HomeMy WebLinkAbout99-06596`\
??
V
I
V
??
V/
1
\\
f'I ILIS LL\L\i ILI.I1I 7 %Nt
11 NnnaJ I??P?n u]4u. I'N
V 11J I
DAWN Ibl. SI IErAFF R, by her mother
and Icgal guardian, SI IL•RRY.101INSON
Plaintiffs
IN IIILCOL,RI OFCO%1\1ONPI-FAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
\'.
,rICO/LEADER INSURANCE
COi\IPANY and DEBRA A. IMESSEMER
and KENNETIi R. NIESSINIIER,
Defendants
CIVIL ACTION - LAW
NO. C(,
AND NOW, this 7 -?'4 day of /V V&,!2I,UY/i 1999, a hearing is set to
consider the Petition to Approve IMinor's Compromise. The hearing will be held before the
Honorable F el OilNOY&nj ---/ 9 , 1999. x.30 R1Y1 .
BYTHELOUR ??
a-d
DAWN M. SHEAPPER, by her mother
and legal guardian, SHBRRYJOHNSON,
Plaintiffs
V.
IN TIIE COURT OR COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO.
TICO/LEADER INSURANCE
COMPANY and DEBRA A. MESSIMER
and KENNETH R. MESSIMER,
Defendants
AND NOW, this day of
1999, Upon consideration of
the attached petition to Approve Minor's Compromise, said petition is granted and Defendant is
ordered to pay all claims in the amount of S4,250.00.
BY THE COURT,
J.
DARN M. SHEAPPL'•R, by her mother : IN Tl I E COURT 017 CO\I\,ION PLI?AS OP
anti Icgal guardian, SHERRI' JOHNSON, : CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiffs
t'• : CIVIL AC'T'ION- LAW
: NO. 99. Gs 96
TICO/LEADER INSURANCE
COMPANY and DEBRA A. MESSIMER
and KENNETH R. MESSIMER,
Defendants
PETITION TO APIIlOVE M NOICS_C_O111PROMISL
1. Petitioner Sherry .tohnson is the parent anti natural legal guardian of the minor
Petitioner, Dawn Sheaffer, whose slate of birth is September 9, 1952.
2. The Respondent TICO/Leader Insurance Company is an insurance company licensed
to do business io Pennsylvania with an address at 100 North Wilkes-Barre Boulevard, Wilkes-Bane,
Pennsylvania 15702.
3. The Respondents Debra A. and Kemieth R. Mcssimcr are adult individuals residing
at R.D. #2, Box 77B, Newport, PA 17074.
4. On or about December 1, 1998, Ibc minor Plaimifl, Dawn Shcaffcr, was driving a
19S7 Pontiac Grand Am owned by her mother, Sherry Jolmsoii.
5. On the aforesaid date, minor Plaimiffwas rear-ended by a 1986 Chrysler Laserdriven
by Debra Ann Mcssimcr.
6. The Defendants' vehicle was insured through TICO hisurance Company/Leader
Insurance.
7. As a result of the accident, the minor Plaintiff, Dawn Shcaffcr, sustained an acute
cervical strain and received physical therapy treatments ceding March 4, 1999, as evidenced by the
note dated March 16, 1999, signed by Joseph B. Bulctza, P.T. (A copy of said note is attached
hereto as Exhibit "A".)
S. The Respondent has agreed to pay S4,250.00 to the minor Plaintiff and seeks court
approval in exchange for a Gcncral Release. (A copy of said Release is attached hereto as Exhibit
"B".)
9. Plaintiffs portion of the settlement will be S3,OS7 25. (A copy of the Settlement
Distribution is attached hereto as Exhibit "C".)
lo. The Petitioner. Sherry Johnson, has recioved this Petition as evidenced by the
auached vcrilicmion.
WHEREFORE, Plaintiffs request that this Court approve the aRxcntcntioned minor's
settlement.
AIARTSON DEARDORFF WILLIAIIIS fi OTTO
/j
George 13. Faller, Jr.. Esquire
I.D. Number 49S 13
Ten Gast high Street
Carlisle, PA 17013-10933
(717) 243-3341
Attorneys for Plaintiffs
Date:
ALEXANDER SPRING REHAB, INC.
27 Brookwood Avenue Carlisle, Pennsylvania 17013
THIS INFORMATION IS FOR YOUR RECORDS. THANK YOU FOR YOUR REFERRAL,
ID it: 5501
**DISCHARGE SUMMARY"
NAME: Dawn Sheaffer DATE INITIATED: 01/22/99
DATE OF BIRTH: 09/09/82
PHYSICIAN: George Branscum, M.D.
INITIAL, FINDINGS:
DATE DISCONTINUED: 03/04/99
(717) 245-2341
DIAGNOSIS: Cervical/lumbar strain, sprain
1. Pain level of 5 on 0-10 scale neck, L trapezius, and lumbar pain.
2. Neck extension painful at 300
3. UE strength/reflexes WNL (lumbar WNL).
4. Negative slump test.
S. R medial knee joint line pain and R medial hamstring sprain.
6. Standing lumbar extension and prone press ups were painful.
FINAL F?GS:
She does still haveesometresidualSupperrbackt&W neck Mart in
Dawn ditiono to sgothat ing to she hihas minimal gh school. pain at
especially on the L side. She is capable of managing at this time. Her UE strength & motion is
ad
good. Pt. also reports improvement of R knee pain that has been bothering her.
DISCHARGE/ROME PROGRAM:
Pt. was initiated on neck ROM, shoulder shrugs, scapular strengthening, pushups, angry cat for
spinal ROM.
ATTENDANCE-
Good.
REASON FOR DISCONTINUATION:
program. continue to work & go to school. She now
This individual controlling he pain level & does
feels s can manage her problem
?''?`^6n??,?"/ k Pr DATE: 03/16/99
?, PT 001299-E Dictated but not read
SIGNATURE: - Buletz?'?J ??.I., ATC
Josep 7l
EXHIBIT "A"
_LEADER
INSURANCE
The Leader In Service and Value
PARENTS_RELEASE_ANQINDEMNITY_AGREEMENT
D atc:09 / 13/99
In consideration of the payment, to the undersigned, or the sum of
on/ 100 Dollnrs 1$4,250.001 the receipt of which is hereby acknot
Faller their attorney, do/does forever release, discharge and covenant to hold harmless TICO/Lcatler
Insurance Company and Debra Ann & Kenneth R. Messimer , and any other person, Firm or corporation
charged or chargeable with responsibility or liability, their heirs, administrators, executors, successors,
and assigns, from any and all claims, demands, damages, costs, expenses, loss of services, actions and
causes of action, belonging to the said minor or to the undersigned arising out of any act or occurrence
up to the present time, and particularly on account of all personal injury, disability, property damage,
loss or damages of any kind sustained or that may hereafter be sustained by the said minor or by the
undersigned, in consequence or an accident that occurred on or about the 11 th day of December 19
98 , at or near Middlesex Township. ;.slid settlaTent Eprl ary claim far fltst petty baeffits
rtr31?_rrxtim,
Or
The undersigned db/does hereby bind herself/himself/themselves and her/his/ their heirs,
administrators, executors, successors and assigns to repay to the said TICO/Leader Insurance and
Debra Ann & Kenneth R. Messimer and to any other person, firm or corporation charged with
responsibility or liability, their heirs, administrators, executors, successors and assigns, any additional
sum of money that any of them may hereafter be compelled to pay, on account of the injuries to said
minor because of the said accident.
To procure the payment of the said sum, I/We hereby declare: that no representations about the nature
and extent of the said injuries, disabilities or damages made by any physician, attorney or agent of any
party released, nor any representations regarding the nature and extent of legal liability or financial
responsibility of any of the parties released have induced me/us to make this release and indemnity
agreement; that in determining the amount of said sum there has been taken into consideration not only
the ascertained injuries, disabilities, and damages, but also the possibility that the injuries sustained
may be permanent and progressive and recovery therefrom uncertain and indefinite, so that
consequences not now anticipated may result from the said accident,
the undersigned agree(s), as a further consideration and inducement for this release and indemnity
agreement, that it shall apply to all unknown and unanticipated injuries and damages directly and
indirectly resulting from the said accident, as well as those now disclosed.
the undersigned understand(s) that the parties hereby released admit no liability of any sort by reason of
said accident and that said accident and that said payment in compromise is made to terminate fua:er
controversy respecting all claims for damages that said minor or the undersigned have heretofore
asserted or might personally or through personal representatives hereafter assert because of said
accident.
CAUTION: THIS IS A RELEASE, READ IT BEFORE SIGNING BELOW:
THE UNDERSIGNED HAS READ THE FOREGOING RELEASE AND FULLY UNDERSTANDS IT.
Signed, and scaled this 31/A day of -(?, 191L.
Signature
Witness' Signature
EXHIBIT "B"
I- I 1) %F,% 111,1: I,%[X)('r''1]N 1161 Lc
GuuJ 411 jl wl ex b8 :7 AM
Hni,d 111 H `rv o: V. n) P%1
Vtti1
DAWN M. SHEAPPER, by her mother
and Icgal guardian, SHERRY JOI INSON,
Plaintiffs
IN THE COURT OP COMMON PLEAS OF
CUvlBERLAND COUN'T'Y, PENNSYLVANIA
TICO/LEADER INSURANCE
COMPANY and DEBRA A. MESSINII?R
and KENNETH R. MESSIMER,
Defendants
CIVIL ACTION - LAW
NO.
?rT r .?.'ml N:LD1S:nUa TL0N
Settlement proceeds from TICO/Leader Insurance ............................. S4,250.00
Less 25% Attorney's Contingency Pec ..................................... -S1,062.50
Less Expenses/Docket Costs ............................................... S133.67
Total Disbursement to Plaintiffs ................... S1 3';
wI
EXHIBIT 11C11
DAWN L%l. SIIEAPPL'-R, by her mothcr
and legal guardian, SI IERRY JOHNSON,
Plaintiffs
TICO/LEADER INSURANCE
COMPANY and DEBRA A. MESSIMER
and KENNETH R. MESSIMER,
Defendants
IN THE COURT OF CO INION PLEAS 01,
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO.
ci11?ISL''1T-OLL'L 1lNTIFF :1i1L? t_1L'U.12r?L G{L?l2D1A11
The undersigned, Sherry Johnson, Plainti ff in the above captioned action and mother of
Dawn M. Sheaffer, a minor, has read the foregoing Pelition for Minor's Compromise and has
reviewed the terms of said Pctition and settlement with our attorney and hereby consent to the
Petition and agree to said settlement.
L-
Sherry JolntA
i
i'
I
Y,
i
CCT ? i °99
r?. ', r ?.. : (..?
CEXfIP1G1T1 OLSERX1CL•'
I, Lori A. Still ivan, an authori•red agent for Martson Deardorff \Villiants & Otto, hereby
certify that a copy of the foregoing Petition for Minor's Cony)ro;:;ise was served Ihis date by
depositing same in the Post office at Carlisle, PA, first class mail, postage prepaid, addressed as
follows:
Mr. Tom Prebola
Leader Insurance
100 North \Vilkcs-Barre Boulevard
Wilkes Barre, PA 15703
Mr. and IMrs. Kenneth R. Nlessinler
R.D. i13, Box 77B
Neuport, PA 17074
MARTSON DEAR-DORPP WILLIAMS & OTTO
y,
B
Lori X. Sullivan
Tcn East High Street
Carlisle, PA 17013
(717) 343-3341
Dated: I11i /17 -?
DAWN N9. SIIEAFFER, by her mother
and legal guardian, SIIFRRY .I Of INSON,
Petitioners
V.
TICO/LEADER INSURANCE
CMIPANV and DEBRA A. II ESSI.9ER
and KENNETH R. IM SSEMER,
Respondents
I\'1'111: ('OUR'1' OF ('Oli,\ION PLEAS OF
CUMBERLANDC'OUNI'Y. PENNSYLVANIA
CIVIL. ACTION - LAW
NO. 99-6596
ORDER
ANDNOW, this 19th dayol'Noconther, 1999, upon considerationofthe PetitiontoApprove
Ni linor's Compromise. Respondents are ordered to pay all claims in the amount of 'S4,250.00 as set
forth in the Petition. Funds in the amount of S;,OS 1 3 shall be deposited in a federally insured
account and shall not be removed until minor Petitioner reoches the ageof 18 orupon further Order
ofthis Court,Mich shall retain continuing jurisdietion. Attorneys' Rxs and cogs in the amount of
S I j 9117 am approwd and to be paid front the settlement.
BY TlIECOURT,
J._
DAWN M. SHEAFFER, by her mother
and legal guardian, SHERRY JOHNSON,
Petitioners
V.
TICO/LEADER INSURANCE
COMPANY and DEBRA A. MESSIMER
and KENNETH R. MF,SSIMER,
Respondents
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 99-6596
ORDER
ANDNOW, this 19th dayofNovember,1999, upon consideration ofthe Petition to Approve
Minor's Compromise, Respondents are ordered to pay all claims in the amount of S4,250.00 as set
forth in the Petition. Funds in the amount of $3,053.83 shall be deposited in a federally insured
account and shall not be removed until minor Petitioner reaches the age of 18 or upon further Order
of this Court, which shall retain continuing jurisdiction. Attorneys' fees and costs in the amount of
$1,196.17 are approved and to be paid from the settlement.
BY THE COURT,
J.
DAWN M. SHEAFFER, by her
mother and legal guardian,
SHERRY JOHNSON,
Plaintiffs
V.
TICO/LEADER INSURANCE
COMPANY and DEBRA A.
MESSIMER and KENNETH R.
MESSIMER,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
99-6596 CIVIL TERM
ORDER OF COURT
AND NOW, this 19th day of November, 1999, upon
consideration of the petition to approve minor's
approved. Respondent is ordered to pay all ciaii
$4,250.00, as set forth in the said petition, in
release of claims which Plaintiff Sherry Johnson
sign. Attorneys costs and fees in the amount of
appr,Dv?d, and to be paid from the settlement.
comprise, it is
ns in the amount of
return for a
is authorized to
$1,196.17 are
The remaining funds in the amount of $3053.83 shall be
deposited in a federally insured account, which shall be restricted
so that no funds may be removed therefrom prior to September 9,
2000, without further order of this Court.
Plaintiff's counsel is to file proof of said account
with the Prothonotary within five business days after it is opened.
By the Court,
Edward E. Guido, J.
George Faller, Esquire_ II/a3'R9•
For the Plaintiff d 5 V.
1 t
9-
DAWN M. SHEAFFER, by her IN THE COURT OF COMMON PLEAS OF
mother and legal guardian, CUMBERLAND COUNTY, PENNSYLVANIA
SHERRY JOHNSON,
Plaintiffs
V.
TICO/LEADER INSURANCE
COMPANY and DEBRA A.
MESSIMER and KENNETH R.
MESSIMER,
Defendants
99-6596 CIVIL TERM
ORDER OF COURT
AND NOW, this 19th day of November, 1999, upon
consideration of the petition to approve minor's comprise, it is
approved. Respondent is ordered to pay all claims in the amount of
$4,250.00, as set forth in the said petition, in return for a
release of claims which Plaintiff Sherry Johnson is authorized to
sign. Attorneys costs and fees in the amount of $1,196.17 are
approved, and to be paid from the settlement.
The remaining funds in the amount of $3053.63 shall be
deposited in a federally insured account, which shall be restricted
so that no funds may be removed therefrom prior to September 9,
2000, without further Order of this Court.
Plaintiff's counsel is to file proof of said account
with the Prothonotary within five business days after it is opened.
By the Court,
Edward E. Guido, J.
George Faller, Esquire_ L`_,„. ( ?II?3?49•
For the Plaintiff d S ??,
It
P! - ED-OFFICE
99 ROY 23 F! 2: 55
r nl.rs unl.rnll or,.L-.,.1.-:r :'gal i.:r
Gun-? 1 ,?. ) NI
Il[u,cd ul uL+l 11 n.-?.\4
Ra 1
DAWN N9. SI-I EAI - ER, by her mother
and legal guardian, SHERRY JOI INSON,
Petitioners
IN THE COIiR"1' OE C'ONIMON PLEAS 01"
CUMBERLAND COUNTY, PENNSYLVANIA
V.
TICO/LEADER INSURANCE
COMPANY and DEBRA A. MESSIMER
and KENNETH R. NIESSINIER,
Respondents
CI\rIL ACI'ION - LAW
NO. 99-6596
PRAGCIPI:
'I'O THE PROTHONOTARY OP C'UN'IB :R1-AND COUNTY:
Please file the attached Proof or Deposit pursuant to .lodge Guido% Order dated
November 19, 1999.
NIARTSON DEARDORFF NILLIANIS CK" OTTO
George B. Faller, t'r.?Etquire
Ten Last Iligh Su•a?t
Carlisle, PA 17013-3093
(717) 243-3341
Attorneys for Petitioners
Date: January 4.2000
....`_: _Mitai••.•? ^?wwu[yplS!l<r[Ei,'r„U-•Yif??i?^':"S-i.^_-??:Y"'"^^??3?'r14'^^`^^•?'?•IIXNS?X
-man
P.O. Box 40 • Mmhnnkabw0. PA 17055.0040
(717) 697-1161
TOLL FREE (800) 283.2328
''.-"SHNU CHECK DEPOSIT -VOUCI'IErC
1896%5 b i SHEA., PAW
i AI1T?? ,3053 B3 TO 5RVIry05as?
1I -MV FEE 2--: 0Ci bALa 'FC` 3?0'
: ,.e'?` s7 rr.
}+'
r
? r n
? i
NC.U%
11 ?
MEMBERSHIP/SIGNATURE CARD bNV U.w iinn"nrtrc
Sue-S.b AllZu Cr•nnie
AUPAemrn C„arg•,
tIWn.Cnan ennosr.,p
Dun-drmeAq vrm.cr.nn
rive nerarc.ry a.,I•v,
DO NOT WRITE ABOVE THIS LINE
Membership Information
?j?i2.GLCLC-_`'nV_T n.1fa WLV n--I?'II?LIUU_G?I_NUalr/
4 tit
.d Willy ?>-l? Q: C?_GIa_?Y_YCCy ?0?1150!J_ Inn ..( pIM•nn Crary,
r ..,.•. to
,
?
fmrF,nr 11.'m I
„nr,
I ni
fn•gyn, Mtxf\
y,n.v...nm
hecc,_y . :rohrso,,__n_+¢L112r s•nnn
l-?JJLL
?•y3r o 'a
rr.mo-.
:[n,--
sv o.?. er an n.aw.
Vmta. ,,l
rmo .+ IW V4.nT.?•`elE I
J>LYV C-?--i12Lt Lt!-
y??-'t:?1k?C- -
r.•„nMnr.Cwla..• ? v..n}ayy. -?r.-ru.+l•. „e..,n,...,,
} y?
Type of Account
Sa
vings' I'I Christmas Club
X I I I IRA- I : Share Certificate''
,
``
'y„inglellJaint i,15inyle :JJaint 1 ')Single i l Single! I Joint
Checking I Investment Savings I 1 IRA Certificate" r ICheck Card/MAC
I iSingle I IJoinl )Single - )Joint I Single ! IOther
IJ Other- _-.. L)Coll-24'• USingle UJoint
?Single ?Joint
'AaYU.wel rip/W bMWAWxro,nr "IauwulMr[.vnnrVWM
® Type of Ownership (Select one)
U Individual Account ?Minor Account UTrust Account C1 Sole Proprietorship ?Corporation UOther
U Joint Account ? Custodian Account ? Estate Account U Partnership U Organizational
Overi Protection (Number in order of prolerence-1, 2, 3)
check biglt Numbrlr>.•.n. mil Savings (00) Imeslmont Savings (oy) Personal Service Loan( I
® W-9 Certification of Taxpayer Identification Number (Social Security Number)
Certiflraluon.-Under penalties of perjury, I car ily Val
I. The number shown on this form is my consel taxpayer idenl,llwWn number (or I am waiting for a number to be issued to me). and
2.1 am net subject to backup withholding because: (a) I am exempt from backup withholding, or (b) 1 have not been notified by the internal Revenue
Service that I am subject to backup withhokfng as a result of a (allure to report all interest or dividei or (e) rho IRS has notified mo not I am no
longer subject to backup withholding.
Ceniacalion Iminotims.-VOU must close out item 2 above if you have bean notified by the IRS mat you are currency subject to backup withholding
cause of u Grrownin9 )merest or of d ntls on your x r )urn. 01 am nor o U. S. Carus or Resident (Complete W 0 Form).
?f p o? I Pa TAI A
R.nvIM $qub. 1,.4
® Beneficiary for Life Savings Insurance (If other than Joint Owner)-Applies only to accounts open prior to May 1, 1995
Name of Beneliciary(s)
Address of Beneficiary
•[yAei.KrYr n,rr b I.IW
® I hereby make application for membership in the Members l u Federal Dred,t Union, and also to conlorm tons bylaws and ameMmonls 11,01001, copes
at whkth have been made available to me, and to sulescnbe for of least one (1) share. Members 19 Is hemby authorized to recognize any of Ino algna•
has subscribed hereto In the Payment of funds or rile transaction of any business for this account and all sub accounts. I acknowledge receipt of The
Membership Amount Agreement which contains all relevant contractual obligations for ibis account and all sub-accounts. I also acknoelodge receipt of
the Regulation Disclosure Pamphlet.
Joint Owner signature
re, errs mmy Members IIt Federal Credit Union
Thisappl"tmVnppmvedbytne CDaad1 OExaCUllvo CerrlmdICU,Of Ohlcni ersh,p Officer Oxle:
Signed: (Pusen ropubanbng approval applicator)
iiI sees
REV . C"A
do to neg-sweCU cilaq Date Pnnl Primary hlembers Former Name, PU,.m.q. rival
CERTI EICATF. OF SERVICE.
1, Lori A. Sullivan, :m authorized agent for Martson DeardorlT Williams & Otto, hereby
certify that it copy of the foregoing Praccipe was served this date by depositing same in the Post
Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows:
Mr. Tom Prebola
Leader Insurance
100 North Wilkes-Barre Boulevard
Wilkes Barre, PA 18702
Mr. and Mrs. Kenneth R. Messimcr
R.D. 1,12, Box 77B
Newport, PA 17074
MARTSON DEARDORFF WILLIAMS & OTTO
By U : 'ILECCG???..
Lori X Sullivan
Ten East High Street
Carlisle, PA 17013
(717) 243-3341
Dated: Jtnumry 4, 2000
I