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99-07246
?; d? 1 1 '; IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to ) No. KIMBERLY M. GREIN, a minor ) KIMBERLY M. GREIN, a minor, by CAROL L. ) GREIN and MONTY C. GREIN, her guardians, CLIFFORD GREIN and AUDREY GREIN, ) Plaintiffs, ) No. 99-390 V. ) TERRY SCHMIDT, Defendant. ) PETITION FOR LEAVE TO RECEIVE ADVANCE PAYMENT IN MINOR'S CLAIM AND NOW, comes Plaintiff, Kimberly M. Grain, a minor, by Carol L. Grain and Monty C. Grein, her guardians, by and through their attorneys, Tucker Arensberg, P.C., and file the within Petition for Leave to Receive Advance Payment in Minor's Claim, staling as follows: 1. Petitioners, Carol L. Grein and Monty C, Grain are the parents of minor-plaintiff Kimberly M. Grain ("Kimberly") in the above-captioned action, and currently reside at 144 Overpeck Avenue, Ridgefield Park, New Jersey. Kimberly is currently 16 years old with a date of birth of November 26, 1982. 2. On or about August 16, 1997, Kimberly was seriously injured in an automobile accident on State Route 31 in Somerset Township, Somerset County, Pennsylvania when the vehicle in which she was riding was struck by a vehicle driven by Defendant, Terry Schmidt ("Schmidt"). At the time of the accident, she was riding in a vehicle owned and operated by her grandfather, Plaintiff, Clifford Grein. Also riding in the vehicle were her grandmother, Audrey Grein, and her younger sister, Sara Grain. (A true and correct copy of the police report for the accident is attached hereto as Exhibit "A"). 3. After the accident, Kimberly was taken by ambulance to the emergency room of Somerset Hospital in Somerset, Pennsylvania. After spending the night at Somerset Hospital so that her condition could stabilize, she was transported by helicopter to Allegheny General Hospital in Pittsburgh, Pennsylvania, where she remained for the next eight (8) days for surgery, treatment, and observation. 4. As a result of the accident, Kimberly sustained significant injuries, including severe facial lacerations, fractured bones in her left cheek and eye socket, nerve damage, damage to her teeth and jaw, and severe damage to the retina and veins in and around her left eye. She underwent several surgeries to repair her eye socket, which had to be repaired through the use of wire mesh and screws. She also underwent surgery to repair nerve damage to her face. 5. Since her initial treatment at Allegheny General Hospital, Kimberly has undergone additional surgeries in order to revive her left eye, muscles and nerves, and to address the disruption of her maxillary sinus. Future surgery is probable, as she still has bleeding in the back of her eye which causes double vision. It is possible that Kimberly may lose sight in her eye altogether because of the retinal problems. Kimberly is also currently receiving treatment for the severe facial scars that resulted from the accident. Additionally, she is suffering from facial palsy, which alters the symmetry of her face. She has to wear braces because her teeth shifted due to the facial injuries, and she does not have any feeling inside of her left cheek and around her gums. All of Kimberly's medical bilis have been paid to date, and it is believed that adequate insurance exists to cover future expenses. -2- 6. To recover for Kimberly's injuries, Petitioners retained the law firm of Tucker Arensberg, P.C. as their counsel. The undersigned counsel commenced the above-captioned civil action in order to protect Kimberly's legal rights while negotiations with various insurers were under way. 7. Upon investigation of the accident it was determined by the undersigned counsel that the following insurance policies and limits were available to Kimberly for her injuries: a. Schmidt was insured by Nationwide Insurance Company ("Nationwide") with policy limits of $100,000 per person/$300,000 per accident (A true and correct copy of declarations page to Schmidt's policy is attached hereto as Exhibit "B"); b. Underinsurance coverage was available to Kimberly Grein under the policy insuring the vehicle In which she was riding from Erie Insurance Exchange ("Erto") with policy limits of $100,000 (A true and correct copy of declarations page of the policy Issued to Clifford and Audrey Grain is attached hereto as Exhibit "C"); C. Additional underinsurance coverage was available to Kimberly under the policy insuring her parents' vehicles in New Jersey from Maryland Casualty Co., now Zurich Insurance Company ("Zurich"), with a single limit of $500,000. (A true and correct copy of declarations page of the Zurich policy is attached hereto as Exhibit 'V). 8. After negotiations with Nationwide, the liability limits of Schmidt's policy in the amount of $100,000.00 were tendered to Petitioners In an effort to settle any and all claims against Schmidt. (A true and correct copy of the letter tendering policy limits from Nationwide is attached hereto as Exhibit "E"), 9. However, while Erie has waived any and all rights of subrogation, Zurich Insurance Company has chosen no to waive its right of subrogation and intends upon pursuing the civil action currently pending against Schmidt as the subrogee of Kimberly Grein. (See letters of Erie and Zurich regarding subrogation rights attached hereto as Exhibits "F" and "G" respectively). -3- 10. Accordingly, as a result of its desire to retain its right of subrogation, and as required by the terms and conditions of its policy, Zurich has tendered to Petitioners the $100,000.00 which would have otherwise been available from Schmidt's liability insurer, Nationwide Insurance. 11. The remaining claims of Kimberly and the Petitioners are against the underinsurance carriers, Erie and Zurich, and lengthy negotiations with these insurers have been ongoing in an effort to resolve Kimberly's claims. However, so that the subrogation action of Zurich against Schmidt may proceed, Petitioners seek approval of this Court for the partial settlement of Kimberly's claims. 12. Based upon a review of the available facts and advice of counsel, Petitioners believes that the partial settlement in the amount of $100,000.00 is a fair and reasonable settlement, in light of the fact that it represents the maximum amount which would have been recoverable from the tortfeasor's insurer. See Statement of Counsel attached hereto as Exhibit "H". 13. In furtherance of Kimberly's claims, the undersigned counsel investigated the facts and circumstances of the accident, and all available sources of insurance coverage. The undersigned further conducted research and analysis of various legal issues surrounding multiple levels of insurance coverage and the Defendant's liability. In addition, the undersigned gathered and analyzed Kimberly's medical records, and conducted lengthy negotiations with representatives of the various insurance carriers involved in this claim. 14. The Petitioners agreed to a contingency fee arrangement with Tucker Arensberg, P.C. for 30% of any settlements obtained before the commencement of trial, or $30,000.00. Tucker Arensbert, P.C. has agreed to accept 25%, or $25,000 in fees. The Petitioner's family -4- 4 has also agreed to reimburse Tucker Arensberg, P.C. for all expenses and costs which to date total $1,475.34, and which consist of the following: A. $556.50 -- Steven M. Cook, Investigator B. $303.71 -- Recordex/Medical Records Copying C. $61.23 -- SMART Corporation/Medical Records Copying D. $518.77 -- COMDOC/Copying Fees E. $15.15 -- Pro-Rated Filing Fees F. $10.98 -- Pro-Rated Sheriffs Fees 15. Petitioners believe that the best interests of the minor would be served by deposit of the partial settlement proceeds into a Certificate of Deposit with a federally insured bank in the State of New Jersey. 16. Nothing in this Petition should be construed as a waiver or compromise of any other claim of Kimberly Grain, including those claims currently pending against Erie Insurance Company and Zurich Insurance Company. WHEREFORE, Kimberly M. Grein, Petitioners, Carol L. Grain and Monty C. Grain, guardians, by and through their attorneys, Tucker Arensberg, P.C., respectfully request that this Honorable Court grant their Petition for Leave to Receive Advance Payment in Minor's Claim. TUCKER ARENSBERG & SWARTZ, P.C. MA_ Ga P. Hunt, E=squire Lee C. Swartz, Esquire 111 North Front Street P. O. Box 889 Harrisburg PA 17108-0889 (717) 234-4121 Attorneys for Plaintiffs 18097e.11iit -5- 0000566-!) 1 COMMONWEALTH OF PENNSYLVANIA 10/A POLICE ACCIDENT REPORT •AA.'EFERI00VERLAYSIIEETS - IILI'OIItAIILL I j POLICE INFORMATION 1111E IAMk' Ida. .J1?-E (('iLtLC ] i•A:pm C- a +1':C71CT ?7L.T?YW?.i Itbc) PA1I1nL (ONE 5-I 5 Vf r9i1:.A OR iTTt. I•rJ. i naµnM RAOCT. HU6111f11 7CA-1 CPvL 'a ;6?•.iEOOY /?.r i8 T?' Q I?4F _fVZ J< lNAl11unI>Cr.LR '! /' '7 it t,' f i I. 4NE071GATION, I _ p NLRNAI ACCIDENT INFORMATION . 9. ACCIJFIR Ill DAY UI V,TEK 1 DATE UVIIV?I l 5XT !I iIAE OF ?17 rIUMIBCR ?•, MY )LIDO OF UNITS 17 1KLLF1) 141 INA'RED ;U I'm I'NUP ` ' ACCII:1 rlt _ f FI I` j'600 VEHICLE HAVE IO BE 11 VEIIK:IL OAMADr REMOVCU FRCM IHE SCE!IE, '1 In1t0 VN111 z 1' NIT I UNIT 7 1 1 Jr. ' 1 1.11111111A11 Y x' 11 Y ?X '1 , $I•/I IN II1N17 3 tp rN6,FiLX]US-_' -./' 14 PI I11KAll MATERIALS Y'.. it ^ VIILIPI NI, 1 11 .Z' UNIT # 1 :]6 LECL cf V N 37 RED -'-_- "? U SIMI PARMEDI: i PLATE 13-13 f3\ PA TITLE OR OUT OFS,ATE V76 L.(o .531°115 (voI +0 CWNER??Ry x.L-IMI L7 i 61 OYmER . ,L It CADODRSSTSATE143I (A NERCtSE? ?12,. 42. I' _ .FITCODE (Y?I Cµ.Fv11CS?uR? t? I`1?y5 63 mm IAA H?V'FIG(,GT i u MODEL • 1110.•... AA VIS - BCOY TYPE) 1 L (?iZ1? F1 Y ?C N NN:. )47.UOOY IAp SPECIAL 115 'RNK:IF I 7YPE `IU USAGE (O B1tlILPSIPt• I ( i50 HIM IMPACT [51 VOIIK:LC I'J If•AV1i • P071T STATUS 0 ,1'110 0'f 15] VERKLE 67. DRIVER ( I :si CHNLII I' G.LDFNT 2. 1 PRFSFOCF I I I tlttllal:llll I :A rILa,BER I-1 52,C) ' 55'(j A 1 S8 DRWEfi IIAME Lp/(pu 5C t-, tE:,T t :59 ORNER ACOIESS '??. 're ::!Y. STATE 616'000E T11 E?tlgtSlCS?.?L.1 K 1'11 L-fiS? ' c 167 DATE OF S I? C I? 1 I ] Rf?NE 11 2 J t - I BIRTH 1111 L:' • J.:MM. VLY 65 DRrJER rY H ;X I CLASS 5 CARRIER :66 CAaRIER ADDRESS -• CRY.STATE 6 ZIPCODE USOOT I q'YEII f.Crdro r10 OF MLES .1A45 111951 .ICC s Pile- (c7. CARGO .•1 GW1R ! BODY i'IPE i'16 t4v A11cous • it vrimi t1I II.L'LIAr . MArfiums t I : It' 11111111 I ti t1UI1 RCI'ONUDIEI I I'Lnniroi use CN6r ACCIDENT LOCATION - '-- ??-?- ' "u'llY COUE SGm)=1Z`J\T ?? 70 71 MUNICIPALIIX UUI:E PRINCIPAL ROADWAY INFORMATION 77 IU)UrE NO OR SIRCETw IE s? , CD03I 1 73 L Ill 'CO S 17i R IMIT ] 'ICIAVAY U IT OL I , INTERSECTING ROAD: 76 NOUM 140 OR 5I11CCTt4AKIE rnuEL.S I^'1J ( I (O•lZ..) , 71 !U'LrU i 1711.nrc „79. ACCESS _I UMR S ? , IIICINVAY U contnot. IF NOT AT INTERSECTION: i ]o CHOSS STREET OR I SLDIACHr MANKTR i ]I WIIEcriDel 37 UISIMIOC i rltu615111 N S E W Fr1OMSITE FT 611.1 ]] O19INICI WAS 611 A5Lnf1] - CSTIMATFII I . ..... •• ]t CUNSINV.:NgN ]S.TRAl I•IIIIICIPAI 1111CIt51:• 111 10 /eNl C0tllltnl .T2 VI 3 C • O O CL E UNIT #2? LGALI Ur Y 11.31 PItEa t;,r 1-:715 39 PA 7111 r IPt Uur Ur swcvw SUS 2.iocj °j?1(? O 1 IO OVRIER 1 CL vfFcAD C-I?'cint At IAVNER nnoSTAIG}1 67 I:IIY. SI( I A/IIY:OL'I FIJ:LE?J\L,LE I]YI All 41 MUDI I .,1101 '•? •A6 INS 1 IIL111Y t,i,r, (.r.'F.S_L.LVZ Y X 11 . i UrIK'. it onoY IAp SPECIAL I19;VEHICLE I IYI'I USAGE GA OVOIERSIIIP I 1 ?.i RNITAI IMI`AL1 151 VEHICLC Si. ?TRAVEL' ' I 1'0IIII I I STATUS U SPEED uI V 51 VI IIICII' r5i DRIVER r55:DRIVER 1 CIAMILIjr I PRESENCE I I I I COUDIIION I i SA l1u NIIA9w SL;IjME I MBGl (D LA -138 ISLD I I.A. 58 DRIVER IIAME cupF:c4CI-) Gr3i=rJ µ1W ,^ __.. ....,,_L 59 nnNEN 1E55 Iql I\r11 rJ ?V GUUrI?-lj ...J? to CITY, STAIC 6 Zill Fwu--yJIL.L7_, ? I K, SEA •G7 GATE Of _. I t 163. PNGHE Y ' N K OIASs C G/ CAIGIII 11 GA CMILIER AIIUIIF SS 67 CITY, SrAif. A /II CCCL r0 USCOTI rJ'vfll [0111'10 , nn Dr MI I :? ICE (/J?l'AOOO BUOY TYPE °!6 Il/d ARDOUS I 61A ICRIAI Y I I PLY: - 1- G'JH11 .1 1 lI HCLEASC Of NiaLAt y : ! N I I utml.I P.mOOT.BIISTE I•ACC 22. 1 ?A 8 EXHIBIT "A" _r7:_.- 0000567 Ire nr..'.+'Orarq rus Ac[NCY i 19 MrucAl rACarrY ,,. w • _ INCIDENT !ACCIDENT ?' A'L, yJ I CATE., C IN7 PECKE HFCRMATION A D r, O E 1 0 r"I AIIUIU ss II I I A I Y, jly! I x 1: A' ,LI 19 I I? 1}{ 3 1 i U IHlnr:cl-tIn1IT ",rlt4: n•. crk' t ' `1 q ; 7 O IC ! ,. Luna :.(_,tln,1L"i, `)nrYC r-5 Cr':`1 ly ??- I I C IU i I_I a' . jM115.. 3_ ! i ICIFxez =1 I iiv ?'' o I j ' ILA 3 I `! , f?ui { C,'LL1w °,nmi: R'; r.7['? ' I I i i 7c')iyo-R=e° ?' I I1?'nIrZ?1hL Cn Cur.: 1li ?itnK 13 I ? I IL t=J BG DNCIIAAI ,!rt raE•Y, I . 81 •.WYNIKIN j -7IrN: NTAIICIIj (J I L7.2 iM1St ARrN+.i57.D. ,tJ? ?e] I.OA0SURFACE I I u?O I?fA1?.°? p: (L`??4t1`I .1 e1 PENNSYLVANIA SCHOOL DISTRICT 16 APPLICABLE) 465 DESCRPTICH OF C> GEOPROPERYY - 2 z 1 `^t ;''l' "'?N? A•T:ct 4U (1 71c' r IOWAER C: T.CL ADL)HESS AiR 3 µ' j `yl•AUEL Z] j j PHONE I 1T. HARRAT YE • IDENTFY PRECIPITATING EVENTS. CAUSAL ION rACTOIIS. SE.CUENCE. Or EVENTS. WITNESS STATEMENTS. AND PROVIDE ACURIONAL -UE_ALS.L9@ HSURANCE. INFORMATION AND LOCATION OF IOWFO VEHICLES. IF KNON'IL. .. ,_-•,-•_ _-__ s 1 --+'S LLCc-L E_r oCC.f22ca AS I•,wA 4 L .,JAS. '-7lzPJCL3..IISGZ_ E$1_S'1,-SLZ =?31 A=rJOn?,?JEO_./?i't'8x'C t?tCzN?!ay. lr1LT°2 LJnSnUEIl??ICLEE?? CA'Z?I r_! _-QI SICIQAL AtJ L7 , 1ttE.L:r ?l?_(r.-LCZ?, .Ci??°.I :S r.: ICrI_rc,1 - wriS .ie P, ?ll_t'? PC-,vI- a'wr:3.ATE -'l ?tl._-act?n') pt= SR rL"31 ..,,1J. 'tiz.._.t i 2_ ASS n9 tl w!5 (.? ,u) 11T°..l wqG r.1[C-G-•;.TE? , .In? ?C' -l j__JP•1.?_ Ll14- -?E-= •in?_?:?.._.l?n!tT!LS,hin?t.-==--- 2C_ST rw! THE Cia,?_LAIJ,E ,•Fl?CE? `,:EAJ.,-;a.::..vN•T,`? , /-aM _TL? ?`L=? ?a ._r±E. f=I',!5%- t:..r,We _ ac _- Zf\??. .lt`.C?•.%. -lEl:c.. ?.4 Lam.-:S-C,C.S51')C= ._;Z'•1i A_NdF _ p•IINNFSOURANCE N I C?1 "rl'CN 1LI!IIX _ URMAN :l:,^.M1' „ ?(j. M INNFIU E 1?5 LO• UNIT UNIT POLICY HCY ^ UNIT LDIZI : I.OLICY ?- ?t I NO Sb 3l L ,SJ, ?SQS 7 NO C?t7_ -lIU 2- L? I t?'(.1c ?1" AI11:r11 1n H N ' l w. NlMt 1/?(U.Y^llN! ?Lr?ij1'LntlLU {a.'E.,i,cCK',:_cz?A IS?-I Cblv?q'..4A-3Cr?{ i i WNM35ES HA PE At EAU Sn I' IO:IC. I ^ i:c. SELI4_F:L QL1 _ t . it'ILV.'eU-1cw'. i•' 49.vgUIgH5c1Ni1'CAILII !' 11'.IRm nuufviiS lOa Ih CHNiGF1U SIC riff:l • UNIT I LLt Irk _rV2f.:l L r -1 _ ?' . jUNIT2 Iai1; 91. PROBABLE 'S: IVPE 'S9 RESUJ IS 91 I'RIIBABIF 97 IYPE ,93.RESULTS i USE 1E51 lE110 IESi „&I IESi 'rIOTESi I94II;%z SiICATKIII Nrl USI IimrusE Comim-eTE' UNIT 1! C, Q ._ .% 'r1:Y IIIIil7 G 0..- _%: LIr1K IVES :4 IJO! 11 AAae(I Iml PACI G. P,.mWT•BH51r. 2 i.2098 =;i -r-- 0000568 ?IFt COMMONWEALTH OF PENNSYLVANIA PAR CONTINUATION SHEET /? aTS AD12111AL'LE ®NOIIIEMMAME ? 11,11 O1WErAA. xa; aEEEA 7O OVERLAY EuE_ . .1I I ACCprtNi uGUN1Y Ss ,AUNIOI CAI vnV i Ada Aa?lb? nn•- Obi IL (?? rr•p? n (in4F490N INFONIUiIOM• USE OYLIMY F. 1nL:;,UBL .b 1 K N Y N C G E F G NAVE ^'+°""•' ?? I I I Jill i II ?' 4 !i f .,,?? i ? ?. fit; ::yM i i 4 e M =? i t Cr L^' 1 l is r i? ?f f? II I? t?v OO.. I rnTT..:r. . ?:4??rt,;<#{i1Etti?1:; 7iiriE#!?i?€ f?tiuG(aisi EXHIBIT "B" #?tarie' ?n ?? ease Tait ? hgerif?t????K`?>' ERIE ERIE INSURANCE EXCHANGE T INSURANCE PIONEER FAMILY AUTO POLICY GROUP 100 Ene In^. PL AMENDED DECLARATIONS 02 *• * EFFECTIVE 08/17/97 ' . ?&14 Ene.PA 16570 ATTACH THIS TO YOUR POLICY. 0 REASON FOR AMENDMENT - SEE *** ON FIRST DECLARATIONS PAGE AGENT ITENI 2. POLIC`! PERIOD POLICY NUMBER AA5107 GULLBORG INS., INC. 12/31/96 TO 12/31/97 Q12 3102892 P I I EIm 1. NAMED INSURED AND ADDRESS ITEM 3. OTHER INTEREST ? Ilrlllllllr??lllllllllll?lllllllll??l?lllllll,llll?lllllllllll I CLIFFORD T GREIN & AUDREY M GREIN 191 MINGO CHURCH ROAD FINLEYVILLE PA 15332-3610 AGENT - GULLBORG INS., INC. 3906 WASHINGTON ROAD AGENT PHONE - (412) 941-8200 MC MURRAY PA 15317 2538 * YOU HAVE BEEN INSURED WITH THE ERIE FOR AT LEAST 15 YEARS. THIS POLICY WIL***Ok*B**SURCHARGED *FOR*FUTURE *****DENTS. *** ITEM 4. AUTOS COVERED AUTO YR MAKE VIN 2 93 DODG INTREPID 2B3ED46T7PH560902 ST TER SYM RATING CLASS DDP PA 90 7 AlAL ITEM 5. INSURANCE IS PROVIDED WHERE A PREMI UM OR INCL IS SHOWN FOR THE COVERAGE. COVERAGES, LIMITS AND AN , NUAL PREMIUMS ARE AS FOLLOWS- n2 - THE LIMITED TORT OPTION APPLIES TO AL *****GOOD DRIVER RATES APPLY***** L PRIVATE PASSENGER VEHICLES - i LIABILITY PROTECTION- . BODILY INJURY 100M/PE,RSON $300M/ACC PROPERTY DAM GE 143 A $100M ACC FIRST PARTY BENEFITS- MEDICAL EXPENSE $1014 36 ACCIDENTAL DEATH $5M 1 FUNERAL BENEFIT $2.5M 1 UNINSURED MOTORISTS COVEERAGE- C-UNSTACKED UNDERINSUREDOMO4 IST OVER 14 OR S C FAGE BOD INJ g100M/PERSON 300M ACC- / UNSTACKED PHYSICAL DAMAGE COVERAGES- 39 COMPREHENSIVE - $100 DED _ 77 COLLISION $500 DED 136 OPTIONAL COVERAGES- ROAD SERVICE 4 TOTAL ANNUAL PREMIUM FOR EACH AUTO 1 $ TOTAL ANNUAL POLICY PREMIUM 5 6 PREMIUM REDUCTION DUE TO THIS CHANGE $ 121CR ITEM 6. APPLICABLE POLICY, ENDORSEMENTS EXCEPTIONS TO DECLARATIONS ITEMS ALL AUTOSABPU02 05/91, ABPNOI 07/96, AFPA03 10/95. ***AUTO 1 AND LIENHOLDER DELETED ***DRIVER INFORMATION AMENDED ***MULTI-CAR DISCOUNT REMOVED ***UNIN/UNDR MOT COVERAGE AMENDED PASSIVE RESTRAINT DISCOUNT APPLIES - AIRBAGS AUTO 2 EXPLANATION OF ADULT &/OR YOUTHFUL DRIVER RATING CLASS AUTO 2-PLEASURE USE, 8,501 OR MORE MILES ANNUALLY EXHIBIT "C" .- 0001162 "' (SEE REVERSE SIDE) "' N AGTNLH 09/18/97 MISCELLANEOUS INFORMATION UNLESS STATED IN THE MISCELLANEOUS INFORMATION THE FOLLOWING APPLY - INEITEA 1T UNLESSOTERRITORYEINIITEME4PIINDICATESYOTHERWISEAT THE ADDRESS SHOWN INSURE. LISTED BELOW, THE NAMED INSURED IS THE SOLE ITEM 9. UNLESS AUTO LIENHOLDER OWNER OF EACH DRIVER ST LICENSE NUMBER BIR O1DATE 1 CLIFFORD T GREIN PA 04438150 10/09/28 2 AUDREY M GREIN PA 12061977 0 DRIVER DISCOUNTS - AUTO 2 - OVER 55. YOUR COLLISION COVERAGE AND DEDUCTIBLE APPLY TO PRIVATE PASSENGER AUTOS SUBJJECTOTO LIMITS, TERMSRANDTCONDRITIONSOIIN3THEAPOLOICYLESS. THIS IS Q12 3102892 ;001163 ? _ - PERSONAL AUTO POLICY r ¦ g r a 0 b O a w AREA NO. AND NAME: 1A TIII POLICY ISSUED BY: MARYLAND CASUALTY CO. NAMED INSURED AND MAILING ADDRESS: MONTY AND CAROL GREIN 144 OVERPECK AVE NJ 07660-1543 RIDGEFIELD PARK PRODUCER'S NAME AND ADDRESS: MULLER AGENCY, INC., ROBERT W. 175 ROCK RD, BLDG 2 NJ GLEN ROCK (800) 439-0292 PRODUCER'S CODE: 02077600 POLICY NUMBER: TP -01175406 FULL TERM PREMIUM: $ 859.85 ACCOUNT NUMBER 07452 POLICY PERIOD: 6 MONTHS FROM: 12-06-97 TO: 06-06-98 IZ-01 AM. STANDARD TIME AT THE ADDRESS OF OF POLICY NO. THAT A IT IS RENEWAL UNDERSTOOD RENEWAL DESCRIPTION OF VEHICLE(S) OR TRAILER(S) COVERED (SEE SUPPLEMENTAL DECLARATIONS PAGE FOR ADDITIONAL INFORMATION) NO. YEAR MAKE MODEL BODY 1 1990 PLYM VOYA WAG 2 1990 FORD AERO VAN NO. YEAR MAKE MUUhL DWI COVERAGE IS PROVIDED WHERE A PREMIUM AND A LIMIT OF LIABILITY IS SHOWN FOR THE COVERAGE. COVERAGES AND LIMITS OF LIABILITY VEHICLES COVERED A. LIABILITY $500,000 EACH ACCIDENT C. UNINSURED/UNDERINSURED MOTORISTS $500,000 EACH ACCIDENT D. DAMAGE TO YOUR AUTO OTHER THAN COLLISION LOSS - ACTUAL CASH VALUE MINUS $500 DEDUCTIBLE COLLISION LOSS -.ACTUAL CASH VALUE MINUS $500 DEDUCTIBLE BASIC PERSONAL INJURY PROTECTION EXTENDED MEDICAL BENEFITS COVERAGE - SECTION II $10,000 TOTAL AGGREGATE NAMED INSURED INCLUDING SPOUSE OPTIONAL PERSONAL INJURY PROTECTION BENEFITS VERBAL TORT THRESHOLD PROPERTY - LIABILITY INSURANCE GUARANTY ASSOCIATIONESURCHALZTY VEHICLE ELIGIBILITY OPERATOR NUMBER POINTS NUMBER POINTS 0 1 0 2 0 2 0 CONTINUED ON REVERSE SIDE 041853 10-22-97 1954 278.00 278.00 39. 39. 36.00 56.00 129.00 INC 1. 1. 2.85 AUTHORIZED SIGNATURE 150*85700 EXHIBIT "D" ¦s CUSTOMER'S COPY •- -- COVERAGE IS PROVIDED WHERE A PREMIUM AND A LIMIT OF LIABILITY IS SHOWN FOR THE COVERAGE. COVERAGES AND LIMITS OF LIABILITY VEHICLES COVERED FULL TERM PREMIUMS END. FORM NUMBERS 41343(05-91) PP0001(06-94) * A0002(05-96) **63075(06-96) **63076(10-96) *PP0181(01-97) *PP0480(10-96) * A0461(07-96) PP0577(10-95) PREMIUMS FOR THIS POLICY WILL BE BILLED BY SEPARATE STATEMENT. FULL TERM TOTAL PREMIUM I 1859.85 f 1015 LOGAN BLVD' ALTOONA PA 16602-4028' GARY P. HUNT, ESQUIRE 1500 ONE PPG PLACE PITTSBURGH PA 15222 OUR INSURED: Terry Schmidt OUR CLAIM NUMBER : 58 37 C 671 595 08-1 6-1 997 01 YOUR CLIENT : KIMBERLY GREIN YOUR FILE NUMBER: DATE OF ACCIDENT : 08-16-1997 Dear Attorney Hunt: NATIONWIDE INSURANCE ENTERPRISE o N3tIonWlde is on yoursldo April 16, 1999 This letter is to advise you that we are willing to tender our policy limit of $100,000. relative to the injuries sustained by your client. Please be advised that we will need waiver of subrogation from any and all underinsured carriers, and court approval of any settlements. I would also ask that you consider a structured settlement in this matter. Thank you: NATIONWIDE MUTUAL INSURANCE COMPANY WADE C PORTER (PA-20-ALTO) Claims Department 814-943-0266 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 a person to criminal and civil penalties. 130•ao0703 a EXHIBIT "E" ?1 ''L.w.u. -.. ?__ ? ?+1 ERIE. i-e MATTHEW W. MYERS. CPC . M. AIC. AIM. AIS Assistant Vice President and Branch Claims Manager ERIE INSURANCE GROUP Branch Office • 301 Commonwealth Dr. • P.o. Box 516 • Warrendale. PA 15086-0516 (724) 776-4000 • Toll Free 1-800-922-1824 . Fax (724) 772.7700 • hltp://v .orio-insurance.com March 15, 1999 Christopher W. Cahillane, Esq. Tucker Arensberg Attorneys-at-Law 1501 PPG Place Pittsburgh, PA 15222 Re: ERIE Claim ERIE Insured: Date of Loss: Your Client: Dear Mr. Cahillane: #010150252317 Cliff Grein 08/16/97 Kimberly Grein, a minor Per our phone conversation today, I explained to you that I would be handling the potential Underinsured Motorists (UIM) claim with you concerning your client, Kimberly Grein, a minor. At this time, you have our permission to settle the Bodily Injury claim with Nationwide for their limits of $100,000. We would waive our subrogation against the at-fault tort-feasor. Once you have settled the Bodily Injury claim with Nationwide, please send me a copy of the court approval, signed Release and any and all medical reports, bills, and current photos to my attention at the above address. Once I have a review of these items, then I will be in a better position to make you an offer under the UIM portion of the policy. As you are aware, there was no stacking under the.policy due to the fact that Kimberly was not.a resident relative of our insured at the time of the loss. Our limits in this matter are $100,000/$300,000. Thanking you in advance for your help and cooperation. Sincerely, 6 Ronald J. Telephone Claims Representative Warrendale Branch Claims (724) 772-7675 RJE:psc EXHIBIT "F" 635456 The ERIE Is Above All In SERVICE, • Since 1925 f?=? -- :.g i? 09/18 198 09:40 140.,491 01/ M2r7laod Casualty Company Telephone P.O. Box 14013 732 7774886 Nn Bmmwldk NJ 089"J3 Maryland Casualty Company Serviced by Material Damage Adjustment New Jersey September 18. 1998 Ken Segamick Esq. Tucker Arenberg P.C. 1500 One PPG Place Pittsburgh, PA 15222 VIA FAX AND CERTIFIED MAIL RRR Z 103 177 464 RE: INSURED: Monty & Carol Grein CLAIM #: 681312294503 DOL: 08/16/1997 YOUR CLIENT(S): Kimberly Grein YOUR FILE: Dear Mr. Segarnick: f? V 11 r As you are aware, I am the Underinsurance adjuster assigned to handle this case. I am in receipt of your. September 8, 1998 brochure. Please be advised that Maryland Casualty WILL be protecting it's subrogation rights in this matter. Therefore, we request that your client NOT release the tortfeasor. Kindly advise this office once the tortfeasor carrier tenders it's policy limits. We will then advise as to the procedures regarding the subrogation issue and future handling of this matter.' Your anticipated cooperation is greatly appreciated. Very 732- Examiner EXHIBIT "G" RECEIVED TIME SEP.IB. 9:45RM PRINT TIME SEP.18. 9:45AM T, ; H VERIFICATION OF COUNSEL I, Gary P. Hunt, Esquire, as counsel for the Plaintiffs/Petitioners in the above-captioned action hereby verify that I have investigated the automobile accident of August 16, 1997, on State Route 31 in Somerset Township, Somerset County, Pennsylvania in which Kimberly M. Grein was injured, and that for the reasons set forth in the foregoing Petition, the partial settlement of $100,000.00 is reasonable under the circumstances based on the injuries sustained by the minor-plaintiff, the availability of insurance coverage from the tortfeasor, her medical treatment, the prognosis for complete recovery, and the questions of liability in this matter. ,/Gary P. 172457.11il EXHIBIT "H" a ?L Fes` `- , U? i Vl 2c? LY. ? 3 0 N W O O N q fA C m Z [c? n (x?60'•aC z Q Z ? a m N C U ? F STATE OF NEW JERSEY COUNTY OF BERGEN SS: Before me, the undersigned authority, personally appeared Carol L. Grein and Monty C. Grein, who, being duly sworn according to law, depose and say that: 1. They have read the attached Petition to Approve Minor's Settlement for their minor child and that they are in agreement with same; and 2. The facts contained in the foregoing Petition are true and correct to the best of their knowledge, information and belief. Carol L. Grein t Monty C. G Vein Notary for Carol L. Grein Sworn to and subsb rd before, me this day of 1999. Notary Public Notary for Monty C. Grein CAHOLCLEVELAND NOTARYPUBLIC OFNEWJERSEY MYCOMMSSION EXPIRES 0.01I0t Sworn to and subscrib d efor me this fL day of I 1999. CMOLCLEVELAND A ? NOTARYPUBLICOFNE ICOFNEWJER JERSEY Notary Public MYCOMMSSION EXPIRES OWI/01 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to ) No. 99• 7-.ZYG C?c, P Ti -. KIMBERLY M. GREIN, a minor ) KIMBERLY M. GREIN, a minor, by CAROL L. GREIN and MONTY C. GREIN, her guardians, CLIFFORD GREIN and AUDREY GREIN, Plaintiffs, V. TERRY SCHMIDT, Defendant. ORDER CIVIL DIVISION No. 99-390 AND NOW, to-wit, this ?_ day of 1999, upon consideration of the foregoing Petition for Leave to Receive Advance Payment in Minor's Claim, it is hereby ORDERED, ADJUDGED, and DECREED that leave to receive advance payment relating to the within claims being brought by Carol L. Grein and Monty C. Grein, on behalf of Kimberly M. Grein, a minor, against Terry Schmidt is GRANTED. In light of the refusal of Zurich Insurance Company to waive its rights of subrogation against Terry Schmidt, Petitioners are granted leave to receive advance payment from Zurich Insurance Company, as subrogee of the Petitioners against Terry Schmidt, in the amount of $100,000.00. Zurich Insurance Company is making the -_ Jt' 0:= ' _ ??: '' pli ?; ? C??;• f? L??? ?';;'??? ?• U ?l,l=?+,i?y ;19Y l ?? T .i' ?1??___ ISM - advance payment in accordance with the holding in Daley-Sand v West American Ins. Co., 564 A.2d 965, 387 Pa. Super. 630 (1989). Said proceeds to be distributed as follows: Tucker Arensberg, P.C. - Fees $25,000.00 Tucker Arensberg, P.C.- Costs $1,475.34 Carol L. Grain and Monty C. Grein, on behalf of Kimberly M. Grain, a minor (born 11-26-82) for deposit in an interest bearing account with a federally insured Bank in the State of New Jersey and marked NOT TO BE WITHDRAWN UNTIL MINOR REACHES THE AGE OF MAJORITY (AGE 18) OR BY FURTHER ORDER OF COURT $73,524.66 Nothing in this Order shall be construed as settling, compromising, denying or foreclosing any other claims Petitioners may have, including underinsured motorist claims, against Zurich Insurance Company, Erie Insurance Company, or any other insurer, person or entity. Proofs of deposit to be filed with the Prothonotary within 45 days of receipt of the settlement check from Zurich Insurance Company. 23681.1 -2- 0m 0 819891 P U I v m o ./? VI T Z W ? W 7 ?1 (O? O N e?rf? Z CI { 4 {? =? h a a n F ? a, z ? H :frc?^:>d= IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLyANIA IN RE: Advance Payment to ) No. 99-7246 Civil Term KIMBERLY M. GREIN, a minor ) KIMBERLY M. GREIN, a minor, by CAROL L. ) GREIN and MONTY C. GREIN, her guardians, ) CLIFFORD GREIN and AUDREY GREIN, ) Plaintiffs, j V. ) TERRY SCHMIDT, ) Defendant. j PROOF OF DEPOSIT TO THE PROTHONOTARY OF CUMBERLAND COUNTY: No. 99-390 The undersigned counsel hereby certifies that the advance payment proceeds in the amount of $73,524.66 in the above-referenced matters have been deposited into an interest bearing account pursuant to the terms of the Order of Court dated December 3, 1999, a true and correct copy of which is attached hereto as Exhibit "A". Copies of deposit slip, rate disclosures, customer access agreements, and account details and registrations are attached hereto as Exhibit "B". W. Cahillane, Esquire 1500 One PPG Place Pittsburgh, PA 15222 (412) 566-1212 186752 .1:lit Attorneys for Plaintiffs IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to ) No. n9- 72 y? l tcYi J KIMBERLY M. GREIN, a minor ) KIMBERLY M. GREIN, a minor, by CAROL L. GREIN and MONTY C. GREIN, her guardians, CLIFFORD GREIN and AUDREY GREIN, Plaintiffs, V. TERRY SCHMIDT, Defendant. ORDER CIVIL DIVISION 0 ip r ~ No 99-390 ' _ ' . h l:1 ?:--Il J l G .- -< AND NOW, to-wit, this 3•?i day of Jicz •?_?'•_, 1999, upon consideration of the foregoing Petition for Leave to Receive Advance Payment in Minor's Claim, it is hereby ORDERED, ADJUDGED, and DECREED that leave fo receive advance payment relating to the within claims being brought by Carol L. Grain and Monty C. Grein, on behalf of Kimberly M. Grein, a minor, against Terry Schmidt is GRANTED. In light of the refusal of Zurich Insurance Company to waive its rights of subrogation against Terry Schmidt, Petitioners are granted leave to receive advance payment from Zurich Insurance Company, as subrogee of the Petitioners against Terry Schmidt, in the amount of $100,000.00. Zurich Insurance Company is making the EXHIBIT "A" t advance payment in accordance with the holding in Daley-Sand v. West American Ins Co, 564 A.2d 965, 387 Pa. Super. 630 (1989). Said proceeds to be distributed as follows: Tucker Arensberg, P.C. - Fees $25,000.00 Tucker Arensberg, P.C. - Costs $1,475.34 Carol L. Grain and Monty C. Grain, on behalf of Kimberly M. Grein, a minor (born 11-26-82) for deposit in an interest bearing account with a federally insured Bank in the State of New Jersey and marked NOT TO BE WITHDRAWN UNTIL MINOR REACHES THE AGE OF MAJORITY (AGE 18) OR BY FURTHER ORDER OF COURT $73,524.66 Nothing in this Order shall be construed as settling, compromising, denying or foreclosing any other claims Petitioners may have, including underinsured motorist claims, against Zurich Insurance Company, Erie Insurance Company, or any other insurer, person or entity. Proofs of deposit to be filed with the Prothonotary within 45 days of receipt of the settlement check from Zurich Insurance Company_ BY THE COURT: 23661.1 117) ::?Iavp?..Y )S:Lil?f.1 C:'!? vt: F?-0'. ... 3:. yS}1 t;! .J is 1:: rn: is•wl:a:Y.1, Y?.'. -2- 0aC:.( ®wet c D®WO."( a0GC-( a 0 (1r,c 0a.C'( '0 ® C._C T.C-.c-C-c=cC5'.GA :c.-C c:c,c;C,? '? ;ca rorlc First Union National Bank RIT 021200025 I:54 7 50 5 2 59t:'`300002b2 8472 0®0 D®? Cr'C.:`C CC;C'C:C.r:?l?`'C'•:;G: `m"?????.,???•l Q C. C. C. C. C C :Q 0 9D&d( C-Gt.,0®: ®©Q\)I: ? \J \_.' \.. ?.- -i?'C/.?•.'tiv6 `...\ .? 'I qy?.®..®.I r.. rY?ViJ ... ? • C?CICOO-, 'a (9 r. ` i' L TOML EXHIBIT "B" ? Na Thank you for inquiring about Rate Disclosura FIRST UNION NATIONAL SANK RIDGEFIELD PRY, OFFICE / RIDGEFIELD PK. NJ PREMIUM PERSONAL SAVINGS The following Information is current as of JANUARY' 14, 2000. 15 : 30 . and presents the interest rate and annual percentage yield for PREMIUM PERSONAL SAVINGS and the balance requirement for the product to earn the disclosed annual percentage yield. Please refer to your Schedule of Fees and Depositors Agreement and Disclosures for further information. Product AMinimum Balance Required To Earn Interest Annual Interest Is Type Annual Percentage Yield Rate Percentage Yield Compounded F'SA.V 0 1 .3? % 1.40% DAILY 5.(Xj? 2.32% 2.359 10.000 2.32% 2.35% 25,000 2.66% 2.70% 50.o()o 3. ?2% 4.00% Existing CDnRA Accounts only: Amount Tenn Account Matures On Renewal option Interest Is Paid Every Let us help you design 'a custom financial package to meet your individual needs. Thank you for making First Union your choice. We look forward to serving you. F 1 537856(7e0/pkp) F N Customer Ac 1-500.1 The Agneenent ==b trtrruie nest outamquerd skj'?ae ? and authorizations when openng Your signature on this Agreement will giro you the convenience of banking arpvhere and anytirre over the Bone. Ibis AgroenanL both row and as it may to a o ded from Vote to tires by Post Won, is BPPk Ue to any deposit araxri Test you open with any Fist Union Bane dhnr now a in to MrmfayousdfajdrbyWlhandhaperucaaWxx mdsiga. However.ifycuc{shon account at behalf of archer person (for exor pe, N you open an account as cafacian, gland m. hdw), you wW need b oonpetoa sepa-dM Agewm d fa M -M If yet havearyquesdo s, peasecdll a First Union Specialist IrBhes at 1.800-ASK-FUND. Instructions. BY signing this Agreema4 l auhalm any First UnIcn Beret CRrst U karO with which I open an axzvt nvv a in the future to accospt and act upon Irsbx9an from me to do the fckwirg • bapendepretatmatswith Fast UNan; • to barmier all a any portion d the beta= of try accounts (Inda9rg twit Ir • to dose deposit eoanb, process dwhgps d azamt lift., a ashawlso saNCe arydny First Uion a®tnI • toobtain mlatedseMmadfeed by First Ufort As used In Ws Agremsn, the terms 'prodxw,'servbes' am'aaxme Include vadors depttlt products. services old accounts made avalada to you by Fast Union. If mxa flan ore Person ts naiad in tine title for any aaamt, such samunt will be considered a)olt aoant IrathoBaa wNdh affect any d my jcim accounts nor, be given by aryjdnt axCUt owner. References to me in this Instructions section shelf also rata to the joint ecmu . ldder(s). I traYgive instructions aallyain wdtlrg, In person, by real, messenger, telephone, facsimile. comp er anrirei. Wre service, auioneted letter nadure, a by try diver nssoaWo medod First Union may accept end act upon adn Instructions which do net ax, an try Signature Win the Sams effect as N such Irsthdans wens signed by bra However. I adovWedge, fiat First Win may. at its cpday require my Mgiral signature a any other documentation before ocisepthig and enrad anhatess F4st Urim to halo ve r balaany Nstrrot ore Yarslganaa on u . this AgreTo elsend stop payment elders , Fast Union rest mc s ve a verbal older for soon extension bslpa Ufa erpirotlon d this sh rtarth period. I audtofae First Dion to mmrd ad mautor arty telephone tills for vadcs purposes, Inducing to muse ac cu acy, to podde a record of adnoxrvasatiem and to irtpcre the quality or service to rte Was to fellow such ready pmchaves as First Union only ire . 7lre soariy procedae agreed upon for vedydng the authenticity of Instructions which a s not delivered In person by ore fa ery purpose Qnduirg, but not tinted to, the Wra tarasks of money from arty of try a;atr. ) Is ere or tram of tla following at the option or First Unuax (1) delivery of a Personal Idertifimtion code by ms or e person purporting to be roar (2) a callback, (3) a redauon by ore a s person purporting to be nor d one a true urns of try personal Iruamatim Wddh Fast Union has in Its reccns about nor, a (4) wise recognition of me exit iced Wah the rso of plain pmhbhg questions The telephone nimbu(s) to which collhacis shall be made shall to any telephone ntuMer(s) First Union may have for roe in its rands a try teephow Mercer assigxed to ms by a bephane service prodder. I agree that this security proco. mstitetes a marncialle reasonable trathod of providing sonny against unauthorized ksbtrokts. I agree to rteirtam the mdderdloliy d any personal Identification code and WO prevent the Unauthorized dsserriratirn of won code. 1 87M to Wemrify and lid First Union harries. iron any bases, darages, suits and experees of whatever Hrd, Indudug arry reasdnat9a attareW lens, fiat First Union nay Irwas a result of relying upxn Onstuctas fan rrA aargeno purporting to be ma, provided gtd Fast Urionhascon ied Wththeapplicableses yprdmdams. I aknoWedge receipt of the First Union rules and regulations gumming money Wx der regents ad agree b be load by itshems as maybe eroded fnzn times totime. Information About Customer. I acknowledge and agree that any information 1 have supplied or will supply In the future to First Union is complete and correct 1 agree that First Union may obtain and use consumer credit reports about me In connection with any accounts, products and services offered by First Union. First Union may also verity my employment, salary, assets, debts and references, and anyone receiving a copy of this Agreement Is authorized to provide First Union with such Information. Acceptance of Terns and Conditions: I agree to be bound by the terms and conditions including, but not limited to First Union's Deposit Agreement and Disclosures, applicable to each product or service which I obtain tram First Union new or In the future, which terns and conditions will be provided to me. 1 also agree to pay all fees associated win such products, accounts and services In accordance with the too schedules which will he provided to me by First Union. ? By checking this box I am requesting issuance of a 24 Hour Banking (ATM) Card or CheckCant. /?'/Customer signature Print Name Address cess Agreement CAA N m r I mot Use nly n uid f,, SW) (IIIf- Op f752 (SK-FUNS FORM WO CERTIFICATE CF FOREIGN STATUS (All owners must sign a separate W-6. Not applicable for U. S. citizens or nsldents): Under pnaltles of perjury, I certify that for Interest and dividend payments I am not a U.S. citizen or resident (or I am filing for a foreign corpantlon, partnership, estate, or trust), and for broker transactions I am an exempt foreign person. Signature d axomp foregn pram Pemmarr street address bW Weq apaNmnt or sure numbed primary ax reekena (P.O. Ben W Slowed) Ctly, plwbca. paw cede and samgalprimay tax reskiaxa What is your country of citizenship? RIGHT OF SURMORSHIP (ONLY NO or TN ACCOUNTS): I understand that by establishing a joint account under the provisions cf. North Carolina Genoml Satute 53.146.1 that Tennnssoo law that 1. First Union may pay the money In the account to, or on the order of, any person named In the account unless we have agreed with the bank that withdrawals require more than one signature; and 2. Upon the death of one joint owner the money remaining In the account will belong to the surviving joint owner and will not pass by inheritance to the helm of the deceased joint owner or be controlled by the deceased joint owner's will. I DO elect to cmato the Right of Survivonhlp for any joint account (For TN: I DO elect the Right of Survivarship for any joint account I establish with First Union new or In the future unless 1 nobly First Union otherwise, in which case Fiat Union will provide me with the appropriate documentation to establish such an account.) Signature FORM W9 SOCIAL SECURITY NUMBER OR SMFLCYER IOENTIFCAT104 NUMMER CERTIFICATION (Not applicable for Non-Resident Aliens): (The Social Security Number or Employer Identification Number should match the first name listed on the account and will be used for tax reporting purposes.) 1. Social Security Number or Employer Identification Number. II. If exempt tram backup withholding and reporting, because you have a custodial account under section 403 (b) (7) or a trust exempt from ax under section 664 or described In section 4947, check this box Q E(EMPr III. Certification- Under penalties of perjury, l certify that 1.. ThAnumber set forth above Is my coned social security number or employer .{degtlficetion number (or l am waiting for a number to be Issued to me), and 2. lam not subject to backup withholding because: (a) l am exempt from backup withholding, or (b) I have not been natified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all Interest or dividends, or (c) the IRS has notified me that I am no longer Subject to backup withholding. Certification Instructions -You must cross out Item 2. above if you have been notified by the IRS that you are enemy subject to backup withholding because of under reporting interest at dividends on your ax rebm. /? (/v-/? (Only one signature per agreement) I. T!"-BE Y M 'TRE3 Although First Union requires that you agree to the Ierms and conditions of this agreement, the IRS does not require your consort to any prevision of this document other than `eTSN'gcabon required to avoid backup withholding. CEFOST SERVICES COPY - CiF.17'- CUSTOM, CC=Y-CANARY Date FN' Customer Ac 1-800-) This Agreement is designed to dlMrete meat sbseWet sigraoae cards Ord aNOlatlrrs when opening future aosasa Yea agnate m this Ag erni t vAti give you the mrnanarra of banking anywhere and anytime ovw the Acne. This Agreement both now and as it may be amended from time b Who by First Unto, is aPplicatle to arydepxait amount did you open with any First Utica Bank alter nmvrr in to hsaehcrycLnWwjoindyWthacterpamaadthaimdsigrw. HoweKr.tycvyman axetat on behalf of ache poser (for ehwrpia, if you open an account as eekdn gueudan, IrLance), you will road to axnplete a separate Agsmmt for that acroab N yon havetryquestions, pesea call a First Union Speciai'atbll-free at 7-800•ASK-FUNS. knsoactonrs: BY signing "a Agmethent.1 at7Wzo arry Fist Linkm BaNc ('First UnirnO with which 1 open an account now a in to Mae to accept and ad tporn Instructions Drum me to do to fcncwfng: • to opetdepostt acccvnmwith First Union; • to Wrier at a any pomp, of to balance Of ny accounts (tdudng aocit ocmrtsk • to dose deposit acurva, grease changes of asxxmt infprnstlm a dhow(se saNcea y of rty First thicn aalyds: • tootainmldWsaAomdfaedly First Urhiah. As used in this Ag ems t, the tarts •pcdp:W. 'swvias' ard 'aooounte Irdorlo vadas depmit Voducb, services and a ocats made oalable to you by Fast Linton. If more than one person Is named In the the for any account such a camas wig to c0nddaed ajdntaccourn. ImhcU=which died ary d my jdrt m its nay be i;Nm by arty prt eauat owner. References to rte in this Inhictlo s session shall also refs to the joint account h clder(sj. I may give Instructions Dray or In writing In person. by mal. messenger, telepnae, fadmde, computer temdral, wire seMca, sus aced tetw nred re, w by any diva mmaratde method Fast Won rtay accept and ad upon such instructions which do not Dustin my slgndtse with to same died a9 If such Instructions wee sighed by rive. Howehe. I acknowledge that Fret UNm may. at Its option. require my OrigircY sig ature or any dher d°°aresaton before accepting and sting upon any Instructions Your signature or this Agreement authafms Fist Union to haw venal stop payment orders up to sb((S) Months. To extend stop payment orders. First Ud n must receive a verbal craw fa such exlpnicn before the expirdtm d this six mahh period I aithorlm First tlrsan to nacre ad nhaita any Weptxrhe calls for vafto; purposes, irxdtrdM to ensure accuracy, to provide a record of such conversatas and to Irtgove the quality of service to ma. 1 egme te fcOl mdu senaly pomdaes m Fuat Urdm nW mgUm Tho seemly procedue agreed (or any purpose ndtsSng 14nled Is. the wire transfer of delivered in person by m =Owls) Is ms or mere of the following d the optlm of First lki? (1) d? dfa Pasonal IdeuMcotlm code by rte or a pa scrr pupating to be me, (2) a ollbaK (3) a mcitatan by ma a a lesson purporting to be rte of One a rtDre Item of my perecal WaTnabc n which First Uri on has in Its max about ere, or (4) voice mcaghutlan of rte contained with the use of cortan probing questlahs. The telephne narter(s) to which catbeda shall be mado shall be any telephone rAamba(s) First Uam may have fame in its mcc, a any telephone rurtber asstg ed to rte by a telephone service povldw. 1 agae the this seaally prOmdtue mr5ltses a comcYCaly reasonable metxd d pWdrg security against uaauthori3d ImNrdlors I agree to maintain the codhdentlaiy of any personal Idenfifi(atlm edeandwill proved Wen unadJh dmddhssadretlmdsudh caeca, 1 agree to indemnify and hold First Union harmless from eery lases, damages, suds and expenses. or whatever kind, incicdrg any reasonable ;eorrxya' fee% that First lkdon may haw as a result of relying upon Instructions; Iran me. Dr ayoa purporting to be rte, Provided that Frt Reim has compiled with to Wroa le seamy prosedtna. I a knaMedge receipt of the First Won odes and reg iatlons governing moral taster m;aests and ages to be bared byits tamm maybe amended hmltime to trthu. • Information About Customer. I acknowledge and agree that any Information I have supplied or will supply in the future to First Union Is completo and correct. I agree that First Union may obtain and use consumer aotlit reports about me In connection with any accounts, products and SOMcas offered by First Union. First Union may also voriy my employment, salary, assets, debts and references, and anyone receiving a copy of this Agreement is authorized to provide First Union with such Information. Acceptance of Terms and Conditions: I agree to be bound by the tam and conditions including, but trot limited to First Union's Deposit Agreement and Disclosures, gpppCable to each product or service which I obtain from First Union now or N the future, which torsos and conditions will be pfWded to mo. I also agree to pay all fees associated with such products, accounts and soMcas in accordance with the fee schedules which will be provided to me by First Union. ? By checking this box I am requesting Issuance of a 24 Hour Banking (ATM) Cad or CheekCard. r Cmlomoragmlure (Only one signature per agreement) Date PMl Name r?7^T_-_ C•GC.F? jr_ ,.I?b-d.' ..•4T Address Although Flat Union requires that you agree to the harms and conditions of this agmemenh, the IRS does not require your cansonh to any provision of this document other than the cortlficaflcan mquimd I.. backup withholding. . CEPOS1TSc'ACES COPY •'i:Y.ITc CUSTO;l.ER& COPY-CANARY 'too 537998 (5apkg Rev 05) if e-a=cted .cS9 raquired (Tax IOfv`Sibrdo ccda d:a ,es eniy), send to Interest Repo r' ing.IC•0 467 Cass Agreement CAA N m "" " a " 1SK-FUNB FCRM WS CERTIFICATE OF FOREIGN STATUS (All ownam must sign a sopante W-S. Not applicable for U. S. clUzems or residents): Under penalties of perjury, I certify that for Interest and dividend payments 1 am not a U.S. citizen or resident (or I are filing for a foreign corporation, partnership, estate, or trus), and for broker transactions I am an exempt foreign person. signaum of eampt bmgn Person (P.O.Bed sent eedhep kxxudyq ePertmenta sues numbrepnmary W rssWrxe (P.O. mr noleMwed) . Gly. Province. Pcdu wade and soway of primary to residence What Is your country of citizenship? RIGHT OF SURVIVORSHIP (ONLY NC or TN ACCOUNTS): I understand that by establishing a joint account under the provision of North Carolina General Statute W-1461 that Tennessee law that 1. FM Union may pay the money In the account to, or on the omleral, any person named in the account unless wo have agreed with the bank that withdrawals require mom than one signature; and 2. Upon the death of one joint owner the money remaining In the account will belong to the surviving joint owner and will not pass by Inheritance to the helm of the deceased joint owner or be controlled by the decsaeed joint owners will. I DO elect to create the Right of Survivorship for any joint account. (For TN: I DO elect the Right of Survivorshlp for any joint account I establish with Fret Union now a In the future unless 1 nosy First Union otherwise, In which case First Union will provide ma with the appropriate dooumentaton to establish such an account) Signature FCF.M Y19 SOCIAL SECURITY NUMBER OR EMPLOYER IDENTIFICATION NUMBE::I CERTIFICATION (Net applicablo for Non•Reaidont Aliens): (The Social Securiy Number or Employer Identification Number should match the first name rated on the account and will be used for tax reporting purposes.) 1. Social Security Number or Employer Identification Number. s S___-I'v!t II. If exempt from backup withholding and reporting. because you have a custodial account under section 403 (b) (7) or a trust exempt from tax under s ion 684 or described In section 4947, check this box EXEMPT III. Certificatim- Under penalties of Nqury, I Witty that 1. The number set font above is my coned social security number or employer Idealfcaton number (a I am wolfing for a number to be Issued to me), and 2.. p am not subject to backup withholding because: (a) I am exempt from backup • withholding, or (b) I have not been notified by the Internal Ravens Service (IRS) this I am subject to backup withholding as a result of failure to report all interest or dividends. or (c) the IRS has notified me that l am no longer subject to backup withholding. Certification Instructions -You must cross out Item 2. above If you have been notned by the IRS that you are currently subject to backup withholding because of under reporting Interest or dividends an ur tax return. FNe Customer A( 1-800-, wren Opening Agreement Is designed to Ara" ?a seen meal su?gtast slgnaaae arr_s as oultxxt tom Your signature the oxhvaierrd h Of bmkbg anywhere and arrytir the plxx> This Agreement, both now, aand as h nay be amended from time to tree by First lkiak is grocaNe to aryde{xsit atmau atat you open with my First Union Be* either nmva in the ftMm orymrsdfwjdmyWthwctwpesmaatdlelmdslgnw. Nawervr,irywopanat I rt on behalf Of sooner person (for ream{ie, If you open an account as c stodort amdm to ssco) you wit neat to 001TOMO a awe Agreement for that atmtrt if you new arty'luestiaR {die call a First Union Specialist Idl-free at 1dOWlSK-FUNK. kmftctfo BY sigdng tots Agreement I authorize any First Uion Bahr ('First Uien7 with which I open an amad now a N the future to accept ad ad upn Instructions from me to do is folfaMng: is gmdaposft amounts wth First Uiag to tarsier all a arty portion Of the balance of ny armtnts (mdehdrg credit aaonts); to does deposit amounts, process; changes Of amount mfonretian a OUWMen service arydmy First Union aool+hLr, to obtain mated services offered by First Union As used to this AgyaarerR the term 'pod car. *services" and -amu-.W tmndo odours dcpoah products. services and akmmb node available to you by First Union ff nmra flan coo person ls naffed In the title for arry account Such amount will be caZdeed a jotritacc ux. Imb one which affect any d i yjdnt ecmmts may be give i by aryjdnt mat Owner. Raaerxme to me in this Istudicre section shelf also refer to the lout amount holder(s) Imay give Instructions sally a in willing, In person. by rteB, nhassa5c, telepthaha, famimle, computer terminal, vim service, automated teem marline, a by any Other reasatade method Fund Union may accopt and ad upon sexh Inshhictlons which do not axhtsin my signature shah to see effect as if such Inst udae were signed by one. However. I adohosyiedgo met Furst UNon may. at its option, aaguire my Original signature a arty otter dZurnerillation bob accepting arid acting upon Agreement atltndzes First Union vemal t stop ry ay mxdiene Your to six on this stop pal orders b r t such rtmaa - To t extend stay payment is six orders. First Ukton on must raxdve a a enter so such ncan aV tB4teitaiephae calls fOrvaneus more1 period. . l Ia gtoIxtoeeFirst ver rst tr Unim b recoml andnof e one q. 4dedkg 0 amaacy,bPrevk'-e a rem: Ocd d huh cornesalas and to i Pt s rrprove one quaky, dseMco to me. ing m b Ww such sandy procodaes air First UMon nay mc;U a The smunty pmocoonv agreed tgxn for verifying the and entldty of instructions which are not dtlhvered in penscm by me for my purpose (including. but not turned le, the vWe transfer Of money from any Of my amaau I ) is are Or mono of the foloving at the option of First Ulalm: (1) delivery or a primal IdaWSmWm Cade by ire, a a Fasrn prpmarg to be me, (2) a callback (3) a radiation by rte a a pension pxapotirg b be me of One a more itens of my Personal Infaratlm which Full Union has In Its reads about ma, or (4) velae nsmgitlcn of ma combined with the use of conein probing Wesdas The telephone mower(s) to which calibada shall be node shall be any telephone n rrber(s) First Uhdm may have for me In its terms or any telephone nuffnb r assigned to me by a telephone service pmvker. I agree it= this security pooe&m ccrothaes a commercially reasonada method of providing eeeurity against unauthorized Imitucahe I agree to maintain the arhlklerdality Of arty PsIzonal Identification code and will prevent the unauthorized dfaemnatlm of such code. 1 agree to Indsndy am hdd First Ualon hamdess.fran any losses, darages, salts and e>peitsm, d wihamai Idrd, including any me,,nable atareye face, that First Undoi may mar as a result d(dying upon Instructions from me, a anyone p roorang to be rte, provided the Fast Union has mxrplled with ate applicable security Procedures, 1 atlmorAedge medpt Of the First Union rules and regulations governing money tmrsta musts and agree to be bound by its terms as may be amedod from time to tone. Idonnation About Customer. I acknowledge and agree that any Information I have supplied or will supply In the future b First Union is complete and conrecL I 891,80 that First Union may obtain and use consumer credit imports about me in connection with any amounts, products and services offered by First Union. First Union may also verity my employment, salary, assets, debts and references, and anyone receiving a copy of this Agreement Is authorized to provide First Union with such Information. Acceptance of Tema and Conditions: 1 agree to be bound by the tarns and conditions Inducting, but not limited to First Union's Deposit Agreement and Dlsdosures, applicable to each product or service which I obtain from First Union new or in the future, which tons and =nd:tens will be provided b me. I also agree to pay all fees associated with such products, accounts and services in accordance with the fee schedules which will be provided to me by Forst Union. ? By checking this box 1 am requestng issuance of a 24 Hour Banking (ATM) Cam or ChockCam. Customer Sgnaten (Orel lure por agmomem) _ F `i "1 4R_IIJ Print Name it, rr k'11.1?`.??[?: ,•-;1;_:jI-rF Morm$ Although Fimf Union requires that you agree to the tons and condWcns of this agreement. the IRS does not require your consent to any provision of this document other than the nrfifacadom mgdmd to avoid backup withholding. C'O_POSIT SERVICE-3- CCPY-'.1'HITE CUSTOMER COPY-CANARY :pig 537998(501pkq Rave,5) 11 comec:ed 1 099 required (To:: IO;Ni It-.hold coda char.,es only), send to Interest Reporting NC-0457 -Ma r-aa Nbmbarlnlemrl Uao On Re uked rem CMU Semen ;assn Agreement pp.37E1 rh 4SK-FUNS -744 FORM Will CERTIFICATE OF FOREIGN STATUS (All owner must sign a separate W-0. Not applicable for U. S. citizens or residents): Under penalties of perjury, I tartly that for Interest and dividend payments I am not a U.S. citizen or resident (or I am filing for a foreign corporation, partnership, astute, or trust), and for broker transactions I am an exempt foreign person. 5pmtme of exempt foreign person P.Imrnem.wet addres, Indmng.p,rment err outs rumbrof primary tax Iwde,ee (P.O. Box not allowed) Coy. amine. portal coca and country of 9dmeY tax raWerce What is your country of citizenship? RIGHT OF SURVIVORSHIP (ONLY NC or TN ACCOUNTS): I understand that by establishing a joint account under the provisions ch North Carolina General Statute 53.140.1 that Tennessee law that 1. First Union may pay the money in the amount to, or on the older of, any person named in the account unless we have agreed with the bank that withdrawals require mole than one signature; and 2. Upon the death of one joint owner the money remaining In the account will belong to the surviving)oint owners and will not pant by Inheritance, to the helm of the deceased joint owner or be controlled by the deceased joint owner's will. 1 DO elect to create the Right of Sumlvomhip for any joint account (For TN: 1 00 elect the Right of Survivorship for any joint account 1 establish with First Union now or In the future unless I notiry First Union otherwise, in which com First Union will provide me with the appropriate dommentaaon to establish such an accourht) Signature FORM W9 SOCIAL SECURITY NUMBER OR EMPLOYER IDENTIFICATION NUMBER CER, IFICATION (Not applicable for Non-Rosident Aliens): (The Social Security Number or Employer Identscoton Number should match the that name listed on the account and will be used for tax reporting purposes.) 1. Social Security Number or Employer Identification Number. It. If exempt from backup withholding and reporting, bemuse you have a custodial account under section 403 (b) (7) or a trust exempt from tax under section 664 or described in section 4947, check this box: Q EXEMPT III. Carilacation - Under penalties of perjury, l tartly that 1. The number set forth above is my coned social sewrity number or employer Identification number (or I am waiting for a number to be issued to me), and ,2- I am not subject to backup withholding because: (a) I am exempt from backup •willtolding, or (b) I have not been notified by the Internal Revenuo Service (IRS) that I am subject to backup withholding as a result of failure to report all Interest or dividends. or (c) the IRS has notified me that I am no longer subject to backup withholding. Certification Instructions -You must moss out item 2 above If you have been notified by the IRS that you are currently subject to backup withholding because of under reporting interest or dividends on Your tax return. Data First Union National Bank _ Ridgefield Park Office 200 Main Street Ridgefield Park, New Jersey 07660 201 712-4936 Fax 201 712-4937 ' FN' CD12 A054412 C51137205 Customer Detail Inquiry 045643786 CZ111901 01/16/40 MORE: Sel KIMBERLY M GREW Tax Id: SiSS763156 144 OVERPECY. AVENUE RIDCEFIELD PARK. NJ 07660 Customer A=--sets $ 0.00+ Customer Liabilities $ 0.00+. S-Orci-Serv-Account Number/Mat Date-Fred-J/S-Stat Date--Cmnt---Balance ---- Conf 075 SAV 3000021258472 PSAV S OP 01142000 N NEW ACCOUNT BALANCE INGU I.RY COMPLETED PRESS F9 FOR BALANCE Command: F'-=He1D F3=Ext F4=N::t,F.S=Sold F6=Add Lead F7=Bkwd FS=Fwd F10=LtOF11=Rt F24=CSEL 4700 1 1 l CZ120101 01/14/00 AD! A054412 C51D7205 Account Detail'Inquiry 16:49 Ora: 075 Sere: SAV Acct: 3000021255472 Memo : Tar: Id: Hold: 075 eAV 3000021255472 PSAV Ocened : 01142000 Stat! Br OPEN -/29 St: Nj P.c=t'Tax Id: 5138763158 Reopened : ROS Fed l1/ 01 01142000 Closed S DLM 01142000 Jnt/S01 Ps-ev W/h d Peru/Com: Src P A054412 Services Secured Mr^r. - Lecal Title KIMBERLY M CREIN Perk Id: MONTY C GREIN AND CAROL L GREIN GUARDIANS FOR Primarv Addree= 144 OVERPECK AVENUE F.IOGEFIEL D PARK NJ 07660 Addr Tvoe: N r ni cliLl IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Settlement of Underinsurance Claim of ) No. I9 7,7 `16 'C' ? L V, KIMBERLY M. GREIN, a minor ) KIMBERLY M. GREIN, a minor, by CAROL L. GREIN and MONTY C. GREIN, her guardians, CLIFFORD GREIN and AUDREY GREIN, Plaintiffs, V. TERRY SCHMIDT, Defendant. No. 99-390 ORDER AND NOW, to-wit, this ?? day of Aiv -4 2000, upon consideration of the foregoing Petition for Leave to Settle U erinsurance Claim of Minor, it is hereby ORDERED, ADJUDGED, and DECREED that leave to settle the underinsurance claim of Kimberly M. Grein, a minor, with Eire Insurance Exchange, for the complete policy limits of $100,000.00 available to her is GRANTED. Monty C. and Carol L. Grein, the parents and natural guardians of Kimberly M. Grein are hereby granted leave to settle the aforementioned claims in the following manner with Erie Insurance Exchange: Payment by Erie Insurance Exchange in the amount of $64,789.19 Carol L. Grein and Monty Grein, on behalf of Kimberly M. Grein, a minor (born 11-26-82) for deposit in an interest bearing account with a federally insured bank in the State of New Jersey and marked NOT TO BE WITHDRAWN UNTIL MINOR REACHES THE AGE OF MAJORITY (AGE 18) OR BY FURTHER ORDER OF COURT $64,789.19 Payment on March 1, 2005 to Kimberly M. Grein (an adult individual) in the amount of $12,915.00 $12,915.00 Payment by Erie Insurance Exchange to Tucker Arensberg, P.C. -Fees $25,000.00 Payment to Tucker Arensberg, P.C. - Costs $210.81 Nothing in this Order shall be construed as settling, compromising, denying or foreclosing any other claims Petitioners may have, including underinsured motorist claims, against Zurich Insurance Company, Maryland Casualty Company, or any other insurer, person or entity/Proof of deposit to be filed with the Prothonotary within 45 days of receipt of the initial settlement check from Erie Insurance Exchange. ? BY THE COURT. 18097e.1:rit J. Z)VA? 42u?) Iq VjG -oo R6 -2- IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Settlement of Underinsurance Claim of KIMBERLY M. GREIN, a minor No. 99 - 7R 416 -Lidi4 KIMBERLY M. GREIN, a minor, by CAROL L. GREIN and MONTY C. GREIN, her guardians, CLIFFORD GREIN and AUDREY GREIN, Plaintiffs, No. 99-390 V. TERRY SCHMIDT, Defendant. PETITION FOR LEAVE TO SETTLE UNDERINSURANCE CLAIM OF MINOR AND NOW, comes Plaintiff, Kimberly M. Grain, a minor, by Carol L. Grein and Monty C. Grein, her guardians, by and through their attorneys, Tucker Arensberg, P.C., and file the within Petition for Leave to Settle Underinsurance Claim of Minor, stating as follows: 1. Petitioners, Carol L. Grein and Monty C. Grein are the parents of minor-plaintiff Kimberly M. Grein ("Kimberly") in the above-captioned action, and currently reside at 144 Overpeck Avenue, Ridgefield Park, New Jersey. Kimberly is currently 17 years old with a date of birth of November 26, 1982. 2. On or about August 16, 1997, Kimberly was seriously injured in an automobile accident on State Route 31 in Somerset Township, Somerset County, Pennsylvania, when the vehicle in which she was riding was struck by a vehicle driven by Defendant, Terry Schmidt ("Schmidt"). 3. A prior Petition was presented to this Court setting forth all of the material facts relating to Kimberly's claims, and which sought approval of an advance payment of $100,000.00 from Maryland Casualty/Zurich Insurance Company ("Zurich"). (A true and correct copy of said Petition is attached hereto as Exhibit "A" and incorporated herein by reference). An Order approving the advance payment was signed by The Honorable George E. Hoffer on December 3, 1999. (A true and correct copy of said Order is attached hereto as Exhibit "B" and incorporated herein by reference). A Proof of Deposit of the proceeds from the advance payment was filed with the Court on January 31, 2000. (A true and correct copy of said Proof of Deposit is attached hereto as Exhibit "C" and incorporated herein by reference). 4. A tentative settlement has now been reached in connection with the underinsured motorist claim of Kimberly against the first level priority underinsurance carrier, Erie Insurance Exchange ("Erie"). Erie insured the vehicle in which Kimberly was riding at the time of the accident, and has underinsurance policy limits in the amount of $100,000.00 available to her. 5. In the tentative settlement, Erie agrees to pay Kimberly its entire policy limits available to her by making an initial payment in the amount of $90,000.00 upon receipt of this Court's approval. Erie further agrees to purchase an annuity in the amount of $10,000.00, which will make a payment on May 1, 2005 in the amount of $12,915.00, for a total payment to Kimberly of $102,915.00 (See proposed settlement agreement attached hereto as Exhibit "D"). 6. Additional underinsurance coverage is available to Kimberly under the policy insuring her parents' vehicles in New Jersey from Zurich with a single limit of $500,000.00. Zurich has given its approval to the aforementioned settlement. See letter from Zurich attached hereto as Exhibit "E"). -2- 7. Based upon a review of the available facts and advice of counsel, Petitioners believe that the settlement of the underinsurance claim against Erie in the amount of $100,000.00 is a fair and reasonable settlement, in light of the fact that it represents the entire policy limits available from Erie. (See Statement of Counsel attached hereto as Exhibit "F). 8. In furtherance of Kimberly's claims, the undersigned counsel investigated the facts and circumstances of the accident, and all available sources of insurance coverage. The undersigned further conducted research and analysis of various legal issues surrounding multiple levels of insurance coverage and the Defendant's liability. In addition, the undersigned gathered and analyzed Kimberly's medical records, and conducted lengthy negotiations with representatives of the various insurance carriers involved in this claim. 9. The Petitioners agreed to a contingency fee arrangement with Tucker Arensberg, P.C. for 30% of any settlements obtained before the commencement of trial. In light of applicable Pennsylvania law, counsel for Petitioner has agreed to reduce its contingent fee to 25% of the recovery. The Petitioner's family has also agreed to reimburse Tucker Arensberg, P.C. for all expenses and costs which to date total $210.81 and which consist of the following: - Express Mail expenses $19.35 - Postage $ 3.20 - Telephone charges $ 9.98 - Computerized legal research $119.69 - Ritz Camera -Photo $58.59 TOTAL $210.81 3 10. Petitioners believe that the best interests of the minor would be served by deposit of the settlement proceeds into an interest bearing account with a federally insured bank in the State of New Jersey. 11. Nothing in this Petition should be construed as a waiver or compromise of any other claim of Kimberly Grein, including those claims currently pending against Zurich Insurance Company or Maryland Casualty Company. WHEREFORE, Kimberly M. Grein, Petitioners, Carol L. Grein and Monty C. Grein, guardians, by and through their attorneys, Tucker Arensberg, P.C., respectfully request that this Honorable Court grant their Petition for Leave to Settle Underinsurance Claim of Minor. Respectfully submitted, SWARTZ, P.C. 1 aso22.1:6t Lee C. S artz, Esquire 111 No Front Street P. O. Box 889 Harrisburg PA 17108-0889 (717) 234-4121 Attorneys for Plaintiffs -4- i ?' i y: i I ' -j i''++ 1p ? ?? i ? ?;. ;? 1, 1 1 .! t. Fil 4, C f 1 :1 ?- ) ?, . i ;:_? ,; r ???? i • a IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to KIMBERLY M. GREIN, a minor No. q-9, -mLa KIMBERLY M. GREIN, a minor, by CAROL L. GREIN and MONTY C. GREIN, her guardians, CLIFFORD GREIN and AUDREY GREIN, Plaintiffs, V. TERRY SCHMIDT, Defendant. No. 99-390 O - 7 n T _ n 2 PETITION FOR LEAVE TO RECEIVE ADVANCE PAYMENT IN MINOR'S CLAIM AND NOW, comes Plaintiff, Kimberly M. Grein, a minor, by Carol L. Grein and Monty C. Grein, her guardians, by and through their attorneys, Tucker Arensberg, P.C., and file the within Petition for Leave to Receive Advance Payment in Minor's Claim, stating as follows: 71 1. Petitioners, Carol L. Grein and Monty C. Grein are the parents of minor-plaintiff Kimberly M. Grein ("Kimberly") in the above-captioned action, and currently reside at 144 Overpeck Avenue, Ridgefield Park, New Jersey. Kimberly is currently 16 years old with a date of birth of November 26,1982. 2. On or about August 16, 1997, Kimberly was seriously injured in an automobile accident on State Route 31 in Somerset Township, Somerset County, Pennsylvania when the vehicle in which she was riding was struck by a vehicle driven by Defendant, Terry Schmidt EXHIBIT n s // r ("Schmidt"). At the time of the accident, she was riding in a vehicle owned and operated by her grandfather, Plaintiff, Clifford Grain. Also riding in the vehicle were her grandmother, Audrey Grein, and her younger sister, Sara Grein, (A true and correct copy of the police report for the accident is attached hereto as Exhibit "A"). 3. After the accident, Kimberly was taken by ambulance to the emergency room of Somerset Hospital in Somerset, Pennsylvania. After spending the night at Somerset Hospital so that her condition could stabilize, she was transported by helicopter to Allegheny General Hospital in Pittsburgh, Pennsylvania, where she remained for the next eight (8) days for surgery, treatment, and observation. 4. As a result of the accident, Kimberly sustained significant injuries, including severe facial lacerations, fractured bones in her left cheek and eye socket, nerve damage, damage to her teeth and jaw, and severe damage to the retina and veins in and around her left eye. She underwent several surgeries to repair her eye socket, which had to be repaired through the use of wire mesh and screws. She also underwent surgery to repair nerve damage to her face. 5. Since her initial treatment at Allegheny General Hospital, Kimberly has undergone additional surgeries in order to revive her left eye, muscles and nerves, and to address the disruption of her maxillary sinus. Future surgery is probable, as she still has bleeding in the back of her eye which causes double vision. It is possible that Kimberly may lose sight in her eye altogether because of the retinal problems. Kimberly is also currently receiving treatment for the severe facial scars that resulted from the accident. Additionally, she is suffering from facial palsy, which alters the symmetry of her face. She has to wear braces because her teeth shifted due to the facial injuries, and she does not have any feeling inside of her left cheek and around her gums. All of Kimberly's medical bills have been paid to date, and it is believed that adequate insurance exists to cover future expenses. 2 _ ?? 6. To recover for Kimberly's injuries, Petitioners retained the law firm of Tucker Arensberg, P.C. as their counsel. The undersigned counsel commenced the above-captioned civil action in order to protect Kimberly's legal rights while negotiations with various insurers were under way. 7. Upon investigation of the accident it was determined by the undersigned counsel that the following insurance policies and limits were available to Kimberly for her injuries: a. Schmidt was insured by Nationwide Insurance Company ("Nationwide") with policy limits of $100,000 per person/$300,000 - per accident (A true and correct copy of declarations page to Schmidt's policy is attached hereto as Exhibit "B"); b. Underinsurance coverage was available to Kimberly Grain under the policy insuring the vehicle in which she was riding from Erie Insurance Exchange ("Erie") with policy limits of $100,000 (A true and correct copy of declarations page of the policy issued to Clifford and Audrey Grein is attached hereto as Exhibit "C"); C. Additional underinsurance coverage was available to Kimberly under the policy insuring her parents' vehicles in New Jersey from Maryland Casualty Co., now Zurich Insurance company ("Zurich"), with a single limit of $500,000. (A true and correct copy of declarations page of the Zurich policy is attached hereto as Exhibit 8. After negotiations with Nationwide, the liability limits of Schmidt's policy in the amount of $100,000.00 were tendered to Petitioners in an effort to settle any and all claims against Schmidt. (A true and correct copy of the letter tendering policy limits from Nationwide is attached hereto as Exhibit "E"). 9. However, while Erie has waived any and all rights of subrogation, Zurich Insurance Company has chosen not to waive its right of subrogation and intends upon pursuing the civil action currently pending against Schmidt as the subrogee of Kimberly Grain. See letters of Erie and Zurich regarding subrogation rights attached hereto as Exhibits "F" and "G" respectively). -3- I 10. Accordingly, as a result of its desire to retain its right of subrogation, and as required by the terms and conditions of its policy, Zurich has tendered to Petitioners the $100,000.00 which would have otherwise been available from Schmidt's liability insurer, Nationwide Insurance. 11. The remaining claims of Kimberly and the Petitioners are against the underinsurance carriers, Erie and Zurich, and lengthy negotiations with these insurers have been ongoing in an effort to resolve Kimberly's claims. However, so that the subrogation action of -Zurich against Schmidt may proceed, Petitioners seek .approval of this Court for the partial settlement of Kimberly's claims. 12. Based upon a review of the available facts and advice of counsel, Petitioners believes that the partial settlement in the amount of $100,000.00 is a fair and reasonable settlement, in light of the fact that it represents the maximum amount which would have been recoverable from the tortfeasor's insurer. See Statement of Counsel attached hereto as Exhibit H" 13. In furtherance of Kimberly's claims, the undersigned counsel investigated the facts and circumstances of the accident, and all available sources of insurance coverage. The undersigned further conducted research and analysis of various legal issues surrounding multiple levels of insurance coverage and the Defendant's liability. In addition, the undersigned gathered and analyzed Kimberly's medical records, and conducted lengthy negotiations with representatives of the various insurance carriers involved in this claim. 14. The Petitioners agreed to a contingency fee arrangement with Tucker Arensberg, P.C. for 30% of any settlements obtained before the commencement of trial, or $30,000.00. Tucker Arensbert, P.C. has agreed to accept 25%, or $25,000 in fees. The Petitioner's family i. -4- -iI El F has also agreed to reimburse Tucker Arensberg, P.C. for all expenses and costs which to date total $1,475.34, and which consist of the following: A. $556.50 - Steven M. Cook, Investigator B. $303.71 - Recordex/Medical Records Copying C. $61.23 - SMART Corporation/Medical Records Copying D. $518.77 - COMDOC/Copying Fees E. $15.15 - Pro-Rated Filing Fees F. $10.98 - Pro-Rated Sheriffs Fees _ 15. Petitioners believe that the best interests of the minor would be served by deposit of the partial settlement proceeds into a Certificate of Deposit with a federally insured bank in the State of New Jersey. 16. Nothing in this Petition should be construed as a waiver or compromise of any other claim of Kimberly Grain, including those claims currently pending against Erie Insurance Company and Zurich Insurance Company. WHEREFORE, Kimberly M. Grain, Petitioners, Carol L. Grain and Monty C. Grain, guardians, by and through their attorneys, Tucker Arensberg, P.C., respectfully request that this Honorable Court grant their Petition for Leave to Receive Advance Payment in Minor's Claim. TUCKER ARENSBERG & SWARTZ. P.C. Ga P. Hunt, squire Lee C. Swartz, Esquire 111 North Front Street P. O. Box 889 Harrisburg PA 17108-0889 (717) 234-4121 Attorneys for Plaintiffs 180978.tait -5- Y7i?RM1 '? ?4iS11PMw - ... -? .. ? _ 1 yi• 1 !J III rlj? kl!V FS. EFERTOOVEnTAYSIEETS j - POLICE INFORMATION HURRIER 7. Arrt&, A A 1 114+41, IAA. STATE TOLILE 0000566 - 3 COMMONWEALTH OF PENNSYLVANIA POLICE ACCIDENT REPORT IICIIOIITAIILL IK- ROILREPONTAULEI 1 VI.NNl10r Mbr city ACCIDENT LOCATION --? - -I m +:DlTrlir coUE , ScmElz•7i: r ?-s ] i . FItU :4 PATROL ,+N% ; CaICT.?. MERSE IILiO : ZONE 5-1 5 4f Csik-. R Wiz. 1.iJ. bao4Arn w Er`q 74-]41 6 .U'Pq^VED BY IIMICC .CPL. 90.&-Pr t elrgvz , Jr; NMlICR y7Eltr 11. v:VESTK`ATK)N 6 NU,NAL I DATE -I i t41P?Y.2.+S ACCIDENT INFORMATION V. µLC4.tN1 III MAY (]r NTEK TE ()e)j lV ?1 I '1 NEOF :171NMOCR Y DAY IL•00 OF UNITS ,Z , 13 1KILLED 14 FINJURED ;15 PNN PROP -7-ACLU fl; - T 11 11 j'6.00 VEMCLEtMvE To at 71, vCI let C n4MAL•E' . REMOVCU FROM THE SCE1rv7 a IlUfa Umt I 2 INIT 1 IR+IT ] 1 I K7 7 x1(114 llnll 7 1 Y X! !1 Y IX. It T SI •II NI tuat ] 3 Ix. IN;NiWUS -• ?• 14 14 fiNIK) 1 MATERIALS YI. N PNUPI Illy 'r 1+ .1• ?? UNIT # :]6 LEON LY T It ]I REC OR •-••-lw KInll PARKED a: 'PLATE 1-3-13 N. PA TITLE kOU -OF-WATOEVII I.I Ip Ip1 i7 I 1b CYrt1EiI?Ln ?? .X. F1 TIAI t5- 41 OWiCR'• ' '4:. AA?-STAST,1.31 C?EI?clSr? ??. O[E ;-43 nAR I~WKE I(`5 ViltS[?,„-( 1? I?IC:? 7? 43 I C irAEv'RCtIT i U MODEL • If10.1.-?; •I?•'f 4r, :,Is Dy TYPE' I IAARA Y ]. I+ I4w ,,,.OD OODY I1` .U SVECW IiS Vk14CLF L.7wE V ! USAOC G n4ttILI1LI4' 1 i!T NTT'IAL WALT 157 VEIRCLE 11i 01Av11 157 VVEIIIICCLE 1ee1' r54.ORATYEP l) 7 :5S o11NL `j R rRRAOENT L I PAESFIIa* I I' CtBNlllnrl I 71 XAuI1CV-AllIk CODE 1 .D lx,-E 5ET -TY.iP. Z?-1 1 PRINCIPAL ROADWAY INFORMATION 77. ROUTE NO OR STREErp E 5k a]jI - ]] VETO 5 U Ij4 17; N IMIT S I CIAVAY V L fROI I CO INTERSECTING ROAD: , 76 nOUIE OO OR st"CCT NWE 5FlcY1LLEt_S n?i ( I' &-a) i . 71 SI'LEU ;70.rrrc ,„77. ACCESS IIMII 57 i 311CIAVAY (J conrROL I -I _ IF NOT AT INTERSECTION: i in CRUSS STREET OR ! SLOMM, MNIKER 31 VIIECI4111 • 37.01611,= - I r110MsAi N S E W + FROMSITE FT MI.1 31 DIMAW1 WAS MrASL rn _ IiSRLIAtrD I -•. •• 4 COIIS1140:14:14 75: IRAFI IC I'NIIICIPAl rllcl ISE•.IrtIC: 11"4 CONTIT01 O DEVKL • p :.? . UNIT #2 - -..- ]61fCM1• Y eI. ]r I1r.C •-?•--]) MtE PNIKFO'+ VMwlr 1115 1-1L:(o i 37 VA itllr CA (IUT Mr SIAICVw SUS Z?ocj (,OI I 40 OMICR Ct_tfFcAD Get:] .l i i A 41 tj%VtJCR rI 1-11 (T111.IC-tL: c:f-\ 4-1-1 ? L?. Y.5 . u nnr.s1A lr A11IY:001 FWLE v\>LE ,I t?A 153?? ; 43 IT A1rr?? 44_,): • 1 JS MODU •IIKIT 46 Its (]Lilly IYI'rl cAS ,C's, i Y X tl..i UNK!. 1 t 4i nnUY 14d SPECIAL 149.NEIIICL-c IYN MADE G I o"'... S" I I yi NIIW IMPALI X01 vEtilcLE 1.52:IRAVCL 1 ''cull STATUS U SPEED 1 4J Vtll;CLI, r? DIIM1ER Ntfl - . '55.011 • . r=na'r+I 1 PRFSFIIrF : t 1 •mrmrtrnu I . S1.br IE i lmq? L A.IMSER l9 1 SG+RMWCN 0,4 %-136 5L) 5za 'ss? 1- ;Se 7RfVEii-._./?.? S6. DRMR 59 IIAME lGK??•I ??'r r.1I 1j IIAME `M L,L?F(i?I ORNT.R 59 1111,411 ACORESS -431 C rI-UUI',EE 7)a.. AUMESS I011 m11.1C-to C.Llurgr%A iLD?_.._._ •!C ::!Y,SIATE r41 CTIY,SIAIE -{I -.!moce Ill[Cft4??1?>LAPC% 1 n ' r'L5S` a11r.DUE Fi?ILCyL?IUF_, i ? 15332 : j670ATE OF __ !__ I. _ Ib]PIIoME-- _ G1 SEK 670ATEOr I 1 16]: P140W IF •c? ea CLASS. N CUSS S. CARRIER :66 U.'iRER ADDRESS ^• CRY, STATE x 1aCODE US00T I 'KC I Pwc r . If VEIN `t].4- +700 f.Obf K: , a4- OY MIL •? IO OF i'16 10.• NICMUS AVLE5 • 4nIrRWs AA15 111861 221 )r),)8 4 CNVIt /l. Rrirw (it Itl.'MAr I I I n! I toml I Y' 14 x: 4h55 C 61 CNNIR N OR CARRIER AUUnrss G7 CRy.11.LTE A IMCCE 10. US00TF r; vrU COfK10 I!. Nn nr ALII:: VACC EXHIBIT "A" 1cc r In'cnnco BODY TYPE !rl6 I N! ARDOUS MAt[RIAIS 1 i PLT, I 1110W/N 1 j!1 RCLEASEOr Ivvwt 1 Y I I N I I uilnl.I PPVIDOT . BIISTE r (!Uf?Uifi7 - Te RE:mrc)m EY5 Acc NCY ?"?IY1Gri<s_"f i 10 Yr0" FACCTTY ?!• fl It?LT..t./1T?CC. (INCIDENT p• FOL. 4y ;, I N1 I,b: fit: T .I •- , ; • ' T 7> ACCIDENT D:,TE: C.rr't I L 1 (' eOYLE NFOFWATK7N ' IL•7 A n yr.? ?jD? E t c ruuu. Auum ss ' 1111 II>1 I-l.' I iD?C)i Y?¦1 ,11 1 J K -{ Y I 1 I of L.1 I9 •7 j I I I; 7 r ,?F .3 1 '-- 1 1 14CC.I7.r:C, sL"M 17'i ; ?A%, C A•. ?.,.? • 1 `I f Ll 7 i 3 llf 1 3 to W?z 'ctln,l.,, 1)nroc A c;. ¦? i`I jJ' ? I .C ic_? I I`j l• I ?? i • L•?F ,-1? Ic, i;3o ; 3 fF (/! 3 1 i I fluffy Cll1_1A , ?IYmi; m; r.t 'L : `4I9 '7 ?G i 1 '_..:J?F I? J I II ,n?aa2l_?C?iC.=. ?Lk,,?iGt1S?ThK?.I?.? \?•W i31?1! IC. iC?' ? I ..?I ¦,VYfNiiON 17 ,N: WC.ITICII I Sc DIAGIM vlrt :E•7. ^ H 1:aw r~ I ? I U{ ?,! 2 I?T•clS,AA.ti ?e. ![J°'1] 5tx3TACE I I S'u• I I 1 Z." O L -tic- AZr.Qrrj f? .1. I iS{ PEIRISYLVANIA SCJIOOL OISTRK:T - (`A?.1?1J-O?.? `E4 16 APPLClULEI ?da CE.cRPT1ON DF DAIAAGEDPROPERTY I -- z?,. ; or1? tiZ?e% Lt, 0, i ADtwESS U: T?CC AL°[JS 7?T+•J .JcF,`75= 'Acr•, I 1 .. yMuLL $,j ai? 3 K, PHONE I i 17. HARRATTVE - IDENTFY PRECIPITATING EVENTS, CAUSATION fAC TOMS. SF.OVENCF, Of - -ALSyI? oESU0.WCE-INFOfUTATION AND LOCATION OF TOWED VEHICLES. IF KNOYRI.'WRM55 STATEYEMS. AND PROVIDE AL`L`RK)NAL '•+IS 4CGA Fr[- oCC+AR2c.P ¦ .. .. _ _-._._._? nS. CIa.T t .JAS '-•_Rr+L1ELLIIJCZ ?J.i?ji_t.Ya1_S'Z cn31 A T i0_??J?_ ?` J`tALLLT t;,C•towcA, . NIaLT'2 _ 14A5 ZaVEIS w1Ct ` * I L"T'6t -5 0 _ E?.? * ? ?,._6GZ?: .C??'sll :S n,•1 •r,I_rc,s ?.?riS ? a., :J?CC91 .? LL PCB .vl-v Li1.iIE i.Ip?'-t••t acI?JY? 057 ?'r'f5n'1Pr.!5 F) •u1?l. t-''1_I v_:1\5 T.1Cc-c?T.;?Zcl?..!!?C? 1, , 1 1 -5 ?Pti nti?`n _t "_`_E_ 14? fl? --1aAiT_`?-.: .L?nl l ? `2 .Irv\.I?AC'TE? ._ 1•tE _L..E• 20 F l=ETL-%Z .!m,?Fi J 1 T• _ • 2C_S? IAl THE - c- .?_. .ttl--LS'tn?L Tc_ /- _Clii_l.,F?AIE_.Ff_YCZ 770C'2 \,1E'f:C ..-tK?•5?1olis t= ?. u {NSURAHCE c??'I1a?Nr :IHFORIMTION I{ Iv 4TICf.11AI11X INIS. n9URANOf' 'C^^M-nANY UNIT I"POLICY ?`• ; UNIT UNIT ON CYI?IE ISIS Co 1 N S^ 3 C t 5 q NI , POLICY i 'H• IC-?I gnats 7 Alll;lu sy No Q\7 ?ICi Z Z.? 1 I wmessES I NA R Wa^n1t'' r?GLU E - " 11 Gua 4n.,1 c.J ?,?.. ADrRINI. +a I I'IECKIASE,t] ?A l5? (b,y?q?.?? i ? . VQa.I lnly LtFr lu+Rt ( 91. J'RO'L47LE •• S• TYPE "+J HE5151s USE ° IESI ? •f. HO IFSi I UUR 1' _ TIFI USI % Mi3 Rlmsl ' ??'i_?.1198 332: RSI ' fFSI '".ncauua ?107EST I W,RI%STICAi gtl j IIEFUSE CAUq[TF. I G O•. _. _%, : UIIK I YES ; 4 N0 1 PACT ?l Z PeIm'OT • BHSTE r r f -- i - .. v of the e ioly. h? a Goae th;a ted by t\le son miss;oner o1+?e ? Co nia state pennsylva :a?? r Fc? SOD ,ii{KEJi»t1C#?3;; ?f11i!d#??E?z f.?ctis:GFats EXHIBIT "B" #?kiae: ?? :: s57 :•: ease fit t?????.°•.?'.???`.< A RIIU ERIE INSURANCE EXCHANGE RANCE "? GROUP GROUP AMENDED-DECLARATIONS 02 * 100 EM ft PL PIONEER FAMILY AUTO POLICY * EFFECTIVE 08/1'7/97 '' Ene. PA IMM ATTACH THIS TO YOUR POLICY . . EMa REASON FOR AMENDMENT - SEE *** ON FIRST DECLARATIONS PAGE AGENT ITEM 2. POLICY PERIOD POLICY NUMBER AA5107 GULLBORG INS., INC. 12/31/96 TO 12/31/97 Q12 3102892'P ITEM 1. NAMED INSURED AND ADDRESS ITEM 3. OTHER INTEREST 1111111I11jill1811111I111III Ills 1111iIIf II111111III1„11&11111 CLIFFORD T GREIN & AUDREY M GREIN 191 MINGO CHURCH ROAD FINLEYVILLE PA •15332-3610 AGENT - GULLBORG INS., INC. i 3906 WASHINGTON ROAD AGENT PHONE - (412) 941-8200 MC MURRAY PA 15317 2538 * YOU HAVE BEEN INSURED WITH THE ERIE. FOR AT LEAST 15 YEARS. THIS POLICY WILL NOT*BE*SUR*** RGED*FOR*FUTURE*ACCIDENTS. **x* ITEM 4. AUTOS COVERED AUTO YR MAKE VIN ST TER SYM RATING CLASS DDP 2 93 DODG INTREPID 2B3ED46T7PH560902 PA 90 7 AIAL ITEM 5. INSURANCE IS PROVIDED WHERE A PREMIUM OR INCL IS SHOWN FOR THE COVERAGE. COVERAGES, LIMITS AND ANNUAL PREMIUMS ARE AS FOLLOWS- m2 *****GOOD DRIVER RATES APPLY***** __- THE LIMITED TORT OPTION APPLIES TO ALL PRIVATE PASSENGER VEHICLES - i LIABILITY PROTECTION- . BODILY INJURY $100M`P$RSON $300M/ACC 1 PROPERTY DANIAGE SIODM NCC 143 / FIRST PARTY S- 65 MEDCA $ 3 g$5M 1 FUNERAL BENEFIT J2 5M 1 i UNINSURED MOTORISTCOVERAGE- - BOD INJ ?S10OM PERSON S300MlACC-UNSTACKED UNDERINSUR D MO ORI 14 >J TT C STS OVERTGE- BOD INJ'$100M/PERSON S300M ACC-UNSTACKED 39 PHYSICAL DAMAGE COVERAGES- COMPREHENSIVE - $100 DIED - 77 I COLLISION - X500 DED OPTIONAL COVERAGES- 136 ROAD'SERVICE 4 TOTAL ANNUAL PREMIUM FOR EACH AUTO 5 $ I TOTAL ANNUAL POLICY PREMIUM 16 PREMIUM REDUCTION DUE TO THIS CHANGE $ 121CR i ITEM 6. APPLICABLE POLICY, END7 SEMENTS EXCEPTIONS TO DECLARATIONS ITEMS TOS A LL A 1 U , ABP. 0 96, AFP 03 A 2 2%9 10/95. UTO ABPU0 0 ***AUTO 1 AND LIENHOLDER DELETED ***DRIVER INFORMATION AMENDED ***MULTI-CAR DISCOUNT REMOVED ***UNIN/UNDR MOT COVERAGE AMENDED PASSIVE RESTRAINT DISCOUNT APPLIES - AIRBAGS AUTO 2 EXPLANATION OF ADULT &/OR YOUTHFUL DRIVER RATING CLASS AUTO 2-PLEASURE USE, 8,501 OR MORE MILES ANNUALLY ' SEE REVERSE SIDE EXHIBIT "C" _ 6001162 "? I ??? N AGTNLH 09/18/97 MISCELLANEOUS INFORMATION UNLESS STATED IN THE MISCELLANEOUS INFORMATION THE FOLLOWING APPLY - ITEM 7. EACH AUTO WE INSURE WILL BE PRINCIPALLY GARAGED AT THE ADDRESS SHOWN IN ITEM 1, UNLESS TERRITORY IN ITEM 4 INDICATES OTHERWISE. ITEM 9. UNLESS A LIENHOLDER IS LISTED BELOW, THE NAMED INSURED IS THE SOLE OWNER OF EACH AUTO WE INSURE. DRIVER ST LICENSE NUMBER BIRTH DATE 1 CLIFFORD T GREIN PA 04438150 10/01/21 2 AUDREY M GREIN PA 12061977 04/09/28 DRIVER DISCOUNTS - AUTO 2 - OVER 55. YOUR COLLISION COVERAGE AND DEDUCTIBLE APPLY TO PRIVATE PASSENGER AUTOS YOU OR A RESIDENT RELATIVE RENT FOR 30 DAYS OR LESS. THIS IS SUBJECT TO LIMITS, TERMS AND CONDITIONS IN THE POLICY. Q12 3102892 ;001163 FKARA NAME: Y: ALTY CO. PRODUCER'S NAME AND ADDRE SS: HULLER AGENCY, INC., ROBERT W. 175 ROCK RD, BLDG 2 P GLEN ROCK NJ (800)439-0292 . 0 0 NAMED INSURED AND MAILING ADDRESS: MONTY AND CAROL GREIN 144 OVERPECK AVE RIDGEFIELD PARK NJ 07660-1543 PERSONAL AUTO POLICY POLICY NUMBER: TP -01175406 RILL TERM PREMIUM: $ 859.85 - PRODUCER'S CODE. ACCOUNT NUMBER 02077600 07452 POLICY PERIOD: 6 MONTHS FROM. 12-06-97 TO: 06-06-98 1201 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED INSURED AS STATED HEREIN IT IS UNDERSTOOD AND AGREED THAT THIS IS A ' RENEWAL OF POLICY NO. TP -01175406 DESCRIPTION OF VEHICLE(S) OR TRAILER(S) COVERED (SEE SUPPLEMENTAL DECLARATIONS PAGE FOR ADDITIONAL INFORMATION) NO. YEAR MAKE MODEL BODY NO. YEAR MAKE MODEL 1 1990 PLYH VOYA WAG BODY 2 1990 FORD AERO VAN COVERAGE IS PROVIDED WHERE A PREMIUM A ND A LIMIT OF LIABILITY IS SHOWN FOR THE CO COVERAGES AND LIMITS OF LIABILITY VERAGE. VEHICLES COVERED A. LIABILITY $500,000 EACH ACCIDENT ppEMIUMS C. U1tINSURED/1TNDERINSURED MOTO 2 278.00 2 RISTS $500;000 EACH ACCIDENT 78.00 D. DAMAGE TO YOUR AUTO 2 39• 39. OTHER THAN COLLISION LOSS - ACTUAL CASH VALUE MINUS $500 DEDUCTIBLE • 36.00 COLLISION LOSS -.ACTUAL CASH VALUE MINUS $500 DEDUCTIBLE 2 56.00 BASIC PERSONAL INJURY-PROTECTI Z 29 ON EXTENDED MEDICAL 'BENEFITS COVERAGE - SECTION II $10 000 T INC .00 INC , OTAL AGGREGATE NAMED INSURED INCLUDING SPOUSE 2 1 1• OPTIONAL PERSONAL INJURY PROTECTION BENEFITS . VERBAL TORT THRESHOLD PROPERTY - LIABILITY INSURANCE GUARANTY ASSOCIATION SUR V CHARGE EHICLE ELIGIBILITY OPERATOR ELIGIBILITY NUMBER 2.85 POINTS 1 0 NUMBER POINTS 2 0 2 0 0 CONTINUED ON REVERSE SIDE 041853 10-22-97 150*85700 •*r•• ,rJCUSTOMER'S COPY EXHIBIT "D" Inver .. AINA r g r a COVERAGE IS PROVIDED WHERE A PREMIUM AND A LIMIT OF LIABILITY IS SHOWN FOR THE COVERAGE. COVERAGES AND LIMITS OF LIABILITY VEHICLES COVERED FULL TERM PflEMIUMS END. FORK NUMBERS 41343(05-91) PP0001(06-94) * A0002(05-96) .**63075(06-96) **63076(10-96) *PP0181(01-97) *PP0480(10-96) * A0461(07-96) PP0577(10-95) PREMIUMS FOR THIS POLICY WILL BE BILLED BY SEPARATE STATEMENT. FULL TERM TOTAL PREMIUM 11859.85 1015 LOGAN BLVD • ALTOONA PA 16602-4028 GARY P. HUNT, ESQUIRE 1500 ONE PPG PLACE PITTSBURGH PA 15222 OUR INSURED : Terry Schmidt OUR CLAIM NUMBER : 58 37 C 671595 08-16-1997 01 YOUR CLIENT : KIMBERLY GREIN YOUR FILE NUMBER : . DATE OF ACCIDENT : 08=16-1997 Dear Attorney Hunt: (NATIONWIDE INSURANCE ENTERPRISE • NaUOmvlde Is on your side April 16, 1999 This letter is to advise you that we are willing to tender our policy limit of $100,000. relative to the injuries sustained by your client. Please be advised that we will need waiver of subrogation from any and all underinsured carriers, and court approval of any settlements. I would also ask that you consider a structured settlement in this matter. Thank you: NATIONWIDE MUTUAL INSURANCE COMPANY WADE C PORTER (PA-20-ALTO) Claims Department 814-943-0266 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 a person to criminal and civil penalties. . ,?'y C n »0.000708{ EXHIBIT "E" a i ; .;, y ?I-e MATTHEW W. IVIYEPS, CPI; . M, AIC, AIM, AIS Assistant Vice President and Branch Claims Manager ERIE INSURANCE GROUP Branch Office • 301 Commonwealth Or. • P.O. Box 516 • Warrendale, PA 15086-0516 T? (724) 776-4000 • Toll Free 1-800.922.1824 • Fax (724) 772.7700 • http:/Av .erie-insurance.com MEN March 15, 1999 Christopher W. Cahillane, Esq. Tucker Arensberg Attorneys-at-Law 1501 PPG Place Pittsburgh, PA 15222 Re: ERIE Claim #010150252317 ERIE Insured: Cliff Grein Date of Loss: 08/16/97 Your Client: Kimberly Grein, a minor Dear Mr. Cahillane: Per our phone conversation today, I explained to you that I would be handling the potential Underinsured Motorists (UIM) claim with you concerning your client, Kimberly Grein, a minor. At this time, you have our permission to settle the Bodily Injury claim with Nationwide for their limits of $100,000. We would waive our subrogation against the at-fault tort-feasor. Once you have settled the Bodily Injury claim with Nationwide, please send me a copy of the court approval, signed Release and any and all medical reports, bills, and current photos to my attention at the above address. Once I have a review of these items, then I will be in a better position to make you an offer under the UIM portion of the policy. As you are aware, there was no stacking under the. policy due to, the fact that Kimberly was not a resident relative of our insured at the time of the loss.' Our limits in this matter are $100,000/$300,000. Thanking you in advance for your help and cooperation. Sincerely, Ronald J. Telephone Claims Representative Warrendale Branch Claims (724) 772-7675 RJE:psc EXHIBIT "F" 635456 The ERIE Is Above All In SERVICE* • Since 1925 UY/"I t3 'yo uy:4u NU.4yl u,I/U'I • • • • 142rylazld Casualty Company ... P.O. Box 140LI `ferephone NM Brunswick. NJ 0890(.4013 732 717,;U8 Maryland Casualty Company Serviced by Material Damage Adjustment New Jersey September 18, 1998 Ken Segamick Esq. Tucker Areasberg P.C. 1500 One PPG Place Pittsburgh, PA 15222 VIA FAX AND CERTIFIED MAIL RRR Z 103 177 464 RE: INSURED: Monty & Carol Grein CLAIM #: 681312294503 DOL: 08/16/1997 YOUR CLUENT(S): Kimberly Grein YOUR FILE: Dear Mr. Segarnick: r-e i ?1 As you are aware, I am the Undm- nsuraace adjuster assigned to handle this case. I am in receipt of your September 8, 1998 brochure. Please be advised that Maryland Casualty WILL be protecting it's subrogation rigbrs in this matter. Therefore, we request that your client NOT release the tortfeasor. Kindly advise this office once the tortfeasor carrier tenders it's 'policy limits. We will then advise as to the procedures regarding the subrogation issue and future handling of this matter.'' Your anticipated cooperation is greatly appreciated Very ttui ours. 732- Examiner EXHIBIT "G" RECEIVED TIME SEP.19. 9:45AM PRINT TIME •SEP.19 9:45RM VERIFICATION OF COUNSEL I, Gary P. Hunt, Esquire, as counsel for the Plaintiffs/Petitioners in the above-captioned action hereby verify that I have investigated the automobile accident of August 16, 1997, on State Route 31 in Somerset Township, Somerset County, Pennsylvania in which Kimberly M. Grein was injured, and that for the reasons set forth in the foregoing Petition, the partial settlement of $100,000.00 is reasonable under the circumstances based on the injuries sustained by the minor-plaintiff, the availability of insurance coverage from the tortfeasor, her medical treatment, the prognosis for complete recovery, and the questions of liability in this matter. 7 172457.1:IIt z { i? si 1 EXHIBIT "H" STATE OF NEW JERSEY ) SS: COUNTY OF BERGEN ) Before me, the undersigned authority, personally appeared Carol L. Grein and Monty C. Grein, who, being duly sworn according to law, depose and say that: 1. They have read the attached Petition to Approve Minor's Settlement for their minor child and that they are in agreement with same; and 2. The facts contained in the foregoing Petition are true and correct to the best of their knowledge, information and belief. Carol L. Grein Monty C. G in Notary for Carol L. Grein sworn to and subscrib d be for me this day of? 1999. - Notary Public CAROLCLEVELMD NOTARYPUBLICOFNEWJERSEY 1 MyCAMWSSIONEXPIRES 05131/0' Notary for Monty C. Grein /y CAROLCLEVELAND NOTARYPUBLIc OFNEWJERSEY Notary Public MYCOMMISSIONEXPIRES05131101 :t Sworn to and subscrib d efor me 1999. this fL day of ? T E` 1? 1t'l Ti ?I IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to ) No. _ 9 S' - 7-2V6 (o,; iQ T1, KIMBERLY M. GREIN, a minor ) KIMBERLY M. GREIN, a minor, by CAROL L. ) CIVIL DIVISION GREIN and MONTY C. GREIN, her guardians, ) CLIFFORD GREIN and AUDREY GREIN, ) Plaintiffs, ) c No. 99-390 -a,=-J o rn r? TERRY SCHMIDT, ? _ ::3 -:A lt S ; n Defendant. ) C ? '- mac io ORDER AND NOW, to-wit, this l-, day of _ k2=..,: , 1999, upon consideration of I, the foregoing Petition for Leave to Receive Advance Payment in Minor's Claim, it is hereby ORDERED, ADJUDGED, and DECREED that leave to receive advance payment relating to the within claims being brought by Carol L. Grein and Monty C. Grein, on behalf of Kimberly M. Grain, a minor, against Terry Schmidt is GRANTED. In light of the refusal of Zurich Insurance Company to waive its rights of subrogation against Terry Schmidt, Petitioners are granted leave to receive advance payment from Zurich Insurance Company, as subrogee of the Petitioners against Terry Schmidt, in the amount of $100,000.00. Zurich Insurance Company is making the EXHIBIT 9 G advance payment in accordance with the holding in Daley-Sand v. West American Ins. Co., 564 A.2d 965, 387 Pa. Super. 630 (1989). Said proceeds to be distributed as follows: Tucker Arensberg, P.C. - Fees $25,000.00 Tucker Arensberg, P.C. -Costs $1,475.34 Carol L. Grein and Monty C. Grein, on behalf of Kimberly M. Grain, a minor (bom 11-26-82) for deposit in an interest bearing account with a federally insured Bank in the State of New Jersey and marked NOT TO BE WITHDRAWN UNTIL MINOR REACHES THE AGE OF MAJORITY (AGE 18) OR BY FURTHER ORDER OF COURT $73,524.66 Nothing in this Order shall be construed as settling, compromising, denying or foreclosing any other claims Petitioners may have, including underinsured motorist claims, against Zurich Insurance Company, Erie Insurance Company, or any other insurer, person or entity. Proofs of deposit to be filed with the Prothonotary within 45 days of receipt of the settlement check from Zurich Insurance Company. BY THE COURT: l S/ (/-Par n c.. C .n 23681.1 -2- _ C 'a ?! ,';? :, k=f ? ') -{ 1- ' I' C ', :, i(• 4, I ,. ,, ;': r, _:. i ?...__. i ' ?, ?; 1 -...:? ? ;? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to KIMBERLY M. GREIN, a minor No. 99-7246 Civil Term KIMBERLY M. GREIN, a minor, by CAROL L. GREIN and MONTY C. GREIN, her guardians, CLIFFORD GREIN and AUDREY GREIN, Plaintiffs, V. TERRY SCHMIDT, Defendant. 9 No. 99-390 PROOF OF DEPOSIT TO THE PROTHONOTARY OF CUMBERLAND COUNTY: C4' " r ?J The undersigned counsel hereby certifies that the advance payment proceeds in the amount of $73,524.66 in the above-referenced matters have been deposited into an interest bearing account pursuant to the terms of the Order of Court dated December 3, 1999, a true and correct copy of which is attached hereto as Exhibit "A". Copies of deposit slip, rate disclosures, customer access agreements, and account details and registrations are attached hereto as Exhibit "B". P. Hunt, Esquire opher W. Cahillane, Esquire 166752.1:1tt 1500 One PPG Place Pittsburgh, PA 15222 (412) 566-1212 Attorneys for Plaintiffs EXHIBIT n i'4e1? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to ) No. ?9. 72 YG KIMBERLY M. GREIN, a minor "`? KIMBERLY M. GREIN, a minor, by CAROL L. ) GREIN and MONTY C. GREIN, her guardians, ) CLIFFORD GREIN and AUDREY GREIN, ) Plaintiffs, ) V. TERRY SCHMIDT, ) Defendant. ORDER CIVIL DIVISION No. 99-390 o ? F •• ? r 1 -e R5 AND NOW, to-wit, this j•_.? day of k&. -.. g 1999, upon consideration of the foregoing Petition for Leave to Receive Advance Payment in Minor's Claim, it is hereby ORDERED, ADJUDGED, and DECREED that leave-lo receive advance payment relating to the within claims being brought by Carol L. Grain and Monty C. Grein, on behalf of Kimberly M. Grain, a minor, against Terry Schmidt is GRANTED. In light of the refusal of Zurich Insurance Company to waive its rights of subrogation against Terry Schmidt, Petitioners are granted leave to receive advance payment from Zurich Insurance Company, as subrogee of the Petitioners against Terry Schmidt, in the amount of $100,000.00. Zurich Insurance Company is making the ]T BIT "A" F-1 advance payment in accordance with the holding in Daley-Sand v West American Ins Co. 564 A.2d 965, 387 Pa. Super. 630 (1989). Said proceeds to be distributed as follows: Tucker Arensberg, P.C. - Fees $25,000.00 Tucker Arensberg, P.C. - Costs $1,475.34 Carol L. Grain and Monty C. Grain, on behalf of Kimberly M. Grain, a minor (bom 11-26-82) for deposit in an interest bearing account with a federally insured Bank in the State of New Jersey and marked NOT TO BE WITHDRAWN UNTIL MINOR REACHES THE AGE OF MAJORITY (AGE 18) OR BY FURTHER ORDER OF COURT 73 524.66 Nothing in this Order shall be construed as settling, compromising, denying or foreclosing any other claims Petitioners may have, including underinsured motorist claims, against Zurich Insurance Company, Erie Insurance Company, or any other insurer, person or entity. Proofs of deposit to be filed with the Prothonotary within 45 days of receipt of the settlement check from Zurich Insurance Company. _ BY THE COURT: ,r'!:'1>s 23681.1 .'......^:s ~+::vi 6`.•f. i 7_`3?.y i,;ia:3 ?... :; ? ^;t; r: I VA -2- rVib?i:t j D F? ®'M. i?rC^.C•>C:iC'C.G&G _. p`ls'%wr.*.\-r lei': •c7'S?sx???!. ?:.®•-®•'LJa?. O'. ® rY:CrGC-C C-C:C Cam:®'C ?'!GrF'?t?'Y?'S=7'R'?''•€? ®®®3??'?`© ??, ? cc)c-c c-c: c'c.c?,^?•cr.:?c c? c,?-? ®®?1?<s? ,`--'.A?.r.A._.SI.YC;yL.?W.t?•SC. Li}°?4. ?./^V??GJ'?Jt./'J ®:4/.:i . ? ???? ?=CM.E?3 ?!L ['MF-aTrcN?iinE?•;-•?:..?. .• ? ? ' ^ !1 i' , i l . . ! 1 i!' '°?L51r5 :dv'Ct_e...:u= _ I . .. . 4 • y 1 ? ? 1 10e 1 ? r ? .;L310>aL , Fint Union Natlonal Bank R/R02i20002S _.? _. 1:5445052591:1(300002 i 472n. > ? ? ?'.e e c`/?+c`` _cc•?oc c:.?. c.c:?=?-c??°?c`c ???,>c;:t 1? ?/?o ® ® ? ? ? ??V~'`: `.?`' C't.s'+?i ?'ti`?/.'`!'Vf??'?•?.:v?T+? ®' ® ??. LJ~.'? ? v 1 ® ® Q. C, C' C. 1 t O .c .c - L?. -%.' '. .4'.:?i?. y?q.?® ®J••?! 0 Q ( rte" tom...': \,,:' ?, t '•:L;r????: ?? .?.?,• i ?.•?,:'??S' ?;?? ?: `GV ®:0 ) ? "^., o00 o r. C, (7l C...c: `' `, ..,. ?. i= ?- ... rte..-_,= r-.•1j ..p. ?,. r> ....? i l/IiLQ I BIT "B" ?I Rata Disclosura FIRST UNION NATIONAL SANK RIDGEFIELD PRY. OFFICE / RIDGEFIELD PK. NJ Thank you for inquiring about PREMIUM PERSONAL SAVINGS The foll6wing information is current as of JANUARY' 14 , 2000, , 16 : 30 and presents the Interest rate and annual percentage yield for PREMIUM PERSONAL SAVINGS and the balance requirement for the product to earn the disclosed annual percentage yield. Please refer to your Schedule of Fees and Depositors Agreement and Disclosures for further information. Product MrimunBalance Required To Earn Interest Annual Interest Is Type Annual Percentage Yield Rate Percentage Yield Compounded PSAV tj 1.39% 1.40% DAILY 5.1100 2.32% 2.35% 10.000 2.32% 2.35% 25,000 2.66% 2.70% 50,000 3.92% 4.00% Existing CDIIRa Accounts oniyi Amount Tern Account Matures On Renewal Option Interest Is Paid Every Let us help you design'a custom financial package to meet your individual needs. Thank you for making First Union your choice. We look forward to serving you. F -i 537858 (100/pk0) PON'. Customer Access Agreement 1.200-ASK-F"m= am Opening; "" accounts. care, and give Ym the Om arryd aartis phcrm, This AgroomeM any deps 110V and as 4 t, rl into may to strzricted than time to Urns by First aPPrlvatlem epo Nurefaryaaselfa wth golfer *M any First Unlcn Bonk eidwnr crllnn;the account on bdrdr of erlalha persah (far s<g:er. Fk yrayw f, epah on aM1 hus tier YOU Will need to ccmp)efa rozarrie. a it for aca? O sex an. you Open an ave anY4tresekro, Fleasecol a First Unkn Specialist tol-hee at 1a for that ac"& Instructfonr. you aannn asig`ft mm r?wi or in ft its amY First Union Bank ('First L6ticn7 with Which 1 c{xvt aoxix and art trait trrstrhsdtcrs horn ns to do O:e to open dePOgtacWS with First Unk,; I+ • to Irarrsfar all or any Portion d the baber e of my aoccunt, (Inducing aecit f amotIntsk ' service arry Of my Fast Union as mn ? of a..mt 4dam Icon Or other l., to obbn reldedsaNcmdfeed by Frst Uion, As used I deposit prr 4 the term -I -. 'saNCes- and -aacunbf include various aoonatsmadeavalabletOYcu ty Fvs1Unkx% a? ecccx then ft I moons In the title forarryamxzd, suCr aosrart wi5 be "'It Owrsn. Retwor ra to ma - of fry Polls accounts; may be gven by cx6cland any ]cirri accost hddw(s), instrurtae sedan stag also refer to the Jdm I computer terminw, my Give imbtxifore craryorin wdtirg, In person, by re mad, rresse6e , tdaFiam, faalmle, martxxf. Fast Won service- and'aOLU tells rtaciina, or by any Other reasonable s '21VrQ Will the sans aired If such Iroy?y? g wtiUr der rid maain rty deo,fwcW ? e Pvt Fine belae accepting mey, at its ?' repdm my original gS+anne or any Agrearnerst auttbelbr; Fuse Lting and to adng upon any kalructicrs. Your sigaaxa on this TToo?ext nd stop lssymsrt adars.? Union trust ?a a verbal °tarder for ? extension enY tde?,e die forr vaapala Purposes. ind i°ahalm first Ihim to recortf and Monitor, wxhcoTersata .a dtakrprmr gLtalitygr toe accuescY,bpmWearucordd 1 agree to fcno m dh somallypaxd?as First lktlon the authenticity of trutrucllaa which are rat delivered in penman pipm amounts) is one a or Incre of the kkwm ndu u lad rot Ignited tD.the Wm Uaafar of rmiey f a wry d my Persona Idetfgmgah code by ms w a pal Oa ?Qh of Fuse LYiax (1) deiivay of a ersort mtoregan ywNaf a Fast arson f up b be me of my date for r?ma its mad can ?pasa)aaj combined vMh the used nxxxds about ne, on (4) vdce don ctrisin corrbir stall th male shell to any of questions. ? tel a) to of rue eptrne manta(s) n vAildr ffbador be telephone numberis; that thm security ptauadue as to ielePtarie to rn have ?g ma In its ally -agemst unauavized uSUUdICZS. I agree agYm no n Inca of ding ily, of Personal Identification code arNwg Prevent the trautirarsd dlsar8atiM at ary, such code. 189103 t t ,aka hold Fast tkYcn hamrlem fern any loses, damages, suits and knras a result of relylry upon urs?gudi n crag on, p rag dud First Won may that Fust Union has cornpiedwth the applaablesrxvgy?`m r5bte r. a, provided regustsaralag receiptor a First won nile9 end r governing to rtm bY y cistamsasmaybeanwide anahced (ram Urta b trxi.ey twdw k bdO mx6on About Customer. I acknovdedge and agree that any inermflon I have supplied or wlil supply In the future to First Union Is complete and correct. I agree that First Union may obtain and use consumer credit reports about me In conmectlon with any acoounis, Products and services offered by First Union. First Union may also verify my employment salary, assets, debts and references, and anyone mceiving a COPY of this Agreement 6 authorized W Provide First Unlon with such Information. Accaptanco of Toms and Conditions: m A41 an t)I)3lGf 4175?. FORM WB CERTIFlCAT^c OF FOREIGN STATUS (All ownon must algn at separate W6. Nct applicable for U. S. citizens or residents): Under penalties perjury,) forb comfy that torinhumat and dividend payments Ism not tl a U.S. tlmnerrresidenI (or Iam filing fora foreign corporation, partnership reker Omnsactlons Iam an exempt foreign person, estate, or oust), and RIGHT OF SURVIVORSHIP (ONLY NO or TN ACCOUNTS): I understand that by establishing a Joint account under the provisions e.. North Carolina General Statute 53.1461 that 1. Font Union may pay the manoy N the acoount to. or on the order of awl that In the account unless we have agreed with the bank that withdrawals require more than one signature; and belong Upon the death iof one Joint owner th no- e money remaining In the account will the deceased Joint ovme or be control ed by the tie easaira of 100 algid to create the Right o ed Joint awnsa will.h f Survivonihip for artyJolt account (For TN: 100 elect the Right of Survivorshlp for any Joint account 1 establish with First Union now or In the future unless 1 natty Fust Union otherwise, in will provide me with the aPProPdate doaanentation to establish which cose First Union such an account) Signature FORM W9 SOCIAL SECURITY NUMBER OR EMFLCyE-' ICEt1TIFw^A710H RUMEER CERTIFICATION (Not applicable for Non-Resldant Aliens): cmeslsted on the Security Number or t and wit he u sex fcrttar?d„jng purpo should match the gust 1. Social Security Number or Employer Identification Numbers) -=$?_31Znc II. If exempt from backup wiltdlolding and reporting, bopuse you have a cuato lal d d account esrAbedinsecsection h'on4 4under cbcn 473 (b) (7) cra trust exempt from tax undersection 664 or describ947, check this box: III. Certincatian _ Under pnnalgea dperjury, I cettity that ? EXEMPT I- RpnwuL•er sal fm6i abuve is my cor-%t Sochi snuurrly nurnberor employer - idallficotion number (or I an walling for a number to be Issued ro me), and 2 I am not subject to backup withholding because: (a) I front backup withholding, or (b) I have not been nogliod am exempt f by the Internal am Rownuo Service (IRS) that I dm , or h backup widing as a mub of failure to report erg Interest or wdividends, ithhdidendsdlnp. or (e) the IRS has nctfieotified me that I am no longer subject b backup %fi ficallon Instructions -You must arose out itom 2 the IRS that you are currently subject b backup wilhholdlbg above because have ee been nottle by interest at dividends on ur tax return. ? By checking this box I am requesting issuance of a 24 Hour Banking (ATM) Card or CheckCard. reporting A /? Customer Signature 7 1 agree to be bound by the arms and conditions inducing, but Print Name not limited to First Union's OOPOsit Agreement and Disclosures, 10 each or serAc, Unon conas or in thProduct future, which Iomns andl coObtain from ntlitiona will be Provided to me. I also agree to pay all leas associated with such p accounts F schedule edule s unts and servicas In accordance with the lee Addma which will be Provided b me by First Union. Although First UNon req,,,e The, You agree to the Terms and conditions or this agreomenf. No IRS does riot require lour consent ro any provlsicn of this document other then m bom5callcn required to ewidbackup withhdding. /• -2 my ne signature per agreement 1-1 r Date 1ELD Ur :t75.t) LE=05iT S=RVIC.-S COFY -kriHlTc CUSTGIi=R COPY-CANARY t? I? I. ?r 1fl i1 r F71 9-0 -,. Customer Act 1-800-A CM Nanbe ? - I Use Ontr IRenaimd eom CAA) Screen) :ass Agreement r "lo'S E0077a SK-FUNB r FORM WS CERTIFICATE OF FOREIGN STATUS (All owners must sign a upends W-S. Not applicable for U. S. citizens or residents): Under penardes of perjury. l tartly Mat for Interest and dividend payments l am not a U.S. cigzen or resident (orI am fling fora foreign corporation, partaershlp, estate, or trust), and for broker transaction 1 am an exempt foreign porter. SppnaNre of axanpt foreign paean pennmemseow, addmw Waxing apaonemar suit Mercer Of pdrtnryta reeasncer (P.O. Sax not Mowed) City. pmw;ce. rascal Coda and Country ofp,Imery m militaries - Ttds Agaemerd Is designed to dlmirata mod 9 bears rart signature cards old when opening future amuds. Your sig hunk on ids Ag erne t will give you the m)vaderce d baNnB aryv4•ae and arydna owruna phcre. This Ageemant boo row and ss K may be amended from tine to vim by First Unilcrn, is applicable to arty deposit ecccurt that you open with arty First Uniah Bark either newa In to hna eraa on LArdaa an behalf if of anrwMeywith parson for amp#o I yen you W open an Howe aam or, u open an ea npix a an re Pgm ernrad for tlrrt as oc aL 11 year Tatar, baat'e), you will need to s r K FUt ff NB. have any gtxstlorul peace Ma a First Union on Specialist aldist 'W tc4hee at 14l00- 0.ASK491NIL kw uctfa BY s!gr ft this Ageerart, I aWlatze any Fast Union Bank rRrst Undo) with whch I open an account now a in the futures to accept end ad upr ktsaudlas ham me to do the fallowing: . to open deposit amix with Fill Union; • to transfer all a any pardon of to balance d my edzwda ordudig aedt eam+t+); • to dose deposit accounts, process changes Of amount Intandloh a Otherwise seMm aryd ay First Urdon amnt; • to obtain rdated s"vime dived by First U*m As used in this Agevmd, to tarns •pcatts•. "WAOoe• ad'a=xW kduee vadoee depose products, services and acccx node avallable layout ty First Unless Hmae t)an she person Ismirad in is tlge fa arty aaaad. such vzaaewth to arsvdaed ajokt accaxad. Instruction; Wrich affect arty of myjcm amounts maybe liven by ayldnt egmat o w ew. References to " In this Iravuyians section shag also enter to the jdrt sauathoide . I may give Instructions ant in willing, N person, by nag, massager, teleoxne, fambnge, mapuvx terminal, wire service. automated teller marline, a by any cttW reasonable molod. First Undo) may accept and act tom such Instructions which do not certain try slgrdae with the sans dfecr as if erdn Inductions wens signed by nA However. I acknowledge that First Union may, at b option, m gadre my, original dgarture or arty Ot err doamasadon betas axapti g and acting eq xr any Instructions. Your signsium an this Agreement aWlorba9 Fist Union to honor verbal stop paynad orders up to six (6) months, To extend stop payment calm First Union must receive a verbal order for such extercim bias the a xpiregon of this six ninch Faded. 1 aaxrize Post Indian to mmrd and monitor any taiephaa calls (evades p rpmev, Including to erase axxracy, to Provide a maid of such conversations and to kaomve to quality dse vim to ma. I agree to fellow such security paedums as First Union may mc;Um The security procedure opesed upon farwaifyig the aNarntldy, d Insotctars which are net ddhttod N person by mar fa any purposes oaiudng, but not Printed to to who transfer of momy from any of m( armatures) Is one or more of tine following at this option of First Wan: (1) denvey of a penaal Idedlhcalim ax's by nor a a person pupating to be me. (2) a caglaUC (3) a mdWm by nor a a prim purporting to be ra of oe, a roe Haas Of nhyr pascal Information which First Union has in is records abut rte, or (4) maim recognition of me combined Win the area of Certain preU g questions. The telephone renter(s) to which setbacks shat be made shall be any telephone mater(s) First Union may have fa nor In its renrda or ary telephone number assigned to Res by a telephaa service provider. I ogee that the asmwity procedure ar6ihtras a cannel lly reason>a. a red Sd of pm4dng seamy against unauthorized lnstructiom i agree to rreirdain the ardrdentldiy of any personal ide nbli atonc de and wN pehad to uacxModmd rfisaniretlondsuch rota. 1 agree to Indemnify and hid First UNan harmess from any lasses. damages, suits and exposes. Of whatever kind. Including arty reasonable altortaye fee, that Fast Unfor1 may Iran are a reset of relying upon Irsbudlons from nor, or anyo no Purporting to be me, provided that Fist Union has compiled with the applicable security prOm6umirs. I acknowledge race p: of to First Union Nes and nag lad" gwembg matey tmrufer mt}rasts and agree to to bard by itstenses maybe amended from Wes to tree ' Information About Customer. I acknowledge and agree that any Inforil I have supplied or will supply in the future to First Union is complete and correct. I agree that First Union may obtain and use consumer aeeit reports about me in connection with any accounts, products and services offered by First Union. Firs Union may aso wily my employment. salary, assets, debts and references, and anyone receiving a mpy of this Agreement Is authorized to provWe First Union with such Information. Acceptance, of Terns and Conditions: I agree to be bound by the terns and conditions Including, but not limited to First Union's Deposit Agreement and Dsclmums, applicable to each product or service which I obtain rmm First Union now or in the future, which terns and conditions will be pmvlded to me. I also agree to pay all fees associated with such products, accounts and services In accordance with the fee schedules which wig be provided to me by First Union. RIGHT OF SURVIVORSHIP (ONLY NC or TNACCOUNTS): I understand that by establishing a joint account under the previsions of North Carolina General Statute 33-146.7 that Tonnossw law that 1. First Unlon may pay the money In the account to, or on the order of. any person named in the account unless we hove agreed with the bank that withdrawals mature more than one signature; and 2. Upon the death of one joint owner the money remaining In the account will belong to the surviving joint owners and will not pass by inheritance to the hairs of the deceased joint ownoror be controlled by the diseased joint ownerss will. 100 elect to create the Right of Survlvcmhip for any joint account (For TN: 1 00 elect the Right of Survtrorship for any joint account 1 establish with First Union now or In the future unless I nogg First Union otherwise, In which case First Union will provide me with the apprepriate documentation to establish such an account) Signature FCRM VI9 SOCIAL SECURITY NUMBER OR EMPLOYER IDENTIFICATION NUMBER CERTIFICATION (Net applicable for Non•Residant Aliens): (The Social Secudy Number or Employer Identification Number should match the lint nano fisted on the account and will be used for lax reporting purposes.) 1. Social Security Number or Employer ldentltcatlon Number t Sccc?:T It. If exempt from backup withholding and reporting, bemuse you have a custodial account under section 403 (b) (7) or a trust exempt from tax under section 664 or described In section 4947, check this box: Q EXEMPT III. Certification- Under penaltes of perjury, l cartiy that 1. The numb" set forth above is my correct social seedy number or employer Idenghmgon number (or I am waiting for a number to be Issued to me), and I an dict cubicct to bec!nrp withholding bwause7 (n) I Rm epnmpt from hernup . withholding, or (b) I have not been roiled by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all Interest or dividends. or (c) the IRS has notified me that I am no longer subject to backup withholding. Certification Instructions -You must cross out Item 2. above If you have been rouged by the IRS that you are currently subject to backup withholding bemuse of under reporting ? By checking this box I am requesting Issuance of a 24 Hour Banking (ATM) Card or CheckCard. `????,t?,• r (only one signature par agreement) bate Curio far tlgnatun Print Nine F'T-air j -L-! _,y Addicts Although First Union mqulms that you agree to the forms and conditions of this agreement the IRS does rat mqulne your consent to any prevision of this document other than . . the cardOcation mqulmd to amid backup wllhholding. CEFOSiT S'cRVICES Cd'r'(-VJHITc CUSTOMER COPY-CANARY :000171999(5"pep Rev OS) If c=: rcCSd TC.9 r3quired (Tax ICA` i:hro!d cods changes oniy), send to Interest Reporting fIC-C:67 FO N ADO FON 1-800-A TNs Agreenrod is designed to etMnae most subsegoed Sigrabae cards and aNcrimtlas Oxen Waring Mae accam Your signaus on this Agrearad YA ghe You the mwsxiaxs or banking anyeha s and anytime Over the Ftx re TNS ppemea. both box ad as R may be amended from dons to dma by First Uncn, Is M*Odg toaydepiait amsad tat you open With any First urarn Eak either now a in d* ktm Wyw-dfajdntiyWthwcdwper=mmtwimdsigrw. H0wM -;fyatopenba aazlrt on behalf Of amber Pens^ (fa example, if you open an eooud as astcdon, ga dfim mates), you will now to con plete a separate Agnotract for the amrad. If you have arty gmstkns, please dl a First Union Specialist toll-(read 14100-MK-FUNIL bebucdons: By aging this Agmefrad, I a thalm any First Udrn Banit Mist UrdcrO with which I Open an saxsad now or in the future to accept and ad UPon kxh dlas from are m do 0x foil AIrg • mopes deposit aaaaAswith First UnIorn to bender all a any portion of the balance of my soxhmb Ndu&g credit accounts); • to dose deposit acoab process changes d 8u9vd Wom' ion a OdwWas service ary rimy First Union amadC • oadain related aavk%cfferedby FustUnkn. As used In the AgreaneR the omre'peOdrde'.'servkes' ad •amx-!s' hdudo vadwa deposit piad^ services and =Dzb made a5ateble bayou by First.U o tnm than one person is nand in the We for any 309:ad, such amaadwit be considered elandecocut. hsbrctlerswhinaffedanydrtyjdm==Lwbnaybegivenbyartyjdd a®ut as,,. References to ma in the Irsmcdons section shat also refer to the laid 9=st hdder(s). i may give Verbuctian aalya In whin In pas% by mall, mess-den Wept-*- faosimte. mrIxnar terminal. Was servlte, automated later madam, or by ary dhef masasde meUad First UNon they axapt and ad upon such 0strudlas which do Ixt contain my dgrehae wish the care effed as If such IretrhACtlas were sigsd by me. Ha vever, I akrcMecige that First tkdco may. at its coo require o rOl 1erag?gre6ae any this Oil" dmnerdatlan befor e me pling end adbg upon ay Instruclions, Fgemrud aulralms First Union to haw verbal stop payraad atlas UP to six (6) minds. To extend snap paymat odors, First U Non must recave a verbal order for such extension before tie expiration of ids six nardh period 1 anhodm First Urim o rend and m mior k? the bdu ofSWAM to eamaacy,mpmAbuareaxdd quality such h and to me, I ages m follow such aeerdy peaches as First Union may require. TIM security procedure agreed upon far verifying the aug mlouy of ircmctione which are bat ddNamd in person by me for ay papose (fncudrg, but not tiirrited to, the wins Carew of maxi from ay d my eaaats) Is one a once Of is fck ing at the option of First Lydac (1) delivery of a pasmel ka yt &m code by m a a pass PuPc dng b be rte, M a atbaX, (3) a radiation by me or a person Purporting to be me of one or more Items of my paeans frionat a vddch First Udon has in itsrecords about ma. or (4) wios recogddm d me oartined ankh the'use of certain Aching questl s The telePlom mfter(sj to wh9c allhads shat be made shall be any taephone nurta(a) First Ukdon may have fa r s In Its reads or any taeplws ante assigred to R8 by a teleptws service provide. I age that T. wart)' Procedure ccraatAce a oarmerdaty rye netiod d peovidim saoxity d on r k6'fiost will Ate entti:e uwoA-®d,rLssertdmtmm Of such ode. t agree to indemnify and hdtl I= Una, harmless it- any losses, damages, sib as ems, of whatever HRt indudrg any neascr'-de stomeys' rasa that First Ukiah ma k" m a msdt d raying upon Irsbuolo a from rre. valyors pupctti g to be rte, provide trodFssttkda has cxnpied Wth the applicade seaaity pncoedu ss. I admowledge receipt of is First Urdm hies and regulations 97-10rdrg Roar made aruersb ad ogee to be laud try is term as may bo amended frantims to tea f ftmation About Customer. I acknowledge and agree that any Information 1 have suppled or will supply In the future to First Union Is complete and correct I agree that First Union may obtain and use consumer credit reports about me In connection with any accounts, products and services offered by First Union. First Union may also verify my employment, salary, assets, debts and references, and anyone receiving a copy of this Agreement Is authorized to provide First Union with such Information. Attwpbmce of Tama and Conditions: I agree to be bound by the terns and conditions Including, but not limited to First Union's Deposit Agreement and Disclosures, applicable to each product or service which 1 obtain from First Union naw or In the future, which tams and conditions will be provided to me. I also agree to pay all fees associated with such products, accounts and services In accordance with the fee schedules which will be provided to me by First Union. "' 'l lto OnN la.,,ue.n M1..... nsel4re,m1 ass Agreement 44 *531200744 5K•FU48 FORM W8 CERTIFICATE OF FOREIGN STATUS (All Oman must sign a sepaate W41. Not appllable for U. S. citizens or residents): ' - Under penalties of perjury, I carby that rot Interest and dividend payments I am not a U.S. citizen or resident (or I am filing for a foreign corporation, partnership, estate, or trust), and for broker transactions 1 am an exempt foreign person. Slpature amemp faslpn person Pq am steel trams Includnp epeanald or suae aanoa at primary tax addaxe (P.O. bas rid aeawed) City, prwii S postal code and am" of primary lexaslderce RIGHT OF SURVIVORSHIP (ONLY NO or TN ACCOUNTS): one signature; and 2. Upon the death of one joint owner the money remaining In the account will belong to the surviving joint owners and will not pass by Inheritance to the halre of the deceased joint owner or be controlled by the deceased joint overroes will. I DO eked to crate the Right of Survivorship for any joint account. (For TN: 1 DO elect the Right of Sundvorship fa any joint account I establish with First Union now or in the future unless I notify First Union otherwise, in which rase First Union will provide me with the appropriate documentation to establish such an account.) Signature FORM V19 SOCIAL SECURITY NUMBER OR EMPLOYER IDENTIFICATION NUMBER CERTIFICATION (Not applicable for Non-Rosidert Aliens): (The Social Secudry Number or Employer Idendfiaaan Number should match the tint name 0.ned an the account and will be used for tax reporting purposes.) 1. Social Security Number or Employer Identification Number. If exempt from backup withholding and reporting, because you have a custodial account under section 403 (b) (n ora test exempt from tax under section IXEMPT described In section 4947, check this box: Codification - Under penalties of perjury. I cerdfy that 1. The number set forth above is my correct social security numbor or employer Identification number (or I am waiting for a number to be Issued to me), and 2. ! am not subject to backup withholdirg hemusa: (a)1 am exempt rmm backup -withholding, or (b) I have not been mtfied by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding. rtification Instructions -You must class out item 2. above if you have been notified by r IRS that You are errantry subject to backup withholding because of under reporting ? By checking this box I am mquesting Issuance of a 24 Hour Banking (ATM) cam or cnmumn. Cusamsr39mlun (On or agreement) Date Pdnt Name _ Ti•,.->-T?! ?r ':a=;' NJ Addass Aahough First Union requires that you 89100 to the farms and conditions of this agreement, the IRS does not require your consent to any pmvlslon of this document other than ' - the tehKabon required to amid backup withholding. OEPOSIT SERVICES CCPY-',VHITE CUSTC\IER COPY-CANARY 300537995 t5aplq Rev 05) If corrected 1099 requi;ed (Tax IOr4Vithhoid code charges only), send to Interest Reporting NC-0457 01 : 14: 21140 i4 I . 03/23/00 R EMFE ERIE INSURANCE GROUP F A X T R A N S M I T T A L DATE:-z3 oa TO: Namur oohPr &Allion!' . Organization FAXNumber FROM: Name 90AJ Erie Insurance Group?-Warrendale Branch Phone: (724) 772- (Station Number) We are transmitting a page document including this cover sheet from our facsimile machine. The telephone number of our machine is (724) 772-7700. COMMENTS: Warrendale Branch Office - 301 Corn y. EXHIBIT . Warrendale. PA 15086-0516 (724) 776 Q - 824 hit GF-3nm 2M E RECEIVED TIME MRR.23. 4r 11 ME MRR.23. 4r12PM IQ 001 03/23/00 THU 15:57 FAX 724 772 7700 1, -Tm 10002 W, ToChristo her w Cahillane Esquire From. Ron Eck ;; Ascm EPURe Diary Date: Su6Jech_...__Kimber] ry-Grein -....... Date: _.._3-23x00•.,_ ,, ,•,_„•„_._._. Dear Mr.....Cahillane.._._-^- -. _...__..___. _ _.... _..._.----_._._.._....._.._ _.... _.. _.._ -- ..._ ._ ._ .._ .._ ._ ..._ ..... . ... Enclosed-is. the gno_te for th, eo oao- D0..pr.emium_f,= -f:Lve-years-and-payout--of---- -$12,.1t5_.00..cash.lump-sum_payment. Also_.a_.lump_sum-of-40,000-00-cash-.upon signature •Of -••• -the xalease and court approval, making-the tokal_oEYer-._c -Kimber-ly..Zr-eln. for-the U!M. _... $100,000.00. -- Please To: + Sign / Date: Signed: odginalor rmmin pink copy: send white & yellow copies Intact RECEIVED TIME MRR.23. 4:11PM IMPORTANT-RETURN WHITE COPY WflH REPLY. PRINT TIME MAR. 23. 4:12PM EIG-6216 •03/23/00 THU 15:58 FAX 724 772 7700 03/23/00 THU 14:35 FAX 614 870 3285 ERIE FAMILY LIFE »»» 11AFIWDALE 004 ERIE FAMILY LIFE INSURANCE COMPANY Page 1 100 ERIE INSURANCE PLACE BRIE, PA 16530 Benefit Cost Summary for KIMBERLY GREIN Quote Id : 010-15-0252317-01 Rate Series : SSLT14 Settlement Date : 05/15/2000 First Payment Date: OS/15/2005 Quote Date : 03/23/2000 Guaranteed for 30 Days State PA State Premium'Tax 0.00 Tax Sex Female Age 17 Date of Birth 1112611982 Rated Ago 17 Lump Sums --- Payment Date Age - -------------- --^- Amount - ------------ --^- Premium ----------- -------------- Guaranteed 05/15/2005 22 $12,915 $10,000 Sub-Total for ---- KIMBERLY GREIN....... ----------- $10,000 Guaranteed Payout : $12,915 Expected Payout TOTAL COST ..................... $12,915 $10,000 * This quote is valid for 30 days from the quote date-and is subject to review for accuracy by the Company. This quote assumes the premium required to provide the benefits indicated will be received by the company on or before the settlement date. If the premium is received after the settlement date, the premium required may change. RECEIVED TIME MAR. 23. 4:11P11 PRINT TIME MRR.23. r. 4:12PM Maryland Cawally Company Telephone 11.0. Ilnx 14011 712777•SRN8 New nnmxalck. NJ IIN7116, 401.1 Maryland Casualty Company Serviced by Material Damage Adjustment New Jersey March 22, 2000 Christopher W. Cahilhlne TUCKER ARENSBERG, P.C. 1500 One PPG Place Pittsburgh, PA 15222 RE: INSURED: CLAIM fl: DOL: YOUR CLIENT: Dear Mr. Cahillanc: Monty & Carol Grcin 68131229,1503 08/16/1997 Kimberly Grcin, an infant This letter will confirm our telephone conversation of this date regarding the above captioned client. Authorization is herewith extended to you to accept the 5100,000.00 Erie Insurance Policy. Kindly forward a copy of the release/closing papers to my attention. At your earliest convenience, kindly forward the additional medical records as we discussed. Upon receipt of same, I will submit this case for settlement authority. Please do not hesitate to contact ale should you have any questions. Very alty Examiner 5604 ;1. ?',: i 'I ';? F VERIFICATION OF COUNSEL I, Gary P. Hunt, Esquire, as counsel for the Plaintiffs/Petitioners in the above-captioned action hereby verify that I have investigated the automobile accident of August 16, 1997, on State Route 31 in Somerset Township, Somerset County, Pennsylvania in which Kimberly M. Grein was injured, and that for the reasons set forth in the foregoing Petition, the payment of the policy limits in the amount of $100,000.00 is reasonable under the circumstances based on the injuries sustained by the minor-plaintiff, the availability of insurance coverage from the tortfeasor, her medical treatment, the prognosis for complete recovery, and the questions of liability in this matter. 189022.1:1i1 C i STATE OF NEW JERSEY COUNTY OF BERGEN SS: Before me, the undersigned authority, personally appeared Carol L. Grain and Monty C. Grein, who, being duly sworn according to law, depose and say that:: 1. They have read the attached Petition for Leave to Settle Underinsurance Claim for their minor child and that they are in agreement with same; and 2. The facts contained in the foregoing Petition are true and correct to the best of their knowledge, information and belief. Notary for Carol L. Grain Sworn to and subscribed before me this (j day of 2000. em Nota ublic MICELE A. WEISS NOTARY PUBLIC OF NEW JERSEY MY Commission Explres Mav 0. 200^ Notary for Monty C. Grein Sworn to and subscrib before me this fz day of/. 2000. Notary Pu is MICHELE A. WEISS NOTARY PUBLIC OF NEW JERSEY My Commission Expires May 5, 2002 Carol L. Grain Illy Monty C. G Win ?? ; ?: ?: ; : _ ::: : ; -._ _._ :. ?? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to KIMBERLY M. GREIN, a minor 2000, upon consideration of AND NOW, to-wit, this inor's Account, it is hereby the foregoing Petition for Leave to Withdraw ORDERED, ADJUDGED, and DECREED that said Petition is GRANTED. Petitioners, Monty C. and Carol L. Grain, the parents and natural guardians of Kimberly M. Grain, are hereby granted leave to withdraw the sum of $3,564.00 from the minor's account currently held by First Union National Bank for the sole and express purpose of purchasing computer equipment and related accessories and services for the use of Kimberly Grain. BY THE COURT: J. 192393.1:11t y-?L-oo RKS No. 99-7246 Civil Term ORDER day of unds From M :: ?__ ? :? -> _• ?> -.t.,.i ??ti"r.9 . ',r.,._._. i IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to ) No. 99-7246 Civil Term KIMBERLY M. GREIN, a minor ) PETITION FOR LEAVE TO WITHDRAW FUNDS FROM MINOR'S ACCOUNT AND NOW, comes Plaintiff, Kimberly M. Grein, a minor, by Carol L. Grain and Monty C. Grein, her guardians, by and through their attorneys, Tucker Arensberg, P.C., and file the within Petition for Leave to Withdraw Funds From Minor's Account, stating as follows: 1. Petitioners, Carol L. Grein and Monty C. Grein are the parents of minor-plaintiff Kimberly M. Grein ("Kimberly") in the above-captioned action, and currently reside at 144 Overpeck Avenue, Ridgefield Park, New Jersey. Kimberly is currently 17 years old with a date of birth of November 26, 1982. 2. On or about August 16, 1997, Kimberly was seriously injured in an automobile accident on State Route 31 in Somerset Township, Somerset County, Pennsylvania, when the vehicle in which she was riding was struck by a vehicle driven by Terry Schmidt ("Schmidt"). 3. A prior Petition was presented to this Court setting forth all of the material facts relating to Kimberly's claims, and which sought approval of an advance payment of $100,000.00 from Maryland Casualty/Zurich Insurance Company ("Zurich"). An Order approving the advance payment from Maryland Casualty Company was signed by The Honorable George E. Hoffer on December 3, 1999. (A true and correct copy of said Order is attached hereto as Exhibit "A" and incorporated herein by reference). A Proof of Deposit of the proceeds from the advance payment was filed with the Court on January 31, 2000. (A true and correct copy of said Proof of Deposit is attached hereto as Exhibit "B" and incorporated herein by reference). 4. Kimberly is currently a junior in high school and is applying to numerous colleges for admission beginning in the Fall 2001 college term. 5. Petitioners, Kimberly's parents, believe that her search for an appropriate college program would be aided by the purchase of a computer and related equipment. In addition, Petitioners believe that Kimberly will need a computer and related equipment for use during college. 6. Petitioners believe that the cost for an appropriate computer system for Kimberly will amount to approximately the following: a. Computer system, monitor, software........ $2,474.00 b. Scanner ................................................$200.00 C. Printer ..................................................$150.00 d. Internet Access (1 year) ...........................$250.00 e. Miscellaneous accessories .......................$500.00 See Computer Pricing Sheet, attached hereto as Exhibit "C" and incorporated herein by reference. -2- 7. Petitioners believe that the above-listed expenses are reasonable and necessary, and are in the best interests of their minor child. See Affidavit and Carol and Monty Grein, attached hereto as Exhibit "D" and incorporated herein by reference. 8. No previous withdrawals have been made from the account since the settlement proceeds were deposited. WHEREFORE, Kimberly M. Grein, Petitioners, Carol L. Grein and Monty C. Grein, guardians, by and through their attorneys, Tucker Arensberg, P.C., respectfully request that this Honorable Court grant their Petition for Leave to Withdraw Funds From Minor's Account. Respectfully submitted, .C. 192393.1:1it ary P. Hu , squire Lee C. Sw rtz, Esquire 111 North Front Street P. O. Box 889 Harrisburg PA 17108-0889 (717) 234-4121 Attorneys for Plaintiffs i A I ?. I r I I i, i i F,. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to ) No. 94 - 7.2 P,;I;v Tc KIMBERLY M. GREIN, a minor ) KIMBERLY M. GREIN, a minor, by CAROL L. ) CIVIL DIVISION i GREIN and MONTY C. GREIN, her guardians, ) CLIFFORD GREIN and AUDREY GREIN, ) 0 o Plaintiffs, No. 99-390 V. H TERRYSCHMIDT, ) ??, 'FCC r' Defendant. ) = ORDER AND NOW, to-wit, this 3 ?'-tkday of 1999, upon consideration of i? the foregoing Petition for Leave to Receive Advance Payment in Minor's Claim, it is hereby ORDERED, ADJUDGED, and DECREED that leave to receive advance payment relating to the within claims being brought by Carol L. Grain and Monty C. Grein, on behalf of Kimberly M. 1 Grain, a minor, against Terry Schmidt is GRANTED. In light of the refusal of Zurich Insurance j Company to waive its rights of subrogation against Terry Schmidt, Petitioners are granted leave to receive advance payment from Zurich Insurance Company, as subrogee of the Petitioners against Terry Schmidt, in the amount of $100,000.00. Zurich Insurance Company is making the ?.`.` 1 -1 advance payment in accordance with the holding in Daley-Sand v. West American Ins. Co., 564 A.2d 965, 387 Pa. Super. 630 (1989). Said proceeds to be distributed as follows: Tucker Arensberg, P.C. - Fees $25,000.00 Tucker Arensberg, P.C.- Costs $1,475.34 Carol L. Grein and Monty C. Grein, on behalf of Kimberly M. Grein, a minor (bom 11-26-82) for deposit in an interest bearing account with a federally insured Bank in the State of New Jersey and marked NOT TO BE WITHDRAWN UNTIL MINOR REACHES THE AGE OF MAJORITY (AGE 16) OR BY FURTHER ORDER OF COURT $73,524.66 Nothing in this Order shall be construed as settling, compromising, denying or foreclosing any other claims Petitioners may have, including underinsured motorist claims, against Zurich Insurance Company, Erie Insurance Company, or any other insurer, person or entity. Proofs of deposit to be filed with the Prothonotary within 45 days of receipt of the settlement check from Zurich Insurance Company. BY THE COURT: f- . /Vfe;L1i. . . V ^ 23687.1 G? 1. TRUE C40 Y F o 9 R C:Gos %1.•} 1 t 1 ?$ {J,4:11:v?: i J ,\?} ?l n i rr•t, i ? ::rx ?:; '-: e-' ;; ? ? ?ti This 3 <+ry .,'1S?CUK • i Lq? _. Fro:licru?`,?9 -2- _ f??? ?' i i? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to KIMBERLY M. GREIN, a minor KIMBERLY M. GREIN, a minor, by CAROL L. ) GREIN and MONTY C. GREIN, her guardians, ) CLIFFORD GREIN and AUDREY GREIN, ) ) Plaintiffs, ) V. ) TERRY SCHMIDT, ) ) ) Defendant. ) TO THE PROTHONOTARY OF CUMBERLAND COUNTY: PROOF OF DEPOSIT No. 99-7246 Civil Term No. 99-390 0 %t ^l r The undersigned counsel hereby certifies that the advance payment proceeds in the amount of $73,524.66 in the above-referenced matters have been deposited into an interest bearing account pursuant to the terms of the Order of Court dated December 3, 1999, a true and correct copy of which is attached hereto as Exhibit "A". Copies of deposit slip, rate disclosures, customer access agreements, and account details and registrations are attached hereto as Exhibit "B". P. Hunt, Esquire #her W. Cahillane, Esquire 166752.1 ait 1500 One PPG Place Pittsburgh, PA 15222 (412) 566-1212 Attorneys for Plaintiffs IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to 9" 7z yG' KIMBERLY M. GREIN, a minor ) No. 2 ) KIMBERLY M. GREIN, a minor, by CAROL L. ) GREIN and MONTY C. GREIN, her guardians, ) CLIFFORD GREIN and AUDREY GREIN, ) Plaintiffs, ) ) V. j TERRY SCHMIDT, ) Defendant. ) ORDER CIVIL DIVISION No. 99-390 -? o Z y L l C 1J? SC. ?c7 ',l v . AND NOW, to-wit, this 1:; day of y -911.1-- --, 1999, upon consideration of the foregoing Petition for Leave to Receive Advance Payment in Minor's Claim, it is hereby ORDERED, ADJUDGED, and DECREED that leave tb receive advance payment relating to the within claims being brought by Carol L. Grain and Monty C. Grain, on behalf of Kimberly M. Grain, a minor, against Terry Schmidt is GRANTED. In light of the refusal of Zurich Insurance Company to waive its rights of subrogation against Terry Schmidt, Petitioners are granted leave to receive advance payment from Zurich Insurance Company, as subrogee of the Petitioners against Terry Schmidt, in the amount of $100,000.00. Zurich Insurance Company is making the E UBIT "A" advance payment in accordance with the holding in Daley-Sand v. West American Ins. Co., 564 A.2d 965, 387 Pa. Super. 630 (1989). Said proceeds to be distributed as follows: Tucker Arensberg, P.C. -Fees $25,000.00 Tucker Arensberg, P.C. - Costs $1,475.34 Carol L. Grain and Monty C. Grain, on behalf of Kimberly M. Grein, a minor (born 11-26-82) for deposit in an interest bearing account with a federally insured Bank in the State of New Jersey and marked NOT TO BE WITHDRAWN UNTIL MINOR REACHES THE AGE OF MAJORITY (AGE 18) OR BY FURTHER ORDER OF COURT $73.524.66 Nothing in this Order shall be construed as settling, compromising, denying or foreclosing any other claims Petitioners may have, including underinsured motorist claims, 'against Zurich Insurance Company, Erie Insurance Company, or any other insurer, person or entity. Proofs of deposit to be filed with the Prothonotary within 45 days of receipt of the settlement check frorrrZurich Insurance Company, BY THE COURT: r ? l> Ff 23681.1 1:7 :-- '?I/:??': •?I ?:+:Y'YI tJ. • i ! i?•M GI •t:7 ?Y.:S:`? ! •'?. f • l!? yY;,W i r- ? u s, N: vi:;?.•TJ. Y/•?n/? = ? .Q 77a Cs{J ' -2- f?:"•` ?.?F.'?S.:GL?yO,i_icM?AFE'Y.i?:?w. : ' J? ? / 1' :! J e k51.5:.JV R.. LE-:?:: 5 o N Rmt Union National Bank Ul ?•;, ji •i`?% pR 017100025 ?.. I:5?, 7.50.5 2 5916 0000 2 i aLa ioTAL I ss casx I i. ? !? c TOTAL J 84.7 2ua :. j ? 40 4".e e e.e: cc,c c c:. ?0eCCC000 Qm? u o` V ViU1. E MBIT „B„ Rate Disclosura !tl0 FIRST UNION NATIONAL BANK RIDGEFIELD FRY, OFFICE / RIDGEFIELD PK' NJ Thank you for Inquiring about PREMIUM PERSONAL SAVINGS The foll6Wing Information is current as of JANUARY-14, 2000. 16:30 the interest rate and annual percentage yield for PREMIUM PERSDNAL SAVINGS and presents and the balance requirement for the product to earn the disclosed annual percentage yield. Please refer to your Schedule of Fees and Depositor's Agreement and Disclosures for further Information. Product IVIrIm rn L'alance Required To Earn Type Annual Percentage Yield F'SA.V C. 10.000 25.000 SO.000 Interest Rate 1.39% 2.32% 2132% 2.66:: 3.?2% Annual Percentage Yield 1.40% 2.35% 2.35% 2.70% 4.00% Interest Is Compounded DAILY _ Exi :Ing CDIIRA'Aeeounts only:.. .. Amount Tenn Interest Is Paid Every Account Matures on Renewal Option Let us help you design'a custom financial package to meet your individual needs. Thank you for making First Union your choice. We look forward to serving you. r $37358(100/pkin ONO Customer Ac, 1-800•P -ass Agrasment J4c by m ""al n 3:"-' I m ?AI 00752. ,SX•FllPlB . FORM WO CERTIFICATE OF FOREIGN STATUS (All amen must sign a separate Wa. Not applicable for U. S. [plans at residents): Under penaltlea of perjury, I cedty that for Interest and dividend payments 1 an not a U.S. damn or resident (a I am filing for a fomlgn corpomdon, parafership, "rare, a bust). and fa broker transactions I am an exempt foreign person. Biraaandmmmptfeegn perm permanent weet address Ntlurring apartment arsues number of R;;-V; tax r"Wence (P.O. Beer not blond) . Cry, powi ce, pasta coda and courayd Phnrytie neddence What is your country of cltJ enship? RIGHT OF SURVIVORSHIP (ONLY NO or TN ACCOUNTS): I understand that by establishing a joint account under the provisions ob North Carolina General Stature 33.1411.1 that Tennessee law that 1. First Union may pay the money N the account to, or on the order of, any person named N the account unless we have agreed with the bank that withdrawals require more than one signature: and 2 Upon the death of one joint owner the money remaining In the account will belong to the surviving joint owners and will not pass by inheritance to the halm of the docaasod joint owner or be controlled by the decreased joint owners will. 100 elect to [Hate the Right of Survlwnhip for any joint account (For TN: 1 00 elect the Right of Sun ership for any pint account 1 establish with First Union new or N the future unless I nogg First Union otherwise, In which case First Union will provide me with the appropriate documentation to establish such an account) Signature FORM W9 SCCIAL SECURITY NUMBER OR EMPLOYER 10MI IMCATI04 NU7,15ER CERTIFCATION (Not applicable for Non-Resident Aliars): (The Serial Security Number or Employer Identification Number should match the first name Wed on the account and will be wed for tax reporting purposes.) 1. Social Security Number or Employer Identification Number. "pt? If. If exempt from backup withholding and reporting, because you have a ousredlal account under section 403 (b) (7) era bust exempt from tax under section 664 or descibed In section 4947, check this brat QEXEMPT III. Certigcatlon- Under penalties of perjury, I certify that -',l.Tilanumber setfonh aboveis my correct, social socially number or employer, • identification number (or I am waiting for a number to be Issued to me), and 2. 1 son not subject re backup wlNhokfug because: (a) i am exempt from backup withholding, a (b) I have not been nagfied by the Internal Revenue Service (IRS) that 1 am subject to backup withholding as a result of fallum to report all Interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding. Certification Instructions -You must cross out item 2. above if you have been nogged by the IRS that you are currently subject to backup withholding because of under reporting interest or dividends an your tax return. 7hs Areatard Is de vied to dMir o s most sued sigincturis cards and vim opening Ran mums. Your slgnIDaa on this Agreement Will 91,va you se oomerierice of baNdrg anywhere, ad anytirte over go {tone. This Agrearent both now and as lt nay be amended from 9rrx to it= by First UnkR Is applicable to any deposit aawd Mdyw open with any Fast Uden Bade either now, or In to Afire fayarselfajcrNyWNax7er Few cx•aIDZrimdsigmer. 1-1cweveg1yohepmah account on bared of and a perm (for caurnple, C you open an otaxri a aatcda4 guardler; trrafee), you will need to oarpete a sepaaI Agreement for that ac out If you have arry¢ostlas, please cell a First Union Speda9m k$4= at 1.3994314FUNIL Instructions.. Airing liltAgreement. I autlzrtas any Fist Won Bads ('First U ikxO vft which 1 open an 1300Clt Irm or In the futures to accept and ad Lq= Instructions from me to do to klk*g • boopen deposit accaatswitir First Union; • to transfer all a eny potion of the balance of rrry acmes (indu'wg neat eonads% • to dose depait actuate, process cl. of aaxxart Wcrt ision or aBmwtm service anyd my First Uniar a?srLS • toobainmUWsavl=dWodby First UrJar. As used In this Agreement, the terms •Pnxk:cW, -services' and -acccnads• include varies deposit produce, services and accounts nude availablereyou by First Unim lfer charerepermsnandhviagdsfaartyacart suchamntwillbe apex accord Irsndos which affect any of rry)dat exam nay berghee by ayjdnt BRVtrd crener. References to me In Cis instructions sediah stroll also refer to the pblt Warrant licidoi(s). I m rypvalrstridors a-any a in writing, in pxson, by real, mersse ricer. teleptxra, facimie, cceplter tarrirW, wire service, aArnetud teller nadirs, a by any chair reascrade megrod. First Union may accept an act upon such Ir-4zudlcrs wtuch den net contain try atgabae with Ce safe effect as If such irstrudam wane signed by ere. Fkwevec. I ad nicWri fie gat Fast Ulm may, at its opf % MgWm my aigind sir6uua a any && dec manakin before aaepgrg and aCfg upon any I strudias Youir sf9raturs on this Areenart a ltrttres First Union to h e=Ye16a1 mop payment orders up to sh (b) acird . To retard slap payrren aden, Fast Urban mat receive a verbal ader fa such adersiar balm tie word oft of gds sbc mbnd period. I authaim First Union to mini act naft anyteleplae callafavariasptwp e,Mu:lrgliteraaoacadray.toprovideamadd axham zcd=adbinprccvegogwfiydswAmtoma. Iozmtokl ws=hsomdyptcedLm wFrst Urionawrerwm. TheseaNyaccedae agreed bpnh fa vertyug the outlsndcity of bstructkm which are not delivered h person by nor for my lu rpone Ondudbg, but not Ihti9ed to. gtq wire her rater of matey ban any of Iffy accounts) Is one or more of via (Waving at ft apUan of Fast LW= (1) delivery of a pmmel Ideratificatlon code by me a a person prpcosng to be me, (2) a caatack, (3) a radiation by ma a a person purporting to be fie of one a mcra items of my personal Inkaretfon which Firm Union Ias In Its nrce; 9 abut me, a (4) vclce m cogrlldon of me condned with the use of certain Probing questiaa. The tdephra rx mberis) to wMdn opbaca mall be made mall be ary, telepixxte mute(s) First Union stay have for fie In b reportI a arty telephone nureer assigned to rte by a telephone seMco provider. I area that this Senaity procedure cosdMes a ¢xfrmdally reasarade rrteded of providing --'decriy ara'risiTa &1horlied tistrudlats.' 1 egme to irairtain via cad'derlidify.d ay personal M.aaficagon rode and wig preventtle unauthorized dissemination ofsuchinde, I spas to i domtify and held First Undcn hanhiess from any losses, lovelies, suits and weperam d whatever kind, irdudrg any reasonable attaneym fens, flat First U= nay kowrasaresultdrelftmornbatucdc" tmrnpre,aapaher apadrg mho ma, prgAded gat Fi stUnnon tens mrpfied withgs ap k2Ue seanypromdtaes. I abawiedlie redpt of the First Won rides and rordagau gwerNrg =nay tl-d'Ya recces aid agree to be bound by Is tarts as may be amended from lino to gnu Information About Customer. I acknowledge and agree that any infomagon 1 have supplied or will supply in the future to First Union is complete and coned. I agree that First Union may obtain and use consuner coedit reports about me in connection with any accounts, products and services offered by First Union. First Union may also verify my emplaymeirL salary, asses, debts and references, and anyone receiving a copy of this Agreement is auttrodzed to provide First Union with such Information. Acceptance of Terms and Conditions: I agree to be bound by the terms and conditions Including, but not limited to First Unian's Deposit Agreement and Disclosures. applicable to each product or service which 1 obtain from First Union new or in the future, which terms and conditions will be provided to me. 1 also agree to pay all fees associated with such products, accounts and services In accordance with the fee schedulos which will be provided to me by First Union By checking this box I am requesting Issuance of a 24 Hour Banking (ATM) Card or ChockCard. /&'z ?a?/t//y//?J} CumamerSigmW Print Name Address (' (OOnly one signature per agreement) 1_I A Fug'\. tj t .y •5?4 Afhough Fast Union requires that you agree to the forms and cenakkins of this agreement, the IRS does prof require. your consent to any proNsicn of this document other than `e'bergr=tkin required to avokl backup withholding. C°_FOSIT S=-F:NiCSS COPY - WHITE CL'STCNIc.'. C--?Y - C?, IARY eau !1/1LL: 31: . N. VON. JIM .. Customer Access Agreement 1.800•ASK-RIMP This Apeemant!s designed to abarem t a lha cvrnetacaabaNdrga and arrytl meeph. ae ad?xe+Ld mdham6c This Agreement, bcth now and as k Trey be o nexod fnm tire b time Urocn, is 4VIMce to aydapoa't rooted gut ycu open with any First lklon F.anit atl rT? nmae fvya,safcJaintlywlm aacmerpermn aautfcdaddgna. as can co behalf of ancmer pan= (for example, if you t'ic'e.gyargranan ). You will now open an cement Ihav Quesat . e a s First a?i as ?Camta AGeamd as fa• tlzat a s a Hy n. Instructiomr ?Faoialist taoi•hea atl•000-ASK-FUNB ? d' Ih arty Fast Union Rwk Mee UnIC-0 with wNch I open n¢ cr in V's to "cr;Ft and act upon ImInctlop from Me to do lie • toopendepcstacoaadswih First Union; . • bak ag a any Potion a ms be),= of my =,,t, * to does deposit Mar4A peace, caret arty dmV First changes of centred infmrsdivr or op?wi? • 10 obtain related se,vlwsdfered by First Uri,, Am two In the gWxt% W4 Agee oaS the aotaDOrtsaas •Fled, '. •Govices" and •?.La• 4uLYa wWaw rtede available toyou byRw Iktlm. If nee Oran ohepaSon is na ed in ft title faarry 1=10, spat ac amt wf0 be oxsid afi aloird aozxnL I I Amer. References to m ma ??ed to groin any Instructions m(jcntuctio action may be given y( arylam occasdInstructions satyr shall aim mfer to gs joint i"ItnalVIS cro I Orally win xritbg In Peen, bymat, r co, a tell, Messenger. Lqe facsimile, lethod. First Union rtediM a by cry ctF, reasonable, SM29 ad act upon Such Signature vlgh the same effect as if Such insnatiors gned Ilias which do not ordain my acknowledge that past Union may, at be cpd My s by na. However, 1 Agee document mad orl before accepting ? l upon any imb atom y gream an all. ? ala"d ? Fermat orders, Fust Udon ma iw, a vital a der (6) Malta for eftrral wryrel Gle COW' of this.1 a??pered t First Udot to M dda any ahytaowwretlcmaar bim,P lien Inydudingt to acaaacy. to Provide a reoxd of I°gree upraw procedures SUCh locally f First lhdrn amY unt. Theseomtyptcodav ?for a?F ? nft uhtolY it d o,rC?s mowhich am not de1wred 4, poxon from are is am a none of but nor limited l0. gm wke berate of by ft AV persona Maurits) ed pads by ma a .1 gee Option of First Uioc (1) dew of e rat by me a a on PuPOdng to be me, (2) a calo-S , (3) a persa, p,;,ft be be iafartagcn wtidh First rte d One c Mae Name d my pascal axntdned with ap use d fttmns in 'is records about T Probing quastlaaa Thn or (4Gp)avoice glint of rte calbacka Shell be records or cry td Niece -hWI be number gned ?b Me by a tele rat neS may how (Qrm in which its sleety security alporst i ?a oWcWy r =mbiee meaxdd d poi personal kuadfxatlm code and will Prevent the agree to maintain me cadidenttafity or any _ J e°.tr+ °ndorNb and Irdd Fust'lJnicn ttaMrnasudt rode. raw as a n=ftof raying upon ingruliam fiarn 0 a tcrne s? rem 00 First U-b t meats that Fka Udw avran; ied with the applkbe Salim, Io beme. polded I I aoimoModge male Of the First Union odes and regulatios rpve mNg =t.7 trar uGS!S and agree to be bound by its tarts as Maybe amended from or. ic am. . Information About Custamor. I acknowledge and agree that any information I have supplied or will supply in the future to First Union fs complete and correct. I agree mat pint Union may obtain and use rOPorts about me In connection with accou consumer credit services offered by First Union F Union mac, Products and employment, saary malts, . Its and references. and verity Union with a co such copy py of d this Information. Agreement Is authorized to Provide First Union with Acceptance of Temp and Conditions: 1 agree to be bound by the lams and amd,U including, but not limited to First Union's Deposit Agmalent and Disclosures, applicable to each product ar serviw which I obtain from Frst Union now or in the future . which term and condtiom will be provided to ma. 1 also agree to pay all fees assodated Will such Products, acCmMIS and services in accordance with the fee Schedules which w1g be Provided to me by Fast Union. ` r)037EgGl73 FORM CERTIFICATE OF FOREIGN STATUS (Ail o & Not ot applicable for U.3. dtlrane orneidenp): W n must algn a evpareb Under pemltles of perjury, l wNy that for Interest and dMdewnsM payments I am not a U.S. oitiubm orkerrestranderNsacDam(ar 1 l er amn Atnganfore foreign corporation, partnership Galata, or busq, and exempt foreign far person. RIGHT OF SURVIVCRSHIP (ONLY NO wTNACCOUNTS): I understand that by establishing ajolm acoowd under the W vacm lit Nam Carolina General Sfahne 33.148.1 mat 1. First Union may pay the manly In me account to, Oran thTannoseei e rd" Or,"mat In the ac cum umeas we have agreed with the bank that withdrawals require m retV M one signature; and 2. Upon the death of one joint owner the money remaining In the account will belongdeea the toaathej edeunMnger oint johorn obewners and will not pass by Inheritance W the helm of own controlled by the dawuedjoim owner's wIIL 1 Do electto orate the Right of Survivorship for artyjolnt account. For TN: 1 DO elect the Right of Survivanhip for any joint account I establish with First Jnlan now w In the future untosa 1 rally First Union Otherwise, in which wse Fuuel Union rill provide me with the appmprbte documentation to establish such an a=unt) Signature FORM V19 SOCIAL SECURITY NUM SER OR EMPLOYER IDEATiFICATION NUMBER CERTIFICA T ION (Not applicable for Non•Rosidant Aliens): (The Social Sewdty Number or Employer Idenadptlon Number should match the Ant I. name listed an the account and will be used for tax mpodmg purposes.) Social Security Number or Employer ldentl0cetlon Number. j 53o2'i''fl met If exempt from bacarp withholding and repomng, bewuse you have a ce Wl stod account under section 403(b)(7) ore Wst exempt (mm tax under s 7M 683 1 described in section 4947, check this box: Cemtication• Under Pen alties of perjury, l certify mat EXEMPT 1. Thenuationnumbermber (bave Identification nis my wrtect soda1 sewdty number or amDlayer ar I am waiting far a numberto be Issued to me), and 2. I_am not subject to backup wlmholdl because: (a) l am exempt faun backup • • w!mhotd!mg, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of faliu e ro MPan ag Interest or dividends, or (e) the IRS has notiffed me that I am no longer subject to backup I Withholding. Ificaaon Imtructlom -You must am Out item 2. above If you have been nat0ed by RS that you are rummy subject to backup withholding act because of under reporting OrdIvidendscn rrexrelum. ? ay chocking the Fax I am requesting issuance of a 24 Novaankin g (ATM) Card or CheckCard. LIS, ')1/?!t /'ln?.. Cuamm (Cniycnesfgnaturo Far agreement) Date PMt Name Address Alg;ough FInd Union requims that you agree to the forms and conditions of this agmemem, the IRS does .at regolm your consent re any provis/on of this documonf Omer than are wmgwlion requbvd to avoid backup wfthhcldng. oco ss7ase. DEPCSiT Sc `DICES CCr'(-Y+'HITE CUSTOVERCCF'Y--CAAIARY (saNW nor M !' oCr,CCad TOS9 rquired (Tic !Cfsilhro!d coda changes only), send to Interest Repc?org NC-0467 ,,7 Y- Nr Customer Access Agreamerit 1.800-ASK-FUNS " 0037200744 4M. TW Aglecnwd ls deslged m dlrtirste mat shdsegrem dsraaae rude and ad101atlps wtlm openirp ft m easuas Yar signature on this Agreansd va give you the mbadaxe d banking arnywtae anted anylme ova gm ptvhe 7He Ameemet loth new and m It may be amended from grte to done by First IHonL b apolradamarry ao=n ma you cpatvdth any First trim Pardo dlhancwcr in the amu?m behalf for with arcacPow aauthahadsignar, Fiowcror, Ifyoualmon Rada4 mamob You Ng need complete If you apex an for that as aemdau h"aygr s, pease call a First Union a separate Pgraeren fa that account H you Spadagd mU-fraa at 7.6611437(T'UNS. ifabmadarlL BY signing this Agreement I aNVtm any First tkdcn Bar* Mid Ukiah with wtidh I open an acmaa now a In the Mae to accept and ad upon ksh d= from me to do am frumbg to q=d0Pcsitaaasdswim FustUionS •' to transfer 20 s any portion of t ha balance of my aonoonls QrdLdbp oedit amoirrok • 10 closer NY of FirstUrion ? d>on6esU? of amxad bddaedon or dhawise • to Obtain mated seMcas drered by plot Udonh. As Used In this AGrourn wt the terms •pnodats', -savkxrs- ard'ad ourtr Irdrde Vmfaa depxeltproaxti.aavidesand ecatri, rtede aa6 toynu lyFlastunicn. Wr Mdalare Personlsnamedmthetitleforaya=uMmxham' wNbemakdo oh Oaolnt Instructions which affect any of my Jdn aaaab may be given by any)* t ?t arsef. Refeences to me In this Insbuatlas section shag also mfrs to the Jdre saaathider(s)- Inreyghe insbucdoro a*-Inwft ih pasta, bym39, rtaroon&C bdeptxns, faskila. offer terminal. wire service, sutcrn i d fella fie ttm 0. by any tdha rm taUe method. First LMon may accept and ac Upon such Instructions %tk h do not orream rty sigma a with the same effect as If such 4aaudions were signed by ma hkwever, I acV Vnfedge ma First LI'm may. at ire cp&m naquba my original 517ahoe a airy other o%ft end A6eemed But' FF hp po any irmbuctlas Your &gnabse an lift rst than 00 stop Payment Orders Lip tosbc (6) mat. To Wand aby POYr,ad aden. Fast Union rna2 receive a verbal Order for suM Wand. bdone Um expragm d Ws sbr nmim pedtd. 1 auarlae First lotionm .. and rmitcr any We*' rags far YwIOU3 F TIMSM mcuIr g to Brown accuracy, to provide a mmd of sutlhaarvasatlma and to Improve an quality of service torte Iagas m kgcwaudh o-eyP=&WW as First Union they re lira 71n eewrayprooasre agmsdcOmfavehymgtinawengdydVr hoj svvtddhonemitddly mdinpecan by me loary amub) is one w mom Of as k1roM at the the wire trarsla of many from cry Of my persod Meson woe option Of First U*m (1) cU7vuwy d a reotdkn by fie or a by me or a person p rpagmg to be ma. (2) a m1ba*, (3) a Person ? 10 be me Of One Or room vd? of tai' Odf,, kla steer which First Union tasb mou axxd me.a( ? personal dNm tha'tse of certain probing quesgors The te g5 dThxJO shag be made shat be ay telephone nwrter(s) First U rkn mamirs(r) to In which is security Procedure O=hdes a a a y telephone marter asslgr d to rte by a telephma Wm ppwids nl that rtagcd d powdng ??dy against UmrwNndmd Instructions, III rheasmada Van fawalkmtitatlm cafe awldw9 agree m rtekaan as o7dk5emhgai4 Of arty preverd7a tm wmftBd dissemination cdr race. I egma m In6cymiy Ord had First urim ha rrd= fmni -- exf saes, Of whoever Hnd, IrxiJ*V ay rm.?rrde Orly IOSSM damages' ails and mcad os FmeatatlhiresUtdrdyingupon bstnxtlone ban ma, arm, IPr'ma to Firtea s pr may on hagdmpgedwim one applatie secar(ty ?'P?dW I adanogedge receipt of tin Fat UNm fides and mgrdadas gwermd rtaney darter requrob end Ogee to be bard tygs tales m may bearterc'edfrom rig rig time to ama. hmkrtnation About Customer. Iadarowtedge and agme that any Information I have supplied or will supply in the Nture to First Union Is wmplate and correct. 1 agree that First Union may obtain and use consumer credit mpoda about me in connection with any accounta, products and Wafts offered by First Union. First Union may also verily my empbymOM salary, assat% debts and references, and anyone mc%Wg a copy of this Agreement is autiodzed m provide Fast Unionvdh such mfonnatlort Acceptance of Tanner and Conditions: I agree to be bound by the tarts and conditions inducting, but rel lmged to First Union's Deposit Agreement and Dlsdosures, appkabla to each product or service which 1 obtain from First Union now w in the fumm, which temp and conditions wig be provided to me. I also agree to pay an foes aseodated wire such Prdducls, accounts and serices in accordance with the fee scheddes which will be prodded to me by First Urdem FORM Wit CERTIFICATE OF FOREIGN STATUS (All 'me- must al W-6. Not applicable for U.9. dUzens orresldonb): Undw penalties d papry, I cartiy that mrlnterest and dMidend payments I am not a U.S. dben or resident (a I am filing far a kmlgn corporation, paMenhlp, estate, a trust), am tar broker eansadkne I am an exempt kmign person. morTpt of RIGHT OF SURWVDRSH)P(ONLY NC or IN ACCOUNT'S): I understand that by establishing aJamt account under the provisions of.. . North Carolina General Statute 53.146.1 that Tennessee law that 1. First Union may pay the money in the acwrmt m, con the order d, any person named In the account unless we have agmsd with the bank that withdrawals require mob than one signature; and 2 Upon the death of one joint owner the money remaining In the account wig belong to the surviving joint owners and will not pap by Inheritance to the hairs of the doc aced joint owner or be controlled by the deceased Joint ownors will. OO sleet to create the Right of Survivorship for any joint account (Far TN: I DO elect the fight of Survivorship for any joint Ocwanl I establish with First Union now or In the future unIm I nobly First Union otherwise, In which rase First Union wig provide me with the appropriate documentation to establish such an account) Signature FORM V19 SOCIAL SECURITY NUMBER OR EMPLOYER IDEymFICAYION NUMBER DERTIFICATION (Not applicable for Non-Rosldent Aliens): (The Social Security (Dumber or Employer Iderttlmcation Number should match the first name listed on the account and will be mad for tax mponng purpoe" 1. Social Security Number or Employer Identification Numbar. ^o? 15- If exempt from backup wimhoiding and reporting, because you have a custodial account under section 403 (b) (7) or a bust exempt from tax under saegan 664 or described In secgan 4947, check gils box: 0 EXEMPT 1. Certification - Under penalties ofpajury, I certify that 1. The numberset forth above is my cannot soda aeady number or employer Identification number (w I am waiting for a number to be Issued to me), and - - 2.J am not subject to backup withholding because: (e)1 am exempt fmm backup, withholding, or (b) I have not been notified by the Internal Revenue Service (IRS)- - that I am subject to backup withholding as a result of fatum to report all interest or dividends, at (c) the IRS has notified me that I am no longer subject to backup withholding, out Item 2 above if you have been notified by up withholding because of under reporting ? By rhecidng this box 1 am requesting Issuance of a 24 How Banking (ATM) Card w CheckCard. Cuskmersgmlure / (On rp ppragmomem) a.b 144i OY-Err=EC).: :VEtti?'? Print Name Address Although First Union mqufms that you agree M the terms and come" Nam d refs agreomen, the IRS does not require year consent to me Ngragon gyprovision d this document other than Ui - m avohlbBOW rv fhholdfng• - - DEPOSITSERV!CESCCPY - WHITE CUSTOMER COPY-CANARY MO oblige (swplr0 NovM If comeded 1099 required (Tax IDAVimheld cads char.-. es only), send to Interest Reporting NC-0467 F, Yr (`F '.. I ?..-?. ?1 -:I ?'.,4 Gateway'M Performance . Irt? swMU FW wIP m nou?r . 64h81131Mtr SDRAM (ePrdtt m 30q-tat . EV700(Iri atc awvlewtl0 . 1&MA3PGr47kAMdaaer • 20.OG0720ORPMUraATAHad DdevvM UNTA6607tnia • 9r(3D(DMROM/3.VDWMb . 311atlatersaUm1 Vale wth Oy W ks:10 OutpR&S I Ao7u91d613AMD1911al • Spealerswth9twadmf . 3M%faUSR 56K'VdM • GazaWGedkg meted Class • 1 Year2LU ONreTraWrg 9tsroon • MdTMWCase • nitfsrndlOn Keyboard&Mos • Morwewindows®985aad FiBkrf • OreDtdssdbvme Bade • Qidan®8asIc2000&Nmtm•ArUVIrs • 3Ye3s Part;tabor,&GYn9zSevtce $1945 liewtla9hm00) As low as $51/month2 $2074p camaro a, As low as $54/month2 . Irti 75DNFtr Paatlm m Roster wCa AAarm$TraNa6dae . IYd•8100MtrMMM (epadtrb384r1M • V)900DT.'aw, urveaw • Mmenyda"GeftoemCTaai6w/1V Out&Dno • D3CS77D0 RFM IArdATAHad tithe w/LNTA66CaibrW • 8y/ MVROM/3SDtlidE . Sari UMVatewthogtalASrdo OiW & Dxtc n A=z& &4735 Dgtal Spml?sswth9tnmda . 3COMUSRdxce556K'Vm:e Wsmodem . GalasvWG0dg9crtedaM • IYear20UonfneTraktg9kscrPtimt . MdToAeC3se M41Ud0mreybcerd&M1s . .: Mi WI d"911 Ec91m . - • OreOtdm9dbme8aadd . QrldoailmsICMM&N IzrnPrdVns . 3YMSPsr%Labor, &Gt9mSevice $2945 g.5M351e2000 As low as $79/month' $3074 0saWH=&I•s CRmmmm As low as $83/mordh' . Ltd60D?rt114rtlmmROO? . vaMelaOMtzsDRAM(e4a?m3a . B/700(I7'nctn li9•*A0Uc) . 16h8AGPG PKIcAmded6r • 20.OGB72M RPM l1traATAHadDhe wALATA660atrder • 8)(CrD(DVDRCM13SDIslat1e • IAe3Vatsewth DkdalPm • Ga2vrayGm1g 9a4dCls • 1Yer2DUOrAxT1mhV9zs0"M MTMVC3se • MlYuadlm Keyboard&Mas • OrcC»oa5dbaare &rtle • M9Kkdav5989aadFS)tlm • Q UckM l as'-2000 &NMMAMt1I ns • 3YMPargta1a;&On92SiNa $ 2.145 pSMMSLn2MM As low as $57/molle $2274 "IddP4MM&65 05e2e09ret&Lmm) As low as $61/month2 . LYd ?DWtrRrihmmROas;crw4h AdramiTYadet3de . 1286a 10061Fiz5DFW4(e4aa,rrm7e?a? • VA90 OT.,var, lrvbld ) . 3268rMJaQFdM256Grap csw/TV Wt&DA-D • FCIN/R4NerCad • 27308720DRM AMATAHadDde w/UATA65CVtder • &'(OD(DVDROM/3SD'S¢!Ie . Sanx0a4rlhe!ValeVMD6gh1AU1o Q.tput & BudOn Amutk 847M0 D Wy® SSY ?oalms & 9wafe wy 9,0000 Speakers . 300M IS Rdactks 5%1 MaceWhm:dan • GatrwayGd&g •A@d am • Ltd AnwR?yt?Hmaet)mwkOrd •.IYoar2DUOrkeTrJ" 9lmpim ?. MdTmerOCe .. • MJJ1Xd !KLyb=d&Mas . M9W4fdna98S5ttdEMM . PISOMM2DO0Snal&Am . Gte orlmsdNae BsrDe • Qddal Bask2000&NafMAOVns • 3YMParle; aba;&Ch51eSONoa $4046 As low as $109/mono Systems. otdm scMrme tduda me rvawvg butlss - ad90aal bu1SCs ney be prdatie] (Q $99 each" x• rrm7aD6tt2Ratllm mROx?rwth Adva calTrms<wCadrt -a• 11ffi•810D•$a?fW-1 (e4adrdem3BatBj :?. Ev7roprnmar,ls9.wpvtta a-• I668AGPGaphtA03daatrr A• 20.05017200 RPM Ura ATA Hand Drhe w(UNTA660aboler :•t• WMDVUROM/35"Dislane 1'• 5oux8astxU,el Valuewth DgtalAudo OUat&&6mPmtatIc&4735 DgW Wes wth WN.0der. 300M LISRrboa656K'Voice Mrnsci n • GaRVmyG9tlrg Class ?'• l Yer2DU OnineTmirkig St9ar on . MdTOnes3m :f• KMrdm%toard&MOs yt• Mmiclawsgill Edition ?• Oneaaxe3lb qura7e #• Qrldan8zdc2000&NotrnAdl Vn5 • 3YMP3%labo,&On9&Senke $23450'5yua9stemm, As low as $63/month2 $2474Mktdtuse&IC 0&eam9M \ As low as $66/monl:W AMBtBlasGedes9.12 • Blua§pus&nde D U R d i • e M i ennot Dix e DVD Advertise Slim-MDROM dice rec k dl • r- e 51reneGOrtgm-Agesl7ardoer. Etatp tkedtotlead-F?¢$tg mll• plaff g r w • Goa[bdxrBmde-OUdoQgamesm ,,yy } a l erv tg} a A• 0 rae; n MtKe Ha2w5Wibtradh asdcGVms O • q'Itrpder7lODOm • Ndtid2r7008 Cradesl-0 • KId84da2000Grades5e • VISFM*Garma20oo • MSRdaaxelkRodadtty2000 M9Spma&nde 6SUYmmeGames= ? mm )m kbA"Yeylalmam p."ae mrewtntla ttaap s+rad mm.rrrri&cWru .:isdadlan Year sft yty pars, 7 Year labor and I rdwar Year limited warranty, dos basic onst hardware & & sa mftware plus basic hardware &s long as you own are PC $99. AdtlarrdmrRrestsdat!rahrmo edrm4m theiatieGmwy Palomaroabrtod wars"Biw9a t m 2000 Gateway, bx. Al rights reserved. Gateway and the Gateway stylized logo are registered tredemad¢ of Gateway, Inc. N Wher broads and product rained am trademarks or registered trademarks of deY rmpsOve companies.'Vlst gateway.oam or 0011 1-800-GATEWAY or write to Gateway Terms & Conditions, P.O. Boz 1951, North Sloss Oty, SO 57049.1951 fir a free copy of applicable limited warranties and service agreements. Services may be provided by third parties. An authorized representable will determine the method of service provided. You may be required to take or send your product to an authorized location for service. If you purchased on-site service, it will be provided only If an authorized representable determines It B necessary because or your problem cannot be corrected through other means. On-site service Is not available In all locations and excludes mice, keyboards, doddng stations, external peripherals and monitors. See agreements for spedf c terms and limitations. 'Prices and omnglvhlom subject to change wlnaut notice or obogadm. Prices oclde stupdng and handling and mars. Financing on approved credit through Independent tender. d a 14.9% ARP. Payment may be higher based on your actual APR from 14.9% to 26.99%. Paces and payment exclude shipping & handling & EXHIBIT Included In amount Manned, In which arse monthly payment wIA be higher. Minimum FINANCE CRARGE $.50.'Madmum dam muder rate lar modems with which You are mnnrnusxatlrp, telephone &xs, •Gmmurdat ns software and comm rd atdn protocols. Updated 01124/2000 GATEWAY Performance Desktop Options Mot all options ara //steel, check KYM yoursalesrepresentative for complete detallsl Upgrades are avallab/e w/th the purchase ofa system only. Gaming Options Logltech® WingMan° Game Pad ...........................................................................................................Add.• Logitech WingMan Game Pad Extreme ' ................................................................................................Add- Printer Options Epson Styiuso 440 Color Jet Printer .................................................................................................... Add. Epson Stylus 660 Color Jet Printer (USB only) ....................... Epson Stylus 740 Color Jet Printer (parallel & USB versions ..... .... Add.• ...'..... Add. Hewlett-Packard Desk)et? 610CL Color Ink ]et Printer............................................................... *-Hewlett-Packard DeskJet 812Cse Color Ink Jet Printer (parallel & USB versions , •'••'•'•••'"•••"""......'•.•.Add.- Hewlett Packard DeskJet 895C Color Ink Jet Printer (parallel & USB versions) .Adel Hewlett-Packard DeskJet 970Cse Color Ink Jet Printer USB only) ......................................... Add: Hewlett-Packard PhotoSmae P1000 Color Ink Jet Printer ................... """" Add. Scanner/image Options Dazzie° Digital Video Creator w/ Intemet Edition Software (Windows 98 only) ......................................•, Add,• Epson Perfection 636 USB Scanner (Windows 98 only) ..........................................................................Add,' Epson PhotoPC7 75OZ Digital Camera ........................................................... Add.Hewlett-Packard PhotoSmart C200 Digital Camera ................... """""""" Hewlett-Packard Scan]et 33000se USB scanner Windows 98 only) )...•••..... "'..Add.' -%Hewlett-Packard ScanJet 42000se USB scanner Windows 98 only) ••••••••••••••••• Add., Hewlett-Packard ScanJet 52000se scanner ............................................................................................Add. Intel PC Camera Pack (Windows 98 only) ............................... Add,• Intel PC Camera Pro Pack (Windows 98 only) """" Kodak° DC215 Zoom Camera .................................. • .... ........................................................ Add, Kodak DC215 Zoom Millennium Camera ................................ ....... Add.• Visioneer® 6100 USB Scanner (Windows 98 only) Visioneer One Touch 7600 USB Scanner (Windows 98 only) ...................................................................Add.' Training Options Gateway Learning Library for Microsoft Works Suite 2000 ............................... ..... Add.• Gateway Leaming Ubrary for Microsoft Office 2000 Small Business ......................................................... Add,• Gateway Learning Library for Microsoft Office 2000 Professional .............................................................Add. Online Training Subscription ................................................................. ...............Add. ................................. ' Software Training (one six-hour course at time of system purchase - where available) .................... Add: Software Training (one six-hour course after 30 days or without system purchase - where available) ............................... Add, Other Options - - APO Back-UPS Pro 350 ....................................................................................................................... Add.• APC Back-UPS Office 400 ..................................................................................................................... Add, APC Back-UPS Pro 500 ......................................................................................................................... Add, APC Back-UPS 500 ......................................................................................... Add, Diamond Rio 500 Digital Audio Player ...................................................................................................Add, Disney's Pooh Learning Keyboard ..................................................................... Add: .................................... Disney's Sketchboard Studio Edition ......................................................................................................Add, IOMEGAm Internal ZIP® Drive ............................................................................................................... Add.- Kensington PC Starter Kit ................................................................................................................... Add,• LinkSys 4-Port USB Hub .......................................................................................................................Add.' $19 $39 $99 $129 $199 $99 $149- $299 $399 $399 $224 $199 $599 $299 $149 $199 $299 $79 $129 $349 $449 $99 $149 $149 $149 $199 $99 $119 $149 ---- $169 $99 $199 $159 $269 $59 $59 $99 $39. $49 STATE OF NEW JERSEY ) COUNTY OF BERGEN ) SS: AFFIDAVIT OF MONTY C AND CAROL L GREIN Before me, the undersigned authority, personally appeared Carol L. Grain and Monty C. Grain, who, being duly sworn according to law, depose and say that:: 1. Our child, Kimberly Grain, is currently a junior in high school and is currently looking to apply to colleges for entrance in the Fall 2001 semester. 2. We believe that her search for an appropriate college program may be aided by the purchase of a computer, related accessories, and internet access. In addition, she will be in need of a computer once she is accepted into a college program. 3. We have investigated the prices and features of numerous computer systems and believe that Kimberly would be best served by the purchase of the Gateway Performance 7000 computer system, the cost of which is set forth on the pricing sheet attached hereto as $2,474.00. In addition, the store has informed us that a printer for the system will cost approximately $150.00 and a scanner would cost approximately $200.00. 4. In addition, we have investigated the prices for one year of internet access for the computer and have been informed that such access will cost approximately $250.00. 5. Finally, we have been informed that additional accessories for the computer, such as disks, paper, and other necessities will cost approximately $500.00 for the year. 6. We believe the purchase of the aforementioned computer for Kimberly is in her best interests as she completes her senior year in high school and seeks to apply to college. 7. No withdrawals have been made from the account since the settlement funds were deposited. 8. The facts contained in the foregoing Petition are true and correct to the best of our knowledge, information and belief. 9. We have read the attached Petition for Leave to Withdraw Funds From Minor's Account for their minor child and that they are in agreement with same. Carol L. Grain / AIL 2/ ?-? Monty C. Gi m Notary for Carol L. Grain Sworn to and subscrib before me this V day of 2000. liM Nota ublic MICHELE A. WMSS NOTARY PUBLIC OF NEW JERSEY Notj%mVgWgL,%s#M1.2002 Sworn to and subscrib befo e me this Ito day of lVgi. 2000. w Notary Pu lic MICHELE A. WEISS 192393.NQTARY PUBLIC OF NEW JERSEY My Commission Expires May 6, 2002 -2- i ?? i, -. ;:: ?, -- ;? ._ ?- - _. ._. V IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to ) No. 99-7246 Civil Term KIMBERLY M. GREIN, a minor ) PROOF OF DEPOSIT TO THE PROTHONOTARY OF CUMBERLAND COUNTY: The undersigned counsel hereby certifies that the underinsurance settlement proceeds in the amount of $64,789.19 in the above-referenced matter has been deposited into an interest bearing account pursuant to the terms of the Order of Court dated April 25, 2000. A copy of the deposit slip is attached hereto as Exhibit W. Hunt, Esquire her W. Cahillane, Esquire 1500 One PPG Place Pittsburgh, PA 15222 (412) 566-1212 Attorneys for Plaintiffs 205407.1:ft F/A'. Transaction Receipt UU??II((??II Deposits May Not Be Available For Immediate Wthdawat Ah Items Accepted Are Subject To The Terms And Conddbns Of Frsl Union's Deposit Agreement. Please Retain This Receipt With Your Banking Records. Shown below are the bank no., transaction no., date and amount of your transaction. Member FDIC It, DUPLICATE 22: 220 CiEiK 9EP0511*1 161.789.19 P &:00021258172 17:31 08A0000 A051371 M021 9512?a051311 21 AVAIL 171.199.29 b000 538020 (1o00/pk0 Rev 0.) EXHIBIT "N' ?:. :: ":'- -- ?:.i :` -. s ;_. -?• IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to KIMBERLY M. GREIN, a minor No. 99-7246 Civil Term ORDER AND NOW, to-wit, this day of 2000, upon consideration of VV\ the foregoing Petition for Leave to Withdraw Fun s From Minor's Account, it is hereby ORDERED, ADJUDGED, and DECREED that said Petition is GRANTED. Petitioners, Monty C. and Carol L. Grain, the parents and natural guardians of Kimberly M. Grain, are hereby granted leave to withdraw the sum of $2,000.00 from the minor's account currently held by First Union National Bank for the sole and express purpose of paying for travel expenses related to college visits by Kimberly Grein and her parents. BY THE COURT: 204552.1:lit e,010? 4ij 9 z ?-vo R?g ., IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to KIMBERLY M. GREIN, a minor ) No. 99'7246 Civil Term AND NOW, comes Plaintiff, Kimberly M. Grein, a minor, by Carol L. Grein and Monty C. Grein, her guardians, by and through their attorneys, Tucker Arensberg, P.C., and file the within Petition for Leave to Withdraw Funds From Minor's Account, stating as follows: 1. Petitioners, Carol L. Grein and Monty C. Grein are the parents of minor-plaintiff Kimberly M. Grein ("Kimberly") in the above-captioned action, and currently reside at 144 Overpeck Avenue, Ridgefield Park, New Jersey. Kimberly is currently 17 years old with a date of birth of November 26, 1982. 2. On or about August 16, 1997, Kimberly was seriously injured in an automobile accident on State Route 31 in Somerset Township, Somerset County, Pennsylvania, when the vehicle in which she was riding was struck by a vehicle driven by Terry Schmidt ("Schmidt"). 3. A Prior Petition was presented to this Court setting forth all of the material facts relating to Kimberly's claims, and which sought approval of an advance payment of $100,000.00 from Maryland Casualty/Zurich Insurance Company ("Zurich"). An Order approving the advance payment from Maryland Casualty Company was signed by The Honorable George E. Hoffer on December 3, 1999. (A true and correct copy of said Order is attached hereto as Exhibit "A" and incorporated herein by reference). A Proof of Deposit of the proceeds from the advance payment was filed with the Court on January 31, 2000. ( A true and correct copy of said Proof of Deposit is attached hereto as Exhibit "B" and incorporated herein by reference). 4. Kimberly is currently a Senior in high school and is applying to numerous colleges for admission beginning in the Fall 2001 college term. 5. Kimberly desires to make visits to several colleges in the next few months in order to help decide which college she should attend, including colleges located in Pittsburgh, Pennsylvania and Rochester, New York. 6. Petitioners believe that the estimated travel expenses for such college visits, including air fare, meals, and lodging, will be approximately $2,000.00. Petitioners further believe that the above-listed expenses are reasonable and necessary, and are in the best interests of their minor child. See Affidavit of Monty C. and Carol L. Grain, attached hereto as Exhibit "C" and incorporated herein by reference. 7. Only one previous withdrawal in the amount of $3,564.00 has been made from the account since the settlement proceeds were deposited. Those funds were withdrawn by leave of court, and were utilized to purchase a personal computer for use by Kimberly in school and in college. -2- WHEREFORE, Petitioners, Carol L. Grein and Monty C. Grein, parents and guardians of Kimberly Grain, by and through their attorneys, Tucker Arensberg, P.C., respectfully request that this Honorable Court grant their Petition for Leave to Withdraw Funds From Minor's Account. Respectfully submitted, 2a4ss2.tn TUCKER ARENSBERG, P.C. kz?,J Q)I Gaily P. Hunt, Esquire Lee C. Swartz, Esquir 111 North Front Street P. O. Box 889 Harrisburg PA 17108-0889 (717) 2344121 Attorneys for Plaintiffs -3- IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to ) No, nq_ 72 Y& KIMBERLY M. GREIN, a minor ) KIMBERLY M. GREIN, a minor, by CAROL L. GREIN and MONTY C. GREIN, her guardians, CLIFFORD GREIN and AUDREY GREIN, Plaintiffs, V. TERRY SCHMIDT, Defendant. CIVIL DIVISION No. 99-390 G' - - z1v v ORDER AND NOW, to-wit, this day of .{ c a'•. 1999, upon consideration of the foregoing Petition for Leave to Receive Advance Payment in Minors Claim, it is hereby ORDERED, ADJUDGED, and DECREED that leave-16 receive advance payment relating to the within claims being brought by Carol L. Grain and Monty C. Grain, on behalf of Kimberly M. Grain, a minor, against Terry Schmidt is GRANTED. In light of the refusal of Zurich Insurance Company to waive its rights of subrogation against Terry Schmidt, Petitioners are granted leave to receive advance payment from Zurich Insurance Company, as subrogee of the Petitioners against Terry Schmidt, in the amount of $100,000.00. Zurich Insurance Company is making the EXHIBIT "A" W- advance payment in accordance with the holding in Daley-Sand v. West American Ins. Co., 564 A.2d 965, 387 Pa. Super. 630 (1989). Said proceeds to be distributed as follows: Tucker Arensberg, P.C. - Fees $25,000.00 Tucker Arensberg,P.C.-Costs $1,475.34 Carol L. Grain and Monty C. Grain, on behalf of Kimberly M. Grein, a minor (born 11-26-82) for deposit in an interest bearing account with a federally insured Bank in the State of New Jersey and marked NOT TO BE WITHDRAWN UNTIL MINOR REACHES THE AGE OF MAJORITY (AGE 18) OR BY FURTHER ORDER OF COURT $73.524.66 Nothing in this Order shall be construed as settling, compromising, denying or foreclosing any other claims Petitioners may have, including underinsured motorist claims, against Zurich Insurance Company, Erie Insurance Company, or any other insurer, person or entity. Proofs of deposit to be filed with the Prothonotary within 45 days of receipt of the settlement check from Zurich Insurance Company_ BY THE COURT: 23681.1 Ip1'...':':l'. ^.".i Y';5i6r? i 7•c ..: L`ii::3 ?'.: ','? =:ffo i -2- IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Advance Payment to KIMBERLY M. GREIN, a minor KIMBERLY M. GREIN, a minor, by CAROL L. GREIN and MONTY C. GREIN, her guardians, CLIFFORD GREIN and AUDREY GREIN, No. 99-7246 Civil Term Plaintiffs, V. TERRY SCHMIDT, Defendant. No. 99-390 - .l PROOF OF DEPOSIT TO THE PROTHONOTARY OF CUMBERLAND COUNTY: The undersigned counsel hereby certifies that the advance payment proceeds in the amount of $73,524.66 in the above-referenced matters have been deposited into an interest bearing account pursuant to the terms of the Order of Court dated December 3, 1999, a true and correct copy of which is attached hereto as Exhibit "A". Copies of deposit slip, rate disclosures, customer access agreements, and account details and registrations are attached hereto as Exhibit "B". 186752.11il EXHIBIT "B" P P. Hunt, Esquire tooher W. Cahillane, Esquire 1500 One PPG Place Pittsburgh, PA 15222 (412) 566-1212 Attorneys for Plaintiffs Aft ® (Z :C=c.-c<C=cic-'F c. DOCC i d ^ I -. 7)?_ ?C {"J i' ""'j ;• fiat Union NaVanal Bank r :•{ V? = RIT 021200025 ...«?sa_c:-+?aTV 44•c ,u-e_'?:C'._ . ,--- I itnS-a."a'-" =CUES C5?? l o? ! L3 iaiRL ! 1'f I ? 1 B47ju- _ 1 -ter .>>•?, ®??_ j, 1:S47SOS2S94' i 3 0000232 f ' ?f r ? ^ ?. V'v7 3 Fc? "yam ^ 1 ®J 6*4 33 rz; r L MEET "B" Rate Disclasura 1ZTRST UNION NATIONAL DANK RIDGEFIELD PRF: OFFICE / RIDGEFIELD PfI. NJ Thank you for inquiring about PREM I Utl PERSONAL SAVINGS The following information is current as of JANUARY 14. 2()00. 1 S : 30 . the Interest rate and annual percentage yield for 'REM I UM PERSONAL =AV INGS and presents and the balance requirement for the product to earn the disclosed annual percentage yield. Please refer to your Schedule of Fees and Depositor's Agreement and Disclosures for further information. Product Minimum Ealance Required To Earn Interest Annual Type Annual Percentage Yield Rate Percentage Yield Interest Is Compounded PS AV 1.3?% 1.40% DAILY _, grin 2.32% 2.35% i 0. 00", B . 32*1 2 351% ==_":11)" C 66Si . ^III 000 2.°2Y. 4.00% Existing CD/IRA Accounts only: Amount Tenn Interest Is Paid Every Account Matures On Renewal Option N Let us help you design a custom financial package to meet your individual needs. Thank you for making First Union your choice. We look forward to serving you. r -? 57785a (1ge/pkg) 196W Customer Ac, 1-800•A In m l n :ass Agreement 0031E00752 SK-FUNB FCRt4 Wil CERTIFiCX,'2 OF FOREIGN STATUS (All owners must sign a separate Wa. Not applicable for U. S. citizens or residents): Under penalties of perjury, I ctrtiry that for Interest and dividend payments I am neta U.S. dtizon or resident (or I am filing for a foreign corpomdan, partnership, estate, or tout), and for broker transactions I am an exempt foreign person. Signal of exempt foreign peseh Permanent tweet adore, iiducug apamram or suae number of primary tax nuxuarics (P.O. Box net ancind) Cry, racvece. postal axis and country, of printer tax maxanct, What is your country of citizenship? RIGHT OF SURVIVORSHIP (ONLY NC or TN ACCOUNTS): I understand that by establishing a joint account under the provisions of. North Carolling General Statute 53.146.1 that Tennessee law that 1. First Union may pay the money in the account to, or on the older of, any person named In the account unless we have agreed with the bank that withdrawals require more than one signature: and 2. Upon the death of one joint owner the money remaining In the account will belong to the surviving joint owners and will not pass by Inheritanca to the helm of the decoased joint owner or be controlled by the deceased joint ownaes will. I CO alact to create the Right of Survivorship for any joint account (Far TN: 1 00 elect the Right or Survivorship for any joint account 1 establish with First Union now or tT the future unless 1 notify First Union otherwise, In which also First Union will provide me with the appropriate documentation to establish such an 2=11111.) Slgnatum FCRM W9 SCCLIL SECURITY NUMEER OR 'c6IF! CY2R!G'eI1TIFiCAT{C9 NU:.1S5ti CER-..FiCATICN (Flat applicable for Non-Rasldanl Ailara): (The Social Security Number cc Employer Identi6ptlon Number should match the first name ilsled on the account and will be used for tax reporting purposes.) 1. Social Security Number or Employer Identification Number: U. If exempt from backup withholding and reporting, because you have a custodial account under section 403 (b) (7) or a Must exempt from tax under sre? on 664 or described In section 4947, check this box: u EXEMPT III. CarOfimdcn- Under penalties of perjury, l autify that 1., Ttenumber set forth above is my corned social seciy numberor employer identification number (orI am waiting fora number to he issued to me), and 2. 1 am not subject to backup wthholding becauso: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of faifure to report all Interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding. Cartification Instructions -You must crass cut item 2. above If you have been notified by the IRS that you are currently subject to backup withhelding because of under reposing interest or dividends on your tax return. The AGmenesre is cleared to elinirete most alacquem sigraose cads arid autherturtions when opering htua amass. Your sgaaao w this Ag erna t will give yw the convectional Of banking anywhere and anyt i s over, the phone. This Agoempm, bath now and as a may be arsrdod fact it= to time by Fist Urkn, is applicable to any deposit acorn that ye. open Wth any Fusl Union Bark eiaxr xw a in the furore amount on am ft W behalf Of anxtMr person r fason ezonammTgaWaq I f you Aou signer. Fbnertr, ayar ofatan as w?-n ter assn open an that hav aal trustee), YOU Will card to mtges a sepu? 4Marart to fret account, FUNEL If you have any t?tlahs, please can a first union Spada9st t74ree at 1.20W19K-FI1N8. Instracflons: By signing this Agreement, I attzda any Fast Union Bark ('First Uicn) with wtidt 1 open an acct rtow a in the futures to a¢spt and ad upon Instructions from rtes to do ores fdlch(rg to open depot azmatts with Frst Uniaq • to transfer all a any portion of the balarxe of cry a2anLV (Inducing cedt axons); • to dose deposit aaaunrs, process changes of acart Information a etlfawlso service any d my First Union aaants; to obtain related services offered by First Union. As used in this Agree ai, the terms -produce, -seMCd' and -acmams' iMude wvlost deposit pxtxg, seMes acid accouts node available to you by First Uncn. If move than one person Is named in the title for wry account, such account will be ca'sidactl a Icim aozvnt Instnxdens which aced ay of rry jcird acsurh may be given by ary jcinl account owner. References to ma in this Instructions section shall at= cola to the jam accou, hcider(s). . I rraygve irmtnxdora oallyain vvddrg, h pessm, by n-ad, rresserx•er, ldephcne, facsimle, aerartar terminal. wire swAc+, automated Idler machine. a by any other reasaaNo mdhed First Union nay accept and rd upon soh irstrualcrs which do not contain my sigatuure with the sore effect as if such insti a s wets, signed by rte. Flo ever, I ecmaNedge the First Union may. at its option, require my signal Signature a any cater doartsnlaUCn befoe aae111 g and acting upon any Nabudlca Ycs Signature on this Ag marten atnhortrm Fast Union to Vance von stop payment orders up to six (6) oaths. To extend stop peyment arias. First Union mot revive a verbal oiler fa such extension before the aspiration of this six rtcnth penal I audtcmize First Union b reca and rtcrilcr any telephone ells fa vatic t purposes, irdu ding to asae aoAUra y, to provide a mcrd of such rxwemaatlcmus and to Improve, ft goaly of servo to mm. 129" to foxlow Such scaufty procedures as Fine. Unicn rtay mount. The security procedure agreed upon for ven" Pe authenticity, d Instructions which are nil delivered in person by ma fa any purpose (Including. but not limted tm Um Wm transfer d matey from any of my accounts) is are a more of ft following at the cpGm or First lkioc (1) delvery of a personal identification code by me a a person pupating to La me, (2) a caDbacr, (3) a motauan by rre a a poison purporting b be rte of we a more items of cry pescral infurratim which First Union has in its moats atot ins, a (4) voice recognition of no carbined with the use of contain probing questions The Wephre meat fir(s) to which rasbads shell be made Shaul be any tehephcre number(s) First Union may have for rte in its moats a any telephxre rarer assigned to nor by a telephone servlm Pravda. I agree that this security procedure mrsiiNtes a .,,nodally leasanide rtednd of pmoviem secaiy against urahodzed irstrueicrs I agram to martan the cwlidertiaiy of any personal ideermfimdon code and VAR prevent the unauthorized assertination of Such pre. I agree to inderinfy and hid First Union hanriess from art/ losses, dartagn, suits oral o oMMSCS, of whatever lard. Including ary macrable attramuys' face, Pat Frost Union may it" as a meant of rdyfrg upon t v,. ' s frm rts, aarri are,aapcmrg to be ro, provided that First Union has complied with the appimUe seaaily prccodures. I admoWedge recapt of the First Urlon nies aid regulations gyemirg money transfer requestsand agree to be ban by its terns asmaybe.a endedfromtimebbme. Information About Customer. 1 acknowledge and agree that any information 1 have supplied or will supply in the future to First Union is complete and correct. I agree that First Union may obtain and use consumer credit reports about me in ccnnedion Win any accounts, products and services offered by First Union. First Union may also verily my employment salary, asses, debts and references, and anyone receiving a copy of this Agreement is authorized to provide First Unicn with such information. Acceptance of Terms and Conditions: i agree to be bound by the terms and conditions including, but not limited to First Union's Deposit Agreement and Disclosures, applimble to each product or somloo which I obtain from First Union nov or in the future, which terms and conditions will be provided to me. 1 also agree to pay all fees associated with such products, accounts and services in acnordanm with the fee schadulos which will be provided to me by First Union. ? By checking this box I am requesting issuance of a 24 Hour Banking (ATM) Card or CheckCard. A116 ul, a 6tiP? Customer Signature (Only one signature par agreement) Print Name ??1_._•1-____ C.c ?. k..^:.r Address Although First Union requires that you agree to tho lama and conditions of this agreement, the IRS does not require mur consent to any prevision of this doament ombcr than -e comalcation required to avoid backup withholding. oat. O co0S;7'ERV:CZS CC FY -'di21Tc CUSTC%.--R CCFY - CAMAR'v Ne Customer ADD 1.800-A This Arpoomd Is designed to eliminate mostM&Ba4iant signature Cares and 11011ibltias vftan opening t,Mxe 20catett. Your 5iGM1ura on this Ageerratt will give You fie caverd of bankng anywhere and arrytlme ova the phone This Mir ee eM both mw and as it may be arnrGad from MW to titre by First Unkn, is appkale to anydeposil acectst that you open with any First Union Bank either ncwa in the futaafor yaursdf aJlndy with another person or authorized signer. kirzwewr, tya 4ern an aarnt on behalf or another person (for wove, S you Clow an actrnd as amour. guardian, hrow), you will road to oxmTdete a separate Agnmxrs fQ that acxtat If you law arty questions, plossa can a First Union Specialist toldres at 1•Jg0-ASK-FUNS. Instructions: By ®ginJ 013 Agreement I eN+alze any First Union Bank ('First Unicn) vlth vilich I open an account now a in fire future to a=pt and ad upon ImbuWons from rte to do the (Clomp: . to open deposit amurtowith Fuss Uriaq to transfer all a arty potion of the balance of my armans Qndudrg acct acarssk • to does deposit accounts, process changes d azRam inmferimatlon a otherwise semioearydrry Fuss UnienaesunLx • toobtartmatedservieesdfeted bylerstUNcn. As used In this Agee enL the to.. "products". '"Aces' and 'a®iunte Include various deposit proclrcg, services and account made available to you by Fast Unla. If more than one person is named in the fide for any aazurhL such account Wit be considered a join account. Instnxt o s which affect arry at try joint accounts may be given by ON joint account weer. References; to me In this Instructions section stall also refer to to joint acaxrn hdder(s). I may give Inst uGos orally grin writing, in person, try mail. messenger. telephone lasmle, computer terminal. Was service. autartated teller moire, a by any other reasonable method Fri Union may accept and act upon such Instructions which do net Cahn try sigat rs with to sarto effect as if such Instructions were signed by rte. Flowao r, I acknowledge that First Unon nay, at Its option, require my ctginai signature a any ether documentation before accepting and acting upon try immucicrm Ycur signature on this Agreement authorizes First Untcn to honor verbal stop Payment orders up to six (6) =ohs. To extend step paytrerit orders, First Union mim receive a verbal order for such extension befor e to expiration d this sbc im it period I aMalm First Unien to record and mo dtor arty telephone calls for various pi mposes. Including to ensure aoxuacy, to provide a record Of such comersedas and to inprcve the quality of service to ma 1 agree to fclcwsui security procedures as First Union may mouse. The seconty Pccacure agreed upon for venfylrg the a lhenilly of Instructions which are net delivered in person by me for any purpose (Inducing, but not limited to, the wire transfer d rra:ey from awry of my a=unts) is one a more of the following at the option of First Uricrc (1) ddvery of a personal k'onfificadon code by rte a a pennon pupatng to be rt . (2) a callback. (3) a recitation by rte or a person poicatirg to to rte of ore a tree item of try personal Irdorrelxn which First Union has in its records about nor, a (4) vefco re=0.gution dare combined win the use of certain probing questions. The telepnccne number(s) to which callbacks shall be trade shall be any telephone n rrta(s) First Unicn ray have for are in its mcx a arty telephone number assigrxsd to me by a ldephare service Provider. I agee dud this security procedure crtiMes a aam,etaaty reasonable redhod of providing security against uraclhcr?d hear cliva. I agree to nacain the confidentiality of any per" Identification code and wit prevent the unauthorized dsserirtatm of such code. I agree to indernry and hold First Union harmless from any low. damages. sits and expenses, of whatever Hr4 inducting arty Reasonable womeye fees, that First Union may incur as a result of relying upon iratrudiass from rte, a anyone purporting to be are, provided that First Union has caeplied with the applicable security procedures. I acknowledge receipt, of the First Uncn mules and regulations; governing afire/ amender mqm= and agree to be bcuxl by its terms as may be arranded from fine to time Information About Customer. I acknowledge and agree that any Information I have supplied or win supply In the future to First Union Is complete and correct. I agree that First Union may obtain and use consumer credit reports about me in connection with any accounts, products and services offered by First Union. First Union may also verify my employment, salary, assets, debts and references, and anyone receiving a copy of this Agreement is authorized to provide First Union with such information. Acceptance of Terms and Conditions: 1 agree to be bound by the terms and conditions Including. but not limited to First Union's Deposit Agreement and Discosures, appriicable to each product or servica which I obtain from First Union now or in the future, which arms and conditions will be provided to me. 121W agree to pay all fees associated with such products, accounts and services in accordance with the fee schedules which will be provided to me by First Union. cm Numl,ar 4,e„mv, U.n rlMv IR-n„1.i. r'eu C. , ass Agraement S- 770 00 7_00 SK-FUNS FORM WS CERTIFICATc OF FOREIGN STATUS (All owners must sign a separate W-S. Not applicable for U. S. clUzons or residents): Under penalties of perjury. I artily that for Interest and dividend payments] am Rot a U.S. ciffzen or resident (or I am filing for a foreign corporation. partnership, estate, or trust), and for broker transactions I am an exempt foreign person. synatun of exempt hemign exnon pem,enam weal addroxe induai g apartment or suee rnm,bsr of primary to rssksnce (P.O. Boa not allowed) Cit. pa+k,Ce. portal code and country of primary m residences RIGHT OF SURVIVORSHIP (ONLY NC or TN ACCOUNTS): I understand that by establishing aJoint account under the previsions of North Carolina General Stalls S3.14&1 that Tennessee law that 1. First Union may pay the money in the account to, or an the order of, any person named in the account unless we have agreed with the bank that withdrawals require more than 2. Upon the death of one Joint owner the money remaining In the account will belong to the surviving joint owners and will not pass by Inheritance to the heirs of the deceased joint owner or be controlled by the deceased jalnt owner's will. 100 elect to create the Right of Survivorehip for any joint account (For TN: 100 elect the Right of Survivorship for any joint account I establish with First Union new or in the future unless I notify First Union otherwise, In which case First Union Wit provide me with the appropriate documentation to establish such an account.) Signature FCfi6n 719 SOCIAL SECURITY NUMBER OR EMPLOYER IOENTIFICA-.ICN NUMBER C23T:FICATICti (Nct applicable for Non•Rosidant Aligns): (The Social Security Number or Employer Idendeodan Number should match the first name listed on the account and will be used for lax reporting purposes.) 1. Social Security Number or Employer Identification Number. 11. If exempt from backup withholding and reporting, because you have a custodial account under socicn 403 (b) (7) or a trust exempt from ax under section 664 or described in secdon 4947, check this box Q EXEMPT Ili. CeNfication- Under penalties of perjury, l certify that 1. The number set forth above is my correct 3=101 security number or employer Identification number (a I am waiting for a number to be issued to me), and 2: I pm not subject to backup withholding because: (a) I am exempt from backup • withholding, or (b) I have not been notifled by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure n. Moon all interest or dividends, or (c) the IRS has notifled me that I am no longer subject to backup withholding. Cortlfication Instructions -You must cross out item 2. above If you have boon notified by the IRS that you are currently subject to backup withholding because of under reporting ? By cheidmg this box I am requestlng issuance of a 24 Hour Banking (ATM) Card or CheckCard. '??J r• :,(.t;i rte,. r•„• i Customarshgnsture (only one signatun per agreement) oohs Punt Name T _._L.. •, ___ c 1' }? ,.1"-'r!'.' A ldnoss Although First Union requires that you agree to the terns and conditions of ibis agreemonl the IRS does not require your consent to any prevision of this document other than the rndiffcation required to avoid baUup withholding. CcoC"G=. h iC_$CCp7 CVE7C5c4 CCFY-CAd1An! :OW 537998($Woke Rev 05) _a.. _ :Ed 7?=U :5gUirLd ({ a:Y.:C?;°:,:`rC:7 ^c1a t`zr;es Cnii). isend 20 IOlemEal RepcClnU )iCC:^•7 y• • Customer Access Agreement 00372007/ 44 F N 1-800-ASK-FUNS This Agraffren is designed to cilmi ate amt aubmwent S17-itrn weds and autxrmtae when opening fimre eocculft your Sigame an this Ag nrnnt will give yw the ornei it s of bwJdrg anywhere and anyone ear the ymo. The Agme end both new and as it may be arzrdod from line to tnd by First Urim is applicable to arrydepsl ecMu t that you open with arty Fast Urim Park now ncwa in the filed l(ryorsdtajoinlywith a-lot"person aaNcrondsgnil. ioweva,dyeeOpe an amount a behalf Of another laracin (fa exam la, if you Open W account as aausdon, guar ibm !meteor), you will need to oampete a separate Agmened fer that aazut. It YOU have try, clumtkis, please call a First Unit Specialist Cbade at 1-800-ASK-FUNS. kistuctf? ctaa hem mat to dot the aann dart dis new, a In t the tfuyld to c pt and art upon ir l blic lnp to open deposit ecociurts win First Uni= to transfer so or arty pardon of the balarza of my amounts (hndudu'9 tacit amvs); to dose deposit acca sts, pazss changes of account ltanatm a ctanss9 service arry Of my Fast Union amcu= FORM WO CERTIFICATE OF FOREIGN STATUS (All ovenom must sign a sapxmto W41. Not applicable for U. S. citizens or residents): ' Under penalties of perjury, I tartly that for interest and dividend payments I am not a U.S. cilium or resident (or I am filing for a foreign corporation, partnership, estate, or trust), and for brokor transactions I am an exempt foreign person. exempt tang"'panon RIGHT OF SURVrVORSHIP (ONLY NC orTN ACCOUNTS): l understand that by establishing a joint account under the previsions of North Carolina General Statute 57.14841 that Tennesai a law that 1. First Union may pay the money in the account to. or on the order of, any person named In the account unless we have agreed with the bank that withdrawals require more than one signature; and 2. Upon the death of one joint owner the money remaining In the account will belong to the auNIving joint owner and will not pass by Inharitancs to the halts of the deceased joint owner or be controlled by the dowased joint owners will. 100 elect to create the Right of Survivorship for any joint account (For TN: 100 elect the Right of Sur"! airship for any joint account I establish with First Uiian now or in the future unless I notify First Union otherwise. In which case will provide me with the appropriate documentation to establish such an account)rst Union • toobWnrdatodsnvi=ctlemdby Fm Uriam ?It 'poyxts adaoocaesaec5s alabl by Frst Urion.ircltdo verlan t mss teen one Isom Is parted in the the fa any acmat. such account will be omWdaed a joint aaamL ksauct!" which affect any of my Jcim accounts marry to given by any join oocoat owner. Rine axis to ore in Iris IrstnaCas section shad aim refer to vie Jcinl account hxider(s). I maygve imttrlm orally a in writing. in person. by rtxul, m mega, Wephcro, facsimile. computer terminal. was se Am. automated tells machine, or by any ctxtr remorade I atxd. First Union may a(?pt and act upon such asanCas which do rot oceftn try signature with the sera effect as ff such iratudlars were s9red by ore. Hcmover. I adanaMedge tat Fast Union may, at its option, require my cdgira signature or any other Qoczarximation befou accepting and acting upon any irsthxtias. Your signature on this Agreement: aehatzes Fast Umcn t horn eereal seep f orders up to six (6) mate. To extend stop payment adem. Fist Want must receive a verbal order la won ex¢auion befce is e)or4m d tits sot rtmlh period. I autndm First Unio n t reoad and naita arytelepha;e calls fa varies purposes, tcduoing to ahstae amcacy, to provide a recd of swharrvasatias and to improve the quality of SWAM in rro. 1 agroe to Ic uv such seamy prc(sd mi s as First union may require. The sea:riy procedure agreed upon for venying the audentoy of irsbuClas wlm ail not delivered in person by me fa any priori (Irdudirg, but not limited to, the woe Lzrsfer of nary from arty of my rso c rte) is an or nxre of the following at the cpdcn Of Furst Lirlorn: (2) a i) deli (3) a personal idctihradon rude by ma a a person p'aixetin9 be me. rail ttn by rte a a person purporting to be rte of as a mot items of my perscral i(Itmnni which First Union has In its records about rte. a (4) Won rOCgnitlon of rte anicined war the use of certain pctiag questias. The telephics ourter(s) to which oalbacks shell be tirade stub be arty telephone nunrta(s) Furst Udon may have for rte in its records a any to eptmet mater assigned to me, by a lelephos mrdm provider. I agree dam this security procedure ¢rstittes a mmrrdany rye .,.it d of providing seeriry against utsNerized IrsthxcJcrs, I agree to maintain se snl'dentialily of try personal identficWem axe and will pevetrte unatnhaizea dwerrinaean d such c 'ate. I agree to Indemnify and hid First Union hamims from any Imam, darages. sus and e¢vtues, d whatever kind. indtfr'g try reasc rable attrceys' fees. that First Urion nay hour as a resat of relying upon irsauaias from mix. aamyce purporting to be rte, provided that Fast Unon has ccnpied with tha appoade secunty, lxa>d(aes• I adTcWe;5a receipt of the Fast Union rtes add regdadcrs gaemirg ncney bal"ia rent .'ests and agree to be bound by is terms as may be amended it=tim to ale. Information About Customer. I acknowledge and agree that any information I have suppled or vnlf supply In the future to First Union is complete and caoect. I agree that First Union may obtain and use consumer credit reports about me in connection with any accounts, products and services offered by First Union. First Union may also vent' my employment, salary, asses, debts and references, and anyone receiving a copy of this Agreement Is authorized to provide First Union with such Information. Acceptance of Toms and Conditions: I agree to be bound by the tonns and conditions Including, but not limited to Fist Union's Deposit Agreement and Oiadasures, applicable to each product or service which 1 obtain from First Union now or in the future, which terms and condidons MR be provided to me. I else agree to pay all fees associated with such products, accounts and services in accordance with the fee schedules which will be provided to me by First Union. Signature FORM S19 SOCIAL SECURITY NUMBER OR EMPLOYER IDENTIFICATION NUMBER CERTIFICATION (Not applicable nor Non-RSSidart Aliens): (-,heSocial on th account and will be used for Identification Number ta i reporting purposes.?uld match the first Number or Employer 1. Social Security Number or Employer Identification Number: I. It exempt from backup withholding and reporting, bemUsO YOU have a custodial account under section 403 (b) (7) or a trust exempt tram tax under section 664 at described in section 4947, check this box: EXEMPT it. Certification- Underpenaltiesef Perjury, I Candy that 1. The number nutmforth abonve Is ber (or am waitl g for soal numbeto t security Isnumber or sued to me), employer Identification 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that 1 am subject to backup withholding as a result of failure to report all interest or dividends. err (c) the IRS has notified me that I am no longer subject to backup withholding. reporting Cartificaation the IRS that you are l currently subject to backup out witem 2. above if ithholding beca se of under by ? By checking this box I am requesting issuance of a 24 Hour Banking (ATM) Card or CheckCard. //?/I /• . s. :rot; _. :tr.: / V 7 Oat. r CustomarSgnature j / (Only one signature per agreement) Print Name 7! r, Address Although First Union requires that you agree to the !arms - and conditions of this agreement, the IRS does rat require your consent to any prevision of this document other Nan the cerdficati in mouthed to avoid backup withholding. CCPCSii ?cnViC23 CC?'i •'r 4.T°_ OUSTCiaER COFY• CANARY if cc^ec:ed 7Ggg regc:2d (Tex iO, :Y(ntc d Cods Cn. gat only), sand to Intarest Regof^g Nc-ct57 100 537998 (saDag Re• os) First Union National Bank Ridgefield Park Office 200 Main Street .Ridgefield Park, New Jersey 07660 201 712.4936 Fax 201 712-4937 F N. CDIE A054412 C511)7205 Customer Detail Inquirv 045643786 CZ111901 01/14/00 15:45 Se MORE: KIMBERLY M GR'=IN Ta:< Id: 5136763156 144 OVERPECK AVENUE RIDGE=I=-[-D PARK: NJ 07660 Customer Asset=- S 0.00+ Customer Liabilities $ 0.00+ S-Ora-Sere-Account Number/Mat. Date-Prod-J/S-St.at Date--Cmnt---5alance----Cunt 075 SAY 300i i!21258472 PSAV S OP 011421u)0 N NEW ACCOUNT BALANCE INQUIRY COMPLETED PRESS F9 FOR BALANCE Command: F'=Hslc F3=E:<t. F4=N::t. '=_=Sold F6=Add Lead F7=Bkwd F3=Fwd F10=Lt F11=Rt F24=CS°-L 471:0 1 1 - 0 9 AD! AOZ4412 CSI D7205 Account Detail -Inquiry CZ120101 01/14/00 16:4= Orc: 075 Se7 : SAY Acct: BC"0 )tj?125x473 Memo. -la>: 1d: Hold: 075 SAY 3000021258472 PSAV Ocemed 01142000 Stat: OPEN Ac=tTez Id: S13S763158 Reomans : 5'7 . ?5729 St: NJ Fed W/hd 01 01142000 Closed ROS : P•-=-v W/hd Jnt/Scl : S DLM : 01 1420Q0 Services Pers/Com: P Src . A054412 Secured Mrr_i-. Lezal Title K:IMBEPL Y M GREIN MONTY C GREIN AND Perk: Id: CAROL L GREIN GUARDIANS FOR Add:-s--, 144 OYE=:••C J,* AVENUE _=G_FISL. PARK: NJ 0766'"1 Add:- Tv=e: -N x STATE OF NEW JERSEY COUNTY OF BERGEN SS: AFFIDAVIT OF MONTY C. AND CAROL L. GREIN Before me, the undersigned authority, personally appeared Carol L. Grein and Monty C. Grein, who, being duly sworn according to law, depose and say that:: 1. Our child, Kimberly M. Grein, is currently a Senior in high school and is currently looking to apply to colleges for entrance in the Fall 2001 semester. 2. Kimberly desires to pursue an education in Sports Medicine and would like to visit several colleges in the next several months so that she may make an informed choice as to which colleges she should apply. Two of the colleges in which she is interested are in Pittsburgh, Pennsylvania and Rochester, New York. 3. We believe that her search for an appropriate college program will be aided by the campus visits. 4. We have estimated the travel expenses for Kimberly and one parent to be approximately $2,000.00 for the college visits. 5. We believe the aforementioned college visits for Kimberly are in her best interest as she completes her Senior year in high school and seeks to apply to college. 6. Only one withdrawal has been made from the account since the settlement funds were deposited. That withdrawal, in the amount of $3,564.00 was utilized to purchase a home computer for Kimberly. 7. The facts contained in the foregoing Petition are true and correct to the best of our knowledge, information and belief. EXHIBIT "C" B. We have read the attached Petition for Leave to Withdraw Funds From Minor's Account for their minor child and that we are in agreement with same. Carol L. Grein Monty C. G Notary for Carol L. Grein Sworn to and subscri d before me this 3 day of L 2000. rn.o`t..-s Notary ?Public, ROLStf fe of Now Yorti No. 4522638 4Notaublic Qualified in haw York cowily Commission Ezpiros AUxch-dg-1%. I/3 J •"I/, yoo I Notary for Monty C. Grain Sworn to and subscribgd before me this A day of : i/_ lk 2000. CAROL HA.%);,Vo "G ?GGLYS Notary Public, stato of Now Yo& No. 4522638 Nota Public Qualified fn Now York County ry Commission Explra: y_ A/3N• •3f, 1001 -2- c., 1 P l , ... Ca;J v: ' U- l.1 J I