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Home My WebLink About03-1699Jfl/minors comp/hall DUSTIN R. HALL, a minor, by and through his natural parent and guardian, RACHELLE HOGUE, Petitioner THOMAS E. HOGUE, Respondent IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW MINOR'S COMPROMISE PETITION FOR LEAVE TO COMPROMISE MINOR'S ACTION Pursuant to Pennsylvania Rule of Civil Procedure Number 2039, Rachelle Hogue, the natural parent and guardian of minor, Dustin Hall, by and through her attorneys, HANDLER, HENNING & ROSENBERG, LLP, by Matthew S. Crosby, Esq., petitions this Honorable Court to enter an Order permitting settlement and compromise of this action, and in support thereof avers: 1. Dustin Hall was born on September 29, 1987, and, therefore, is 15 years old and a minor. He currently resides with his mother, Rachelle Hogue, at 15 Thomas Drive, Mechanicsburg, Cumberland County, PA 17050. 2. Rachelle Hogue, an adult individual, is the natural parent and guardian of Dustin Hall and currently resides at 15 Thomas Drive, Mechanicsburg, Cumberland County, PA 17050. 3. On or about February 7, 2001, the minor, Dustin Hall, a Ford F150 pickup truck, driven by his step-father, (hereinafter "Respondent's vehicle"). was a passenger in Respondent, Thomas Hogue. 4. At all times material hereto, Respondent's vehicle was traveling westbound on the Pennsylvania Turnpike near the entrance ramp at the Bedford interchange in Bedford County, Pennsylvania. 5. Respondent, Thomas Hogue, was traveling in the right-hand lane on the Turnpike when he violently struck the rear of a tractor-trailer that had been traveling in front of him. Attached hereto, made a part hereof, and marked, "Exhibit A," is a copy of the Police Accident Report. 6. As a direct and proximate result of Respondent's negligence, the minor, Dustin Hall, suffered multiple brain contusions, a left upper-lid laceration, a left-eye hemorrhage, and fractures to both arms. Attached hereto, made a part hereof, and marked, "Exhibit B," is a copy of Dustin's discharge summary from The Children's Institute in Pittsburgh, Pennsylvania. Said summary outlines his injuries. 7. Dustin was transported from the scene via helicopter to Memorial Medical Center on February 7, 2001, where he was hospitalized for several weeks. 8. Dustin continues to recover from his collision-related injuries and now suffers residual problems with concentration. 9. At all times material hereto, Respondent's vehicle was insured under a policy of motor vehicle insurance issued by Encompass Insurance Company. To date, all of the minor's medical bills have been paid by Encompass and/or Dustin's health insurance carrier, Keystone Health Plan/Independence Blue Cross. 10. After protracted negotiations, Encompass Insurance Company has offered to settle Dustin Hall's claim for its bodily-injury liability policy limits of one hundred thousand dollars ($100,000.00). Attached hereto, made a part hereof, and marked, "Exhibit C," is 2 a copy of the Encompass declaration page, confirming the $100,000 bodily injury liability policy limit. 11. Petitioner, Rachelle Hogue, through her counsel, Matthew S. Crosby, Esq., intends to pursue additional settlement monies via Underinsured Motorist benefits available through Dustin's aunt, Rebecca Hall's, insurance coverage with Erie Insurance Group 12. Matthew S. Crosby, Esq., of HANDLER, HENNING & ROSENBERG, LLP, has been the attorney for the minor in this action and he requests counsel fees of $556.50 for services rendered pursuant to a Fee Agreement signed by Petitioner and costs of $71.12. Thus, the total amount requested by counsel is $627.62. See a true copy of the Fee Agreement, hourly billing summary, and costs summary, attached hereto, made a part hereof, and marked "Exhibit D." 13. Petitioner further requests that this Honorable Court approve a structured settlement. If approved, the remaining settlement proceeds of $99,372.38, will be invested in a structured settlement. Allstate Assignment Company (AAC) will purchase an annuity from Allstate Life Insurance Company (ALIC), which is rated A+ (Superior) by A.M. Best, Aa2 by Moody's, and AA+ by Standard & Poor's. ALIC will issue a statement of Guarantee that guarantees the payment obligation assigned to AAC. 14. The structured settlement proposal now before this Honorable Court provides for the following payments: (1) (2) (3) (4) (5) $10,000.00 on 8/1/2006 $10,000.00 on 8/1/2007 $15,000.00 on 9/29/2011 $36,875.00 on 9/29/2014 $104,000.00 on 9/29/2017 Attached hereto, made a part hereof, and marked, "Exhibit E," is a copy of the proposed release and structured settlement plan. 15. Petitioner, Rachelle Hogue, believes said settlement is in the best interest of her minor son, Dustin Hall, and proposes to accept said gross settlement offer of $100,000 from Encompass Insurance Company, thereby releasing the Respondent from any and all claims, suits, and/or actions in the future. Petitioner also proposes that the Honorable Court approve the structured settlement proposal as set forth in "Exhibit E." WHEREFORE, Petitioner requests this Honorable Court to: a. Approve the Compromise stated above; b. Authorize the payment of fees stated above from funds due to the minor; and c. Direct payment of the net funds due, in accordance with the Compromise stated above. Date: Respectfully submitted, Matthew S., Crosby, Esq. I.D. # 69367 1300 Linglestown Road Harrisburg, PA 17110 (717) 238-2000 Attorneys for Petitioner 4 Exhibit A May-c=-4UUl 1Z:58pm From-INTEESTATE SAFr-v XX REFER rD OVER[AY .~'tf:t:TS POLICE INFORMAT ON + T-GZ4 P.OOZ . F-668 I ! VEHICt. 1 - LIGH ' 2 - MOD UNIT # 1 12. NUMBE [' OF UNI1 S Z 15 PP.;V p~ O~ .......... ACCff~c IT y N ~ DAMAGE Ul'lll ! UrllT 2 Y: 34. COr~STRUCTiON - ZONE ACCIDENT LOCATION · ~T~¢~76~ .... ~% ..... ~ ........... . NTERSECTING ROAD: ~ ROUTE Hh OR ...................... ~. SPEED ~ ~'TYP[ ......... ~(~:)AC~ ......... I I~ NOT AT INTERSECTION: ............... E~ ~ ~Tei~f~ .......................... t ROM SI[E N S j FROM SffE 33. DISTA~E WA~ ..... ]'~ ~ ';Pa, Fi:lC -' CONTROL DEVICE PRINCIPAL INTERSECTING · '? 7 . i .__ F'o,P4- "-'-,',~, q,.,, · [,,,.,~i.~ ................... · eom. 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P.O0?/01O. F-506' ~.,'aVOOT u~ C~,~. y ACCIDENT:TiME & LOCATION }NLY THE iNFORMATIO cb'r.c~:.STaTE Wa · .' . 40.0W~R "" : · ' uNrrs .: ORIGINAL "7. h~ARRAHTiVE . IDEI'~TII~r PRE~PKr&TI.O EVEN CENTER FOR FET~ From-.INTE~STATE SAFF~,, REFER TO OVERLAy S~'~ETS ' COMMONWEAL.TH OF PEI~NSYL VANIA 'POLICE ACCIDENT SUPPLEMENTAL POLICE INFORMATIO! ,, - ... ACCIDENT TIME & LOCATION PrlCC,,a:::: r . .: OATE DAY D : t~n's BIRTH CLASs S.S. i~ Pf~F ~:~'~T USAGE ; ~Ai) ll'r,I r P. O01~,~OlO F-506 REPORT J '~. ~'vE s'r ~7.,AT [:~ CoMPt. E-t-E ? -- CENTER FOR HiGHWA--~AFETy Exhibit B INSTITUTE THE CHILDREN, S 6301 NORTHUMBERLAND ST PITTSBURGH, PA 15217 412-420-2400 FINAL REPC Name: HALL,DUSTiN R MR#: 0261-27 DOB~"09/29/1987 Adm/t Date: 02/23/2001 Discharge Date: 03/13/2001 Acct. NUmber: 015799 Service: ~ INPATIENT MEDICAL DISCHARGE 02/23/01 _ 03/13/01 accident on 02/07,^~-~/~ year old male ' ~, ~/ul_ resulting in ~'=~u lnv°l~gd in a motor '~~~~~_ ~ ', ~~el _ ~mlssion i - " ~ ' ~omnl~ ~ set me ofThe source of lnforma t his mother and father· He was referred for inpatient1 ~ ~nuerview by = .... ~=~a~ nos~i~ mary, copy of Dr S Lee Miller. Rehabilitative goals at the time of admission were 1. Maintaining medical stability, rehabilitation by 2. Management of tracheostomy. : 3. Obtaining follo ' . ~' . Rehabilitativ~ ~w~..P~_.E~NT and ortho ed' re nracheosto~ c=~ ~ ~urslng manaceme p mc assessments include ~.f~. ~t=- ~e was to ~i_. nt f~r bowel/bl~_ enduranc~'~Y~a~ therapy for i~ye renabilitativ~' shin care, and Oc .... ' ~CZional m~=~ ~uvement of ~ .... ~ue~ention =upa=iona~ ~= , u~uv. iTM.... =~ mo~ -=- s perce~t.,-~ ~.unerapy for e~,~%_='?P~uvement of b=~___~ o~rength, ~_ ~ ~=~ motor, a~ .... f~juuulon and ~ ~- ~=~ce anG co ~ucn-lan a "= ~lvltles of . ~.~prove fine ordln=t~on. Pass - . ~ge for mona=or' _ .da~ly l~v~n . .= .motor, Y Muir sea ~ ..... ~ng, ~k~n _ ~ act~v~t~e , and for court,ye ~.=__~lons re~ardinc --oussment, Speech, lan~age, and co~ication assessme for neuropsycholog~ca nt and discharce ~;~lly was to recei ...... =~ eaucational- ~ ~ln9 with goals o='~ U~ucation and · ~ re~urn ~ ~___ ~caRce w' Pertanent ~nf°~at~on.regardin9 histo~ ~3 3"~' SCQool, and ~aun~ty. Dustin was a 13-1/3 year old male in his until 02/07/01 when -= ~ present illness was that motor vehicl : .he was the r = ~ U~ual state e accxdent i .... ~ . estra~n=d aro_~ . of 9~d neal-~ that rear ended a fl ~=~-un , .... ,_ . K ounger in ~onsciousne _ .atbed tracto . = ~u=~ in Which he was ~o Con .... ~s, emesls at -~- - r trailer. He ...... =,,~ugn Valley MemorliT ~ene. of th~ accid~ferl~ced loss of ~ hospital u= ~_ --, a~u was take ' --= w~s ~ovi~c ~ __~ ~ by air ~ ~ ~xuremities, HALL, DUSTIN R MEDICAL DISCHARGE SUMMARY Page 2 MR#: 0261-27 but was not able to follow .commands and-became combative in the emergency department at which time he was intubated. ~~~ also had delayed diagnosis on 02/18/01 of right 2nd metacarpal and left 5th metacarpal fractures. He was extubated on 02/10/01, but subsequently developed increased respiratory distress until 02/16/01 through 02/18/01 where he was received q2h. treatments with Albuterol and racemic E inephrine. ~t that time h,~e . n~d had undergone barium swallow on 02/20/01 which sho .... ~ ....... ' He w=~ ~m~ swallowing function. There was a report of pneumomediastinum 02/19/01 post tracheostomy placement felt to be.-secondary to that procedure. Post tracheostomy placement, Dustin received a course of Decadron. Due to some complaints of pain in the right knee, x-ray of the right knee taken, negative for fracture on 02/16/01. By 02/19/01, he had advanced his diet to soft diet. Most recently On 02/20/01, his laboratory studies showed hemoglobin/hematocrit 11.7/34, white count 8,200, creatinine 0.5, BUN 15, calcium 9. Electrolytes - showed sodium 137, potassium 4.2, chloride 97, carbon dioxide 26. At the time of his admission, he was able to mouth words and had some return of movement in the left upper extremity. His return of movement to the left lower extremity had preceded the more recent return in the arm. During his initial evaluation, cervical spine films and films of chesu, pelvis, and total spine series wer~ all negative as was CT of the abdomen and pelvis. ' PAST MED, ICAL ~TSTOR¥ Pre~nancy History: Noncontributory to his present illness GENERAL~ICAL W~.ALTH General medicat care from Blue Cross. Dr. Lock, his primary care physician MEDICAL D~SCHAR~E SUMMARy HALL, DUSTIN R MEDICAL DISCHARGE SUMMARY Page 3 MR#: 0261-27 IMMUNIZATIONS His immunizations are up-to-date. PAST HOSPITALIZATIONS/SURGeRieS: None other than .those mentioned in history of present illness. ALLERGIES No known drug allergies. MEDICATIONS Chloral Hydrate 500 mg p.o.q.h.s. Augmentin 400 mg per 5 cc, 2 teaspoons p.o. ql2h. x 10 days Zoto HC Otic Drops 3-4 drops, to the right ear q4h. to be discontinued on 02/24/01 after I2 noon dose Tylenol Elixir 650 mg p.o. 'q4~r p.r.n, for discomfort~r temperature equal to or greater, than 101 degrees Dulcolax Suppository q. 3 days p.r2'n, no bowel movement. bowel movement the day prior'to admission. Last ~EVIEWOF.SYST~ Sleep: Parents described Dustin's premorbid sleep pattern as good. He had awakened'early over the 2 nights prior to admission at approximately 4:00 am. Chloral Hydrate had been prescribed to assist with sleep. He tends to dislike the mist on his tracheostomy and had tendency to early awakening. , Skin: Negative. ' Vision: · Reportedly tested yearly. His vision was fine except under stress and he does have corrective lenses that he was to wear for long reading assignments. Hearing: Parents requested an audiology assessment to retest his hearing. Dental Status & Care: He was followed by Dr. Livingood in Bedford, PA for his dental care. Cardiovascular: He had no history of any cardiovascular problems. Respiratory: Negative premorbid to the history of present illness. He presently basra tracb in place for treatment of subglottic stenosis. GI: Negative for diarrhea, constipation or Hepatitis. He was presently having normal bowel movements. Hematologic: Negative. ~u: Negative. Musculoskeletal: Negative with the exception of a fracture of the left thumb approximately 3 years ago. HALL, DUSTIN R MEDICAL DISCHARGE SUMMARY Page 4 MR#: 0261-27 Neurological: He had no history of seiz-~res. '~DUCATIONAL ~!STORY Significant for family noting that.educationally there had been concerns regarding the possibility of attention deficit/hyperactivity disorder (AD/HD) versus learning disability. He had received a trial pf Ritalin in 1st grade, but the Ritalin made him lethargic and was discontinued. He did relatively well until 2 years prior, at which time in 6th grade his reading skills were at a 4th grade level. He was presently receiving grades that average out to'D's. His counselors at school premorbidly were asking him to have recheck for attention deficit and parents requested testing to rule out learning disability. He attends Cumberland Valley School where he is a 7th grade middle school student in Cumberland .County School District. Family reports that reading remaine-~'pl~oblematic. He can d~'assignments with assistance, but isn,t motivated to do. reading assignments on his own. Mr. J. Rouger is his guidance counselor. Father reports that Dustin is not a discipline problem, but he tends to be not very sociable and has poor attentional and organizational skills. ~AMILY ~ISTORY: Mother: Rachelle Hogue, 31 years of age. She has joint custody of the patient with his biological father. She is alive and well and is a homemaker. Father: Raymond O'Neil, 33 years of age. Parents were never married. He is employed as a CAD technician at Seton Manufacturing. Mr. O'Neil has history of headache~ and has been tested for low blood sugar, but testing was negative. There was a strong family history of'diabetes, however. Siblings: There are 3 half siblings on the mother,s side. Darion 7 years of age, Dalton 5-1/2 years of age and Devon 11 months of age; all alive and well. There is a half brother, Brendon 16 months of age and a half sister Morgan 6 .years of age on the father,s side of the family. ~OCIAL HISTORY Dustin lives with his mother and stepfather as the primary caretakers. Dustin has been baptized in both the Trinity Lutheran Church in Bedford and baptized through Bible Baptist in York, PA. He enjoyed recreational video games, roller blades, computers, and enjoys crafts, tools, and board games. There is 132 mile drive between the 2 homes. Dustin,s father is active in his care, sees him every other week 2 months in the summer, and every other major holiday. ' ..MEDICAL DISCHARGE.S~y HALL, DUSTIN R MEDICAL DISCHARGE SUMMARY Page 5 MR#: 0261-27 .'PHYSICAL RY~MINATION Measurements: Height: 61-1/2 inches Weight: 91.6 pounds Vital Signs: Temperature: 98.1 degrees Respiration: 16 per minute Pulse: 72 per minute Blood Pressure: 92/58 General Appearance: Dustin presented as an alert and attractive'young man appearing his stated age. He did exhibit emotional lability% Eyes: Extraocular movements were intact. He denied diplopia or blurred vision. Pupils. were equal, round~' and reactive to light. Both eyes could be.shut tightly, although.left was asymmetric in comparison to the right. There was also asymmetry!'0~%~ smile, left being Weaker than right. There .was resolving subcOnjunctival, hemorrhage on left eye also noted. Ears: Tympanic membranes were clear bilaterally. ENT: Oral pharynx was clear. He had a tracheostomy in place, had a strong cough, and was able to cough up clear secretions through the tracheostomy. Lungs: Lung fields are clear to auscultation. Heart: Sl and.S2 to be normal without murmur, rub, or gallop. Abdomen: 'Soft and nontender with normoactive bowel sounds Liver and spleen were not palpable. · Skin: Significant for ~he relatively new tracheostomy. There was no erythema, warmth, or discharge in the area of the tracheostomy. Spine: Straight~. sF~_~_~e~e~:. T~e l~ft_ wrist in an immobilizer and ri ht i p~lnu ~naK lnc£ude~ th~ ~ ..... ~ ....... g n a gutter th~ ~: .... ~ ~**~=~ =~u oru ~lnger in the s~li~ = ~=y'KO raise bo~ ~ ......... = .... ~u~ua~ had u~ xow~r ex=rem~u~es above his head. although the left shoulder strength, does not have full active extension'and could not be maintained above the head foriextended periods of times and was weaker within its range of motion in comparison to the right. Biceps were 3+ strength, triceps were 3/5. On the left upper extremity, grasp was also difficult toexamine due to splints. The left grasp was 4/5. In the lower extremities, Dustin had antigravity strength of both lower extremities. His hip flexors were 4/5 on the left and 4+/5 on the right. Hamstrings were 4- on the left, quads were 4/5 on the left in comparison to the right. He had active dorsiflexion bilaterally, but only 4/5 strength on the left'in comparison to the right. Toe was upgoing on the left and downgoing on the' right There was no clonus at either ankle. · HALL,DUSTIN R MEDICAL DISCHARGE SUMMARY page 6 MR#: 0261-27 Neurological: Dustin was able to mouth the answers to .questions. He was able to understand humor and his response to sensory examination at 'times seemed unreliable, but ~e generally expressed intact sensation to light.touch in all extremities. ASSESSMENT 2. Dustin had alsov~sustained left 5th'metacarpal and right 2nd metacarpal fracture. 3. Left upper lid laceration. 4. Left' eye subconjUnctival .... ..... ~ t~ Dustin was admitted to The Children,s Institute, Dr. Cynthia Smith, attending, Dan.~Leger, case.manager. 1. He-was ptaced on regular.-soft diet and thin liquids. 2. Vital~signs,~q. sh/~ft.andp.r.n... 3. Immunizations~were notably up-to-date· 4. Order~dCBC.&~differ~ntial.' 5. onsultatiuns were scheduled with orthopedic evaluation Children,s Hospitalof Rittsburgh, an~appointment with Dr. Yellonat Children,s Hospital. ofPittsbur~h ENT was~attemp~ed, pre-arranged~followup with. ~ maugh~al~ey Memorial Hosp~nal scheduled 1-2 weeks'~af~er~i~~ge. 7. Mediuations~were~,aSfOllows: Augmentin400?n~3 per'5 cc 2 teaspoons p.o. ql2h. x 10 days, discontinue after, am dose on 03/04/01 ZOto HC Otic Drops 3-4 drops AS q4h. discontinue after 12 noon dose on 02/24/01. ' Tylenol 'Elixir 650 mg p.o. q4h. for discomfort or a temperature equal to or.greater than~101 ·degrees. " DulcOlax SuPPository I'PR.q. 3 days p r.n. no bowel movement HALL,DUSTIN R MEDICAL DISCHARGE SUMMARY Page 7 MR#: 0261_27· Chloral Hydrate 500 mg p.o.q.h.s.-' 8. He was order to have the inner cannula of tracheost-omy changed q4h. .and suction the tracheostomy p.r.n. 9. He was ordered continuous pulse oximetry for the first 48 hours and to give supplemental oxygen as needed only to keep oxygen saturation equal to or greater than 93%. Humidified air to be delivered by tracheostomy collar. 10. He was ordered right hand splint and left wrist brace x ~ weeks. 11. It was noted for him not to'use speaking valve until Monday and only as directed by speech-language therapy. 12. Calorie counts were ordered for' first 3 days of admission. 13. It was noted that he would require a CT scan 2-3 days prior to his followup with Dr. Deme, neurosurgeon at Conemaugh Valley Memorial Hospital. - 14. Therapeutic intervention was ordered for physical therapy evaluation and treatment to improve gross motor skills, balance, coordination,.strength in the lef~--'-bemibody. Occupational ~herapy to evaluate and treat to improve fine:motor,-perceptual motor, activities of daily living, and cognitive skills. 'Speech-language therapy to evaluate and treat to outline use of P~ssy-Muir valve, assess cognitive speech, language, communication skills, and hearing evaluation. Dietary was~'requested~-for caloriecounts for 3 days Psychologyfor neuropsychOlogical assessment C.A.B.L~E. to continue educational prog=amming andi~recreati6nal therapy. Estimated length of stay at time of admission was 3-4 weeks. .LABG~A~.~O~"STUDIES: ..... ' - , =~=~=~ ~us .neuurophi±s, 0% bands. %~m lYmp~ocylles, 11% monocles, platelet co~t 469,000. A culture of the tracheosto~ site~revealed no white, blood cells and no bac ' ~C-s~aln.::and:::~ogro~h at 48 ~s. No metmci~lin ~o,=~erla on ~u~pny~ococc~.:a~eus:recOVered - , ......... CON~ILTATTON_8~: Dustin. was~seen; by Dr?'Elizabeth Pickvance of pediatric orthopedics on 03/05/01. She noted that he had fracture of the right base 5th metacarpal and left indexproximal and distal. Splints were removed. There was slight tenderness noted around the left 2nd metacarpal phalangeal joint. His x-ray showed fractures to be healed. He was placed weightbearing as tolerated in the upper extremities. She noted that he Would require time for range of motion of joint to return. She MEDICAL DISCHARGE SUMMARY HALL,DUSTIN R MEDICAL DISCHARGE SUMMARY Page 8 MR#: 0261-27 asked for followup in 2 weeks. .Dustin saw Dr. Carrau of Eye and Ear Hospital on 02/28/01 in that Dr. Yellon of Children's Hospital of Pittsburgh was unavailable. At that time he underwent CT scan to evaluate his subglottic area. Upon return, Dustin had forms for surgery at Mohtifiore same day surgery scheduled for 03/22/01. Recommendations were to continue Au~mentin 400~ mg per 5 cc to be given 7.5 cc p.o.b.i.d, x 30 days. Upon verbal communication with Dr. Carrau, ENT on 03/02/01,'inner-cannula change was decreased to q.d. and p.r.n. DL&B schedule was moved up to the week of 03/16/01 with repeat CT scan and tracheostomy change scheduled at that time with hopes to change to uncuffed unfenestrated tracheostomy. HOSPITAL COURSE: On 03/02/01, biological father was learning tracheostomy care on model at that time and by 03/05/01 was 9ather was able to perfor~'tracheostomy care with supervision. On 03/06/01, mother informed attending physician that there had been a recommendation for' use of Tagamet or Zantac to reduce the possibility of irritation if reflux were to occur given the severity of Dustin's subglottic stenosis. 'Therefore, he was started on Tagamet 200 mg p.o. q6h. It was noted that this information had not been transferred in his discharge summary from Conemaugh however. By 03/07/01, Dustin.remained medically stable and was requiring no suctioning. He was requiring mist to tracheostomy and continued on Tagamet and Augmentin. His weight by 03/07/01 was up 1.9 pounds compared to admission weight. On 03/08/01, Dustin's mother requested that possibility of transfer to another inpatient facility closer to home be explored. At m~ltidisciplinary staffing on 03/08/01 it was noted that Dustin was able to ambulate 500' with supervision, ascend/descend 24 stairs with supervision and no railing, he had 1/2 grade weakness in the left lower extremity. Dynamic standing balance was mildly decreased, single limb stance on the left lower extremity was 30 seconds. Occupational therapy noted significant weakness in the left upper extremity with shoulder' flexion and abduction strength 2+/5, elbow extension/flexion 3+/5, pronation and supination were within no=mal limits, and he was able to 'move all joints in the distal upper extremity, although s~ill complaining of some discomfort with right index finger. His opposition skills of thumb'and finger were improved and functionally he could open drinking containers. Proximal weakness remained his deficit in the upper extremity. Visual perceptual testing noted that he required minimal assistance to complete activities and took 10 minutes and cueing and strategies. His occupational therapy needs were-felt to be ongoing. Speech-language therapy noted his languagescores were average with memory and attention below average. MEDICAL DISCHARaESUMMARY HALL, DUSTIN R MEDICAL DISCHARGE SUMMARY Page 9 MR#: 0261-27 Cognitive issues were noted premorbidly, but exaggerated by head injury. After re-contact with ENT service at Eye and Ear Hospital initial -tracheostomy change and tracheostomy change training for family members was scheduled for Monday, 03/12/01. On 03/12/01, Dustin successfully underwent his first tracheostomy change under the care of Dr. Thedke who had demonstrated tracheostomy cha~ge to all family members (mother, father, stepmother, and stepfather). However, they had not performed tracheostomy change. I informed them that it was our policy that all caregivers be able to demonstrate the'ability to change tracheostomy prior to discharge. Mother had demonstrated at that time her ability to do routine tracheostomy care as did Patient's stepfather. Sterile technique was used with very few verbal cues'needed. On 03/13/01, both biol¢ e Details of the neuropsychological assessment and-~dOmmendations are as pe~ the neuropsychological assessment from the psychology department dated 03/10/01 and will not'be reiterated in this document. There is also a cognitive andbehaviorallearning environment discharge, summary dated 03/13/01 as well with the following recommendations made: 1. Homebound education until he is medically cleared for school return. 2. SPecial education t~acher to administer homebound education. 3. Extra time to complete all~ assignments. 4. Practice~andrepet±tion to retain newly learned information. 5. Return to a highly structuredspecial education program that will meet his unique needs~.r~_~ated to acquired brain injury. 6. His cognitive abilities.to be ~reevaluated to better assess his abilities before return~o~school. It was~ noted~that he had:~:difficulty counting items, related to difficulty with visual perception, in that he may need physical or verbal-prompting to ass±stwith.math activities. On 03/13/01, Dustin was discharged in stable condition to the care of his mother and stepfather.. DISC"F~%RGE MRBI~ATIONg: Tagamet 200'mg p.o.q.i.d. Augmentin 600 mg chewable tabs b.i.d. HALL, DUSTIN R MEDICAL DISCHARGE SUMMARY Page 10 MR#: 0261-27 1. Dustin had scheduled followup with Dr. Carrau, ENT at short stay at Montifiore changed to 03/26/01 as per mother's report. -2. His primary care followup was to be scheduled by mother with Dr. Lock. 3. He had a scheduled appointment with Dr. Elizabeth Pickvance, Department of Orthopedics, Children's Hospital of Pittsburgh on 03/16/01 at 9:00 am. 4. He had trauma followup at Conemaugh Memorial Hospital scheduled for 03/19/01 at 11:00 am. 5. Followup with Dr. Deme, neurosurgery, Conemaugh Memorial Hospital on 04/18/01 at 3:00 pm. 6. CT scan 2-3 days before Dr. Deme's followup scheduled for 04/13/01 at 1:00 pm at Conemaugh. 7. Retest of hearing needed in 6 months to follow a mild high frequency loss noted in the left ear during testing at The Children's Institute. 8. He was discharged to supervision at all times. 9. Further neuropsychiatric evaluation to be done in his local community. 10. Post discharge therapy was to be provided by HealthSouth Mechanicsburg. Physical therapy requested 2 times perweek, occupational therapy 3' times per .week and speech,language therapy 2 times per week. ' 11. Homebound education~was requested with occupational therapy and speech-language therapy support. 12. ' Dustin was to return to school with learning support. 13. Neuropsych01ogical reevaluation was requested in 6 months time. 14. Respiratory and tr~cheostomy equipment was ordered through Apria (1-800-882-2924). cc: HealthSouth Rehabilitation Hospital Mechanicsburg, PA 17050 Darren Locke, M.D. Hove Family P~act±ce~o Nason Drive Roaring Springs, PA 16673 Eagle View Middle School (Counselor, Principal only) Carlise Place Mechanicsburg, PA 17050 Rachelle Houge Exhibit C ENCOMPASS. INSURANCE TO THE BEST OF OUR KNOWLEDGE WE DO HEREBY CERTIFY THAT THIS IS A CORRECT COPY OF DECLARATIONS PAGE: ISSUED TO: Policy Number: US 198974866 Thomas E & Rachelle Hogue 15 Thomas Drive Mechanicsburg, PA 17050 03-17-00 to 03-17-01 CONTINEN SWORN TO BEFORE ME THIS 21st day of January, 2003 ~, :~T~JAL SEAL i ~i~5~ -~C~-:._£G:'=.-.L Notary Public My Commission ~-×p,;:... :~/2004 USP Special Policy Endorsement Coverage Summary Policyholder: THOMAS E & RACHELLE HOGUE 15 THOMAS DRIVE MECHANICSBURG PA 17050 Agent: ROBERT C STIRLING INC P.O. BOX 6425 LANCASTER PA 17607 PHONE: 717-397-7531 Policy Number: US 198974866 Policy Period: 03/17/2000 tO Insurance ProvidodBy: CONTINENTAL INSURANCE COMPANY P.O.BOX 16020 READING,PA 19612-6020 03/17/2001 12:01 AM Standard Time CNA YOUR POLICY HAS B,-,-N CHANGED As of: For All the Commitments You Make' 470-072285-0000 Policyholder Since: 03/1999 24 HOUR CLAIM REPORTING 800-588-7400 01/05/2001 CHANGED NAME/MAIL ADDRESS Nochangeinpremium IMPORTANT INFORMATION ABOUT YOUR POLICY We p,-ov.~-: ~o11~.'.~ ¢~,-~.-..~. for a non-~w¥,.~ priv-~;, paam~ngM motor vehicle rented by you, during the term of this policy, if at least one of your autos shown below has collision-coverage. (The collision coverage we' provide ia subject to the lowest applicable deductible.) Please review your policy for coverage details. MOTOR VEHICLE PRO~ECTION (Coverage ,,p.-!ies only if a premium or limit is sho~vr,) V~hlc-~e 1 Vehicle 2 Description: 1997 FORD F-150 STD/XL 1995 PLYMOUTH VOYAGER VIN: 1FTDX1864VNA56982 2P4GH2535SR161132 Rated Driver: THOMAS E HOGUE RACHELLE L HOGUE Use: Work 10 miles Pleasure Class Code: 814221 814121 cOVERAGES: BODILY INJURY (per person/per accident) PROPERTY DAMAGE (per accident) FULL TORT OPTION UNINSURED MOTORISTS- STACKED LIMITS (per person/per accident) UNDERINSURED MOTORISTS STACKED LIMITS (per person/per accident) FIRST PARTY BENEFITS (FPB) COVERAGE: BASIC FPB COVERAGE Medical Expense Benefit $ 100,000/300,000 $ 204.00 $ 100,000/300,000 $ 198.00 100,000 $ 115.00 $ 100,000 $ 113.00 Applies Applies 50,000/100,000 $ 17.00 $ 50,000/100,000 $ $ 50,000/100,000 $ 54.00 $ 17.00 50,000/100,000 $ 54.00 $ 30.00 $ 28.00 5,000 $ 5,000 US 198974866 Chairman of the Board ~Secrela ~'~''' Continued on Next Page C0115 Page 01 of 04 USP Special Policy Endorsement Coverage Summary CNA For Atl the ¢omrnitmenls You Make' MOTOR VEHICLE PROTECTION (Cover~e applies only if a p,-ei~ilum or limit Is ihown) V~hlci~ i Vehicle 2 CO~A~ES : liMITS ~Jb'M~i::i i:i ~j~Si i Work Loss Benefit $ 1,000/5,000 $ 1,000/5,000 (per month/maximum) Funeral Expense Benefit Accidental Death Benefit COMPREHENSIVE (Comp) COLLISION (Coil) TOWING RENTAL REIMBURSEMENT Premium Per Vehicle $ 2,500 $ 2,500 Excluded Excluded $ 100 Deductible $ 32.00 $ 100 Deductible $ 19.00 $ 500 Deductible $ 277.00 $ 500 Deductible $ 193.00 $ 50 $ 12.00 $ 50 $ 12.00 $ 20/600 $ 20/600 Per Day/Maximum $ 15.00 Per-Day/Maximum $ 15.00 $ 756.00 $ 649.00 Gold Rate Level Multiple Car Discount Anti-Lock Brake Discount Passive Restraint Discount (Driver and Passenger side) Applied Applied Applied Applied Applied Applied Applied ToTAEi VEHIc£E(S)~ ~"ISMS~:.AND cHARGES: Your Total Premium For~AII Vehicles $ 1,405.00 DRIVER INFORMATION Name Years Licei%r, ed Date of Birth Drivers License Number 01 THOMAS E HOGUE 13 02/04/71 22325722 02 RACHELLE L HOGUE 14 04/14/69 22816913 LIENHOLDER/OTHER INTERES'iED PA~JiES INFORMATION Vehicle 1 Loan Number Type of Interest CORESTATES P O BOX 13687 Lienholder ROANOKE VA 24036 Vehicle 2 FIRST MERCHANTS ACCEPT CORP INS SVC CENTER P O BOX 700247 DALLAS TX 75370 Loan Number Type of Interest Lienholder GENERAL POLICY INFORMATION The coverages and limits shown here are subject to the restrictions, conditions, and exclusions of the policy and its endorsements. YOUR POLICY IS SUBJECT TO THE FOLLOWING FORMS AND ENDORSEMENTS G-18537-A (09-93) SPECIAL MOTOR VEHICLE US 198974866 Continued on Next Page 00115 Page 02 of 04 USP Special Policy Endorsement Coverage Summary CNA For AII the CDrnmitments You Make' GENERAL POLICY INFORMATION YOUR POLICY IS SUBJECT TO THE FOLLOWING FORMS AND ENDORSEMENTS G-18538-A (09-93) INTRODUCTION G-18540-A (09-93) Gl-14786-B (09-97) Gi-14791-A (03-95) G2-14797-A (03-95) G!-!4801-A (03-95) G!-!5376-A (06-95) Gi-32346-A (07-98) G!-32347-A (07-98) GENERAL PROVISIONS AMENDMENT OF MOTOR VEHICLE PROVISIONS PENNSYLVANIA FIRST PARTY BENEFITS COVERAGE - PENNSYLVANIA UNINSURED MOTORISTS COVERAGE SPLIT LIMITS STACKED - PENNSYLVANIA UNDERINSURED MOTORISTS COVERAGE SPLIT LIMITS STACKED - PENNSYLVANIA TRANSITION ENDORSEMENT - SPECIAL MOTOR VEHICLE SEGMENT TOWING COVERAGE TRANSPORTATION COVERAGE SPECIAL PLEASE READ THIS IMPORTANT INFORMATION CONCERNING YOUR POLICY *C-!5402-A (03-90) IMPORTANT INFORMATION REGARDING YOUR MOTOR VEHICLE IDENTIFICATION CARDS *G-39555-E (08-95) PENNSYLVANIA FINANCIAL RESPONSIBILITY INSURANCE IDENTIFICATION CARD The forms marked with .... or '#' reflect revised or new forms included with this coverage summaw SUMMARY OF YOUR POLICY'S PREMIUMS COverageType Motor Vehicle Total For All Exposures $ 1,405.00 $ 1,405.00 For any insurance need, or questions on your policy, contact your independent CNA agent, whose name and number are shown on the first page of this Coverage Summary. US 198974866 Continued on Next Page C0115 Page 03 of 04 USP Special Policy Endorsement Coverage Summary CNA For AII the Commitments You Make' AGENT'S USE ONLY Policy Level Renewal Number 03. Auto Credit Level Data ss (Tier Level) Vehicle Level veh 3. vel3 2 Territory 118 13. 8 Symbol 10 04 Cost New Symbol 15 3.2 Performance Std Std Sex M F Marital Status M M Rate Level G G Prior Term's/Original Rate Level G C VARIABLE ENDORSEMENTS US 198974866 C0115 Page 04 of 04 Exhibit FEE AGREEMENT The undersigned, RACHELLE HOGUE, natural parent and guardian of DUSTIN HALL, hereinafter referred to as, "client", hereby retains and employs HANDLER, HENNING & ROSENBERG, LLP, to be my attomeys for me and in my name, place and stead, to represent me and to provide legal services, including all required appropriate research, investigation, conferences, interviews, negotiation searches, correspondence, telephone conferences, drafting, advice and litigation. HANDLER, HENNING & ROSENBERG, LLP, accepts the representation on the terms set forth below: We will represent you to the best of our ability in the matter, but can guarantee no result. We shall keep you fully informed as to thc progress of your case. We will send you copies of all correspondence sent in connection with your case. We will be available to you by telephone or in person for consultation. If no one is available when you telephone, your call will be returned promptly. You agree to pay for our services on a time expended basis at an hourly rate of $150.00 per hour. It is impossible to determine in advance the amount of time that will be required to bring your case to a conclusion. We assure you that we will proceed in an expeditious and efficient fashion and will consult with you in advance if any exceptional activity is necessary. Costs will be incurred by us in our handling of this matter. Costs are our out-of-pocket expenses for such items as court filing fees, investigation, auto mileage, photocopies, court reporters. medical records, expert witness fees, toll telephone charges, postage, etc. HANDLER, HENNING & ROSENBERG, LLP shall have the authority to make advances of costs on client's behalf of such amounts as they shall deem necessary to assist in the preparation and trial or the proper handling of client's case or the matter for which they are being retained. You agree that a final billing will be submitted to you at the conclusion of this matter. You agree that the final bill, if anything due, will be paid promptly, but no later than thirty (30) days after submission. In the event we are required to institute any legal action for collection of our fees or costs, you agree to pay additional fees, costs and the value of our time in bringing such an action. I acknowledge that I have read, approved and understood the above Fee Agreement and I acknowledge having received a copy of the same. The terms set forth herein are accepted. IN WITNESS WHEREOF, I have ~---~~, 2003. hereunto set my hand and seal this cF_.3 day of CHELLE HOGUE,~'~tural parent and guardian of DUSTIN HALL ondle,r, nmng senberg ATTORNEYS AT LA~C 1300 Linglestown Road, Harrisburg, PA 17110 Dustin Hall cio Rachelle Hogue 15 Thomas Drive Mechanicsburg, PA 17050 INVOICE February 27, 2003 Invoice#: 5071 Client #: 208113 Attorney: MSC Billing through:02128/2003 INVOICE FOR PROFESSIONAL SERVICES RENDERED 02/27/2003 0.20 0.20 150.00 30.00 02~7/2003 MSC 1/10/2003-LegalResearch ]MSC 02/27/2003 0.05 0.05 150.00 7.50 02/27/2003 MSC 1/13/2003 - Telephone discussion, Jennifre Shumway, Encompass MSC 02/27/2003 O. 02 O. 02 150. O0 3. O0 02/27/2003 MSC 1/14/2003 - Correspondence to Kocher, Erie re consent to settle etc. [MSC 02/27/2003 O. 02 O. 02 150. O0 3. O0 02/27/2003 MSC 1/14/2003 - Correspondence to Kocher, Erie, re request for policy & Dec page MSC 02/27/2003 0.02 0.02 150.00 3.00 02/27/2003 MSC 1/15~003-Le~erofrepresent~ionto Keystone Hel~hPlan ]MSC 02/27/2003 0.02 0.02 150.00 3.00 02/27~003 MSC 1/15/2003-Le~erofrepresent~ion, requestfile& policy [MSC 02/27/2003 0.02 0.02 150.00 3.00 02~7~003 MSC 1/15~03-Initialle~erofclient [MSC 02/27/2003 0.02 0.02 150.00 3.00 02~7/2003 MSC ERISAletterreliensto Keystone Health Plan [MSC 02/27/2003 0.02 0.02 150.00 3.00 02/27/2003 MSC 1/16/2003-ERISAletterreliens ~ Oitnikre Highmark MSC 02/27/2003 0.50 0.50 150.00 75.oo 02/27/2003 MSC 2/18~003-Review ofEncompassIns. Co.'sfile HSC 02/27/2003 0.02 0.02 150.00 3.00 02/27~003 MSC 2/18~003-Co~espondencetoEncompasslns. Co. 0.05 0.05 150.00 MSC 02/27/2003 7.50 02/27~003 MSC 2/18~003-Review ofDustin Hallfiles MSC 02/27/2003 0.50 0.50 150.00 75.00 02~7/2003 MSC 2~6~003-Telephonecon~ence, DonSuss MSC 02/27/2003 0.50 0.50 150.00 75.00 02/27/2003 MSC 2~6~003-Review ofstructuredsettlementproposal MSC 02/27/2003 0.50 0.50 150.00 75.00 02~7/2003 MSC 2/26/2003-Review ofcompletefile MSC 02/27/2003 1.00 1.00 150.00 150.00 02~7~003 MSC 2/27~3-Preper~ion/Review of Minor'sCompromiseP~etion MSC 02/27/2003 0.25 0.25 150.00 37.50 02~7~003 MSC 1/10~003-Review offile/case 208113 Hall, Dustin Invoice# 5071 Page 2 TOTAL FEES FOR THIS MATTER $556.50 EXPENSES ]CASE 02/27/2003 55.50 I 02/27/2003 Vendor PROTH OF CUMBERLAND CO; General Case Expense IcoPY 02/28/2003 6.00 02/28/2003 Document Reproduction IISI 02/28/2003 0.40 ] 02/28/2003 Document Reproduction [POS 02/28/2003 2.22 J 02/28/2003 PostageCosts [POST 02/28/2003 7.00 ] 02/28/2003 Postage Costs TOTAL EXPENSES MSC 3.71 3.71 150.00 556.50 3.71 3.71 556.50 Total due this invoice 55.50 6.00 0.40 2.22 7.00 $71.12 $627.62 TOTAL BALANCE DUE $627.62 PAYMENT DUE UPON RECEIPT Exhibit E FROM STRAT. IVE SER'VI,CES (?UE)APR 8 2003 6'57/ST. 6:54/N0.63~60265~3 P 2 PARENTS' RELEASE AND INDEMNITY AGREEMENT CLAIM NO. R1246341 IN CONSIDERATION OF the payments specified herein, by CONTINENTAL INSURANCE COMPANY and THOMAS E. HOGUE (hereinafter, 'Releasees') and intending to be !awfuli~ bound, RACHELLE HOGUE, Natural Parent and Guardian of DUSTIN HALL, a minor (hereinafter, 'Releasor'), does accept Said sum in full satisfaction of all sums of money claimed ' by Releasor to be owing, payable, or due Releasor fi'om Releasees. in consideration of the payment of the aforementioned payments. Releasor dc~es hereby remise, release,' quitclaim, and forever discharged Releasees, their heirs, executors, administrators, successors,,.and assigns, and every one of them. and all other persona and entities, whether herein named ~)r no~, of, and from7 any and all deter persona and entities, whether herein named or not, of, and from, any and all manner of actions, causes of action, suits, debts, sum or whatsoevqr, in law ~ equity, or otherwise howsoever, which Releasor ever had, now has, or which Releasor. his heirs, executors, administrators, successors or assigns, can, shall, or may have, against Releasee~ for. upon, or by mason of any matter, cause or thing, from the beginning of the world to the date of these premises, and especially for, upon, or by reason of all injuries, damages, and losses that arose as a result of that automobile collision that allegedly occurred on the Pennsylvania Turnpike, near the Bedford Interchange, in Pennsylvania, on February 7.2001 It is the intension of Releasor to accept the aforementioned payments in full settlement of all claims and potential claims against Releasees arising out of Said occuc[ence~. Releasor is executing this release in favor of the above-referenced Releasees only;. -i~eleasor reserves the right to pursue any claim Releasor may have against any other party. If-Releasor obtains a judgment against in any other party, this Release shall not bar or reduce Releasor's recovery on that judgment in any way. unless Releasees are Judicially determined to be joint tortfeasors, in that event, Releasor's recovery on the judgment shall be reduced by Releaseees' ~ rate share of liability for the judgment, without regard to the amount of consideration paid for this Release. This Release is in settlement of a doubtful and disputed claim and is not to be construed as an admission of liability, the same being expressly denied. To procure the payment of the said amount, the under-signed hereby declare: that no representations about the nature and extent of the Said injuries, disabilities or damages made by any physician, attorney or agent of any party released, nor any representations regarding the nature and extent of legal liability or financial responsibility of any of the parties released have induced the under-signed to make this release and indemnity agreement; that in determining the amount of the said sum there has been taken in to consideration not only the ascertained injuries. disabilities and damages, but also the possibility that the injudes sustained may be permanent and progressive and recovery therefrom uncertain and indefinite, so that consequences not now anticipated may result from the said accident. The undersigned agrees as a further consideration and inducement for this release and indemnity agreement, that it shall apply to all unknown and unanticipated injuries and damages directly and indirectly resulting from the said accident, as well as to those now disclosed. Obligor, amounts: 1. Payments. Continental Insurance Company, hereby agrees to make payment of the following (a~) Fetiodic Payments: To Dustin Hall, ~P'~i) $10,000.00 payable annually for 2 years guaranteed beginning on August 1, 2006. and ii) the following guaranteed lump sum payments: $15,000.00 on September 29, 2011, $36,875.00 on September 29, 2014, and $104.000.00 on September 29, 2017. FROM ADMINISTRAT't VE' S E,R'V ICES (TUE)APR. 8 2003 6'57/$T. 6'54/N0.6346026533 P 3 (b) Forthwith Payments; To the Guardian*of Dustin Hall and the Law OffiCes of HAndler Henning & Rosenberg, jointly, the sum of $627.62, to be disbursed as the Court directs. All payments set forth above constitute damages on' account of personal Injuries.or sickness arising' under the Complaint or as a result of the Incident, within the meaning of Section 104(aX2) of the Internal Revenue Code of 1986, as amended. " -, 2. Right of Ofi.qinal Oblk3or t~ Substitute De_-!gna!_~.J__NeW_Obli(~or. It i~ .understood and agreed by and between the'parties hereto that Obligor may, as a matter of right, and in Obligor's sole discretion, assign the duties and obligations as set ;~Srth herein with respect to the ped. adic payments to Releasor, Dustin Hall, to Allstata-Assignment Company and that such assignment, if made. shall be accepted by the Releasor without right ~5 rejection and in full discharge and release of the duties and obligations of the Obligor. In the event of such an assignment of the duties and obligations of the Obligor as authorized above, the payments and rights of the parties shall conform to Section 130 of the Internal RevenUe Code. If an assignment is made. the Obligor shall be released from all such future obligations and the assignee shall at all times remain directly and solely responsible for the payment of ell such sums and obligations. 3. Purchase of Assets(s) to Fund Periodic Payments, To assure the ready availability to the Obligor or an assignee, should an assignment be made pursuant to paragraph 2 hereof, of Periodic Payments payable under paragraph 1 of this Agreement, the Obligor or an assignee, should an assignment be made~-'~y, prompfly upon the execution o1' this Agreement,' purchase an annuity from Allstate Life Insurance Company as sole owner. Releasor acknowledges that the periodic payments cannot ~ accelerated, deferred, increased, or decreased by the Releasor or any Payee; nor shall the Releasor or any Payee have the power to sell, mortgage, encumber, or anticipate the periodic payments, or any part thereof, by assignment or otherwise. As a matter of convenience. Releasor may be designated as a payee and Releasor's estate designated as a beneficiary In applying for the aforesaid annuity. Any payments to be made after the death of the Payee pursuant to the terms of this Agreement shall be made to such person or entity as shall be designated in writing by said each Releesor to the Assignee. If no such person or entity is so designated by said each Releasor or if the person designated is not living at the time of the Payee's death, such payments shall be made to the estate of the Payee. The obligation of the Obligor, or of an assignee should an assignment be made. to make each pedodic payment shall be discharged upon the mailing of a valid check in the amount of such payment to the designated address of each Payee named in this Agreement. It shall be the obligation of said each Releasor to keep Assignee advised of the address to which payrnents are to be tendered. Any change of address shall be supplied in writing at least thirty (30) days prior to the due date of any payment date. The undersigned understands that the parties hereby released admit to no liability of any sort by reason of said accident and that said payment in compromise is made to terminate further controversy respecting all claims for damages that said minor or the undersigned have heretofore asserted or might personally or through personal representatives hereafter assert because of said accident. Signed and sealed this In the presence of STATE OF _ ~ COUNTY OF. ~ On this __ day of instrument, and acknowledge that day of ,. (SEAL) 'Rachelle Hogue, Guardian of Dustin Hall before me personally appeared , to me known to be the person., who executed the foregoing executed the same as. free act and deed. My commission expires Notary Public FROM ADM NISTRATIVE S~ERVfCES (TUE)APR 8 2003 '6'58/ST. 6'54/NO. 63~6&265~3 P 4 Uniform Qualified Assignment and Release -Claimant" 'Assignee" "Annuity Issuer' 'Effective Date" Dustin Hall, a minor, by and throug.h J~is parent and natural guardian, Rachelle Hogue ,~. _ ~='Continental Insurance Company .;, Allstate Assignment Company Allstate Life Insurance Company This Agreement is made and entered into by and between the parties hereto as of the Effective Date with reference to the following facts: Claimant has executed a settlement agreement or release dated ,20 (the "Settlement Agreement") that provides for"~'~ Assignor to make certain periodic payments to or for the benefit of the Claimant as stated in Addendum No. I (the 'Periodic Payments"); and The parties desire to effect a 'qualified assignment' within the meaning and subject to the conditions of Section 130(c) of the Internal Revenue Code of 1986 (the 'Code"). NOW, THEREFORE, in consideration of the foregoing and other good and valuable consideration, the parties agree as follows: 1. The Assignor hereby assigns and the Assignee hereby assumes all of the Assignor's liability to make the Periodic Payments. The Assignee assumes no liability to maU~, any payments not specir~:[ in Addendum No. 1. ~ = ' 2. The Pedodic Paym~.~ constitute damages on account of personal injury or sickness in a case involving physical injury or physical sickness within the meaning of Sections 104(a)(2) and 130(c) of the Code. The Assignee's liability to make the Periodic Payments is n-~ greeter than that of the Assignor immediately preceding this Agreement. Assignee is not required to set aside specific assets to secure the Periodic Payments. The Claimant has no dghts against the Assignee greater than a general creditor. None of the Pedodic Payments may be accelerated, deferred, increased or decreased and may not be anticipated, sold, assigned or encumbered. The obligation assumed by Assignee with respect to any required payment shall be discharged upon the mailing on or before the due date of a valid check in the amount specified to the addrea~ of record. This Agreement shall be governed by and Interpreted in accordance with the laws of the State of Pennsylvania. The Assignee may fund the Pedodic Payments by purchasing a "qualified funding asset" within the meaning of Section 130(d) of the Code in the form of an annuity contract issued 'by the Annuity Issuer. All rights of ownership and control of such annuity contract shall be and remain vested in the Assignee exclusively. The Assignee may have the Annuity Issuer send payments under any 'qualified funding asset" purchased hereunder directly to the paye.e_(s) specified in Addendum No. 1. Such direction of payments shall be solely for the Asstgnee's convenience and shall not provide the Claimant or any payee with any rights of ownership or control over the 'qualified funding asset" or against the Annuity Issuer. FROM ADMINISTRATIVE S, ERV,ICES (TUE)APR 8 2003 6'58/,,ST. 6:54/NO. 63,46&265,33 P 5 10. Assignee'~ liability to make the PeriodiC Payments shall continue without diminution regardless of any bankruptcy or Insolvency of the Assignor. In the event the Settlement Agreement is declared terminated by a court of law or in the event that Section .130(c)' Of the Code has not been satisfied, this Agreement shall terminate. The Assignee shall then asslgM .ownership of any "qualified funding asset~ purchased heret.,~der to Assignor, ahd Assignee's liability for the Periodic Payments shall terminate. This Agreement shall be binding upon the res~oective representatives, heirs, successors and assigns of the Claimant, the Assignor and the Assignee and upon any person or entity that may assert any right hereunder or to any of the Periodic Payments. 11. The Claimant hereby accepts Assignee's assumption of all liability for the Periodic Payments and hereby releases the Assignor from all liability for the Periodic Payments. Assignor: Continental Insurance Company Assignee: Allstate ~ssigi~ment Company By: Title; Authorized Representative By: Title: Authorized Representative Claimant: Dustin Hall, a minor, by and through his parent and natural guardian, Rachelle Hogue Approved as to Form and Content: National S~ructured Set~lernen[s Trade Association FROM ADMINISTRATIVE S':R'V?CES~ I (TUE)APR 8 2003 6'58/ST. 6'54/N0.63~6~265~3 P 6 Addendum No. 1 Description of Periodic Payments Periodk: Payments: - To DUstin Hall, .-' i) $10,000.00 payable annually for 2 years guaranteed beginning on Augub,-1, 2006, and II) the following guaranteed lump sum payments: $150000.00 on September 29. 2011, $36,875.00 on September 29, 2014, and $104,000.00 on September 29. 2017. lnitisls ~lalmant: Assignor: Assfsnee: VERIFICATION THE UNDERSIGNED hereby verifies that the statements in the foregoing dOcument are based on information that was gathered by counsel in preparation of this lawsuit. The language of the above-named document is of counsel and not of my own. I have read the said document and, to the extent that it is based on information that I gave to counsel, it is true and correct to the best of my knowledge, information and belief. To the extent that the contents of the said document is that of counsel, I have relied upon my counsel in preparing this Verification. THE UNDERSIGNED also understands that the statements therein are made subject to the penalties of 18 Pa.R.C.P. 2252(d), relating to unsworn falsification to authorities. natural parent and guardian of DUSTIN HALL, a minor DUSTIN R. HALL, a Minor, by and through his natural parent and guardian, RACHELLE HOGUE, Petitioner THOMAS E. HOGUE, Respondent · IN THE COURT OF COMMON PLEAS · CUMBERLAND COUNTY, PENNSYLVANIA NO. - CIVIL ACTION - LAW MINOR'S COMPROMISE ORDER AND NOW, this i ~ day of_~~ 2003, upon consideration of the within Petition, ' IT IS HEREBY ORDERED that the disbursement of funds, including counsel fees and expenses, is approved as set forth in said Petition and the funds shall be disbursed in accordance with the terms and conditions of the settlement agreement as follows: A. Direct payment of $627.62 to Matthew S. Crosby, Esq., representing reasonable attorneys' fees and reimbursement of costs; B. Direct payment of the remaining $99,372.38 to Allstate Assignment Company (AAC) for the purchase of an annuity from Allstate Life Insurance Company (ALIC), which is rated A+ (Superior) byA.M. Best, Aa2 by Moody's, and AA+ by Standard & Poor's. ALIC will issue an Evidence of Guarantee Certificate that guarantees the payment obligation _ assigned to AAC. The annuity ~ fqr..the followi.ng lump sum paymentsc[~~ (1) $10,000.00 on 8/1/2006 (2) $10,000.00 on 8/1/2007 (3) $15,000.00 on 9/29/2011 ~ (4) $36,875.00 on 9/29/2014 (5) $104,000.00 on 9/29/2017 Proof of deposit is to be filed with the Court. THE COU ~T.'~' . J. DUSTIN R. HALL, a minor, by and through his natural parent and guardian, RACHELLE HOGUE, Petitioner V= THOMAS E. HOGUE, Respondent IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 03-1699 CIVIL TERM CIVIL ACTION - LAW MINOR'S COMPROMISE PROOF OF DEPOSIT AND NOW, comes the Petitioner, RACHELLE HO, GUE, natural parent and guardian of DUSTIN R. HALL, a minor, and by and through her attorneys, HANDLER, HENNING & ROSENBERG, LLP, and avers that a restricted account was opened for the said minOr, in a structured settlement annuity for the minor, in accordance with the April 16, 2003, Order of Court, signed by The Honorable Edgar B. Bayley, Judge. Attached hereto, made a part hereof, and marked, "Exhibit A," is documentation evidencing the opening of the said restricted account for 'Ihe said minor. DATE: HANDLER/,/HENNIi~G & ROSENBERG, LLP /I (_.--M~tthew S. Crosby, Esq. 1300 Linglestown Rd. Harrisburg, PA 17110 Tel. No.: 717-238-2000 Supreme Court: ID No.69367 Attorneys for Petitioner gitEO FINANCIAL ASSOCIATES JEFFREY F. SWTGART, J.D. Vice president DONALD B. SUSS, J.O. Vice president WARREN J. AD.R, J.O. Sett~me.t Sp~.inii~t April 30, 2003 Matthew S. Crosby, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harfisburg,'PA 17110 Re: Dustin R. Hall DOL: 2/712001 .Our File No. 02-10-9335 Dear Mr. Crosby: Pursuant to your request and to comply with the terms of the Court Order, enclosed ase letter from Allstate Life Insurance Company please find a roof-of-purch n aid for the confirming that tPl~e premium in the amount of $99372.38 has bee p structured settlement annuity in this matter. The original structured settlement documents have been forwarded to Continental Insurance Company for execution. Upon our receipt we will forward all the documents to Allstate Life to have the annuity policy issued. We will provide you with a copy of the annuity policy and fully executed documents as soon as we receive them from Allstate Life. If you have any questions, please give us a call. Very truly yours, STRUCTURED FINANCIAL ASSOCIATES, INC. :pgs(hall) Enclosure OFFICES: Anchorage At, nra 13altJmore Baton Rouge Boston Ch~,ago Cleveinnd Dallas Denver Des Moines Detroit Grand Rapids Hawaii Houston Los Angeles New Ymk Nodh Carolina Oklahoma City Orlando Philadelphia Phoenix Pittsburgh Roanoke Rockford St. Paul San Antonio San Francisco Seattle Topeka Tulsa Washington, D.C. Structured Financial Associates, inc. Phitadeyhia OtfK:e ~ Chester County Commons I 8 Mystic Lane I P.O. Box 880 I Frazer, PA 19355 I Tel: 610.647.2611 ~ Fax: 610.647.2674 ~ small: sfaphila~voicenet.com EXHIBIT A AIIsl'afe. Allstate Life Insurance Company~,~ 3100 Sanders Road, M3B Northbrook, IL 60062 (847) 402-2281 FINANCIAL (847) 418-4221 FAX Structured Settlement Administration ^pA1 28, 2003 Structured Financial Associates Attention: Trish Swigart Reference: Dustin R. HaH Case # 90-832-409 Dear Trish: This letter shall serve as an acknowledgment for receipt of premium in the mount of $99,372.38 for the purchase of an annuity for the above referenced individual. The Structured Settlement contract will pay for the benefit of Dustin R. Hall the following: · $10,000.00 annually guaranteed for two years on August 1, 2006. $15,000.00 guaranteed lump sum on September 29, 2011. · $36,875.00 guaranteed lump sum on September 29, 2014. · $104,000.00 guaranteed lump sum on September 29, 2017. The above referenced contract will be issued upon receipt and review of all required documents. Should you have any questions, or require additional information, please feel free to contact me at the number listed above. S~cere~_.) , Saffiantha Reidy f ) Structured Settlement A'dhainistration