury: art: ccident - Asbestos exposure may have occured during fire fighting operations interior. FIRE FIGHTER Fire Fighter N/A Descr: 05/05/2008 05/09/2008 3325957 MCGAFFIN, SHAWN 05/23/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 61 ASBESTOSIS Body 60 LUNG ide: Injury: Part: ccident.:. Exposed to asbestos by contact with debris & through inhalation of airborn particles. On scene assisting family with clothing shelter & insurance needs. FIRE FIGHTER/INCIDENT REPRESENTATION Descr. Fire Fighter/Incident Representation N/A 05/20/2008 05/20/2008 3327364 RUSSELL, ANDREW M 06/03/2008 FALL - MISCELLANEOUS $0.00 $363.68 $0.00 $0.00 $363.68 Natureof 49 SPRAIN ody 55 ANKLE Side:, Right Injury: art: - Accident Removing door, employee fell backward onto ankle. Employee felt it pop was was able to continue working. FIREFIGHTING Firefighting N/A Descr: 05/24/2008 05/27/2008 3328259 HOUCK, JAMES V 06/18/2008 STRAIN -USING TOOL/MACHINE $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 49SPRAIN Botly 34 WRIST idei;-.;-` Left Injury: Part:. ccident::.,i. Extracting patient from vehicle, strained wrist handing cutting tool. EXTRACTING PATIENT FROM VEHICLE Extracting patient from vehicle Cutting tool Descr: O5/2612008 05/28/2008 3328468 BREDEHOFT, BRANDON A 06/24/2008 MISCELLANEOUS STRAIN OR INJURY $0.00 $886.79 $0.00 $0.00 $886.79 Natureof 52STRAIN Body 56 FOOT ide: _.. Right Injury: Part: . ccident _ Doing PT in the morning, running 6 miles, hurt right foot FITNESS RUNNING Fitness Running NONE Descr. 06/01/2008 06/03/2008 3329422 EWY, LEONARD K 06/10/2008 FALL- SAME LEVEL $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 40LACERATION ody 11 SKULL ide: lnjury. Part: ccident. I slipped and fell while stepping out of the shower at PFA station # 4. FIRE FIGHTER CAPTAIN Fire Fighter Captain N/A Descr: 06/19/2008 06/20/2008 3332455 TAYLOR, SCOTT G 12/10/2008 MISCELLANEOUS STRAIN OR INJURY $169.62 $6,365.50 $0.00 $0.00 $6,535.12 Natureof 52STRAIN Body'- 56 FOOT Injury. idea.. Left _ art:. Accident =:;: As I was exiting apparatus, I stepped on the step, felt quick pain in right foot. I kept walking. I feel discomfort & pain in right ball of foot. Pain does not feel right. FIREFIGHTER FireFighter NONE Descr: 07/07/2008 07/08/2008 3334892 DAIRON, MICHAEL W 07/11/2008 ANIMAL OR INSECT $0.00 $0.00 $0.00 $0.00 $0.00 ature of 43 PUNCTURE Body. 31 UPPER ARM (INCL. CLAVICLE & SCAPULA) ide: Both Injury: . Part: ccident_. While working on a patient in weeds and by the river I was bitten several times by mosquitos FIRE FIGHTER/EMT Fire Fighter/EMT N/A Descr:,.L.: Page 38 . 01M200908:51AM PWCIS uw651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2008 thru 01/01/2009 Claim. Accident Report - Claim Inured W Claim orker P 1 .Closed - - - Expenses ., � Medical ;. 'Indemnity Current ,Total Date Received Name .. Date In'u Caus ; ry e ,Paid 'Paid ,. Paid Reserve Incurred ;. 07/07/2008 07/08/2008 3334883 WIGGINS, SCOTT 07/11/2008 ANIMAL OR INSECT $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 43 PUNCTURE ody. ,, 31 UPPER ARM (INCL. CLAVICLE & SCAPULA) Injury: art: We were working on a patient at the edge of the poudre river while doing this we were bitten by several mosquitos. FIRE FIGHTER ACTING CAPTAIN Fire Fighter Acting Captain N/A ccident Des". 07/07/2008 07/08/2008 3334889 GALLEGOS, ARTURO 07/11/2008 ANIMAL OR INSECT $0.00 $0.00 $0.00 $0.00 $0.00 Nat ure of 43 PUNCTURE Body 31 UPPER ARM (INCL. CLAVICLE & SCAPULA) ide: Both Injury: :,-. .. While working on a patient on the banks of the poudre Part river I experienced multiple mosquito bites. FIRE FIGHTER EMT Fire Fighter EMT N/A Accident Descr.'- 07/12/2008 07/14/2008 3335794 FOWLER, MARK W 09/12/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 73 CONTAGIOUS DISEASE ody 66 NO PHYSICAL INJURY Injury: Part: Accident ' Exposure to contagious disease. Provising EMS care. INCIDENT COMMAND EMS Incident Command EMS N/A Descr: 07/12/2008 07/14/2008 3335792 HILL, CHRISTOPHER M 07/29/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00, $0.00 INJURY ature o 73 CONTAGIOUS DISEASE ody 66 NO PHYSICAL INJURY njury:. dart r ccident -. Exposer to communicable possible disease while attending patient care. FIREFIGHTER FireFighter N/A Descr: 07/12/2008 07/14/2008 3335797 ANDUSS, MURRAY B 07/29/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE Body ` 66 NO PHYSICAL INJURY ide: - Injury: • , Part: ccident Exposed to possibly contagious disease while doing patient care. EMERGENCY MEDICAL TECHNICIAN Emergency Medical Technician N/A escr:. 07/16/2008 07/18/2008 3336789 CULBERTSON, ELIZABETH A 07/22/2008 STRAIN OR INJURY BY TWISTING $0.00 $343.51 $0.00 $0.00 $343.51 Natureof Injury: 'r:. 49SPRAIN I was running with my crew when I fell and twisted my right Body, - 55 ANKLE Part. ankle. FIREFIGHTER FireFighter N/A ide: Right ccident`p: Descr:,. ` 07/17/2008 07/18/2008 3336856 MIROWSKI, JAMES 09/30/2008 STRUCK BY -LIFTED OBJECT $0.00 $1,999.24 $0.00 $0.00 $1,999.24 Nature of 13 CRUSHING ody r 36 FINGER(S) Side:.. Right Mury: PULLING OUT OUTRIGGER ONTO ENGINE 5 AND END art DROPPED AND SMASHED THE END OF MY FINGER. MECHANIC SUPERVISOR Mechanic Supervisor ,. N/A Accident-. Descr. r. 07/26/2008 07/29/2008 3338608 DINI, CHRISTOPHER M 09/22/2008 MISCELLANEOUS STRIKING AGAINST OR $0.00 $0.00 $0.00 $0.00 $0.00 STEPPING ON Natureof 1000NTUSION Injury: Body 56 FOOT - ide: Right Accident Getting out of shower @ Station # 3 stepped onto linoleum floor and slipped. Did not fall completely, but the metal bench in front of me stopped me hit it with my right front small toes. FIRE FIGHTER Fire Descr. Fighter NONE Page39 01232M908:51AM MCIS UW651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01101/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2008 thru 01/01/2009 Claim ., Accident Worker nses Medical;Paid � '�' ExPePad Inde Current -Total DateRecewed,, Nuaim mberlNamed 'CloDatedmnity� .InjuryCause �, Paid Reserve Incurrred.,:. 07/28/2008 07/29/2008 3338620 VANGORDER, JOHN H OPEN MISC, OTHER THAN PHYSICAL CAUSE OF $98.00 $0.00 $0.00 $3,000.00 $3.098.00 Nature of 59 ALL OTHER INJURY Body 66 NO PHYSICAL INJURY ide: Injury: art: Accident Received diagnosis of Chronic Lymphatic Leukemia from physician Dr. Ross McFarland at Front Range Cancer Specialists 2315 E Harmony Road Unit 110 212-7600 WAREHOUSE VOLUNTEER Descr: COORDINATOR Warehouse Volunteer Coordinator N/A 08/01/2008 08/04/2008 3339674 STACHURSKI, JUDY L 09/22/2008 MISCELLANEOUS STRIKE OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 1000NTUSION Body,, . 33 LOWER ARM ide:, Left Injury: Part: ccident Attempting to start gas powered ventilation fan while in rear compartment pull out tray, I pulled cord with left hand & scraped lop of left arm on underside of plate step on left side of engine. Descr. FIREFIGHTER FireFighter N/A 08/07/2008 08/11/2008 3340835 LINDHOLM, LENOARD E 09/22/2008 STRUCK OR INJURED BY FELLOW WORKER, $0.00 $1,840.67 $0.00 $0.00 $1,840.67 PATIENT Nature of 52 STRAIN ody-,, 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Side: Injury:. Part:: ,r. ccident+ Carrying patient out to main lot on backboard. Had small area where I had to hold backboard & patient to side of me rather then in front. Heard pop in middle back. Left side immediate pain. Descr. FIREFIGHTER CAPTAIN Firefighter Captain N/A 08/13/2008 08/14/2008 3341542 CALLAHAN, RANDY L 09/25/2008 MISCELLANEOUS CAUGHT IN OR BETWEEN $0.00 $354.45 $0.00 $0.00 S354.45 Nature of 10 CONTUSION Body 44 CHEST (INCL RIBS, STERNUM, SOFT TISS) Side: Right Injury: Part: ccident Doing search training in black out conditions I was crawling on floor. When I reached up to check a window I fell onto a wooden chair. FIREFIGHTER TRAINING FireFighter Training N/A Descr: 08/20/2008 08/22/2008 3342792 KLASSEN, JAY S 10/22/2008 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 52 STRAIN ody 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide: .. Injury: Part ccident was pulling hose while training in the burn house. I turned to the right to pull hose & felt sharp pain in lower back on right side. The pain radiates to my right buttocks & right groin area. FIRE FIGHTER Descr:: CAPTAIN Fire Fighter Captain HOSE 08/26/2008 08/29/2008 3344156 TEMPLETON, JOHN E 09/30/2008 FALL - SAME LEVEL $0.00 $794.38 $0.00 $0.00 S794.38 Natureof 49 SPRAIN ody, ._- 53 KNEE ide: Left Injury: cci-de nt. I was rolling hose and slipped on the 5 inch which was wet. As I fell I rolled my knee and heard a pop. ROLLING HOSE Rolling Hose N/A Descr:, 08/30/2008 09/02/2008 3344448 VANGORDER, JIM 10/22/2008 BURN -CONTACT HOT OBJECT $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 04 BURN Sody.;: 52 UPPERLEG ide:. Right Injury: art: ccident '. While doing Saturday apparatus check I started Floating pump carried on Tender 12. Afterwards, I picked up pump the hot exhaust muffler came in contact with right inside leg. First degree bum. FIRE Descr.'- FIGHTER Fire Fighter N/A 09/01/2008 11/26/2008 3357523 GILIOTTI, TYLER C 12/03/2008 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 371NFLAMMATION E ody, 61 ABDOMEN INCLUDING GROIN ide: Injury: art: Swollen finger from injury in september 08 during academy when finger was injured during a training evolution. FIRE FIGHTER Fire Fighter N/A ccident Descr.' Page 40 012=00908:51 AM awns uw651R PINN/I\COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data asof:01/23/2009 Policy Period: 01/01/2008 thru 01/01/2009 • 'Claim':. Report Claim Injured w °rker Medical Indemnity, Currem Total" • Datedent ReceiveC Number Name IDafeed Injury,Cause,; .�:, ,. .Expense serve :Incurred : 09/10/2008 09/11/2008 3345940 HEGSTROM, TIMOTHY C 09/19/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE ody 66 NO PHYSICAL INJURY ides, Injury:;,.,, ,,,. Part ccident Engine 3 dispatched to woman giving birth. Patient was Help C positive. I was exposed to air blood particles. Baby was delivered. FIREFIGHTER/EMT Firefighter/EMT NONE Descr: 09/10/2008 09/11/2008 3345950 LEMAN, MIKE D 09/19/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE Body . : 66 NO PHYSICAL INJURY ide:' Injury. ` Part. ccident. ] Responded to medical call to female in labor. Patient was Hap C positive and a drug user. Assisted with labor. Exposure to airborne fluids. PPE was worn. FIREFIGHTER/EMT Firefighter/EMT NONE Descr: 09/10/2008 09/12/2008 3346224 MCLEAN, RYAN C 10/0712008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature -of 73 CONTAGIOUS DISEASE Body :. 66 NO PHYSICAL INJURY ide: Injury:;.... art ccident': Responded to women in labor. She advised she was a drug user and Hap C. Child was delivered while en route to hospital. Delivery was normal with airborne fluid. Extent of contamination was unknown Desci: ,: z FIRE FIGHTER CAPTAIN Fire Fighter Captain N/A 09/10/2008 09/11/2008 3345925 STANCZYK, QUENTIN C 10/13/2008 CUT -MISCELLANEOUS $0.00 $867.43 $0.00 $0.00 $867.43 0 ture of 40 LACERATION Body is 54 LOWER LEG ide: Right njury`:, Carried a steel rack which had a sharp edge that brushed against my calf. FIRE FIGHTER Fire Fighter STEEL RACK c escident. Dcr: 09/23/2008 09/24/2008 3347887 MCGAFFIN, SHAWN D 10/22/2008 CAUGHT -OBJECT HANDLED $0.00 $340.18 $0.00 $0.00 S340.18 Nature of 13CRUSHING FP`ody:-j 36 FINGER(S) ide: Right njury:-� art I was at the training center practicing forcible entry and smashed my pinky on my right hand with a hallgan tool. FIRE FIGHTER Fire Fighter N/A ccident.:;: Descr: „ 09/25/2008 09/26/2008 3348314 MCKEON, JON M 10/22/2008 ANIMAL OR INSECT $0.00 $0.00 $0.00 $0.00 $0.00 ature of Injury" 43 PUNCTURE Jon was assisting Fort Collins Police capture a small dog ody _] 35 HAND art: (poodle) that got away from them when the dog bit him on both the right and left hand. FIRE FIGHTER Side: , ACTING DO Fire Right Fighter Acting DO N/A ccideht:,,,;: Descri'. 09/27/2008 09/29/2008 3348579 HORNING, WILLIAM C 10/03/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY ature. of 73CONTAGIOUS DISEASE Body -: 66 NO PHYSICAL INJURY ide - Injury:, Part: ccident I was exposed to copious amounts of blood while treating a patient who had been in a MVA. FIRE FIGHTER Fire Fighter All PPE Descr::' Page 41 01a3rz00908a1 AM rwcis UW651R PINNn, COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data asof:01/23/2009 Policy Period: 01/01/2008 thru 01/01/2009 Claim . rker Closed Ex ensas d We', �� p Me Paid) ,aide mn current Total DateIty Received NReport umber Nameim , Received Date ' - Injury Cause Paid' Paid 'Reserve incurred D9127/2008 09/29/2008 3348591 CHAMPLIN, TIM J 10/0312008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE Body 66 NO PHYSICAL INJURY ide: Injury:, Part „ ccident. Patient was bleeding profusely from the head while lying in the back of a pickup. While treating the patient and moving him out of the truck, onto the cot and into the ambulance. FIRE Descr: FIGHTERIEMERGENCY MEDICAL CALL Fire Fighter/Emergency Medical Call NONE 09/27/2008 09/29/2008 3348604 JONES, SEAN E 10/03/2008 MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 52 STRAIN Body , r 42 LOW BACK (LUMBAR & LUMBO-SACRAL) ide:. Injury:,,. Part Accident Exposed to patients blood while treating him for injuries received in auto accident. I also strained my lower middle back when backboard slipped and I had to catch it while standing on uneven terain. Descr:. FIRE FIGHTER Fire Fighter NONE 09/28/2008 09/29/2008 3348746 GILIOTTI, TYLER C 11126/2008 MISCELLANEOUS STRIKE OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 371NFLAMMATION Body - 53 KNEE _Skdel.7 Right Injury:.. art. ccident After obtaining an abrasion on my right knee it became warm swollen and painful. Doctor visit was done in boulder doctor stated skin infection. FIRE FIGHTER TRAINING Fire Fighter Training NOT escr:: SPECIFIED 09/29/2008 09/30/2008 3348968 KOBIELUSZ, BRAD C 10/22/2008 CUT -MISCELLANEOUS $0.00 $0.00 $000 $0.00 $0.00 Nature7of 40LACERATION Body 35 HAND ide: y Right Injury:'. Part , Accident Stepping out of engine and caught hand on piece of rough metal and grab bar. FIRE FIGHTER TRAINING CAPTAIN Fire Fighter Training Captain NONE Descr: 09/30/2008 10/01/2008 3349093 GILIOTTI, TYLER C 10/08/2008 CUT MISCELLANEOUS $0.00 $140.44 $0.00 $0.00 $140.44 Natureof 40 LACERATION Body 36 FINGER(S) ide:` Right Injury: art: ccident Small abrasion to right index finger doing search drill. FIRE FIGHTER TRAINING Fire Fighter Training N/A Descr 09/30/2008 09/30/2008 3348946 RICE, SPENCER C 10/22/2008 CUT TOOL, NOT POWERED $0.00 $0.00 $0.00 $0.00 $0.00 Nature.of 40LACERATION ody 37 THUMB ide: Injury:. Part: ccident Was preparing vegetable for dinner when I cut my thumb with a knife. FIRE FIGHTER Fire Fighter KNIFE Dose, 10/02/2008 10/03/2008 3349616 MIROWSKI, RANDY 10/22/2008 STRIKE-STEP,SHARP OBJECT $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 43 PUNCTURE Body, ,37 THUMB ide: Right Injury: ccident While setting up the Combat Challenge Course for fitness, I was poked in the hand with a steel wire. SPECIAL OPS Special OPs N/A Descr.a 10/21/2008 10/22/2008 3352316 MAKRIS, MARY E 12111/2008 FALL - SAME LEVEL $0.00 $1,424.61 52 STRAIN Body _s 42 LOW BACK (LUMBAR & LUMBO-SACRAL) $0.00 $0.00 Side: Right $1,424.61 Nature of njury.. Part:., Walking to staff vehicle and slipped on wet leaves in front of station 4 and landed on right side. Right lower back spasm and right shoulder wrenched. EMS COORDINATOR EMS Coordinator NONE Accident .: Descr.-. Page 42 0123I200908'51AM PWCis UW651R Fire Suppression 9725 BATTALION CHIEF II -40 HRAVK 103456.14 524.14 Fire Suppression 9670 COMPANY OFFICER I - 56 HRNVK 69210.07 5759.92 Fire Suppression 9715 BATTALION CHIEF 1- 56 HR/WK 10330848 1614.98 Fire Suppression 9640 FIREFIGHTER 11- 56 HRNVK 81245.03 5175.29 Fire Suppression 9670 COMPANY OFFICER I . 56 HR/WK 81410.56 2879.71 Fire Suppression 9570 COMPANY OFFICER I - 56 HR/WK 87782A1 6030.81 Fire Suppression 9670 COMPANY OFFICER I - 56 HR K 80862.02 266272 Fire Suppression 9670 COMPANY OFFICER I - 56 HR K 81332.3 2275,83 Fire Suppression 9670 COMPANY OFFICER I - 56 HRANK 85057.86 3670.83 Fire Suppression 9690 COMPANY OFFICER II - 40 HR/WK 85311.57 152.81 Fire Suppression 9640 FIREFIGHTER 11- 56 HR/WK 73863.37 2363.64 Fire Suppression 9670 COMPANY OFFICER I-56 HRfWK 86864.89 4506.42 Fire Suppression 9640 FIREFIGHTER 11 - 56 HR V K 77832.12 3676.53 Fire Suppression 9 10 FIREFIGHTER It - 56 HR/WK 786736 4095.28 Fire Suppression 9640 FIREFIGHTER II - %HR 79938.62 444663 Fire Suppression %55 FIRE INSPECT COORD- 56 HRNVK 77210.34 2953.1 Fire Suppression 9670 COMPANY OFFICER I - 56 Hl N 85664.2 4028.8 Fire Suppression 9670 COMPANY OFFICER 1-56 HR/WK 91077,13 6791.39 Fire Suppression 9670 COMPANY OFFICER 1. 56 HR/WK 87701.95 4772.7 Fire Suppression 9640 FIREFIGHTER 11- 56 HRfWK 79450.07 4378.52 Fire Suppression 9670 COMPANY OFFICER 1- 56 HR/WK 86139.23 4974.56 Fire Suppression 9670 COMPANY OFFICER 1- 56 HRNVK 80396,45 2054,29 Fire Suppression 9640 FIREFIGHTER II - 56 HR/WK 73228.1 2352.1 Fire Suppression %70 COMPANY OFFICER 1- 56 HRNVK 93246.2 6815, 83 Fire Suppression 9670 COMPANY OFFICER I - 56 HR K 85778.17 4461.2 Fire Suppression 9640 FIREFIGHTER II - 56 HRNVK 81231.27 4910.38 Fire Suppression 9670 COMPANY OFFICER I - 56 HRNVK 82670,53 3417.88 Fire Suppression 9670 COMPANY OFFICER I . 56 HRMK 83889.% 2947.48 Fire Suppression 9640 FIREFIGHTER II-56 HR/WK 74748.05 301061 Fire Suppression %70 COMPANY OFFICER I - 56 HRWK 99488.73 9145.46 Fire Suppression 9670 COMPANY OFFICER I -%HR 99200.36 10770.05 Fire Suppression 9640 FIREFIGHTER 11 . 56 HR/WK 79269.28 4688 Fire Suppression 9665 FIREFIGHTER II - 40 HRNVK 85468.51 5957.03 Fire Suppression 9640 FIREFIGHTER II-56 HRAVK 79554.55 45744 Fire Suppression 9735 DIVISION CHIEF 113500.5 Fire Suppression 9645 FIREFIGHTER II -40 HRANK 76485.31 2931.24 Fire Suppression 9640 FIREFIGHTER II - 56 HRfWK 76176,96 2979.66 Fire Suppression %40 FIREFIGHTER 11- 56 HRMK 79232.08 4789.27 Fire Suppression 9640 FIREFIGHTER II-56 HRWK 77511,91 4013,11 Fire Suppression 9640 FIREFIGHTER 11-56 HR K 89716,19 8173.51 Fire Suppression 9665 FIREFIGHTER 40 HOUR (SPECIAL) 91763.35 7972,05 Fire Suppression 9655 FIRE INSPECT COORD - 56 HRNVK 77226.58 2819.27 Fire Suppression %70 COMPANY OFFICER I - 56 HR K 88484.08 4228.95 Fire Suppression 9670 COMPANY OFFICER I - 56 HRANK 94931.12 8484.75 Fire Suppression 9670 COMPANY OFFICER I . 56 HRIWK 8771262 3710.38 Fire Suppression 9640 FIREFIGHTER 11- 56 HRANK 75947.75 2935.19 Fire Suppression 9670 COMPANY OFFICER I - 56 HRANK 48926.88 1785.84 Fire Suppression 9670 COMPANY OFFICER I-56 HR/WK 80218.47 1876.3 Fire Suppression %70 COMPANY OFFICER I-56 HRfWK 82953.51 3364.61 Fire Suppression 9640 FIREFIGHTER II - 56 HR 93847.38 9486.7 Fire Suppression 9640 FIREFIGHTER II - 56 HR/WK 74261,26 2597.87 Fire Suppression 9640 FIREFIGHTER 11-56 HR/WK 16776,37 350.37 Fire Suppression 9640 FIREFIGHTER 11- 56 HRMK 74184.32 3064.5 Fire Suppression 9640 FIREFIGHTER 11- 56 HR/WK 84769,25 6425.85 Fire Suppression 9640 FIREFIGHTER 11-%HRIWK 78392.91 4186.38 11403399.4 620491.31 Total Home Business Unit Volunteer Program 9690 COMPANY OFFICER II-40 HRNVK 85255.14 85255.14 Total Home Business Unit Equipment Maintenance 9540 FLEET MAINTENANCE TECHNICIAN 103517.8 8756.67 103517.8 8756.67 Total Home Business Unit Public Education 9690 COMPANY OFFICER 11 .40 HRfWK 96716.26 3800.11 96716.26 3800.11 Total Home Business Unit Training 8 New Prog Developmer 2555 FIRE SUPPORT ASSISTANT 2745.8 Training 8 New Prog Developmer 2555 FIRE SUPPORT ASSISTANT 1012.5 Training 8 New Prog Developmer 2555 FIRE SUPPORT ASSISTANT 4890.3 8648 6 Total Home Business Unit Training Center Ops B AGmin 9725 BATTALION CHIEF II-40 HR/WK - 103564 Training Center Ops B AEmin 9700 TRAINING OFFICER-40 HRIWK 85620.96 1160.21 Training Center Ops 8 Aomin 97M TRAINING OFFICER - 40 HR K 119205 10232.35 308389.96 11392,56 Total Home Business Unit Administrative Services 3720 ADMINISTRATIVE FIRE CHIEF 134662.78 134662.78 Total Home Business Unit Emergency Management 9725 BATTALION CHIEF II-40 HR/WK 103729 103729 Total Home Business Unit SystemsMlormation Managemen 9690 COMPANY OFFICER 11 .40 HRNVK 94707.26 3321.56 94707.26 3321.56 Total Home Business Unit Inspection Services 9690 COMPANY OFFICER 11- 40 HRNVK 105850.95 5306,49 105860.95 53M 49 Total Home Business Unit Technical Services 9560 ASST FIRE MARSHALL-NON ROTATE 85480.17 Technical Services 9665 FIREFIGHTER 40 HOUR (SPECIAL) 78524,29 836.28 164004.46 836.28 Total Home Business Unit Investigations/Prev Support 9690 COMPANY OFFICER II - 40 HRNVK 97489.15 2483.5 97489.15 2483.5 Total Home Business Unit Fire Protection Services 9665 FIREFIGHTER 40 HOUR (SPECIAL) 76386.94 114.69 Fire Protection Services 9550 FIRE PROT TECH - NON ROTATE 80219.3 389.07 15660634 503.76 Total Home Business Unit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2008 thru 01/01/2009 claim:.., ;. .'...'. .. ,. ,,. .; ...• _.. .:.,,, . Accident Report Claim,In ured Worker Closed ExP e'nses: Medical C ' Total Date Received Number Name Date In;uryCause ', 'Indemnidl Paid Paid, PaltlL,'':IReserve Incurred+ ' 10/25/2008 10/27/2008 3353030 ROSEN, ANDREW 12/18/2008 MISCELLANEOUS STRAIN OR INJURY 59 ALL OTHER ody?':a 53 KNEE $0.00 $0.00 $0.00 $0.00 ide: Right $0.00 Nature of Injury: art: Checked command light as part of engine check. Its a very tall step up to left side . Felt something pull awkardly in right knee as I got down. Injury is not bad enough to stop work. ENGINE CHECK Fire Accident Descr. I Fighter NONE 10/29/2008 10/29/2008 3353438 KOBIELUSZ, BRAD 12/01/2008 CAUGHT -OBJECT HANDLED 1000NTUSION Body.,, 36 FINGER(S) Part Resetting safety hatch when hatch kicked free and crushing right ring finger FIRE FIGHTER Fire Fighter N/A $0.00 $0.00 $0.00 $0.00 ide: Right $0.00 Natureof Injury:, ccident... Descr:"- 11/01/2008 11/03/2008 3354106 MACCARINI, GENE F 11/12/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59ALL OTHER ody _ 66 NO PHYSICAL INJURY Side:,. Injury:.' Part ccident r.. Was investigatin odor in neighborhood when we came upon a resident who was sealing his driveway with sylene and concrete smulsifier sealant. FIREFIGHTER DRIVER FireFighter Driver NONE 11/01/2008 11/03/2008 3354101 PIETRANGELO, JAMES H 11/1212008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 59ALL OTHER ody 66 NO PHYSICAL INJURY ide: Injury: art ccident Investigating odor it was discovered homeowner was resealing his concrete driveway with concrete emusifing sealant and xylene. The cars of sylene were open & was 5 gallon bucket of sealant/xylent Descr:. mix. FIREFIGHTER CAPTAIN FIREFIGHTER CAPTAIN NONE 11/01/2008 11/03/2008 3354104 WIGGINS, SCOTT D 11/12/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature-oT 59ALL OTHER Botly. 66 NO PHYSICAL INJURY itle: njury:. , Part:r;: 1 Accident = ; Investingating Odor. Occupant was resurfacing driveway & sidewalk. Chemicals were xylene & emulsifying concrete sealant. The wind would shift occasionally. FIREFIGHTER FireFighter NONE Descr: 11/03/2008 11/05/2008 3354524 MACARTHUR, JOHN D 11/06/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $94.31 $0.00 $0.00 $94.31 INJURY Nature of 73 CONTAGIOUS DISEASE Body 66 NO PHYSICAL INJURY Injury::,,!Part: ccWentfe. Extricating patient from vehicle blood splattered on face. A few minutes later I could taste blood. Once back at station checked mouth & face for source of blood. Source of blood came from patient. Descr: ^ EXTRICATION ACCIDENT Extrication accident N/A 11/06/2008 11/07/2008 3354842 SAILING, STEPHEN L 11/12/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $D.00 $0.00 $0.00 $0.00 $0.00 INJURY ature of 59 ALL OTHER . ody, 66 NO PHYSICAL INJURY Injury: art: bcidentipr. PATIENT WAS DIAGNOSED WITH HEPATITIS C. TOOK PROPER BSI PRECAUTIONS. TOOK C-SPINE PRECAUSTIONS GOT BLOOD ON SHOES WHILE CARRYING PATIENT HAND HIT WALL Descr ;'i AND GLOVES TORE. FIREFIGHTER FireFighter N/A Page 43 01931200906'51 AM MCIS ❑W651R PINN/ICOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01101/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data as of:01/23/2009 Policy Period: 01/01/2008 thru 01/01/2009 Claim ..' ... Accident p Claim injured'. Worker Report Closed ,.• „. `', Expenses Medical Indemnity. Current, -.Total Date.. Received l Number. Name Date In'u Cause Paid Paid Paid Reserve °Incurred:,. 11/07/2008 11/13/2008 3355614 GILIOTTI, TYLER C 11/14/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $173.30 $0.00 $0.00 $173.30 INJURY Nature of 68 DERMATITIS Body 31 UPPER ARM (INCL. CLAVICLE & SCAPULA) ide: Right njury: Part: Accident On Friday the 7th of November a pimple was found on my right bicep. An appointment was made to prevent reoccurence on going skin check for MRSA. FIRE ACADEMY Fire Academy NONE Descr: 11/10/2008 11/12/2008 3355486 ENGLAND, TIM 12/26/2008 BURN FIRE, FLAME $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 04 BURN Body38 SHOULDER(S) ide: Both Injury: ' Partr ccident Exposed to high heal during a training exercise involving live fire in a burn building. FIREFIGHTER FireFighter N/A Descr: 11/14/2008 11/17/2008 3356055 DRAGAN, ANTHONY R 12/26/2008 STRUCK BY -MOVING PARTS $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 1000NTUSION ody. � 56 FOOT ide: Right Injury: art: - ccident. `, While loading the burn bins at the training center a gust of wind blew the door shut and hit my right heel. FIREFIGHTER FireFighter N/A Descr.r ' 11/14/2008 11/17/2008 3356061 MURPHY, TIM R 11/20/2008 BURN -STEAM, HOT FLUIDS $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 04 BURN Body-_.. 35 HAND Left ide: Injury: )Part: ccident While functioning as member of a search team in a live bum training exercise, I experienced minor burn to small portion of left hand & wrist when came into contact with heated water & steam on floor Descr: FIREFIGHTER FireFighter N/A 11/16/2008 11/17/2008 3356084 LIPPERT, JOHN C OPEN MISCELLANEOUS STRIKE OR INJURY $196.46 $15,776.96 $0.00 $35,589.07 $51,562.49 Natureof 10 CONTUSION oily ,• 38 SHOULDER(S) ide: Right Injury::'. art. ccent - idr: I was acting B/C on a extrication accident, I stepped out of the B/C vehicle into a hole. I caught myself and injured my right shoulder. FIREFIGHTER/ACTING B/C Firefighter/Acting B/C N/A asc 11/17/2008 11/20/2008 3356611 ROSEN, ANDREW 12/17/2008 OTHER $0.00 $0.00 $0.00 $0.00 $0.00 ature of 371NFLAMMATION Pody ,_ 35 HAND ide: Both Injury: art: ccident Assigned in training evolution to enter burn house & locate & control fire. Found victim & grabbed it to pull out of of burn house. It was wet with hot water soaked into fire gloves leaving red marks, Descr' ��'" FIREFIGHTER FireFighter N/A 11/29/2008 12/01/2008 3357655 GARNER, ROBERT L 12/53/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE ;Body' . 66 NO PHYSICAL INJURY Sider , njury: part:: Accident - Responded to emergency @ doctors office. Suspected meningitis wore mask & gloves had little contact with patient. PVH infection control is to inform if test is positive. FIREFIGHTER/EMS Descr: FireFighter/EMS MASK 11/29/2008 12/01/2008 3357641 REINKING, ROSS 12/03/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 . $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE Botly 66 NO PHYSICAL INJURY ide: _.,I: Injury: Part: - °. ccident . Responded to emergency medical call @ a doctors office. Suspected Meningitis due to signs & symptons. Wearing mask & gloves. Never touched patient. PVH infection control to inform if tests positive Descr: FIREFIGHTER EMS FireFighter EMS MASK Page 44 01=00908:51 AM PWCIS UW551R PINN/ICOIL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 0110112010 Policy: 51045 POUDRE FIRE AUTHORITY 8: POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PROTECTION DISTRICT Data asof:01/23/2009 Policy Period: 01/01/2008 thru 01/01/2009 Claim .Accident;. Report ClaimInjured Worker Closed,.;� - - _'.,. :Expenses r' Medical l' Indemnity, Current: .Total', Date. Received Number. Name. - Date Injury.Cause.. Paid Paid? , Paid.. Reserve ..Incurred 11/29/2008 12/01/2008 3357650 WIGGINS, FOREST W 12/26/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $6.00._ INJURY Natureof 73 CONTAGIOUS DISEASE ody' 66 NO PHYSICAL INJURY Side: Injury: .; art: Accident Dispatched to Doctors Office. Wore Mask & Gloves. Had little contact with patient. Assisted securing the IC and transporting patient on cot from exam room to ambulance. FIREFIGHTER/EMS Descr: FireFighter/EMS MASK 11/30/2008 12/02/2008 3357963 STANCZYK, QUENTIN C 12/05/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 73 CONTAGIOUS DISEASE ody 7 33 LOWER ARM idei ` Right njury: art: Accident. Skin to skin contact with patient with shingles. Patient was down in the shower - my arm touched his torso which had open sores. FIREFIGHTER/EMS-D/O FireFighter/EMS-D/O N/A Descr.. 11/30/2008 12/01/2008 3357777 RICE, SPENCER L 12/26/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Natureof 73 CONTAGIOUS DISEASE Body . 66 NO PHYSICAL INJURY ides.. Injury: art:' Ace ident' Ptie ant had collapsed in shower. Patient had to be carried from shower to bed. Patient had sores from shingles about his abdomen. In process of working on patient gloves tore. I had wound on my hand. Des FIREFIGHTER/EMT FireFighter/EMT NONE 12/07/2008 12/08/2008 3358637 WARREN, BRYAN L 12/10/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 . $0.00 $0.00 INJURY ature of 73 CONTAGIOUS DISEASE Body 66 NO PHYSICAL INJURY ider,- Injury:- .'. art:, ccident?, Responded to medical emergency. We were notified by medics that the patient was being tested for possible meningitis. Possible Mengitis exposure. FIREFIGHTER/ACTING CAPTAIN FireFighter/Acting Descr:'.+;,.;,'; Captain N/A 12/07/2008 12/08/2008 3358645 EDELMON, TRENT C 12/10/200B MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY ature'of 73 CONTAGIOUS DISEASE otly: 66 NO PHYSICAL INJURY Sider Injury: art:, ccidentz;. Responded to a patient with possible memingitis. FIREFIGHTER FireFighter N/A Descr. 12/07/2008 12/08/2008 3358659 WRIGHT, ELLEN E 12/10/2008 MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY attire of 73 CONTAGIOUS DISEASE ody 66 NO PHYSICAL INJURY ide:.. Injury:. �� art: ccidenta, We responded to a medical call where the patient may have meningitis. FIREFIGHTER FireFighter N/A Descr..: -:°;' ' 12/11/2008 12/12/2008 3359547 DELANEY, DEAN M 52 STRAIN 12/1812008 MISCELLANEOUS STRIKE OR INJURY ody_. 21 NECK VERTEBRAE $0.00 $0.00 $0.00 $0.00 $0.00 Nature of Injury: Responded to water flow alarm, while trying to open a art: aux drain the soffit & all the water weight fell & hit me on head. Area of soffit is 4' x 12' & unknown of water weight. All PPE worn. FIREFIGHTER ccident.;.l� De, cr. `.: ! '% FireFighter N/A Page45 01231200908:51AM mcis UW651R Data as of:01/23/2009 PINN/I COL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 0110112006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY 8: POUDRE VALLEY FIRE PRnTFCTInNI nIRTRICT Policy Period: 01/01/2008 thru 01/01/2009 '.AccidentClaim Report Claim. Worker Closed ,.- ..,-, Expenses. ,Medical. .Indemnity Current Total„ Date Received Number Name - :' ;_ Date Injury Cause --Paid. .Paid: Paid Reserve Incurred 12/18/2008 12/19/2008 3360631 LYNXWILER, JAMES R OPEN CUT -BROKEN GLASS $0.00 $294.69 $0.00 $0.00 $294.69 Natwe of 73CONTAGIOUS DISEASE F,—d—y7 36 FINGER(S) InInjury:. Part: ccldent Small puncture wound to left thumb when piece of glass pierced glove. Occurred while assisted coroner with removal of body deceased female. Chance of blood exposure is low. FIREFIGHTER Descr. Fire Fighter N/A 12/20/2008 12/22/2008 3360709 SALMON, WILLIAM A OPEN FALL ON ICE OR SNOW $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 1000NTUSION Body 7 32 ELBOW ide: Right Injury: Part: ccldent Employee reported while carrying the RIC back to vehicle, he slipped and fell on ice in the driveway. CARRYING RIC BAG TO VEHICLE Carrying RIC bag to vehicle Standard boots - instructed crew to Descr: wear clamp-on's 12/20/2008 12/22/2008 3360707 WEBER, BRETT OPEN FALL ON ICE OR SNOW $0.00 $0.00 $0.00 $0.00 $0.00 Nature of 10 CONTUSION Botly. :.,, 32 ELBOW ide: Left Injury: Part: ccident Employee reported after hooking up a hose to a hydrant, he slipped and fell on some ice in teh driveway. He landed on his L.elbow, jammed his shoulder, and his L.hip and L. wrist are sore as well. escr: WALKING Walking N/A 12/27/2008 12/29/2008 3361376 MIROWSKI, JAMES A OPEN MISCELLANEOUS STRAIN OR INJURY $0.00 $1,125.05 $0.00 $0.00 $1,125.05 Nature of 52 STRAIN Body.,: ; 42 LOW BACK (LUMBAR & LUMBO-SACRAL) Kidde: .. Injury: Part: ccident While turning front tires, steering linkage by hand I pulled something in my back. PFA MECHANIC PFA Mechanic N/A _ Descr: Policy Period Totals: Total Claims: 129 $17,758.58 $51,248.80 $14,083.38 $41,516.65 $124,607.41 Open: 10 Open: $14,059.39 $17,580.68 $0.00 $73,156.72 Closed: 119 Closed: $3,699.19 $33,668.12 $14,083.38 $51,450.69 Average: $137.66 $397.28 $109.17 $965.95 Minimum: $0.00 $0.00 $0.00 $0.00 Maximum: $13,764.93 $15,776.96 $7,397.83 $51,562.49 Page46 01r23200908:51AM PWcis UW651R P,NNACOL Standard Loss Run Report Gross Claims Loss History Report ASSURANCE Requested for Policy Periods with Coverage between 01/01/2006 and 01/01/2010 Policy: 51045 POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE Policy Number: 51045 Policy Name: POUDRE FIRE AUTHORITY & POUDRE VALLEY FIRE PP0T1=CT1(AAI r11CTPIRT Data asof:01/23/2009 Policy Period: 01/01/2009 thru 01/01/2010 Claim, Worker ClosExPePad �.Inju Me ical Indemnity 1 rent Date Received Received: Number.,Named Date ury Cause.. Pad Reserve Incurrel;'. curved 01/12/2009 01/13/2009 3363153 PIETRANGELO, JIM H OPEN STRAIN -REACHING $0.00 $0.00 $0.00 $0.00 $0.00 Natureof 52STRAIN ody 38 SHOULDER(S) Side: 7 Both Injury:; Part: Was removing spare gear & wildland gear from top shelf when felt sharp pain in both shoulders, mainly in left. I awakened this morning to pain in left & little in right. Still able to move. FIRE FIGHTER coldent' Descr: CAPTAIN Fire Fighter Captain GEAR 01/15/2009 01/20/2009 3364339 PONCELOW, ROBERT OPEN MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 MOO ature of 49 SPRAIN Body E 53 KNEE idle:.• Left Injury:. Part:' 11 ccidentr, Running on the treadmill. EXERCISE Exercise N/A Descr:? 01/15/2009 01/21/2009 3364532 HANSON, BRYAN K OPEN MISCELLANEOUS STRAIN OR INJURY $0.00 $0.00 $0.00 $0.00 $0.00 ature of 52 STRAIN ody 61 ABDOMEN INCLUDING GROIN Left njury: ^': art: ,idle: Accident Working out doing sit up to meet mandatory physical level of dept. On second set felt sharp bum in lower left quad of abdomen. I was told to go see my personal physician, which I did. FIRE FIGHTER escr: Fire Fighter N/A 01/20/2009 01/21/2009 3364429 MONTOYA, KENNETH J OPEN MISC, OTHER THAN PHYSICAL CAUSE OF $0.00 $0.00 $0.00 $0.00 $0.00 INJURY Nature of 71 ALL OTHER OCCUPATIONAL DISEASE Body 60 LUNG Injury:..' Part: ,idle:;, ccldent� Smoke exposure from treated fence when wind shifted. FIRE FIGHTER/ENTINGUISHMENT Fire Fighter/Entinguishment N/A Descr.> Policy Period Totals: Total Claims: 4 $0.00 $0.00 $0.00 $0.00 $0.00 Open: 4 Open: $0.00 $0.00 $0.00 $0.00 Closed: 0 Closed: $0.00 $0.00 $0.00 $0.00 Average: $0.00 $0.00 $0.00 $0.00 Minimum: $0.00 $0.00 $0.00 $0.00 Maximum: $0.00 $0.00 $0.00 $0.00 Total Policy : 51045 POUDRE FIRE AUTHORITY & POUDRE Total Claims: 340 $19,953.41 $237,213.18 $171,251.27 $41,516.65 $469,934.51 VALLEY FIRE Open: 14 Open: $14,059.39 $17,580.68 $171,251.27 $73,1%72 Closed: 326 Closed: $5,894.02 $219,632.50 $171,251.27 $396,777.79 Average: $58.69 $697.69 $503.68 $1,382.16 Minimum: SO.00 $0.00 $0.00 $0.00 Maximum: $13,764.93 $22,857.67 $74,305.73 $90,246.09 Page 47 oin312N908a1 AM awns UW661R Poudre Fire Authority 09/10 & 08/09 Premium Comparison (with Loss Control Dividend) Confidential Class Code 09/10 08/09 09/10 08/09 09/10 08/09 Payroll Payroll % Difference Pinnacol Rate Pinnacol Rate % Difference Manual Premium Manual Premium % Difference .Firefighters & Drivers 7710 $11,102,162 $10,726,727 3% 2.8402 3.4808 -18% $315,324 $373,376 -16% .Firefighters Cancer Disease Load 1008 $11,102,162 $10,726,727 3% 0.9516 0.7090 34% $105,648 $76,052 39% .Firefighters & Drivers - Volunteer 7711 $30,000 $45,000 -33% 2.8402 3.4808 -18% $852 $1,566 -46% .Firefighters Cancer Disease Load 1008 $120,000 $180,000 -33% 0.9516 0.7090 34% $1,142 $1,276 -11% Outside Salesperson 8742 $3,100 $3,000 3% 0.2910 0.3610 -19% $9 $11 -17% Non -salaried Board Members 8811 $124,800 $124,800 0% 0.0485 1 0.0475 1 2% $61 $59 2% Office 8810 $684,303 $626,380 9% 0.1940 0.2280 -15% $1,328 $1,428 -7% Total Payroll: Total Payroll w/o Load: Manual Premium: Manual Premium w/o Load: 09/10 08/09 % Difference $23,166,527 $22,432,634 3% $11,944,365 $11,525,907 40/0 $424,363 $453,769 -67/6 $317,573 $376,441 -16% 09/10 I 08/n9 nvin I nwn- twin I nnhno Debit/Credit Debit/Credit Factor Debit/Credit Factor % Difference Adjustment Amount Adjustment Amount % Difference Adjustment to Manual Adjustment to Manual % Difference $1000 Deductible Discount Hazard Grp F 0.962 0.961 0% $12,068 $14,681 -18% $305,505 $361,759 -16% E-Mod (Experience Modification Factor 0.88 0.85 4% $36,661 $54,264 -32% $268,845 $307,495 -13% Schedule Rating 0.810 0.820 -1% $51,080 $55,349 -8% $217,764 $252,146 -14% Designated Provider Discount .975 .975 0% $6,721 $7,687 -13% $211,043 $244,459 -14% Cost Containment 0.950 0.950 0% $10,552 $12,223 -14% $200,491 $232,236 -14% Loss Control Surcharge 1.000 1.000 0% $0 $11,612 -100% $210,515 $243,848 -14% Premium Discount 1 0.9121 0.885 3% $17,643 $26,707 -34% 1 $177,434 $2057529 -14% nun n I nR/n4 I no/in I namo Other Fees Fee Fee % Difference Adjustment to Manual Premium Adjustment to Manual I Premium % Difference Annual Policy Fee $165 $165 0% $183,013 $205,694 -11% Terrorism $1,194 $3,170 -62% $184,2071 $208,863 -12% Catastrophe $1,194 $1,153 4% $185,4021 $210,016 -12% Workers' Compensation Premium: Firefighters Cancer Disease Load: Estimated Annual Premium: 9/10 08/09 %Difference $185,402 $210,016 -12% $106,7901 $77,329 38% $292,1921 $287,3451 1.7% Applied Risk Solutions, LLC Ynrrr Risk Mm,ugemew l'arrurr TrucklPick Up 2009 Vehicle Inventory Parking Fart. Parking Fac. Model Make Location DEPT Inside/Outside Locked/Lighted UNIT YEAR Date Acquired Purchase Price Accessories Total 2500 PICKUP CHEVROLET 413 Bryan PARK MAINT-NORTHSIDE Outside Locked &Lighted 24044 2004 62MON $ 17,548 $ - $ 17.548 2500 PICKUP DODGE 835 Woad St FLEET SERVICES -PARTS DEPT Outside Locked & Lighted 26006 2002 21112002 $ 19,237 $ - $ 19,237 314 TON UTIL CHEVROLET 1441 Horaetooth COLLINDALE Outside Lighted 2801 1995 627/1995 $ 17,143 $ - $ 17.143 314 TON UTIL GMC 700 Wood L&P DISTR. Outside Locked & Lighted 2310 1999 726/1999 $ 19,090 $ 7.766 $ 26.856 3/4 TON UTIL GMC 835 Wood St BLDG, REPAIRSMVJNT Outside Locked It Lighted 2664 1999 525/1999 $ 21,165 $ 3,233 $ 24.398 314T PICKUP DODGE W36 Environmental WATER SHED MGMT Outside Locked & Lighted 27008 2002 8/192002 S 22,578 $ - S 22,578 4X4 PICKUP FORD 1745 Hoffman Rd. NAT. RESRESOURCE MGMT Outside Locked It Lighted 25501 2001 5/172001 $ 25.N6 $ - S 25,046 04 PICKUP FORD 1745 Hoffman Rd. NATURAL AREASPUBUC Outside Locked & Lighted 25502 2001 7262001 $ 25,363 $ - $ 25,363 IMPROVEMENT 4X4 PICKUP CHEVROLET 1745 Hoffman Rd. NATURAL AREAS RANGERS Outside Locked & Lighted 25508 2005 3/102005 $ 16,083 $ - $ 16.083 4X4 PICKUP DODGE 215 N. Mason PARKING ENFORCEMENT Outside Lighted 26600 20N =DN $ 17,798 $ - $ 17,798 4X4 PICKUP FORD 300 College CS&AMETERS Outside Locked &Lighted 23042 2003 8212003 $ 15,7W $ - S 15,7W 4X4 PICKUP FORD 413 Bryan PARK MAINT-PROJECT SUPPORT Outside Locked &Lighted 2452 2000 41122W0 $ 21,964 $ - $ 21,961 4X4 PICKUP FORD 4316 W. Laporte WATER TREATMENT #2-ADMIN Outside Locked & Lighted 27004 2001 9/122001 S 22,700 S - S 22,701) 4X4 PICKUP CHEVROLET 625 Ninth STREETS -SWEEPING Outside Locked &Lghled 22011 2004 21J2004 $ 16,698 $ 1,022 $ 17.7M 4X4 PICKUP FORD 626 Unden TRAFFIC ENGINEERING Outside Locked & Lighted 22402 2003 M00003 S 15,7W $ - $ 15,736 4X4 PICKUP CHEVROLET 626 Linden TRAFFIC ENGINEERING Outside Lacked & Lighted 224M 2005 4/12005 $ 17,217 $ - $ 17,217 4X4 PICKUP FORD 700 Wood L&P DISTR. Outside Locked & Lighted 23024 2001 9/122001 $ 20,592 $ - $ 20,592 4X4 PICKUP CHEVROLET 700 Wood L&P DISTR. Outside Lacked & Lighted 23051 2005 1/112005 $ 17,612 $ - $ 17,612 4X4 PICKUP CHEVROLET 700 Wood SEWER TRUNK AND COLLECTION Outside Locked &Lighted 27027 2005 3/102005 $ 17,612 $ - $ 17,612 4X4 PICKUP CHEVROLET 700 Wood WATER TRANSMISSIONIDISTR. Outside Lacked & Lighted 27022 2005 1/52005 $ 17.612 $ - S 17.612 04 PICKUP CHEVROLET 7W Wood WATER TRANSMISSIONIDISTR. Outside Locked & Lighted 27023 2005 1/112005 $ 17.612 $ - $ 17.612 4X4 PICKUP FORD 700 Wood St. DRAINAGE AND DETENTION Outside Locked & Lighted 27703 2003 2272003 S 18,/42 S - S 18.142 4X4 PICKUP CHEVROLET Howes St. CODE COMPLIANCE Outside Locked B Lighted 22020 2005 5272005 $ 15.593 $ - S 15.593 4X4 PICKUP FORD FIRE OPERATIONS Home Outside or Garaged 78760 2002 6162002 $ 32626 $ - $ 32.626 4X4 PICKUP FORD FIRE OPERATIONS Home Outside or Garaged 78761 2002 6/62002 $ 32,626 $ - $ 32,626 4X4 PICKUP FORD MOUNTAIN PARK 24004 2001 12152000 $ 26,857 $ - $ 26.857 4X4 PICKUP CHEVROLET PEDESTRIAN ACCESS 22604 2002 8/132002 $ 17,896 $ - $ 17896 4X4 PICKUP CHEVROLET POLICE -INVESTIGATION Home Outside or Garaged 2101 1988 9/16/1999 $ 2,500 $ - $ 2,5W 4X4PU K1500 CHEVROLET 625 Linden SIGNS & PAINT -TRAFFIC Outside Locked & Lighted 22504 2005 422005 $ 19304 S - S 19,304 4X4PU K15W CHEVROLET Howes St. ENGINEERING Outside Locked &Lighted 22609 2005 11IM005 $ 18,814 $ - $ 18,814 4X4PU K1500 CHEVROLET Howes St. ENGINEERING Outside Locked & Lighted 22610 2005 1/132005 $ 19,109 $ - $ 19,109 C10 PICKUP CHEVROLET 1900 W. Mountain GRANDVIEW GROUNDS MT Outside Lighted 2450 1988 3/1611988 $ 9,827 $ - $ 9,827 C10 PICKUP CHEVROLET 413 S. Bryan FORESTRY Outsde Locked A Ughted 2409 1988 3/3111988 $ 9,895 $ - $ 9,895 C10 PICKUP CHEVROLET 413 S. Bryan FORESTRY Outside Lacked & Lighted 2410 1990 10/111990 $ 11,298 $ - $ 11,298 C10 PICKUP CHEVROLET 6570 porter FLEET SERVICES-TRANSFORT SIT Outside Locked & Lighted 2619 1995 62911995 $ 14.593 $ - $ 14,593 C1500 GMC 413 S. Bryan FORESTRY Outside Locked & Lighted 2456 1991 W1911991 $ 10.508 S - $ 10,508 C1500 GMC 700 Wood WATER METER SHOP Outside Locked & Lighted 2263 1991 1/17/1991 S 11.597 $ - $ 11.597 C150 GMC POLICE -PATROL SERVICES Home Outside or Garaged 2131 1991 3911991 S 11,479 S - S 11,479 C25 CHEVROLET 625 Ninth STREETS -SWEEPING Outside Locked &Lighted 2081 1996 6/411996 $ 20.016 $ - S 20.016 C25 CHEVROLET 625 Ninth STREETS -WORK FOR OTH Outside Locked &Lighted 2083 19% 6/411996 $ 20,016 $ - $ 20,016 C25 CHEVROLET 700 Wood St. DRAINAGE AND DETENTION Outside Looked & Lighted 2082 1996 6/4/1996 $ 20,016 $ 3,275 $ 23.291 C2500 GMC 1745 Hoffman Rd. HORTICULTURE Outside Locked It Lighted 2507 1992 5/19/1992 $ 19,387 $ - S 19,387 C2500 GMC 3036 Environmental RESOURCE RECOVERY Outskle Locked & Lighted 27007 1990 518/1990 $ 11,283 $ 2.999 $ 14,282 C25W GMC 30M Environmental RESOURCE RECOVERY Outside Locked & Lighted 2792 1992 428/1992 $ 16,559 $ - $ 16,559 C2500 CHEVROLET 413 Bryan PARK MAINT-NORTHSIDE Outside Looked &Lighted 2443 19% 12/1996 $ 17.613 S - $ 17,613 C2500 CHEVROLET 413 Bryan PARK MAINT-PROJECT SUPPORT Outside Locked & Lighted 2445 19% 1019% $ 17.613 $ - $ 17,613 C2500 GMC 413 BryaruGolf CITY PARK GOLF Outside Lighted 2814 1990 6/19I1990 $ 13.973 $ - $ 13,973 C2500 GMC 4316 W. Laporte SOURCE OF SUPPLY Outside Locked & Lighted 2289 1993 213/1993 $ 18.313 $ - $ 18,313 C2500 GMC 5750 S. Lemay SOUTHRDIGE GOLF COURSE Outside Lighted 2818 1993 72011963 $ 16,058 $ - $ 16,058 C2500 GMC 626 Linden TRAFFIC ENGINEERING Outside Locked & Lighted 2788 1991 BO/1991 $ 14.524 $ 2.193 $ 16,717 02500 GMC 700 Woad INSTRUMENTAL AND ELECTRICAL Outside Locked & Lighted 2252 1991 7/1/1941 S 16.160 $ 2.565 $ 18.725 C25W GMC 700 Wood L&P DISTR. Outside Looked &Lighted 2315 1993 350/1963 $ 14,679 S 3,298 S 17,977 C2500 GMC 700 Wood L&P DISTR. Outside Lacked & Lighted 2382 1989 711 Ill989 $ 10.587 $ 3.015 5 13.602 C2500 GMC 835 Wood St BLDG. REPIMNT-HVAC Outside Locked & Lighted 2667 1989 4MI989 $ 10,690 S 2,473 $ 13.163 C2500 GMC 835 Wood St BLDG. REPAIRSIMAINT Outside Looked & Lighted 2669 1989 727/1989 $ 12,931 $ 2,473 $ 15,4N C2500 GMC MAINTENANCE Outside Locked It Lighted 2790 1992 428I1992 $ 12875 $ 2,163 $ 15,038 C2500 GMC MEDIANS & DOWNTOWN 24054 1987 724/1987 $ 9,727 $ 1,785 $ 11,512 C30TRUCK CHEVROLET 300 College METERS -MINOR CAPITAL Outside Locked &Lighted 2723 1995 12/1 ill 995 $ 17,070 $ 3,375 $ 20,445 C30TRUCK CHEVROLET 3036 Environmental RESOURCE RECOVERY Outside Locked & Lighted 2742 1986 522/19N $ 10,213 $ 4,120 $ 14,333 C30TRUCK CHEVROLET 700 Wood L&P DISTR. Outside Locked & Lighted 2351 1995 wit l996 $ 16,835 $ 6,477 $ 23.312 C30TRUCK CHEVROLET 700 Wood WATER TRANWISSIONIDISTR. Outside Locked & Lighted 2798 1995 3/1511995 $ 15.851 $ 15,246 5 31,097 C3500 GMC 2718 E. Mulberry ROSELAWN GROUNDS MT Outside Lighted 25W 1991 2126/1991 $ 12.182 $ 4.539 $ 16,721 C35W CHEVROLET 300 College METERSWINOR CAPITAL Outside Locked &Lighted 2714 1997 822/1997 S 21.964 $ - $ 21,964 C3500 CHEVROLET 413 S. Bryan FORESTRY Outside Locked & Lighted 2487 1995 227A996 $ 49,870 $ - $ 49.870 C3500 GMC 625 Linden SIGNS & PAINTTRAFFICOutside Locked & Lighted 2226 1998 82611998 $ 23,678 $ - $ 23.678 C35W GMC 626 Linden TRAFFIC ENGINEERING Outside Locked & Lighted 2202 1989 2J1311995 $ 9.500 $ - $ 9.500 C3500 CHEVROLET 700 Wood L&P DISTR. Outside Locked &Lighted 23018 2001 10/112001 $ 23,555 $ 6,075 $ 29.630 C35W CHEVROLET 700 Wood LAP DISTR. Outside Looked &Lighted 23019 2001 10/1&2001 $ 23.555 $ 6,075 $ 29.630 C35W CHEVROLET 700 Woad L&P DISTR. Outside Looked & Lighted 23020 2001 10/312001 $ 23,555 $ 6.075 S 29,630 C35W CHEVROLET 700 Woad L&P DISTR. Ou6itle Locked &Lighted 2342 1998 1027/1998 $ 40,833 5 - S 40833 C35W CHEVROLET 700 Woad LAP DISTR. Outside Locked & Lighted 2372 1998 1027/1998 $ 40,833 $ - $ 40,833 C3500 GMC 700 Wow WATER METER SHOP Outside Locked & Lighted 2782 1991 22511991 $ 12,310 $ 2,890 $ 15,200 C3500 GMC 700 Wood WATER METER SHOP Outside Locked & Lighted 2789 1991 4/17/1962 $ 12,870 $ 3,249 $ 16,119 C3500 GMC 635 Wood St FLEET SERVICESSHOP Outside Locked & Lighted 2601 1991 315/1991 $ 15.270 $ 6,516 $ 21,786 C3500.FL.ATBC CHEVROLET 625 Linden SIGNS & PAINT -TRAFFIC Outside Locked & Lighted 22501 2001 1/182002 S 22.305 $ 6.125 $ 28.430 C70 GMC 7W Wood WATER TRANSMISSIONIDISTR. Outside Locked &Lighted 2757 1987 9/1511987 S 22,W2 $ 26,857 $ 48.919 C70 TRUCK CHEVROLET 413 Bryan PARK MAINT-PROJECT SUPPORT Outside Looked & Lighted 2454 1989 9/15/1989 $ 17,421 $ 5.459 S 22,880 CHEYENNE CHEVROLET 413 Bryan PARK MAINT-SOUTHEAST Outside Looked & Lighted 2514 1998 1/5/1998 $ 20,734 $ - $ 20,734 CHEYENNE CHEVROLET 700 Wood SEWER TRUNK AND COLLECTION Outside Locked &Lighted 2719 1998 42111998 $ 23,157 $ - $ 23,157 CHEYENNE CHEVROLET 835 Wood St BLDG. REPAIRSM NT Outside Locked & Lighted 2651 1998 511 Ill 998 $ 19,149 $ - $ 19,149 CHEYENNE CHEVROLET CAPITAL IMPROVEMENTS 2624 1998 12/911997 $ 20,422 $ - $ 20,422 CHEYENNE CHEVROLET T&C MINOR CAPITAL 2772 1998 6/15I1998 $ 22,525 $ - $ 22,525 DAKOTA DODGE 300 College CS&A METERS Outside Locked &Lighted 23035 2002 7252002 $ 11,979 $ - $ 11.979 DAKOTA DODGE 300 College CS&A METERS Outside Locked & Lighted 23036 2002 7252002 $ 11,979 $ - $ 11.979 DAKOTA DODGE 413 Bryan PARK MAINTENANCE Outside Looked &Lighted 24011 2002 3/132002 $ 14,968 S - $ 14.968 DAKOTA DODGE 413 Bryan PARK MAINTSOUTHEAST Outside Locked & Lighted 24018 2002 7182002 $ 12,647 $ - $ 12.647 DAKOTA DODGE 413 Bryan PARK MAINT-SOUTHWEST Outside Locked &Lighted 24019 2002 7/82002 $ 12.647 $ - S 12,647 DAKOTA DODGE 413 Bryan PARK MAINT-SPORTSTURF/COUR Outaide Locked &Lighted 24020 2002 7/122002 $ 12,647 $ - $ 12,647 DAKOTA DODGE 700 Wood L&P DISTR. Outaide Locked & Lighted 23028 2002 5/92002 $ 15,244 $ - $ 15,244 DAKOTA DODGE 835 Wood St BLDG. REPAIRSA WNT Outside Locked & Lighted 2008 7/92008 16,042.00 0.00 $ 16,042 DAKOTA DODGE 835 Wood St BLDG. REPAIRSMIAINT Outside Looked & Lighted 2008 752D08 16,042.00 0.00 $ 16,042 DAKOTA DODGE Howes St. BUILDING INSPECTION Outside Looked & Lighted 26700 2002 2152002 $ 16.479 $ - $ 16,479 DAKOTA DODGE Howes St, BUILDING INSPECTION Outside Locked & Lighted M701 2002 2 002 $ 16.479 S - $ 16,479 DAKOTA DODGE Howes St. BUILDING INSPECTION Outside Locked & Lighted 26702 2002 2r2002 $ 16,479 S - S 16,479 DAKOTA DODGE MEDIANS & DOWNTOWN 24021 2002 7/122002 $ 12,647 $ - $ 12,647 DAKOTA DODGE MEDIANS & DOWNTOWN 24022 2002 7242002 $ 12647 S - $ 12,647 DAKOTA,IX4 DODGE Howes Sl. ENGINEERING-ADMIN Outside Locked & Lighted 22603 2002 6I182002 $ 18,658 $ - $ 18,658 F150 FORD 2718 E. Mulberry ROSELAWN GROUNDS MT Outside Lighted 2447 1995 8/31/1995 $ 12,360 $ - S 12,360 F150 FORD 413 S. Bryan FORESTRY Outside Locked & Lighted 2415 1993 8/19/1993 S 9,421 $ - $ 9.421 F150 FORD - 700 Wood WATER TRANSMISSION/DISTR. Outside Locked & Lighted 2777 1990 1025/1990 $ 11,853 S - S 11,853 F15004 PAI FORD 1745 Hoffman Rd. NAT. RES-RESOURCE MGMT Outside Locked & Lighted 2559 2000 51B2000 $ 26,742 $ - $ 26,742 F1504X4 PA) FORD 1745 Hoffman Rd. NATURAL AREASPUBUC Ouside Locked &Lighted 2558 2000 4222000 S 26,742 S - S 26,742 IMPROVEMENT F150 4X4 PAI FORD 625 Ninth STREETS -WORK FOR OTH Outside Locked & Lighted 22008 2003 41140003 $ 16,903 $ 4.558 $ 21.461 F150 04 PN FORD Howes St ENGINEERING Outside Locked & Lighted 22605 2002 8202002 $ 19.192 $ - $ 19,192 F1504X4 PN FORD Howes St, ENGINEERING Outside Locked & Lighted 22606 2003 4114QD03 $ 18,286 $ - $ 18,286 F1504X4 PIU FORD Hawes SL ENGINEERING Outside Locked & Lighted 22607 2003 41142003 $ 18,286 $ - $ 18,2W F1504X4 PM FORD Howes SL ENGINEERING Outside Locked & Lighted 22608 2003 4/152003 S 18,286 $ - $ 18,286 Fl W PICKUP FORD 1900 W. Mountain GRANDVIEWGROUNDS Outside Lighted 2008 1252008 14.73500 000 S 14,735 F150 PICKUP FORD 4316 W. Laporte INTAKE Outside Locked & Lighted 2721 2000 7262000 $ 24.513 S - $ 24.513 F150 PICKUP FORD 625 Linden SIGNS & PAINT -TRAFFIC Outside Locked & Lighted 22500 2001 8/152001 $ 22.005 $ - $ 22.005 F150 PICKUP FORD 625 Ninth St 2004 STREET MAINTENANCE Outside Locked & Lighted 2539 2000 7242000 $ 24.513 $ - $ 24,513 F150 PICKUP FORD 626 Unden TRAFFIC ENGINEERING Outside Locked & Lighted 2086 1997 1/14/1997 $ 20.774 $ - $ 20,774 FI50 PICKUP FORD 700 Wand L&P DISTR. Outside Locked & Lighted 2338 2000 4/122000 $ 20,332 $ - $ 20,332 F150 PICKUP FORD 700 Wood WATER TRANSMISSIONMISTR. Outside Locked & Lighted 2729 1997 601997 $ 20.748 $ - $ 20,748 F150 PICKUP FORD 700 Wood St. DRAINAGE AND DETENTION Outside Locked & Lighted 27U 2000 1/112000 $ 22,080 S - $ 22,080 F150 PICKUP FORD POLICE -PATROL SERVICES Home Outside or Garaged 2128 20M WI2000 $ 23,942 $ - $ 23,942 F250 FORD 1745 Hoffman Rd. HORTICULTURE Outside Locked & Lighted 25303 2002 8/302001 S 19,514 $ 2,075 $ 21,589 F250 FORD 3036 Emirenmental RESOURCE RECOVERY Outside Locked & Lighted 2720 20M 1212000 $ 22,533 $ 4,274 $ 26,807 F250 FORD 413 Bryan PARK MAINT-NORTHSIDE Outside Locked &Lighted 2422 1997 122711996 $ 18,522 $ - $ 18,522 F250 FORD 413 Bryan PARK MNNT-SOUTHEAST Outside Locked & Lighted 24000 2001 10202000 $ 19,609 $ 3,598 $ 23,207 F250 FORD 413 Bryan PARK MAINT-SOUTHEAST Outside Locked & Lighted 24008 2001 611WO01 $ 21,399 $ 3,698 $ 25,097 F250 FORD 413 Btydn PARK MAINTSOUTHEAST Outside Locked & Lighted 2423 1997 1227/1996 $ 18,522 S - $ 18,522 F250 FORD 413 Bryan PARK MAINT-SOUTHWEST Outside Locked &Lighted 2419 1997 1226/19% $ 18.630 $ - $ 18,630 F250 FORD 413 Bryan PARK & 1AINTSPORTSTURF/LOUR Outside Locked & Lighted 24001 2001 101=000 $ 19609 S 3.598 5 23,207 F250 FORD 413 Bryan PARK MAINT-SPORTSTURF/COUR Outside Locked & Lighted 2420 1997 1227/1996 $ 18,522 $ - $ 18,522 F250 FORD 413 S. Bryan FORESTRY Outside Locked &Lighted 24U 1985 6/12I1985 $ 8240 $ 1.956 $ 10.1% F250 FORD 413 S. Bryan FORESTRY Outside Locked & Lighted 25302 2002 8202001 $ 21.494 $ - $ 21.494 F250 FORD 4316 W. Lagode WATER TREATMENT#2-MAINT Outside Locked&Lighted 2753 1994 415/1994 $ 13,492 $ 2,186 $ 15.678 F250 FORD 4316 W. LaPorte WATER TREATMENT #2-MAINT Outside Locked & Lighted 2794 1992 9/1511992 $ 12.579 $ 3432 $ 16.011 F250 FORD 625 Ninth STREETS -WORK FOR OTH Outside Locked & Lighted 2078 1997 8/14/1997 $ 17,703 S - $ 17.703 F250 FORD 625 Ninth STREETS -WORK FOR OTH Outside Locked&Lighted 2079 1997 7/18/1997 S 16.653 S 1,133 $ 17.786 F250 FORD 625 Ninth STREETS -WORK FOR OTH Outside Locked &Lighted 2092 1997 422/1997 $ 20,452 $ - S 20,452 F250 FORD 625 Ninth St FLEET SERVSTREETS Outside Locked &Lighted 2660 1993 8/19/1993 $ 12685 $ 2.417 $ 15.102 F250 FORD 700 Woad INSTRUMENTAL AND ELECTRICAL Outside Locked & Lighted 2743 1986 529/1986 $ 8,935 $ 1,773 $ 10,708 F250 FORD 700 Wood L&P DISTR. Outside Locked & Lighted 23007 2000 6212000 $ 19,762 $ 5.230 $ 24,992 F250 FORD 700 Wood L&P DISTR, Outside Locked & Lighted 23008 2000 6202000 $ 19,762 $ 5,230 $ 24.992 F250 FORD 700 Woad L&P DISTR. Outside Locked & Lighted 23015 2001 1262ool $ 21,344 $ 5.579 $ 26.923 F250 FORD 700 Wood L&P DISTR. Outside Locked & Lighted 23043 2004 4222004 S 16,220 $ 3.366 $ 19,586 F250 FORD 700 Wood WATER TRANSMISSIONIDISTR. Cotsitle Locked &Lighted 27000 2001 10232000 S 19,502 S 4.280 $ 23.782 F250 FORD 700 Woad WATER TRANSMISSIONIDISTR. Outside Locked! &Lighted 27018 2004 6/15200d $ 16,8m $ - S 16,884 F250 FORD 700 Wood WATER TRANSMISSIONIOISTR. Outside Locked & Lighted 2799 1996 271211996 $ 17,7U S 2.599 $ 20.383 F250 FORD 835 Wood St BLDG. REPAIRSIMANT Outside Locked & Lighted 2665 1988 10/19/1988 $ 11.533 $ 3,300 $ 14.833 F250 FORD MEDIANS & DOWNTOWN 24009 2001 6/182001 $ 21.399 $ 3,698 $ 25,097 F25004 PN FORD 625 Ninth STREETS -WORK FOR OTH Outside Locked &Lighted 2093 1999 12/l/1998 $ 24.380 $ - $ 24.380 F2504X4 PN FORD 625 Ninth STREETS -WORK FOR OTH Outside Locked B Lighted 2094 1999 12///1998 $ 24,380 $ - $ 24,380 F2504X4 PAl FORD 625 Ninth St 2004 STREET MAINTENANCE Outside Locked &Lighted 2536 1999 M/1999 $ 25.155 $ - S 25,155 F2504X4 PAl FORD 700 Woad SL DRAINAGE AND DETENTION Outside Locked & Lighted 2008 1/142008 21 057,00 0.00 $ 21,057 F2504X4 PAI FORD 635 Woad St BLDG. REPAIRSMIAINT Outside Locked & Lighted 2639 1998 3116/1999 $ 25,741 $ - S 25.741 F2504X4 PN FORD Howes St. ENGINEERING Outside Locked &Lighted 2535 1999 8/3I1999 S 25.155 $ - $ 25,155 F2504X4 PAl FORD Howes St ENGINEERING Outside Locked & Lighted 2537 1999 BnII1999 $ 25.155 $ - $ 25.155 F2504X4 PAl FORD POLICE-ADMIN Home Outside or Garaged 21607 2004 1292004 $ 22,118 $ - $ 22.118 F2504X4 PN FORD POLICE -INVESTIGATION Home Outside or Garaged 21817 20M 8/52005 $ 22.600 $ - S 22.800 F25004 PM FORD TECHNICAL SERVICES 2733 2000 2282000 $ 22,941 $ 2.328 $ 25.269 F350 FORD 413 S. Bryan FORESTRY Outside Locked & Lighted 2453 1988 7/1/1988 $ 11.001 $ 4,052 $ 15,053 F350 FORD 625@Men SIGNS & PAINT -TRAFFIC Outside Looked &Lighted 2213 1986 720/1988 $ 11.608 $ 34,355 S 45,%3 F350 FORD 700 Woad L&P DISTR. Outside Locked & Lighted 2654 1989 5/18/1989 $ 11,652 $ 3.352 $ 15,004 F350 FORD 700 Woad WATER METER SHOP Outside Locked & Lighted 27020 2004 7272004 $ 17,216 $ 32W $ 20.422 F350 FORD 700 Wood WATER METER SHOP Outside Locked &Lighted 27021 2004 7/122004 $ 17,216 $ 3208 $ 20.422 F350 FORD MEDIANS & DOWNTOWN 2490 1985 7/31/1985 $ 8.559 $ 3.066 $ 11,625 F350 DUMP FORD 413 Bryan PARK MAINT-SOUTHEAST Outside Locked &Lighted 24002 2000 10202000 $ 23.665 $ 7.277 $ 30.942 F350-BUCKET FORD 625 Ninth STREETS -WORK FOR OTH Outside Locked &Lighted 2254 1990 9/18/1990 $ 14.624 $ 12,897 $ 27.521 F470 FORD 700 Wood L&P DISTR. Outside Locked & Lighted 2307 1997 52211997 S 18.920 $ 13,193 S 32.113 F700 FORD 6570 Parma, FLEET SERVIOESTRANSFORT ST Outside Locked &Lighted M09 19" 1126/1984 $ 16.789 S 11,213 $ 28,002 "DO FORD 700 Woad L&P DISTR. Outside Locked & Lighted 2395 1992 826/1992 $ 29.423 $ 57,562 $ 86,985 F700 FORD 700 Wood SEWER TRUNK AND COLLECTION Outside Locked &Lighted 2708 19% 1214/1995 S 26,800 $ 43.430 $ 70,230 F800 FORD 413 S. Bryan FORESTRY Outside Locked & Lighted 2449 19M 720/1993 $ 25,850 $ 7,267 $ 33.117 F800 FORD 413 S. Bryan FORESTRY Outside Locked & Lighted 2491 1986 1127/1985 $ 21,113 $ 24,043 $ 45,156 FLATBED CHEVROLET 1745 Hoffman Rd. NATURAL AREAS -PUB. IMP. Outside Looked &Lighted 2430 1997 401997 $ 24.233 $ - $ 24,233 FLATBED FORD 413 S. Bryan FORESTRY Outside Locked & Lighted 25301 1979 5/11/1982 S 3.00 $ - S 3.000 FLATBED GMC 625 Ninth STREETS -WORK FOR OTH Ouside Locked &Lighted 2247 1994 6/1/1994 S 17.510 $ - $ 17.510 FLATBED GMC 625 Ninth STREETS -WORK FOR OTH Outside Locked &Lighted 2264 1994 424/1995 $ 25.079 S 2,480 $ 27,559 FLATBED GMC 626 Un ten TRAFFIC ENGINEERING Outside Locked & Lighted 2237 1976 5/11/1982 $ 7,104 S - $ 7,104 FLATBED FORD 6570 P.M., TRANSPORT Inside Locked 2608 2000 6212000 $ 23,180 $ 3,820 $ 27,000 FLATBED GMC 835 Wood St FLEET SERVICES -POOL RENTAL Outside Locked & Lighted 2616 1980 620/1994 $ 3,500 $ - $ 3.500 FLATBED CHEVROLET 835 Wood St FLEET SERVICES -POOL RENTAL Outside Locked & Lighted 2652 1968 5/11/1982 $ 3,586 $ - $ 3.586 FLATBED CHEVROLET 835 Wood St FLEET SERVICES -POOL RENTAL Outside Locked & Lighted 2670 1980 5111/1982 $ 5,515 $ 1.738 $ 7,253 FLATBED 1500 CHEVROLET 625 Ninth STREETS -WORK FOR OTH Outside Locked & Lighted 220D5 2002 5M2002 $ 18,720 S 1.320 $ 20.040 FLATBED F250 FORD 625 Linden SIGNS &PANT -TRAFFIC Outside Locked & Lighted 22503 2005 2242005 $ 17.915 $ 2,926 S 20,741 FLATBED F250 FORD 625 Ninth STREETS -WORK FOR OTH Outside Locked &Lighted 22000 2001 4/182001 $ 18.699 $ 1.649 S 20,348 FLATBED F350 FORD 1745 Hoffman Rd. NAT. RESRESOURCE MGMT Outside Locked & Lighted 2570 2000 52m000 $ 25,881 $ 3,560 $ 29,441 FLATBED F350 FORD 625 Linden SIGNS & PAINTTRAFFICOutside Locked & Lighted 2069 20M 7242000 $ 23,540 $ 3,931 $ 27,471 FLATBED F450 FORD 1745 Hoffman Rd. NAT. RES-RESOURCE MGMT Outside Locked & Lighted 25509 2005 4262005 $ 30,821 $ 2.757 $ 33,578 FLATBED F450 FORD 700 Woad WATER TRANSMISSION/DISTR. Outside Locked & Lighted 27002 2001 5242001 $ 26,336 $ 3.622 $ 29,958 FLATBED F450 FORD 700 Woad St, DRAINAGE AND DETENTION Outside Locked & Lighted 27705 20D4 711WON $ 21.105 $ 7.604 $ 28.709 FLATBED F55C FORD 700 Wootl L&P DISTR. Outside Locked & Lighted 23011 2000 71192000 S 28.820 $ 3.214 S 32.034 FLATBED F55C FORD 700 Wood WATER TRANSMISSIONA]ISTR. Outside Lacked & Lighted 2008 27122008 27.078.00 6,953.55 $ 34,032 FSUPER DUT'FORD 700 Wood L&P DISTR. Outside Locked & Lighted 2352 19% 52/1996 $ 19471 S 12,698 $ 32,169 F-SUPER DUT' FORD 700 Woad LSP DISTR. Outside Locked 8 Lighted 2354 1996 513/19W $ 19,471 $ 12.698 $ 32,169 G3500 GMC 413 Bryan PARK MANT-NORTHSIDE Outside Locked B Lighted 241E 1992 . 428/1992 $ 12,765 $ 4.607 $ 17,372 G3500 GMC 626 Linden TRAFFIC ENGINEERING Outside Locked 8 Lighted 2224 1985 9/121985 $ 24.564 $ - $ 24,564 G35W GMC 700 Wood SEWER TRUNK AND COLLECTION Outside Locked B Lighted 2285 1986 9221986 $ 129.800 $ - $ 129.800 HD 25W CHEVROLET 625 Linden SIGNS S PAINT -TRAFFIC Outside Locked 8 Lighted 22502 2002 3/132002 S 20.5% S 1.820 S 22.416 K15004X4 PU GMC POLICE -INVESTIGATION Home Outside or Garaged 21611 2000 4/192004 S 5.000 S - $ 5.000 K150004 PU GMC POLICE -INVESTIGATION Home Outside or Garaged 51612 2000 1OW003 $ 15.000 $ - $ 15.000 K15W 4X4 PU GMC TBD MINOR CAPITAL 2791 1992 6/5/1992 $ 14.571 $ - $ 14.571 K2500 HD PU CHEVROLET 1745 Hoffman Rd. NAT. RES-RESOURCE MGMT Outside Locked S Lighted 25504 2004 2102004 $ 22.844 $ - $ 22,8d4 K2500 HD PU CHEVROLET 1745 Hoffman Rd. NATURAL AREAS -PUBLIC Outside Locked 8 Lighted 25505 2004 2/102004 $ 20,629 $ - $ 20,629, IMPROVEMENT K2500 PICKUP CHEVROLET 5833 S. Lemay FOSSIL CREEK COW PARK MAIN Outside Locked S Lighted 2464 1995 112011995 $ 19.653 $ - $ 19.853 K2500 PICKUP CHEVROLET FIRE OPERATIONS Home Outside or Garaged 78556 2002 12/132004 $ 19,850 $ - $ 19,650 K30 CHEVROLET 4316 W. Laporte SOURCE OF SUPPLY Outside Locked 6 Lighted 2706 1997 72411997 $ 21.700 $ 2,775 $ 24.475 K30 CHEVROLET 4316 W. LaPorte SOURCE OF SUPPLY Outside Locked A Lighted 2712 1997 724/1997 S 21,945 $ 4,103 S 25.948 PICKUP CHEVROLET 1745 Hoffman Rd. HORTICULTURE Outside Locked B Lighted 25300 2000 8242000 $ 19,505 $ - $ 19.506 PICKUP CHEVROLET 19W W. Mountain GRANDVIEW GROUNDS MT Outside Lighted 2462 1997 5/19/1997 $ 22,442 S - S 22,442 PICKUP CHEVROLET 3W College CSSA METERS Outside Locked S Lighted 23052 2005 51192W5 $ 11,381 $ - $ 11,381 PICKUP CHEVROLET 300 College CS" METERS Outudde Locked S Lighted 23053 2005 5/192005 $ 11,381 $ - $ 11,381 PICKUP CHEVROLET 413 Bryan PARK MANT-FACILITIES Outside Locked 8 Lighted 24047 2005 1152005 $ 13,121 $ - $ 13,121 PICKUP FORD 413 Bryan PARK MANT-SOUTHWEST Outside Locked B Lighted 2550 1998 2/17/1998 $ 15,944 $ - $ 15,944 PICKUP FORD 413 S. Bryan FORESTRY Outside Locked 8 Lighted 2459 1999 911/1999 $ 22,309 $ - $, 22,309 PICKUP CHEVROLET 626 Linden TRAFFIC ENGINEERING Outside Locked 8 Lighted 22403 2005 2/112005 $ 15.371 $ - $ 15,371 PICKUP CHEVROLET 700 Wood SEWER TRUNK AND COLLECTION Outside Locked 8 Lighted 2711 1998 42111998 $ 18.858 $ - $ 18,858 PICKUP CHEVROLET 835 Wood St BLDG. REPMWT-1-VAC Outside Locked 8 Lighted 2680 1998 3/1711998 $ 16.446 $ - $ 16,446 PICKUP CHEVROLET 835 Wood St BLDG. REPARSNNNT Outskle Locked 8 Lighted 2678 1998 3/1711998 $ 16.671 $ - S 16.671 PICKUP TOYOTA 835 Wood St FLEET SERVICES -POOL RENTAL Outside Locked S Lighted 2701 1981 5/1111982 $ 7.610 $ - $ 7.610 PICKUP FORD Howes St. PM PLANNING S DEVELOPMENT Outside Locked 8 Lighted 2446 1998 6/15A998 $ 16.062 $ - $ 16,062 PICKUP GMC FIRE OPERATIONS Home Outside or Garaged 7566 1991 6/1/1991 $ 19,969 $ - $ 19,969 PICKUP FORD FIRE OPERATIONS Home Outside or Garaged 7579 1999 22411999 $ 24,820 $ - $ 24,820 PICKUP FORD FIRE OPERATIONS Home Outside or Garaged 7580 1999 M411999 $ 24,170 $ - $ 24.170 PICKUP F250 FORD 700 Wood SEWER TRUNK AND COLLECTION Outside Locked 8 Lighted 27010 2003 1242003 $ 18,271 $ - $ 18,271 RAM 15004WL DODGE POLICE -INVESTIGATION Home Outside or Garaged 51623 2005 41132005 $ 20.000 $ - $ 20.000 RAM 2500 DODGE 1745 Hoffman Rd. NATURAL AREAS -PUB. IMP. Outside Locked 8 Lighted 25503 2002 6/132002 $ 22.518 $ 4,377 $ 26,895 RAM 2500 DODGE 5833 S. Lemay FOSSIL CREEK COW PARK MAN Outside Locked B Lighted 24023 2002 91122002 $ 20,614 $ 3,850 $ 24,464 RAM 2500 DODGE 700 Wood INSTRUMENTAL AND ELECTRICAL Outside Locked 8 Lighted 27026 2005 2282005 $ 17,539 $ 2,954 $ 20.493 RAMBOX EAST 30M Enwonmenlal RESOURCE RECOVERY Outside Locked 8 Lighted 4285 1996 4118/1996 S 56,649 $ - $ 56,649 RAMBOX EAST 30M Enwonmental RESOURCE RECOVERY Oulage Locked S Lighted 4290 1968 41TV1988 $ 57,205 $ - $ 57,205 RAMBOX EAST 30M Environmental RESOURCE RECOVERY Outside Locked 8 Lighted 4297 1988 3/16I1988 $ 57,205 $ - $ 57,205 RANGER FORD 215 N. Mason PARKING ENFORCEMENT Outside Lighted 2208 1998 427I1998 $ 15,213 S - S 15,213 RANGER FORD 215 N. Mason PARKING ENFORCEMENT Outside Lighted 2277 2000 7/182000 $ 15,446 $ - $ 15,446 RANGER FORD 300 College CSSA METERS Outside Locked B Lighted 23023 2001 7272001 $ 13,933 $ - $ 13,933 RANGER FORD 300 College CSBA METERS Outside Locked B Lighted 23045 2004 522004 $ 11,929 $ - $ 11,929 RANGER FORD 300 College CSSA METERS Outside Locked B Lighted 23046 2004 5/102004 It 11.929 $ - $ 11,929 RANGER FORD 3036 Environmental RESOURCE RECOVERY Outside Locked B Lighted 2773 1990 4/1111990 $ 11.717 $ - $ 11,717 RANGER FORD 413 Bryan PARK MANT-FACILITIES Cutdtle Locked B Lighted 2444 1999 52711999 $ 16.440 $ - S 16.440 RANGER FORD 413 Bryan PARK MANT-FACILITIES Outside Locked B Lighted 2551 1998 429/1998 $ 16420 $ - $ 16420 RANGER FORD 413 Bryan PARK MNNT-NORTHSIDE Outside Locked 8 Lighted 2563 2000 5/192000 $ 13.457 $ - S 13.457 RANGER FORD 413 Bryan PARK MANT-PROJECT SUPPORT Outside Locked S Lighted 2538 1998 901998 $ 18,591 $ - $ 18.591 RANGER FORD 413 Bryan PARK hWNT-SOUTHEAST Outside Locked S Lighted 24025 2003 2272003 $ 12.385 $ - $ 12,365 RANGER FORD 413 Bryan PARK MANT-SOUTHEAST Outside Locked 8 Lighted 2562 2000 4282000 S 13,457 S - $ 13.457 RANGER FORD 413 Bryan PARK MANT-SOUTHWEST Outside Looked B Lighted 2552 1998 42911998 $ 16,420 $ - $ 16,420 RANGER FORD 413 Bryan PARK MATT -SOUTHWEST Outside Locked B Lighted 2561 2000 4272000 $ 13,457 $ - $ 13,457 RANGER FORD 4316 W. Laporte PROCESS CONTROL 2294 1992 311111992 $ 10,695 $ - $ 10,695 RANGER FORD 5833 S. Lemay FOSSIL CREEK COW PARK MAIN Outside Locked a Lighted 24024 2003 227QO03 $ 12,385 $ - $ 12,385 RANGER FORD 5833 S. Lemay FOSSIL CREEK COW PARK MAIN Outside Locked 8 Lighted 24028 2003 42B2003 $ 12,443 $ - $ 12,443 RANGER FORD 5833 S. Lemay FOSSIL CREEK COW PARK MAN Outside Locked $ Lighted 24029 2003 4282003 $ 12,443 $ - $ 12.443 RANGER FORD 625 Ninth St 2004 STREET MANTENANCE Outside Locked S Lighted 269 1998 42711998 $ 15.781 S - $ 15.781 RANGER FORD 700 Wood LBP DISTR. Outside Locked S Lighted 23002 1997 7/1811997 $ 18,863 $ - $ 18,863 RANGER FORD 7W Wood LSP DISTR. Outside Locked B Lighted 2325 1992 Y1111992 $ 11.522 $ - S 11.522 RANGER FORD 700 Woad L&P DISTR. Outside Locked 8 Lighted 2327 1992 42011992 $ 11.747 $ - $ 11.747 RANGER FORD 700 Woad SEWER TRUNK AND COLLECTION Outside Locked B Lighted 2726 1999 42911999 $ 15,951 $ - $ 15,951 RANGER FORD 700 Wood STORMWATER DUAL ADMI Outside Locked B Lghted 2705 2000 3272000 $ 18.820 $ - $ 18,820 RANGER FORD Howes St. BUILDING INSPECTION Outside Locked 8 Lighted 2649 2000 1/122000 $ 15,784 $ - $ 15,784 RANGER FORD Howes St, BUILDING INSPECTION Outside Locked 8 Lighted 2659 2000 1/142000 $ 15.784 $ - $ 15,711,11 RANGER FORD Howes St. P/R PLANNING 8 DEVELOPMENT Outside Locked 8 Lighted 2477 2000 2102000 $ 19.886 $ - $ 19,886 RANGER FORD MEDIANS S DOWNTOWN 2564 2000 4282000 $ 13.457 $ - S 13457 RANGER FORD MEDIANS S DOWNTOWN 2565 2000 5/192000 $ 13,457 $ - $ 13.457 RANGER PU4}FORD 300 College CSBA METERS Outside Locked B Lighted 23044 2004 502004 $ 18,231. $ - $ 18,231 S10 PICKUP CHEVROLET 112 E. Willow YOUTH ADMIN Outside Lighted 250W 1994 7/1411994 $ 10.3% $ - $ 10,356 S10 PICKUP CHEVROLET 1441 Hmsetocth COLLINDALE Outside Lighted 2847 1986 6mil986 $ 8,121 $ - $ 8,121 $10 PICKUP CHEVROLET 1745 Hoffman Rd. NATURAL AREAS -RANGERS Outside Locked $ Lighted 2511 1997 7/1011997 $ 20,299 $ - $ 20,299 S10 PICKUP CHEVROLET 1801 Riverside EDORA POOL AND ICE C Outside Lighted 2615 1987 8,6/1987 $ 8,528 $ - $ 8,528 S10 PICKUP CHEVROLET 300 College CSBA CUSTOMER SERVICE Oulide Locked B Lighted 2329 1999 717/1999 $ 14,953 $ - $ 14.953 S10 PICKUP CHEVROLET 300 College CSBA CUSTOMER SERVICE O.M. Locked 8 Lighted 2346 1996 28/1996 $ 17,241 $ - $ 17.241 $10 PICKUP CHEVROLET 300 College CSSA METERS Outsde Locked S Lighted 2303 19W 12911996 $ 13,071 $ - $ 13.071 S10 PICKUP CHEVROLET 300 College CSSA METERS Outside Locked S Lighted 23041 2003 8/182003 $ 12.845 $ - $ 12,845 S10 PICKUP CHEVROLET 300 College CSBA METERS Outside Locked B Lighted 2330 1996 129119% $ 13.071 $ - $ 13.071 S10 PICKUP CHEVROLET 413 Bryan PARK MANT-FACILITIES Outside Locked! 8 Lighted 2478 1999 7911999 $ 14,953 S - $ 14.953 S10 PICKUP CHEVROLET 413 Bryan PARK MANT-NORTHSIDE Outside Locked 8 Lighted 2470 1999 6QW1999 $ 14,958 $ - $ 14.958 $10 PICKUP CHEVROLET 413 Bryan PARK MANT-PROJECT SUPPORT Outside Looked 8 Lighted 24M 1988 3/8/1988 $ 9.611 $ - $ 9,611 S10 PICKUP CHEVROLET 413 Bryan PARK MANT-PROJECT SUPPORT Outside Locked 8 Lighted 2480 1999 7911999 $ 14,953 $ - $ 14.953 S10 PICKUP CHEVROLET 413 Bryan PARK MANTSOUTHEAST Outside Locked 8 Lighted 2482 1999 72111999 $ 14,953 $ - $ 14,953 S10 PICKUP CHEVROLET 413 S. Bryan FORESTRY Outside Locked 8 Lighted 2476 1984 72711984 $ 7,557 $ - $ 7,557 S70 PICKUP CHEVROLET 424 W. Mulherry RECREATION -MULBERRY Outside Lighted 2407 1988 377/1988 $ 8,973 $ $ 6,973 S10 PICKUP CHEVROLET 4316 W. Laporte INTAKE Outside Locked 8 Lighted 2749 1997 3/5/1997 $ 19,791 $ - $ 19,791 S10 PICKUP CHEVROLET 4316 W. Laporte WATER POLLUTION CONTROL Outside Locked 8 Lighted 2774 1991 42411990 $ 16,267 $ - $ 16.267 S10 PICKUP CHEVROLET 4316 W. LaPorte WATER QUALITY Outside Locked S Lighted 2745 1996 5114119% $ 17,452 $ - $ 17.452 SI0 PICKUP CHEVROLET 4316 W. Laporte WATER TREATMENT V-MANT Outside Locked B Lighted 2251 1996 2I/1996 $ 17,121 $ - $ 17.121 S 10 PICKUP CHEVROLET 625 Ninth STREETS -WORK FOR OTH Outside Locked B Lighted 2085 1996 62711996 $ 17.546 $ - $ 17.546 S10 PICKUP CHEVROLET 625 Ninth St 2004 STREET MANT-PERMITS Outside Locked B Lighted 22600 2001 3/92W1 $ 16,827 S - $ 16.827 S10 PICKUP CHEVROLET 625 Ninth St FLEET SERVSTREETS Outside Lacked 8 Lighted 22M 1988 10/19/1988 $ 7,588 $ - $ 7,588 S10 PICKUP CHEVROLET 626 Linden TRAFFIC ENGINEERING Outside Locked 8 Lighted 22405 1997 401997 $ 20,394 $ - $ 20,394 S10 PICKUP CHEVROLET 626 Linden TRAFFIC ENGINEERING Outside Locked S Lighted M7 1995 727/1995 $ 12,322 $ - $ 12,322 $10 PICKUP CHEVROLET 700 Woad WATER METER SHOP Outside Locked 8 Lighted 2765 1988 7/111988 $ 8,661 $ 2,372 $ 11,033 S10 PICKUP CHEVROLET 700 Woad WATER TRANSMISSIONMISTR. Outside Locked 8 Lighted 2613 1987 72811987 $ 8,528 $ - $ 8,528 S10 PICKUP CHEVROLET 835 Wood St FLEET SERV CESPOOL RENTAL Outside Locked 8 Lighted 2691 1994 711411994 $ 10,356 $ - $ 10,356 S10 PICKUP CHEVROLET 835 Woad St FLEET SERVICES -POOL RENTAL Outside Lacked B Lighted 2692 1994 7/1411994 S 10.356 $ - $ 10.356 S10 PICKUP CHEVROLET 835 Wood St FLEET SERVICES -POOL RENTAL Outside Locked 8 Lighted 2693 1994 7/1411994 $ 10,356 $ - $ 10.3% S10 PICKUP CHEVROLET 635 Wood St FLEET SERVICES -POOL RENTAL Outside Locked 8 Lighted 2694 1994 7114119M $ 10.356 $ - $ 10.356 S10 PICKUP CHEVROLET 835 Woad St FLEET SERVICES -POOL RENTAL Outside Locked 8 Lighted 2695 19M 7/1411994 S 10.3% $ - $ 10.3% S10 PICKUP CHEVROLET 835 Wood St FLEET SERVICES -POOL RENTAL Outside Lacked S Lighted 26% 19N 7/1411994 $ 10.356 $ - S 10,3M S10 PICKUP CHEVROLET 835 Woad St FLEET SERVICES -POOL RENTAL Outside Locked 5 Lighted 2697 1995 72611995 $ 11,194 $ - $ 11.194 S10 PICKUP CHEVROLET 835 Wood St FLEET SERVICES -POOL RENTAL Outside Locked $ Lighted 2698 1995 726/1995 $ 11,194 $ - $ 11,194 S10 PICKUP CHEVROLET 835 Wood St FLEET SERVICES -SHOP Outside Locked 8 Lighted 2612 1987 62911987 $ 11.489 $ - $ 11,489 S10 PICKUP CHEVROLET MEDIANS B DOWNTOWN 2614 1987 728/1987 $ 8,528 $ - $ 8,528 S10 PICKUP CHEVROLET NATURALAREAS-RANGERS Home garaged 2512 1997 711011997 $ 20,299 $ - $ 20,299 S10 PICKUP CHEVROLET SUPERVISION AND SUPPORT 2291 1992 3/4/1992 $ 18,544 $ - $ 18,544 S15 PICKUP GMC 1745 Hoffman Rd. HORTICULTURE Outside Locked 8 Lighted 25304 1993 701993 $ 12,204 $ - $ 12,204 S15 PICKUP GMC 4316 LaWde CANAL IMPORTATION BASIN Outside Locked S Lighted 2265 1992 3DI11992 $ 14.815 $ - $ 14,815 S15 PICKUP GMC 4316 W. Laporte PROCESS CONTROL 2 % 1992 5/8/1992 $ 12,731 $ - S 12,734 S15 PICKUP GMC 7W Wood INSTRUMENTAL AND ELECTRICAI Outside Locked $ Lighted 2767 1989 3=1989 $ 10,642 $ - $ 10,642 S15 PICKUP GMC 700 Wood L&P DISTR. Outside Locked S Lighted 2308 1991 424/1990 S 10.802 $ - $ 10.802 S15 PICKUP GMC 835 Wood St BLDG. REPtMNT-I/VAC Outside Locked 8 Lighted 2657 1991 7/19/1991 $ 10.508 $ - $ 10,508 S15 PICKUP GMC MAINTENANCE Outside Locked B Lighted 2255 1992 3/31/1992 $ 14,695 S - S 14.695 SIERRA GMC FIRE OPERATIONS Home Outside or Garaged 7258 1995 7/12/1995 $ 30,000 $ - $ 30,000 SIERRA 1500 GMC 700 Wood STORMWATER QUAL ADMI Outside Locked B Lighted 2008 2/262008 22.964.00 OM $ 22,964 SIERRA 1500 GMC LARIMER COUNTY DRUG TASK Home Outside or 2008 5272008 23.378.00 0.00 $ 23,378 FORCE Garaged SILVERADO CHEVROLET 625 Ninth STREETS -UNPAVED ROAD Outside Locked B Lighted 22014 2004 4162004 $ 13,228 $ - S 13,228 SILVERADO CHEVROLET 700 Woad UCSA-LOCATORS Outside Locked 8 Lighted 23022 2001 V102001 $ 20,994 S - $ 20.994 SILVERADO CHEVROLET 700 Woad WATER TRAhISMISSIONMISTR. Outside Locked S Lighted 2700 2000 3282000 $ 21,291 $ - S 21,291 SILVERADO CHEVROLET MEDIANS B DOWNTOWN 24043 2004 61112OU S 13.931 $ - $ 13.931 UDL4X4 F250 FORD 413 Bryan PARK MAINT-FACILITIES Outside, Locked $ Lighted 2008 31122008 18,079.00 4.872.00 $ 22,951 UTIL4X4 F250 FORD 413 Bryan PARK MINT-NORTHSIDE Outside Locked S Lighted 24036 2003 511 W003 $ 19,774 $ 2,328 $ 22.102 UTIL4X4 F250 FORD 413 Bryan PARK MAINT-SOUTHWEST Outside Locked $ Lighted 2008 31132008 18,079.00 4.872.00 $ 22,951 UTIL4X4 F250 FORD Howes St ENGINEERING -SURVEYING Outside Locked S Lighted 2008 3/122008 22,580,00 8,285.00 $ 30.865 UTIL4X4 F250 FORD M INTENANCE Outside Locked 8 Lighted 27015 2003 71152003 $ 18,316 $ 2,328 $ 20,644 UTI1_4X4 F250 FORD MAINTENANCE Outside Locked 8 Lighted 2008 4WOOS 18,474.00 4.823,00 $ 23.297 UTIL4X4 F250 FORD MAINTENANCE Outside Locked S Lighted 2008 31140008 18,474,00 4,872.00 $ 23.346 UTILITY 3500 CHEVROLET 700 Wood L&P DISTR. Outside Locked 8 Lighted 23033 2002 7242002 $ 22,615 $ 16,072 $ 38687 UTILITY 35M CHEVROLET 700 Wood L&P DISTR. Outside Locked S Lighted 230U 2002 9116M02 $ 22,615 S 16.072 $ 38.687 UTILITY F250 FORD 300 College METERS -MINOR CAPITAL Outside Locked S Lighted 2008 9/172008 19,221.00 6,191.00 $ 25.412 UTILITY F250 FORD 300 College METERS -MINOR CAPITAL Outside Locked 5 Lighted 2008 9/172008 19,221.W 6.191.00 $ 25,412 UTILITY F250 FORD 413 Bryan PARK MINT-NORTHSIDE Outside Locked B Lighted 2493 2000 7/192000 $ 17476 S 3.116 $ 20,592 UTILITY F250 FORD 413 Bryan PARK MAINTSOUTHEAST Outside Locked B Lighted 24030 2003 552003 $ 15.117 $ 2,328 $ 17.445 UTILITY F250 FORD 413 Bryan PARK MINT -SOUTHEAST Outside Locked B Lighted 24032 2003 5192003 $ 15.117 $ 2,328 $ 17,445 UTILITY F250 FORD 413 Bryan PARK MAINT-SOUTHWEST Outside Locked B Lighted 24033 2003 5192003 $ 15,117 $ 2,328 S 17.445 UTILITY F250 FORD 413 Bryan PARK MINT -SOUTHWEST Outside Locked B Lighted 24042 2004 5/102004 $ 13,929 $ 2,330 $ 16,259 UTILITY F250 FORD 5833 S. Looney FOSSIL CREEK COMM PARK MAIN Outside Locked 8 Lighted 24031 2003 5192003 $ 15,117 $ 2,328 $ 17.445 UTILITY F250 FORD 5833 S. Lemay, FOSSIL CREEK COMM PARK MAIN Outside Locked 8 Lighted 240U 2003 5F.12003 $ 15,117 $ 2,328 $ 17,445 UTILITY F250 FORD 5833 S_Lemay FOSSIL CREEK COMM PARK MIN Outside Locked $Lighted 24UI 2004 51102004 $ 13,929 S 2,330 S 16,259 UTIUTY F250 FORD MAINTENANCE Outside Locked S Lighted 2008 67d02008 16,362.00 5,214 00 S 21.576 UTILITY F250 FORD MINTENANCE Outside Locked S Lighted 2008 61302008 16,MZ00 5,69400 $ 22,056 UTIUTY F450 FORD 626 Unden TRAFFIC ENGINEERING Outside Locked S Lighted 22406 2005 5/42005 $ 22.953 $ 9,724 S 32B77 UTILITY F450 FORD 626 Linden TRAFFIC ENGINEERING Outside Locked 8 Lighted 2272 2000 6202000 $ 26.858 $ 8.953 $ 35,811 UTILITY F450 FORD 700 Wood L&P DISTR. Gorski. Locked 8 Lghted 23013 2000 10/312000 $ 26,983 S 21.695 $ 46,678 UTILITY F450 FORD 700 Wood L&P DISTR. Outside Locked S Lighted 23037 2003 1212003 $ 21.012 $ 16.072 $ 37,084 UTILITY F450 FORD 700 Wood L&P DISTR. Outside Locked 8 Lighted 23038 2003 1212003 $ 21.012 $ 16.072 $ 37,084 UTILITY F450 FORD 700 Wood L&P DISTR. Outside Locked B Lighted 2339 2000 4/19200D $ 26.498 $ 20.190 $ 46.688 UTILITY F450 FORD 700 Wood L&P DISTR. Outside Locked B Lighted 2341 2000 4/192000 $ 28498 S 20,190 $ 46.668 UTILITY F450 FORD 700 Woad L&P DISTR. Outside Locked B Lighted 2374 2000 4/192000 $ 26.498 $ 5.892 S 32,390 UTILITY TRUC GMC 700 Wood LSP DISTR. Outside Locked 8 Lighted 2377 1997 1027/1998 $ 40,224 $ - $ 40.224 UTILITY TRUC GMC 700 Woad WATER METER SHOP Outside Locked S Lighted 2725 2000 1129/1999 S 19,920 $ 4,095 S 24.015 UT1UTYTRUG CHEVROLET 700 Wood St. DRAINAGE AND DETENTION Outside Locked S Lighted 27701 2002 1242002 $ 23,688 $ 4,760 $ 28,448 UTIUTY#2500 CHEVROLET 4316 W. Laporte WATER TREATMENT 12JdAINT Outside Locked S Lighted 27017 2004 61112004 $ 16.479 $ 3,090 S 19.569 UTILITY#2500 CHEVROLET MAINTENANCE Outside Locked 6 Lighted 27019 2004 6222004 $ 16.913 $ 2,772 $ 19,685 UTILTY C4500 CHEVROLET 700 Wood L&P DISTR. Outsde Locked B Lighted 23047 2005 11/IWOU $ 24.581 $ 21.678 $ 46259 UTILTY C4500 CHEVROLET 700 Wood L&P DISTR. Outside Locked B Lighted 23048 2005 1111WO04 $ 24.581 $ 21,678 $ 46,259 UTILTY C4500 CHEVROLET 700 Wood L&P DISTR. Outside Locked B Lighted 23049 2005 11/192004 $ 24.581 $ 21,676 $ 46.259 UTL 4X4 2500 CHEVROLET 1745 Hoffman Rd. NATURAL AREAS -PUBLIC Outside Locked 8 Lighted 25507 2005 3IM005 $ 23.380 $ 2,890 $ 26,270 IMPROVEMENT UTL 4X425M DODGE 4316 W. Laporte SOURCE OF SUPPLY Outside Locked S Lighted 27014 2003 6/162003 $ 26,901 $ 2,393 $ 29,294 UTL TRK F550 FORD 625 Unden SIGNS 5 PAINT -TRAFFIC Outside Locked A Lighted 2008 1022008 26.763,00 0,00 S 26,763 UTL TRK F550 FORD 700 Wood L&P DISTR. Outside Locked $ Lighted 2008 1242008 26,247.00 26,754.00 $ 53.001 UTL TRK F550 FORD 700 Wood L&P DISTR. Outside Locked S Lighted 2008 1242008 26,247.00 34,544 00 $ 60,791 UTL TRK F550 FORD 700 Wood SEWER TRUNK AND COLLECTION Outside Locked $Lighted 2008 51IM008 30,031.00 16,08300 $ 46,114 UTL TRK F550 FORD 700 Woad WATER TRAhISMISSION/DISTR. Outside Locked B Lighted 2008 1/142008 26.828,00 13,04500 $ 39,873 Total 352 Bus 2009 Vehicle Inventory Parking Fac. Parking Fac. Model Make Location DEPT Inside/Outside Locked/Lighted UNIT YEAR Date Acquired Purchase Price Accessories Total 35LFW3510.01 NABI 6570 Partner TRANSFORT Outside Locked B Lighted 2008 5/152008 371.754,00 0.00 $ 371,754 35UF 510.01 NABI 6570 Partner TRANSPORT Outside Locked S Lighted 2008 5I152008 371,754.00 0.00 $ 371.754 35LFW3510.01 NABI 6570 Fortner TRANSFORT Outside Locked S Lighted 2008 5/152008 371,75400 0.00 $ 371.75 CITYBIRD BLUEBIRD 6570 Partner TRANSFORT Inside Locked 0017 1983 2/16II983 $ 105.639 $ - S 105.639 LOW FLOOR GILLIG 6570 Porter TRANSFORT Inside Locked 0049 2001 9282001 $ 246.919 $ - $ 246.919 LOW FLOOR GILLIG 6570 Partner TRANSFORT Inside Locked W50 2001 9282001 $ 246,919 $ - $ 246.919 LOW FLOOR GILLIG 6570 Porter TRANSFORT Inside Locked 0051 2001 9282001 $ 246,919 $ - $ 246,919 LOW FLOOR GILLIG 6570 Fortner TRANSFORT Inside Locked 0052 2001 9282001 $ 246,919 $ - S 246,919 LOW FLOOR GILLIG 6570 Partner TRANSFORT Inside Locked 0053 2001 10152001 $ 246919 $ - $ 246,919 LOW FLOOR GILUG 6570 Partner TRANSFORT Inside Lacked 0054 2001 9282001 $ 246,919 S - $ 246.919 LOW FLOOR ELDORADO 6570 Partner TRANSPORT Outside Locked L Lighted 55 2005 3M0008 S 314,578 $ 314.578 PHANTOM GILUG 6570 Partner TRANSPORT Inside Locked 0026 1993 8/17/1993 $ 204,162 $ - $ 204.162 PHANTOM GILLIG 6570 Partner TRANSFORT Inside Locked 0028 1993 8/17/1993 $ 204,162 S - S 204,162 PHANTOM GILLIG 6570 Further TRANSPORT Inside Locked 0029 1993 8/17/1993 S 204.162 $ - $ 204.162 PHANTOM GILLIG 6570 Porter TRANSPORT Inside Locked 0030 1993 W1711993 $ 204,162 S - $ 204.162 PHANTOM GILLIG 6570 Partner TRANSFORT Inside Locked 0031 1993 8/17/1993 $ 204,162 $ - $ 204,162 PHANTOM GILLIG 6570 Partner TRANSFORT Inside Locked 0032 1993 8117/1993 S 204,162 $ - $ 204.162 PHANTOM GILLIG 6570 Porter TRANSPORT Inside Locked 0033 1994 5/611994 $ 186,678 S - $ 186,678 Office of the Fire Marshall 2556 FIRE SAFETY INSPECTOR Office of the Fire Marshall 9735 DIVISION CHIEF Total Home Business Unit Total For Workers Comp Code 7704 Workers Comp 8227 Equipment Maintenance 2451 ASSISTANT MECHANIC Total Home Business Unit Total For Workers Comp Code 8227 Workers Camp 8742 Administrative Services 2623 MAIL CLERK (PFA) Total Home Business Unit Total For Workers Camp Code 8742 Workers Comp 8810 Fire Suppression 9520 ADMINISTRATIVE SECRETARY 11 Fire Suppression 2486 CLERICALAIDE Total Home Business Unit Pre -Fire Planning 9537 CIS MAPPING TECHNICIAN Total Home Business Unit EMSAED/CPR Program 2486 CLERICAL AIDE EMS-AED7CPR Program 9580 EMERGENCY MEDICAL SVCS COORD Total Home Business Unit Training Center Ops 8 Admin 9520 ADMINISTRATIVE SECRETARY It Total Home Business Unit Administrative Services 9530 ADMINISTRATIVE ASSISTANT Administrative Services 9520 ADMINISTRATIVE SECRETARY II Administrative Services 3710 PFA DIR OF ADMINISTRATIVE SERV Administrative Services 9535 BUDGET COORDINATOR Administrative Services 9570 SR POLICY AND PERSONNEL SPEC Total Home Business Unit Syslemslinformation Managemen 9585 IT ANALYST Total Home Business Unit Office of the Fire Marshall 9520 ADMINISTRATIVE SECRETARY II Office of the Fire Marshall 1260 SPECIAL PROJECTS COORDINATOR O<fce of the Fire Marshall 9530 ADMINISTRATIVE ASSISTANT Total Home Business Unit Total For Workers Camp Code 8810 Total Dollar for Period 13756186 Grand Totals 2470 90 111013 113483 90 12976470 65698224 21483 21483 21483 3002,62 3002.62 3002.62 35143A5 142.5 6013.28 41156.73 142.5 42647.68 42617,68 948.13 78140 79088.13 40949,23 39.44 40949.23 39.44 39165,53 37.72 38320.19 469,79 111013 55736.02 301.64 65336.55 309571.29 809.15 7859844 7859844 36256,85 52800 39052.37 128109.22 720090.72 991.09 Premium Adjustment 657973 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Premium PHANTOM GILLIG 6570 Partner TRANSFORT Inside Locked 0039 1997 326/1997 $ 219,980 $ - $ 219.980 PHANTOM GILLIG 6570 Portner TRANSFORT Inside Locked 0040 1997 326/1997 $ 219.980 $ - S 219980 PHANTOM GILLIG 6570 P.Mer TRANSFORT Inside Locked out 1997 326/1997 $ 219,980 $ - $ 219,980 PHANTOM GILLIG 6570 Partner TRANSFORT Inside Locked 0042 1997 326/1997 $ 219,980 $ - S 219,980 PHANTOM GILLIG 6570 Portner TRANSFORT Inside Locked 0043 1997 326/1997 $ 224,980 $ - $ 224,980 PHANTOM GILLIG 6570 Partner TRANSFORT Inside Locked 0044 1998 527/1998 $ 228,406 $ - S 228,406 PHANTOM GILLIG 6570 Portner TRANSFORT Inside Locked 0045 1998 527/1998 $ 228,406 $ - IS 228,406 PHANTOM GILLIG 6570 Porter TRANSFORT Inside Locked 0046 1998 527/1998 S 228,406 $ - $ 228406 PHANTOM GILLIG 6570 Portner TRANSFORT Inside Locked 0047 1998 52711998 5 228,406 IS - S 228406 PHANTOM GILLIG 6570 Forever TRANSFORT Inside Locked 0048 1998 10/511998 $ 228,406 IS - $ 228,406 SCHOOL BUS INTERNATL 112 E. Willow YOUTH ADMIN Outside Lighted 1994 12222008 1,800.00 0.00 $ 1.800 Total 29 Car 2009 Vehicle Inventory Parking Fac. Parking Fac. Model Make Location DEPT InsidelOutside Locked/Lighted UNIT YEAR Date Acquired Purchase Price Accessories Total ACHIEVA OLDSMOBILE Howes St BUILDING INSPECTION Outside Locked 8 Lighted 1288 1997 527/1997 $ 14,471 $ - $ 14.471 CAMARO CHEVROLET POLICE -INVESTIGATION Home Outside or Garaged 1051 1983 5/1/1995 $ 2,500 $ - $ 2,500 CAPRICE CHEVROLET POLICE -INVESTIGATION Home Outside or Garaged 1091 1996 1/8/1996 $ 17,5% $ - 5 17,5% CAPRICE CHEVROLET POLICE -PATROL SERVICES Home Outride or Garaged 1069 1994 721/1994 $ 14,962 $ - $ 14,952 CAVALIER CHEVROLET POLICE -INVESTIGATION Home Outside or Garaged 1080 19M 72211998 $ 1500 $ - IS 1,600 CMC HYBRID HONDA 700 Wood UCSA-UTILITY POOL CA Outside Locked 8 Lighted 13002 2003 12/32002 $ 19,200 $ - S 19.200 CMG HYBRID HONDA 700 Wood UCSA-UTIUTY POOL CA Outside Locked 8 Lighted 13003 2004 3/162004 $ 20,126 1$ - $ 20.126 CIVIC HYBRID HONDA MPO-ADMINISTRATION 16401 2003 722003 $ 19,200 5 - $ 19,200 CONTOUR FORD 700 Wood UCSA-UTILITY POOL CA Outside Locked B Lighted 1301 1998 120/1998 $ 14,161 $ - $ 14,161 eSCAPE HYBR FORD 700 Wood UCSA-UTILITY POOL CA Outside Locked 8 Lighted 1303 1998 120/1998 $ 14,161 $ - $ 14,161 CROWN VIC FORD POUCE-INVESTIGATION Home Outside or Garaged 11600 2000 9292000 $ 20,937 $ - $ 20,937 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 1052 2000 5RI2000 $ 21,246 $ - $ 21,246 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 1055 2000 5A12000 $ 21,246 $ - $ 21,246 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 1056 2000 6112000 $ 21,246 $ - S 21246 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 1063 2000 6I12000 $ 21,246 $ - $ 21,246 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 1064 2000 61112000 $ 21,246 $ - S 21246 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 1089 2000 6112000 $ 21.246 S - $ 21.246 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11005 2001 7n2001 $ 21.953 $ - S 21,953 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11006 2001 7Gnoci $ 21.953 S - $ 21.953 CROWN VIC FORD POLICE -PATROL SERVICES Homo Outside or Garaged 11007 2001 7n2001 $ 21,953 $ - $ 21953 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11008 2001 7/32001 $ 21,953 $ - $ 21.953 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11016 2002 4/122002 IS 23.993 $ - $ 23,993 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11017 2002 41122002 $ 23,993 $ - $ 23.993 CROWN VIC FORD POUCE-PATROL SERVICES Home Outside or Garaged 11018 2002 4/122002 $ 23,993 $ - S 23,993 CROWNVIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11019 2002 411WO02 $ 23,993 $ - $ 23,993 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11020 2002 4/122002 $ 23,993 $ - $ 23,993 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11021 2002 4/152002 $ 23,993 $ - IS 23,993 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11022 2002 4/152002 $ 23,993 S - $ 23.993 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11023 2002 4/172002 IS 23.993 S - $ 23.993 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11024 2002 4/172002 IS 23.993 $ - $ 23993 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11025 2002 4/182002 $ 23,993 $ - $ 23.993 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11026 2002 4242002 $ 23,993 S - $ 23993 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11027 2002 4252002 S 23,993 E - $ 23,993 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11028 2002 4252002 $ 23,993 $ - $ 23,993 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11033 2003 522003 $ 23,872 S - $ 23,872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11034 2003 5l72003 $ 23,872 $ - S 23.872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11035 2003 5/72003 $ 23,872 $ - $ 23.872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11036 2003 5N2003 $ 23,872 $ - $ 23.872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11037 2003 5Mn003 $ 23.872 $ - S 23,872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11038 2003 5/92003 $ 23.872 S - $ 23.872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11039 2003 5/132003 $ 23,872 $ - $ 23872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11040 2003 5/162003 IS 23,872 $ - $ 23,872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11041 2003 5/16.2003 IS 23872 $ - $ 23,872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11042 2003 5/162003 § 23,672 $ - $ 23,872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11043 2003 51192003 $ 23,872 $ - S 23.872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11044 2003 511SQ003 $ 23,872 $ - IS 23.872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11045 2003 5/192003 $ 23,872 $ - $ 23.872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11D46 2003 5222003 $ 23,872 $ - $ 23872 CROWNVIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11047 2003 5222003 $ 23.872 $ - $ 23,872 CROWN VIC FORD POLICE -PATROL SERVICES Home Oulslde or Garaged 11048 2003 5232003 $ 23.872 $ - $ 23,872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11049 2003 5232003 $ 23,872 $ - $ 23,872' CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11050 2003 5232003 $ 23872 IS - IS .23,872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11051 2003 5232003 $ 23872 $ - $ 23,872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11052 2003 5282003 $ 23,872 $ - $ 23,872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11053 2003 5282003 $ 23,872 $ - S 23.872 CROWN VIC FORD POUCE-PATROL SERVICES Home Outside or Garaged 1105,1 2003 5282003 $ 23,872 $ - $ 23.872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11055 2003 5n80003 $ 23,872 $ - $ 23,872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11056 2003 5292003 8 23,872 $ - $ 23.872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11057 2003 5292003 $ 23,872 $ - $ 23,872 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11058 2003 6262003 $ 23,872 $ - $ 23,872 CROWN VIC FORD POUCE-PATROL SERVICES Home Outside or Garagetl 11059 2003 6262003 S 23,733 $ - S 23.733 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11065 2005 9222004 S 24,625 $ - S 24.625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11066 2005 9=004 $ 24,625 $ - $ 24.625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11067 2005 9QM004 $ 24,625 $ - $ 24.625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11068 2005 9232004 $ 24.625 $ - $ 24.625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11069 2005 10/52004 S 24.625 $ - $ 24,625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11070 2005 10/52004 S 24.625 $ - $ 24,625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11071 2005 10/52004 $ 24,625 $ - $ 24.625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11072 2005 10/52004 $ 24,625 $ - $ 24,625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11074 2005 10R0004 $ 24,625 $ - $ 24.625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11075 2005 10/72004 $ 24,625 $ - $ 24.625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11076 2005 1022004 $ 24.625 $ - S 24,625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11077 2005 10172004 $ 24,625 $ - $ 24,625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11078 2005 101720D4 $ 24.625 $ - $ 24,625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11079 2005 101112004 $ 24,625 $ - S 24625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11080 2005 1Oil 12004 $ 24,625 $ - S 24625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 11081 2005 10/112004 IS 24,625 $ - $ 24,625 CROWN VIC FORD POUGE-PATROL SERVICES Home Outside or Garaged 11082 2005 1118200d $ 24,625 S - $ 24.625 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 1134 1998 2r2411998 IS 20,803 $ - $ 20.803 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 1150 1997 121/1997 $ 19,905 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 1161 1997 V30/1997 S 19,905 CROWN VIC FORD POUCE-PATROL SERVICES Home Outside or Garaged IIU 20M 11/18I1999 $ 21,368 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 1165 2000 11/19/1999 $ 21368 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 1166 2000 1120/1999 $ 21,368 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 1167 2000 112271999 $ 21368 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 1168 2000 11/19/1999 $ 21,368 CROWNVIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 2008 9=08 25.720.00 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 2008 9l32008 25,72000 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 2008 973200E 25.720.00 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 2008 922008 25,72000 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 2008 922008 25.720.00 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 2008 922008 25,72000 CROWN VIC FORD POLICE -PATROL SERVICES Home Outside or Garaged 2008 922008 25.720.00 CUTLASS OLDSMOBILE 700 Woad LSP DISTR. Outside Locked 8 Lighted 1320 1993 1/15/1993 $ 12,518 ESCAPE HYBR FORD 117 N. Mason FLEET SERVICE3-ADMIN Outside Locked 8 Lighted 26001 2005 2252005 $ 29,084 ESCAPE HYBR FORD 1745 Hoffman ad NAT RES-NATURALAREA Outside Lacked 8 Lighted 25506 2005 wl=05 $ 29,225 ESCAPE HYBR FORD 1745 Hoffman Rd. NATURAL AREAS -RANGERS Outside Looked 8 Lighted 2008 6/132008 25,084.00 ESCAPE HYBR FORD Howes St ENGINEERING-ADMIN Outside Locked B Lighted 2009 9/122008 24,354.00 ESCAPE HYBR FORD POLICE -INVESTIGATION Home Outside or Garaged 2009 8272008 27,004.00 ESCAPE HYBR FORD POLICE -INVESTIGATION Home Outside or Garaged 2009 8272008 27,004,00 ESCAPE HYBR FORD POLICE -INVESTIGATION Home Outside or Garaged 2009 8272008 27,004.00 ESCAPE HYBR FORD POLICE -PATROL SERVICES Home Outside or Garaged 2008 12232008 0.00 ESCAPE HYBR FORD POLICE -PATROL SERVICES Home Outside or Garaged 2008 W132008 21,15600 ESCAPE HYBR FORD TECHNICAL SERVICES 27024 2005 2/112005 $ 25,374 GRAND PRIX PONTIAC POLICE -INVESTIGATION Home Outside or Garaged 1050 2000 1I312000 $ 17775 GRAND PRIX PONTIAC POLICE -INVESTIGATION Home Outside or Garaged 1059 1995 11/17/1994 S 13.123 IMPALA CHEVROLET 300 College CSBA BILLING OULside Looked B Lighted 13001 2002 5/12002 $ 19.200 IMPALA CHEVROLET 413 Bryan PARK MAINTENANCE Outside Locked B Lighted 14000 2003 12r242002 $ 14,%7 IMPALA CHEVROLET Howes St. BUILDING INSPECTION Outside Looked 8 Lighted 12000 2002 5202002 $ 16,755 IMPALA CHEVROLET POLICE-ADMIN Home Outside or Garaged 1017 2000 W172000 $ 18,616 IMPALA CHEVROLET POLICE-ADMIN Home Outside or Garaged 11060 2003 6252003 $ 15,785 IMPALA CHEVROLET POUCE-ADMIN Home Outside or Garaged 1107 2000 2222000 $ 19,099 IMPALA CHEVROLET POLICE -INVESTIGATION Home Outside or Garaged 1018 2000 2/172000 $ 18.616 IMPALA CHEVROLET POLICE -INVESTIGATION Home Outside or Garaged 11601 2002 111M002 S 17.952 IMPALA CHEVROLET POLICE -INVESTIGATION Home Outside or Garaged 11602 2002 622002 $ 16638 IMPALA CHEVROLET POLICE -INVESTIGATION Home Outside or Garaged 11603 2003 3252003 $ 14.817 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1019 2000 2J172000 $ 18,616 IMPALA CHEVROLET POUCE-PATROL SERVICES Home Outside or Garaged 11000 2001 4/302001 $ 19,396 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 11001 2001 4/3=001 S 19,396 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 11002 2001 5I1201 $ 19,396 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 11003 2001 5=001 S 19.3% IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 11004 2001 522001 $ 19.3% IMPALA CHEVROLET POUCE-PATROL SERVICES Home Outside or Garaged 11009 2002 31142002 $ 19,725 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 11010 2002 3/142002 S 19725 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 11011 2002 3114QD02 $ 19.725 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 11012 2002 3I152002 $ 19,725 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 11014 2002 3/152002 $ 19,725 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 11029 2003 4212003 $ 17.303 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 11030 2003 4212003 S 17,303 IMPALA CHEVROLET POUCE-PATROL SERVICES Home Outside or Garaged 11031 2003 4242003 $ 17,303 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 11032 2003 4282003 S 17,303 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1106 2000 2232000 $ 19.099 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 11061 2004 6/142004 $ 18430 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 11062 2004 6222004 S 18.430 IMPALA CHEVROLET POUCE-PATROL SERVICES Hama Outside or Garaged 1IN3 2004 6232004 $ 18430 IMPALA CHEVROLET POUCE-PATROL SERVICES Home Outside or Garaged 11064 2004 6232004 $ 18430 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1108 2000 2/172000 $ 19,099 IMPALA CHEVROLET POLICE -PATROL SERVICES Homo Outside or Garaged 1109 2000 2/182000 $ 19,099 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1112 2000 2/172000 $ 19,099 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Canada or Garaged 1114 2000 Vl72000 $ 19,099 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1117 20M V172990 $ 19.009 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1119 2000 V172000 $ 19.099 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1136 2000 27172000 $ 19.099 IMPALA CHEVROLET POUCE-PATROL SERVICES Home Outside or Garaged 1144 2000 VI72000 $ 19,099 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1149 2000 2/172000 $ 19,099 IMPALA CHEVROLET POUCE-PATROL SERVICES Home Outside or Garaged 1154 2000 V172000 S 19,099 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1155 20M 21172000 $ 19.099 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1157 2000 2/172000 $ 19099 IMPALA CHEVROLET POLICE -PATROL SERVICES Homo Outside or Garaged 1169 2000 2/182000 $ 19.099 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1173 2000 2,182000 $ 19,099 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1175 2000 27182000 $ 19.099 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1179 2000 2/182000 $ 19,099 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1183 2000 W182000 S 19,099 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1189 2000 2/182000 $ 19,099 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1195 2000 Vl8/2000 $ 19,099 IMPALA CHEVROLET POUCE-PATROL SERVICES Home Outside or Garaged 1196 2000 21182000 S 19.099 IMPALA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 2008 81132008 19.845.00 INTREPID DODGE 117 N. Mason FLEET SERVICES -POOL RENTAL Outside Locked 8 Lighted 1610 1999 6/1111999 $ 15.032 INTREPID DODGE 117 N. Mason FLEET SERVICES -POOL RENTAL Outside Locked 8 Lighted 1612 2000 10011999 $ 18,235 INTREPID DODGE 117 N. Masan FLEET SERVICES -POOL RENTAL Outside Locked 8 Lghted 1618 2000 4/122000 S 18,206 INTREPID DODGE 117 N. Mason FLEET SERVICES -POOL RENTAL Outside Locked B Lighted 1619 20M 3222000 $ 18,205 INTREPID DODGE POUCE4NVESTIGATION Home Outside or Garaged 1032 1999 5/14/1999 $ 15032 INTREPID DODGE POLICE -INVESTIGATION Home Outside or Garaged 1039 1999 6MI1999 $ 15032 INTREPID DODGE POLICE -INVESTIGATION Home Outside or Garaged 11604 2004 3nl1 003 $ 14.Wl INTREPID DODGE POLICE -INVESTIGATION Home Outside or Garaged 11605 2004 5/12003 $ 14.861 INTREPID DODGE POLICE -INVESTIGATION Home Outside or Garaged 116% 2004 51112003 $ 14,861 INTREPID DODGE POLICE -INVESTIGATION Home Outside or Garaged 11607 2004 5WO03 S 14,861 INTREPID DODGE POLICE -INVESTIGATION Home Outside or Garaged 11608 2004 51M003 S 14,861 INTREPID DODGE POLICE -INVESTIGATION Home Outside or Garaged 11609 20M 5WO03 $ 16861 INTREPID DODGE POLICE -INVESTIGATION Home Outside or Garaged 11610 2004 5M=3 $ 14.661 INTREPID DODGE TRANSPORTATION ADMIN Home Outside or Garaged 1212 1999 3/31/1999 $ 15.032 LUMINA CHEVROLET 625 Nm01 STREETS HEALTHLSAFET Outside Looked 8 Lighted 1203 1997 2/1011997 $ 16,055 LUMINA CHEVROLET 625 9m111 STREETS.HEALTHBSAFET Outside Lacked 8 Lighted 1205 1997 2/10/1997 $ 16,055 LUMINA CHEVROLET 6570 Partner TRANSPORT Inside Locked 1602 1995 5I5/1995 $ 13,954 LUMINA CHEVROLET 700 Woad L&P DISTR. Outside Lacked 8 Lighted 1306 1990 5/11/1990 S 12,663 0.00 0.00 0,00 0.00 0,00 0.00 0,00 0.00 0.00 0,00 0.00 0,00 0.00 0.00 0 00 19,905 19,905 21.368 21,368 21,368 21,368 21.368 25,720 25.720 25.720 25,720 25.720 25.720 25,720 12,518 29,084 29.225 25,084 24.354 27,004 27,004 27,004 21.1% 25.374 17,775 13,123 19,200 td 967 16,755 18616 15.785 19,099 18.616 17.952 16,638 14,817 18,616 19.3% 19,396 19,396 19,396 19,396 19.725 19725 19.725 19,725 19,725 17,303 17,303 17,303 17,303 19.099 18430 18.430 18.430 18,430 19,099 19,099 19,099 19,099 19,099 19.099 19,099 19,099 19,099 19 099 19.099 19,099 19,099 19.099 19,099 19,099 19,099 19.099 19.099 19.099 19,845 15,032 18,235 18,206 18,206 15,032 15.032 14,861 14,861 14,861 14,861 14.861 14,861 14.861 15.032 16,055 16,055 13,954 12,663 LUMINA CHEVROLET 835 Wood St FLEET SERVICES -POOL RENTAL Outside Locked 8 Lighted 1611 1990 6/19/1990 $ 13.611 $ - $ 13,611 LUMINA CHEVROLET Howes St. ENGINEERING-ADMIN Outside Locked $ Lighted 1217 1997 2l3/1997 $ 16.055 $ - $ 16,055 LUMINA CHEVROLET BUILDING OPERATIONS 16300 1991 4/12/1991 $ 13.925 $ - $ 13,925 LUMINA CHEVROLET MPO-ADMINISTRATION 16400 1992 528I1992 $ 14,213 $ S 14,213 LUMINA CHEVROLET POLICE-ADMIN Home Outside or Garaged 1104 1996 3/4/1995 S 16,106 $ - $ 16,106 LUMINA CHEVROLET POLICE-ADMIN Home OUL4tle or Garaged 1186 1997 49/1997 $ 17,539 $ - S 17.539 LUMINA CHEVROLET POLICE -INVESTIGATION Home Outside or Garaged 1036 1995 5/111995 $ 13,954 $ - $ 13.954 LUMINA CHEVROLET POLICE -INVESTIGATION Home Outside or Garaged 1038 1995 5/111995 $ 14,039 $ - $ 14.039 LUMINA CHEVROLET POLICE -INVESTIGATION Home Outside or Garaged 1044 2000 823/1999 $ 15,958 $ - $ 15.958 LUMINA CHEVROLET _ POLICE -INVESTIGATION Home Outside or Garaged 1194 1997 422/1997 $ 18,750 $ - $ 18.750 LUMINA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1160 1998 5118/1998 $ 18,989 $ - $ 18.989 LUMINA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1190 1997 4/911997 $ 18,750 $ - $ 18.750 LUMINA CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 1191 1997 4111997 $ 18.750 S - $ 18.750 PRIUS HYBRID TOYOTA 117 N. Mason FLEET SERVICES -POOL RENTAL OuAadd. Locked 8 Lighted 1600 2001 8I102000 $ 20,520 S - $ 20.520 PRIUS HYBRID TOYOTA 117 N. Mason FLEET SERVICESPOOL RENTAL Outside Locked B Lighted 16000 2001 12/42000 $ 20.520 $ - $ 20,520 PRIUS HYBRID TOYOTA 117 N. Mason FLEET SERVICES -POOL RENTAL OULside Locked S Lighted 2008 W15RO08 23.820.00 0.00 S 23,820 PRIUS HYBRID TOYOTA 117 N. Mason FLEET SERVICES -POOL RENTAL Outside Locked 8 Lighted 2008 V152008 23,820.00 0,00 $ 23,820 PRIUS HYBRID TOYOTA 700 Wood UCSA-UTILITY POOL CA Outside Locked 8 Lighted 13000 2002 111192001 $ 20,566 $ - $ 20.566 PRIUS HYBRID TOYOTA NEIGHBORHOOD RESOURC 16526 2002 M62002 $ 20,566 $ - $ 20,566 SEBRING 4 DR CHRYSLER POLICE -INVESTIGATION Home Outside or Garaged 11611 2006 9282005 $ 13.976 $ - $ 13,976 Total 195 Motorcycle 2009 Vehicle Inventory Parking Fac. Parking Fa, Model Make Location DEPT Inside/Outside Locked/Lighted UNIT YEAR Date Acquired Purchase Price Accessories Total MOTORCYCLE HONDA 30M Environmental RESOURCE RECOVERY Outside Locked 8 Lighted 3288 1984 12/31/1983 $ 1,848 $ - $ 1,848 MOTORCYCLE HONDA 4316 W. Laporte SOURCE OF SUPPLY Outside Locked 8 Lighted 3280 1980 5111/1982 $ 500 $ - $ 500 MOTORCYCLE HARLEY DAV POLICE -PATROL SERVICES Home Outside or Garaged 51015 2005 1212005 $ 15.000 $ - $ 15,000 MOTORCYCLE HARLEY DAV POLICE -PATROL SERVICES Home Outside or Garaged 51016 2005 1212005 $ 15.000 $ - $ 15,000 MOTORCYCLE HARLEY DAV POLICE -PATROL SERVICES Home Outside or Garaged 51017 2005 1242D05 $ 15,000 $ - $ 15,000 MOTORCYCLE HARLEY DAV POLICE -PATROL SERVICES Home Outside or Garaged 51018 2005 1252005 $ 15,000 $ - $ 15,000 MOTORCYCLE HARLEY DAV POLICE -PATROL SERVICES Home Outside or Garaged 51019 2005 1262005 $ 15.000 $ - $ 15,000 MOTORCYCLE HARLEY DAV POLICE -PATROL SERVICES Home Outside or Garaged 2008 7/11)2008 0,00 0.00 $ - MOTORCYCLE HARLEY DAV POLICE -PATROL SERVICES Home Outside or Garaged 2008 7192008 0,00 0,00 $ - MOTORCYCLE HARLEY DAV POUCE-PATROL SERVICES Home Outside or Garaged 2008 7A2008 0.00 0.00 $ - SCOOTER YAMAHA 117 N. Mason FLEET SERVICES -POOL RENTAL Outside Locked 8 Lighted 2008 6242008 2.550.00 0.00 $ 2,550 SCOOTER YAMAHA 117 N. Mason FLEET SERVICES -POOL RENTAL Outside Locked 8 Lighted 2008 6242008 2,550D0 000 $ 2.550 Total 12 SW 2009 Vehicle Inventory Parking Fac. Parking Fac. Model Make Location DEPT Inside/Outside Locked/Lighted UNIT YEAR Date Acquired Purchase Price Accessories Total BLAZER CHEVROLET 413 Bryan PARK MAINTENANCE Crusade Locked $ Lighted 2510 1997 1115/1997 $ 22.958 $ - $ 22,958 BLAZER CHEVROLET 4316 W. Laporte WATER QUALITY Outside Locked $ Lighted 2709 1998 622/1998 $ 23.555 $ - $ 23,555 BLAZER CHEVROLET 4316 W. Laporte WATER TREATMENT#2-MAINT Outside Locked E Lighted 2797 1994 M4119N $ 19.571 $ - $ 19,571 BLAZER CHEVROLET 4316 W. Laporte WATER TRMT FACIL-MASTER PLA _ Outside Locked $ Lighted 2740 1999 W17/1999 $ 20.738 $ - $ 20.738 BLAZER CHEVROLET 700 Wood LSP DISTR. Outside Locked S Lighted 23029 2002 52212002 $ 21.959 $ .- $ 21,959 BLAZER CHEVROLET 700 Wood UCSA-INFORM TECH Outside Locked $ Lighted 2737 1999 6/1011999 $ 21,374 S - $ 21.374 BLAZER CHEVROLET 700 Woad UCSA-fTDLRY POOL CA Outside Locked $ Lighted 2707 1997 4n/1997 $ 22,953 $ - S 22.953 BLAZER CHEVROLET Howes St. CODE COMPLIANCE Outside Locked B Lighted 22001 2002 1V302001 $ 21,959 $ - $ 21,959 BLAZER CHEVROLET Howes St. PR PLANNING B DEVELOPMENT Outside Locked B Lighted 24014 2002 5222002 $ 21.237 $ - $ 21.237 BLAZER CHEVROLET CRIME LAB Home Outside or Garaged 2118 1998 4/13/1998 $ 24.727 $ - $ 24,727 BLAZER CHEVROLET FIRE OPERATIONS Home Outside or Garaged 78172 1998 4/1411998 $ 24.727 $ - $ 24,727 BLAZER CHEVROLET FIRE OPERATIONS Home Outside or Garaged 78173 1998 4/1411998 $ 24,727 $ - $ 24.727 BLAZER CHEVROLET HARMONY LIFT STATION Outside Locked B Lighted 2713 1997 tOnl/1997 $ 22.917 $ - $ 22,917 BLAZER CHEVROLET OLD TOWN BASIN 2744 1998 622/1998 $ 23,702 $ - $ 23,702 BLAZER CHEVROLET POLICE -INVESTIGATION Home Outside or Garaged 21616 1992 7282005 S 15,000 $ - S 15,000 BLAZER CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 2116 1998 4/14/1998 $ 24,727 $ - $ 24.727 BLAZER CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 2117 1998 4/14/1998 $ 24,727 $ - $ 24.727 BLAZER CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 2119 1998 4/13/1998 $ 24.727 $ - $ 24.727 BLAZER CHEVROLET SOUTHWEST SYSTEM IMPROVEMENTS 2703 1997 102411997 $ 23.991 $ - $ 23,991 BRONCO FORD FIRE OPERATIONS Home Outside or Garaged 7553 1993 1/l/1993 $ 21,391 $ - $ 21.391 BRONCO FORD FIRE OPERATIONS Home Oulside or Garaged 7554 1993 1/1/1993 $ 21.391 $ - $ 21,391 CHEROKEE JEEP 300 College CS$AMETERS Outside Locked B Lighted 2300 1989 6/1311989 $ 16.436 $ - $ 16,436 CHEROKEE JEEP 3036 Environmental WATER RECI M ICE MINOR CAPIOutside Locked 8 Lighted 2293 1990 6/1911990 $ 18.171 $ - $ 18,171 CHEROKEE JEEP 4316 W. Laporte WATER POLLUTION CONTROL Outside Locked 8 Lighted 2710 1996 722/1996 $ 17.993 $ - $ 17,993 CHEROKEE JEEP 4316 W. Laporte WTF4CE MINOR CAPITAL Outside Locked $ Lighted 2292 1990 6I19I1990 $ 15.171 $ - 5 10,171 CHEROKEE JEEP 625 Ninth St 2004 STREET MAINTENANCE Outside Locked 8 Lighted 2278 1990 401990 $ 17,766 $ - S 17.766 CHEROKEE JEEP 626 Linden TRAFFIC ENGINEERING Outside Locked $Lighted 2238 19% 7207996 $ 18,635 $ - $ 18.635 CHEROKEE JEEP FIRE OPERATIONS Home Outside or Garaged 7559 1996 1020/1997 $ 19,208 $ - $ 19,208 CHEROKEE JEEP FIRE OPERATIONS Home Outside or Garaged 7569 1992 IIW1993 $ 18,001 $ - $ 18.001 CHEROKEE JEEP INDUSTRIAL PRE-TREATMENT Outside Locked 8 Lighted 2770 1989 6/5/1989 $ 16.660 $ - $ 16.660 CHEROKEE JEEP POLICE -INVESTIGATION Home Outside or Garaged 21615 2003 7292005 $ 15,000 $ - $ 15.00 CHEROKEE JEEP POLICE -INVESTIGATION Home Oud ide or Garaged 51621 2003 10222004 $ 15.000 $ - $ 15,000 DURANGO DODGE 4316 W. Laporte TRMT PLANT IMPROVEMENTS - Outside Locked 8 Lighted 27028 2005 6/62005 $ 22.997 $ - $ 22,997 DURANGO DODGE 700 Wood St. DRAINAGE AND DETENTION Outside Locked 8 Lighted 27011 2003 4222003 $ 24,040 $ - $ 24,040 DURANGO DODGE H. St, CODE COMPLIANCE Outside Locked 8 Lighted 2200 1999 7911999 $ 27,094 $ - $ 27,094 DURANGO DODGE FIRE OPERATIONS Home Outside or Garaged 78584 2002 3282002 $ 26,332 S - $ 26.332 DURANGO DODGE POLICE-ADMIN Home Outside or Garaged 2008 1252008 21,156.00 0.00 S 21.156 DURANGO DODGE POUCE4NVESTIGATION Home Outsideor Garaged 2008 722008 21,156,00 0.00 $ 21,156 DURANGO DODGE POLICE -INVESTIGATION Home Outside or Garaged 2008 7n2008 21,156.00 0,00 $ 21,156 DURANGO DODGE POLICE -INVESTIGATION Home Outside or Garaged 2008 7172008 21,156.00 0.00 $ 21.156 DURANGO DODGE POLICE -PATROL SERVICES Home Outside or Garaged 2008 711KO08 21.156.00 0,00 $ 21,156 DURANGO DODGE POLICE -PATROL SERVICES Home Outside or Garaged 2008 7/162008 21.156.00 0.00 $ 21,156 DURANGO DODGE POLICE -PATROL SERVICES Home Outside or Garaged 2008 7/92008 21,15600 0.00 $ 21,156 DURANGO DODGE POLICE -PATROL SERVICES Home Outside or Garaged 2008 7/32008 21,156.00 0.00 $ 21.156 DURANGO DODGE POLICE -PATROL SERVICES Home Outside or Garaged 2008 6/52008 21,156,00 0.00 $ 21.156 DURANGO DODGE POLICE -PATROL SERVICES Home Outside or Garaged 2008 622008 21,156,00 000 $ 21.1% DURANGO DODGE POLICE -PATROL SERVICES Home Outside or Garaged 2008 7292008 23.988.00 000 $ 23,988 EXPEDITION FORD FIRE OPERATIONS Home Outside or Garaged 7571 2001 7/122001 $ 31.913 S - $ 31,913 EXPLORER FORD 413 Bryan PARK MAINTENANCE Outside Lacked B Lighted 2466 2000 6292000 $ 22.069 $ - $ 22.069 EXPLORER FORD 413 S. Bryan FORESTRY Outside Locked 8 Lighted 2492 1995 712811995 $ 24,293 $ - $ 24.293 EXPLORER FORD 700 Wood WATER TRANSMISSIONMISTR. Outside Locked $ Lighted 2734 20M 2/102000 $ 22,069 $ - $ 22,069 EXPLORER FORD 700 Wood WATER TRANSMISSIONIDISTR. Outside Locked 8 Lighted 2781 1991 2/4/1991 $ 17,612 $ - $ 17.612 EXPLORER FORD FIRE OPERATIONS Home Outside or Garaged 7169 2000 4202000 $ 25,160 $ - $ 25.160 EXPLORER FORD FIRE OPERATIONS Home Outside or Garaged 7570 1992 1/1/1992 S 19,256 $ - $ 19,256 EXPLORER FORD FIRE OPERATIONS Home Outside or Garaged 7583 2002 7/122001 $ 26,129 $ - S 26,129 EXPLORER FORD POLICE-ADMN Home Outside or Garaged 21025 2004 12/162003 S 26,711 $ - $ 26.711 EXPLORER FORD POLICE -ADMAN Home Outside or Garaged 2008 31J2008 21.490.95 0.00 $ 21.491 EXPLORER FORD POLICE -PATROL SERVICES Home Outside or Garaged 2140 2000 352000 $ 25.616 $ - $ 25.616 GRAND CHERIJEEP 117 N. Mason REAL ESTATE SERVICES Outside Locked B Lighted 26801 2002 1/112002 S 28.902 $ - $ 28.902 GRAND CHERI JEEP 625 Ninth St 2004 STREET MAINTENANCE Outside Locked 8 Lighted M601 2001 522/2001 $ 21.638 $' - $ 21.638 GRAND CHERUEEP POLICE -INVESTIGATION Home Outside or Garaged 21612 2004 3232004 $ 26,716 $ - $ 26.716 JIMMY GMC 3036 Environmental WATER RECLANLICE MINOR CANT Outside Locked 8 Lighted 2784 1991 4/18/1991 $ 16,572 $ - $ 16.572 JIMMY GMC 4316 W. LaPorte PROCESS CONTROL 2728 1995 65/1995 $ 21,601 $ - $ 21.601 JIMMY GMC 4316 W. LaPorte SOURCE OF SUPPLY Outside Locked 8 Lighted 2716 1998 3/31/1998 $ 22,795 $ - $ 22.795 JIMMY GMC 4316 W. Laporte WATER QUALITY Outside Lacked $ Lighted 2257 1995 2/13/1995 $ 21,284 $ - S 21,284 JIMMY GMC 4316 W. LaNne VVTF-ICE MINOR CAPITAL Outside Locked B Lighted 2702 1998 M511998 $ 22,300 $ - $ 22.300 JIMMY GMC 625 Ninth STREETS -PATCHING Outside Locked B Lighted 2244 1991 ini/1991 $ 15,948 $ - S 15,946 JIMMY GMC 700 Wootl LBP DISTR. Outside Locked $Lighted 2332 1998 828/1998 $ 23,010 $ - $ 23,010 JIMMY GMC FIRE OPERATIONS Home Outside or Garaged 7573 1993 112611993 $ 19,586 $ - $ 19,586 JIMMY GMC FIRE OPERATIONS Home Outside or Garaged 7574 1993 1/1/1993 $ 19,420 $ - S 19.420 JIMMY GMC FIRE OPERATIONS Home Outside or Garaged 7577 1998 3QB11998 S 23.744 $ - $ 23,744 JIMMY GMC FIRE OPERATIONS Home Outside or Garaged 7578 1998 32611998 $ 23,744 $ - $ 23.744 LIBERTY 4WD JEEP 625 Ninth STREETS -WORK FOR OTH Outside Locked B Lighted 22012 2004 3/32004 $ 16,801 $ - $ 16,801 LIBERTY 4WD JEEP Howes St ENGINEERING-ADMN Outside Locked B Lighted 22611 2006 10/192005 $ 16,872 $ - $ 16.872 S 10 BLAZER CHEVROLET 700 Wood UP DISTR. Outside Locked B Lighted 2344 1993 1/8/1993 S 18,486 $ - $ 18486 S10 BLAZER CHEVROLET 700 Wood UP DISTR. Outside Locked 8 Lighted 23% 1993 1/15/1993 $ 18,486 $ - $ 18.486 SONOMA GMC 300 College CSSA CUSTOMER SERVICE Outside Locked B Lighted 2323 1997 528/1997 $ 13,234 $ - S 13234 TRAILBLAZER CHEVROLET FIRE OPERATIONS Home Outside or Garaged 182 2009 1192009 $ 24.629 $ 24,629 TRAILBLAZER CHEVROLET FIRE OPERATIONS Home Outside or Garaged 183 2009 1/122009 $ 24,629 $ 24,629 TRAILBLAZER CHEVROLET FIRE OPERATIONS Home Outside or Garaged 78176 2005 4/162005 $ 23.557 $ - S 23,557 TRAILBLAZER CHEVROLET P0LICE4NVESTIGATION Home Outside or Garaged 51622 2004 3112005 $ 15,000 S - $ 15,000 TRAILBLAZER CHEVROLET POLICEINVESTIGATION Home Outside or Garaged 51626 2005 10/J12005 $ 15,000 $ - $ 15,000 Total 82 TruckJTractor 2009 Vehicle Inventory Parking Fac. Parking Fac. Model Make Location DEPT InsidelOutside LockedlLighted UNIT YEAR Date Acquired Purchase Price Accessories Total 2554 NAVISTAR 625 Ninth STREETS UNPAVED ROAD OuWde Locked B Lighted 2232 1995 45/1995 S 69.310 $ 4.265 $ 73.575 2554 NAVISTAR 625 Ninth STREETS -WORK FOR OTH outside Locked B Lighted 2211 1995 45/1995 $ 69.310 $ 4265 $ 73.575 2554 NAVISTAR 625 Ninth STREETS -WORK FOR OTH Outside Locked $ Lighted 2219 1995 46/1995 $ 69,310 S 4,265 $ 73,575 2554 NAVISTAR 625 Ninth STREETS -WORK FOR OTH Outside Locked 8 Lighted 2220 1995 415/1995 $ 69,310 $ 4,265 $ 73,575 2554 NAVISTAR 625 Ninth STREETS -WORK FOR OTH Outside Locked 8 Lighted 2241 1995 45/1995 $ 69,310 $ 4,265 $ 73,575 2554 NAVISTAR 700 Wood St. DRAINAGE AND DETENTION Outaide Locked $ Lighted 2084 1996 625/1996 $ 202,320 $ - $ 202,320 2574 NAVISTAR 625 Ninth STREETS -WORK FOR OTH Outside Locked B Lighted 2230 1993 720/1993 $ 93,248 $ - $ 93,248 2574 NAVISTAR 625 Ninth STREETS -WORK FOR OTH Outside Locked 8 Lighted 2234 1990 4/11/1990 $ 94,903 $ - $ 94,903 2574 NAVISTAR 700 Wood SEWER TRUNK AND COLLECTION Outside Locked B Lighted 2286 1990 227/1990 $ 59,790 $ - S 59,790 2574 NAVSTAR 700 Wood WATER TRANSMISSIONAJISTR. Outside Locked B Lighted 2281 1991 wit 991 $ 74,380 $ - $ 74,380 2574 NAVISTAR 700 Wood WATER TRANSMISSIONIDISTR. Outside Locked $ Lighted 2768 1990 5111/1989 $ 44.593 $ - $ 44,593 2574 NAVISTAR 700 Wood St. DRAINAGE AND DETENTION Outside Locked 8 Lighted 2209 1991 125/1991 $ 102,748 $ - $ 102.748 4700 I.M. I'm Wood UP DISTR. Outside Locked B Lighted 23DI 1999 11/17/1998 $ 41.250 $ 69.218 $ 110.468 47M NAVISTAR 700 Wood St. DRAINAGE AND DETENTION Outside Locked 8 Lighted 2207 1992 62/1992 $ 49.988 S - $ 49.988 7100 NAVISTAR 835 Woad St FLEET SERVICES -SHOP Outside Locked 8 Lighted 2622 1990 4/5/1996 $ - $ 31,000 $ 31,000 9100 SEMI I.H. 625 Ninth STREETS -PATCHING Outside Locked 8 Lighted 2075 1998 1128/1997 $ 63,000 $ - $ 63.000 9400 NAVISTAR 625 Ninth STREETS -WORK FOR OTH Outside Locked B Lighted 2221 1993 2/9/1996 $ 36,010 $ - $ 36,010 AIR TRUCK CHEVROLET Fire Station FIRE OPERATIONS Inside Locked 7550 1986 7/13/1988 $ 185,000 $ - $ 185,000 ASPHALT DIST FREIGHTLNR 625 Ninth STREETS -PATCHING Outside Locked 4 Lighted 2099 2000 7/132000 $ 93,600 $ - $ 93,600 BUCKET LH, 413 S. Bryan FORESTRY Outside Locked 8 Lighted 2467 1998 3/13/1998 $ 36,724 $ 83,547 $ 120,271 BUCKET TRUC FREIGHTLNR 700 Wood L&P DISTR. Outsde Locked S Lighted 23014 2000 12/62000 $ 45,376 $ 53.011 $ 98,387 BUCKET TRUC FREIGHTLNR 700 Wood UP DISTR. Outside Locked 8 Lighted 23025 2002 12/72001 $ 45,376 $ 54,236 $ 99,612 CF8000 FORD 625 Linden SIGNS 8 PAINT -TRAFFIC Outside Locked 8 Lighted 2031 1992 911511992 $ 37.819 $ 94,708 $ 132.527 COLUMBIA FREIGHTLNR 625 Ninth STREETS -WORK FOR OTH Outside Locked B Lighted 22006 2003 6282002 $ 69,500 $ - S 69.500 DMP TRK 7500 INTERNATL 625 Ninth STREETS -WORK FOR OTH Outside Locked 6 Lighted 22017 2005 4/152005 $ 60,000 $ - $ 60.000 DMP TRK 75001NTERNATL 625 Ninth STREETS -WORK FOR OTH Outside Locked B Lighted 22018 2005 4/152005 S 60,000 S - S 60,000 DMP TRK 75001NTERNATL 625 Ninth STREETS -WORK FOR OTH Outside Locked 8 Lighted 22019 2005 4/152005 $ 68,764 $ - $ 68,764 DMPTRK F550 FORD 5833 S. Lemey FOSSIL CREEK COW PARK MAIN Outside Locked 8 Lighted 24035 2003 5/122003 $ 23,501 $ 8,250 $ 31,751 DOUBLEBUCK I.H. 700 Wood L&P DISTR. Outside Locked S Lighted 2368 2000 3222000 $ 114.499 S - $ 114,499 DUMP #3500 CHEVROLET 700 Wood St. DRAINAGE AND DETENTION Outside Locked 8 Ughled 27702 2001 5282002 $ 23.632 $ 8,500 $ 32,132 DUMP #C5500 GMC; MAINTENANCE Concede Locked $ Lighted 27001 2001 2/142001 $ 30,084 $ 6,314 $ 36,398 DUMP CART CARRYALL 413 BryaniGolf CRY PARK GOLF Outside Lighted 2816 2000 422000 $ 6,392 $ - $ 6,392 DUMP F450 FORD 413 Bryan PARK MAINT-NORTHSIDE Outside Looked B Lighted 2494 2000 7202000 $ 27.193 S 8.099 $ 35,292 DUMP TRU55 FORD 413 Bryan PARK MAINT-PROJECT SUPPORT Outside Locked! 8 Lghtetl 240M 2000 1232001 $ 28,335 $ 7275 $ 35.610 DUMP TRU55 FORD 700 Wood SEWER TRUNK AND COLLECTION Outside Locked B Lighted 2008 1282008 26.288.00 8,082.00 S 34,370 DUMPTRUCK FORD 1745 Hoffman Rd. NATURAL AREAS -PUB OAP Outside Locked S Lighted 2556 1999 1/13/1999 $ 28,052 $ 5,844 $ 33,896 DUMPTRUCK FORD 19M W. Mountain GRANDVIEW GROUNDS MT Outside Lighted 2425 1981 5/11/1982 S 3,000 $ - $ 3,000 DUMPTRUCK GMC 190O W. Mountain GRANDVIEW GROUNDS MT Outside Lighted 2451 1998 827/1998 $ 26,027 $ - S 26,027 DUMPTRUCK FREIGHTLNR 413 Bryan PARK MINT -PROJECT SUPPORT Outside Locked 8 Lighted 24012 2002 5282002 $ 67,050 $ 18.241 $ 85,291 DUMPTRUCK CHEVROLET 413 S. Bryan FORESTRY Outside Locked 8 Lighted 2437 1974 5111/1982 $ 7,996 $ - $ 7,996 DUMPTRUCK FORD 5750 S. Lemay SOUTHRDIGE GOLF COURSE O.Wde Lighted 2479 1981 5111/1982 $ 8,271 S 3,125 $ 11,396 DUMPTRUCK CHEVROLET 625 Ninth STREETS -PATCHING Outside Locked 8 Lighted 2077 1997 1020/1997 $ 22,807 $ 4,310 S 27,117 DUMPTRUCK NAVISTAR 625 Ninth STREETS -WORK FOR OTH Outside Locked B Lighted 2087 1997 325/1997 S 81.620 $ - S 81.620 DUMP TRUCK NAVISTAR 625 Ninth STREETS -WORK FOR OTH Outside Locked &Lighted 2089 1997 W511997 5 81,620 S - $ 81,620 DUMPTRUCK CHEVROLET 625 Ninth STREETS -WORK FOR OTH Outside Locked B Lighted 2091 1997 401997 $ 17,426 $ 4.061 $ 21,487 DUMP TRUCK FREIGHTLNR 625 Ninth STREETS -WORK FOR OTH Outside Locked B Lighted 2095 2001 1222001 S 82,094 $ 51,935 $ 134,029 DUMP TRUCK FREIGHTLNR 625 Ninth STREETS -WORK FOR OTH Outside Locked B Lighted 2096 2001 1=001 S 82.094 $ 51.935 $ 134.029 DUMP TRUCK FREIGHTLNR 625 Ninth STREETS -WORK FOR OTH Outside Locked 8 Lighted 2097 2001 1222001 $ 82.094 $ 51,935 $ 134.029 DUMPTRUCK FREIGHTLNR 625 Ninth STREETS -WORK FOR OTH Outside Locked 8 Lighted 2098 2001 11272000 $ 82.094 $ 49,335 $ 131.429 DUMPTRUCK CHEVROLET 626 Unction TRAFFIC ENGINEERING Outside Locked 8 Lighted 2442 1980 5/11/1982 $ 5.602 $ 2,905 $ 8,507 DUMPTRUCK GMC 626 Unden TRAFFIC ENGINEERING Outside Locked $ Lighted 2717 1984 315119M $ 23,788 $ 5,350 $ 29.138 DUMPTRUCK I.H. 700 Wood UP DISTR. Outside Locked B Lighted 23005 1999 2IW1999 $ 56,845 $ - $ 56,845 DUMPTRUCK FREIGHTLNR 700 Wood UP DISTR. Outside Locked $ Lighted! 23021 2002 7/172001 S 64,502 $ 13.183 $ 77,685 DUMP TRUCK CHEVROLET 700 Woad UP DISTR. Outside Locked $ Lighted 23032 2002 7242002 $ 22.485 $ 7,625 $ 30,110 DUMP TRUCK FREIGHTLNR 700 Wood UP DISTR. Outside Locked B Lighted 23040 2003 552003 $ 63.683 $ 19,624 $ 83,307 DUMPTRUCK CHEVROLET 700 Woad UP DISTR. Outside Locked 8 Lighted 2318 1997 42/1997 $ 17,546 $ 4.061 S 21,607 DUMP TRUCK FREIGHTLNR 700 Wood SEWER TRUNK AND COLLECTION Outside Locked 8 Lighted 27003 2002 7117MOOl $ 67.502 $ 13.035 $ 80.537 DUMPTRUCK NAVISTAR 700 Wood WATER TRANSMISSIONIDISTR. Outside Locked B Lighted 2747 1997 317/1997 $ 66,629 $ 14,333 $ 80.962 DUMPTRUCK FREIGHTLNR 700 Wood St. DRAINAGE AND DETENTION Outside Locked $Lighted 27700 2001 122001 $ 66,500 $ 34,024 $ 100,524 DUMPTRUCK FREIGHTLNR 700 Wood St. DRAINAGE AND DETENTION Outside Locked 8 Lighted 277N 2003 5/52003 $ 63,683 $ 23,945 $ 87,628 DUPLEX LTI SIMON Fire Station FIRE OPERATIONS Inside Locked 7455 1997 4/1/1997 $ 394,345 $ - $ 394.315 F1754 NAVISTAR 700 Wood L&P DISTR. Outside Locked & Lighted 2333 1982 5/1111982 $ 21.614 S 48,433 $ 70,047 F1854 NAVISTAR 700 Wood L&P DISTR. Outside Locked & Lighted 2360 1982 5/1111982 $ 18,846 $ 35,594 $ 54,440 F1954 NAVSTAR 1745 Hoffman Rd. NAT. RES-RESOURCE MGMT Outside Locked & Lighted 25500 1986 324I1986 $ 38.980 $ - $ 38,980 F1954 NAVSTAR 413 Bryan PARK MAINT-PROJECT SUPPORT Outside Locked & Lighted 2481 1985 1221/1984 $ 37.612 $ - $ 37,612 F1954 NAVSTAR 625 Ninth STREETS -PATCHING Outside Locked & Lighted 2214 1987 6/15/1987 $ 33.889 $ 7,357 $ 41,246 F1954 NAVSTAR 625 Ninth STREETS -SNOW Outside Lacked & Lighted 2210 1988 420/1988 $ 48.987 $ - S 48,987 F1954 NAVISTAR 625 Ninth STREETS -UNPAVED ROAD Outside Locked & Lighted 2218 1987 62W1987 $ 33.889 $ 7.357 $ 41,246 F1954 NAVISTAR 625 Ninth STREETS -WORK FOR OTH Outside Locked & Lighted 2212 1988 42911988 $ 48.987 $ - $ 48,987 F1954 NAVISTAR 700 Wood WATER TRANSMISSION/DISTR. Outside Locked! &Lighted 2287 1988 3al/1988 $ 67447 $ 592 $ 58,039 F1954 NAVISTAR 700Wood WATER TRANSMISSION/DISTR. Outside Looked &Lighted 2738 19M 304119M S 39,664 $ - $ 39,6&1 F2574 NAVISTAR 4316 W. Laporte SOURCE OF SUPPLY Outside Locked & Lighted 2288 1989 62D1989 $ 69,377 S - $ 69,377 F2574 NAVISTAR 700 Wood SEWER TRUNK AND COLLECTION Outside Locked &Lighted 2267 1989 10O/1988 $ 85.477 $ - $ 85,477 F4700 NAVISTAR 625 Ninth STREETS -PATCHING Outside Locked & Lighted 2248 1991 W/1991 $ 33.513 $ - $ 33,513 F4700 NAVISTAR 700 Wow L&P DISTR. Outside Locked & Lighted 2309 1991 3011991 $ 46.270 $ - $ 46,270 F4700 NAVISTAR 700 Wow St. DRAINAGE AND DETENTION Outside Locked & Lighted 2228 1991 125/1991 $ 63.125 $ - $ 63,125 F4900 NAVISTAR 625 Ninth STREETS -WORK FOR OTH Outside Locked & Lighted 2080 1996 6/511996 $ 75,722 $ - $ 75,722 F4900 NAVISTAR 700 Wow L&P DISTR. Outside Locked & Lighted 2306 1995 823/1995 $ 37.300 $ 66.749 $ 104,049 F4900 NAVISTAR 700 Wow SEWER TRUNK AND COLLECTION Outside Locked &Lighted 2290 1993 11 N11992 $ 49,620 $ 40.139 $ 89,759 F4900 NAVISTAR 700 Woad SEWER TRUNK AND COLLECTION Outside Locked &Lighted 2296 1993 6/11/1993 $ 51.392 $ 51,992 $ 103,384 F49M NAVISTAR 700 Wood WATER TRANSMISSION/DISTR. Outside Locked & Lighted 2295 1993 6/10/1993 $ 73.615 $ - $ 77615 F49M DUMP I H. 700 Wood L&P DISTR. Outside Locked & Lighted 2313 1998 12119/1997 $ 54,525 $ - $ 54,525 F9300 NAVSTAR 3036 Environmental RESOURCE RECOVERY Outside Locked & Lighted 2775 1991 BI611990 $ 76.210 $ - $ 76,210 F9370 NAVSTAR 30M Environmental RESOURCE RECOVERY Outside Locked & Lighted 2735 1986 9/18/1985 $ 62.054 $ - $ 62,054 F9370 NAVSTAR 30M Environmental RESOURCE RECOVERY Outside Locked & Lighted 2741 1989 4911989 $ 72,210 $ - $ 72,210 FIRE TRUCK SPARTAN Fire Station FIRE OPERATIONS Inside Locked 7258 1991 1/111991 S 203.405 $ - $ 203,405 FL8G­GRAPPLI FREIGHTLNR 413 S. Bryan FORESTRY Outside Locked & Lighted 2448 2000 1M7/1999 $ 57,250 $ 37,530 $ 94,780 FLATBED FREIGHTLNR 700 Wood L&P DISTR. Outside Locked & Lighted 23027 2002 iW2001 $ 49.000 $ 2,300 $ 51,300 FLATBED 49001.H. 700 Wood L&P DISTR. Outside Lacked & Lighted 23003 1999 2l➢1999 $ S6,772 $ - $ 54,772 FLATSED FOAI FORD FIRE OPERATIONS Home Outside or Garaged 78277 2001 3232001 $ 3 .%7 $ - $ 34,567 FLUSHER FREIGHTLNR 625 Ninth STREETS -SWEEPING Outside Locked &Lighted 22007 2003 1222002 $ 93,500 $ 48,450 $ 141,950 FLUSHER INTERNATL 700 Wood SEWER TRUNK AND COLLECTION Outside Locked &Lighted 2009 11/122008 76,52600 97,840,00 $ 174,366 FLUSHER FL81 FREIGHTLNR 700 Wow SEWER TRUNK AND COLLECTION Outside Locked & Lighted 27016 2003 922003 $ 142.433 $ - $ 142,433 FOAM TRUCK FORD FIRE OPERATIONS Home Oulside or Garaged 7260 1994 11/4/1998 $ 13.704 $ - $ 13.7N HAZMAT I.H. Fire Station FIRE OPERATIONS Inside Locked 7453 1993 11/1/1993 S 145.276 $ - $ 145,276 LINE TRUCK FREIGHTLNR 700 Wood L&P DISTR. Outside Locked & Lighted 23016 2001 5292001 $ 50.908 $ 74,740 $ 125,648 LINE TRUCK FREIGHTLNR 700 Wood L&P DISTR. Outside Locked & Lghted 23017 2001 6142001 S 50.908 $ 74.740 $ 125,648 PLATFORM TR GMC 625 Ninth STREETS -WORK FOR OTH Outside Locked & Lighted 2008 2/132008 25.045,00 10,325.00 $ 35.370 PLATFORM TR I.H. 626 Unden TRAFFIC ENGINEERING Outside Locked & Lighted 2235 1999 3/132000 $ 65,750 $ - $ 65.750 PUMPER AMER LAFRA Fire Station FIRE OPERATIONS Inside Locked 7200 1924 11/4/1998 $ 9.059 $ - $ 9,059 PUMPER FORD Fire Station FIRE OPERATIONS Inside Locked 7250 19" 7/13/1988 $ 125.000 $ - $ 125,000 PUMPER SPARTAN Fire Station FIRE OPERATIONS Inside Locked 7251 1984 7/13/1988 $ 135.000 $ - $ 135,000 PUMPER SPARTAN Fire Station FIRE OPERATIONS Inside Locked 7257 1939 1027/1998 $ 280.000 $ - $ 280,000 PUMPER CHEVROLET Fire Station FIRE OPERATIONS Inside Lacked 7261 1972 7/13/1988 $ 8,000 $ - $ 8000 PUMPER TELESOUIRT Fire Station FIRE OPERATIONS Inside Locked 7264 1987 7/13/1988 $ 175,000 $ - $ 175,000 PUMPER GENERAL Fire Station FIRE OPERATIONS Inside Locked 7265 1987 7/1311988 $ 145,000 $ - $ 145,000 PUMPER GENERAL Fire Station FIRE OPERATIONS Inside Locked 7266 1994 129/1996 $ 275,000 $ - $ 275.000 PUMPER GENERAL Fire Station FIRE OPERATIONS Inside Locked 7269 1996 M6/1997 $ 265.814 $ - S 265,814 PUMPER FORD Fire Station FIRE OPERATIONS Inside Locked 7270 1997 1127/1998 $ 22,098 S - $ 22.098 PUMPER FORD Fee Station FIRE OPERATIONS Inside Locked 7271 1997 1127/1998 $ 22,098 $ - $ 22,098 PUMPER AMER LAFRA Fire Station FIRE OPERATIONS Inside Locked 7272 1998 11/4/1998 $ 276.750 $ - S 276,750 PUMPER AMER LAFRA Fire Station FIRE OPERATIONS Inside Locked 7273 1998 11/4/1998 $ 276.750 $ - S 276.750 PUMPER GENERAL Fire Station FIRE OPERATIONS Inside Locked! 7274 1998 9/14/2000 $ 29Q419 $ - $ 296,419 PUMPER AMER LAFRA Fire Station FIRE OPERATIONS Inside Locked 78276 2001 9/12000 $ 310.379 $ - S 310.379 PUMPER AMER LAFRA Fir. Station FIRE OPERATIONS Inside Locked! 78278 2001 12/142001 $ 326.099 $ - $ 326,099 PUMPER AMER LAFRA Fire Station FIRE OPERATIONS Inside Locked 78279 2002 1272003 $ 330,000 $ - $ 330.000 PUMPER AMER LAFRA Fire Station FIRE OPERATIONS Inside Locked 78280 2002 1272003 $ 330,000 $ - $ 330,000 PUMPER HME Fire Station FIRE OPERATIONS Inside Locked 78281 2003 10252003 $ 368,450 $ - $ W8,450 S1954 NAVISTAR 4316 W. Laporte SOURCE OF SUPPLY Outside Locked & Lighted 2722 1984 MOM 984 $ 37,917 $ - $ 37,917 S1954 NAVSTAR 700 Wood L&P DISTR. Outside Locked & Lighted 2384 1990 122/1990 $ 28,457 $ 4.095 $ 32,552 S1954 NAVSTAR 700 Wow L&P DISTR. Outside Locked & Lighted 2385 1990 122/1990 $ 28,527 $ 7,600 $ 36,127 TRUCK SPARTAN Fire Station FIRE OPERATIONS Inside Locked 7450 1982 50/1982 $ 325,000 $ - $ 325.000 TRUCK SPARTAN Fire Station FIRE OPERATIONS Inside Locked 7452 1991 1D27/1998 $ 191,390 $ - $ 191,390 TRUCK FORD Fire Station FIRE OPERATIONS Inside Locked 7582 2000 9/142000 S 23,938 $ - $ 23.938 TRUCK N4300 INTERNATL 413 S. Bryan FORESTRY Outside Locked &Lighted 2009 3282008 55.824.00 19.416,38 $ 75,240 UTILITY TRUC FREIGHTLNR 700 Wood L&P DISTR. Outside Locked & Lghted 23026 2002 1Z?2001 $ 49.000 $ 7.01 $ S .901 UTILITY TRUC I.H. 7W Wood L&P DISTR. Outside Locked & Lighted 23W 19% 1127/1995 $ 35,325 $ 14,764 $ 50,089 UTILITY TRUC IH, 700 Wood L&P DISTR. Outside Locked &Lighted 2353 Ism 11/27/1995 $ 35,325 $ 14.764 $ 50,089 VACMASTER INTERNATL 700 Wood WATER TRANSMISSION/DISTR. Outside Locked & Lighted 27025 2005 MM005 $ 54,223 $ 91. 6 $ 145,287 VACT/FLUSHE IWERNATL 700 Wood St. DRAINAGE AND DETENTION Outside Locked & Lighted 2609 11/72008 86,768,00 217,545,00 $ 304 313 Total 129 Various 2009 Vehicle Inventory Parking Fac. Parking Fac. Model Make Location DEPT Insidel0utside LockedlLighted UNIT YEAR Date Acquired Purchase Price Accessories Total BIKES MISC MARKETING -LOCAL -FREEWHEELS BIKES is% 1229/1995 $ 100 $ - $ 10D BUCKET TRUC FORD 626 Linden TRAFFIC CONSTRUCTION Outside Locked &Lighted 2008 12/42006 2645300 53,29300 $ 79,746 BUCKET TRUC FORD 626 Linden TRAFFIC ENGINEERING Outside Locked! &Lighted 22400 2002 1772002 $ 76.741 $ - $ 76,741 BUCKET TRUC FORD 626 Linden TRAFFIC ENGINEERING Outside Locked & Lighted U401 2002 18 1302 5 76.741 $ - $ 76,741 CAMERA RAD7 CHEVROLET POLICE -PATROL SERVICES Home Outside or Garaged 5100E 2003 4WO03 $ 22.000 $ - $ 22,000 Total 5