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Home My WebLink About07-3826HARRISON JAMES KOPPENHAVER, : IN THE COURT OF COMMON PLEAS a minor, by his parents and guardians, : OF CUMBERLAND COUNTY, BENJAMIN J. KOPPENHAVER and : PENNSYLVANIA JAMIE L. KOPPENHAVER, : CIVIL ACTION - LAW Plaintiffs V. NO. o7 REBECCA ELIZABETH GILES, Defendant PETITION FOR COURT APPROVAL OF A MINOR'S SETTLEMENT NOW comes Benjamin J. Koppenhaver and Jamie L. Koppenhaver, his wife, by and through their attorney, Gregory R. Reed, Esquire, and petitions the court as follows: 1. Benjamin J. Koppenhaver and Jamie L. Koppenhaver, his wife, (hereinafter collectively referred to as "Petitioners") are the parents and natural guardians of Harrison James Koppenhaver, a minor (hereinafter referred to as Minor Plaintiff), all of whom reside at 1044 Walnut Street, Lemoyne, Cumberland County, Pennsylvania. 2. Minor Plaintiff is approximately 6 '/2 months of age having been born on November 28, 2006. 3. On November 27, 2006, at approximately 7:20 p.m., Benjamin J. Koppenhaver was operating a 2001 Ford F250 pick-up on the 1900 block of Market Street in Camp Hill, Cumberland County, Pennsylvania. 4. Jamie L, Koppenhaver, then approximately seven and one-half months pregnant, was a belted front seat passenger. 5. The Koppenhaver vehicle was traveling in the eastbound lane when a 1999 Subaru Forester, operated by Rebecca Elizabeth Giles and moving in the opposite direction, without warning or apparent reason, swerved directly into the path of the Koppenhaver vehicle resulting in a collision. 6. Rebecca Elizabeth Giles had a blood alcohol content of .201 and was charged with driving under the influence and recklessly endangering another person (a copy of the police report is attached hereto, marked Exhibit "1" and incorporated herein by reference). 7. As a result of the aforesaid collision, Jamie L. Koppenhaver was taken to the Holy Spirit Hospital in Camp Hill where she prematurely delivered Minor Plaintiff in the very early hours of November 28, 2006. 8. When born, Minor Plaintiff weighted 41bs., 12.7 oz. and was placed in the Neo Intensive Care Unit. He had respiratory complications and suffered from jaundice, apnea and anemia. In the NICU he suffered continuing episodes of apnea and bradycardia. Some of the episodes were associated with his feedings because he was not fully developed and had difficulty sucking and swallowing. He was fed intravenously. On December 16, 2006, eighteen days after the accident, Minor Plaintiff was discharged (a copy of the discharge report is attached hereto, marked Exhibit "2" and incorporated herein by reference). 9. Although Minor Plaintiff is doing well, doctors have advised Petitioners that medical issues with premature infants often do not surface for many years. 2 10. Both vehicles involved in the collision were insured by Allstate Indemnity Company. 11. The limits of the policy covering the Giles' vehicle are minimal, to wit: $15,000.00 per person. 12. Allstate has tendered the $15,000.00 policy limits for the injuries suffered by Minor Plaintiff. 13. Plaintiffs' propose to settle the claim with Defendant for the $15,000.00 policy limits. 14. Petitioners have underinsured motorist coverage under their Allstate policy and have reserved the right to pursue the underinsured claim once the third party claim is paid. 15. Unfortunately, the $10,000.00 of first party medical benefits for Minor Plaintiff under Petitioners' Allstate policy have been exhausted (a copy of the Explanation of Medical Bill Payment report from Allstate is attached hereto, marked Exhibit "Y and incorporated herein by reference). 16. About $18,904.95 of unpaid medical bills for Minor Plaintiff have been submitted to Petitioners' health insurance company, to wit: Regence B1ueCross/Blue Shield. 17. Regence BlueCross/B1ueShield have put Petitioners on notice that any monies paid on behalf of Minor Plaintiff will be subject to a subrogation claim (a copy of the notice is attached hereto, marked Exhibit "4" and incorporated herein by reference). 3 18. Petitioners, through their counsel, intend to make all reasonable efforts to minimize Minor Plaintiff's medical bills and any subrogation claim. 19. However, Petitioners intend to use the proceeds of this settlement to cover Minor Plaintiffs' unpaid medical bills, if any, and subrogation claim, if any. 20. Under no circumstances will Petitioners' counsel receive attorney's fees from this proposed settlement although Petitioners' counsel may, if appropriate, claim attorney's fees against the subrogation amount, if any, so as to maximize net proceeds to Minor Plaintiff. 21. Plaintiffs' propose that the $15,000.00 be allocated as follows (a) $236.42 to Gregory R. Reed, Esq. as reimbursement for actual out-of-pocket expenses for medical records and filing fees; (b) Minimum amount possible to satisfy Minor Plaintiff's medical bills and/or subrogation claim; and (c) the balance to Minor Plaintiff in accordance with Pennsylvania Rule of Civil Procedure No. 2039(b). WHEREFORE, your Petitioners request your Honorable Court to enter an Order approving the settlement as above set forth, directing the distribution of the proceeds in accordance herewith and authorizing your Petitioners to execute a good and sufficient Release to Rebecca Elizabeth Giles (except for restitution, if any, ordered in the 4 criminal proceeding) and her insurer for all claims arising as a result of the personal injuries sustained by Minor Plaintiff, Harrison James Koppenhaver. Gregory R. Reed, Esquire Attorney for Plaintiffs 3120 Parkview Lane Harrisburg, PA 17111 (717) 238-0434 Attorney I.D. #23705 5 VERIFICATION We, Benjamin J. Koppenhaver and Jamie L. Koppenhaver, hereby verify that the statements in the attached Petition for Court Approval of a Minor's Settlement are true and correct to the best of our personal knowledge or information and belief. We understand that false statements herein are made subject to the penalties of 18 Pa. C.S.§4904 relating to unsworn falsification to authorities. Date: oG Date: 0 G l O 7 -7 it B j in .Koppenhaver r mie L. Koppenhaver i `? P V ?r n ? ? O N ? EXHIBIT ??1" METRO THE HARRISBURG AREA POLICE INFORMATION RESOURCE SYSTEM (CRSIPINC) PAGE: 1 CRASH REPORT 01/29/07 DKL1 CAM1 CRASH NUMBER: F0007003 INCIDENT NUMBER: 20061100304 CAM CASE CLOSED: Y ------------------------------------------------------------------------------ AGENCY: 21401 CAMP HILL BOROUGH DISP-TM: 1919 ARRV-TM: 1920 PATROL-ZN: 02 PRECINCT: 2199 WALNUT ST. INV-DT: 11-27-20.06 INVESTIGATOR: PRYOR, LANE P BADG: 1712 APP-DT: 12-11-2006 REVIEWER: HOPE, MICHAEL L BADG: 0173 MUNICIPALITY: 401 CAMP HILL BOROUGH COUNTY: 21 CUMBERLAND CRS-DT: 11-27-2006 TM: 1919 #UNIT: 2 #PEOP: 4 #INJ: 2 #KILL: REPORTABLE: Y NOTIF HIWY MAINT: N PENNDOT PROP: N SCH BUS RELATED: N SCH ZON RELATED: N FOLLOW UP: N CITY PROP DAM: Z CRASH DESC: 2 REL TO RDWY: 1 ILLUM: 3 WEATHER: 1 RDWY SURF COND: 0 INTERS TYP: 00 SPEC LOC: 0 SPEC JURIS: RDWY SURF TYPE: PRINC RD - CNTY: STR NM: INSEC RD - CNTY: STR NM: LANDMARKI - RT#: STR NM: LANDMARK2 - RT#: STR NM: 21 RT#: SEG MARKET ST RT#: SEG MILEPOST: 0000 MILEPOST: 0000 TRAF CONTROL DEVICE TYPE: 0 WORK ZONE - TYP: LOC: LN CLOS: RD CL/DETOUR: LANE CLOSED DUE TO CRS: 2 I FIRST HARMFUL EV: 01 UN#: 02 ENV/RDWY FACTORS: 00 #LNS: 02 SPD LIM: HOUSE#: 1900BL #LNS: SPD LIM: SEG MARKER: DIST FR CRASH - FT: SEG MARKER: 25 ORIENT: E RT S ORIENT: RT SIGN: ORIENT: MI: .0 ORIENT: FUNCTIONING: 0 SPEED LIM: WORKERS PRES: SHLD/MED WK: MOVING WK: FLAGGER: OTHER: DIRECT: 6 TRAF DETOUR: Y EST TM CLOSE: 2 MOST HARMFUL EV: 01 UN#: 02 PRIME FACTOR: D 05 UN#: 01 I EMERGENCY TRANSPORT - EMS AGENCY: CAMP HILL EMS MID FACILITY: HOLY SPIRIT ER I EMERGENCY TRANSPORT - EMS AGENCY: EAST PENNSBORO TOWNSHIP EMS MED FACILITY: NONE I WITNESS: NANCY LEE BIGELOW PH: 7177613289 ADDR: 20 SOUTH 26TH STREET CAMP HILL, PA 17011 I WITNESS: LINDA MARIE RUTHERFORD PH: 7172337708 ADDR: 1417 NORTH FRONT STREET HARRISBURG 17102 >N MONDAY, NOVEMBER 27, 2006, AT APPROXIMATELY 1919 HOURS, THIS OFFICER WAS >ISPATCHED TO THE AREA OF NORTH 22ND AND MARKET STREET FOR AN AUTO ACCIDENT IITH UNKNOWN INJURIES. THIS OFFICER WAS AT THE CAMP HILL BOROUGH POLICE )EPARTMENT AND RESPONDED TO 22ND AND MARKET AND WAS UNABLE TO LOCATE ANYTHING. :UMBERLAND COUNTY COMMUNICATIONS INDICATED THAT IT WAS POSSIBLY UP NEAR NORTH ;1ST STREET AND MARKET STREET AT WHICH TIME THIS OFFICER PROCEEDED TO THAT INTERSECTION. [PON ARRIVING THERE ONLOOKERS WERE WAVING FOR THIS OFFICER IN THE 1900 BLOCK ?F MARKET STREET WHERE THIS OFFICER OBSERVED TWO VEHICLES INVOLVED IN WHAT ,PPEARED TO BE A HEAD ON TYPE COLLISON. BOTH VEHICLES WERE BLOCKING THE METRO THE HARRISBURG AREA POLICE INFORMATION RESOURCE SYSTEM (CRSIPINC) PAGE: 2 CRASH REPORT 01/29/07 DKL1 CAM1 CRASH NUMBER: F0007003 INCIDENT NUMBER: 20061100304 CAM ------------------------------------------------------------------------------ EASTBOUND AND WESTBOUND LANES OF MARKET STREET IN THE 1900 BLOCK. THIS OFFICER WAS ADVISED BY CUMBERLAND COUNTY COMMUNICATIONS THAT FIRE DEPARTMENT AND EMS WERE ALSO ENROUTE. THIS OFFICER DONNED THE DEPARTMENTAL ISSUED TRAFFIC VEST AND GRABBED THE FIRST NID BAG AND BEGAN TO APPROACH THE SCENE OF THE ACCIDENT TO RENDER FIRST AID. THIS OFFICER OBSERVED A FEMALE STANDING AT THE DRIVER'S DOOR OF A BLACK 1999 3UBARU FORESTER WHICH WAS FACING EASTBOUND IN THE WESTBOUND LANE OF MARKET STREET WITH THE FRONT LEFT WHEEL AGAINST THE CURB. THIS OFFICER NOTED THAT THE VEHICLE HAD MODERATE DAMAGE AND UPON APPROACHING THE FEMALE THE FEMALE YELLED TO THIS OFFICER THAT SHE DID NOT NEED PARAMEDICS. THIS OFFICER DIRECTED MY ATTENTION TO THE SECOND VEHICLE INVOLVED, THAT BEING k BLUE 2001 FORD F250 PICK UP. THAT VEHICLE WAS IN THE EASTBOUND LANE OF MARKET STREET FACING EASTBOUND. THIS OFFICER COULD NOT FIND THE OCCUPANTS OF THE VEHICLE AT FIRST THEN LOCATED A MALE, WHICH APPROACHED THIS OFFICER. THAT MALE WAS IDENTIFIED AS THE DRIVER OF THE FORD PICK UP TRUCK, WHO PROVIDED THIS DFFICER WITH A DRIVER'S LICENSE, REGISTRATION AND INSURANCE INFORMATION. THIS DFFICER NOTED THAT THE DRIVER OF THE FORD WAS IDENTIFIED AS BENJAMIN ZOPPENHAVER. KOPPENHAVER DIRECTED THIS OFFICER TO A FEMALE WHO WAS SITTING ON THE SIDEWALK IN FRONT OF THE TRINITY LUTHERAN CHURCH WHO HAD A VOICED CHIEF ?OMPLAINT OF ABDOMINAL PAIN. THIS OFFICER NOTED THAT IT APPEARED THAT THE FEMALE WAS IN HER LATER STAGES OF PREGNANCY. ACCORDING TO BEN KOPPENHAVER HE aAS THE DRIVER AND HIS WIFE, WHO WAS PREGNANT AND SEATED ON THE SIDEWALK, BIAS THE FRONT RIGHT SEAT PASSENGER INVOLVED IN THE ACCIDENT. THIS OFFICER DIRECTED EMS TO THE FEMALE WHO WAS LATER IDENTIFIED AS JAMIE ZOPPENHAVER. OTHER THAN HER VOICED CHIEF COMPLAINT OF ABDOMINAL PAIN, THIS DFFICER DID NOT SEE ANY VISIBLE TRAUMA ON JAMIE OR ON BENJAMIN OR ON THE FEMALE STANDING BY THE SUBARAU. %FTER RETRIEVING THE NECESSARY INFORMATION FOR THE FORD F250 THIS OFFICER ASKED BENJAMIN WHAT HAPPENED AT WHICH TIME HE STATED HE WAS TRAVELING EAST ON QARKET STREET AT APPROXIMATELY 25 MPH AND NEVER SAW THE OTHER VEHICLE CUT IN FRONT OF HIS PATH. BENJAMIN STATED EVERYTHING HAPPENED SO FAST HE HAD NO TIME CO REACT AND HAD NO IDEA WHERE THE OTHER CAR CAME FROM. BENJAMIN FURTHER STATED THAT HIM AND HIS WIFE WERE BOTH WEARING SEAT BELTS AND THIS OFFICER 40TED THAT BOTH DRIVER AND PASSENGER AIR BAGS WERE DEPLOYED INSIDE OF THE FORD. VHILE EMS TENDED TO JAMIE KOPPENHAVER'S INJURIES, BENJAMIN INDICATED HE WAS JOT INJURED. CHIS OFFICER REAPPROACHED OFFICER ASKED THE FEMALE CNDICATED SHE WAS TURNING 3HE USED HER TURN SIGNAL. ADDITIONAL INFORMATION AT JAS AT FAULT BECAUSE THAT THE FEMALE WHO WAS STANDING BY THE SUBARU. THIS 3Y THE SUBARU WHAT HAPPENED AT WHICH POINT SHE LEFT INTO THE TRINITY LUTHERAN PARKING LOT AND THAT THIS OFFICER ASKED GILES FOR ADDITIONAL DETAILS OR WHICH TIME SHE CLAIMED THAT THE DRIVER OF THE FORD DRIVER WAS "FLYING." CHIS OFFICER DID OBTAIN A DRIVER'S LICENSE, REGISTRATION AND INSURANCE CNFORMATION FROM THE DRIVER OF THE SUBARU AT WHICH TIME SHE WAS IDENTIFIED CHROUGH A PENNSYLVANIA DRIVER'S LICENSE AS REBECCA E. GILES. IN SPEAKING WITH "ILES THIS OFFICER COULD DETECT AN ODOR OF AN ALCOHOLIC BEVERAGE COMING FROM IER BREATH. GILES ALSO HAD GLASSY, BLOODSHOT EYES, SLURRED SPEECH AND IT METRO THE HARRISBURG AREA POLICE INFORMATION RESOURCE SYSTEM (CRSIPINC) PAGE: 3 CRASH REPORT 01/29/07 DKL1 CAM1 CRASH NUMBER: F0007003 INCIDENT NUMBER: 20061100304 CAM ---------------------- ----------------------------- ?iPPEARED THAT HER MOVEMENTS WERE SLOW AND DELIBERATE. WHILE SPEAKING WITH 3ILES OUTSIDE OF THE VEHICLE THIS OFFICER COULD SEE TWO 50 ML BOTTLES OF YAGERMEISTER ALCOHOL, ONE OF WHICH WAS ON THE DRIVER'S FLOORBOARD, THE JTHER WHICH WAS WEDGED BETWEEN THE DRIVER'S SEAT AND THE DOOR JAM OF THE VEHICLE. THIS OFFICER ASKED GILES ON MORE THAN ONE OCCASSION WHAT HAD 3APPENED AT WHAT POINT SHE COULD ONLY INDICATED THAT SHE WAS TURNING INTO THE TRINITY LUTHERAN CHURCH FOR AN AA MEETING AND WAS USING HER TURN SIGNAL. 37ILES REFERRED A COUPLE OF TIMES TO THE OTHER DRIVER WHICH SHE CLAIMS WAS SPEEDING. THIS OFFICER ASKED GILES IF SHE HAD ANY ALCOHOL TO DRINK AT WHICH TIME SHE DENIED HAVING ANY ALCOHOL. PHIS OFFICER NOTED THAT GILES HAD MODERATE TO MAJOR FRONT END DAMAGE ON HER JEHICLE AS RESULT OF THE IMPACT AND THAT HER DRIVER AND PASSENGER AIR BAGS 4ERE DEPLOYED. ACCORDING TO GILES SHE WAS THE ONLY OCCUPANT IN THE VEHICLE AT PHE TIME OF THE CRASH AND WAS WEARING HER SEAT BELT. 3ASED ON THIS OFFICER'S OBSERVATIONS THIS OFFICER INFORMED GILES THAT THERE VOULD BE AN INVESTIGATION CONDUCTED BY THIS OFFICER TO DETERMINE IF GILES IS )RIVING UNDER THE INFLUENCE OF ALCOHOL. %FTER A PRELIMINARY BREATH TEST AND STANDARDIZED FIELD SOBRIETY TESTS GILES VAS ARRESTED FOR DRIVING UNDER THE INFLUENCE OF ALCOHOL. GILES WAS PLACED IN {'HE REAR OF PATROL CAR #1. '.THIS OFFICER RETURNED TO THE ACCIDENT SCENE AND NOTED THAT BOTH VEHICLES WERE kT REST AT APPROXIMATELY 34 YARDS FROM THE ENTRANCE TO THE TRINITY LUTHERAN =RCH WHERE GILES WAS ATTEMPTING TO TURN INTO. BOTH VEHICLES HAD MODERATE TO MAJOR FRONT END DAMAGE AND NEITHER ONE OF THE VEHICLES WERE DRIVEABLE. 3ECKER'S SERVICE CENTER RESPONDED AND TOWED BOTH VEHICLES BACK TO THEIR SERVICE CENTER. BOTH VEHICLES ALSO HAD AIR BAG DEPLOYMENT. TAMIE KOPPENHAVER WAS TRANSPORTED TO THE HOLY SPIRIT EMERGENCY DEPARTMENT THERE SHE WAS SUBQUENTLY ADMITTED AND GAVE BIRTH TO HER CHILD, THAT BEING A ?REMATURE BABY BOY. ACCORDING TO BENJAMIN KOPPENHAVER THE PREMATURE BIRTH WAS )UE TO THE RESULT OF THE TRAFFIC ACCIDENT. 'HIS OFFICER DID USE MARKING PAINT TO MARK THE VEHICLES WHERE THEY RESTED kFTER IMPACT ON MARKET STREET AND DID TAKE PHOTOGRAPHS USING THE DEPARTMENTAL -SSUED DIGITAL CAMERA. IHILE GILES IN CUSTODY THIS OFFICER DID TRANSPORT HER TO THE CUMBERLAND COUNTY ;ENTRAL PROCESSING CENTER WHERE HE WAS DETERMINED THAT GILES HAD A LEGAL BLOOD ALCOHOL CONCENTRATION OF 0.201. 'HIS OFFICER WILL SUMMONS GILES THROUGH DISTRICT COURT 09-1-02 FOR DUI AND )THER OFFENSES DEEMED APPROPRIATE. 7PON RETURNING TO THE CAMP HILL BOROUGH POLICE DEPARTMENT THIS OFFICER :ONTACTED TWO WITNESSES WHO WITNESSED THE ACCIDENT AND STOPPED AND PROVIDED 'HEIR NAMES AND PHONE NUMBERS. THOSE TWO WITNESSES WERE IDENTIFIED AS LINDA :UTHERFORD AND NANCY BIGELOW. IN SPEAKING WITH RUTHERFORD SHE INDICATED SHE IAS IN THE TRINITY LUTHERAN PARKING LOT AND OBSERVED GILES IN HER SUBARU TURN >IRECTLY IN FRONT OF THE FORD F250. RUTHERFORD BELIEVED THAT GILES DID HAVE IER HEADLIGHTS ON AND NOTED SHE DID NOT NOTICE ANY EXCESSIVE SPEED FROM THE METRO THE HARRISBURG AREA POLICE INFORMATION RESOURCE SYSTEM (CRSIPINC) PAGE: 4 CRASH REPORT 01/29/07 DKL1 CAM1 CRASH NUMBER: F0007003 INCIDENT NUMBER: 20061100304 CAM -------------------------------------- -------------- FORD AS IT TRAVELED EASTBOUND ON MARKET STREET. PHIS OFFICER SPOKE WITH BIGELOW ON THE PHONE WHO WAS DIRECTLY BEHIND THE KOPPENHAVER'S TRAVELING EASTBOUND ON MARKET STREET. ACCORDING TO BIGELOW SHE 4AS FOLLOWING KOPPENHAVER FROM AROUND 22ND STREET AND ALTHOUGH SHE WAS UNSURE DF THEIR SPEED SHE KNOWS THAT THERE WAS NO EXCESSIVE SPEED OR ANYTHING OUT OF rHE ORDINARY WITH HOW FAST HERSELF AND THE KOPPENHAVER'S WERE TRAVELING. kCCORDING TO BIGELOW SHE COULD SEE THE HEADLIGHTS FROM THE SUBARU WHICH 7ROSSED IN FRONT OF KOPPENHAVERIS VEHICLE. BIGELOW INDICATED SHE PREDICTED rHE ACCIDENT PRIOR TO IT EVEN HAPPENING, UPON SEEING THE HEADLIGHTS FROM THE 3UBARU CROSS INTO THE PATH OF KOPPENHAVER'S TRUCK. BIGELOW INDICATED THAT THE COPPENHAVER'S NEVER HAD A CHANCE TO EVEN BRAKE PRIOR TO THE IMPACT AS IT ALL 4APPENED SO FAST. BIGELOW WAS CERTAIN THAT THE KOPPENHAVER'S WERE NOT DRIVING IN EXCESS OF THE POSTED SPEED LIMIT OF 25 MPH. )N WEDNESDAY, NOVEMBER 29, 2006, THIS OFFICER DID COMPLETE A CHPD FORM 02-02 1ND DID MAIL A COPY OF THAT FORM TO GILES AND TO KOPPENHAVER. DUE TO THE JNUSUAL CIRCUMSTANCES OF THIS INCIDENT THIS OFFICER WILL CONTACT THE -7UMBERLAND COUNTY DISTRICT ATTORNEY'S OFFICE REGARDING THE CIRCUMSTANCES. ------------------------ UNIT NUMBER: 01 TYPE: O1 COMMERCIAL VEH: N ------------------- OWNR NAME: GILES REBECCA E 7172335185 OWNR ADDR: 1229 NORTH 3RD STREET HARRISBURG PA 17102 VIN: JFlSF6357XG717472 YR: 1999 MAKE: 48 LIC PLATE: DXB0088 PA TRAV SPD: 999 INS CO,PO,PH: ALLSTATE 908868902 6106872103 TOW TO,BY,PH: 3150 GETTYSBURG RD, CAMP BECKER'S SERVICE CENTER 7177615738 # TRL UNITS: 0 TYP UNIT: TAG NO,YR,ST: TYP UNIT: TAG NO,YR,ST: VEHICLE COL: 05 TYP: 01 SPEC USAGE: 00 ROLE: 3 POSITION: 07 INIT IMP PT: 01 DAMAGE: 3 DIR TRAV: W MOVEMENT: 12 GRAD: 1 ALIGNM: 1 ALCOH,DRG SUSP: 2 TEST TYP: 2 RESULT: 20 PHYSICAL COND: 1 OWNER/DVR CD: 01 DVR PRESENCE: 1 PEDESTRIAN SIGNAL: PED LOC: VIOLATION CD: 75 3802 Al CHARGED: Y VIOLATION CD: 75 3322 CHARGED: Y HARM EVENT 1: 02 L/R: MHE: Y UTIL POLE##: DRIVER ACTION 1: 05 HARM EVENT 2: L/R: MHE: UTIL POLE#: DRIVER ACTION 2: HARM EVENT 3: L/R: MHE: UTIL POLE#: DRIVER ACTION 3: HARM EVENT 4: L/R: MHE: UTIL POLE#: DRIVER ACTION 4: VEH FAILURES: 00 (45F1) DVR RESTRICTIONS COMPL: DVR ENDORSEMENT COMP PEDEST ACTION L: DVR LICENSE COMPL: AVOIDANCE MANEUVER: UNDER RIDE INDICATOR: EMERGENCY USE: DRUG TEST TYPE: RESULTS: PRINCIPLE IMPACT PT: METRO THE HARRISBURG AREA POLICE INFORMATION RESOURCE PAGE 5 SYSTEM (CRSIPINC) : CRASH REPORT 01/29/07 DKL1 CAM1 CRASH NUMBER: F0007003 INCIDENT NUMBER: 20061100304 -------------------------------------------------------- CAM ---------------- ----------------- ----------------- UNIT NUMBER: 02 TYPE: 01 COMMERCIAL VEH: N ------ ---------------------- OWNR NAME: KOPPENHAVER BENJAMIN J 7175036701 OWNR ADDR: 1044 WALNUT STREET A-5 LEMOYNE PA 17043 VIN: 1FTNX21LOlEC35041 YR: 2001 MAKE: 12 LIC PLATE: YNS5993 PA TRAV SPD: 025 INS CO,PO,PH: ALLSTATE 90186398808/15 TOW TO,BY,PH: 3150 GETTYSBURG RD, CAMP BECKER'S SERVICE CENTER 7177615738 # TRL UNITS: 0 TYP UNIT: TAG NO,YR,ST: TYP UNIT: TAG NO,YR,ST: VEHICLE COL: 01 TYP: 01 SPEC USAGE: 00 ROLE: 3 POSITION: 01 INIT IMP PT: 12 DAMAGE: 3 DIR TRAV: E MOVEMENT: 01 ALCOH DRG SUSP 1 GRAD: 1 ALIGNM: 1 , : TEST TYP: 0 RESULT: OWNER/DVR CD: 01 DVR PRESENCE 1 PHYSICAL COND: 0 : PEDESTRIAN SIG VIOLATION CD: NAL: PED LOC: CHARGED: HARM EVENT 1: 01 L/R: MHE: Y UTIL POLE#: DRIVER ACTION 1: 00 HARM EVENT 2: L/R: MHE: UTIL POLE#: DRIVER ACTION 2: HARM EVENT 3: L/R: MHE: UTIL POLE#: DRIVER ACTION 3: HARM EVENT 4: L/R: MHE: UTIL POLE: VEH FAILURES: 00 DRIVER ACTION 4: (45F1) DVR RESTRICTIONS COMPL: DVR ENDORSEMENT COMPL: PEDEST ACTION DVR LICENSE COMPL: AVOIDANCE MANEUVER: UNDER RIDE INDICATOR: EMERGENCY USE: DRUG TEST TYPE: RESULTS: PRINCIPLE IMPACT PT: METRO THE HARRISBURG AREA POLICE INFORMATION RESOURCE SYSTEM (CRSIPINC) PAGE: 6 CRASH REPORT 01/29/07 DKL1 CAM1 CRASH NUMBER: F0007003 INCIDENT NUMBER: 20061100304 CAM ------------------- _____ ------------------- * * * * * * * * * * * * PEOPLE INFORMATION PERSON TYPE: 1=DRIVER 2=PASSENGER 7=PEDESTRIAN 8=OTHER* 9=UNKNOWN INJ SEVERITY: 0=NONE 1=KILLED 2=MAJOR INJ 3=MODERATE 4=MINOR 9=UNK UNIT NO: 01 PERSON NO: 01 TYP: 1 INJ SEVERITY: 0 DOB: 19711127 SEX: F NAME (L,F,M,S): GILES REBECCA E ADDRESS: 1229 NORTH 3RD STREET PHONE: 7172335185 HARRISBURG PA 17102 DRIVER LICENSE: PA 22565500 SEAT POSN: 01 SAFE-EQ1,2: 03 01 EJECT: 0 EJ-PATH: 0 EXTRIC: 0 TRANSP: N UNIT NO: 02 PERSON NO: 01 TYP: 1 INJ SEVERITY: 0 DOB: 19800404 SEX: M NAME (L,F,M,S): KOPPENHAVER BENJAMIN J ADDRESS: 1044 WALNUT STREET A-5 PHONE: 7175036701 LEMOYNE PA 17043 DRIVER LICENSE: PA 25295976 SEAT POSN: 01 SAFE-EQ1,2: 03 01 EJECT: 0 EJ-PATH: 0 EXTRIC: 0 TRANSP: N UNIT NO: 02 PERSON NO: 02 TYP: 2 INJ SEVERITY: 3 DOB: 19800607 SEX: F NAME (L,F,M,S): KOPPENHAVER JAMIE L ADDRESS: 1044 WALNUT STREET A-5 PHONE: 7173951482 LEMOYNE PA 17043 SEAT POSN: 03 SAFE-EQ1,2: 03 01 EJECT: 0 EJ-PATH: 0 EXTRIC: 0 TRANSP: Y UNIT NO: 02 PERSON NO: 03 TYP: 8 INJ SEVERITY: 9 DOB: 20061128 SEX: M NAME (L,F,M,S): KOPPENHAVER HARRISON J ADDRESS: 1044 WALNUT STREET A-5 PHONE: 7173951482 LEMOYNE PA 17043 SEAT POSN: 03 SAFE-EQ1,2: 03 01 EJECT: 0 EJ-PATH: 0 EXTRIC: 0 TRANSP: Y Camp Hill Borough Police Crash Report Form Crash* F DD07 Q3 Incident #-2006=1 L-104 Agency Code 4j)j_ Date ll/27/2DD6 Arrival Time 1920 3M Investigatinq Officer rnnr n rrmc Agency Name Ca p Hill Police Want Badge # 17 hCampHillPoliceCrashForm.p65 COPY 1 - PennDOT EXHIBIT ??2" Holy Spirit Hospital Neonatology Patient name: Koppenhaver, Boy Michael Paszek, M.D. Birth date: 11/28/06 Fabio Olarte, M.D. Admitting date 11/28/06 Estela Prudencio, M.D. Discharge Date: 12/16/06 Linda Good, NNP Summary date: 12/16/06 Earla Bucher, NNP 717 763-2205 (NICU) 717 972-4501 (Office) This a case of a 35 Weeks Pretenn Newborn Male who was born to a 26 y/o G2POO 10, white, married, 0 positive, RPR NR, Rubella immune, HBsAg negative, Grp B Strep unknown female who presented for observation following a motor vehiclar accident involving a head on collision. As she was observed, spontaneous rupture of membranes occurred. This progressed into labor. DOUROM 8 %s hrs. Prenatal course is unremarkable. Baby was born by SVD with Apgars of 9 and 9 at 1 and 5 minutes. Routine care was done at delivery consisting of drying with wall and bulb suctioning. AOG 34 6/7 weeks. EDC 1/2/07. He was pink and vigorous in room air. Initial BBGT was 80. He was given to mother, then transported to the NICU for prematurity. Birth Parameters: HC 29 cm (10-25%) 11.5 in L 46 cm ( 50-751/6) 18 in Wt 2175 gm ( 50%) 4lbs 12.7 oz Course in the NICU: Respiratory: Baby was noted to have periodic breathing/ apneic episodes with HR decrease to the 90s and 80s with no desaturations. This was attributed to mother receiving Nubain during labor.This subsequently resolved. ID. Sepsis work up was done and antibiotics was started. Grp B Strep status was unknown and mother received 2 doses of Ampicillin with the second dose given about 1 hour and 40 min before delivery. Initial CBC showed WBC 13,400 39Seg 29Lymph 2013ands 9Monos 1 Eos 244,000 platelet count 16.2/44.4 H/H. Blood culture was negative. Placental pathology showed no pathology. Baby received antibiotics for 3 days. Jaundice. Baby was jaundiced on day 2. He was on phototherapy for about 24 hours. Peak bili was I I.O. Last bill was 5.9 on 12/10/06. Mother is O positive and Baby is A positive. Apnea. Baby had intermittent episodes of apnea and bradycardia, some associated with feedings and others spontaneous. This later resolved and improved as suck and swallow incoordination improved. Last episode of As and Bs were 9 days ago. No intervention recommended at this time Page 1 Holy Spirit Hospital CamP ML re nsyhm" DISCHARQ SUMMARY KOPPENHAVER BABY BOY 0 M PRUDENCIO MARIA ESTEL/28/2006 NSC 574690 11/28/06 289026 56 3WST Koppenhaver, Baby Boy Nutrition. Baby was initially NPO and started on IVF. He was started on small feedings which were gradually advanced. He was on full feedings by day 3. He was on Enfamil lipil then Breastmilk up to 180 ml/kg/day. He did well breastfeeding with supplementation. Physiologic weight gain was noted. Anemia. Initial H/H was 16.2/44.4 on admission. Last H/H on 12/12/06 showed 12.3/33.8 retic cout of 1.8%. Polyvisol with iron was started lml once daily. Newborn Screen. State Metabolic screen is pending. Hearing screen passed. Head US on day3 was normal. Car seat test passed. Physical Examination Head circumference:32.5cm Heart rate: 142/min Length:46.5 cm Respiratory rate: 50/min Weight: 2584 grams(5lbs 11.1oz) Blood pressure: 72/50(50) Temperature: 36.9 Head: Fontanel soft. Eyes: Pupils equal in size. Bilateral red reflex present. Mouth: Normal. Neck: Normal. Chest: Normal. Heart: Regular, no murmur. Lungs: Equal breath sounds. Abdomen: Soft, no mass. Extremities: Normal. Good femoral pulses. Neg Ortolani. Neuromuscular: Good tone and activity. Genito urinary: Normal male. Circuncised Skin: Normal. DX: 1. 35 Weeks Preterm Newborn Male AGA 2. Respiratory Depression, Transient 3. Sepsis, ruled out 4. Hyperbilirubinemia, Physiologic 5. Apnea of Prematurity, resolved 6. Anemia, Physiologic Page 2 Holy Spirit Hospital camp ®. tbausylvaula DISCRAIM SUMMARY KOPPENHAVER BABY BOY 0 M 11/28/2006 PRUDENCIO MARIA ESTEL NSC 574690 11/28/06 28902658 3WST Koppenhaver, Boy Plan: 1. Follow-up with Dillsburg Family Practice in 3-5 days 2. Continue Breastmilk/ Breastfeeding ad lib q 3hours, supplement as needed 3. Continue Polyvisol with iron 1 ml OD po 4. For outpatient immunizations Ama. Estela O. Prudencio MD Page 3 Holy Spirit Hospital Camp ®, res"Ovaela DLSCBAAGZ SUiY URY KOPPENHAVER BABY BOY 0 M 11/28/2006 PRUDENCIO MARIA ESTEL NSC 574690 11/28/06 28902658 3WST HOLY SPIRIT HOSPITAL KOPPENHAVER BABY BOY 574690 28902658 Gender : Male Age :0 Disposition : Home, Self Care (1) Disch Date :12116/2006 Medicare ORG 387 PREMATURITY W MAJOR PROBLEMS CMS wt 3.1771 A/LOS 13.3 G/LOS 13.3 Principal Diagnosis *V3000 Single livebom, bom in hospital Secondary Diagnoses '77181 Septicemia (sepsis) of newborn *76528 35-36 completed weeks of gestation 77089 Respiratory problems after birth 7746 Unspecified fetal/neonatal jaundice 77082 Apnea of newborn 7766 Anemia of prematurity Principal Procedure ?sy?s 640 Circumcision dA j W1 ?/6--l `f r yi?v\ EXHIBIT 1% 3" V ALL&TATE INDEMNITY COMPANY PO BOX 440519 KENNESAW GA 30160 WAIIStefie. 1buV*in good hsndL EXPLANATION OF MEDICAL BILL PAYMENT Service Provided For: HARRISON KOPPENHAVER 1044 WALNUT STREET A LEMOYNE PA 17043-1433 Date: Bill Received Date: Claim #: File Handler: Invoice #: Eligible Injured Person: Treatment Rendered By: Provider Specialty: TIN: 01/08/2007 01/02/2007 1555618337-03 20L 28902658 HARRISON KOPPENHAVER HOLY SPIRIT HOSPITAL 23-1512747 Diagnosis codes VV30.00 765.28 SINGLE DISORD LIVEBORN, BORN IN HOSPITAL, ERS RELATING !'O 35 3 DELI 771.81 SEPTICEMIA (SE PSIS) OF NEWBORN - 8 COMPLET ED W 770.89 OTH ER RESPIRATORY PROBLEMS AFTER BIRTH Date Of Service Code/ Procedure/Revenue Modifier Description i Type Of Billed Covered Reason Un ts Service Amount Amount Code(s) 11/28/06 11/28/06 99436 99295 Attendance at delivery (w 1.00 $ 300.00 $ 0.00 X202 11/29/06 99233 Initial inpatient neonata Subsequent hospital car 1.00 1 00 $ 2639.00 $ 0.00 X202 11/29/06 99233 e, Subsequent hospital care, . 4.00 $ $ 300.00 1200 00 $ $ 0.00 0 0 X202 12/12/06 12/04/06 99233 99232 Subsequent hospital care, 1.00 $ . 300.00 $ . 0 0.00 X202 X202 12/04/06 99232 Subsequent hospital care, Subsequent hospital car 1.00 7 00 $ 180.00 $ 0.00 X202 12/13/06 99232 e, Subsequent hospital care, . 1.00 $ $ 1260.00 180 00 $ $ 0.00 0 0 X202 12/13/06 12/16/06 99232 99239 Subsequent hospital care, 2.00 $ . 360.00 $ . 0 0.00 X202 X202 Hospital discharge day ma 1.00 $ 141.00 $ 0.00 X202 Total: $ 6860.00 $ 0.00 Reason Cade (s) : X202 Policy benefits have been exhausted. *** Fraud Prevention - Pennsylvania warning *** The enclosed payment has been calculated in accordance with Section 1797 of the Pennsylvania Autc Insurance Reform Act (House Bill 121). Any person who knowingly and with intent to injure or defraud any insurer, files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000.00. If you have any questions about this claim, please contact your file handler, LINDA BAUGH at (366) 575-4363 Copy(s) of this Explanation of Benefits has been sent to: HARRISON KOPPENHAVER, 1044 WALNUT STREET A, LEMOYNE, PA, 17043-1433 HOLY SPIRIT HOSPITAL, 503 N 21ST ST, CAMP HILL, PA, 17011-2288 070100 M29R1818 0000821 OOM OOM ALL'STATE INDEMNITY COMPANY PO BOX 440519 WAII. KENNESAW GA 30160 Moore in owd hwxk Mai I Date: 01/08/2007 Bill Received Date: 01/02/2007 Service Provided For: HARRISON KOPPENHAVER Claim #: 1555618337-03 1044 WALNUT STREET A File Handler: 20L LEMOYNE PA 17043-1433 Invoice #: 28902658 Migible Injured Person: HARRISON KOPPENHAVER Treatment Rendered By: HOLY SPIRIT HOSPITAL Provider Specialty: TIN: 23-1512747 Diagnosis Codes- V30.00 SINGLE LIVEBOP.N, BORN IN HOSPITAL, DELI 64.0 CIRCUMCISION 771.81 SEPTICEMIA (SEPSIS) OF NEWBORN 765.28 DISORDERS RELATING TO 35-38 COMPLETED W 770.89 OTHER RESPIRATORY PROBLEMS AFTER BIRTH 774.6 UNSPECIFIED FETAL AND NEONATAL JAUNDICE 770.82 OTHER APNEA OF NEWBORN 776.6 ANEMIA OF PREMATURITY Date Of Procedure/Revenue Type Of Billed Service Code/Modifier Description Covered Reason Units Service Amount Amount Code(s) 11/29/06 0172 Nursery Newborn Level 1.00 $ 580.00 $ 0.00 87 11/28/06 0173 Nursery Newborn Level 17.00 $ 25500.00 $ 0,00 87 11/28/06 0250 Pharmacy General 21.00 $ 361.25- $ 0.00 87 11/28/06 0270 Medical/Surgical Supplies 20.00 $ 250.74 $ 0.00 87 11/28/06 0272 Medical/Surgical Supplies 37.00 $ 407.86 $ 0.00 87 11/28/06 0300 Laboratory - General 49.00 $ 2848.00 $ 0.00 87 12/01/06 0402 Other Imaging Services - 1.00 $ 738.00 $ 0.00 87 11/28/06 0636 Pharmacy - Drugs Requirin 1.00 $ 6.50 $ 0.00 87 11,/28/06 0960 Professional Fees - Gener 20.00 $ 6860.00 $ 0.00 87 11/28/06 DRGVL Diagnostic Related Group 1.00 $ 0.00 $ 10000.00 X202 Total: $ 37552.35 $ 10000.00 Eligible Amount Based on 100% Coverage $ 10000.00 Reason Code(s): X202 Policy benefits have been exhausted. 87 This line is included in a Diagnostic Related Group (DRG) calculation. *** Fraud Prevention - Pennsylvania Warning *** The enclosed payment has been calculated in accordance with Section 1797 of the Pennsylvania Auto Insurance Reform Act (House Bill 121). Any person who knowingly and with intent to injure or defraud any insurer, files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000.00. If you have any questions about this claim, please contact your file handler, LINDA BAUGH at (866) 575-4363 Payment for $ 10000.00 was made on 01/08/2007 to: HOLY SPIRIT HOSPITAL Copy(s) of this Explanation of Benefits has been sent to: HARRISON KOPPENHAVER, 1044 WALNUT STREET A, LEMOYNE, PA, 17043-1433 HOLY SPIRIT HOSPITAL, 503 N 21ST ST, CAMP HILL, PA, 17011-2288 S 07010800042981818 0000819 0002 0004 EXHIBIT "4" nl!31!2(I(17 10:45 F?? 503'20845?J .......................................... ............ REGE\CE SL'BRCIG?TIUN DEPT . 003 Your Regence BlueCross BlueShield of Oregon (Regence BCBSO) health benefit plan includes a subrogation or reimbursement provision which stipulates that if Regence BCBSO makes any payments on your behalf for injuries caused by another party, Regence BCBSO is entitled to recover those payments from the other party or from any settlement that results from claiming the injury. I understand that if I or any of my covered dependents have been injured by another party, the benefits of my health benefit plan will be available to me or my covered dependent, subject to the terms, limitations, and exclusions of the plan. As a condition of those payments, I and/or my covered dependent agree to cooperate with Regence BCBSO in its efforts to recover the benefits from the responsible party. I agree to reimburse Regence BCBSO the amount of benefits paid as stated in the health benefit plan, subject to applicable law. Benefits for continued treatment of the injury may be excluded under the plan after a settlement. Please refer to your benefits booklet (health benefit plan) for specific details- I hereby authorize Regence SCBSO and anyone acting on its behalf to release any information about my accident and the benefits and medical service I received in connection with my accident to any persons who may be liable to me, my injured dependent, Regence BCBSO, and to the insurance company of any such person, and any insurance company that provides coverage for injuries related to this accident. I further authorize my insurance company to release any information concerning my coverage to Regence BCBSO_ I also authorize Regence 8CBSO to review any workers' compensation claims files. pertaining to me so that Regence BCBSO can determine whether workers' compensation coverage is available for any of my injuries. certify that the information on this form is true and accurate to the best of my knowledge. J Subscriber Signature Date Identification Number Address 01-7) 7.3i-/Ye)3' Home Phone ?-tmo-i ne • P4 Work Phone 9 U? I ure Dependent/Guardian Signature Dat Relationship r e r O F C) ? Q I J .? JUN 2 7 2001 X HARRISON JAMES KOPPENHAVER, a minor, by his parents and guardians, BENJAMIN J. KOPPENHAVER and JAMIE L. KOPPENHAVER, Plaintiffs V. REBECCA ELIZABETH GILES, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW 67 - 3?.L O s L £?'t ORDER AND NOW, this _A day of T,?A ?, , 2007, upon presentation and consideration of the within Petition, IT IS HEREBY ORDERED AND DECREED as follows: 1. The Petition for Court Approval of a Minor's Settlement in the above action is hereby approved. 2. The distribution of the sum of Fifteen Thousand and 00/100 ($15,000.00) shall be as follows: (a) $236.42 to Gregory R. Reed, Esq. for out-of-pocket expenses for medical records and Prothonotary costs; (b) Minimum amount possible for Minor Plaintiff's medical bills and/or subrogation claim; (c) The balance, if any, to Benjamin J. Koppenhaver and Jamie L. Koppenhaver, parents and natural guardians of Harrison James Koppenhaver, a minor, to be invested in a segregated account of Harrison James Koppenhaver until he is at least eighteen (18) years of age, with no withdrawals from said account until Minor Plaintiff's eighteenth birthday except upon order of this court. ?y s eat LLI 7 { Lf On iJ iws cli y c?+ 3. Petitioners are authorized to execute a good and sufficient Release for all claims against Defendant (except restitution, if any, ordered in the criminal proceeding) and her insurer for all claims arising as a result of the personal injuries sustained by Minor Plaintiff, Harrison James Koppenhaver. BY THE COURT, Gregory R. Reed, Esquire 3120 Parkview Lane Harrisburg, PA 17111 (717) 238-0434 lawoffice(a)epix-net HARRISON JAMES KOPPENHAVER, : IN THE COURT OF COMMON PLEAS a minor, by his parents and guardians, : OF CUMBERLAND COUNTY, BENJAMIN J. KOPPENHAVER and : PENNSYLVANIA JAMIE L. KOPPENHAVER, : CIVIL ACTION - LAW Plaintiffs V. : NO. 07-3826 Civil Term REBECCA ELIZABETH GILES, UNDERINSURED CLAIM Defendant PETITION FOR APPROVAL OF THE SETTLEMENT OF A MINOR'S UNDERINSURED CLAIM NOW comes Benjamin J. Koppenhaver and Jamie L. Koppenhaver, his wife, by and through their attorney, Gregory R. Reed, Esquire, and petitions the court as follows: 1. Benjamin J. Koppenhaver and Jamie L. Koppenhaver, his wife, (hereinafter collectively referred to as "Petitioners") are the parents and natural guardians of Harrison James Koppenhaver, a minor (hereinafter referred to as "Minor"), all of whom reside at 2828 West Rosegarden Blvd., Mechanicsburg, Cumberland County, Pennsylvania. 2. Minor is approximately 17 months of age having been born on November 28, 2006. 3. On November 27, 2006, at approximately 7:20 p.m., Benjamin J. Koppenhaver was operating a 2001 Ford F250 pick-up on the 1900 block of Market Street in Camp Hill, Cumberland County, Pennsylvania. 4. Jamie L. Koppenhaver, then approximately seven and one-half months pregnant, was a belted front seat passenger. 5. The Koppenhaver vehicle was traveling in the eastbound lane when a 1999 Subaru Forester, operated by Rebecca Elizabeth Giles and moving in the opposite direction, without warning or apparent reason, swerved directly into the path of the Koppenhaver vehicle resulting in a collision. 6. Rebecca Elizabeth Giles had a blood alcohol content of .201 and was charged with driving under the influence and recklessly endangering another person. 7. As a result of the aforesaid collision, Jamie L. Koppenhaver was taken to the Holy Spirit Hospital in Camp Hill where she prematurely delivered Minor in the very early hours of November 28, 2006. 8. When born, Minor weighted 4 lbs., 12.7 oz. and was placed in the Neo Intensive Care Unit. He had respiratory complications and suffered from jaundice, apnea and anemia. In the NICU he suffered continuing episodes of apnea and bradycardia. Some of the episodes were associated with his feedings because he was not fully developed and had difficulty sucking and swallowing. He was fed intravenously. On December 16, 2006, eighteen days after the accident, Minor was discharged (a copy of the discharge report is attached hereto, marked Exhibit "1" and incorporated herein by reference). 9. Minor is doing well with no present symptoms from the pre-mature birth. According to Kristina M. Wagner, M.D., Harrison's treating physician, "Harrison appears to be progressing well with developmental milestones...." A copy of Dr. 2 Wagner's January 10, 2008 letter is attached hereto, marked Exhibit "2" and incorporated herein by reference. 10. Petitioners' know of no residual physical, mental, psychological or emotional problems with Minor resulting from his premature birth on November 28, 2006. 11. Plaintiffs settled the third party claim against Rebecca Elizabeth Giles for the $15,000.00 policy limits, which was approved by this court on June 29, 2007 (a copy of the order is attached hereto, marked Exhibit "3" and incorporated herein by reference). 12. Petitioners have underinsured motorist coverage under their Allstate policy with total coverage of $50,000.00 for Minor. 13. Petitioners' propose to settle the underinsured claim for $20,000.00 which Petitioners' deem reasonable given the Minor's lack of symptoms and his normal developmental progress. 14. A statement of counsel related to the fairness and reasonableness of the proposed settlement is attached hereto, marked Exhibit "4" and incorporated herein by reference. 15. Regence Blue Cross/Blue Shield of Oregon has a subrogation claim of $1,687.60 that has been negotiated down to $1,125.12 as evidenced by an April 17, 2008 letter from Regence, a copy of which is attached hereto, marked Exhibit "5" and incorporated herein by reference. 3 16. In the third party action Petitioners' counsel waived attorney's fees because the underinsured claim seemed less than certain at that time, the $15,000 policy limits was minimal and counsel wanted to guarantee Minor a minimal damage award. 17. Petitioners' counsel waives a claim for reimbursement of expenses, which are less than $100.00, in this underinsured proceeding. 18. Petitioners' counsel's claim for fees are limited to the amount set forth in paragraph 19(b) and he will not receive additional or collateral fees as a result of the subrogation claim or from any other source whatsoever 19 Petitioners propose to distribute $20,000.00 as follows: (a) $1,125.12 to Regence Blue Cross/Blue Shield of Oregon in full satisfaction of its subrogation claim; (b) $5,000.00 to Gregory R. Reed, Esq., as a 25% contingent fee pursuant to a written Contingent Fee Agreement, a copy of which is attached hereto, marked Exhibit "6" and incorporated herein by reference; and (c) $13,874.88 to Benjamin J. Koppenhaver and Jamie L. Koppenhaver, parents and natural guardians for Harrison James Koppenhaver, a minor, to be invested in a segregated account for Harrison James Koppenhaver until he is at least eighteen (18) years of age, with no withdrawals from said account until Minor's eighteenth birthday except upon order of this court in accordance with Pennsylvania Rule of Civil Procedure No. 2039(b). 20. A copy of the proposed underinsured Release is attached hereto, marked Exhibit "T' and incorporated herein by reference. 4 WHEREFORE, Petitioners request your Honorable Court to enter an Order approving the settlement as above set forth, directing the distribution of the proceeds in accordance herewith and authorizing your Petitioners to execute a good and sufficient Release to Allstate Insurance for all claims arising as a result of the personal injuries sustained by Minor, Harrison James Koppenhaver. ? 9 Zuc? ? Gregory R. Reed,`F-squire Attorney for Plaintiffs 3120 Parkview Lane Harrisburg, PA 17111 (717) 238-0434 Attorney I.D. #23705 HARRISON JAMES KOPPENHAVER, : IN THE COURT OF COMMON PLEAS a minor, by his parents and guardians, : OF CUMBERLAND COUNTY, BENJAMIN J. KOPPENHAVER and : PENNSYLVANIA JAMIE L. KOPPENHAVER, : CIVIL ACTION - LAW Plaintiffs : NO. 07-3826 Civil Term STATEMENT OF GUARDIANS We, the undersigned parents and natural guardians of Harrison James Koppenhaver, our 17-month old son, hereby certify that we know of no residual physical, mental, psychological or emotional problems with our son resulting from his premature birth of November 28, 2006 as a result of a motor vehicle accident. Harrison is doing well and meeting all developmental milestones. We approve of the proposed settlement of $20,000.00. We hereby verify, subject to the penalties of 18 Pa. C.S. §4904 (relating to unsworn falsification to authorities), that the facts set forth above are true. 4BBejainin J. Koppenhaver amie L. oppenhaver VERIFICATION We, Benjamin J. Koppenhaver and Jamie L. Koppenhaver, hereby verify that the statements in the attached Petition for Approval of the Settlement of a Minor's Underinsured Claim are true and correct to the best of our personal knowledge or information and belief. We understand that false statements herein are made subject to the penalties of 18 Pa. C.S.§4904 relating to unsworn falsification to authorities. Date: Date: q- Z `, - D 8 Benjamin . Koppenhaver /-Oc- ?mie L. Koppenhaver EXHIBIT Holy Spirit Hospital Neonatology Patient name: Koppenhaver. Boy Michael Paszek, M.D. Birth date: 11/28/06 Fabio Olarte, M.D. Admitting datel 1/28/06 Estela Prudencio, M.D. Discharge Date: 12/16/06 Linda Good, NNP Summary date: 12/16/06 Earla Bucher, NNP 717 763-2205 (NICU) 717 972-4501 (Office) This a case of a 35 Weeks Preterm Newborn Male who was born to a 26 y/o G2P0010, white, married, O positive, RPR NR, Rubella immune, HBsAg negative, Grp B Strep unknown female who presented for observation following a motor vehiclar accident involving a head on collision. As she was observed, spontaneous rupture of membranes occurred. This progressed into labor. DOL/ROM 8 %: hrs. Prenatal course is unremarkable. Baby was born by SVD with Apgars of 9 and 9 at 1 and 5 minutes. Routine care was done at delivery consisting of drying with will and bulb suctioning. AOG 34 6/7 weeks. EDC 112107. He was pink and vigorous in roam air. Initial BBGT was 80. He was given to mother, then transported to the NICU for prematurity. Birth Parameters: HC 29 cm (10-25%) 11.5 iD L 46 cm ( 50-75%) 18 in Wt 2175 gm ( 50%) 4lbs 12.7 oz Course in the NICU: Respiratory: Baby was noted to have periodic breathing/ apneic episodes with HR decrease to the 90s and 80s with no desaturations. This was attributed to mother receiving Nubain during labor.This subsequently resolved. ID, Sepsis work up was done and antibiotics was started. Grp B Strep status was unknown and mother received 2 doses of Ampicillin with the second dose given about 1 hour and 40 min before delivery. Initial CBC showed WBC 13,400 39Seg 29Lymph 20Bands 9Monos lEos 244,000 platelet count 16.2/44.4 H/H. Blood culture was negative. Placental pathology showed no pathology. Baby received antibiotics for 3 days. Jaundice. Baby was jaundiced on day 2. He was on phototherapy for about 24 hours. Peak bili was 11.0. Last bili was 5.9 on 12/10/06. Mother is O positive and Baby is A positive. Apnea. Baby had intermittent episodes of apnea and bradycardia, some associated with feedings and others spontaneous. This later resolved and improved as suck and swallow incoordination improved. Last episode of As and Bs were 9 days ago. No intervention recommended at this time Page 1 Holy Spirit Hospital KrJ?PENHP,VER , Bh.BY BOY or Camp MUL Penn:ytvsnu 1-/2a;2ooc PRUDENCIO MARIA ESiEL NSC DLSC?[ARGE SUMMARY 574690 11/28/06 28902658 3WST %Pw Koppcnhaver, Baby Boy .. Nutrition. Baby was initially NPO and started on IVF. He was started on small feedings which were gradually advanced. He was on full feedings by day 3. He was on Enfamil hpil then Breastmilk up to 180 mVkg/day. He did well breastfeeding with supplementation. Physiologic weight gain was noted. Anemia. Initial H/H was 16.2/44.4 on admission. Last H/H on 12/12/06 showed 12.3/33.8 retie tout of 1.8%. Polyvisol with iron was started lml once daily. Newborn Screen. State Metabolic screen is pending. Hearing screen passed. Head US on day3 was normal. Car seat test passed. Physical Examination Head circumference: 32.Scm Heart rate: 142/min Ler*:46.5 cm Respiratory rate: 50/min Weight: 2584 grams(5lbs 11.1oz) Blood pressure: 72/50(50) Temperature: 36.9 Head: Fontanel soft. Eyes: Pupils equal in size. Bilateral red reflex present. Mouth: Normal. Neck: Normal. Chest: Normal. Heart: Regular, no murmur. Lungs. Equal breath sounds. Abdomen: Soft, no mass. Extremities: Normal. Good femoral pulses. Neg Ortolani_ Neuromuscular: Good tone and activity. Genito urinary: Normal male. Circuncised Skin. Normal_ DX 1. 35 Weeks Preterm Newborn Male AGA 2. Respiratory Depression, Transient 3. Sepsis, ruled out 4. Hyperbilirubinemia, Physiologic S. Apnea of Prematurity, resolved <-1 6. Anernia, Physiologic Page 2 Holy Spirit Hospital KO: PENHAVE2 , BABY BOY 0 M CAMP Hill, pConsylvada 11/28/2006 PRUDE CIO Y-kRIA ESTEL NSC DISCHARGE SUMMARY 574690 11/28/06 28902658 3WST v _1 Koppenhaver, Boy Plan: 1. Follow-up with Dillsburg Fatuity Practice in 3-5 days 2. Continue Breastu-dW Breastfeeding ad lib q 3hours, supplement as needed 3. Continue Polyvisol with iron i ml OD po 4. For outpatient immunizations /Ma. Estela O. Pruden Page 3 cio MD Holy Spirit Hospital Casnp KW, PennsylvaWs KOPPE.VIIAVF±R BABY BOY 0 M 11/28/2006 DISCHARGE SUbUdARY PRUDENC10 MARIA 3STEL NSC 574690 11/28/06 28902650 3WST DISCHARGE INSTRUCTION SUMMARY SPECIAL CARE NURSERY (NICU 11) BABY'S NAME: ` DATE OF BIRTH: t f l lag-Mo DISCHARGE DATE: I Gf IW FEEDINGS yy???? 1. FORMULA: ?? $?t _W 2. SCHEDULE: It/??`?" I IVY'S , 1 3. AMOUNT: ?? VI rnt Y1A M? ??Iltd 4. SPECIAL FEEDING INSTRUCTIONS: BIRTH DISCHARE WEIGHT: Q` (1f- ?- I P'7 ( J_!< • 1 LENGTH: a+ n ? ?& '?C HEAD CIRCUMFERENCE: V APPOINTMENTS 1. PEDIATRICIAN: U iWuALO-3 Pamm H-AveCP PHONE NO: 3:: Ip 2. HEARING SCREEN: PHONE NO: 3. EYE EXAM: PHONE NO: GENERAL CARE INSTRUCTIONS 1. Cord Care: Alcohol on cotton ball to cord with each diaper change, until cord falls off. NO tub baths until cord falls off and skin at base is dry. 2. Avoid crowds for six weeks. 3. Have visitors wash hands thoroughly before handling. Limit handling of baby by persons other than primary caregiver for six weeks. 4. Circumcision Care: Vaseline to circumcision for at least one week after discharge. Wash daily with soap and water, SIGNATU S: PHYSICIA G• V ?'?1 a? NURSE: PARENT: Y? HOLY SPIRIT HOSPITAL CAMP HILL, PA 17011 SPECIAL CARE NURSERY (NICU II) DISCHARGE INSTRUCTIONS 4. HOME CARE NURSE: AGENCY: PHONE NO: 5. SPECIALIST; PHONE NO: MEDICATIONS NAME DOSAOE t. ?Wv 44 SO/ /YAM ??17 CDC (noom) 2. MISCELLANEOUS -IF YOUR if -P A I IMP E IN PEDIATRICIAN KOPPENHA'IER ,BAY BOA / 2 8/ 2 0 6 PRUDENCIO Mp,RIR ESTEL 289036S8NSC 57*690 11/28/06 3WST FORM 211 NICU 11 (12/90) WHITE - CHART COPY YELLOW - PARENTS COPY ' A 02SCRM Neck J ? wY.. r Srsa&WThorax 17 ? Caidia+?.sculer E} ? tt k.ury?s E 0 Abdor+nen ? Q CI Q Arius 13' 13 E+iNrrNlga 13 C3 Extremltier Upper Q ? Lower 0 ? Neurological 13. - ? 7rt•-VIA 3.j ... B. j r.. j 4. 9. 5, 10. PLAN: Laboratory (circle) Blood Gases - Chest X-Ray Urinalysis / Urine Culture CBC - With Manual Differential I Blood Cultur6 CRP CSF Culture / CSF Antigen _ Serum Antigen Other Blood Type INITIAL TREATMENT. 02 Therapy- NC / NCPAP / Hood / Ventilator NPO Volume Expansion Ill Fluids Ampicillin Tobramycin Other ml / kg / day at mg r kg / dose every /J Hours mg / kg / dose every Hours KGPP WHIAVER , BABY BOY q pt 11/28/2, 006 RU11 --NCIO MARIA :ESTET_. f351' 574690 11/28/06 28902658 NNP/MID 3WS^ EXHIBIT e2d 4400 Carlisle Pike Camp Hill, PA 17011 975-9800 975-5509 Fax d? January 10, 2008 PINNACLEHEALTH FamilyCare RE: Harrison Koppenhaver DOB: 11/28/06 To Whom It May Concern: Harrison was born on 11/28/06. He was born at 30-weeks, after a motor vehicle accident induced labor. He was in the NICU for eighteen days. When he was born, his APGARs were excellent. However, he was quite premature. He did have some periodic breathing and was admitted to the NICU. His birth weight was 4 pounds, 12.7 ounces. He had some physiologic hyperbilirubinemia, some apnea prematurity and physiologic anemia. He progressed well in the NICU. He did well in the postpartum period and is doing quite well at this time. Unfortunately we do not know the full extent of depression on brain development when a child is born five weeks early. There has been some research that children continue to be delayed over time when they are premature. Harrison appears to be progressing well with developmental milestones at this time, but the ultimate consequence of his premature birth will not be fully obvious until he progresses through maturity. Sincerely, stina M. Wagner, M.D. KMW/lkd EXHIBIT (*(034)4) JUN 57 2001 HARRISON JAMES KOPPENHAVER, a minor, by his parents and guardians, BENJAMIN J. KOPPENHAVER and JAMIE L. KOPPENHAVER, Plaintiffs V. REBECCA ELIZABETH GILES, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW 67-3pa.e C?w?L7? &hay RDER AND NOW, this o 2007, upon presentation and consideration of the within Petition, IT IS HEREBY ORDERED AND DECREED as fol lows: 1. The Petition for Court Approval of a Minor's Settlement in the above action is hereby approved. 2. The distribution of the sum of Fifteen Thousand and 00/100 ($15,000.00) shall be as follows: (a) $236.42 to Gregory R. Reed, Esq. for out-of-pocket expenses for medical records and Prothonotary costs; (b) Minimum amount possible for Minor Plaintiff's medical bills and/or subrogation claim; (c) The balance, if any, to Benjamin J. Koppenhaver and Jamie L. Koppenhaver, parents and natural guardians of Harrison James Koppenhaver, a minor, to be invested in a segregated account of Harrison James Koppenhaver until he is at least eighteen (18) years of age, with no withdrawals from said account until Minor Plaintiff s eighteenth birthday except upon order of this court. 3. Petitioners are authorized to execute a good and sufficient Release for all claims against Defendant (except restitution, if any, ordered in the criminal proceeding) and her insurer for all claims arising as a result of the personal injuries sustained by Minor Plaintiff, Harrison James Koppenhaver. RV T14P 1 r)T TT?T EXHIBIT 44 4" HARRISON JAMES KOPPENHAVER, : IN THE COURT OF COMMON PLEAS a minor, by his parents and guardians, : OF CUMBERLAND COUNTY, BENJAMIN J. KOPPENHAVER and : PENNSYLVANIA JAMIE L. KOPPENHAVER, : CIVIL ACTION - LAW Plaintiffs V. : NO. 07-3826 Civil Term REBECCA ELIZABETH GILES, UNDERINSURED CLAIM Defendant STATEMENT OF COUNSEL 1. I, Gregory R. Reed, Esquire, am duly licensed to practice law in the Commonwealth of Pennsylvania. 2. I have experience representing Plaintiffs in personal injury cases. 3. I am the attorney representing all of the Plaintiffs in this matter. 4. Minor Plaintiff suffered from a premature birth but he is doing well and meeting all developmental milestones according to his treating physician. 5. As such, the undersigned counsel verily believes that the settlement proposal of $20,000.00 for the underinsured claim (plus the original $15,000.00 from the third party claim) is fair and reasonable. Date: off`/ X00 Gregory R. Reed, squire Attorney for Plaintiffs 3120 Parkview Lane Harrisburg, PA 17111 (717) 238-0434 Attorney I.D. #23705 EXHIBIT 46 5" APR-17-2008 10:31 From:REGENCE BCBS 5033918622 To:7172388469 P.1/2 201 High Street SE PO Box 12625 s w. • Regenez _ Salem, Oregon 97309 Rap?na 9NOrow B1wrBliaM a ore0an d an kid?asb uowp d ? ? Ctma aM Olw Shwa Awr?an Apr 17, 2008 Gregory Reed FAX: 1-717-238-8469 3120 Parkview Lane Harrisburg, PA 17111 Member Name: Harrison Koppenhaver Injury Date: Nov 27, 2006 Regence B1ueCross BlueShield of Oregon ID#: 949-32-6432 Group #: 808115003 Dear Mr. Reed: I am confirming our recent conversation regarding the amount of the lien on Harrison Koppenhaver. Please find enclosed a Regence BlueCross BlueShield of Oregon claims summary showing the total amount of our payments to be $1,687.60. We agree to reduce our lien to $1,125.12 to assist our member(your client) with attorney fees and cost. We will accept this amount as full satisfaction of our lien in this matter. Please feel free to contact me if I can be of further assistance to you in this matter. Sincerely, Tones Subrogation Coordinator The Regence Group Ph: 1-800-643-4512 ext: 2440 Fax: 1-877-804-8728 APR-17-2008 10:31 From:REGENCE BCBS 5033916622 Re nce BCBSO Claim Summary PO OX 12625 SALEM, OR 97309 DATE ME: 1ARRISON KOPPENHAVER TIN: 949326432 To:7172388469 P.2/2 DATE OF LOSS 11/27/06 11/26/07 FROM: ANN JONES PHONE: 503-587.2440 LAIM PROVIDER DATE OF AMOUNT AMOUNT MEMBER MBER SERVICE BILLED WE PAID BALANCE' 7 260439 KRISTINA WAGNER 11/28/06 $6,860.00 $992.60 $1,425.40 7 260462 1 QUANTUM IMAGING 1211/06 $130.00 $27.30 $11.70 7 260463 BERN MAGLIA 1216/06 $185.00 $73.50 $31.50 7 260464 HSH BIRTH PLACE 12/16/06 $141.00 $102.00 $0.00 7 947787 KRISTINA WAGNER 2/23/07 $396.00 $247.10 $105.90 7 260465 KRISTINA WAGNER 4/13/07 $386.00 $245.10 $105.36 TOTAL $8,098.00 $1,687.60 $1,679.86 'MEMBER BALANCE MAY NOT BE ACCURATE IF SERVICES WERE BY NONPARTICIPATING PROVIDERS EXHIBIT 64 6" CONTINGENT FEE AGREEMENT IT is agreed between BENJAMIN J. KOPPENHAVER and JAMIE L. KOPPENHAVER, in their own right, and as parents and natural guardians of HARRISON JAMES KOPPENHAVER, (hereinafter known as "Plaintiffs") and GREGORY R. REED, ESQUIRE, (hereinafter known as "Attorney"), as follows: 1. Plaintiff(s) engage Attorney to represent them against REBECCA ELIZABETH GILES, for injuries sustained by JAMIE L. KOPPENHAVER and HARRISON JAMES KOPPENHAVER, a minor, in an automobile accident on November 27, 2006. 2. The Attorney agrees to devote his best efforts to collect damages for injuries sustained in the above claim on behalf of the Plaintiff(s). 3. For services to be rendered by the Attorney and in the event Attorney obtains a settlement or verdict in favor of Plaintiff(s), Plaintiff(s) agree to pay to the Attorney a contingent fee of Twenty-Five (25%) Percent of all monies collected from the any insurance company before, during or after a lawsuit. 4. The Plaintiff(s) agree to be responsible for all costs incurred in the litigation which shall include but not be limited to court costs, witness fees, medical reports and testimony, photographs, photocopies, long-distance telephone calls, postage, etc. costs will be paid by Attorney and deducted from Plaintiffs' portion of any recovery. 5. In the event that the Plaintiff(s), after the Attorney has instituted court action, for whatever reason, discharges the Attorney, retains other counsel to prosecute the action, and receives a settlement or verdict, the Attorney shall be entitled to charge the Plaintiff(s) the time the Attorney has spent working the case on an hourly basis or twenty percent of any settlement or verdict the Plaintiff(s) receive, whichever is the greater sum or amount. 6. Although the Attorney shall utilize his best effort the on behalf of the Plaintiff(s), the Attorney cannot and does not guarantee any result favorable to the Plaintiff(s). IN WITNESS WHEREOF, the parties hereto have hereunto set their hands and seals the 30th day of December, 2006. Gregory R. Reed, Esq. - We, Benjamin J. Koppenhaver and Jamie L. Koppenhaver, hereby acknowledge receipt of a copy of the above Contingent Fee Agreement dated the 30th day of December, 2006. 7 Bye j mm J. Koppenhaver mie L. Koppenhaver EXHIBIT x x7l' GENF005 RECEIPT, RELEASE AND TRUST AGREEMENT UNDERINSURED MOTORIST INSURANCE - Coverage SU CLAIM # 1555618337-1327 In consideration of the payment of Twenty Thousand Dollars $20,000.00) by Allstate Insurance Company, the receipt of which is hereby acknowledged, the undersigned hereby forever releases and discharges Allstate Insurance Company from any and all liability and from any and all contractual obligations whatsoever under the coverage designated above of Policy No. 901863988 issued to Benjamin Koppenhaver by Allstate Indemnity Insurance Company and arising out of bodily injuries sustained by Jaime Koppenhaver due to an accident on or about the 27th day of November, 2006. Jaime Koppenhaver, hereinafter referred to as the Trustee, further agrees in consideration of said payment by Allstate Indemnity Company as Beneficiary to hold for the Beneficiary all rights, claims, and causes of action which the Trustee has or may have against any person or persons, organization, association or corporation other than the Beneficiary because of bodily injuries which is the subject of the claim made against the Beneficiary. The Trustee agrees to take, through any representative designated by the Beneficiary, such action as may be necessary or appropriate to recover the damages suffered by the Trustee from any person or persons, organization, association or corporation other than the Beneficiary who may be legally liable therefore, such action to be taken in the name of the Trustee, the Beneficiary to pay all costs and expense in connection therewith. It is further agreed that any monies recovered by the Trustee as the result of judgment, settlement, or otherwise, will be held in trust by the Trustee and paid to the Beneficiary, provided, however, any sum recovered in excess of the total amount paid by the Beneficiary to the Trustee under the terms of the above mentioned policy, shall be retained by the Trustee for his own use and benefit. I/we further understand and agree that this Release is inclusive of any and all present and future liens or claims for subrogation against the payments to be made in accordance with this Release. I/we understand and agree that I/we are responsible for the payment of any liens or charges against the payments to be made hereunder should any such liens, subrogation claims, or claims for expenses and charges be asserted. This includes, but is not limited to, medical expense liens, workers' compensation liens, ERISA liens, liens asserted by any federal, state, or local governmental entity or agency or any health care benefit claim. Should any person or entity make claim for payment of any liens or charges against Allstate Indemnity Company, I/we agree to indemnify and hold harmless Allstate Indemnity Company from any such liens, charges, fees, claims, attorney fees, costs, interest and any other sum. "Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and the payment of a fine of up to $15,000." GENF005 RECEIPT, RELEASE AND TRUST AGREEMENT UNDERINSURED MOTORIST INSURANCE - Coverage SU (continued) CLAIM # 1555618337-1327 "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties." IN WITNESS WHEREOF I have hereunto set my hand this day of (Seal) (Insured or Parent or Guardian Or Surviving Spouse) STATE OF COUNTY OF SS On this day of , before me personally Appeared , to me known to be the person who executed the foregoing instrument, and acknowledged that executed the same as free act and deed. My commission expires Witnesses: Notary Public ( carry the above to page 2 if it is absolutely has to be 2 pages) Accepted: By Allstate Indemnity Insurance Company - Beneficiary .-s -- _, i - - , uA: _. ,t ., .. + { 4 f Gregory R. Reed, Esq. 3120 Parkview Lane Harrisburg, PA 17111 (717) 238-0434 lawoffice()eyix.net MAY d 1 2008 /'4 ? HARRISON JAMES KOPPENHAVER, : IN THE COURT OF COMMON PLEAS a minor, by his parents and guardians, : OF CUMBERLAND COUNTY, BENJAMIN J. KOPPENHAVER and : PENNSYLVANIA JAMIE L. KOPPENHAVER, : CIVIL ACTION - LAW Plaintiffs V. REBECCA ELIZABETH GILES, Defendant NO. 07-3826 Civil Term : UNDERINSURED CLAIM AND OR DER L NOW, this 4 ` day of 2008, upon presentation and consideration of the within Petition, IT IS HEREBY ORDERED AND DECREED as follows: 1. The Petition for Approval of the Settlement of a Minor's Underinsured Claim, filed by Benjamin J. Koppenhaver and Jamie L. Koppenhaver, parents and natural guardians of Harrison James Koppenhaver, the minor, is hereby approved. 2. Distribution of the sum of Twenty Thousand and 00/100 ($20,000.00) shall be as follows: (a) $1,125.12 to Regence Blue Cross/Blue Shield of Oregon in full satisfaction of its subrogation claim; (b) $5,000.00 to Gregory R. Reed, Esq. for attorney's fees; and (c) $13,874.88 to Benjamin J. Koppenhaver and Jamie L. Koppenhaver, parents and natural guardians of Harrison James Koppenhaver, a minor, to be invested in a segregated account of Harrison James Koppenhaver until he is at least eighteen (18) years of age, with no withdrawals from said account until Minor Plaintiff's eighteenth birthday except upon order of this court. 3. Petitioners are authorized to execute a good and sufficient Release for all r.? clq ...., co c` '`? CJ underinsured motorist coverage under their Allstate policy for all claims arising as a result of the personal injuries sustained by Minor Plaintiff, Harrison James Koppenhaver. BY THE COURT, ?? ?? c ??