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Home My WebLink About00-04685 , , ARTHUR D. TUBBS, JR., and DEBORAH E. TUBBS, as parents and natural guardians of Benjamin Tubbs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA Petitioners (' NO. (JtJ - tjG#J ~ VI. ARTHUR D. TUBBS, JR., and ARTHUR D. TUBBS, SR. Respondents CIVIL ACTION-LAW NUNORSCONWRONUSE ORDER AND NOW, this I!i!rlay of ~iooo, upon presentation of a Petition for Minor's Compromise, it is hereby directed thaI: h~ing on the merits take place on the J.) 4 fay of /J-u 1~ , 2000, at 3:rf) o'clock in thef"m. , J. ~aplw fY\o.JJ. '7-jg.oO RX~ \. "~",' " -~-- -,-"~' '7"'?"_",_ ~_~':", _~, L_ "'^'c,~ ~ r_ ,_," - "_ "' _.0 -" -~ " ~~lliIi~~~iI!IilililW"".:.;~' -- "",,' .,,~- ~----- ',.'" .. .,.- ~. ','" ,- , ">~"-lir\~I-M'J\1 . i." ,r,)_,-;.i! "'JC> 'U'I l'l !! ..iV W -h, 10 ,(; 111'-j 9: 12 CUMf3::F{L/~~"~D COUNTY PENNSYLVANIA , --~ ~.- ". .~~,- <''- " ,~,. '"- , " , ARTHUR D. TUBBS, JR., and DEBORAH E. TUBBS, as parents and natural guardians of Benjamin Tubbs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Petitioners NO. 00- 4~PS' (3~, (~~ v, ARTHUR D. TUBBS, JR., and ARTHUR D. TUBBS, SR. Respondents ;, AND NOW, thi~ day 0 CIVIL ACTION-LAW MINORS COMPROMISE , 000, upon consideration of the within Petition, and after a hearing thereon, it is hereby ORDERED and DECREED that the settlement among State Farm Mutual Automobile Insurance Company, the insurance company for Respondent, Arthur D. Tubbs, Sr., Nationwide Insurance Company, the insurance company for the Respondent, Arthur D. Tubbs, Jr., and Petitioners Arthur D. Tubbs, Jr., and Deborah E. Tubbs, on behalf of the Minor, in the amount of Twelve Thousand Three Hundred ($12,300.00) Dollars and all future medical bills related to the accident up to the Nationwide policy limit of $50,000.00 is APPROVED. Payment of the settlement proceeds shall be made to Benjamin Tubbs on April 3, 2004. Petitioners are authorized to execute a Release in favor of State Farm Mutual Automobile Insurance Company, Nationwide Mutual Insurance Company and Arthur D. Tubbs, Sr. and Arthur D. Tubbs, Jr. Said Release shall be in the form of the Release attached to Petitioner's Petition as Exhibit "E". BY THE COURT: J. . ~,~,. -, .",'~ '00'- ,.r,-_'" , -"" '9',-,T~_":"__ "'~d~~".",,7,,__~,':;,<,:,,_"",__ "".,.-,_ ,_,_ 'f-'_-~r: __"'",_r~___ Nf_'_~'- "", ',-1" . - ~_.. ,-",,- ~- ,. , , ." -lIiII~~. . ~..""---".",-,,.~-, c'; . .-c -"t:~:'" .......... \'.!TARY 00 nus? " PI"! 1: I I _ <,) , ,"> , CUMl:3EhLf-'[\4D COUNT{ PENNSYLVANUl, CopIes F!1D.lly 10 01) (/Irks . ~IVIB _~, n ,,-, ""y_-" -<'<" ";;-,, , , . , ARTHUR D. TUBBS, JR., and DEBORAH E. TUBBS, as parents and natural guardians of Benjamin Tubbs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Petitioners NO. tJ1J- '-IdS' ~ 1$.cAV'- v. ARTHUR D. TUBBS, JR., and ARTHUR D. TUBBS, SR. Respondents CIVIL ACTION-LAW MINORS COMPROMISE PETITION FOR MINOR'S COMPROMISE AND NOW, come your Petitioners, Arthur D. Tubbs, Jr., and Deborah E. Tubbs, as parents and natural guardians of Benjamin Tubbs, a Minor ("Minor"), and respectfully petition this Court as follows: L Petitioners are adult individuals, who currently reside at 221 Meadows Road, Newville, Pennsylvania 17241. 2. Petitioners are the parents and natural guardians of the Minor who currently resides with Petitioners at the above address. 3. Petitioner, Arthur D. Tubbs, Jr., is also a Respondent in this matter. 4. Respondent Arthur D. Tubbs, Sr., is an adult individual who currently resides at 1514 Newville Road, Carlisle, Pennsylvania 17013. 5. The Minor was born on April 3, 1986, and is now thirteen (13) years of age. 6. On December 28, 1998, Respondent Arthur D. Tubbs, Sr., was insured under a automobile policy issued by State Farm Mutual Automobile Insurance Company ("State Farm"), which is an insurance company licensed to transact business in the Commonwealth of Pennsylvania with a place of business at 115 Limekiln Road, :':~-'f--_T": - - ~_"'"_"f""'__ "',,",'c'-r-> - - <--~ } _~~ - '" 0 ',': _;---_.v,;_,_'.',,_,,;--:__.',,- .,",.,_._ _-'o'_=,__':'--~C. -'0',' "'__",;0._" 0-'- ,. . ",-,', '1"/ 'f <', . Post Office Box 257, New Cumberland, Pennsylvania 17070-0257. A copy of said declaration page is attached hereto as Exhibit" A" . 7. On December 28, 1998, Respondent Arthur D. Tubbs, Jr., was insured under an automobile policy issued by Nationwide Mutual Insurance Company ("Nationwide") which is an insurance company licensed to transact business in the Commonwealth of Pennsylvania with a place of business at 100 Nationwide Drive, Harrisburg, Pennsylvania 17105. Acopy of said declaration page is attached hereto as Exhibit "Boo. 8. State Farm and Nationwide as the insurers for Respondents, have offered to compromise this claim as a structured settlement with a guaranteed lump sum of $12,300.00 payable on April 3, 2004 to Benjamin Tubbs. 9. Nationwide has agreed that all future medical bills up to the policy limit of $50,000.00 will be covered for treatment of any residual injuries suffered as a result of this accident. 10. This Petition is filed as a result of injuries sustained by the Minor when his grandfather, Arthur D. Tubbs, Sr., allowed the vehicle owned by his father, Arthur D. Tubbs, Jr., to roll backwards onto him. II. As a result of the accident, the Minor sustained lacerations to the left thigh. 12. As a result of this accident, Petitioner has made a claim to State Farm and Nationwide under the provisions of the auto policies under which Respondents were insured. "0'_7"_ "" '~,-^,,= - .-,~' ,_.. "',' ",.."" ,,~,' -;?r_ ~'\"""'-}O""'f;:;-_:_-Y- .T- ',~"', --c""'" ;," -,,"C"""~,- ,,-,.,_ _-, '1'1' "",c ._,~ F ~T ,~" "" 13. Minor was taken to the Carlisle Hospital, where surgery was performed. A copy of the Operative Report and Discharge Summary are attached hereto, incorporated herein by reference and labeled as Exhibit "C". 14. Following said surgery Minor had follow up treatment with Dr. Daniel P. Hely, an orthopedic surgeon. 15. The Minor was released to full activity and released from care on January 19, 1999. Copies of reports by Daniel P. Hely, M.D., regarding follow-up treatment of the Minor are attached hereto, incorporated herein by reference and labeled as Exhibit "D". 16. It is anticipated that there will be no future treatment. 17. To date, Minor's medical bills have been paid by Nationwide. 18. Nationwide has paid for the Minor's clothing damaged as a result of the accident in the amount of $84.00. 19. At the time of the accident, the Minor was under the care and custody of Petitioners. 20. Petitioners have made a careful and diligent inquiry and investigation in ascertaining the facts surrounding the accident, the responsibility therefor, and the nature, extent and seriousness of the Minor's injuries. 21. Petitioners believe that this compromise with State Farm and Nationwide is fair and in the best interest of the Minor. 22. Petitioners request that upon approval of the proposed compromise that they be authorized to execute the Releases which Nationwide and State Farm have requested and which are attached hereto as Exhibit "E". ;,.. t,'," " " "> _ :~'<" ., _><o_~ "" "_,"," ','':'_\. "_""_';'<"'~C"'__ ,<.:- --7 ,->-'_"""o~'~,,~_-^_,,",, _,_,~< " .'" ,,'-,' ~"" . - ,-- 1--'-' ,- WHEREFORE, Petitioners, Arthur D. Tubbs, Jr., and Deborah E. Tubbs, pray this Honorable Court enter an Order approving this Minors Compromise. Respectfully submitted, Dated: ~\~O\ c::TD & CONNELLY, LLP By: DUR Att, eyLD. #29563 JOHN J. MCNALLY, I , Attorney LD. #52661 P.O. Box 650 Hershey, PA 17033-0650 (717) 533-3280 Attorneys for Petitioners I [". "~~"; ',- - '",?_">"'T_'''_ - ~-- "",c--'r-'_"-,,~~-~;,:,--,",.,_,'-, _'~'_' ~q",,_~ ",~~_~__~",,_"_' ',"',. _ _ ",__~ - ',--. ~ - I I I I I;'" VERIFICATION The undersigned, ARTHUR D. TUBBS and DEBORAH E. TUBBS, hereby verifies that the facts set forth in the foregoing document are true and correct to the best oftheir knowledge, information and belief and further states that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities. Date: ~~ J-. oCJ Arthur D. Tubbs, Individua and as a a natural guardian of Benjamin Tubbs q~ ""(.-0,) Date: .r-. vi f1J~G-l~ Deborah E. Tubbs, Individually and as a a natural guardian of Benjamin Tubbs '-" "'1f',:'" " ',,:'-- "^~-" -', "-"-:';-"'/"" " =,,", ".~ -- ,"- -- t "-' ,- . , . CERTIFICATE OF COVERAGE The undersigned is a Claim Team Manager for the State Farm Mutual Automobile Insurance Company of Bloomington, Illinios. This certifies that Policy number 7265-824-38B car 001, covering a 1992 Plymouth Voyager Van was issued to Arthur D. Tubbs, Sr. and was in effect on the accident date of 12/28/98. The coverages and limits of liability for this policy on that date were A 50/100/50, C2 10,000, D, G 250, H, U-BI 50/100, F 1,500, V 5,000, W 50/100. This policy provides Full Tort option. clmm~amt:9 State of Pennsylvania County ofVork Subscribed and sworn to before me this 24th day of September, 1999. 'kM:L #.. rf? L1 A ~ Notary Public M Commission Ex ires: NOfAIIM IIAI. 1A1HIIIN.. ~ ......, MIc New Cu............", ...... Yodt Co., PA "" Co_hda- ..... March 21, 2001 .. " .i ,,- J l f~.. ~ ,,_._, '.,' OCT 05 '99 07:33 ~R TO 917172637834 . " P.01/03 I , , l._ FRAME: G 14 1Il(\l\. NATIONWIDE '1JP IN.~'y'~~~,R,f. <l;ENTURY II AUTO POLICY DECLARATIONS i Pag. I gr 3 11',.., l).alar.lIon1 .r. I PI" of thl poliO)' na",ld abov' """ Id.inllll.d by pelley numb,' below Th.y .up.rl4KlI al"lY O.d"'UQhl'lilutd .arilt,. YOur poll;)' I). rovtd,. 11"1_ OOy.rag.. ."d IlInll.' Ihown In the Igh.dull cl Gov.t.O" They IPbly 10 ..oh l"lurld vlhlol. .. Indlc'l.d. Your pQ/-IOy oompll.. wlln Ih, mOlorla'" flnlt'lClIII rlll'l'lO"'llbHlty law. of your .t,1I 0/11y fgr Vllhlol.. h:lr whloh PlOP'"Y Ollm.g. ,nct BodIly Injury ~1.omlY .......g...rt D,O\'Jdld. politi)' NU""Ut: M~ 3'1' R 903~71' luu.d: JUN oa. ,Qga P.II.~~.ld": (N.mo. In'ur~dl A~6~~f1 H:DElJOllAll Ii WDMer RO^D MIIT , .A 112~' .0700 Policy P'rlod From:' .JUL 01. 'ge8 to JAN 01. 1999 but only If thl r.qult.a prlmllJrtl fOf lhl. "'lIaCf hat blJJn p'Jd. .tl;l''ld tor IJ:.: monlh nmewat PttlOdI It "newal Ptemlum. art paid .u rt(lutred. Ea~h PDrlod boatna and ends al 12~OI A.M 113ndar.d rime at the addrlJl 0' tne polICYhOlder, 'NSUflEO VEHtCLE($)' BCHEIlU~E OF COVERAGES 1. 1991 DoDO IlISO Cov.,...g.. XOMPREH&::S I VE ~2l,~mv D.........oE LIABILITY BODILY I~JURY LIABILITY UNINSuRED MOTORISTS.BOOILY I~JURY UNDER INSURED MOTORI$TS.600ILY INJURY III "Q7"E'6Y9Y$32QQ~7 Llmh. Or LI.b".y ACTUAL CASli >,IALvE ACTUAL CASH~LU~LE$$ $ 600 I 25.000 E H CURRENCE 50.000 H EASON 100.000 ~ H OCCURRENCE ENDORSEMENT 2357 ,58: 888 ~~~ ~OO~~ENCE . ENDORSEMENT 2358 50.000 EACH PEASON 100.000 eACH OCCURRENCE 50.000 5. 000 TD~AL , .000 MONTHLY 25.000 I. 500 t ! FIRST PARTY BENEFITS OPTION 1.MEOICA~ BENEFIT OPTION 2. INCOME LOSS BENEFIT OP,'ON 3.ACCIOENTAL DEATH BENEFIT OP,'ON '.FUNERAl BENEFIT FUl L TORT $ I s TOT A~ LIENHOLDER.OAUPHIN DEPOSIT LIEN EXP'R..S ON NOV 2'. '996 Post-it. Fax Note Ton .... l.-U I 'C:. Co.lDept. Pl\one II. 2-07/d 51:1 Mont,.. P.remlum I 24 5.0 .7 10 3' 90 5 52. I~ 5 ,() 10 5 22. 70 S .0 70 5 8 10 5 5 70 S .30 5 249. 20 ~ ,', A\J\C.71(;Q FR,.\\IL; /I i~ ~ "~ .-"" ~'"' -.j- ',", OCT 05 '33 07:34 FR JJ " I _ I ~~O'''OO TO 917172537834 P.02/03 ,I I I i L FRAME: H i4 ! CENTURY It AUTO POLICY OECLARA.TIONS ~ 1990 CHEY CORSICA Coveragts CCl>\PREI-\ENSIVE COLLISION PIlOPERlY OAMAGE II 1JlI ~ I TY BODILY INJURY LI1JlILllY UNINSURED MOTORISTS.BODILY INJURY UNOE~INSUAEO MOrOAISTS.BODILY INJURY FIRST PARlY BENEFITS OPTION I.MEDICAL BENEFIT OPT I ON 2. I NCOt.lE LOSS SENEF IT OPTION 3.ACCIOENTAL DEATH BENEFIT OPTION 4.FUNERAL BENEFIT FUL L TORT YEHICLE CLASSIFICATIONS Premium 1. aU~d On: 1991 DOOO USE OF YEHICLE PLEASURE RATED DRIVER ADULT PRINCIPAL MARRIED APPLIED DISCOUNTS ANNUAL MILEAGE /.<<JLrl CAR LON<l TEFt.! SPECIAL RATING SAFE DRIVER FULL TORT 10 'lGl~T.'GOLe1260.5 PaQe;(! of.3 Six Month L1m~. Of L1.bll~y Premium ^C1UAL CASH VALUE S 2430 ACTUAL CAsH VALUE LESS 5 500 S 49,50 ~ 25,000 J;ACH OCCURRENCE 5 48.00 50,000 EACH PERSON S 100.000 EACH OCCURRENCE S 85 40 ENDORSEMENT 2357 $ 50.000 EACH PERSON $ 100,000 EACH OCCURRENCE S '0. '0 ENDORSEMENT 2358 ~ 50,000 E^CH PERSON 100.000 E^CH OCCURRENCE 3 22 70 S 50.000 S 30.90 S 5.000 TOTAL ~ 1.000 MON1I-\LY S '.80 25.000 S 3.40 S 1,500 S .20 TOTAL S 259.30 1990 CHEV WEEKLV COIotNTE 125 MI LES AOO~T PRINCIPAL MARRIED PASSIVE RESTRAINT MULTI CAR LONG TE~ SAFE DRIVER FULL TORT Office Uu: Policy Form &. Endorsement3: A.UTO 60000 2264A 2391 DEC 08. 1997 luued By; NA r I QNtN I DE MVTUAl COl.lntentg:J"le-d Al: HARFlI SBUFl;1. S 0.00 INSURANCE COMPANY 23781 PA. By:M. FEASTER Home Ottice - Columbus. Ohio .______..J I:It\\l!:: I 14 ',. "~~"'J"," ~ r ~' , ..-.J ,,,',_" OCT 05 '99 07:3d FR TO 9!.717263783d P.03/03 I', l FRAME: I 14 .A. NATIONWIDE I![J.' t~..,sJH~~!'!S~ CENTURY /I AUTO POLICY DECLARATIONS Page 3 of 3 Policy Number: 58 31 D 993517 P.llcy~old.r: (NIMOd In..ured) ARTHUR 0 & OESORAH E Pol'lcy PMlad From; JUL 0'. .998 TO JAIl 01. 1999 Issued: JUH 05. 1998 LO$$ PAYABLE CLAUSE ENOOflSEMENT This en<:lOr3sment applies to tl"le Comprehensl\le ana COllision coverages provIded bV this po/rey II prOloGtlS the lIonholder named In Hie poIl~y OEtclar-atJcns. Payment lor loss will be made aCCOrc1inQ to th.e Interes.t ot the ~lfYhol.d$r and lienholder. Pay.manl m~y be made to both JoIntly. or to eltner separately. Either way. the company wll protect the Interests of both The 1i8nhotder'~ I~tere$t will be protected. except from lrll.ud or omIssions by Ihe polIcyhOlder or the pol;cynold8(1!I repfesantallVa. If the comparlY cancels or refuses to reflew the pclley. !hB llenholder will receive nOtice t'lllet'l31 10 atlys DetOre prol:actlon Of It, Interest will and, The lienhcld-er shall notify the Company upon learning sny chenQe in owner'6flip of the vehIcle. To the ell:tenT. of .ptlyment to tr'I'3lienholder. the company will be entitled to tho IIBnMlder'a rights of reeovory. The endorumont ia iSsued by the N8tlonwlde Mutuallnsurllnce Company or NI1l1onwl0'8 Mutual rire Insurance Company. wnlchOVQr has Issued the po/Icy to whICh ft Is attacned. NATIONWIDa MIlTUAllNSURANCa COMPANY NATIONWIDE MUTUAL FIRE INSURANCE COMPANY ~e.."'h,'~~ s.n..... ~~ ,..,.."....nw , , L ..----.- FlU \11:: J I 4 "'""'" TnTr.1 or.r.c G1"":? ',,"..,," ,""-"' ""- c~ _ '^' ,~ .1. A . TUBBS, BENJAMIN L. 302-W / / MR# 035091 DATE OF OPERATION: SURGEON: ASSISTANT SURGEON: 12/28/98 Daniel P. Hely, M.D. PREOPERATIVE DIAGNOSIS: Deep laceration left thigh. POSTOPERATIVE DIAGNOSIS: Deep laceration left thigh. OPERATION: Cleansing and debridement with repair of laceration left thigh. DESCRIPTION OF OPERATION: After satisfactory general anesthesia was achieved, the patient's left thigh was carefully examined. The laceration was oblique in nature, approximately 20 cm in length. The laceration was down through the skin and subcutane- ous tissue. The quadriceps muscle appeared to be intact. The laceration seemed to have undermined creating more tissue loss proximally than distally. The leg was prepped and draped. The debridement was completed taking a millimeter of skin from the edges of the wound on both proximal and distal sides. The subcutaneous tissue was similarly debrided and hemostasis was assured. The wound was then copious- ly irrigated with antibiotic solution. Palpation showed that the injury tunneled proximally but did not go deep to the quadriceps fascia. The wound sufficiently cleansed, the subcutaneous fat C' was reapproximated using interrupted sutures of 2-0 Vicryl. The more superficial fat was approximated using interrupted sutures of 4-0 Vicryl. A running suture of 4-0 Nylon was used to close the skin. A drain was brought out through a separate stab inci- sion proximally. A sterile dressing was applied. The patient was awakened without mishap and return to the Recovery Room in satisfactory condition. ESTIMATED BLOOD LOSS: Minimal. DPH/bpm D: 12/28/1998 - 06:12 pm T: 12/29/1998 c Daniel P. Hely, M.D. Daniel P. Hely, M.D. TUBBS, BENJAMIN L. 302-W MR# 035091 12/28/1998 04/03/1986 Daniel P. Hely, M.D. Page 1 of 1 ORIGINAL CARLISLE HOSPITAL OPERATIVE REPORT l'~~"'I'I , .". ~" =, ,! ' , -~ .1, ~ TUBBS, BENJAMIN L. 302-W / / MR# 035091 ADMITTING DIAGNOSIS: Deep laceration of the left thigh. CHIEF COMPLAINT: Pain in the left thigh. HISTORY OF PRESENT ILLNESS: This 12-year-old boy was helping his father unload a workbench from the back of the pickup truck when his grandfather put the truck into gear. The truck apparently slipped out and backed into the boy with the tailgate cutting his left leg. He had immediate painful swelling. The laceration was appreciated with bleeding. He was brought to the emergency room for evaluation. Clinical examination there showed the laceration but failed to show any evidence of underlying fracture. The x-ray of the femur and pelvis confirm the diagnosis of soft tis- sue injury only. He was admitted to the hospital for definitive wound care. PAST MEDICAL HISTORY: Unremarkable. No past hospitalizations. ALLERGIES: No allergies. MEDICATIONS: No medications. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Nothing to add. DPH/bks D: 12/28/1998 - 06: 14 pm T: 12/29/1998 Daniel P. Hely, M.D. TUBBS, BENJAMIN L. 302-W MR# 035091 12/28/1998 04/03/1986 Daniel P. Hely, M.D. Page 1 ORIGINAL CARLISLE HOSPITAL HISTORY "'~" o " .. t-- . . TUBBS, BENJAMIN L. 302-W / / MR# 035091 GENERAL: This is a healthy-appearing obese 12-year-old boy. HEENT: Negative. NECK: Supple. Full motion. LUNGS: Clear. HEART: Regular rhythm. S" S, heard without murmur. ABDOMEN: Soft, nontender, no organomegaly. EXTREMITIES: The left lower extremity showed an oblique lacera- tion across the front of the thigh. The lacera- tion appeared to extend into the subcutaneous tissue. There were jagged wound edges contaminat- ed with grease. The laceration appeared to extend approximately 20 cm in length by measurement. The femoral nerve appeared to be intact based on straight leg raise and sensibility distally. There is a good dorsalis pedis pulse in both lower extremities. IMPRESSION: Deep laceration left thigh. PLAN: Admission to the hospital. Cleansing and debride- ment and surgical repair of the laceration. The procedure is explained to the patient and his family. They understand and want to proceed. DPH/bks D: 12/28/1998 - 06:14 pm T: 12/29/1998 Daniel P. Hely, M.D. ) TUBBS, BENJAMIN L. 302-W MR# 035091 12/28/1998 D4/03/1986 Daniel P. Hely, M.D. Page 1 ORIGINAL CARLISLE HOSPITAL PHYSICAL EXAMINATION !"" . ~" '. " - r~>~ ,. . '" TUBBS, BENJAMIN L. 302-W MR# 035091 DATE DISCHARGED: 12/29/1998 DISCHARGE DIAGNOSIS: Yfo 0 e- '>' / %. '7 Deep laceration left thigh.', t:> OPERATION, left thigh. DATE: 12/28/98 'llo.d:;l. ?c". S 9 Cleansing and debridement with repair of laceration SURGEON: Daniel P. Hely, M.D. CLINICAL SUMMARY: This is a 12-year-old boy who was injured when a truck slid out of gear with the tailgate cutting across the front of the boy's thigh. He was brought to the Emergency Room for evaluation. He was taken to surgery for cleansing and de- bridement and repair of the laceration. He tolerated the proce- dure well. Postoperative course uneventful. He is discharged with the recommendations to continue Keflex 500 mg q.i.d. times five days, Darvocet-N 100 for pain, rest, limited activity and crutches. Follow-up appointment my office one week. To call in the interim if problems arise. DPH/bpm D: 12/29/1998 - 07:10 am T: 12/31/1998 c Daniel P. Hely, M.D. Daniel P. Hely, M.D. TUBBS, BENJAMIN L. 302-W MR# 035091 12(28(1998 D4(03(1986 Daniel P. Hely, M.D. Page 1 of 1 ORIGINAL CARLISLE HOSPITAL DISCHARGE SUMMARY '-, . ~~. "-, . ~. I .1. ....... ,. --"- , Orthopaedic Surgery of Carlisle, LID. Daniel P. Hely, M.D. John C. Rodgers, M.D. OFFICE RECORDS PATIENT NAME WBBS, Benjamin DATE OF BIRTH 4/3/86 PAGE # 1 I 12/28/98 Pt. admitted through E.R. of deep laceration to left truck and shed. SURGERY: as above for surgery: Cleansing & debridement w/ repair thigh in accident when pt. was pinned between I 12/28/98 I , 1 I I ,. \\ I I I: l I I I I t I' " !i j' I , ,. I Ii Ii I' " I Ii I I " Ii 1/5/99 OV: Ben's wound is clean. No sign of infection. Sutures out. Steri-strips applied. PlAN: Advance activity based on symptoms. Bear weight as tolerated. F.U. 2 weeks re-exam. DPH:nes 1/19/99 OV: Clean surgical wound. No sign of function problems. PlAN: full activity. F.u. PRN. DPH:nes 'V~""'_ , . ., , . FULL AND FINAL RELEASE FOR AND IN CONSIDERATION of the sum of Five Thousand Dollars ($5,000.00) and other good and valuable consideration, receipt of which is hereby acknowledged, the undersigned, ARTHUR D. TUBBS, JR. and DEBORAH E. TUBBS, as parents and natural guardians of Benjamin Tubbs, a Minor, agree to fully release, discharge and hold harmless and indemnify Arthur D. Tubbs, Sr., State Farm Mutual Automobile Insurance Company and all other persons, associations and corporations whether or not named herein, their heirs, executors, administrators, successors, assigns at"ld insurers, respective agents, servants, and employees from any or all causes of action and claims, including any and all claims whether based upon tort or contract theories and demands of whatsoever kind on account of all known and unknown injuries, losses and damages allegedly sustained by the undersigned, and specifically from any claims or joinders for sole liability, contribution, indemnity, or otherwise as a result of, arising from, or in any way connected with injuries or damages sustained by the undersigned, on account of which a legal action was instituted by the undersigned as a result of an automobile accident occurring on or about December 28, 1998, and the defense and handling thereof from the inception of the claim until the date of this Full and Final Release. The undersigned understands and agrees that the acceptance of said sum is not an admission of liability by any party named herein. IT IS EXPRESSLY UNDERSTOOD and agreed that this release and settlement is intended to cover and does cover not only all now known injuries, losses and damages, but any further injuries, losses and damages which arise from or are related to the occurrence set forth in the legal action noted above. ;-m ^-. . " " , , IT IS FURTHER UNDERSTOOD and agreed that this is the complete release agreement and that there are no written or oral understandings or agreements directly or indirectly connected with this release and settlement that are not incorporated herein. This agreement shall be binding upon and inure to the successors, assigns, heirs, executors, administrators, and legal representatives of the respective parties hereto. The existence of this settlement and the amount paid pursuant hereto shall be kept in strictest confidence and shall not be disclosed to any other person. Neither I nor my attorneys or other representatives will in any way publicize or cause to be publicized in any news or communications media, including but not limited to newspapers, magazines, journals, radio or television, the facts of or the terms and conditions of this settlement. All parties to this agreement expressly agree to decline comment on any aspect of this settlement to any member of the news media. This paragraph is intended to become part of the consideration for settlement of this case. THE UNDERSIGNED HEREBY DECLARES that ARTHUR D. TUBBS, JR. and DEBORAH E. TUBBS are oflegal age and that the terms of this settlement have been completely read, and that they have discussed the terms of this settlement with legal counsel of choice, and that said terms are fully understood and voluntarily accepted for the purpose of making a full and final compromise adjustment and settlement of any and all claims on account of the injuries and damages above-mentioned, and for the express purpose of precluding forever any further or additional suits arising out of the aforesaid claims. -2- ~~_r"_'"'' . " ~ . " .. . " I IN WITNESS WHEREOF, we have hereunto set my hand and seal this _ day of May, 2000. WITNESS: (SEAL) ARTHUR D. TUBBS, JR. WITNESS: (SEAL) DEBORAH E. TUBBS -3- ;'~~--~ " -~ " , . " . RELEASE AND SETTLEMENT AGREEMENT This Release and Settlement Agreement ("Agreement") is made and entered into among Benjamin Tubbs, a minor, by his parents and natural guardians, Arthur Tubbs, Jr., and Deborah Tubbs and Arthur Tubbs, Jr., and Deborah Tubbs, individually; Arthur Tubbs, Sr., and Arthur Tubbs, Jr., and Deborah Tubbs, as husband and wife; and Nationwide Mutual Insurance Company and State Farm Insurance Company ("the Parties") The "Claimant" shall collectively mean Benjamin Tubbs, a minor, by his parents and natural guardians, Arthur Tubbs, Jr., and Deborah Tubbs and Arthur Tubbs, Jr., and Deborah Tubbs, individually, their respective heirs, executors, administrators, personal representatives, successors and assigns, the "Insureds" shall collectively mean Arthur Tubbs, Sr., and Arthur Tubbs, Jr., and Deborah Tubbs, as husband and wife; and the "Insurance Companies" shall mean Nationwide Mutual Insurance Company and State Farm Mutual Automobile Insurance Company. I. RECITALS A. On or about December 28, 1998, at 221 Meadows Road, Newville, Cumberland County, Pennsylvania, Benjamin Tubbs claims to have sustained physical injuries as a result of the alleged conduct of Arthur Tubbs, Sr., in operating the motor vehicle owned by Arthur Tubbs, Jr. (the "Incident"). In connection with the Incident, the Claimant has asserted a claim against Arthur Tubbs, Sr., and Arthur Tubbs, Jr., based on negligence. B. The Insurance Companies and the Insureds have entered into a liability insurance contract which provides that the Insurance Companies shall defend the Insureds . l< ,,-,,~-,_,~ -- -, ' . _ _~" ,t,' - -", _ ",-,""._=O'_?__.' ,_. "_N,_ ~',___' "",._- ~ " . " ., , . " \ The Claimant acknowledges and agrees that this release and discharge is a general release. The Claimant expressly waives and assllllles the risk of any and all claims for damages and expenses which exist as of this date, but of which the Claimant does not know or suspect to exist with the exception of medical expenses as set forth below whether through ignorance, oversight, error, negligence, or otherwise, and which, if known, would materially affect the Claimant's decision to enter into this Agreement. The Claimant further agrees that the Claimant has accepted the considerations set forth in Paragraphs III. A. and B. as a complete compromise of matters involving disputed issues of law and fact. The Claimant assllllles the risk that the facts or law may be other than the Claimant believes. It is understood and agreed to by the parties that this settlement is a compromise of a doubtful and disputed claim, and the payments are not to be construed as an admission of liability on the part of the Insureds by whom liability is expressly denied. The Parties agree that the Claimant's release and discharge under this Agreement does not release Nationwide Mutual Insurance Company from any and all current or future responsibilities to the Claimant for future payments that would be made under the medical portion of policy nlllllber 5837 B 993577, under the terms and conditions for any such coverage as set forth in said policy. B. Iniuries Known and Unknown. The Claimant fully understands that the Claimant may have suffered personal injuries that are unknown to the Claimant at present and that unknown complications of present known injuries may arise, develop or be discovered in the future, including, but not limited to, subsequent death or disability. The Claimant acknowledges that the consideration received under this Agreement is intended to and does release and discharge the Insureds and the Insurance Companies from any claims for, or consequences arising from, the ",0'" , c . ~, ~~ '~.' ,'-": - - "~ -'''~''1 , ,.e , " . ., I <) J , " I injuries which allegedly arose from the Incident, except as stated in Section II. A., above; and the Claimant hereby waives any rights to assert in the future any claims not now known or suspected even though, if such claims were known, such knowledge would materially affect the terms of this Agreement. III. PAYMENTS TO CLAIMANT. PAYEE AND/OR BENEFICIARY A. Payment. The Insurance Companies have paid Eight Four Dollars ($84.00) to the Claimant, receipt of which is acknowledged. B. Future Payments. The Insurance Companies on behalf of the Insureds, agree to pay or cause to be paid the following Payment: (I) To Benjamin Tubbs ("Payee"), the following guaranteed lump sum payment of Twelve Thousand Three Hundred Dollars ($12,300.00) on or about April 3, 2004. (2) Nationwide Insurance Company agrees to pay for any future medial expenses under the medical portion of policy number 5837 B993577 subject to the terms and conditions for such coverage as set forth in said policy. (3) Should Benjamin Tubbs die before April 3, 2004, then the guaranteed Payment set forth in Subparagraph III. B.(I) shall instead be paid, subject to the provisions of Subparagraph III.B.(3) below to the estate of Benjamin Tubbs ("Beneficiary"), with the Payment to be made on April 3, 2004. -.- <" -'U"" '-,'0_, .' .,_ _ .0" . ~ -"~ - '.'. 1--' - -" . .. - j " . ~ ., , IV. RESPONSmILlTY AND FUNDING FOR FUTURE PERIODIC PAYMENT A. Responsibilitv for Payment. The Parties understand and agree that Nationwide Mutual Insurance Company will be directly and solely responsible for making the future Payment set forth in Paragraph III.B of this Agreement. B. Annuitv Fundin\!:. The Parties understand and agree that Nationwide Mutual Insurance Company may fund its obligation to make the Payment by purchasing an annuity contract (the "Annuity Contract") from Nationwide Life Insurance Company "the "Annuity Issuer"). If such Annuity Contract is purchased Nationwide Insurance Company shall be the owner of the Annuity Contract and shall have and retain all rights of ownership in the Annuity contract. For its own convenience Nationwide Insurance Company may direct the Annuity Issuer to make the Payment directly to the respective Payee and/or Beneficiaries designated in Paragraph III.B. Each Payee and Beneficiary designated in Paragraph m.B shall be responsible for maintaining his/her current mailing address with the Annuity Issuer. The obligation to make the Payment shall be fully discharged upon the mailing of a valid check or electronic funds transfer in the amount of such payment on or before the due date to the last address on record for the Payee or Beneficiary with the Annuity Issuer. If the Payee or Beneficiary notifies Nationwide Insurance Company that any check or electronic funds transfer was not received Nationwide Insurance Company shall direct the Annuity Issuer to initiate a stop payment action and, upon confirmation that such check was not previously negotiated or electronic funds transfer deposit, shall have the Annuity Issuer process a replacement payment. ,,' . < ,~, _.0 "-, ,'~ - "' '~',--.. -",~'-' --"~'-'~"" _""n_'___ . ., ~, C. Status of Claimant. Pavee and Beneficiaries. The Claimant, each Payee and each Beneficiary, as applicable, shall, at all times, remain a general creditor of Nationwide Insurance Company and shall have no rights in the Annuity Contract nor in any other assets of the Nationwide Insurance Company. Nationwide Insurance Company shall not be required to set aside sufficient assets or secure its obligation to the Claimant, each Payee, or each Beneficiary, in any manner whatsoever. V. NO CHANGES IN PERIODIC PAYMENT The Claimant acknowledges and agrees that all, some, or any part of the Payment cannot be accelerated, commuted, transferred, deferred, increased or decreased by the Claimant or by any Payee or Beneficiary and that the Claimant or any Payee or Beneficiary shall not have the power to sell, mortgage, encumber, or otherwise anticipate all, some, or any part of the Payment by assigrunent or otherwise. VI. ENTIRE AGREEMENT This Agreement contains the entire agreement between the Claimant, the Insureds, and the Insurance Companies with regard to the matters set forth in it. There are no other understandings or agreements, verbal or otherwise, in relation to the Agreement, between the parties except as expressly set forth in it. This Agreement is intended to conform with the requirements or Internal Revenue Code Sections 104(a)(2). All provisions of this Agreement should be construed in a manner so as to effectuate that intent. '<'c' , -, ,.,.'.'".":''-' ", . ~. :'l ~.' "',,"~ "'.~'-'~~~ ' '. .~. 'r";~~~',' -',"C" . .. I .1 ---::1: . ....... VII. READING OF AGREEMENT In entering into this Agreement, the Claimant represents that the Claimant has completely read all of its terms and that such terms are fully understood and voluntarily accepted by the Claimant. VIII. INDEMNITY AND HOLD HARMLESS The Claimant does hereby expressly stipulate and agree, in consideration of the aforesaid payments, to indemnify and forever hold harmless the Insureds and the Insurance Companies against loss from any and all future claims, demands, or actions that may hereafter or at any time be made or brought against the Insureds and Insurance Companies by the Claimant or by anyone on behalf of the Claimant for the purpose of enforcing a further claim for damages on account of the injury and damage sustained in or arising from the aforesaid Incident; and, The undersigned further agrees to indemnify and hold harmless the Insureds, the Insurance Companies, and their agents, servants or employees against any outstanding subrogation interest, liens, claims, demands, or lawsuits held or brought by any persons, firm, government agency or instrumentality, Medicare or Medicaid, other insurance companies, employer, collection agency, hospital or corporation, whether known or unknown to the Claimant, who deem themselves entitled to reimbursement out of any settlement or judgment obtained by the Claimant, including costs and reasonable attorney fees incurred in the defense thereof; and, further, the Claimant agrees to satisfy all such liens or claims from the proceeds of the settlement of this case. ~ ~-, -7 , - -~-- ,', _".,L,' "?'_''''~_ _ '~''IT'1,'-_''~_ - ".. --, ~,'- ~, ,"" "_"'1' . .., l . .- . .' . IX. FUTURE COOPERATION All Parties agree to cooperate fully, to execute any and all supplementary documents, and to take all additional actions that may be necessary or appropriate to give full force and effect to the terms and intent of this Agreement which are not inconsistent with its terms. X. DRAFTING OF DOCUMENT AND RELIANCE BY CLAIMANT This Agreement has been negotiated by the respective Parties. The Parties to this Agreement contemplate and intend that all payments set forth in Section III constitute damages received on account of personal injuries or sickness, arising from the Incident, within the meaning of Section I04(a)(2) of the Internal Revenue Code of 1986, as amended. However, the Claimant warrants, represents, and agrees that the claimant is not relying on the advice of the Insurance Companies, anyone associated with them, including their attorneys and the insurance broker placing the Annuity Contract as to the legal and income tax or other consequences of any kind arising out of this Agreement. Accordingly, the Claimant hereby releases and holds . hannless the Insureds, the Insurance Companies and any and all counselor consultants for the Insureds and the Insurance Companies from any claim, cause of action, or other rights of any kind which the Claimant may assert because the legal, income tax or other consequences of this Agreement are other than those anticipated by the Claimant. The Parties signing this Agreement, and each of them, warrant and represent that no promise, inducement or agreement not expressed in this Agreement has been made to them and that this Agreement constitutes the entire agreement between the parties and that the terms of this Agreement are contractual and not mere recitals. - - -~,--",.-' ,~ . "" ,- .' ~'1 -'1-', . '" , , .- . . , The Claimant represents and agrees that he/she has read the Agreement and fully understand it, and are aware of the propriety and legal effect of executing it, and neither the Agreement nor the compromise and settlement recited in it were induced by fraud, coercion, compulsion or mistake, nor is this Agreement nor the compromise and settlement made in reliance upon any statement or representation of any of the Parties released by this Agreement, or their representatives, agents or attorneys. XI. WARRANTY OF CPACITY TO EXECUTE AGREEMENT The Claimant represents and warrants that no other person or entity has, or has had, any interest in the claims, demands, obligations, or causes of action referred to in this Agreement, and that the Claimant has the sole right and exclusive authority to execute this Agreement and receive the sums specified in it and that the Claimant has not sold, assigned, transferred conveyed or otherwise disposed of any of the claims, demands, obligations or causes of action referred to in this Agreement. XII. COURT APPROVAL The Parties agree that the Claimant will file petitions for all necessary court approvals, that all such petitions and orders shall be in a form satisfactory to all Parties, and that this Agreement will not be effective until such approvals have been obtained. XIII. CONTROLLING LAW This Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. " ','-. -~,. _.- . ,.,., '.' , "+-,---. _ _C~ . ... ~ . ..- . III l "J Dated: Arthur Tubbs, Jr., individually and as parent and natural Guardian of Benjamin Tubbs, a minor, Claimant Dated: Deborah Tubbs, individually and as parent and natural Guardian of Benjamin Tubbs, a minor, Claimant Dated: Duly Authorized Representative for Nationwide Mutual Insurance Company APPLICABLE TO PENNSYLVANIA ONLY: For your protection, Pennsylvania requires the following to appear on this form: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. " " ^. .,..,." ~,- ,--" >