HomeMy WebLinkAbout01-04659NATIONWIDE ASSURANCE
COMPANY d/b/a COLONIAL
INSURANCE COMPANY,
PETITIONER
V.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
GARY HIPPENSTEEL AND DIANNA
HIPPENSTEEL, as Parents and
Natural Guardians of CASEY
HIPPENSTEEL,
RESPONDENTS 01-4659 CIVIL TERM
ORDER OF COURT
AND NOW, this '1'O day of August, 2001, upon consideration of the
petition for Leave to Settle or Compromise Minor's Action, it is hereby ordered that the
minor, Casey Hippensteel, born August 6, 1986, a minor through her parents and
natural guardians, Gary Hippensteel and Dianna Hippensteel, is authorized to enter into
a settlement agreement with the petitioner, Nationwide Assurance Company d/b/a
Colonial Insurance Company, for the minor child in the gross sum of Twenty Thousand
Three Hundred Dollars ($20,300.00), with a lump sun payment of Five Thousand Three
Hundred Dollars ($5,300.00) to be paid to Casey Hippensteel on or about August 6,
2004, and Fifteen Thousand Dollars ($15,000.00) to be paid to Casey Hippensteel on or
about August 6, 2007.
Amy L. Coryer, Esquire
For Petitioner
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NATIONWIDE ASSURANCE
COMPANY d/b/a COLONIAL
INSURANCE COMPANY,
PETITIONER
V.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
GARY HIPPENSTEEL AND DIANNA
HIPPENSTEEL, as Parents and
Natural Guardians of CASEY
HIPPENSTEEL,
RESPONDENTS 01-4659 CIVIL TERM
ORDER OF COURT
AND NOW, this ~ ~ day of August, 2001, IT IS ORDERED that a
hearing shall be conducted on the within petition at 8:45 a.m., Monday, August 20,
2001, in Courtroom Number 2, Cumberland County Courthouse, Carlisle, Pennsylvania.
By the
Edgar B. Bayley,
Amy L. Coryer, Esquire
For Petitioner
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POST & SCHELL, P.C.
BY: AMY L. CORYER, ESQ.
I.D. # 82718
240 GRANDVIEW AVENUE
CAMP HILL, PA 17011
(717)731-1970
ATTORNEYS FOR PETITIONER
NATIONWIDE ASSURANCE
COMPANY d/b/a COLONIAL
INSURANCE COMPANY
NATIONWIDE ASSURANCE COMPANY,
d/b/a COLONIAL INSURANCE COMPANY
Petitioner,
v.
GARY HIPPENSTEEL AND DIANNA
HII'PENSTEEL, as Parents and Natural
Guardians of CASEY HIPPENSTEEL
Respondents.
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY,
PENNSYLVANIA
CIVIL ACTION -LAW
ORDER APPROVING MINOR'S COMPROMISE FOR DISTRIBUTION
AND NOW this day of , 2001, upon Consideration of the
Petition for Leave to Settle or Compromise Minor's Action, it is hereby ORDERED that the
Minor, Casey Hippensteel, a minor through her parents and natural guardians, Gary Hippensteel
and Dianna Hippensteel, is authorized to enter into a settlement agreement with the Petitioner,
Nationwide Assurance Company d/b/a Colonial Insurance Company, for the minor child in the
gross sum of Twenty Thousand Three-Hundred Dollars ($20,300.00), with a ltunp sum payment
of Five Thousand Three Hundred Dollars ($5,300.00) to be paid on or about August 6, 2004, and
Fifteen Thousand Dollars ($15,000.00) to be paid on or about August 6, 2007.
BY THE COURT:
M
POST & SCHELL, P.C.
BY: AMY L. CORYER, ESQ.
I.D. # 82718
240 GRANDVIEW AVENUE
CAMP HILL, PA 17011
(717) 731-1970
NATIONWIDE ASSURANCE COMPANY
d/b!a COLONIAL INSURANCE COMPANY
Petitioner,
v.
GARY HIPPENSTEEL AND DIANNA
HIPPENSTEEL, Individually, and as Parents
and Natural Guardians of CASEY
HIPPENSTEEL
Respondents.
ATTORNEYS FOR PETITIONER
NATIONWIDE ASSURANCE
COMPANY d/b/a COLONIAL
INSURANCE COMPANY
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY,
PENNSYLVANIA
CIVIL ACTION -LAW
NO: UI -' 111.$9 ~tu~~~'~
PET TION FOR LEAVE TO SETTLE OR COMPROMISE MINOR'S ACTION
AND NOW, comes the Petitioner, Nationwide Assurance Company d/b/a Colonial
Insurance Company, by and through its attorney, Post & Schell, who files this Petition to
compromise action for approval of settlement and aver the following in support thereof:
1. Petitioner is an insurance company who writes business in the State of
Pennsylvania.
2. Respondents, Gary Hippensteel and Dianna Hippensteel, are adult individuals
currently residing at 243 Neil Road, Shippensburg, Cumberland County, Pennsylvania, 17257.
3. Respondents, Gary Hippensteel and Dianna Hippensteel, are the parents and natural
guardian of the Minor, Casey Hippensteel, who resides with the Respondents at the above-noted
address. ee Affidavit of Parents attached hereto as Exhibit "A".
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4. This petition is filed as a result of injuries sustained by the Minor child, Casey
Hippensteel, as a result of an automobile accident that occurred on February 16, 2001.
5. The Minor child, Casey Hippensteel, sustained a laceration to the forehead, a
sprained right ankle, and soft tissue injuries to her neck, back and left shoulder. See copy of
medical records attached hereto as Exhibit "B".
6. At the time of the accident, the Minor child was under the majority care and control
of the Respondents.
7. Petitioner has made a careful and diligent inquiry and investigation into the facts
surrounding the accident, the responsibility therefore, and the nature, extent and seriousness of
the Minor child's injuries.
8. All of the Minor child's medical bills have been paid.
9. The Respondents, Gary Hippensteel and Dianna Hippensteel, carried a policy of
insurance with the Petitioner, Nationwide Assurance Company d/b/a Colonial Insurance Company,
on the date of loss with unstacked Underinsured Motorists Benefits with limits in the amount of
$15,000 per person. See declarations page with rejection of stacked underinsured motorists
benefits form attached as Exhibit "C".
10. The Petitioner, Nationwide Assurance Company d/b/a Colonial Insurance
Company, has agreed to compromise this Underinsured Motorists claim for the policy limits of
Fifteen Thousand and 00/100 ($15,000.00). The $15,000.00 is being paid to purchase a structured
settlement which will result in a total payment of Twenty Thousand Three Hundred Dollars
($20,300.00) to the Minor Child, with a lump sum payment of Five Thousand Three Hundred
Dollars ($5,300.00) to be paid on or about August 6, 2004, and Fifteen Thousand Dollars
($15,000.00) to be paid on or about August 6, 2007. It is a fair and reasonable resolution under
the circumstances. See Exhibit "D".
11. The Respondents, Gary Hippensteel and Dianna Hippensteel, understand and
approve the settlement achieved. See Exhibit "A".
12. The Respondents, Gary Hippensteel and Dianna Hippensteel, have executed both
a Release Agreement and a Uniform Qualified Assignment and Release, copies of which are
attached hereto as Exhibit "E".
WHEREFORE, Petitioner prays that an Order be entered approving the Minor's
Compromise and ordering that distribution pursuant to the Court's Order.
Respectfully submitted,
POST & SCHELL, P.C.
DATE: ~_ a~ (lsri~0.
AMY L. RYER SQUIRE
Attorney for Petitioner
I, Shany D. Semans, an employee of Post & Schell, P. C., do hereby certify that on the date
listed below, I did serve a true and correct copy of the notice of deposition upon the following
person(s) at the following address(es) by sending same via United States mail, first-class, postage
prepaid:
Gary and Dianna Hippensteel
243 Neil Road
Shippensburg, PA 17257-9403
Respectfully submitted,
POST & SCHELL, P. C.
DATE: ~~.2~~7/ BY ~S^v~.~~,c~, ~Q"'~ ~""-~O
Sharry D. S nans
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AFFIDAVIT OF PARENTS
In the Commonwealth of Pennsylvania:
County of Cumberland:
Gary Hippensteel and Dianna Hippensteel, being duly sworn according to law, depose and
state:
We are the parents and natural guardians of the minor, Casey Hippensteel.
2. We have reviewed and approved the Petition for Leave to Compromise Action on
Behalf of a Minor and the Order Approving Minor's Compromise for Distribution and concur with
the distribution.
Sworn to and subscribed
before me this ~~' day of
2001.
Notary Seal
NOTARIAL S Not ry Public
pEBORAH WARREN,
Shippensburg, Cumberland County
My Commission Ex~hes`Nov. S, 2001
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".- NAME AND ADDPE55 TELEPHONE N0. MEDICAPE SECONDARY PATER INFO. ADMIT BY
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REFERRING PHYSICIAN
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PRINCIPAL DIAGNOSIS (reason for admission afrer study) list one:
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I certify that the narrative descriptions ofthe principal and secondary diagnoses and [he major procedures performed are accurate
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Dischazge Date/Att station Date Physician's Signature/Date
STEEL, CASEY 0269101 ~. ...
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ALPPEN18215-1 RmlBed: , 021161
MR#: 518233 Adm Dt.
poctor: GGRMAN MD14Y HSexp• F
7175325538
pOBIAge: 08106186
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ADDITIONAL INSTRUCTIONS APPOINTMENTS
Prima Doctor's Appointment: `j~; /~,,,~
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Consuttafwn Appointment:
Dr. phone:
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Any driving restrictions: ^ yes ^ no (if yes
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HIPPENSTEEL, CASEY M CALL IN EMERGENCY:
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MR#: 518233 Adm Dt: 02/16/01
Doctor: ,GORMAN MD, RICHARD E
DOB/Age: 08/06/86 14Y Sex: F
IyOtlfy; DIANNA 7175325538
understand these instructions:
WHITE COPY-CHART VELLOW COPY-PATIENT PINK COPY-PHYSIC/AN ~ " - msuucrlons uwen ny R: 4/95
P03348
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THE CHAMBERSBURG HOSPITAL
112 N. Seventh St.
Chambersburg, PA 17201
DISCHARGE SUMMARY
HIPPENSTEEL, CASEY M. Medical Record #: 518233
R. E. Gorman, M.D. Admission Date: 02/16/2001
Discharge Date: 02/17/2001
ADMITTING DIAGNOSIS: 1. Multiple trauma secondary to motor vehicle accident.
SPECIFIC DIAGNOSES: 2. Laceration to the forehead.
3. Multiple contusions and abrasions.
HISTORY: This is a 14-yeaz-old female, unbelted, rear seat driver's side passenger who was T-
boned in a motor vehicle accident which subsequently struck a telephone pole on the driver's
side. She lost consciousness and she has amnesia related to the events of the accident. Her vital
signs were stable in the field and en route. She was complaining on admission of some pain in
her head, her left shoulder, her back throughout the thoracic and lumbaz regions. Her past
medical history is significant for asthma. Medications include Singulair and Albuterol.
Physical examination: She was awake and alert and in no distress. Vital signs were stable.
HEENT: There was noted to be a laceration on her forehead, just beneath tlae hairline extending
transversely that goes deep down to but not through galea. Pupils were equally round and
reactive. 'TMs were clear. Neck was supple, minimally tender posteriorly. Lungs were clear.
Heart was RRR. Abdomen was soft without masses. Pelvis stable. Rectal: Guaiac negative. On
examination she is noted to have an abrasion of the left shoulder and left knee. Point tenderness
in the medial aspect of the right ankle. Neurologically she was grossly intact.
'LABS: Amylase was 98; white count elevated at 16,000. Beta HCG was negative. X-rays: Chest
x-ray, pelvis x-ray, C-spine f lms, thoracic lumbar films, ankle films, CT scan of head, facial
bones, abdomen and pelvis all were negative.
HOSPITAL COURSE: The patient was admitted. In the Emergency Room she underwent
rep~ii~ 8ftfie laceration of her face by myself. She was kept under observation and was
discharged the following day with prescripfion for pain medications and to follow-up with me in
the office in a week.
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REG/TKaas/268881
D: 02/26/2001
T: 02/27/2001
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Registration Data Sheet
CHART COPY
An u~liNre nf5ummit Hcaltp GEflVICE 000E METHOD OF APPIVAL CLEflK'S INITIALS ACCOUNT N0. TYPE MEDICAL RECOPDS N0.
--- 75 AMB MED TSK 3182151 2 518233
- NAME AND AOORESS TELEPHONE N0. PATIENT OCCUPATIONIEMPLOYEfl NAME & ADOPE55 ~ PPIMARY TELEPHONE N0.
HIPPENSTEEL, CASEY M (7171532-5538
: 243 NEIL ROAD UNEMPLOYED EMP CODE:
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W' FIN DATE OF EEgVICE TIME AGE DATE OF BIPFH SEX flACE MARITAL NE%T OF KINIPEgGON TO NOTIFY IINF01
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SPECIAL INFO
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°:`;ERGENCY CARP ='IT RECORD ~~~
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Time Seen L'~!' pCC Time=_min preaching Physician present for key port proc+ Eval Management Plan N (if yes, place a green tlot on ch rt.
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ETOH STREP SCREEN TIBIFIB' RIB SERIES LS SPI PULSE OX: HX OBTAINED pSPOUSEp FAMIL
IV - NS KVO, MONITOR ~ BABY ASA 2 PO ^ NI Ttl O.SCC POTHER
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KEFLEX 250mg - 7 po qid TYLENOL #3 _ po q 4 hr with food prn pain ANOXIC 125mg/Scc _tsp po tid
ROBITUSSIN AC _cc TG, _tsp po q 4 hr NLENOL #3 ELIXIR _cc TG, _tsp q 4 hr prn pain ANOXIC 250mg/SCC _ tsp po tid
GENTICIDIN DROPS _gtts OD/OS qid PERCOCET - 4TG -1 po q 4 hr with food prn pain BACTRIM DS - 2TG -1 po bid
FLEXERIL 1 po iid prn spasm DARVOCEf - i po q 4 hr with food prn pain BIAXIN - SOOmg - i po bid
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Physician's Signature Referral Physician's Signature ~- Discharge Time
Name: HIPPENSTEEL
CASEY M E rgency Care Unit / A endi g Doctor .Time otified
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Acct Nb: 318215-1 Date Fa Wily Doctor
02/16/01
MR No: 518233 CHANIBERSBiJRG
Age: 14Y DOB: 08106/86 Sex: F Time Referred to Doctor HOSPITAL
13:00 (MA A, _ ' 2 ~ ~
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Chambersburg, PA
CHART COPY
P00090 (O:6/97,R:4/00)
N~
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,Date
~~1~~°I Triage Time
~`5oS Triage Priority - ~'
~ Room
~
plaint:
Chief Com vital signs Arrival Mode:
lI
~ L
v1A~ ~t-~-+ fJ""`~' Time T P R BP 02 sat%
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lk
^
a
^ W/C
HPI Pain Score- ~ ~ " ~ S
2 S
~-BLS
~~ ~}2ei~ •~d
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- r1/tB~~;<,wGt W ~r ~: ~
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"~ ^ Other
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C ~ ^ .,~ ~ ~ ~A . p <n
Yr ~ fJ~" Info provided by (if other than patient):
^ Family ^ Other
2 ~ ~^ Language spoken other than English:
Airway/Breathing Mental Status Speech
Other concerns ^ No Able to speak
^ Assisted lert
^ Oriented X -~I~ormal
^ Aphasic
PMH:
N
PSH:
^ None ^ Labored
^ Shallow
^ Apneic ^ Unresponsive
^ Confused ^ Slurred
^
one
^ iris
Asthma
^ CA
^ Cardiac
^ COPD
^ CVA
^ Diabetes
^ Hypertension ^ Appendectomy
^ Cardiac
^ Cholecystectomy
^ Hysterectomy
^ Other 06/GYN
^ Prostate
^ Tonsillectomy -
^ Hernia repair
Behavior
ooperative
^ Uncooperative
^ Calm
^ Agitated
t] Violent
Conversation
~herent
^ Silent
^ Overtalkative
^ Incoherent
^ Crying Ideation
NA (Not Applicable)
^ Harmful to Self
^ Harmful to Others
^ Psychosocial
^ Seizures
^ Smokes
^ Substance Abuse ^
^
Visual Acuity:
OS OD
^ Corrected ^ Not Corrected
MP WT
^ Tet us:
ithin 5 yrs
^ >5
rs
^ Never
^VIS
iven
rior to Td Ped Immunization:
^UTD
^ Not UTD ^VIS
iven
i
t
Td
Medications, Herbs, & Vitamins: ^ None ^ Unknown Las[ Dose y g
p g
pr
or
o
., Emotional /Safety / Religious.lssues:
^ No
^ Yes ^ Domestic Violence /Abuse Referral
^ SS R
f
l
- e
erra
^ Chaplain Referral
I ~ ; ~ ^ Yes ^ No Age appropriateness RR Growth and Development < 17 years
^ N/A
PRE-HOSPITAL CARE: ^ N/A
Vital signs: BP: P: Rhythm: R:
- Oxygen
^ ET Tub
# Airway: ^ Nasal ^ Oral
T
d
_ -
- e
^ Cervical Collar ape
@ cm -
ALS MEDS
Allergies• - Reaction: ^ Longboard
^ CID
^ Splint ^ Albuterol med neb ^ Atropine
^ NTG x ^ Epinephrine
^ Lasix ^ Lidocaine
^ CPR Begun @
^ Blood Sugar ^ Morphine
^ Dextrose 50
^ I.V. ^ Other
. Triage RN ,`("
Signature 4• ~ ,~
HIPPENSTEEL, CASEY M ECU Triage Assessment C//dlnb@rSbUrgw
Acct: 318215-1 Hospital
MR#f: 518233 d .~,Kr;,~e of s~mmu seatm
Oate: 1)2/16/01 tl2 North Sevemn Street • P.O. Box 6005
DOB/Age:O8/O6/86 14YSex: F cnambersnurg,Pnuzm-eons • pt»zb~aooo
Patient Phone: (717)532-5538
White -Chart Copy Yellow -Physician Billing PoooBac lo:aloo)
THE CHAMBERSBURG OSPITAL
112.N. Seventh St.
Chambersburg, PA 17201
4~
~~ \^~
~~
Page 1
EMERGENCY CARE UNIT
(717) 267-7146
HII'PENSTEEL, CASEY M
Patient #: 3182151
Treatment Date: 02/16/2001
J. M .Connor, D.O.
Medical Record #: 518233
Patient Type: 2
D.O.B: 08/06/1986
CHIEF COMPLAINT: Motor vehicle accident.
HISTORY OF PRESENT ILLNESS: This is a 14-year-old female who was a rear seat, behind
the driver, passenger in a motor vehicle accident. The driver apparently ran a stop sign and the
car was T-boned on the driver's side. It was then pushed into a telephone pole. The patient does
not recall the accident. She had apparent loss of consciousness. She was transported to the
emergency department on back board and CID. She complains of pain to her entire back, left
side of her face, her neck, her left knee and her right ankle.
PAST MEDICAL HISTORY: Significant for asthma.
PHYSICAL EXAM: Saturations are 99% on room air, blood pressure 125/56, respiratory rate is
22, pulse 120, temperature 97.6. Examination of the head reveals an approximately 6 inch
laceration over the mid forehead at the hairline. It extends full-thickness. Pupils are equal and
reactive to light. Extraocular movements are intact. The neck has some tenderness in the right
paraspinal muscles. Thorax has some bruising over the left side of the chest. No subcu. or
crepitants. The lungs are clear. Cardiovascular is regular rate and rhythm. The abdomen is soft
with mild tenderness. No localizing pain. Pelvis is nontender to rocking. The right lower
extremity reveals pain in the right ankle and pain in the left knee. No obvious deformities with
mild bruising present. The upper extremities show no obvious trauma.
DIAGNOSTIC STUDIES: Portable chest, pelvis and C-spine show no significant
abnormalities. CT of the head to evaluate the swelling and periorbital ecchymosis over the left
orbit are pending. White count was 16.2 with a hemoglobin of 13.4 and hematocrit of 40.
Pregnancy test was negative. Urinalysis was negative. Drug screens were all negative.
DIAGNOSIS: 1. Multiple trauma from motor vehicle accident.
2. Facial trauma.
3. Scalp laceration.
TREATMENT: Immediate general surgery consultation was obtained on arrival to the
emergency department. The patient had CT of the head and facial bone, CT of the abdomen and
~_.:
~~.
THE CHAMBERSBURG HOSPITAL
112N. Seventh St.
Chambersburg, PA 17201
Page 2
EMERGENCY CARE UNIT
(717) 267-7146
HIPFENSTEEL, CASEY M
Patient #: 3182151
Treatment Date: 02/16/2001
J. M .Connor, D.O.
Medical Record #: 518233
Patient Type: 2
D.O.B: 08/06/1986
pelvis and plain x-rays of the involved extremities. The patient will be subsequently admitted to
Dr. Gorman's service for continued care and treatment.
7MC/rlr
D: 02/16/2001
"~~~`~T: 02/17/2001
cc:
'C~'.
J. M,.. Connor, D.O.
THE Ci3AMBERSBUR OSPITAL '" ~ Page 1"
' 112 N. Seventh St.
Chambersburg PA 17201
HISTORY & PHYSICAL EXAMINATION
HII'PENSTEEL, CASEY M
Patient #: 3182151
Admission Date: 02/16/2001
R. E. Gorman, M.D.
Medical Record #: 518233
Patient Type: 1
DOB: 08/06/1986
Patient Rm: 0269-01
DIAGNOSIS:
SECONDARY DIAGNOSIS: Asthma.
HISTORY OF PRESENT ILLNESS: This is a 14-year-old unbelted, reaz-seat, driver-side
passenger who was T-boned in an MVA, and the car was struck into a telephone pole on the
driver's side. She did lose consciousness, and she has amnesia about the events surrounding the
accident but none since. Her vital signs were stable in the field and en route. She is complaining
of some pain in her head,. her left shoulder, her back throughout the thoracic and lumbar regions,
her right ankle and her left knee.
PAST MEDICAL HISTORY: Her past medical history is significant for asthma.
ALLERGIES: She has allergies to penicillin.
MEDICATIONS: Her medications include Singulair and albuterol.
PHYSICAL EXAM:
GENERAL: She is awake and alert. She is in no acute distress. Vital signs were stable.
HEENT: Normocephalic. There is a laceration on her forehead just beneath the
hairline extending transversely that goes deep almost down to the gales.
Pupils aze equally round and reactive. TMs are clear.
NECK: Her neck is supple. Mildly tender posteriorly.
LUNGS/CHEST: Lungs are clear.
HEART: Heart is regulaz rate and rhythm.
ABDOMEN: The abdomen was mildly tender in the right upper quadrant without
_ guarding or rebound.
PELVIS: Stable.
n, ~
PATE ~ ~ I ~ ( -z ~ 2 ( ZZ
HOUR A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M.
4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12
105
t04
103
T
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M 102
P
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A
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R
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~~
HIPPENSTEEL, CASEY M
Acct: 318215-1 Rm/Bed: 0269/01
MR#: 518233 Adm Dt:02/16/01
Doctor: GORMAN MD, RICHARD E
DOB/Age: 08/06/86 14Y Sex: F
Notify: DIANNA 7175325538
THE CHAMBERSBURG HOSPITAL
` 112 North Seventh Srreet • Chambersburg, PA 17201
GRAPHIC SHEET
P04060
Date: ~_
7-3 3-11 it-7
oral '7 a'U
Enteral
Pazenteral ~~
OR Fluids
Other
ShiftTotals
Urine a7s
Gastric Suction
Drain(s) Type:
Emesis
OR Output
Shift Totals ,~Sb
Intake: _
(24 hrs.)
Output:
(24 hrs.)
Date:
Intake: _
(24 hrs.)
Output:
(24 hrs.)
7-3 3-11 11-7
Oral
Enteral
Pazenteral
OR Fluids
Other
ShiftTotals
Urine
Gastric Suction
Drain(s) Type:
Emesis
OR Output
Shift Totals
Fi1PPEIVSTEEL, CASEY M
Acci:318215-1 Rm/Bed: 0269/01
MR#: 518233 Adm Dt:02/16/01
Doctor: GORMAN MD, RICHARD E
DOB/Age: 08/06/86 14Y Sex: F
NOtlfy: DIANNA 7175325538
~;~:~~
J
d Chamhershurg_
HosPltai
...mr..r s~~
~11I North Setath StlW • P.O. Box 6005
i. PA I7IOIfi00r • Ql7) 267-7000
24 HOUR FLUID INTAKE AND OUTPUT
(Record in c.c.)
P04310 (0:3/82,R:2/93,R:6/97)
0,2/17/01:003' .-'-~' Th -~-fAMBERSBURG HO -.'AL - ~ PAGE 4 ~~-
FC.RP2100.1 P H Y S I C I A N S' S U M M A R Y
From 026701 to 027202
NRS ROOM/BD PATIENT NAME PAT# AGE SEX WGT HT ADMITTED
205 0269/01 HIPPENSTEEL, CASEY M 318215 14Y F 159 LB 0 IN 021601
DOCTOR ADMISSION DIAGNOSIS
CONNOR DO E, J MICHAEL MULT TRAUMA ,
A L L E R G I E S/ D I S E A S E S T A T E S
PENICILLIN ALLERGY
DESCRIPTION STR/UNIT RT & FREQUENCY- START STOP
*** SCHEDULED ORDERS ***
SINGULAIR lOMG PO BEDTIME 02/16: 21
ANCEF/KEFZOL 1GM PB Q 8 HRS 02/16: 21 02/17:05
*** NON-SCHEDULED ORDERS ***
PROVENTIL**MDI BY RT** 2PUF IH Q4H PRN 02/16: 20
TORADOL 15MG IV Q6H PRN 02/16: 20 02/21:19
PERCOCET / ENDOCET 1TAB PO Q3H PRN 02/16: 20 02/23:19
*** DISCONTINUED ORDERS ***
SYRINGE INJECTABLE 1EA PB ONCE 02/16: 20 02/16:20
**DIPHTHERIA/TETANUS O.5ML
TORADOL 30MG IV ONCE 02/16: 21 02/16:21
DATE TIME ROOM/BD PATIENT NAME PA~R"# yAGE
02/17/01 00:37 0269/01 HIPPENSTEEL, CASEY M 318215 14Y
r _
• ~ -... ~ _'• ~~ ~ Standard Register® 2IPSEi®
Chambersbarg=w
HosP.e~
an aNfwte of Summit HealN
l12 Noah Seventh Street • P.O. Bax 6005
Cham6ersburg, PA 17201-b005 (717)267-3000
PFIYSICIAN'S ORDERS
DATE TIME USE BALL POINT PEN-PRESS FIRMLY PHYSICIAN'S ORDERS
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HIPPENSTEEI, CASEY M
02691D1
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:
Acct: 318215-1 RmlBe
MR#^ 6~nnMAN MD RIDCIHARD Ej01 HEIGHT
WEIGHT DIABETIC ^
NON-DIABETIC ^
DOB/Age: 08/06186 7175325536
~lOtlfx/: DIANNA
AUTHORIZATION IS HEREBV GIVEN TO DISPENSE A THERAPEUTIC
ALTERNATE DRUG (AS RECOMMENDED RV THE PHARMACY
THERAPEUTIC COMMITTEE) UNLESS OTHERWISE INDICATED BY THE
WORDS-NO SUBSTITUTE
~ P04190 (O:ONO,R:0.3100)
<~~g~~
SlantlarU Register ® ZIYSEC®
Cbann6ersburg.~
HosP,r~
an alfi0ate of summit Heallh
l l2 NoRh Seventh St<eet • P.O. Box 6005
Chambecsbucg, PA 17201-6005 • (717)267-3000
PHYSICIAN'S ORDERS
DATE TIME USE BALL POINT PEN-PRESS FIRMLY PHYSICIAN'SORDERS
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HIPPENSTFEL, CASEY M
C Acct: 31821'5-1 Rm/Bed: 0269/01 r
MR#: 518233 Adm Dt:02/16/01
Doctor
GOR ~~yl/.--
;
MAN MD, RICHARD E
DOB/Age: 08/06/86 14YSex: F
NOtify: DIANNA 7175325538 HEIGHT
WEIGHT - DIABETIC ^
NON-DIABETIC ^
.
- _
- -AUTHORIZATION IS HEREBY GIVEN TO DISPENSE A THERAPEUTIC
ALTERNATE DRUG (AS RECOMMENDED BY THE PHARMACY
THERAPEUTIC COMMITTEE) UNLESS OTHERWISE INDICATED BV THE
WORDS - NO SUBSTITUTE
P04190 O'ONO R'03/00)
ORIGINAL COPY
- Date
o it~.~-rte ~
HIPPENSTEEL, CASEY M
Acct: 318215-1 Rm/Bed: 0269/01
MRJI: 518233 Adm Dt:02/16/01
Doctor: GORMAN MD, RICHARD E - ~ -
DOB/Age: 08/06/86 14Y Sex: F
NOtlfy: DIANNA 7175325538
P04260 (4/00 Chdmlb@r5burg,.
f _ na ,HosPifalHe n
- Ph SI(aa11 PY® ress N®tes
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' ~ PROGRESS NOTES
HIPPENSTEEL, CASEY M ~
Acct: 318215-1 Rm/Bed: 0269/01 ~ ADMISSION NOTE - REGULATIONS REQUIRE
MR#: 518233 Adm Dt: 02/16/01
Doctor: GORIVIAN MD, RICHARD E ~ THAT THIS BE COMPLETED WITHIN 24
D08/Age:08/06/86 14Y Sex: F HOURS OF ADMISSION.
C Notify: DIANNA 7175325538. 1
r J ; I n~
Admitting Diagnosis• M ~~7q ~t7'~ .f~-:- ~h+Q,u„ e
Other Diagnoses/Conditions• q SQL n
Signs & symptoms that re4uire admission and recent prior treatment:
J j ~~~r~ ~,-.,._ ~_~;,,,~ ~,~1„(a,~s.,,. ~ -r.~~~6- ice=-" "==9~
~'M Ik o-- C ~`~ - .~.p0- Pf.N ~h~esf~c',~a~~/~t'.i~-
_ ~_ _ ~ .B _.,, ti ,nrc
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Treatment plan:
Tentative Discharge plans:
Nursing Home: /~ Home:-
~Y
TO: (CONSULTIN~i .PHYSICIAN)
- ;/f to
%~ ~G-~ i SIGNATURE OF PERSON
MAKING THE CALL DATE NOTIFIED: TIME NOTIFIED: NAME OF PERSON RECEIVING
CALL:
CONSULT REQUESTED REGARDING:
SIGNATURE OF ATTENDING PHYSICIAN:
STAT Ordering physician to call consultant if consult needed within one hour
^ URGENT History and Physical on chart or attending physician call consultant if consult needed within 2 - 12 hours
^ ROUTINE Consult to be done within 24 hours
( )OPINION ONLY E WITH FOLLOW-UP CARE
( )OPINION AND CONTIN
U ( ) ASSUME CARE OF PATIENT
-
7
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DATE & TIME OF CONSULTATION: ~ 1~ ` DR.~ ~ 1cxATURS of coxsuLTANT)
1
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~~~~ ~j~J/S~
C ~S~"?y ~ REPORT OF CONSULTATION
HIPPENSTEEL, CASEY NL.
Acct: 318215-1 Rm/Bed: 0269/01
MR#: 518233 Adm Dt:02/16/01
Doctor: GORMAN MD, RICHARD. E
DOB/Age: 08/06/86 14Y Sex: F
- Notify: DIANNA 7175325538
White Copy -Chart Yellow Copy -Consultant
P04275. (O:OND,R:3/97)
Chartrbey,,'~rg_ ~ ',_,~'''
~~ eosPnar RESPIRATORY CARE FLOWSHEET
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Type ~ Q
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Flowrate
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~~
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(see MAR) V ~
Peak Flows
Pre,Post ~ Zen .~
Heart Rate
Pre/Post ~t ~' ,~
Resp Rate ~
Sputum `
, .
Specimen y
Sputum
Amount & ~ ~ ~ \~
t
A
Color V
I
Breath
Sounds ~ ~ ' ~ -
Incentive ". -
Spirometcr
Volumes
See Patient
Progress
Notes
Initials ~ ,~ ,l ~iv
OXYGEN LEGS l'RFAI'M11ENT L[G[ND MEDICATION LEGIiND SECRETION LEGEND SPUTUM SPF,CMEN
n,~c: Nasal Cannula MN: Medication 1. Mucomvst d9m1 Amount: Colnr. C Induced
OM: Simple Oxygen Mask Nebuli-rer 2. Normal Saline 3.11 ml t-Large C -Clear L: Luken's'Crap
NRB: Non-rebreatherMask CN: Continuous , 3. Alupent 03 ml 2 -Moderate W-White *: Coughed On 0\\n
VM; Venti-mask (venmr+) Nebulizer 4. Albutem! 025 ml 3 -Small Y - Yeiluw +: Sample Obtained
CA: Cool Aerosol IPPB: Intermit Positive S. Albuterol O.S ml A: Absent B -Blood - -: No Sample
# - Pressure Breathing Atrovent unit dus'e C- 'Chick tinged Obtained
other ~ IS: Incentive Spiromc(cr 7 Other: f,75 Xt1I\idM°i
- FI-Thin (i-(ircen
.Other: _~ npr, P -Purulent
' Nun=p1•oductive Cough
- L.t1;:,lvtiinnature:
~IIP ~ BREATH SOI.MD '- SX =Suction
PENSTEEL, CASEY M
I 1. clear ~. Stidor NC Nasal Tracheal
,cct: 318215-1 2
Di
i
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WR#: 518233 .
m
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3. Wheezing R: Right on
:
ra
uct
'CL: Tracheal
ate: 02
/16/01 4. Rhonchi Ail: Bilateral
OB/Age: 08/06/86 14YSex: F 5. Crackles
,
~tient Phone: (717)532-5538 6. nbsent
i
THE C'i3AMBERSBUR USPITAL
112 N. SEVENTH ST.
CHAMBERSBURG PA 17201
4
Page i.,;
OPERATIVE REPORT
HIPPENSTEEL, CASEY M
Patient #: 3182151
Surgery Date: 02/16/2001
R. E .Gorman, M.D.
Medical Record #: S 18233
Patient Type: 1
DOB: 08/06/1986
Patient Rm:
~~+ 5c {iAr+j
1 I ~'l~ J ~
PREOP DIAGNOSIS: ~,~~
POSTOP DIAGNOSIS:
OPERATION: Repair of laceration of forehead.
SURGEON: R. E .Gorman, M.D.
INDICATIONS: The patient was in a motor vehicle accident, multiple abrasions and also a
concussion. She has a laceration of her forehead that measures approximately 7 cm in length.
PROCEDURE: The patient was prepped and draped. The skin was anesthetized with 1%
lidocaine with epinephrine. The wound was imgated out copiously with saline under pressure.
The. skin was cleaned with hydrogen peroxide. The skin was then closed with interrupted 5-0
nylon sutures of either vertical mattress or mostly simple. She tolerated the procedure well.
Bacitracin ointment and clean dressings were applied. The head was wrapped. The patient
tolerated the procedure well and was admitted.
REG/rlr
D: 02/16/2001
T: 02/20/2001
R. E'~~an, M.D.
LHAIVIBERSr"'RG HOSPIT SUMMIT ~..,- ~LTH CENT''~?I
• Rhonda B. ~ Shreiner Wi. '~;h's Center
. • Summit Diagnostic Services
RADIOLOGIST'S REPORT (7l~)-267-7149
FINAL
Name: HIPPENSTEEL, CASEY M MR#: 518233 RegSeq: 998131
Date Dane: 02-16-2001 TPD Date: 02-17-2001 Time: 0753
Ordering Difc C.V,E.A, C. V. EMERGENCY ASSOC. Transcriptionist: MH
Nurs Stat: 205 Pat Class: 1
Faculty Dr: M. D., THOMAS L. CARTER
Room no.: 026901 Date of Birth: OS-06-1986
Admitting Diag: MULT TRAUMA
Rsn for Exm:
Patient phone: 7175325538 ACCOUNT NO: 318215 *** F/C: 14 ***
** FINAL **
HISTORY: 14 YEAR OLD FEMALE SUSTAINED INJURIES FROM AN MVA.
2/16/01
LATERAL CERVICAL SPINE; A LATERAL VIEW OF THE CERVICAL SPINE SHOWS
A NORMAL ALIGNMENT AND STATURE OF THE CERVICAL VERTEBRAL BODIES.
THERE IS NO DISPLACEMENT NOTED Afi THE UNCOVERTEBRAL JOINT.
IMPRESSION: A SINGLE VIEW OF THE CERVICAL SPINE DOES NOT SHOW
OVERT FRACTURE OR DISPLACEMENT.
PORTABLE CHEST: THE PORTABLE ERECT CHEST EXAMINATION SHOWS NORMAL
AERATION OF THE LUNG FIELDS. THERE IS NO INFILTRATE, PNEUMOTHORAX,
CONSOLIDATION, OR FLUID. THE CARDIOMEDIASTINUM IS NORMAL. THERE IS
NO OBVIOUS RIB FRACTURE.
IMPRESSION: THE PORTABLE ONE VIEW CHEST EXAMINATION IS
UNREMARKABLE.
PELVIS: AP VIEW OF THE PELVIS WAS TAKEN WITH THE PATIENT STILL ON
THE TRAUMA BOARD. PELVIS AND SI JOINTS ARE NORMAL. BOTH PROXIMAL
FEMURS ARE UNREMARKABLE.
IMPRESSION: NO OVERT FRACTURE OF THE PELVIS OR PROXIMAL FEMURS.
62020 61012 62170
723.1 786.5 724.6 ~µw ~ ~.~-
Signed. by DR. THOMAS L. CARTER M. D.
~_
CHAPvIBERS'~_'RG HOSPIT ` ,
SUNIlVIIT ``'':ALTH CEN'f'';'`~.
;:: .
• Rhonda b_ ~ :z Shreiner W'" n's Center
• Summit Diagnostic Services
RADIOLOGIST'S REPORT . (717) 267-7149
FINAL
Name: HIPPENSTEEL, CASEY M MR#: 518233 RegSeq; 998220
Date Done: 02-16-2001 TPD Date: 02-16-2001 Time: 1820
Ordering Dr: C.V.E.A, C. V. EMERGENCY ASSOC. Transcriptionist: DMS
Nurs Stat: 205 Pat Class: 1
Faculty Dr: M. D., ROBERT S PYATT
Room no.: 026901 Date of Birth: OS-06-1986
Admitting Diag: MULT TRAUMA
Rsn for Exm:
TRAUMA AUTO ACCIDENT
OMNI 150 CC
Patient phone: 7175325538 ACCOUNT N0: 318215 *** F/C: 14 ***
** FINAL **
HISTORY: 14 YEAR OLD MALE, MVA.
2-16-01
CRANIAL CT: SOFT TISSUE SWELLING
THE VERTEX. THERE DOES NOT APPEAR
FRACTURE, INTRACRANIAL HEMORRHAGE,
ABNORMALITY,
IMPRESSION: NEGATIVE STUDY.
IS NOTED OVER THE FOREHEAD NEAR
TO BE EVIDENCE OF A SKULL
OR OTHER SIGNIFICANT ACUTE
FACIAL BONES: AXIAL AND REFORMATTED CORONAE IMAGES DEMONSTRATE NO
EVIDENCE OF ORBITAL FLOOR FRACTURE THE ZYGOMATIC ARCHES ARE INTACT.
THERE IS NO EVIDENCE OF ORBITAL EMPHYSEMA. EXAMINATION IS
OTHERWISE UNREMARKABLE.
IMPRESSION: NORMAL FACIAL BONE CT.
CT ABDOMEN: CT SECTIONS WERE OBTAINED AFTER THE ADMINISTRATION OF
150 CC. OF OMNIPAQUE-300. ORAL CONTRAST WAS ALSO ADMINISTERED. THE
VISUALIZED PORTIONS OF THE LIVER, LUNG BASES, SPLEEN, GALLBLADDER,
AND PANCREAS ARE NORMAL. THERE IS NO EVIDENCE OF FREE
INTRAPERITONEAL AIR, OR FREE INTRAPERITONEAL FLUID. THE. KIDNEYS ARE
NORMAL.
IMPRESSION: NORMAL ABDOMINAL CT.
CT. PELVIS: CT SECTIONS WERE OBTAINED IN STANDARD TRANSAXIAL
PROJECTION AFTER THE ADMINISTRATION OF IV CONTRAST. THERE IS NO
EVIDENCE OF FREE INTRAPERITONEAL FLUID. THE BLADDER IS
CATHETERIZED. THE LATERAL PELVIC SIDEWALLS ARE UNREMARKABLE.
PRESACRAL SOFT TISSUES ARE ALSO NORMAL. THERE IS NO~,EVIDENCE OF
CHAlVIBERS"`?RG HOSPI SUNIlI~IIT ALTH CENT'^~d
,' ~ • Rhonda E" ° _e Shreiner W ' "n's Center
• Summit Diagnostic Services
RADIOLOGIST'S REPORT (717) 267-7149
FINAL
Name: AIPPENSTEEL, CASEY M
Date Done: 02-16-2001
ACUTE ABNORMALITY.
IMPRESSION: NEGATIVE PELVIC CT.
60450 60486 66375 64160
959.1
Signed by DR
MR#: 518233 RegSeq: 998220
TPD Date: 02-16-2001 Time: 1820
62193 ~~ QQ µ~
ROBERT S PYATT M. D.
PAGE 2
>,6
CIIAI4IBERF"TTR'r HO5PI" ~ SUNIMI" ~ .. ,ACTH CEN'-;" .R
' • Rhonda f. '~:e Shreiner w - '~~n's Center
• Summit Diagnostic. Services
RADIOLOGIST'S REPORT (717) 267-7149
FINAL
Name: HIPPENSTEEL, CASEY M MR#: 518233 RegSeq: 998162
Date Done: 02-16-2001 TPD Date: 02-16-2001 Time: 1718
Ordering D.~: C.V.E.A, C. V. EMERGENCY ASSOC. Transcriptionist: DMS
Nurs Stat: 205 Pat Class: 1
Faculty Dr: M.D., PHILIP J. SABRI
Room no.: 026901 Date of Birth: OS-06-1986
Admitting Diag: MULT TRAUMA
Rsn for Exm:
Patient phone: 7175325538 ACCOUNT NO: 318215 *** F/C: 14 ***
** FINAL **
HISTORY: 14 YEAR OLD MALE INVOLVED IN MVA
2-16-01
CERVICAL SPINE: PORTABLE CROSS TABLE LATERAL EXAM DEMONSTRATES NO
EVIDENCE OF FRACTURE OR PREVERTEBRAL SOFT TISSUE SWELLING. NO MAL
ALIGNMENT IS NOTED.
CERVICAL SPINE (FULL SERIES): OPEN MOUTH, AP, OBLIQUE, AND LATERAL
VIEWS DEMONSTRATE NO EVIDENCE OF FRACTURE OR MAL ALIGNMENT. NO SOFT
TISSUE SWELLING IS NOTED IN THE PREVERTEBRAL SOFT TISSUES. NO DISC
SPACE NARROWING IS NOTED.
LUMBOSACRAL SPINE: AP, LATERAL, OBLIQUE, LATERAL LS-S1 SPOT FILMS
DEMONSTRATE NO EVIDENCE OF FRACTURE OR COMPRESSION DEFORMITY OR DISC
SPACE NARROWING OR MAL ALIGNMENT. THERE IS A LARGE AMOUNT OF GAS
IN OVERLYING SMALL BOWEL LOOPS WHICH MAKES VISUALIZATION OF THE BONY
STRUCTURES SOMEWHAT MORE DIFFICULT.
IMPRESSION: NO FRACTURE DEMONSTRATED. PROMINENT OVERLYING GAS IN
NONDISTENDED SMALL AND LARGE BOWEL-MAKES VISUALIZATION OF THE SPINE
SOMEWHAT LESS THAN OPTIMAL. THERE IS CONTRAST'TN THE RENAL
COLLECTING SYSTEMS.
RIGHT ANKLE: NEGATIVE STUDY WITH NO EVIDENCE OF FRACTURE,
DISLOCATION, OR BONY DESTRUCTIVE CHANGE.
LEFT ATIVE STUDY WITH NO EVIDENCE OF FRACTURE,
DISLOCATION, OR BONY DESTRUCTIVE CHANGE.
THORACIC SPINE: VERTEBRAL BODIES AND DISC SPACES ARE WELL MAINTAINED
IN GOOD HEIGHT AND ALIGNMENT. THERE IS NO EVIDENCE OF FRACTURE, OR
BONY DESTRUCTIVE CHANGE. THE ALIGNMENT IS NORMAL. SOFT TISSUES
ARE UNREMARKABLE.
IMPRESSION: NORMAL THORACIC SPINE.
;.,,~,~
+CHAMBERS-' `RG HOSPI SUMMIT ,:. ~I.TH CENTT''t
• Rhonda B: s Shreiner Wi.' ''a's Center
_ • Snnunit Diagnostic Services
RADIOLOGIST'S REPORT (717) 267-7149
FINAL
Name: HIPPENS-TEEL, CASEY M MR#: 518233 RegSeq: 998162
Date Done: 02-16-2001 ~ TPD Date: 02-16-2001 Time: 1718
LEFT SHOULDER: NEGATIVE STUDY WITH NO EVIDENCE OF FRACTURE,
DISLOCATION, OR BONY DESTRUCTIVE CHANGE.
62050 62110 63610 562LT 62072 63030 , !~"""' ~1~
959.1 959.6 952.0 952.1 959.7 ~~~%~o ~R
Signed by DR. PHILIP J. SABRI M.D.
t
PAGE 2
• THE CHAMBERSBURG HOSPITAL
_ ~ Department of Pathology
(717J 267-7154
DISCHARGED: 02/17/20
NAME: HIPPENSTEEL, CASEY M AGE: 14Y LOCATION: 2ND FLOOR WEST
MR# 518?33 SEX: F ROOM NO.: 0269-01
ACCT: 318275 PHYSICIAN:GORMAN M.D., RICHARD E.
DIAGNOSIS: MULT TRAUM
++x+++x+++xx+++xxx++xx+++++x++++++++ COMPLETE HLOOD COUNT *+++++++x++++++++++xxx++++++++xx+++++
DAY: 1
DATE: 02/16/01 -
TIME: .1325 - - NORMAL UNITS
LOC: ECU
WBC 16.2 H 4-11 K/UL
RHC 4.73 - 3.8-5.4 M/UL
HGB 13.4 10.3-16.0 G/DL
HCT 40.0 35-40
MCV 85 85-9B CUMIC
MCH 28.3 ~ 27-32 MMG
MCHC 33.5 32-37 e
RDW 13.2
PLATELET 293 150-400 K/UL
MPV 11.3 FL
PERCENT DIFFERENTIAL
BAND 9
NEUT 69
LYM 16 L
MONO 6
EOS 0
BASO 0
ABSOLUTE DIFFERENTIAL
NEUT 12.6
LYM 2.6
MONO 1.0
EOS 0.0
BASO 0.0
COMMENTS
RBC MORPHOLOGY NORMAL
PLT ESTIMATE ADEQUATE
HIPPENSTgEL, CASEY M,
INPppATIENT MEDICAL RECORDS COPY
~~ Report Prin Bed: 02/17/2001 ~-22:01
O
CONTINUED
0-11 e
20.0-70.0 e
20-70 e
1-12 s
0-8.0 s
0,0-2.0 s
K/UL
0.8-4.4 K/UL
K/UL
0-0.6 K/UL
0,0-0.2 K/UL
NORM.
ROOM NO.: 0269-01
PAGE: 1
,€.:,xu~ax.R~~..
..
THE CHAMBERSB URG HOSPITAL
_ Department of Pathology
(717) 267-7154
NAME: HIPPENSTEEL, CASEY M AGE: 14Y ROOM NO. c-0269-01
MR# 518233 SEX: F LOCATION: 2ND FLOOR WEST
ACCT: 318215 PHYSICIAN: GORMAN M.D., RICHARD E.
DIAGNOSIS: MULT TRAUM
+++++++++++++++++++++++++++++++++++++++++• CHEMISTRY ++~.e+++++++++++++++++++++++++++++++++++++++
DATE: 02/16/01
TIME: 1325 NORMAL UNITS
LOC: ECU
__________________
______
_
_____________
GLUCOSE ____________________________________
110 _____________
_______
_
70-110 MG/DL
BUN 15 8-20 MG/DL
CREATININE 0.8 0,6-1.1 MG/DL
CALCIUM 10.3 - 8.6-10.3mg/dL
SODIUM 142 135-145 mM/L
POTASSIUM 4.0 3.6-5.1 mM/L
CHLORIDE 98 L 101-111 mM/L
TCO2 26 22-32 mM/L
AGAP 18 R 5-15
TOTAL PROTEIN 7.2 6.1-7.9 G/DL
ALBUMIN 4.2 3.4-4.8 G/DL
ALKALINE pHOSPHATASE 79 <350 IU/L
BILIRUBIN, TOTAL 0.5 0.3-1.2 MG/DL
GPT 18 14-54 IU/L
GOT 34 15-41 IU/L
AMYLASE 98 25-125 IU/L
HIAPENSTEEL, CASEY M
ZNAATZENT MEDICAL RECORDS COPY
Report Arinted: 02/17/2001 22:01
CONTINUED
ROOM NO.: 0269-01
PAGE: 2
r«n..
THE CHAMBERSBURG HOSPITAL
- Department of Pathology
(71.7) 267-7154
NAME: HIPPENSTEEL, CASEY M AGE: 14Y ROOM NO.: 0269-01
MR# 518233 SEX: F LOCATION: 2ND FLOOR WEST
ACCT: 318215 PHYSICIAN: GORMAN M.D., RICHARD E.
DIAGNOSIS: MULT TRAUM
:t~*:t:t:t**:tt***+*****+ ****~**++~*:t,rt***~** BLOOD ALCOHOL x++*****~****~~
02/16/01
1325
BLOOD ALCOHOL
BLOOD DRAWN BY:
PREP USED:
COLLECTION SITE
TEST PERFORMED BY:
RESULT OF:
PLASMA/SERUM VALUE
SEAL INTEGRITY
Connie R. Harris, LPN
ALCOHOL PREP USED
RIGHT ARM
Linda Jean Sheffield, M.L.T.(ASCP)
[0] o
NONE DETECTED
INTACT
CONTINUED ~ .-
HIPPENSTE$L, CASEY M
a -,;~:NPATIENT MEDICAL RECORDS COPY
Report Printed: 02/17/2001 22:01
ROOM NO.: 0269-OZ
- PAGE: 3
YxAFPask~ew+. _..
- THE CHAMBERSBURG HOSPITAL
- Department of Pathology
(717) 267-7154
NAME: HIPPENSTEEL, CASEY M AGE: 14Y ROOM NO.: 0269-01
MR# 518233 SEX: F LOCATION: 2ND FLOOR WEST
ACCT: 318215 PHYSICIAN: GORMAN M.D., RICHARD E.
DIAGNOSIS: MOLT TRAUM
+++x+x++++xx+++x+++xx+++x++++++xxx++++xxx URINALYSIS x++++xx++++xxxx+++++xxx+++xxxx+++++xxxx+++
DATE: 02/16/01
TINE: 1318 NORMAL UNITS
LOC: ECU
TYPE ING
COLOR YELLOW
CHARACTER CLEAR
GLUCOSE NEGATIVE NEG MG/DL
BILE - NEGATIVE NEG
KETONES NEGATIVE NEG MG/DL
SPECIFIC GRAVITY 1.025 1.003-1. 026
BLOOD NEGATIVE NEG
PH 6.0 5.0-8.0
PROTEIN NEGATIVE NEG MG/DL
UROBILINUGEN 0.2 0.1-1.0 EU/DL
NITRITE NEGATIVE NEG
LEUKOCYT$S NEGATIVE NEG
EPITHELIAL CELLS <1 /HPF
---FOOTNOTES---
ING INFORMATION NOT GIVEN
CONTINUED
e HIppENSTEEL,"CASEY M
INpATI'ENT MEDICAL RECORDS COPY
Report Printed: 02/17/2001 22:01
ROOM NO.: 0269-01
PAGE: 4
:-er.~V .:.,x.. .
- THE CHAMBERSB URG HOSPITAL
- Department of Pathology
(717) 267-7154
NAME: HIPPENSTEEL, CASEY M AGE: 14Y ROOM NO.: OZ69-OZ
- MR# 518233 SEX: F LOCATION: 2ND FLOOR WEST
ACCT: 318215 PHYSICIAN: GORMAN M.D., RICHARD E.
DIAGNOSIS: MULT TRAUM
++++r+++++++++++++++++ +++++++++++++ QUALITATIVE TOXICOLOGY ++++++++++++++++.++++•+++++.++++++++
TEST: AMPHETAMINES BARBITURATES BENZODIAEPINE COCAINE
QUAL., URINE QUAL., URINE QUAL., URINE QUAL., URINE
UNITS:
_____
_____________________________________________
____________________________
02/16/01 _________________
1318 NEGATIVE NEGATIVE NEGATIVE NEGATIVE
====z_________________ _____________ QUALITATIVE TOXICOLOGY =_____-_ ________;___________________
TEST: OPIATES PHENCYCLIDINE CANNABINOIDS TRICYCLIC ANTIDEPRESSANT
QUAL., URINE QUAL., URINE QUAL., URINE QUAL., URINE
UNITS:
02/16/01
1318 NEGATIVE NEGATIVE NEGATIVE NEGATIVE
CONTINUED .. ~.-
HIPPEN,~TEEL, CASEY M ROOM NO.-: 0269-O1
INPATIENTMEDICAL RECORDS COPY PAGE: 5
Report Printed: 02/17/2001 22:01
e
NAME: HIppBNSTEEL, CASEY M
MR# : 518233
ACCT: 318215
DATE:
TIME:
LOC:
PROTIME
INR
THE CHAMBERSBURG HOSPITAL
Department of Pathology
(717) 267-7154
AGE: 14Y
SEX: F
PHYSICIAN: GORMAN M.D.
DIAGNOSIS: MULT TRAUM
ROOM NO.: 0269-01
LOCATION: 2ND FLOOR WEST
RICHARD E.
+++++++++++++++++++++++++++++++++++++++++ COAGULATION *+++++>+++++>++++++++++++++++++++++++++++
02/16/01
1325 - NORNAL UNITS
ECU
_______________________________________________________________________________________________
11.8 10.9-12.7 SEC
1.0
CONTINUED
HIPPENSTEEL, CASEY M -
INPATIE;NT MEDICAL RECORDS COPY
Report-Printed: 02/17/2001 22:01 -
ROOM.NO.: 0269-01'
PAGE: 6
v~.zm-.+~..;wo
THE CHAMBERSBURG HOSPITAL
Department of Pathology
(7171 267-7154
NAME: HIPPENSTEEL,CASEY M AGE: 14Y ROOM NO.: 0269-O1
MR# 518233 SEX: F LOCATION: 2ND FLOOR WEST
ACCT: 318215_ PHYSICIAN: GORMAN M.D., RICHARD E.
DIAGNOSIS: MULT TRAUM
++xxxx++xxxx++xx++xxx++x+xx+++xx+++++x SEROLOGY-ROUTINE xxxx+++x+x++++xxxx+++xxx++++x+xxx++++x+
DATE: 02/16/01
TIME: 1325 NORMAL UNITS
LOC: ECU
HCG NEGATIVE
HIPPENSTEEL, CASEY M`
INPATIENT MEDICAL RECORDS COPY
Report Printed: 02/17/2001 22:01
CONTSNUED
ROOM NO.: 0269-OZ
PAGE: 7
• THE CHAMBERSBURG HOSPITAL
• Department of Pathology
(717) 267-7154
NAMfi; HIPPENSTEEL, CASEY M AGE: 14Y ROOM NO.: 0269-01
MR# 518233 - SEX: F LOCATION: 2ND FLOOR WEST
ACCT: 318215 PHYSICIAN: GORMAN M.D., RICHARD E.
DIAGNOSIS: MULT TRAUM
+++x++xxx++++x+++xx+++xx++++xx+ BLOOD TYPE AND ANTIBODY TESTING ++++xxx+++xxxx++++xx+++++xxxxx+
02/16/01
1325 TYPE AND SCREEN (XM CONVE
ABO/RH (D) A NEGATIVE
ANTIBODY SCREEN NONE DETECTED
ARM BAND NUMBER R38174
CONTINUED .. W
HTppENSTEEL, C&SEY M ROOM NO.: 0269-01
INPATIENT MEDICAL RECORDS COPY PAGE: 8
Report Printed: 02/17/2001 22:01
THE CHAMBERSBURG HOSPITAL
Department of Pathology ,
(717) 267-7154
NAME: HIPPENSTEEL, CASEY M AGE: 14Y ROOM NO.: 0269-01
MR# 518233 SEX: F LOCATION: 2ND FLOOR WEST
ACCT: 318215 PHYSICIAN: GORMAN M.D., RICHARD E.
DIAGNOSIS: MULT TRAUM
++~.:++++++:++.+~++++++++++++++++a,+++++ CANCELLED TESTS **++++++:++++++++++++x•+++++~+++++w+++~.r+
02/16/01 1325 CANCELLED: DIFFERENTIAL
REASON: MANUAL DIFFERENTIAL ORDERED
.. END OF REPORT A V-
HZPPENSTEF,L~rCASEY-M ROOM NO.: 0269-01
INPATIENT MEDICAL RECORDS COPY _ ~ _ PAGE: 9
Report Printedn 02/17/2001 22:01 - ~- - -
-,a:,:ti~
RPR 05 2001 10 29 FR RUTO CALL SUPPORT 877 775 500? TO 95825071
,~fRAN.1E: K 15
S
NA OMMDE
;~N'~RI~N~~~E
AUTO PoucY
DECLARATIONS
, Na1q~Maa n M Yanf ttaa P!W 101 ~
These Declaretlons era a part of the pd~y named about end Wtntkled by pdky numWr pelpaa. They
supersedt any Dedtrt410ns Issueed eetlltr. Your policy 1p~rovldn Iht'OOwttgEt endYllmks tkown In 1~!
m 10 19Ia'llnenolal ~ea ~~~p0 ~ bI1Ry laws of your staieo ly for v,hicltioewniCh Propiny Dimapl end ~B,oeAy
Injury liability coverages aro provided.
Policy Number: Po11Cyh01der:
59 37 D 357t9t (Ntmtdlnsurtd)
DIANIVl. MIPPENSTEEL
Issued: 43 NEIL ROAD
JAN t7, 200t 7257 gg03~' PA
ppinTi~uml NDwnabnbw, mia Dellcy ii?. hbyl~:wUne:c eol~eaioliey P.rloetaaiua ~t~etl~naia sDianitloni iaDi i eeru~ ori~e i
paDlaralmna wnatnar OY ammemanl or etMnriu.
Peery Pw10O ~1RJ1Gi VN~ ~ GVV• ~~ ~ ~c. av
PollcY Q1.NCtil$ 12:01 A.M. a11M AEDnIa alma Namae R1aun0 a aUtae
IMPORTANT MESSAGES:
THIS IS A CONTINUOUS LIMITED POLICY •• READ CAREFIk.IY
SEE ENClOSEO NOTICE FOR PREMIUM DETAIL
Description of Unlt: THIS POLICY COVERS ONLY THE VEHICLE(S) OESCRIBEO'.
t. 1985 NERC NAROUIS
Covanages
PROPERTY DMIAGE LIABILITY
BODILY INJURY LIABILITY
UNINSURED MOTORIST
U~ttD RINSURED~M)~)TORIST
FlRNST~PARTYIBENEFI7S
OPTION i•MEDICAI BENEFIT
FULL TORT
ID e'101AW69K4C812217t
Limkt 01 LltDllky
60; OOS ~ P ~RErICE
I~5,000 EA P ONRETICE
5;000 EA p RRENCE
30.000 EACH OCCURRENCE
a lo.ooo
P.01i02
Two Montle
Pnmlum
S J3.00
S 25.10
S 3.20
s 2.20
a z2.sD
TOTAL S 86.J0
CO65 (12/97)
rRr~~rr•• r IS
POLICY DOES NOT COVER COLLISION DAMAGE TO RENTED VEHICLES.
aPR Os z0e1 i0:zs FR aura caLL suPPORr svv vvs s0ei ro ssezse~i P.ez~ez
a as u,. •.... v ...
,,
~1
AUTO POLICY DECI.ARATiONS
VEHICLE CLASSIFICATIONS
Premium Is Baead On: 1965 MERC
USE OF VEHICLE PLEASURE
RATED DRIVER FRNCIPAL
MARRIED
APPLIED DISCOUNTS MULTI CAA
SPECIAL RATING FULL TDRT
Policy Form 8 Endoroements: C046P C1 a30 C171 t
Ottice Uae: D~286s 9200281501 S 0.00
Isauad By;PIATIONNIDE ASSURANCE COMPANY
Countorolgned At: HARRISBURGi, PA
By: R. OANGELLO
Page 201 2
PO BOx x655
HARRISBURG PA 17105.2655
800.854.8845
LOSS PAYABLE ENDORSEMENT
We will psy loss or damage due antler lhls policy according to your Interest end that of the Ilenhdder. We may
make separate payments according to those Interests.
we will pay the Ilenholder for a loss under this pdicyY even though you have violated the terms of the polcy by
something you have done or Ialled to do, MoweVar, we wIIF not pay for any Ices caused by conversl0n,
embezzlement or secretion by you or anyone acting on your behell,
We will not notlfy the Ilenholder each time you renew this polcy and wo may cancel ehls ppolcy according to Its
terms. We will protect the lienhdder's Interest for 10 days from the date we notify hlYn that the polcy has
termlriatad. for any reason. If we pay the Ilenhdder for any foss or damage nattered during that t0 day parlad, we
have the right to reaovar the amount of any such peymenl from you.
II you tell to gtre prool of loss within the time allowed, Iha Ilenhdder may protect his Interest Dy tning a prool d
loss within DO days nher that lime.
The Ilenhdder must notlry tis of any known change of ownership or Increase In the risk. II ha does not, ha will not
be enthled to any payment under this endOrsemen6
I! we pay the Ilenhdder under the terms of this endorsement for a loss not covered under the pdicy. we are
subrogTeted to his rights against )nu. This will not aRect the Ilenhdder s N011t to recover Ne full amount tN his
claim. he Ilenhdder must essipn us his Interest and lransler to u9 all suppo nq documents, 11 we elect to pay the
balance due him on the vehlCl9.
In those stales where we show a deductlde In excess d 5250 for comprehensive and~or ednslon the Ilenhdder
has a 5250 deduCUGe for comprehensNe and~or Cdtislon to the wont of repossession.
LOSS PAYEE: Any loss under .;omprehenstve or cNllslon coverage provided on the reverse side Is payade es
Interest may appear to rwmod InnureJ and loaa payee, •..
FRAME: M 15
** TOTRL PRGE.OZ **
02/19/2001, 16:32
7175327151
p~~
~'~
REESE DANGELLO AGENV
o ~.~
~~ ,~
MOTORIST COVSRAQ$ AUTHORI2ATYON FORM
PAGE 03
VIM 2
Please issue my policy with Underinsured Motorist Coverage limits of:
(Cannot exceed your Liability Coverage Limits or be lees than Financial
Responsibility Limits.) Do not complete this form if your UIM limits
match your limits of Bodily Injury Liability.
Bodily Injury
Per person/per occurrence
$15,000/$30,000*
_ $25,000/$50,000
$50,000/$100,000
$100,000/$300,000
Agent 12 SUE
DANGELLO
_ $250,000/$500,000
5300,000/$300,000
$500,000/$500,000
*minimum limit
County -#rBPg1s
JRN 24 1996 23 46 7175327151 PRGE.63
Policy Number 58D357191 Date y / a
02;1°/2001 16:32 775327151 REESE DANGELLO AGENV PAGE 01
~„~,,,
<¢RV~
REJECTION pF STACREA UNDERINSURED COVERAC7E LYMIT3 VIDE 3
Hy signing this waiver I am rejecting stacked limits of underinsured
motorist coverage under the policy for myself and members of my
household under which the limits of coverage available would be the
sum of limits for each motor vehicle insured under the policy.
Instead the limits of coverage that I am purchasing shall be reduced
to the limits stated in the policy. I knowingly and voluntarily
reject the stacked limits of coverage. I understand that my
premiums will be reduced if I reject this coverage.
gnature ((~j~~ i st Named Insured ate
Policy Number 58D357191
Agent R SUE DANGELLO County ADAMS
JAN 24 1996 23 45 7175327151 PF1GE.61
MAR 29 2001 1S 56 FR FSS 7158438688 TC 91717582507?. p.04i1?.
~~~
Today's Date:
Name:
Date of Birth:
March 29, 2001
Casey Hippensteel
August 6, 1986
Female °HT
Age: 14
Plan #2
Guaranteed Lumo Sum Benefits:
Payable - 08-06-2004 (age 18).
Payable - 08-06-2007 (age 21).
LUMP SUM TOTALS;
TOTAL STRUCTURE AMOUNT:
Guaranteed
Amount: Cost:,
$5,300 $4,500
$15,000 $10,500
$20,300 $15,000
$20,300 $15,000
The Internal Rate of Return is approximately 5.75% and
the Tax Equivalent Yield is 8.21%, based on a 30% tax bracket.
This proposal is ®ff®ctive through APRIL 9, 2001. This is the date that the funds for the
structure must be at the annuity company or this proposal will expire.
This is an illustration, not a contract.
a.
RELEASE AGREEMENT
This Release Agreement ("Agreement"} is entered into among Casey Hippensteei,
a minor, by her parents and natural guardians, Gary Hippensteel and Dianna
Hippensteel, Gary Hippensteel and Dianna Hippensteel, individually, and Colonial
Insurance Company (hereinafter collectively referred to as "the Parties"). The "Insured"
shall collectively mean Casey Hippensteel, a minor, by her parents and natural guardians,
Gary Hippensteel and Dianna Hippensteel, Gary Hippensteel and Dianna Hippensteel,
individually, their respective heirs, executors, administrators, personal representatives,
successors and assigns; and the "Insurance Company" shall mean Colonial Insurance
Company, its successors and assigns.
I. RECITALS
A. On or about February 16, 2001, at or near the intersection of Airport Road\T-
317 & Gilbert Road\State Route 3002, Southampton Township, Cumberland County,
Pennsylvania, Casey Hippensteel sustained personal injuries as a result of an automobile
accident (hereinafter referred to as the "Occurrence"). In connection with the Occurrence,
the Insured has asserted a claim against Colonial Insurance Company.
B. The parties desire to enfer into this Agreement to provide, among other things,
for certain payments in full settlement and discharge of all claims and actions of the
Insured for damages arising out of or due to the Occurrence, on the terms and conditions
set forth herein. NOW THEREFORE, it is hereby agreed as follows:
II. UNDERINSURED MOTORIST RELEASE AGREEMENT
Know all men by these presents: That, for the promise to make the periodic
payments referred to in Paragraphs IV.A.(1) and (2) from the Insurance Company, the
Insured in his/her capacity as an insured does hereby forever release and discharge the
Insurance Company of and from all claims of whatsoever kind and nature prior to and
including the date hereof growing out of the Underinsured Motorist Coverage of an
Automobile Insurance Policy number 5837 D 357191, issued by the Insurance Company
to Dianna Hippensteel, and resulting from the Occurrence.
III. INJURIES KNOWN AND UNKNOWN
The Insured fully understands that the Insured may have suffered personal injuries
that are unknown to the Insured 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 Insured acknowledges that the consideration
received -under this Agreement is intended to and does release and discharge the
Insurance Company for any claims for, or consequences arising from, such injuries and
the Occurrence; and the Insured 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.
2
~~:~.,~r.:;:,
IV. PAYMENTS TO INSURED
A. Periodic Pavments. The Insurance Company hereby agrees to make the
following payments:
(1) To Casey Hippensteel ("Payee"), the following guaranteed lump sum payments:
Five Thousand Three Hundred Dollars ($5,300) on or about August 6, 2004.
Fifteen Thousand Dollars ($15,000) on or about August 6, 2007.
(2) Should Casey Hippensteel die before August 6, 2007, then any remaining
guaranteed payments set forth in Paragraph IV.A.(1) shall instead be paid, as they
become due, to the estate of Casey Hippensteel, with the last guaranteed payment
to be made on or about August 6, 2007.
(3) Casey Hippensteel shall have the right, after reaching the age of majority, to
submit a request to change the Beneficiary by filing a written request with the owner
of the annuity. This request will be reviewed by the owner of the annuity, and if
approved by the owner of the annuity and the issuing annuity company it will
become effective. Said request will be made in writing by Casey Hippensteel.
C. Nature of Pavments. All sums set forth in this Paragraph IV constitute
damages on account of personal injuries or sickness, arising from the Occurrence, within
the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended.
3
,w~x~~
V. FINANCING OF PERIODIC PAYMENT OBLIGATION
A. Assignment of Obligation. It is understood and agreed by and between the
parties hereto that the Insurance Company may, as a matter of right and in its sole
discretion, assign its duties and obligations to make such future payments as set forth in
Paragraphs IV.A.(1} and (2) to Hartford Comprehensive Employee Benefit Service Co.
pursuant to a "Qualified Assignment and Release Agreement," within the meaning of
Section 130{c) of the Internal Revenue Code of 1986, as amended, in the form attached
hereto as Exhibit A. Such assignment is hereby accepted by the Insured without right of
rejection and in full discharge and release of the duties and obligations of the Insurance
Company and all parties released by this Agreement with respect to such future
payments. If the Insurance Company assigns the duties and obligations as provided
herein, it is understood and agreed by and between the parties that Hartford
Comprehensive Employee Benefit Service Co, as the assignee, shall make said future
payments directly to the respective payees designated in Paragraphs IV.A.(1) and (2).
THE PARTIES HERETO EXPRESSLY UNDERSTAND AND AGREE THAT WHEN
AN ASSIGNMENT OF THE DUTIES AND OBLIGATIONS TO MAKE SAID FUTURE
PAYMENTS IS MADE BY THE INSURANCE COMPANY TO HARTFORD
COMPREHENSIVE EMPLOYEE BENEFIT SERVICE CO PURSUANT TO THIS
AGREEMENT, ALL OF THE DUTIES AND RESPONSIBILITIES OTHERWISE
IMPOSED UPON THE INSURANCE COMPANY BY THIS AGREEMENT WITH
4
RESPECT TO SUCH FUTURE PAYMENTS SHALL CEASE, AND INSTEAD BE
BINDING SOLELY UPON HARTFORD COMPREHENSIVE EMPLOYEE BENEFIT
SERVICE CO. IT IS FURTHER UNDERSTOOD AND AGREED THAT WHEN AN
ASSIGNMENT IS MADE, THE INSURANCE COMPANY SHALL BE RELEASED FROM
ALL OBLIGATIONS TO MAKE SUCH FUTURE PAYMENTS AND HARTFORD
COMPREHENSIVE EMPLOYEE BENEFIT SERVICE CO SHALL AT ALL TIMES
REMAIN DIRECTLY AND SOLELY RESPONSIBLE FOR, AND SHALL RECEIVE
CREDIT FOR, THE FUTURE PAYMENTS. IT IS FURTHER UNDERSTOOD AND
AGREED THAT WHEN AN ASSIGNMENT IS MADE, HARTFORD COMPREHENSIVE
EMPLOYEE BENEFIT SERVICE CO ASSUMES THE DUTIES AND
RESPONSIBILITIES OF THE INSURANCE COMPANY WITH RESPECT TO SUCH
FUTURE PAYMENTS.
B. Third Party Payment. It is further understood and agreed by the parties that all
future payments as set forth in Paragraphs IV.A.(1) and (2) may, solely at the option of
the Insurance Company, or its assignee, Hartford Comprehensive Employee Benefit
Service Co, be financed by the purchase of an Annuity Contract from Hartford Life
Insurance Company (the "Annuity Contract"). When such an Annuity Contract is
purchased, the assignee, Hartford Comprehensive Employee Benefit Service Co 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, the assignee shall direct Hartford Life
Insurance Company to make all periodic payments directly to the respective payees
5
designated in Paragraphs IV.A.(1) and (2). Such payments will be applied against the
obligation of the Insurance Company or its assignee and shatl operate as a pro Canto
discharge of the scheduled obligations set forth in this Agreement.
C. Status of Insured. The Insured shall, at all times, remain a general creditor of
the Insurance Company or its assignee and shall have no rights in the Annuity Contract
nor in any other assets of the assignee. The Insurance Company or its assignee shall not
be required to set aside sufficient assets or secure its obligation to the Insured in any
manner whatsoever. The Insured acknowledges that the Insured has no right to receive
the present value of the payments due the Insured pursuant to Paragraphs IV.A.(1) and
(2), or to control the investment of, or accelerate, defer, increase or decrease the amount
of any payment required to be made to the Insured. The Insured shall only be entitled to
receive the payments specified in Paragraphs IV.A.(1) and (2), as they are due.
VI. NO CHANGES IN FUTURE PAYMENTS
Neither the Insured, his/her estate, nor any subsequent beneficiary or recipient of
any payments or any part of any payments under this Agreement, shall have the right to
accelerate, commute, or otherwise reduce to present value or to a lump sum any of the
payments or any part of any payments due under this Agreement.
6
Neither the Insured, his/her estate, nor any subsequent beneficiary or recipient shall
have the right to transfer, assign, anticipate, mortgage, or otherwise encumber in advance
any payments or any part of any payments due under this Agreement.
VII. ADEQUATE CONSIDERATION
The Insured agrees and acknowledges that the Insured accepts payment of the
sums that the Insured is to receive pursuant to this Agreement as a full, complete, final
and binding compromise of matters involving disputed issues regardless of whether too
much or too little may have been paid.
VIII. ENTIRE AGREEMENT
This Agreement contains the entire agreement between the Insured and the
Insurance Company with regard to the matters set forth herein. There are no other
understandings or agreements, verbal or otherwise, in relation thereto, between the
parties except as herein expressly set forth.
IX. READING OF AGREEMENT
In entering into this Agreement, the Insured represents that the Insured has
completely read all terms hereof and that such terms are fully understood and voluntarily
accepted by the Insured.
7
X. 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.
XI. DRAFTING OF DOCUMENT AND RELIANCE BY INSURED
This Agreement has been negotiated by the respective parties. The Insured
warrants, represents and agrees that the Insured is not relying on the advice of the
Insurance Company, or anyone associated with them as to the legal and income tax or
other consequences of any kind arising out of this Agreement. Accordingly, the Insured
hereby releases and holds harmless the Insurance Company, and any and all counsel or
consultants for them from any claim, cause of action or other rights of any kind which
Insured may assert because the legal, income tax or other consequences of this
Agreement are other than those anticipated by the Insured.
The undersigned, and each of them, warrant and represent that no promise,
inducement or agreement not herein expressed has been made to them and that this
Agreement constitutes the entire agreement between the parties hereto and that the
terms of this Agreement are contractual and not mere recitals.
8
~.~~~_
The undersigned, and each of them, have read the foregoing Agreement and fully
understand it, and are aware of the propriety and legal effect of executing the same, and
neither the Agreement nor the compromise and settlement recited herein were induced
by fraud, coercion, compulsion or mistake, nor is this Agreement nor the compromise and
settlement made by the undersigned in reliance upon any statement or representation of
any of the parties hereby released, or their representatives, agents or attorneys.
Xil. COURT APPROVAL
The Insured represents that the Insured has received any and all necessary court
approvals to enter into this Agreement.
9
R,~,,..~_,_
XIII. CONTROLLING LAW
This Agreement shall be construed and interpreted in accordance with the laws of
the Commonwealth of Pennsylvania.
Dated: ~/~~/~1
bated: ~~~ /~ ~i3 I
Dated:
.~ /~~,.~v_~
Gary ppenstersl; ~d vidually and as parent and
natural guardian of Casey Hippensteel, a minor,
Insured
Dianna Hippen a I, individually and as parent and
natural guardian of Casey Hippensteel, a minor,
Insured
Duly Authorized Representative for Colonial 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,
10
M~~ ~~~
• f ~~` ` MMONWEALTH OFPENNSYLV
-~ . ' ~ `~~ \r.~!` POLICE ACCIDENT REPORT
-..
RFPflRTARI F 141 Nr1N.RFPORTARIF 11
POWCE•INFORMATION ACCIDENT LOCATION
I. INCIDENT H2-1177196 Z0. COUNTY Cumberland cooE 21
NUMBER
2. AGENCY Pennsylvania State Police 21. MUNICIPALITY Southampton 't-WP CODE 215 '
NAME
3. STATION/ Carlisle/2tzo 4 PATROL 21 PRINCIPAL ROADWAY INFORMATION
PRECINCT ZONE
5. INVES GATOR BADGE
8397
~~ 22. ROUTE NO.OR I
T 3171 AlfpOrt Rd.
NUMBER
Tpr. John Lifz STREET NAME
6. APPR YED BY BADGE I /p~/q 13. SPEED
40 24. tYPE
D 25. ACCESS
1
CQC LV• C. P ALI'1 ERO NUMBER `! I -L_,) LIMIT HIGHWAY CONTROL
7. INVESTIGATION 2/18101 8. ARRNAL 1221 INTERSECTING ROAD:
DATE TIME
ACCIDENT INFORMATION 26. RourENO.oR SR 3002/Gilbert Rd.
STREET NAME
9. ACCIDENT
2/16/D1
70. DAY OF WEEK Friday 21. SPEED
MIT 40 28. TYPE
HIGHWAY D 29. ACCESS
CONTROL 1
DATE LI
H, TIME OF 1200 72. NUMBER 2 IF NOT AT INTERSECTION:
Dnv of unlrs
13. #KI LED 14. pINJUREO 15. PRN. PROP. 30. CR0955TREET OR
Q 4 ACCIDENT y N ® SEGMENT MARKER
16. OID VEHICLE NAVE 708E 17. VEHICLE DAMAGE 37. DIREDTIDN
N .S E W 32. DI6TANCE
MI
FT
MO
FR
M TH
CENE? 0-NONE UNIT1 a FROM 617E .
•
FROM 617E
RE
VED
O
E S 33. DISTANCE WA6
UNIT1 UNIT2 1 -LIGHT
2
MODERATE MEASURED ^ ESTIMATED ^
V ® N ^ V ® N ^ -
UNIT2
3 71. CONSTRUCTION P I ICPLE INTER6ECTING
3-SEVERE ZONE ^ 35. TRAFFIC
13. HAZARDOUS 19. PENNDOT D DEVICEOL
MATERIAL6 Y ^ N PROPERTY Y ^ N
UNIT#1 - UNIT.#2
36. LEGALLY Y N 97. REG.
BPW 5405 38. STATE 36. LEGALLY V N 77. REG.
H69017H 30. 6TATE
PARKED? ^ ^ PLATE PA PARKED? ^ ^ PLATE PA
39. PA TITLE AA 43291409302 39. PA TITLE OA 50430181901 DA
OUT-0FSTATE VIN OUT-0F-STATE VIN
40. OWNER RGSe Ann Lauver 40. OWNER South Mountain Auta Sales
at owNER 1168 Means HollDw Rd 41. oYmER 100 Hi h Rd
9
.
ADDRESS .
ADDRES6
Ix. sl P CODE Shippensburg, PA 17257 4z. clrY. STATE Shi rg,
a zIP CODE ppensbu PA 17257
43. EAR 44. MAKE 43. Y R 14. MAKE
1984 Dod a 1997 GMC
45. MOOEI-(NOr
Charger 43, JNS, 45, MODEL-(NOT
Jimmy ae. INS..
BODY TYPE) Y ~ N ^ LINK BODY TYPE) y ®i N UNK ^
4I. BODY
D3 48. SPECIAL
D 40. VEHICLE
2 47. BODY
D5 96. SPECIAL
D 49. VEHICLE
2
TYPE USAGE OWNERSHIP TYPE U6AGE OWNERSHIP
50. INITIAL IMPACT
12 51, VEHICLE
D 52, TRAVEL
35 50. INn1Al IMPACT
1D 51. VEHICLE
D 52. TRAVEL
35
POINT STATUS SPEED POINT STATUS SPEED
53. VEHICLE
1 5/. DRIVER
1 55, DRIVER
1' 57. VEHICLE
1 54: ORNER
1 55. DRIVER
1
GRADIENT PRESENCE CONDmON GMDIENT PRESENCE CONDITION
56. ORNER
26593874 57. STATE 58. DRIVER
25583258 5T. STATE
NUMBER pq NUMBER PA
58. DRIVER Karen Renee Lauver
M 58. DRIVER '
Austin John Myers
NA
E NAME
59. DRNER 1168 Means HOIIOW Rd 59. DRIVER 777 Oakville Rd
.
ADDRESS .
ADDRESS
60. CITY, 6TATE Shl n g
621P CODE ppe sbur , PA 17257 60
Shi ensbur
PA 17257
E PP 9
,.
dZP ODE
6f. SE% 62. DATE OF
9/1183 63. PHONE fii, SE% 62. DATE OF
3/30/81 ,PHONE
F BtATH 53D-9567 M BIRTH 776-7767
fi4. COMM. VEH. 65. C IVES C 64. COMM. VEH. 65.
R
Y ^ N ®
Y ^ N Ci
CIASS
87. CARRIER fi7. CARRIER
66. CARRIER 68. CARRIER
ADDRESS ADDRESS
69. CITY, 6TATE fig. CITY, STATE
8 ZIP CODE 6 ZIP CODE
70. USDOT # ICC k PU # 70. USOOT 9 ICC # PUC #
72. VEX T3. CARGO 74. GVWR T2, VEH. 73. CARGO 74. YWR
CONFIG. BODY TYPE CONFIG. BODY TYPE
75. N0. OF 7fi. HAZARDOUS 77. RELEASE OF NAZMAT 75. N0. OF 76. HAZARDOUS 77. RELEASE OF HAZAIAT
ALES MATERIAL6 V 0_ N ^ UNK ^ AXLES MATERIAL6.___.. _.._ _. V ^ N ^ UNK ^
AA45 (11195) PAGE, O1 INVESTIGATING AGENCY
~. ,
RESPONDING EMS AGENCY Cu erland Valley EMS, Life Lion, Shippensburg Hose INCIDENTA H2-1177196
T9. MEDICALFacILm Carlisle Hospital, Hershey Medical Center ACCtDEMDATE 2n6rot
80, pEOPLEINFORMATQN -
A B C 0 E F G NAME ADDRESS N I J K L M
t t F 17 3 9 0 Oper. # 1 3 3 2 8 6 2
1 3 F 16 3 2 . 0 Mandy N. Grove P, O. Box 144 Newburg, PA 17240 2 3 9 B 6 1
t 4 F 14 3 Z 0 Casey M. Hippensteel 243 Neil Rd. Shippensburg, PA 1725 4 2 2 B 6 1
1 6 F 13 3 2 0 Holly M. Lauver 1168 Means Hollow Rd. Shipp. PA 17257 0 0 D B 6 0
2 1 M 19 3 2 2 Oper. # 2 3 3 7 B 9 1
~
a 66. DIAGRAM F,NAi. 1Z(ya ~ ~ ~)
r
i
St ILLUMINATION
2, 82. WEATHER >'ELC?a,o.K.
1 r l
L
.J
r
~clG V
r r
/
83. ROAD SURFACE ~ / ~
F W
K
C
C
ed PENNSYLVANIA SCHOOL DISTRICT i
(IF APPLICABLEI ~ ~ yt
TM
~
NA AZ
O
_
^
,
'
BS DESCRIPTION AGED OPERTY ~
~ ~
~
'
Tire Ruts, debris in field V
~
`
~ I
WNER Walter S. Burkholder M6i~ ~1~~~~
t"~~T' 2°
/~
DORESS ' I 1-~ j
~! \J
518 South Mtn. Estate Rd. ?J'
N
NONE 532-9373 V t
ST. NARRATIVE -IDENTIFY PRECIPITATING EVE TS, CAUSATION FACTORS, SEQUENCE OF EVENTS. WITNESS STATEMENTS, AND PROVIDE ADDITIONAL DETAILS, LIKE INSURANCE
INFORMATION AND LOCATION OF TOWED VEHICLES, IF KNOWN.
Unit # 1 cell phone no4 present Unit # 2 cell phone present not in use.
This accident occurred as unit # 1 travelled SB on Airport Rd. and failed to stop at a properly posted stop
sign. Initial impact occurred as Unit # 1 entered the intersection with SR3002 and struck Unit # 2, which
was travelling EB, on the left side driver's door with its front end. The force of the collision- spun unit # 1
into a counterclockwise rotation and forced Unit # 2 off the roadway where it landed in an adjacent field
and rolled over as the vehicle turned sideways. Unit # 1 came to a final rest facing WB partially on the
EB berm of High Rd. Unit # 2 came to a final rest facing NB and on its right side.
Physical evidence: debris field at point of impact, heary front end damage of Unit # 1, heavy left side
damage of Unit # 2.
On 02/19!01 at approx 1500 hrs. this R.O. interviewed Oper # 1 via telephone, she related that she did
not remember anything abou4 the accident and didn't know how it happened. Continued..
INSURANCE
INFORMATION COMPANY State Farm Insurance INSURANCE
INiORMATION COMPANY Erie Insurance Exchan e
9
uNlr
1 PoucY - 685344880538V
N0. uNir
2 PDUCr 082580116
N0, Q '
NAME ADDRESS PHONE '
ae. Glenn Edward Halter 940 Forest Court Carlisle, PA 17013 218-8905
WITNESSES NAME ADDRESS PNONE
59. VIOLATIONS INDICATED 90 SECTION NUMBERS IONLV IF CHARGED) TC NTC
UNIT t Stop Signs & Yield Signs 3323 (b) ® ^
uNlr z None ^ ^
91 PROBABLE 92. TYPE 93. RESULTS ®NOTEST 91. PROBABLE 92. TYPE 93. RESULTS IpI NO TEST gd. INVESTIGATION
USE TEST ^ USE TEST ^ R
F COMPLETE7
REFUSE E
USE
e
VN1T1 O D a
O._~9 ^UNK UN1T2 D D O._Io ^UNK YES ® NO ^
AAd6 (11-96)
PAGE: 02
u ' • `~' ' ~'` '~ MMONWEALTHOFPENNSYLVA
'' ~i PAR CONTINUATION SHEET
REPORTABLE ® NON•REPORTABLE
MClDENT H.Z•.).177,(96.
NUMBER ~~ EN7 LN5/O1 CODETM 21 CODE IPAL 215
90. PEOPLE INFORMATION-USE OVERLAY l25HEET FOR CODES
A B C D E F G NAME ADDRESS N I J K L M
BT. NARRATIVE
On 02/19/01 at approx. 1600 hrs. this R.O. interviewed Oper. # 2 via telephone. He related, I was
headed east bound to return the vehicle I was driving to the dealership that owned it. I wasn't real sure
where I was going so I wasn't going very fast, maybe around 35 MPH. I came up to the intersection and
saw the other car coming at me as I looked out my window and then I got hit.
On 02!21/01 at approx 1030 hrs this R.0 interviewed the right front seat passenger, Mandy N, Grove,
via telephone. She related, We were on the way to my boyfriend's house coming back from school. As
we got closer to the stop sign I wondered to myself if she was going to stop. As we got to the stop sign it
was too late to say anything to her and we hit the other car. I think she may have slowed down but I'm
sure she didn't stop.
On 02/16/01 this R.O. interviewed the witness on scene. He related, 1 was right behind the GMC Jimmy,
he was going around 35 to 40 MPH and he got hit from the side by the girl driving the other car. She
completely ran 4he stop sign.
Both vehicles removed from scene by Chuck's Auto Repair, Shippensburg, PA
SP7-0015 Mailed to owners of Units 1 & 2.
89. DE DRIBE VIOLATIDNS 90. SEC ION NUMBERS (ONLY IF CHARGED) TC NTC
UNIT I ^ ^
UNIT2 ^ ^
91. PROBABLE
VSE 92. TYPE
7ESi 93. RESULTS ^ NO TEST
^ 97. PROBABIE
USE 92. TYPE
TEST 93. RESULTS ^ NO TE57 94. INVESTIGATION
COMPLETE ?
^ R
UNIT i REFUSE
O. % ^UNK UNIT 2 EFUSE
O. °/a ^UNK YES ® NO ^
AA<sc (77-9s) PAGE: O9 INVESTIGATING AGENCY
Exhibit A
;.~ '
4 .y
Uniform Qualified Assignment and Release
"Claimant" Casey Hippensteel, a minor, by her parents and natural guardians, Gary Hippensteel and Dianna
Hippensteel
"Assignor" Colonial Insurance Company
"Assignee" Hartford Comprehensive Employee Benefit Service Co
"Annuity Issuer" Hartford Life Insurance Company
"Effective Date"
This Agreement is made and entered into by and
between the parties hereto as of the Effective Date
with reference to the following facts:
B. 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 1 g86 (the "Code").
A. Claimant has executed a settlement agreement or
release dated , 2001 (the
"SetNement Agreement") that provides for the
Assignor to make certain periodic payments to or
for the benefit of the Claimant as stated in
Addendum No.1 (the "Periodic Payments"); and
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 make any payment not
specified in Addendum No. 1.
2. The Periodic Payments 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.
3. The Assignee's liability to make the Periodic
Payments is no greater than that of the Assignor
immediately precetling this Agreement. Assignee
is not required to set aside specific assets to
secure the Periodic Payments. The Claimant has
no rights against the Assignee greater than a
general creditor. None of the Periodic Payments
may be accelerated, deferred, increased or
decreased and may not be anticipated, sold,
assigned or encumbered.
4. 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
address of record.
5. This Agreement shah be governed by and
interpreted in accordance with the laws of the
Commonwealth of Pennsylvania.
6. The Assignee may fund the Periodic 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 payee(s)
specified in Addendum No. 1. Such direction of
payments shall be solely for the Assignee'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.
8. Assignee's liability to make the Periodic
Payments shalt continue without diminution
regardless of any bankruptcy or insolvency of the
Assignor.
9. 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 assign ownership of any "qualified
funding asset" purchased hereunder to Assignor,
and Assignee's liability for the Periodic Payments
shall terminate.
„~.
A
10. This Agreement shall be binding upon the
respective 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.
Assignor:
Colonial Insurance Company
By:
Authorized Representative
Claimant: C~/~_ ~ ~.~1.,~~s ~,r
Gary Hippensteel as parent and natural guardian of
Casey Hippensteel, a minor ,, ~
Claimant: ~ pU~a , . - Ayr~®~i e
Dianna Hi p nsteel, as parent~a~i 'natural guardian of
Casey Hippensteel, a minor
Approved as to Form and Content;
Claimant's Attorney
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.
Assignee:
Hartford Comprehensive Employee Benefit Service Co
Authorized Representative
Title
~~,~,4
.~
r, J' t
,'
i ~-
Addendum- No. 1
Description of Periodic Payments
The following payments:
(1) To Casey Hippensteel ("Payee"), the following guaranteed lump sum payments:
Five Thousand Three Hundred Dollars ($5,300) on or about August 6, 2004.
Fifteen Thousand Dollars ($15,000) on or about August 6, 2007.
(2) Should Casey Hippensteel die before August 6, 2007, then any remaining guaranteed payments set forth in
paragraph (1) shall instead be paid, as they become due, to the estate of Casey Hippensteel, with the last guaranteed
payment to be made on or about August 6, 2007.
(3) Casey Hippensteel shall have the right, after reaching the age of majority, to submit a request to change the
Beneficiary by filing a written request with the owner of the annuity. This request will be reviewed by the owner of the
annuity, and if approved by the owner of the annuity and the issuing annuity company it will become effective. Said
request will be made in writing by Casey Hippensteel.
Initials
Claiman . ,~
Assignor:
Claimant: /,,i'. ~. KL .
Assignee:
d
e ., ~c
~ ~ C
~ o ~,~
~~~ ~-
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r,
y
t
c`' ``~
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as -<
":. r3:aa3.. .n;!~ ~,:.,. .:a?g~.,'hiS~Fe.n!H'S~ :&:tis-ttp?:~E41'~'.~8~.. _ '.
NATIONWIDE ASSURANCE IN THE COURT OF COMMON PLEAS OF
COMPANY d/b/a COLONIAL :CUMBERLAND COUNTY, PENNSYLVANIA
INSURANCE COMPANY
V.
GARY HIPPENSTEEL AND DIANNA
HIPPENSTEEL, as Parents and
Natural Guardians of CASEY
HIPPENSTEEL 01-4659 CIVIL TERM
ORDER OF COURT
AND NOW, this ~ day of November, 2005, the within petition, IS
DENIED.'
~ey M. Hippensteel
243 Neil Road
Shippensburg, PA 17257
:sal
Edgar B. Bayley, J.
'This was a structured settlement in which the last $15,000 that was placed into
an annuity is not payable until August 6, 2007.
,~;A41~~ ~%~~'~hz';J~~3
.YV!~~
I ~ :1f dd~~ Z- ~aNSd~Z
A~~a~va~zaad = ~a
~~~~~~ .
~~~ ~~~' C
~/- y~~`l ~w~~~
£'asey i~I ;-Iippensteei
263 ~ieil Rd
Shippensburg, Pa 17257
i}ctober 25,30135
RECEIVED
O('T t ~ Z005
BY:
Dear Judge Bailey,
I am submitting a petition to withdraw money from my Annuity Account. I need this
money to purchase a car. The car I am driving now is very unsafe. The headlights keep _.
going off and the motar is ready to go and there are a lot of other things a wrang with this
car. If I were to fix this car it would cost me a couple thousand dollars and it's not worth
it. I don't feel that that this car will make it thru the winter without causing an accident,
1 really can't afford to buy a car straight out or put a down payment on one right now and
my parents are disabled and cannot help me tivith #his. I am trying to do dais on my awn.
So if you please expidate your decision as soon as possible I would really appreciate it.
Thank you #or you time in this matter.
Sincerely Yo~u/rs,
/yi~ .
Cas M Hippensteel
4
Casey iU:. Hippensteel
243 Neil ltd
Shippensbcsg, Pa 17257
717-477-842$
Casey M. ~Iippensteel
Petitioner
V
Nationwide Assura,~ce ~,",ornp aay,
di'bia Colonial Insurance Company
C?-4559 Civil Tenn
1. Petitioner is Casey Plf. Hippensteel. I live aY 243 Neil Rd Shippensburg, Pa
17257, Cmnberiand Cowzty. My birthdays August 5, 1986.
2. The settlement urns e; ?erect by my mom and dad, f racy ~ ?Jianra Hippensteel on
July 18, 2001. Thru Post & Scheil, Pc.
3. The cau=`t order <.vas approved on AuausT 2C, 2001 ir. tl:e court of cam~*"~an pleas
Cumberland Co~:n#y, Penr:syivania. It was signed by Judge Edgar B._Bailey.
4. Tlae settiement fund is held u; my name until I taro 2 i years oid on August 5,
2007. The ta`a1 arnotnt is $15.OOG.
5. l petition T'ne courts to atiow me To withdraw $S,000to purchase a vehicle. I
can't a_~ard to purchase one. lViy vehicle is really getting unsafe a;?d war_'t last
too much longer. I°d Lke to do T'r_is before, the weather bets Bad.
5. I need t1:e vehicle to get back and for,..''. to work.
7. I respeetfly request a withdrawal of $5,000 to p~?rchase a new vehicle and Ta
n~
cover tax and Transfer costs.
$. Enclosed are same estimates of verieles i have checked an, one is a private
vehiele.
9. i have been stopped two days in a raw Pennsyivarua State Police because of a
defect in the Tights and my motor is ready to blow up.
ifl. i travel about 25 miles to work every day. Then 25 miles home.
i~
Respectfully yours,
~ `~--'
~~
Casey M.Hippensteei
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. Application For Annuity Hartford 11fe Insurance Company
THE Hartford Life and Accident
~ y. -.x Insurance Company
TJ ...-.T ~ ~ artford, Connectiput osii5
1. Proposed Annuitant (Please Print) ~ A K_ ~ `,~~ ~ .
a
Full Name nn ' lj Sex.
(~C152~/ l~ippen5fee~ ;,a ~'.„ ^Male_[~Fema(e
a43 1~1ei1 Kd ~"
City State Zp Code
~S'h i ens bu>^ ~R I'7a57
Tax ID/Social Security Number Date of Birth (Month, Day, Year) Place of Birth
1"70- (n$-507-7 S-CD- 8Cn
2. Second Annuitant
Full Name Sex
fl Male I-7 Female
City
Security Number
3. Contract-Owner
Year) ~ Place of Birth
Fufl Name
Hartford CEBSCO
Street Address `'
City
Hartford
4, Send Anne
Tip Code
~. iaunium u~ eau, r~unw~y raymenc$ 1300 ~ ~~ ODO p/1 g-(y'oZOO7
8. Annuity Payments
Does~the Proposed AnnuitanYintendthe replacement or change of any Annuity or
any ompany with this application?
Yes ~ No (If yes, give details in 11)
in
^ Life ^ Years Certain and Life
® Ocher: c`~ ~-l.(.fY~ (~ S' Urn S
6. Frequt ncy of Annuity Payments: f-l Monthly 15a Other ~(J c~M S
CONTRACT SPECIFICATIONS
AGE AND SEX OF 15 FEMALE FIRST ANNUITANT CASEY HIPPENSTEEL
FIRST ANNUITANT
SECOND ANNUITANT N/A
AGE AND SEX OF
SECOND ANNUITANT N/A INCOME PAYMENT $5,300.00
DATE OF FIILST PAYMENT 08/06/2004 INCOME PAYMENT FREQUENCY ANNUAL
DATir OF ISSUE 11/01/2001 ANNUITY NUMBER CCX 23771
OWNER
FORM NUMBERS
HL-
9353,9421-1,11084-0
HARTFORD CEBSCO
SCHEDULE OF BENEFTTS AND PREMIUIVIS
DESCRIPTION OF BENEFIT
SINGLE PREMIUM ANNUITY CERTAIN
LUMP SUM PAYMENTS
$ 5,300.00 ON 08/06/2004
$15,000.00 ON 08/06/2007
SINGLE
PREMIUM
PAID IN FULL
~~
~`~~ ~
:...~
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HL-9353 Page 3
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