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HomeMy WebLinkAbout03-2881 IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS In Re: Frederick Harvey, Jr., a minor: : No. ~-~/ ~ ~/-~-~ PETITION FOR LEAVE OF COURT TO SETTLE AND COMPROMISE MINOR'S CLAIM Pursuant to Pa. R.C.P. No. 2039(a), Petitioner State Farm Insurance Company, by its attorney, Brigid Q. Alford, Esquire and Boswell, Tintner, Piccola & Wickersham, petitions this Honorable Court for leave to settle and compromise the personal injury claim of Frederick Harvey, Jr., a minor, and in support thereof avers as follows: 1. Petitioner is State Farm Insurance Company, an insurance company licensed to do business in the Commonwealth of Pennsylvania. 2. As of August 6, 2001, Petitioner had issued a motor vehicle insurance policy to one Dae Woo Lee, owner of a vehicle that was involved in a motor vehicle accident on that date, having been driven with the owner's permission by one Andy Lee. 3. Laurie A. Harvey, an adult individual, sui juris, is the guardian and natural mother of the minor child, Frederick Harvey, Jr. 4. Petitioner Harvey and her son reside at 3 Creek Road, Mechanicsburg, Cumberland County, Pennsylvania. 5. The minor child, Frederick Harvey, Jr., was bom on January 22, 1989, and is presently 14 years of age. 6. On or about August 6, 2001, the minor child, Frederick Harvey, Jr., was a front-seat passenger in a car being driven by his mother, Laurie A. Harvey, in Silver Spring Township, Cumberland County, Pennsylvania, on the Carlisle Pike near the Kohls Department Store. 7. At the aforementioned time and place, the automobile driven by Andy Lee was traveling behind the vehicle driven by Laurie A. Harvey when the Harvey vehicle came to a stop and was struck in the rear by the vehicle driven by Andy Lee. 8. The minor child, Frederick Harvey, Jr., suffered personal injuries as a result of the motor vehicle accident, including a small abrasion to his right knee, back pain, and a minor burn to the right side of his face, caused by the release of powder from the airbag upon deployment. 9. The injuries suffered by the minor child, Frederick Harvey, Jr., required medical management that consisted of EMS treatment, ambulance transport to and treatment at Harrisburg Hospital, and four office visits to a chiropractor (Michael J. Bartell, D.C.) for examination and manipulation. True and correct copies of the minor child's relevant medical records are attached hereto, made part hereof, and identified as Exhibits A (EMS records), B (Pinnacle Health Hospital records), and C (Dr. Bartell records), respectively. 10. State Farm Insurance Company has offered the sum of $5000.00 to settle the minor child's personal injury claim against its insured, subject to this Court's approval of the settlement and Petitioner's execution of a Release relative to the same. An Affidavit executed by State Farm Claim Representative Nadine Alviani, confirming the existence of the said policy, and the $5000.00 settlement offer is attached hereto, made part hereof, and identified as Exhibit D. -2- 11. Laurie A. Harvey proposes to act as guardian of the funds payable to her minor child, Frederick Harvey, Jr., and understands that the said sum shall be deposited in a federally insured interest beating savings account or certificate of deposit with a financial institution in Cumberland County, Pennsylvania, and that the said funds shall have a notation on the account or certificate that no sums may be withdrawn from said account without prior Order of Court until the minor attains the age of eighteen (18) years, at which time the funds shall be free of restriction and turned over to the minor. 12. Laurie A. Harvey believes and therefore avers that the proposed settlement and guardianship of funds for the minor is fair and just and should be approved by this Honorable Court, and has executed an Affidavit of Consent to that effect, which is attached hereto, made part hereof, and identified as Exhibit E. WHEREFORE, Petitioner prays that this Court approve the above-described settlement proposed on behalf of the minor child. Respectfully submitted, Date: By: Bn~id Q. ~Alford, Esquir~/j Supreme Court I.D. #385'90 BOSWELL, TINTNER, PICCOLA & WICKERSHAM 315 North Front Street Post Office Box 741 Harrisburg, PA 17108-0741 Attorneys for State Farm Insurance Company Exhibit A Service Ntme W~t Sltor~ EMS ~ddeflt L~on C~SIc ~ ~ Kot~ ~pt. Sto~ ~ ~03 W~ Way ~ M~csbu~ ~ ~ ALS U~ 'Pennsylvania EMS Report Unit No. 2102261 MCD 21910 Phone No. (717) 69%8603 PCRNo. Cotmtylncid. No. ]Date 907456g 11368 [ 08/06/2001 Re~al~ng Facility Harrisbur~ Hospilal ~ Age Date of Birth Socinl Sec. No. [Sex ~} 12 01/22/1989 800-17-84~8]Male ,~ A#1 Wright, Kennith State Zip A~2 Evam, Micbelle PA 17055 Out 91730 Aller~te~ {med~): n~ae Crew On-Scene ~ In 91734 91752 91767 [M~llcal Command physician EMT 083067 Dispatch 17:53 EMT 041536 Enroute 17:53 EMT 16392~ Arrive Scene 18:01 Depart Scene 18:21 ArriVe FacllitT 18:34 Avaflabk 19:32 In Quartem 19:50 MCC Narrative Cumberland ambulance 182 dispatched cia~ two for a 2 veMcle MVA on ~c Cadlsle Pike at Kole~ Dept, Store. A.O.S. to find a 12 y/o white male standing along the side of road by vehicle. Pt. had self extracatbd himself out of vehicle. Pt. was C.A.O. x 4 upon our arrival. No pr~nival give~ by CCCC. HPI- Pt. was reswained front seat passenger o f vehicle timt was travelling along I~azlisle Pike w~....eE_ mother vehicle cut in ~ont of vehiale be was ridi~ in. Upon impact of velfic, les air ling deployment occun~d in l~s veMcle~ Vehiclea we~ travelling ~ro~'40'~V~H~.~. ~vebicle susta~bd moderate left' s~de fi'ont ~d damage. No visible damage to inside eomparlment, windshield hi tact, dashboard and stewing wheel in tact. -, CC- Pt. was complaining ora burning s~asa6on to the right side of his face. possible powder bum ~'~m air bag. PMH- none MEDS- none PE- Upon msessment Pt was found to be conscious and alert, and was able to recall entire incident. Pt de~ied any loss ofcensdouaness. Pupils were PEARL. Skin color was pink and dry. Pt had ~orne r~d~ess to the right side of bls face and neck and was ccmplai~ag of burning sematlon to that area. Pt. d~ied any n~:k ~ or back pain upon pdipation. Pt also d~n/ed any chest pain or difficulty breathing. Lung~ were alear bilaterally. Pt did pr~ent with some ~d~ess to his cbest ~ also possibly fi~an powder fi'om air bags. Pt did not e~mplain fzom any discomf~r~ to ¢be~t ~ No/VD abd trachea was midline, Abdomen ~ soft and non-tender upon palpation. No er~pitu.s upon palpation of pelvic area. Pt had good movement and se~ation RX- C- collar applied, Pt placed onto LSB, CID's spplibd, and then placed onto liter.. Applied dry sterile gauze to face area ar~a for comfort. Monltorbd Pt. vitals throughoot transport. Transferred Pt. car~ to Harrisburg E.R. staff'with complete verbal reporL kdw 083067 18:03 / ' % c spine / c - cellar aoplied lg:05 / % Isb/cid applied 18:07 · / % placed pt. onto 18:15 72 20 r20/80 % focused ~ent 18:25 . ! % on~:oinR ~t 18:23 80 20 120/p % Copyright. 2000 bled-Media, All Rights Reserved Page: I of l Exhibit B :, PI NNACLEHE~LTH. Hospitals EJCIAN U~VEL OF CARE: MEDICAL RECORDS TIME OUT: [] FIRST PL~,CE AM~ , EMERGENCY ROuM ASSOC: ~,~ ~Y~c~ DOCTOR UNKNOWN P ' R T CONSULT [] GUARANTOR NAME HRRYEY ~LAURIE ~E 999--5_8~.-B96~R~ - - NOTIFICATION NAME HARVEY ,LAURIE ~E 999-999-999~ ;SP SERV I AREAS. TO VISIT HER PATIENT # I DATE :~00~._ 9cI 08/06/01 PATIENT NAME AND ADDRESS HARVEY ,FREDERICK 2303 WAREN WAY MECHANICSBUR PA 17055 GUARANTOR EMPLOYER INFORMATION HARRISBURG PA PA~IENT EMPLOYER IN~ORMA'AON 999- - N/A DIAG. CODE RELIGION NPS 00000 TIME j AGE DATE OF SJRTH I S M R SOCIAL SECURITY #I P/'r F/C MEDICAL RECORD# I DOC 18:5~ 12 01/~/8~ M S C' 8001784~8 E A 80017~468 j INSURANCE CO. NAME GROUP NO. POLICY NUMBER SUBSCRIBER NAME XSg/SHELBY R092037~ FATHER , / / ~(10Lr~(s0pl2hS.5v0~0b0T~&10L~&lT'.5C ~(3@ Patient Name: HARLEY ,FREDERICK Sex: M Room/Bed ./ Pt~ 2200329.92 ~ed Rec~: Age: 12 800178468 JUN fl 5 2002 Home Address: City: 2303 WAldEN WAY MECHANICSBURG PA Zip: 17055 Home Phone: 999-999-9999 Work Phone: Soc Sec~: 800-17-8468 Contraindications Ty~e Description Reaction Date Sev Found Type: ~l=Drug, 2=Food, 3=Misc Allergy, 4=No Known Allergies Severity: l=Severe, 2=Moderate, 3=Mild ~llergies ~reviously entered in Patient Profile. Please update contraindications. Date of Pneumonia Vaccine information from previous admission: A3~LERGY IDENTIFICATION FORM PE~ CPIAi~T COPY 18:50 08/06/01 FROM PSCS,ALLERGF1 KSPT7415 Vital Signs 2 0 Level of rJVentilation Circulation JUN n 5 2002 ~Harrisburg (~ Polyclinic [~ bG~(~EIVED I-'1 First Place ~Non-Urgent ~ Urgent ~ Emergent Sex: ~ Wt.(kg}: Mode of A~rivat: Arrived wi~: ~ Spea~ No Englis~ Language: Tmnsla~en By: ~Alen --'1 Clear · --I Obstructed ~- I~ Whee~crta~r BP: ~ ~ Ver~al ~ ~ored ~resent ~N~n-~or~ ~regular ~i~egular ~ Card~ Pulse: ~ Pain i~ Apneic Resp: ~ ;~ Unres~o~ive ~ In,bated ~ strong ...... .... ~~ [ '~. ': · , .... :=~'- ~..-~ - -, ..... ~" · ~ Smo~.~ N .... i~~ C~il,ho~lmmun~a,o~: ~NotUTD~Oemes,c~,ence ~ Disposition: ~ Regi~ffon ~To Rm¢ ~ ~ X-Ray Triage Nurse Signature: ~me: PATIE~ INFORMATION Hospkats EMERGENCY NURSING MR: 800178468 CASE: 220032992 ASSESSMENT SHEET H48VEY,FRED~R/C~ ~ (¢o~s~-~* MEDICAL RECOR[ PhC: 999 999-9999 AGE: 12 Admissions called: In ~e c~re of: ~ ~ ~ ~e~: ~me: Repo~ ~lf~ by:~me: , to: To Bed: Mede: Tmbulato~ ~ Ambu~nce Monito~ Yes ~ No ~ WC ~ Ca~ed Mede: ~ WC ~Stretcher ~ Othen l~l~ P! N NAC LEH F~LTH Hospitals -EMERGENCY NURSING FLOW SHEET CONTINUATION PATIENT iDENTIFICATION MR: 800178468 CASE: 220032992 HARVEY .FREDERICK M DATE: 08/06101 DOB: 01/22~1989 Ph#: 999 999-9999 AGE: 12 DR: $SN: 800178~68 ./ CGOH · .?~,Harrisburg Hospital -' Polyciinic'~F~ 2002 -- Phone: 6~7-7295' .f 'Phone: 782-5257 .. Please note that the instructions circled or checked below pe~ain to you. ._..~.You have been dis;:harged' with the diagnosis of ' ~e examination and treatment you have received in the Emergency Department have been rendered on an emergency "Basis only and are not intended to be a substitute for or an effort to provide complete medical care. If you develop problems and complications, contact your physician or this Emergency Department. General Instructions Rest for Off work / school from to Return to wor~ on Light duty for Regular duty :Eol!ow-up Care' · ' 1. Return to the Emergency Department immediately if -." unexpectedly worse or not improved. 2. Emergency Department on 3. Family Physician _~,,.:4. See Dr. on at AM / PM. 5, Call for an appointment within hours / days to the following Clinic: Medical Clinic, Education Bldg, 2nd Floor (782-2421) Surgical Clinic, Education Bldg, 2nd Floor (782-2421) Orthopedic Clinic, Landis Bidg, 2nd Floor (782-2142) Pediatric Clinic, Kiine Bldg, 4th Floor (782-4650) WomanCare Clinic, Professiona! Bldg, 3rd Street, ~rd Floor (782~6500) LabOratory Instructions Call for results of pending lab tests. Q~-Ray Instructions ""~'%ur x-rays have been read by the Emergency Physician. If any abnormalities are found that have not been called to your attention, you or your doctor will be called immediately. Sometimes, fractures or abnormalities may not show up on x-rays for several days. If symptoms persist or get worse, call your Physician or return to the Emergency Department. More x;.m_...y~s may have to be taken. Emergency Department Patient Instruction Sheet PINNACLEHEALTH Diet force fluids __ soft diet __ clear Iiqu~,d~.'~.." as tolerated __ Supplemental Instructions Sheet ~1 Yes Medication(s) ...... .' q. _ ~.. - ~-'~ Miscellaneous Emergency Department P.O. Box 8700 Harrisburg, PA 17105-87{3~ Date CGOH~657-7295 Ha~sburg-782-5257 Polyclinic-782-4132 ~ubstitution Permissible , M,D., C.O. IN ORDER F~R A ~RAND NAME PRODUCT TO SE DISPENSED, THE PRESCRISER MUST WRITE *BRAND NECESSARY' OR '~RANO MEDICAJ~Y NECESSARY' IN THIS SPADE MAY REFILL TIMES PA Lic ~ /" DEA No. /" PRINT ,-" PHYSICIAN NAME LABEE ALL PRESCRIPTIONS PATIENT INFORMATION MR: 800178468 CASE: 220032992 HARVEY ,FREDERICK M DATE: 08106/01 DOe: 011221191~9 Ph#: 999 999-9999 AGE: 12 OR: SSN: 8001784,68 AUTHORIZATION TO TREAT Harrisburg Hospit~al, 111 S. Front St. Harrisburg PA 17101 08/,. 1 800178468- 2~~ HARVEY ,FREDERI:CK .JU.,~ 01/22/1989 00193 RECEJVI~ AUTHORIZATION FOR TREATMENT- ~ consent to the rendering of medical care, which may include diagnostic procedures and such medical treatment as my a~ending or consulting physician considers to be necessary. I also understand it is customary, absent emergency or extraordinary circumstances, that no substantial procedure will be performed upon me unless or until I have had an opportunity to discuss them with my physician or other heath care professional to my satisfaction. If I am a competent adult, I have the right ~(>consent or refuse to consent to any proposed procedure to therapeutic treatment. I will not be involved in an?.-research or experimental procedure wrthout my full knowledge and consent. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risks of injury or even death and at:knowledge that no guarantee has been made to me as to the results of any examination or treatment in this hospital. RELEASE OF MEDICAL INFORMATION- I hereby authorize PinnacleHeaith System my attending physician and for other physicians associated with him/her or whom he/she may designate to release all or part of my med cai record from this admission to any other health care providers involved in my continuing care and treatment, to my insurance company and its contractual venders, Social Security Administration, Health Care Financing Administration and th rd-party cart ers and their contractual vendors, or their representatives, for the purpose of collecting insurance benefits so long as I am listed on the account as having coverage with such carrier. PRE-CERTIFICATION REQUIREMENTS- If my insurance company or third-par~y requires 13re-certiflcat on, then I understand that it is my responsibility to contact them to obtain such certification. EXCEPTION: Medicare. ASSIGNMENT OF INSURANCE BENEFITS- I hereby authorize my Medicare and/or medical insurance benefits payab e to me under the terms of my insurance policies to be paid directly to PinnacleHealth System. If my attend ng phys c an and/or other physician associated with him or whom he may designate accepts insurance assignment, then hereby authorize my Medicare and/or medical insurance benefits to be pa~d directly to those physicians. I understand that lam financially responsible for non-covered services, as well as any deductibles, coinsurance or amounts in excess_of insurance benefits. I perm.it a copy of this authorization to be used in place of the or g hal. GRIEVANCE APPEAL CONSENT- I hereby authorize Pinnacle Health System to act on my behalf in request n.q a reconsideration of a medicaJ determination made by my managed care plan or utilization review entity regarding my medical care. INPATIENTS AND OBSERVATION I~ED PATIENTS ONLY PATIENT SELF-DETERMINATION ACT OF 1990 (ADVANCE DIRECTIVES)- I acknowledge that PinnacleHealth System has provided me with wri~en information on my rights to make health care treatment decisions in compliance with the Patient Serf-Determination Act of 1990. PERSONAL-VALUABLES- I understand that PinnacleHealth S~/stem provides facilities for the safekeeping of any va uab e and any valuables kept by the patient are kept at the patient s risk. I hereby accept full responsibility for anypersonal effects taken to the hospital room, including such things as dentures, eye gtasses, contact lenses, hearing aids and radios. MEDICARE INPATIENTS ONLY- I certify that the information given by me in .applying for payment under Tit · XVI .of the Social Security Act is correct. I acknowledge that I have received a copy of An Important Message from Medicare My signature acknowledges my receipt of this message from Pinnacle Health and does not wa ye any of my r ghts to request a review or make me liable for any payment. I realize that lifetime reserve days are a once lifet me max mum of 60 days. If I should use all my full days andco-~nsurance days, I agree to use my lifetime reserve days for any remaining days. CHAMPUS INPATIENTS ONLY- I acknowledge that I have received a copy of "An Important Messaoe from CHAMPUS". My signature acknowledges my receipt of this message from PinnacleHeaith System and does not ~vaive any of my rights to request a review or make me liable for any payment. AUTHORIZATION MUST BE SIGNED BY THE PATIENT'S LEGAL REPRE~ENTATIVI~ IN THE CASE OF A MINOR, OR WHEN THE PATIENT IS PHYSICALLY OR I~A~LY I~CAF~AC~IT~TED. Hospitat Representative 153 ER FP MEDICAL RECORD Exhibit C 7 9 MICHAEL J. BARTELL, D.C. (717) 697-8030 FA.X: (717) 691-6755 RECEPVED RADIOGRAPHIC EVALUATION-DOCq'OR RECORDS PATIENT: SEX/AGE: DOCTOR: EXAH DATE: FRED HARVEY MALE/13 YEARS OLD MICHAEL J. BARTELL, D.C. SEPTEMBER 17, 2001 CERVICAL SPINE N/A PRO3ECTIONS- OSSEOUS STRUCTURES- DEGENERATIVE CHANGES- BIOMECHANICAL ASSESSMENT- O~ ADD['I-[ONAL NOTE- THORACIC SPINE N/A PRO3ECTION- OSSEOUS STRUCTURES- DEGENERATIVE CHANGES- BIOMECHANICAL ASSESSMENT- OF ADDi-]'IONAL NOTE- TREA~qNG CHIROPRACTOR 1001 S. M,,\RKET STREE'F SUITE A MECI IANICSBURG, I% 17055 M3B/bb cc: file J.uN ri 5 2002 RECEIVED EX,~'~4: INITI^L ~ DATE: F.E-EVALU^TION ?I'PrSIGAL EVALUATION f'/ t,'lSE ONe; ?A TIENT,~ T.~NDIN~ '"'F' I IE^D 'IILT: RIGHT E^I~ LOWEF. TH/~ THE LEFT LEFT fAF` LOWEI~ TH,~N 'file NECK 5FIOWED (NO) DIDE CUIL~ATUIZ. E TOWAP-.D THE (LEFT) (F-JGH'O. MUSCLE TENSION ON^S) ONA5 NOT) PI~SEI~ tN THE NECF. ON TFIE (LEFT) (P-JGHT) ~ ,51'IOULPEP-, TILT: THE (LEF0 (~I~GHT) `5HOULDE.~ I.'5 LONEF. THAN THE (~ (FJGHT). Tt-IF~ CHEST OF. THOI~ SHOWED (NO) SIDE CUILW'ATUF. E TOWAR~ THE (LEFT) (P-J~IT). ABNORMAL DAEIKWAP-.D CUk:3/ATURF OP. KYPH0515 (IS) (1,5 NOr) PP. ESENT IN THE (C-~,',L) ~ (LUM[~,',~) ~C~C~ ADNOF. MAL FO~VAP. J~ CU~ATUF~ 0~. LOF. Oq5. ~`5 05) (IS NOr) PP.E`SENT ~N 'rile ('n-~o~,,,c-'~ (LUM~,'~) ~ ON_._.A_A_A_A_A_A_A_A~ (WA5 NOT) NOF. N~_AL 5t-lOWED (LEFT) (l~H'r) ILIUM HIGHER THAN THE (LEPO (~-rO. ~',CXDLDIEP.`5 -[E`5'r; CEk'VIC^L F`ADICULFI15 + ~ENO~iWAS) (WAS NO0 FOUND ~N THE F, EG~ON OF THE VEI~TADI~.~E IN THE NF_~K. DECH1EP-~-W~VALC~ALVA MANEtJ~i'EI~ ~1~ LOW D~K P~N + ~ JUN. 0 5 2 02 R~CEIVED NECR 5tO~A~ DENDI~ TO ~E LE~W~ (~&) (F~R) (P~R) AT. D~. NECK 51DE~A~ DENOI~ TO ~IE ~Gt-ITW~ (~AL) (FAI~) (~E) AT DEGAS. ~E~ ~CAL ~I'A~ON: ~Gt IT CE~CAL ~I'A~ ~: F~MINA ~M~FS5DN 3~T 5~O (~) I~E OF PAIN ~ (LE~ (~1 A~. DU~'5 DE~Ii 5tGN; + ~EE ~FL~ W~ (~E~3ED) (~ (SL~ISI I) (~r P~SE~) ~EE ~FL~ W~ (~E~O) (~AL) (5L~151.1) (~r ~EKO IN ~-IE ~GI IT "-. KNEE mCE~ ~F~ ~N ~ IE U~ ~ ~ W~ (~E~O) (~ (SL~S~-0 3DCE~ ~FL~ IN 3HE UPPER ~ ~ W~ (~E~D) {~AL) (5L~ISH) ~I-IT HAN~. ~A~NBE~ ~l~ I~EL ~A~INAI~N ON P~ ~ I~l~ 6U~E OF F~A~ ?t IA~ Tf-/NEE: FA TIENT ~U?INE TIlE "A??AP-,EN'ILY 51101~F LEG" MEASURED DETWEEN THE IJMDILICUD AND '111E IN.~IIDIE 'il IE ANKLE WAS THE (LEPTJ (I~GI.I'I) LEG. 'iI-IE "tRUE 51101~'T LEG" MEASUP-,ED BETWEEN THE AN'IEI~OI~ 5UI~EP-dQR ILIAE SPINE AND TI IE INSIDE OF TI-lB ANI~ WA.~ THE (LEFT) (PJCd-FI) LEG. 50'l O-IIALL TE~T: LEVEL OF VEI~A~P-,AL INJUt~ NECK (EXCF_U.e¢O THE ?ELM¢ ELEYA'IOF-.5 WEF. E (ID(CF_LLEh~ LASEGUE'5 5K~N SHOWED (Ntg) .~":IAI~ NEIk:5/IE I~F.E~SUF-JE IN T! IE [LEFT') (R/OI rl] LE~. ?A'I PJCK'S 'rE~T 511QWEP (i~D)-i~F_.~TFJCTED HIP MQYEMENT ON 'I liE (LEF1) (Y-J~HT) ,5(,JN 5ENSiTI~IIE5 GHEGr-.ED WITH ']'HE ~INWHEEL 5HC/WED THE FOLLGW1N~ EESULTS: 'FRONT AND INSIDE ,GUI~J:~--q~ OF THI~ HAD (NO~AL) (MOF,.F_) (LES5) 5ENSATION- 'FF-,ONT AND INSIDE 5UI~:AC'E OF 'TI-IIC~H AND LEC~ HAD (NOIR~AL) (MOIRe) (LES5) ,SEN.GATION - L~. 'IN.51DE 5UI~F:/~q~ OF L~F~ AND FCOT' HAD (NORMAL) (MORE) (LE~5) 5ENSA~IION- L4~ 'FP-.Z~NT 5UIR~:/V~'E OF: LF~ AND FC01-HAD (NOIKIvl/~L) (MOI~ (LES5) SENSATION- 1_5. 'OUTSIDE 5U~J~--~ OF THE FO(Tr HAD (NC~) (MOF.~--) (LESS) SENSATION- ,51. 'DAli(. AND OUTSIDE 5UF-J:..~--E OF TH~,+t AND LF_.~ HAD (NC)F,~AL) (~IKE) (LES5) 5EN..GATI©N - 52_ LF_WVlN LEg KAISEr, 5ICON: + WELL LE~ KAISI~IK '~IC~N; FAIN ON A~:FECTED 51DE + LEC~ DF-,C)~' 'r~ST 51-tOWeD (..~), DISC COMF'F-,E~51ON AT THE LU~F__,C)SACRAL JOINT. ?HA~E FOUfC' ?A TIENT ?f~ONE D/'~KW^~ DENPlNC~ OF THE NECK, W~ (~LLE~ D~KW~ DENOI~ OF ~E ~NK W~ (~LLE~ (~O) (FAIK) ~FL~ IN THE LE~ ~E ~N W~ · ~FL~ IN ~IE ~Gt tT ~E ~N~N W~ (~E~D) {~ ) (~ ~E~. . D~I~D ~T (Sk~) (~D ~ 5~ ~ OF mE TO~ INS~ ~ FL~ION ON 5~MULAI~N ~ mE ~ ~ mE ~ ~O IND~AIED (~) (~) (O~ ~L~5 5~N OK ~E HEEL-TO-~K ~T AD~AL 5~N 5ENSI~ W~ ~ IN THE ~ION OF C . T L - . (~ (~ 5~LI~ ~N'5 ~T-UF T~T: + ~ MENNELL~I~'r: LA~ + ~ ~ED~AL RI~CEIVED i"AL?A lION: RECE/VED MICHAEL J. BARTELL, D.C. {717) 69'/-8030 JU'N.'rl 5 200;~ R~CEIVED PHASE OF CARE 'PARC. K-~.q 'PRE AR~..AS OF SOFT TISS~ AS WILL BE Dm'I'R~ BY A ~-~UATI~ CLINICAL DIAGNOSIS CERVICAL SPRAIN, LUMBAR STRAIN/SPRAIN, ILIUM SUBLUXATION CC~IPLEX AND L1-L5 ~UBLUXATIONS, LEFT; LUMBALGIA AND LUI~SACRAL STRAIN/SPRAIN, LF-~. SUBMI. T~TED B~: MICHAEL J. BARTELL,D.C. 1001 S. MAKKET STREET SUITE A MECHANICSBURG, PA 17055 No. SIGNS/SYMPTOMS: KEMP SIGN + - EXAM/DOCTOR: ·CERVICAL ELY'S + STAIR STEP + - SOTO HALL + - - PALPATION: C + - T +- L/S + - STATUS (ASSESSMENT): SIGNS/SYMPTOMS: KEMP SIGN + - EXAM/DOCTOR: CER¥ICAL STAIR STEP + - SOTO HALL + - ~+ ELY'S +. r PALPATION: C + - T + - L/S + - STATUS (ASSESSMENt): ~ ~ ~ EECEIVED RECEIVED SIGNS/SYMPTOMS: PATIENT KEMP SIGN + - EXAM/DOCTOR: 'CER¥ICAL STAIR STEP + - $OTO HALe -~ - ELY'S + - PALPAl'ION/ C ¢- - T + - L/S ~.~- KEMP SIGN + - EXAM/DOCTOR: CERVICAL STAIR STEP + - SOTO HALL + - ELY'S +. :- PALPATION: C + - T + - L/S + - STATUS (ASSESSMENT): , TX: RECEIVED RECEIVED SIGNS/SYMPTOMS: P ATIE N'T EXAM/DOCTOR: CERVICAL STAIR STEP + - SOTO HALL + - ~- ~ ELY'S +. ~- PABPATION: C'+ - T · - L/S ~- - Exhibit AFFIDAVIT OF NADINE ALVIANI I, Nadine Alviani, Claim Representative for State Farm Insurance Company, do hereby state the following: 1. I am the Claim Representative assigned to handle the bodily injury claim made by Lame A. Harvey, in her capacity as guardian and natural mother of Frederick Harvey, Jr., a minor child, in connection with injuries sustained in the motor vehicle accident described in the foregoing Petition (Claim # 38-J751-768); and 2. At all times relevant hereto, Andy Lee, driver of the vehicle in which struck he Harvey vehicle, was a named insured on a motor vehicle policy issued by State Farm Insurance Company (Policy 7020-491-38D); and 3. Upon presentation of the claim made on behalf of Frederick Harvey, Jr., and review of the applicable facts and medical records, I extended a settlement offer in the amount of Five Thousand ($5,000.00) and further represented that such monies would be paid upon receipt of an Order of Court approving the same and an executed Release of Claims. Date: Sworn to and s~ub,sc~i~ed before me this.~ ~lay of Nadine Alviani, Claim Representative State Farm Insurance Company Exhibit E VERIFICATION AND AFFIDAVIT OF CONSENT I, Laurie A. Harvey, hereby verify that the facts contained in the foregoing Petition for Leave of Court to Settle and Compromise Minor's Claim are true and correct to the best of my knowledge, information and belief, that I understand the terms of the settlement and restrictions to be placed on the settlement funds once deposited, and that ! believe the terms are fair and just and should be approved by this Honorable Court. I further understand that false statements herein are subject to the penalties of ! 8 Pa. C.S.A. 4904 relating to unswom falsification to authorities. Date: Laurie A'O~Harv?~~n and natural mother of the minor child, Frederick Harvey, Jr. CERTIFICATE OF SERVICE I do hereby certify that I have served a true and correct copy of the foregoing Petition for Approval of Minor's Settlement, by placing the same in the United States Mail, first class, postage prepaid, at Harrisburg, Pennsylvania, addressed as follows: Laurie A. Harvey 3 Creek Road Mechanicsburg, PA 17055 Parent/Natural Guardian Date: By: ford, iN RE: · IN THE COURT OF COMMON PLEAS OF · CUMBERLAND COUNTY, PENNSYLVANIA FREDERICK HARVEY, JR., a minor : 03-2881 CIVIL TERM ORDER OFCOURT AND NOW, this ~ day of ~~2003, hearing on the Petition for Leave of Court to Settle and Compromise Minor's Claim is set for ~ ~ '-~J ,2003, in Courtroom No. 2. Edgar B: Bayl~y, J. Brigid Q. Alford, Esquire BOSWELL, TINTNER, PICCOLA WICKERSHAM 315 North Front Street PO Box 741 Harrisburg, PA 17108-0741 IN RE: FREDERICK HARVEY, JR., A minor : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : 03-2881 CIVIL TERM AND NOW, this ORDER OFCOURT day of July, 2.003, the hearing currently scheduled for July 21,2003, on the petition for leave of court to settle and compromise minor's claim is cancelled and rescheduled for Monday, August 18, 2003, in Courtroom Brigid Q. AIford, Esquire 315 North Front Street P.O. Box 741 Harrisburg, PA 17108-0741 Number 2, Cumberland County Courthouse, Carlisle, Pennsylvania. By the~g~ Edgar B.'Ba~ :sal PENNS~ L~/~,,N A IN RE: FREDERICK HARVEY, JR., A minor · IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : 03-2881 CIVIL TERM AND NOW, this _ ORDER OF COURT _day of August, 2003, following a hearing, IT IS ORDERED: (1) The petition for leave to settle the claims of a minor, Frederick Harvey, Jr., born July 27, 1989, against Dae Woo Lee and his insurance carrier, State Farm Insurance Company, for injuries occurring in an accident on August 6, 2001i, for $5,000, IS APPROVED. (2) The total $5,000 settlement shall be deposited in a federally insUred interest bearing account at the Vartan National Bank in the name of Frederick HarVey, Jr., with the following notation NO WITHDRAWAL MAY BE MADE UNTIL THE MINOR, FREDERICK HARVEY, JR., BORN JANUARY 27, 1989 ATTAINS HIS MAJORITY EXCEPT FROM AN ORDER OF A COURT OF COMPETENT JURISDICTION. (3) Laurie A. Harvey, the mother and guardian of Frederick HarveY, Jr., may execute a release of claims and settle the docket upon the payment of said settlement. (4) Counsel shall file proof of the deposit in the required form with the Prothonotary. ,,/~rigid Q. Alford, Esquire 315 North Front Street P.O. Box 741 Harrisburg, PA 17108-0741 ,,/ oS. By th~ (- / ~dg~ :sal//' In Re: FREDERICK HARVEY, JR., A minor IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA 03-2881 CIVIL TERM yERIFICATION OF DEPOSIT OF SETTLEMENT FUNDS Pursuant to Judge Bayley's Order of August 19, 2003, and based upon information provided to me by Laurie Harvey, mother and natural guardian of the minor, Frederick Harvey, Jr., I hereby verify that, on August 25, 2003, the settlement monies were deposited in Account Nos. 3011361, 3011362, 3011363, 3011364 and 3011365 at Vartan National Bank in the name of Frederick C. Harvey, Jr. by his mother and natural guardian, Laurie Harvey; no withdrawals of monies so deposited shall be made until Frederick Harvey, Jr. attains his majority, except from Court of competent jurisdiction, an order of a Respectfully submitted, By: Supreme Court I.D. ~3859~/ BOSWELL, T1NTNER, PICCOLA & WlCKERSHAM 315 North Front Street Post Office Box 741 Hanfisburg, Pennsylvania 17108-0741 Attorney for Dae Woo Lee and Andy Lee CER-_~TIFICATE OF S_ERV[CE I do hereby certify that I have served a true and correct copy of the foregoing Verification of Deposit of Settlement Funds by placing the same in the United States Mail, first class, postage prepaid, at Harrisburg, Pennsylvania, addressed as follows: Laurie A. Harvey 3 Creek Road Mechanicsburg, PA 17055 Date:_ By: