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03-5624
MEGAN E. CALDWELL, a minor, by L1NDA A. CALDWELL, her mother and natural guardian and LINDA A. CALDWELL in her own fight, Plaintiffs VS. BRIAN C. SPONAR, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA C1VIL ACTION - LAW JURY TRIAL DEMANDED PRAECIPE FOR WRIT OF SUMMONS TO THE PROTHONOTARY: Kindly issue a Writ of Summons against Defendant Brian C. Sponar. The Writ of Smmnons should be delivered to the Sheriff for service upon Defendant Brian C. Sponar at 7 Surrey Lane, Cumberland County, Mechanicsburg, PA 17055 METZGER, WICKERSHAM, KNAUSS & ERB, P.C. Date: October 23, 2003 By Clark DeVere, Esquire I.D. No. 68768 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorneys for Plaintiffs 291111-1 MEGAN E. CALDWELL, a minor, by LINDA A. CALDWELL, her mother and natural guardian and LINDA A. CALDWELL in her own right, iPlaintiffs VS. BRIAN C. SPONAR, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. C1VIL ACTION - LAW JURY TRIAL DEMANDED TO: Brian C. Sponar 7 Surrey Lane Mechanicsburg, PA 17055 WRIT OF SUMMONS You are hereby notified that Plaintiffs have commenced an action against you. Dated: t~---~ ~t.] t ~Lt'l~ Prothonotary 291111-1 SHERIFF'S RETURN - CASE NO: 2003-05624 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND CALDWELL MEGAN E ET AL VS SPONAR BRIAN C REGULAR CPL. TIMOTHY RETIZ , Cumberland County, Pennsylvania, says, the within WRIT OF SUMMONS SPONAR BRIAN C DEFENDANT , at 1325:00 HOURS, at 7 SURREY LANE MECHANICSBURG, PA 17055 CHARLES SPONAR, FATHER a true and attested copy of WRIT OF SUMMONS Sheriff or Deputy Sheriff of who being duly sworn according to law, was served upon the on the 31st day of October , 2003 by handing to together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 18.00 Service 6.90 Affidavit .00 Surcharge 10.00 .00 34.90 Sworn and Subscribed to before me this /~ ~ day of ~.~.~ ~¢;3_ % A.D. ! Prothonotar~ So Answers: R. Thomas Kline 11/03/2003 METZGER WICKERSHAM MEGAN E. CALDWELL, a minor, by LINDA A. CALDWELL, her mother and natural guardian and LINDA A. CALDWELL in her own right, Plaintiffs VS. BRIAN C. SPONAR, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 03-5624 CIVIL ACTION - LAW JURY TRIAL DEMANDED PETITION FOR APPROVAL OF MINOR PLAINTIFF'S COMPROMISE SETTLEMENT Pursuant to Pa. R.C.P. No. 2039, Linda Caldwell, as parent and natural guardian of Megan Caldwell, files this Petition for Court Approval of her daughter's settlement and in support thereof avers the following: 1. Petitioner Linda Caldwell is an adult individual residing at 1541 Grandview Avenue, Mechanicsburg, Cumberland County, Pennsylvania, 17055 -5914. 2. Petitioner Linda Caldwell is the parent and natural guardian of minor Plaintiff Megan Caldwell, who resides with her and who is 12 years old, having been bom on March 14, 1991. 3. Minor PlaintiffMegan Caldwell has selected Petitioner, as her parent and guardian, to represent her interests in this Petition. 4. Defendant Brian Sponar is an adult individual who resides at 7 Surrey Lane, Mechanicsburg, Cumberland County, Pennsylvania 17055. 5. On November 9, 2001, Megan Caldwell was a passenger in a car operated by her mother and Petitioner Linda Caldwell. 6. While Petitioner was waiting to turn left, her vehicle was struck in the rear by a Jeep operated by Defendant Brian Sponar. A tree and correct copy of the Police Accident Report for the motor vehicle accident on November 9, 2001 is attached hereto as Exhibit "A" and incorporated herein by reference. 7. As a result of the aforesaid accident, Megan Caldwell was taken to Holy Spirit Hospital by ambulance for complaints of neck pain, chest pain and sternum pain. After a physical evaluation and studies, Megan was discharged from the emergency department with a diagnosis of cervical sprain. 8. At the time of discharge on November 9, 2001, Megan was instructed to wear a cervical collar for support for two days, to rest and to avoid bending, lifting or any strenuous activity for two days. Additionally, Megan was instructed to apply moist heat for 15 minutes, 3 times a day and use medications as needed for pain. A true and correct copy of the ambulance and emergency room department records are attached hereto as Exhibit "B" and incorporated herein by reference. 9. After complying with the emergency room instructions, Megan's complaints resolved and she has had no further medical follow-up related to the accident. 10. Megan Caldwell has returned to her normal activities without restrictions. 11. Megan Caldwell's medical bills have all been paid through her mother's automobile insurer, State Farm and there are no liens or legal rifi~t to reimbursement for those bills. 12. While the Defendant has not admitted liability, he has offered, through his liability insurer the sm of $2,500.00 in an effort to amicably resolve Megan's claim. 2 13. Petitioner believes that the settlement offer is fair and reasonable, after consultation with her counsel, and believes it would be in the best interest of Megan to accept the offer. 14. Petitioner requests that this Honorable Court approve the compromise settlement of Megan's claim in the gross mount of $2,500.00. 15. Counsel was retained by Petitioner to represent Megan on a contingent fee basis in the amount of twenty-five percent of gross recovery. A true and correct copy of the fee agreement is attached hereto as Exhibit "C" and incorporated herein by reference. In addition, counsel has incurred the following expenses in pursuing the claim on behalf of Megan: Medical & Billing Records $ 59.82 Postage $ 3.46 Photocopies $ 26.64_ TOTAL $89.92 16. Petitioner requests that this Court approve the compromise settlement of this claim in the gross amount of Twenty-Five Hundred Dollars ($2,500.00) out of which Petitioner Linda Caldwell, as parent and natural guardian of Megan Caldwell, will receive the sum of Seventeen Hundred Eighty-Five Dollars and Eight Cents ($1785.08 ) on behalfofMegan Caldwell and their counsel will receive the sum of Seven Hundred Fourteen Dollars and Ninety- two Cents ($ 714.92 ), which includes the attorney fess and costs. 17. Petitioner proposes to place her daughter's settlement proceeds in a federally insured account at a bank, credit union or savings and loan association organized or existing under the laws of the Commonwealth of Pennsylvania in the name of her daughter. 18. Petitioner desires the funds to be made available ~Io her daughter when she attains her eighteenth birthday on March 14, 2009 except as authorized by prior Court Order. 3 19. Petitioner also has been requested to sign the Release attached hereto as Exhibit "D" upon approval of the settlement, which would release Defendant from any further claims by Megan Caldwell or on her behalf as a result of the accident at issue. 20. The Petitioner also desires to discontinue the action filed against the Defendant upon filing of the proof of deposit with the Court. 21. The Defendant concurs with the filing of this Petition and also seeks approval of the minor compromise settlement under the terms set forth above. WHEREFORE, the Petitioner respectfully requests this Honorable Court to approve the minor Plaintiff's compromise settlement and enter an Order distributing the funds as follows: (1) To be paid to Linda Caldwell, as parent and natural guardian of Megan Caldwell, for the purposes of this Order, to be placed in an insured savings account or certificate of deposit, to be marked "not to be withdrawn, assigned, negotiated, or otherwise alienated until Megan Caldwell reaches her maturity on March 14, 2009, except upon prior Order of the Court" - $1,785.08; (2) To be paid to Metzger Wickersham, P.C. for counsel fees and expenses - $ 714.92. METZGER, WICKERSH,MM, KNAUSS & ERB, P.C. Dated: January d? ,2004 By: Clark DeVere, Esquire Attorney I.D. No. 68768 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorney for Petitioners 4 REPORTING FORM 0 New Case Cibsed Page: ~ C~ Change/ ~ Yes C~ No Continuation Precinct Crash Number P022636,6 Polke Agency Patrol Zone Investi~c[ation Date (MM-DD-YYYY) I I7~'~-I'~1~ I~ Arrival Time (mi~) Investi~lator Badge Number I'1~1~1~11¢~'c~'~/~//'~/~, ~/~, I I/l~'l~l~r I Re~ew~ Badge Number ~Da~ (MM-D~ ~'.~~.~~' I I/l~l~l I~-~-I~l~'l~l '1 Coun~ Name ~ Munldpall~ Name ~ [ ~y of Week Crash Da~(MM-DDr~ Crash~(~/lita~ No~Un~ No~P~ple ~d NoK ~~t ~ Moa ~Fri ~ Tue ~ Sat ~-~-I~1olo I/II ~1~ I~1~ I ~ ~l ~ ~ ) OWed ~Unk Retable Crash NoU~ Highway Maintenance School Bus Rela~ Scho~ Zone Related PennDOT ~pe~ ~ Y~ O NO O Yes ~ No O Yes ~ NO O Yes ~ NO ~ Yes ~ NO ~n~ Number I U~or Vehicle in O H~ & Run Vehid~ O IIl~al~ Parked O ~ally hrk~ O Non - Mmrized ~ Del~e? ~pe ~-- Trans~ ~ Unit ~ Peri.tHan ~ Pede~dan on Skies. ~ Disabled From ~ in Wheel~aJr. etc ~ P~vlous ~ash ~ Train ~ Phantom Vehicle Owner ~ Name (If ~de~an. skip ~ Form ~ ~ 3 f} R MI Telephone Number Address ~ S~te Zip 0 Yes VIN M~el Year V~icle Make* Form: Uce~se Plat. ~ *l.f~r ~ List on Insu~nce Insurance Company Poli~ No I~urance Company Phone Vehicle Towed Tow~ To Towed By Tow Agen~ ~one Unit Number ~ MoOr Vehicle In Dele~? TF~ ~ Tran~ O H~ & ~un Vehicle O Illegally Pa~ O ~gal~ Parked O Non - Motorized 0 Un~ F ~1 Pede~ian ~ Pede~dan on S~tes, ~ Disabl~ From in,~lchair, etc ~ Pm~ous Crash ~ Train ~ Phantom Vehicle ~er ~ Name (ff ~des~ian, skip ~ Fo~ ~ 45 3 1) FI MI T~ephone Numar VIN Mod~ Yea~ Vehicle Make* Ll~nse Insulate Insurance Company Poli~ No Insurance ~mpany Phone Vehide Tow~ Towed To , Towed ~ Tow Agency Ph~e ~' ~OLICE cRAsH REP(~RTING FORM · ~ New AA 45 2 1 Page:~ C~) Change! Continuation Crash Number P0226366 ! [ ~ Number ~ 1=Towing Passenger Veh 6=Trailer Tag No ; Year State of Traifing L~ 2=Towing Truck 7=Semi-Trailer Units: --3=Towing Utility Trailer 8=Other ~[~ Tag No I [TagI Tag r-- 4=Mobile or Modular Home 9=Unknown Year State / 01=Blue Usaae 12=Commercial 02=Red 08=Gold 01=Automobile 11=Farm Equip 22=Horse and Buggy 00=Not Applicable passenger Carrier 03=White 09=Brown 02=Motorcycle 12=Construction Equip 23=Horse and Rider 01=Fire Veh 13=Tax~ 04=Green 10=Orange 03=Bus tS=Other Type Special Veh 24=Train 02=Ambulance 21=Tractor Trailer 03=Police 22=Twin Trailer 05=Black 11=Purple O4=Small Truck 19=Unknown Type Special Veh 2S=Trolley OR=Other Emergency 23=Triple Trailer 06=Yellow 12=Other 05=Large Truck 20=Unicycle, Bicycle, Tricycle 98=Other Vehicle 31=Modified Veh 07=Silver 99=Unknown lO=Snowmobile 21=Other Pedalcyde 99=Unknown 11=Pupil Transport 99=Unknown ilnitiallmDactPoint~ Damaaelndicator~VehicleRole~VehldePodtion 11 12 01 0=None 00=Not Applicable 10,~ ~02 00=Non-Collision 1=Miner (Driveable) O=Non-Collision 01=Right Lane (Curb) · 2=Functional 1=Striking 02=Right Turn Lane 08=Left of Trafficway 03=Left Lane 09=Right of Trafficway 09~--~ ~-03 13=Top (Moderate Damage, 2=Struck O4=Laft Turn Lane tO=-HOV Lane 0 14~Undercarriage May Not be Driveable) 3=Both Striking 05=2-Direction 11=Shoulder Right 15=Towed Unit 3=Disabling (Severe - and Struck Center Turn Lane 12=Shoulder Left 06=Other Forward 13--One Lane Road 07 06 0S 99=Unknown Not Driveable) Moving Lane 98=Other 9=Unknown 07=Oncoming Traffic Lane 99=Unknown Direction of ~ Movement ~ 07=Entering a Parked 14=Backing Up Gradient ~ 3=Downhill TravelI~JIII Position 15=Changlng LanesI.~L, I 4=Sag/Bottom of Hill 01=Going Straight 08=Trying to Avoid Animal, or Merging 1=Level Roadway S=CrastgTop of Hill S=SouthN=N°rth 02=Slowing/Stopping in Lane Pad. Object, VeL etc 16=Negotiating 2=Upbifl 9=Unknown E=East 03=Stopped in Traffic Lane 09=Turning Right on Red Cuwe - Right W=West 04=Passing/Overta~Jng Veh 10=Turning Right 17=NegotJatlng Alianment ~ 1=Straight 11=Turning Left od Red Curve - Left U=Unknown OS=Leaving a Parked Position 12=Turnhlg Left 98=OtherI ] 2=Curved 06=Parked 13=Making a U-Turn 99=Unknown 9=Unknown Year[ I Tag ~----~ Number ~'~ 1=Towing Passenger Veh 6=Trailer State of Trailing I_~ 2=Towing Truck 7=Semi-Trailer Units: 3=Towing Utility Trailer 8=Other bi I TagHo [ ] Tag -- 4=Mobile or Modular Home g=Unknown ri I Yearl I Tag [State Vehide C°lor ~-~vehide Tvne ~--~ Snecial ~T~ 01=Blue Usaae 12=Commercial 02=ROd 08=Gold 01=Automobile 11=Farm Equip 22=Horse and Buggy 00=Not Applicable ' Passenger Carrier OS=White 09=Brown 02=Motorcycle 12=Construction Equip 23=Horse and Rider 01=Fire Veh 13=Taxi 04=Groan 10=Orange 03=Bus 18=Other Type Special Veh 24=Train O2--Ambulance 21=Tractor Trailer 05=Black 11=Purple ' 04=Small Truck 19=Unknown Type Special Veh 25=Trolley 03=Police 22=Twin Trailer 08=Other Emergency 23=Triple Trailer 06=Yellow 12=Other ! OS=Large Truck 20=Unicycle, Bicycle, Tricycle RS=Other Vehicle 31=Modified Veh 07=Silver 99=Unknown 10=Snowmobile 21=OtherPedalcycle 99=Unknown 11=PupilTranspott gg=Unknown In~tlaIIml~ctPoint~..1,.. Darna~Ind'cat°r~Veh'cIeRoIe~ 0=None 00=Not Applicable 1 00=Non-Collision 02=Right Turn Lane 08=Laft of Trafficway ~:~ ~/.~ 2=Functional 1=Striking 03=Left Lane 09--Right of Trafficvvay 09 03 13=T0p (Moderate Damage, 2=Struck 04=Left Turn Lane IO=HOV Lane 0~/ ~'~,/04 14=Undercarriage May Not be Driveabi.) 3=Both Striking 05=2-Direction 11=Shoulde~ Right 15=Towed Unit 3=Oicabling (Severe - and Struck Center Turn Lane 12~Shoulder Left 06=Other Forward 13=One Lane Road 07 ~6~ 05 99=Unknown Not Driveable) Mevin~ Lane 98=Other 9=Unknown 07=Oncormng Traffic Lane 99=Unknown Direction of ~-~ Movement [ ~'~-1~--[ 07=Entering a Parked 14~Backlng Up Gradient~ 3=Downhill Travel Posit~on 15=~anging Lanes 4=Sag/Bottom of Hill N=Nocth el=Going Straight 08=Tzying to Avoid Animal, or Merging 1=Level Roadway S=CrastFop of Hill 5=South 02=Slowing/Stopping in Lane Ped0 Object, VeL etc 16=Negotiating 2=Uphill 9=Unknown E=East O3=Stopped in Traffic Lane 09=Turning Right on Red Curve - Right W=West 04=Passing/Overtaking Veh 10=Turning Right 17=Negetlat{ng Alianment ~ 1=Straight U=Unknown 05=Leaving a Parked Position 11=Turning Left on Red Curve - Left 06=Parked 12=Turning Left 98=Other 2=Curved 13=Making a U-Turn 99=-Unknown 9=Unknown " I ' ' COMMONWEALTH OF PENNSYLVANIA * POLICE CRASH REPORTING FORM ~ New AA 45 3 1 Page: ~ O Change/ Continuation Unit Na~,be~ Last Name FI MI Telephone Number Address City State Zip Li~n~ Number S~te Al~o~m~s Sus~ ~ ~an Siqnal at ~ce~ of Oash ~ No ~ Ill.al Drugs ~ M~i~tion ~ ~ No Ped~rian Signal ~ Not at Inte~e~ion ~ Alcohol ~ Alcohol and D~gs ~ UnknownE ~ P~e~rian signal Alcohol Te~ Ty~ ~ ~s~an Location ~ In Roadway ~ Road ~ Te~ N~ Given O Brea~ ~ ~her ~ ~ Ma~ed Crosswal~ at Inte~e~lon ~ Not in Roadway ~ Bl~ ~ Urine O Unkn~nif O ~ >lOF~t Te~ Given ~ ~ At Inte~ion - No ~ Median ~ Road -- C~swal~ Alcohol Test Resul~ ~ ~ Island ~ O~ide Treffi~ay ~~ ~ Te~ Refused ~ Unknown ~ Non4nta~e~ion R~ul~ Cmsswal~ ~ Shoulder ~ Sha~ Paths/ ~n~mlna~d Resu ~ ~ ~ Driveway Access ~ Sidewalk ~ Unknown D~ver or ~de~an Physl~l Condi~on Vehicle C~e Ust any Vehicle Code Se~ion ~is d~ver h~ Cha~ed with ~ ApparentlYNo~al ~ Ill.al Drug ~ Fatigue ~ Medication violat~ and ma~ ~ they were charge. ~olation7 Use 0 DHn~ng O Sick O ~leep O Unknown [ ] ~Yes ~ No ~n~er O~Not Appli~ble 03=R~ Vehicle ~h~ Municipal D~ ~s~ ~e 01=Private Vehicle ~/ ~St~ Poli~ Vehicle Ga~rnme~t Vehicle ~ 1=Driver O~rat~ 3=DHver FI~ Scene L~d by Driver 0S=PennDOT Vehicle 09=~deral Gov Vehicle I ~ I ' Vehicle ~H~ and Run 0~ivate Vehicle Not ~h~ S~ Gov V~kle 98~her Ow~/L~s~ ~ Ddver 07=Munldpal ~li~ Vehicle ~=Unknown 2-No D~ver 9=Unknown Unit Numar ~ Name FI MI Telepho~ Numar Add~s C~ S~te Zip Ucen~ Number S~ Alcoho~qs Sus~ ~ ~e~an Siqnal at $ce~ of Crash ~ 0 No P~an Signal 0 Not at Inta~on No IllegM Drugs Med?~ion O Alcohol ~ Alcohol and Drags O Unkno~ ~ ~ P~rian Signal Alcohol Te~ Ty~ ~ ~es~an L~a~o~ - ~ In Roadway O ~ 10 ~e~ ~ Te~ Not Giv~ O Brea~h O ~ber ~ O Mark~ Cms~al~ Off Road· O BIo~ ~ UH~ ~ Un~own if ~ at Inte~on ~ N~ in Ro~way Te~ Given g ~ At Inte~on - No ~ Median ~ > 10 Feet Off R~d ~cohol re~ Resu~ · ~s~al~ ~ O~ide Tramway ~ ~~ ~ Te~ R~sed ~ Unknown i ~ N°n'lnte~e~on ~ 'sta~ R~u~ C~swal~ ~ Sh~ldet ~ Sha~ Paths/ Trails · ~ Tes~ Giv~ Contra n~ R~u~ ~ ~ D~eway ~ce~ ~ ~deWalk ~ Unknown D~v~ or ~de~n Ph~i~l Cond~n ~V~ide C~e U~ any VehJde Code ~on this d~r h~ ~g~ wi~ ~ Ap~rentiy Ill.al Dr~ vlolat~ and ~ ~ ~ey were cha~. No~al ~ U~ ~ Fa~gue ~ ~i~tion ~ HadB.n t I~ Yes ~ N° Drinking ~ Sick ~ ~leep ~ Un~own L ] ~Yes ~ No Owne~river 00~Not Applicable 03=Rent~ Vehicle 08=~ Munl~pal D~r P~sence Co~ 01=Private Vehicle Owned/ ~S~ Police Vehicle ~ve~men't Vehkle ~ l~D~ver Operated 3=Driver Fled Scene ~d by D~ver 0S=~nnDOT Vehicle ~Fed~al Gov Vehicle Vehicle 4=H~ and Run 02=P~va~ Vehicle N~ ~=~e~ S~te Gov Vehicle ~er ~ned/~sed by Dzivez 07=Municipal Polke Vehicle 99=Unknown 2=No Driver 9=Un~own ' COMMONWEALTH OF PENNSYLVANIA Crash Number · POLICE CRA$,HREPO, RTING FORM ~1.e. P 0 2 2 6 3 6 6 '--] A~ 45 4.1 Page: ~ O Change/ Continuation Per~on TVDe: Seat Posit[on: Safetv EauiDrnent One: E' ion: A 1=Drivel D 00=Net A Phssenger/Occupant E 00=None US,, / NotApplicable G ~pplicable 2=Passenger 01=Driver- All Vehicles 01 =Shoulder Belt Used 1=Not Ejected 7=podestrian 02=Front Seat Middle Position 02=Lap Belt Used 2=Totally Ejected 8=Other 03=Front Seat Right Side 03=Lap And Shoulder Belt Used 3=Partially Ejected g=Unknown 04=Second ROw- Left Side Or 04=Child Safety Seat Used 9=Unknown · Motorcycle Passenger OS=Motorcycle Helmet Used 05=Second Row- Middle Position 06=Bicycle Helmet Used 5e_~; 06=Second Row- Right Side 10=Safety Belt Used Improperly .. E/ectJon Path: e F =Female 07=Third Row Or Greater - 11 =Child Safety Seat Used Imp~:operly I~ 0=Not Ejected / Not Applicable ~ - M=Male Left Side 12=Helmet Used improperly 1=Through Side Door Opening '~ U =Unknown 08=Third Row Or Greater. gO=Restraint Used. Type Unknown 2=Through Side Window Middle Position 99=Unknown S=Through Windshield 09=Third Row Or Greater - 4=Through Back Door Right Side Safety EauiDment Two: S=Through Rack Door Tailgate Opening ~ ~: 10=SleeperSectionOfTruckcab F 00=NoneUsed/NotApplicable 6=ThroughRoofOpening(Sunroof/ C 1=Killed 11 =In Other Enclosed 01 =Front Air Bag Deployed (For This Seat) Convertible Top Down) ~ Passenger Or Cargo Area 02=Side Air Bag Deployed (For This Seat) 7=Through Roof Opening (Convertible ~ 2=Major Injury 12=In Open Area 03=Other l~pe Air Bag Deployed Top Up) 3=Moderate (Back Of Pickup, Etc,) 04=Multiple Air Bags Deployed 9=Unknown · Injury 13=Trailing Unit 05=Motorcycle Eye Protection 4=Minor Injury 14=Riding On Vehicle Exterior 06=Bicyclist Wearing Elbow/Knee/ 9=Unknown 15=Bus Passenger Other Pads ] ~cable 98=Other 1*=Net Extricated 10=Air Bag Not Deployed. Switch On 99=Unknown 11=Air Bag Not Deployed. Switch Off 2=Extriceted By Mechanical Means 12=Air Bag Not Deployed, 3=Freed By Non - Mechanical Means Unk Switch Setting 8=Other ' 13=Air Bag Removed (~Prlor To (:rash) 9=Unknown 19=Unknown If Air Bag Deployed 99=Unknown Unit No Person No Date of Birth (M M~_~_L~yyyy) A B C D E F G H , [~-[~ ~ Delete? ' EMS T[ansport ' · O Yes ~ No Unit No Person No Date of Birth (MM-DD-YYYY) A B C D E F G H I ~-~ ~ Delete? EMS Transport Name/Address / Phone0 '- I I J I J--JJ--jJ--Jj--T-J J--Jj--J J--J EMSTranspo~ ~' I OYes CSH° UnitNo PersonNo D '-- - DateofBirth (MM-DD-YYYY) A B C D E · F G H I Name / Address / Phone EMS Transport EMS Transport .-'~ ' ' * COMMONWEALTH OF PENNSYLVANIA Crash Number ·POLICE CRASH REPORTING FORM' ~.ew P 0 2 2 6 AA 45 5 1 Page: ~ O Change ,'~;~=~b'un Type (~ "Y" Intersection (~ Off Ramp S. pedal Location ~) Midbiock (~ Traffic Orde/ ~ Not App cab e (~ Bridge (~ Cross Over Related ~ 4 Way intersection Round About (~ Crossover (~ Underpass (~ Tunnel (~ Driveway/Parking Lot ~ "T' Intersection {~ Multi-Leg (~ Railroad Crossing , (~ Ramp (~ Toll Booth (~) Ramp & Bridge Intersection ~ On Ramp (~ Other (if "Ramp" is indicated, please see manual) (~ Unknown Complete the ~,,:r,~;~al Road $~.~.*;.~i for all type of c;as;,,~s. For gashes at intersections, enter information in the Interse~ng Road Section or the GPS Section. If you have a midbio(k crash, you should enter information in the "Distance from Landmark' Section, the GP$ Section, or the House Number Section in the Principal Road area. County Route Number Segment (Optional) Travel Lanas Speed Umlt = ~ North House Number (if applicable) o (~ South Street Name Street Ending 0 ~ Unknown Route Siqninq (~) Interstate (~) Turnpike ~ Turnpike ~ State (~ County ~ Local Road (~) Private (~) Other/ (Not Turnpike) -- (East/Wast) Spur Highway Road or Street Road Unknown i i C°unty ~~TravelLanes SpeedUmit c .North Street Name Street Ending ~ C:) East I O Unknown ~ Route$iqninq (~ Interstate (~ Turnpike (~ Turnpike (~ State (~ County ~ Local Road (~ Private (~ Other/ :~ (Not Turnpike) (EastYtNest) Spur Highway Road or Street Road Unknown Inter;~.~.~ Rt Num Or Mile Post Or Segment Marker . ; ~ Pleese ) Or Intersec~ng S~reat Name 'st,ndiog,,OSo hl I I I I I C:) East Information for BOTH ~ Landmarks Intersecting Rt Num Or Mile Post Or Segment Marker ' This Option I O North Distance From Crash · O South Scene to Landmark 1 t ~ ~ ~,; m;er~--c, ng :~'.reet Name St Ending ~ O East (For Crash be~w~n Landma ,.nd ~ CZ) west Landmark Degrees Minutes Seconds Degrees Minu~s Seconds Tcaffic'~Control Dev~ '~- -- CZ) Stop Sign ~ Passive RR TCD Functioninq ~ Nat Applicable '--' Crossing Controls Device Functioning Emergency Flashing Traffic O Yield Sign p-~ Police Officer or ~ No Contreis (~ Improperly CZ) Preemptive Signal CZ) Signal C} Active RR Crossing ~ Flagman O Traffic Signal Controls CZ} Other Type TCD CZ) Device Not Device Functioning CZZ~ Unkrmwn Functioniog C~) Prnperly C~ Unknown Type of Work Zone elf "Not a Work Zone", skip rest of Work Zone ~-.~.'~i; Work Zone (Mark.all that apply) ~ Not a Work Zone [] Lane Closu., [] Work on Shoulder [] Flogger Control C~ Construction .Work Zone Location (~ Transition Area or Median C~ Maintenance C~ Before 1st Work [] Road Closed with [] Intermittent or [] Other Zone Warning Sign © Activity Area Detour Moving Work C~ Utility Company C~ Advance Warning C:) Termination Area Work Zone Workers C~ Other Area C~ Other ~[peedUmit L I I present C:) Yes C=) No C~ Unknown Lane Closed (If ·Not Applicable', skip cast of the Lane Closure section) ,~ ~ Not Applicable C3 Partially C:) Fully C3 Unknown Traffic Detoured C:) Yes ~l No i Lane Closure ~:~;~,~ ;st~ated nme Closed C~ 1-a hours C:~ S-1~ hours C~ No~h C~ East C:) North and South C~ < 30 Minutes C~ 3-6 hours (~ · 12 hours C:) South ~ West C~ East and West C~ 30-60 Minutes C~ G-g hours C=) Unknown I .j ' ' COMMONWEALTH OF PENNSYLVANIA Crash Number ~ '~'~"""~g POLICE CRASH REPORTING FORM ~ew P 0 2 2 6 3 6 6 "~ ~ 45 6 ] Page: ~ ~ Chaoge/ ~ Continua~on Crash Descrlotian ~ 0=Non-Collision 2=Head On 4=Angle s=Sidaswipe 8=Hit Pedestrian '~I ' I 1=Rear End s=Roar to Rear s=Sideswioe (Opposite Direction) o (Backing) ~, (Same Direction) 7=Hit Fixed Object 9=-Other/Unknown 2=Shoulder 4=Roadside s=ln Parking Lane 9=-Unknown ° r'~ 1=Daylight 3=Dark - Street s=Dawn ~ Ii/urn/nationIII 2=Dark- No Ughts s=Dark.. Unknown 8=Other = Street U~lhts 4=Dusk Roadwa~f Li~lhtin~l n~ 1 =No Adverse ~ Weather Condition~ Conditions 3=Sleet (Hail) S=FOg 7=Sleet & Fog 9=Unknown zI~ I 2=Rain 4=Snow s=Rain & Fog 8=Other ~RoadSurfaceCondition~ ~ 0=Dry 2=Sand, Mud, Dirt, 4=Slush 6=Ice Patches Oil · 8=other 7=Water. Standing 1=Wet s=Snow Covered s=lce or Movin~l Harm Event L/R Most? Utiflty PoCo Number Harmful Evene;/Harm Eventl 30=Hit Fence Or Wall I I~--~ [-~ . ~ 01=Hit Unit I 31=Hit Buitding Unit No 02=Hit Unit 2 32=Hit Culvert . OS=Hit Unit 3 3s=Hit Bridge Pier Or Abutment OS=Hit Unit 5 3s=Hit Bridge Rail OS=Hit Other Traffic Unit 36--Hit Boulder Or Obstacle Please Put Eventsin 3~ ~ C~ I I I I I I I I07=HitDeer Oneoadway Sequential OS=HIt Other Animal 37=Hit Impact Attenuator Os=Collision With Other Non 38=Hit Fire Hydrant · Fixed Object 39=Hit Roadway Equipment Order 4[----~ [~ .(~ i i i i i i I i 11=StruckByUnitI 40=Hit Mail Box 12=Strock By Unit 2 41=Hit Traffic Island 13=Struck By Unit 3 42=Hit Snow Bank Harm Event L/R Most7 Utility Pole Number 14=Struck By Unit 4 4s=Hit Temporary Construction ~ r----q ~ Is=Struck By Unit 5 Barrier 111,111 r.,l] ,1111 16=Struck By Other Traffic Unit 48=Hit other Fixed Object Unit No 21=Hit Tree Or Shrubbery 49=Hit Unknown Rxed Object 22~Hit Embankment S0=Overturn/Roll Over ilo I o 24="'t2S=Hit Utility PoleTraffic SignBI=Struck By Thruwn Or Fallingobject is=Hit Guard Rail S2=Pot Holes Or Other P/ease Put Eventsin 3~'~ ~-~ C~) ~ 27=Hit2s=HJt Guard Rail Endcurb 53--JacknlfePavement ,r~gulaHties Sequential 28=Hit Concrete Or - 54=Rre In Vehicle Longitudinal Barrier 58=other Non-Collision Order 4[~-~-]C~1 I I I [ I I I29=Hit Ditch 99=Unknown Harmful Event Left/Ria~ht (I~R) L=Left R=Right O=Other U=Unknown First Unit No Harm Event Most Unit No Harm Event Driver Actigg (D~ 16=Driving The Wrong Way Event in~ On l-Way Street ~.~ ~ 00=No Contributing Action 17=Careless Or illegal 01=Driver Was Distracted Backing On Roadway De not repeat ~lls Infownatiml on muppie pages 02=Driving Using Hand Held Phone 18=Driving On The Wrong Potential Factor~ (EIR) 1 2 3 04=Making IIIogal U-Turn Is=Making'Improper i 0Co-None OS=Improper/Careless Turning Entrance to Highway 06=Turning From Wrong Lane 20=-Making Improper Exit 01=Windy Conditions 11=Slippery Road Conditions (ice/Snow) 07=Proceediog W/O From Highway 02=Sudden Weather Conditions 12=Substance On Roadway Clearance After Stop Os=Other Weather Conditions ls=Potholas 21=Careless Parking/Unparking 04=Deer in Roadway 14=Broken Or Cracked Pavement Os=Running Stop Sign 22=Over/Under Os=Running RedUght Compensation At Curve 0S=ObstacJe On Roadway ls=TCD Obstructed 10=Failure¥o Respond To 23=Speeding Os=other Animal In Roadway 16=Soft Shoulder Or Shoulder Drop Off Other Traffic Control Device 24=DHving Too Fast For Conditions 08=Work07=Glare Zone Related 9s=Unknown2s=Other Roadway Factor 11=Tailgating 2s=Failure To Maintain Proper Speed 12=Sudden Siowing/Stoppiog 26=D~ver Fleeing Police 13=-Illegally Stopped On Road (Police Chase) Possibl~ Vehicle Failures (I/) 12=Wipers 14=Careless Passing Or Lane 27=Driver Inexperienced 00=None 06=Exhaust 13=Driver Seating/Control Change 2s=Failure To Use Specialized Equip 01=Tires 07=Heedlights 14=Body, Doors. Hood, Etc ~ Is=Passing In No Passing Zone 02=Brake System 08=Signal Ughts Is=Trailer Hitch es=Other Improper Driving Actions 03=Steering System 0g=Other Lights Is=Wheels Unit l--L'-~--1 {~'-~ [-~-] ~--~ r[ 04=Suspension 10=Horn ~17=Airbags No O~_~_J I 2 3 4 0S=Power Train 11=Mirrors 18=Trailer Overloaded 10=Improper Towing . 21=Obstructed Windshield 00=None 04=Pushing Vehicle 01=Enterlng Ch' Crossing At 05=Approaching Or Leaving Vehicle Specified Location 0s=Playin~ Or Working On Vehicle Indicated Prime Factor Unit No Factor Code 02=Walking~ Running Jogging, OT=Standmg Do not repeat this informaUon on multiple pages P ay nB, Or Cycling 98=Other EIR V D P (~ ~) . (~) IfE/RistheP~imeFoctor Unit No Fi---~ ~ Unit No [~--~ ~ Type, leave Unit NO blank COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM AA45 7.1 Page: C~) Change/ Con~nuation Q~) Delete Page Crash Number P0226366 COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM* Crash Number P022636'6 --'] C~ Change/ Continuation AA 45 8 1 Page: ~ Q Delete Page Place emergency transport, witness, and other information here. It is:not required to restate information from the form. W~ness 2: Address: ~ ' Phone: NarraUve: ~ ~ ll/lg/2001 08:04:13 PENNSYLVANIA EMS REPORT Fairview Township EMS MEGAN CALDWELL 81555443 67919 Fairview Township SSAN TRANSPORT DATE - 11/09/2001 AFFILIATE UNIT # 6700701 SERVICE INCIDENT # 0111038 P~tGE .1 PATIENT INFORMATION PATIENT MEGAN CALDWELL SEX ADDRESS 1541 GRANDVIEW AVE. DATE OF BIRTH CITY, STATE, ZIP MECHANICSBUR, PA 17055 AGE (YEARS) TELEPHONE ~ (717) 691-1497 P~ACE PRIVATE PHYSICIAN SSAN FEMALE 03/14/1991 1i N/A AFFILIATE/UNIT ~ MILF~AGE OUT MILEAGE SCENE MILEAGE DESTINATION MILEAGE IN OTHER ASSISTING UNIT: PRE-HOSPITAL PROVIDER INFORMATION 6700701 DISPATCH 76764 ENROUTE 76769 ARRIVE SCENE 76777 DEPA/{T SCENE 76778 ARRIVE DESTINATION AVAILABLE IN QUARTERS 16:49 16:50 16:57 17:22 17:36 18:00 18:20 LOCATION: DISPATCHED AS INCIDENT LOCATION MCD PRE-ARRIVAL INFORMATION CC LOWER ALLEN TWP. MAIN STREET LISBURN MCCORMICK EMERGENCY INCIDENT TYPE VEHICULAR OTHER TP~AFFIC WAY WORK RELATED? UNKNOWN FAIRVIEW TOWNSHIP REC'D BY HOLY SPIRIT HOSPITAL CONDITION ON SCENE WITNESSED ARREST? CONDITION ON ARRIVAL Minor BYSTANDER CPR?' N SAFETY DEVICES: Lap/Shoulder N PHYSICAL EXAMINATION SUSPECTED ILLNESS: INJI3RY SITE/TYPE: INJURY SITE/TYPE: INJURY SITE/TYPE: 719.49 PAIN - Multiple Sites NECK/SPINE SOFT/CLOSED CHEST SOFT/CLOSED ABDOMEN SOFT/CLOSED MEDICAL COMMAND COMMAND FACILITY ARREST TO CPR ARREST TO DEFIBRILLATION TRFJ~TMENT Protocol IV 1 FLUID IV 1 P.ATE IV 2 FLUID IV 2 RATE ~1/10/2001 08:04:14 PEArNSYLVANIA EMS REPORT Fairview Township EMS MEGAN CALDWELL 81555443 67919 Fairview Township SSAN TP~ANSPORT DATE - 11/09/2001 AFFILIATE UNIT # 6700701 -SERVICE INCIDENT # 0111038 RAGE ARREST TO ALS INITIAL EKG LAST EKG SUCCESSFUL IV'S UNSUCCESSFUL IV'S SUCCESSFUL ETT'S UNSUCCESSFUL ETT's BLS: C-Spine Stabilize Attendant ~i3 BLS: Cervical Collar Attendant ~1 BLS: Cervical Collar Attendant ~:3 BLS: C-Spine Imm. Dev. Attendant ~:2 BLS: Board-Long Attendant #1 BLS: Board-Long Attendant #2 BLS: Board-Long Attendant #3 0 0 0 TRANSPORT TO FACILITY RESPONSE OUTCOME Transported RECEIVED BY Holy Spirit Hospital TRANSPORTED AS NON EMERGENCY CONDITION AT FACILITY Stable CLASS 3 E/R INFORMATION CHIEF COMPLAINT: MVA IMPRESSION: PT. CC NECK, STER/gIJM, AND SIDE PAIN CURRENT NONE MEDICATIONS: ALLERGIES: NKDA PAST MEDICAL HISTORY: NONE KNOWN VITAL SIGNS TIME p R BP RTS RHYTHM TREATMENT PROVIDER 17:20 100 18 110/64 12 VITt~ SIGNS CREW 17:34 102/P 8 B/P A1 INTAKE OUTPUT GLASGOW COMA SCALE 0 0 Blood Loss 0 EYES 4 - Spontaneous 11/10/2001 08:04:14 PENiqSYLVANIA EMS REPORT Fairview Township EMS MEGAN CALDWELL 81555443 67919 Fairview Township SSAN TRANSPORT DATE - 11/09/2001 AFFILIATE I/NIT # 6700701 SERVICE INCIDENT # 0111038 ~AGE 3 P.O. 0 Vomitus 0 VERBAL Med's. 0 Urine 0 MOTOR TOTAL 0 0 TOTAL 5-Oriented 6-Obeys Commands 15 NARP~ATIVE D.D.- To the above location along with CC 74 and Lisburn FD by YCC class 2 for an auto accident with injuries. Amb. 68-1 advised YCC and CC that we are responding. Responded class 2 to the scene. No pt. information was given by YCC or CC. Arrival/HPI- Upon arriving on scene there were 2 vehicle to be found. Chief 24 stated that we would have 2 pt.'s one complaining of leg pain and the other complaining of neck pain. Upon approaching the pt.'s the restrained driver was found to be out of the vehicle walking around. At this: time amb. 74 took care of this pt. The second pt. was found to be sitting in the car. She was the restrained front passenger with (-) airbag deployment. At this time EMT A3 had c-spine held. The vehicle was traveling south when it was struck from behind, the rear of the vehicle had moderate rear end damage, the damage was more on the left side. The interior of the vehicle including the seat, door, dash, and windshield was intacted with no damage. PE- The pt., a 10yof, was found to be CAOx4. She at this time stated that the sides of her neck hurt. She did remember the entire accident and denies and LOC. The pt.'s ears and airway were clear of all fluids. The pt.'s head and neck had (-) deformities or trauma noted. Pt.'s chest rise was symmetrical with no pain upon inspiration or expiration. Abdomen was soft and non-tender with no masses felt. Pt. had (-) deformities or trauma noted to her chest or abdomen at this time. The pt. did complain of sternum and left rib pain upon palpation. Pelvis was stable with no crepitation. Pt.'s legs was (+) for PMS and had (-) deformities or trauma noted. The pt.'s arms had (+) PMS and (-) for deformities and trauma noted. The pt.'s skin was warm and dry to touch and was "normal" color. Pupils were = and reactive to light. Upon palpation of the pt.'s back no deformities were palpated or traum~ noted. Tx- Upon arriving on scene EMT A3 had c-spine. A pediatric c-collar was placed on the pt. The pt. was then removed from the veiiicle and placed on the long spine board. CID's were in place and spider straps were placed on the pt. The pt. was then seat belted onto the stretcher and transferred to the amb. In the amb. the pt.'s vital signs were; B/P- 110/~54, P-100 regular, R- 18 non-labored and even. Pt.'s mother requesting the pt. to go to Holy Spirit Hospital ER. At this time due to the divert status medical command was notified and agreed to accept the pt. Am~. 68-1 enroute class 3 to Holy spirit Hospital ER. Enroute to the hospital the pt. was kept comfortable and vital signs were monitored. PENNSYLVANIA EMS REPORT Fairview Township EMS MEGAN CALDWELL 81555443 67919 Fairview Township SSAN TRANSPORT DATE - 11/09/2001 AFFILIATE UNIT # 6700701 SERVICE INCIDENT ~ 0111038 PAGE ~4 Lower Allen EMS obtained a pt. refusal on the driver of this vehicle. Enroute to the hospital the driver (who was the mother of the passenger) stated to complain of left inner calf pain. She was given an icep,ak and was told that upon arrival at the hospital that the ER would be notified of her condition. Arrival- Upon arriving at the ER The pt. was tansferred[ to a bed in the hall. Report was given on the pt. and care as well was transferred to ER staff. Upon giving report, report was also given on the driver of the vehicle. Medications- none. Allergies- NKDA. PMH- None. End. Mollie Jean SinsabaUgh EMT#l18535 BILLING INFORMATION PRIMARY INSURER PATIENT PRIMARY INSUP~ANCE # 6566730-C24-38K GROUP # SUPP. INSURER PATIENT SUPPLEMENTAL INSURANCE ~ GUARANTOR NAME ADDRESS CITY STATE ZIP CODE TELEPHONE ~ ( ) RELEASE INFO? y ACCEPT ASSIGNMENT? y SIGNATURE ON FILE? y PURPOSE OF ROUND TRIP: MODIFIER SH REFERRING PP~ACTITIONER UPIN OTM000 TYPE OF TiLANSPORT INITIAL BED-CONFINED BEFORE TRANSPORT? N BED-CONFINED AFTER TRANSPORT? N MOVED BY STRETCHER? y UNCONSCIOUS OR IN SHOCK? N EMERGENCY SITUATION? y PHYSICAL RESTRAINTS USED? N VISIBLE HEMORRhaGING? N RESPONSE OUTCOME EMERGENCY PRIOR AUTHORIZ~FION # REASON MEMBERSHIP? TO NEAREST FACILITY N Crew Signatures: 08:04:1.6 PENNSYLVANIA EMS REPORT Fairview Township EMS MEGAN CALDWELL 81555443 67919 Fairview Township SSAN TR3%NSPORT DATE - 11/09/2001 AFFILIATE UNIT %.6700701 SERVICE INCIDENT ~ 0111038 PAGE ~5 Person Receiving Patient Time S IN!~ABAUGH, HOLLIE tv- 118535 - EMT ID# A%2 ~3~UCK, MATTHEW E 118085 - EMT DRIVER A#3 LAi~DIS, BRIAN E 80070 - EMT NAHE; CALDHELL . HEGAN SS HCDRESS; 154t ~NDV~EN AVE ,MECHANiCSBURG /FA/'~,O.,¢ BiRTHDATE: u~, i~, i~91 AGE: 10 =~X: F ,l¢~. ] RACE: i 3EO: EHPLO'FER: ONEflPLC'FEE, OCCUPATION;~" CUURC~: AHB: EftERGENCf C©NTACT INFORHATION hAHE: 3ALDWELL .BR!AN REL TO PT: F WK PH - ADDRESS: '~'' ~- _ ,m - ~~, GRANDViEW AVE /HECHANICSBURG /PA, I,uS5 PH 717 o,I 14~~ ADDRESS: ADHIT DR: ATTND OR; REFER DR .' ADMIT DX; COMPLA I NT: AMS BAT 180019 MVA iN BY: FAiRVIEW REL TO PT: HK PH - ~ ,..{ "~SE iNFORMATiON EO~R~;~ REG SC)URgE: ED PATIENT Tt'PE: ~ ~ HOSP SERV: ERI FINAHCIAL *CL2; ~D 9 D~. BRT IN BY; BLS ACCIDENT LAIE/TIfE. tI.O~/OI 17:00 ACC ,ND. DESCRIPTION; RESTRAINED PASSENGER INFORMATION A JOB RELATED: Fi LOCAT I ON: IIAfIE: ADDRESS; EMPLOYER: ADDRESS: PL AN INSURANCE CO SUBSCRIBER AUTO INSURANCE I/0 1 CALDWELL ,BRIAN iNSUR.ADDRESS: E ~99 8/C 2ND-I/PtO/P 2ND CALDWELL *SRIAN INSUR.ADDRESS: GUARANTOR INFORMATION CALOWELL ,SRIAN PT REL TO GUAR: D 1541 GRANDVIEW AVE ,'MECHANICSBURG /PA/17055 aK CALDWELL INC ~ONTACT NANE: / / / PH INSURANCE INFORMATION · COB POLICY # REL PC VFY CARD PRECERT/AUTH # I D Y N INSUR.ADCC~ESS= 4 INSUR.ADDRESS: PATIENT NAHC: CALDWELL ,MEGAN a OAF~lI54700 3 D Y y ~= ~: 2II-54-7008 PH ?l? - 691-1497 GROUP # PRECERT PHONE # CONSENTTO MEDICAL TREATMENT I HEREBY CONSENT AND AUTHORIZE Holy Sprat Hospital, its a{~ente, az~d employees, to the rendenng of medical cars, which may ~nc~ude routine d~agnosf~c p¢ocedures and such medical treatment as. my ~;tend~ng or consulting physician considers to be necessary I als~under- unbl I have had an opportun*ty to discuss them w~th a physician or other health care professional to my satrslactlon If I am a competent adult, have the nght to consent or refuse to consent I understand that the practice of medmms and surgery ~s not an exact science and that d~agno- I understand 1'3any of ~he physmlans on the staff of Holy Spirit Hospital are not employees or agents of the Hospital, but rather are ~ndependenl Hospital ~s a teaching Heap:tel and et the Hospflal are health care personnel ~n training who, unless expressly requested otherwise, may participate I understand Ihat m order to ensure a safe enwronment for patients, waders and staff all property on the premises of Holy S~p~sp~tal sul::)tect to reasonable search and/or seizure at any brae w~thout further notice ~nR~a~s RELEASE OF MEDICAL INFORMATION I authorize Holy Spent Hospital to release to requesting health insurance carrrer(s), the. representatives end auditors, and any refemng health I understand and consent that the manufacturer of any Imp~=ntable de'rice inserted by my physician dunng the course of my s~r~er~:~cedure may be prowded with my ~dentlflc&bon mforma, tloe, ~ncludlng social securlty~ number, as mandated by Federal Law left,ars INSURANCE ASSIGNMENT OF BENEFITS I aulhonze payment directly to Holy Sp~rll Hospital and my treating phys~c~aos of all benefits payable under my ~nsurance po cles I ur~.e~rGtand- lam responsible to the Hospital and phys~c,ans for all oha,ges not sovered by this ass,§nment Inltrals~, STATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDERS, PHYSICIANS AND PATIENT I request paymenl of Authonzed Medicare benefits to me or on my behalf for any servK;es furmshed me by or m Holy Sprat Hospital mctudmg Initials MEDICAL ASSISTANCE RECIPIENT My signatures cerbfles that I received a service or flems from Holy Sprat Hospital and Dr on the date flsted below be reimbursed by Federal and State lunds and that I may be responsible for non covered charges Also, I agree that ~f at the t~me of serwco, If I am not ehg~b~e for Medical Ass~stance, I will be responsible for balances owed to Holy Splnt Hospital ty to ask questlon_~ rs,,~din(~'~ac;h~of.~ ~/ /~/'/ /) ~,,////~e~aectlo~s and al.l-3tt#h questions asked have been answered to my satisfaction -- .,m.' .at. ,r HOLY SPIRIT HOSPITAL, CAMP HILL, PA CONSENT FOR TREATME~VI'/ RELEASE OF INFORMATION INSURANCE ASSIGNMENT CHART COPY Nov i0 11/10/2001 08:04:~3 FA'RVI~W_TWSP_E M $ PENNSYLVANIA ~MS ,REPOR? Falrv~ew To~nshzp EMS MEGAN C~J~DW~qLL 81555443 67919 Falrvlew Townshzp SSAN TPO%lqSPORT DATE - 11/09/2001 AFFILIATE UNIT # 6700701 SERVICE INCIDENT # 0111038 No 0602. P 2/6 PAGE 1 pATIENT INFORMATION PATI~U~T MEGAN C3LLDWELL SEX ADDRESS 1541 GRAAPOVIEW AVE. DATE OF BIRTH CITY, STATE, ZIP MECHANICSBUR, PA 17G55 AGE (YEDd~S) TELEPHONE ~ (717) 691-1497 RACE PRIVATE PHYSICIAN SSAN FEMALE 03/14/1991 1t N/A AFFILIATE/UNIT MILEAGE OUT MILEAGE SCENE MILEAGE DESTINATION MILEAGE IN OTHER ASSISTING UNIT PRE-HOSPITAL PROVIDER INFORMATION 6700701 DISPATCH 76764 E1TROUTE 76769 ;LRRIVE SCENE 76777 DEPART SCENE 76778 AR/~IVE DESTINATION AVAIL0kBLE IN QUARTERS 16:49 16:50 16:57 17:22 17:36 18:00 18:20 LOCOkTION DISPATCHED AS INCIDENT LOCATION MCD PRE-ARRIVAL INFORMATION CC LOWER A/~LEN TWp_ MAIN STREET LISBURN MCCORMICK EMERGENCY INCID~ TYPE VEHICULAR OTHER TRAFFIC WAY WORK RELATED? UNK~0WN FAIRVIEW TOWNSHIP REC'D BY HOLY SPIRIT HOSPITAL CONDITION ON SCENE WITNESSED ARREST? CONDITION ON ARRIVAL Minor BYSTANDER CPR? N SAFET~ DEVICES: Lap/Shoulder N PHYSICAL EXAMINATION SUSPECTED ILLNESS- INJURy SITE/TYPE: INJIFRY SITE/TYPE- INOJ3~y SITE/TYPE. 719.49 PAIN - Multiple Sltes NECK/SPINE SOFT/CLOSED CHEST SOFT/CLOSED ;%BDOMEN SOFT/CLOSED MEDICAL COMMAND COMMOkND FACILITY ARREST TO CPR ARREST TO DEFIBRILLATION TREATMENT Protocol IV 1 FLUID IV 1 RATE IV 2 FLUID IV 2 FATE Nov lO ~001 9 17AM 11/10/200t 08.0~'14 FAIRVIE~ T~$~ E M S PENNSYLVANIA EMS REPORT Falrvzew Township EMS MEGANCALDWELL 81555443 679L9 Falrvlew Township SS;tN TRAuNSPORT DATE - 11/09/2001 AFFILIATE I/NIT # 6700701 -SF~RVICE INCIDENT ~ 01110IS No 0~92, PAG~ P ~/~ 2 · d~REST TO ALS INITIAL EKG LAST EKG SUCCESSFUL IV'S UNSUCCESSFUL IV'S SUCCESSFUL ETT'S UNSUCCESSFUL ET'Ers BLS: C-Spine stabilize Attendant BLS: Cervical Collar AttendanL ELS: Cervical Collar Att~ndan~ BLS: C-Spine Imm. Dev. Attendant BLS: Board-Long Attendant BLS. Board-Long Attendant BLS: Board-Long Attendann 0 0 0 TRANSPORT TO FACILITY RESPONSE oUTCOME Transported RECEIVED BY ~oly Spzrlt Hospital TP~ANSPORTED AS NON EMERGeNCy CONDITION AT FACILITY Stable CLASS 3 E/R INFORMATION CHIEF COMPLAINT. MVA IMPRESSION: PT. Cc NECK, STER/qLrM, ~ SIDE PAIN CURRENT NONE MEDICATIONS~ ALLERCIES: NKDA PAST MEDICAL NON~ K~OWN VITAL SIGNS TIMB p R B~ RTS R34Y~HM TREA~MENT PROVIDER 17;20 100 18 110/64 1~ VITAL SIGNS CREW 17:34 102/p 8 B/P A1 INTAKE OUTPUT GLASGOW COMA SCALE 0 0 Blood LOss 0 EYES 4-Spontaneous I V. Up I,V ~ov 10 2001 9 11/10/2001 08:04/14 17A~ FAIRVIEW_TWSR_E M S PENNSYLVANIA EMS REPORT Fazrvzew Townshlp EMS MEGAN CALDWELL 81555443 67919 Falrvlew Township $SAN TRANSPORT DATE - 11/09/2001 AFFILIATE I/NIT ~ 6700701 SERVICE INCIDENT ~ 0111038 No 0692 P 4/6 PAGE 3 P.O. 0 VomltUS 0 VERBAL 5-Oriented Med's 0 Ur~n~ 0 MOTOR 6~Obeys Commands TOTAL 0 0 TOTAL 15 NARRATIVE D.D.- TO the above location along wi[h CC 74 and Lisburn FD by YCC class 2 for an ak~to accmdent with l~]urles. A~b. 68-1 advised YCC and CC that we responding. Responded class 2 to the scene. NO pt. ~n~ormat~on was glven Dy ¥CC or CC Arrlval/HPI- Upon arr~vlng on scene 5here were 2 vehicle to be found. ~hlef 24 stated ~hat we would have ~ pt.'s one complaln~n~ of leg pa~n ~nd the other Co.plaiting of neck pal~. Upon approaching the pt.'s the, restrained driver was ~ound to be out o~ the vehicle walklng around. At th=s t~me a~b. 7~ took care of thas pt. The second pt. was found to be sitting ~n the car. She was the restrained front passenger with (~) a~rbag deployment. At this t~me EMT A3 had c~ep[ne held. The vehmcle was travelmng south when ~t was struck from beh~md, the rear of the vehicle had moderate rear end damage, the damage was more on Lhe left ~lde. The ~nterzor of the vehzcle including the seat, door, dash, and w~ndsh~eld was ~ntacted w~th no damage PE- The pt., a 10yof, was found to be CA0x4. She at th~s tkme stated that the sides of her neck hurt. She dld remember the entmre accmdent and denies and LOC. The pt.'s ears and am~way were clear of all fluids. The pt.'s head and neck had (-) deformzt~es or trauma noted. Pt.,s chest rise was symmetrical w~th no pal~ upon xnsplratlon or expiration. Abdomen was soft and non-tender with ~o masses felt. Pt had (-) deformities or trauma noted to her chest or abdomen at thLs time. The pt. did complain of sternum and left rib pain upon pal~atlon Pelvis was stable with no creprtat~on. Pt.~e legs was (+) for PMS and had (-) deformities or trauma noted. The pt 's arms had (+) PM$ and (-) for defor~lgleS and trauma noted. Th~ pt 's skin was warm and dry to touch and was "normal" color PupllS were = and reactive to light Upon palpation of the pt. ~s hack no deformities were palpated or trauma noted. Tx- Upon arrzv~ng on scene EMT A3 )lad c-spine A pediatric c-collar was placed on the pt. The pt was then removed from the vehicle and placed on the long spine board_ CID's were ~n place and spider straps were placed on the ~t. The pt was then meat belted onto ~he stretcher and transferred to the ~r~o. In till a~tD. the pt.'s v~tal s~gns were; B/P- 110/64, P-100 regular, R- iB uon-labored and even. Pt.~ mother requesting the pt to go to Holy Spirit 4OSpltal ER. ~t thks time due Lo the divert status med%cal command was not~fled and a~reed to accept the pt Amb. 68-1 enroute class 3 to Holy spirit 4osp~tal ER. Enroute to the hospital the pt was kept c~mfortable and v~tal signs were monztored. ~ov 10 2001 11/10/2001 08 0~:'15 FA[RVIEW_TWSP_E M S P~qNSYLVANIA EMS R~PORT Falrvlew Township EMS MEGAN CALDWELL 81555~43 67919 Fa~rvlew Township SSAN TR~NSPOET DATE ~ 11/09/2001 AFFILIATE UNIT ~ 6700701 SERVICE INCIDENT # 0111038 No 0692. p 5/6 PAGE 4 Lower Allen EMS obta,nad a pt. refusal on the driver of thzs vehicle Enroute to the hospltal the drzver (who was the mother of the passenger) stated to complain of left ~nner calf pazn She was g~ven an icepak and was told that upon arrxval at the hospital that the ER would be not,fled of ~er condition ~rrlval- Upon arr~vlng at the ER The pt. was tansferred to a bed ,n the hall. Report was gmven on the pt. and care as well was transfe~rred to ER staff Upon g~n9 report, report was also g~ven on the dr~ver of the vehicle. Medications none. Allergies- NKDA. PMH- None End. Holl~e Jean Sznsabaugh EMT#118535 BILLING INFORMATION PRIMARy INSURER PATIENT PRIMARY INSURANCE ~ 6566730-C24-38K GROUP # SUpp. ~NSURER PATIENT SUPPLEMENTAL INSUR3kNCE # GUARANTOR NAME ADDRESS CITY STATE ZIP CODE TELEPHONE ~ ( ) RELEASE INFO? y ACCEPT ASSIGNMENT? y SIGNATURE ON FILE~ y PURPOSE OF ROLTArD TRIP: MODIFIER SM REFERRING PRACTITIONER UPIN OTKD0O TYPE OF TRANSPORT INITIAL BED~CONFINED BEFORE TP.A~SpORT~ N BED-CONFINED AFTER TRANSPORT? ~ MOVED BY STRETCHER~ y UNCONSCIOUS OR IN SHOCK? N EMERGENCY SITUATION? y PHYSICAL RESTRAINTS USED? N VISIBLE ~EMORRHAGING? N RESPONSE OUTCOME EMERGENCY PRIOR AUTHORIZATION ~ REASON MEMBERSHIP? TO NF3%REST FACILITY N Nov lO 2OOT 9 18AM 11/10/2001 FAIRVIEW_TWSP_E M S Falrvlew Township EMS MEGAN CALDWELL 81555443 67919 Fairvzew Towrlshlp SSAN TP~DL~SPORT DATE - 11/09/2001 AFFILIATE LrNIT ~ 4700701 SERVICE INCIDENT ~ 0I~i038 PAGE 5 Time S IN~d~AUGH, 118535 - EMT A~2 HAU(~, MA%~THEW E 118085 - EMT DRIVER LANq)I9, BRIAN E 80O70 - EMT ADM. DATE: 11/09/2001 CHIEF COMPLAINT: Auto accident HISTORY OF PRESENT ILLNESS: This 10 -year-old female came to us complaining of some neck para She was *nvolved in an auto accident She was the front seat restrained passenger ~n a rear-arid colhsion w~th moderate damage She ~s complal~'~mg of some para a~ong her chest and sternal area, which gradually subsided by the t~me she arr'~ved hero and moat probably was being caused by seatbett as per patient PAST MEDICAL HISTORY: Noncontributory MEDICATIONS: None ALLERGIES: None REVIEW OF SYSTEMS: Constitutional No weight loss, weight gain, fever, or chdls Eyes No wston ~oss, eye pa~n, double wsto~, glaucoma, or cataracts ENT No wslon loss, earache, dizziness, nosebleeds, s~nus trouble, or sore throat Gastrointestinal No nausea, vomiting, diarrhea, constipation, abdominal pain, or rectal bleeding Genitourinary No blood in urine, painful unnat~on, or frequent unnatlon NeurologicaJ No d~zzrness, blackouts, seizures, paralysis, numbness, or tingling Psychiatric No depression, mood change, or nervousness Endocrine No d~abetes or thyroid disease Allergic/Immunologic No known allergies SOCIAL HISTORY/FAMILY HISTORY: Noncontributory PHYSICAL EXAMINATION: VITAL SIGNS: See nurse's notes GENERAL: Young female of th~n build HOLY SPIRIT HOSPITAL Camp H~II, PA 17011 EMERGENCY ROOM REPORT Pag..e 1 of 3 NAME Caldwell, Megan MR#. 380126 ROOM ER1 DR RAMESH ARORA, MD ORIGINAL NAME: Cal~Jwell, Megan MR#: 380126 HEAD: Normocephahc Atraumat~c EYES: Conjunct~va w~thout d~scharge or ~nject~on Lids wrthout les~ons PERRL NECK: Mtnor spasm and tenderness m paracerv~cal muscles Nc spinal tenderness Range of motion shghtly hmited LUNGS: Normal respiratory effort Breath sounds equal No tales, rhonchh or wheezes CHEST; No Iocahzlng tenderness Pain ~n left anterior chest wall Gl/ABDOMEN: Non-tender PELVIS: Nontender EXTREMITIES: Nontender NEUROLOGICAL: Alert and oriented to person, place, and t~me Cranial nerves intact Sensory and motor function normaf Reflexes symmetncal SKIN: Normal color and turgot No rashes or les~ons PSYCHIATRIC: Onented to person, place, and brae Mood s~nd affect appropriate COURSE IN THE DEPARTMENT: Soft C-collar was g~ven to the pabent after the patient was examined and taken off the long board and cervical ~mmob~hzabon Cervical spree x-rays were done CLINICAL IMPRESSION: Cervical sprain PLAN: As per mstrucbon sheet HOLY SPIRIT HOSPITAL Camp Hdl, PA 17011 EMERGENCY ROOM REPORT Pa~e 2 of 3 NAME Caldwell, Megan MR# 380126 ROOM ER1 DR RAMESH ARORA, MD ORIGINAL NAME: Cai'dwell, Megan MR#: 380126 PA/ts DOC # 190750 D 11/09/2001 T 11/10/2001 407A 127817 CC Signed RAMESH ARORA, MD 11/12/2001 09 44 RAMESH ARORA, MD HOLY SPIRIT HOSPITAL Camp H~I[, PA 17011 EMERGENCY ROOM REPORT Page 3 of 3 NAME Caldwell, Megan MR# 380126 ROOM ER1 DR RAMESH ARORA, MD ORIGINAL Prellmin~ry Abbreviated Repo~ D.~TF. Nov 0 200'I ~:04Pbl ..... STATU~,: ~TAT HO,~P SVC ERS LOCATION: ER1 .. METNOD~OF TRANS: PATIENT: CALDWELL, MEOAN ADDRESS; t541 GRANDVLEW AVE SOC SEC: 91~-~3-~4~? MECHANIC:$~I.JRG, PA 17055 ORDER # 0000~ PHONE: (717) 691-1497 MED REC#: 380126 ADM#: 17841164 AGE: 10Y DOB 03/14/1991 ORD DATE'. Nov 9 2001 6 03Phi SE.Y,: F QRD DR, ARORA, RAMESH - (7~17) S72-43{30 EXAM DAT~: Nov 9 200'~ e:03PM i[IBIHI! .... Tach Bar Co~e 1641395 COMMENT-,~: OxTg~n: tV: laoiatmn PROC 2086 CERVICAL SPINE 72052 IIIIIIIIli REPORT ~oa RXl)IOLOGI~'TS' L~E ONLY READING II~DIOLOGL~T: REPORT DICTATItD: ¥ ~' TIME READ: Holy Spirit Hospital Department of Radiology end Diagnostic Imaging Camp Hill,'P.ennsylvania 17011 PATIENT: CALDWF-LL, MEGAN MR#: 380126 SOC SEC: 999-03-1491 ORD DR: RAMESH ARORA M D PT TYPE: E DOB: 03/14/1991 LOCATION: ER1- (717) 763-2600 DICTATION DATE: Nov 9 2001 6 53P TRANSCRIPTION DATE: Nov 9 2001 8 24P ADM DATE: 1116912001 ARRIVAL DATE: 11/09/2001 HOSP SERVICE: ER1 ***Final Report*** EXAMINATION: CERV[CALSPINE (2V) 72052 - COMMENTS INDICATION Motor veh~cre accident C1 through T1 ~re shown on the lateral wew There ~s no prevertebral soft t~ssue swelJmg Vertebral alignment ~s normal on f~ontel and lateral wews There ~s no fracture CONCLUSION: Normat study DICTATED BY: SIMON WESTACOTT M D / RJL DATE OF EXAM: 11/09/2001 SIGNED ElY: DATE/TIME: SIMON WESTACOTI' M D Nov 9 2001 9 50P Imaging Services Consultation Page 1 Initial Lab & X-Ray Orders: Labs [ ] Acel~m~nephen ~ [ ] Acetone tSACE) ] ESR [ I Alco~o~ (ALCO) ] Glucose I ] Amylasa/Lrpe, se ] HCGS [ ] ApTT ] HIV [ ] BEH ] Liver Radzolo,c(y I UA I i O~P [ 1 DIAG Specie! Procedures Ultrasound CT' (W=With con,'sst, WO=Wffhout) REASON ] Abdemen/Pelws W WO ~ ] VO Scan ] Bram/Hea~ W WO [ ] Echo- Specimens/Cultures Bdllng Class~flcabon: PHYSICIAN CHARGE FACILITY CHARGE I ] Level II [ ] Level ti [ ] Med~cat [ ]LeveIV [ ]Leve[V Holy Spirit Hospital Camp Hill, PA John R D~etz Emergency Center Physician Order Sheet CHART COPY ' Cardiac t [ ] EKG Medications / IV's / Additional Orders IV: NSW DSW/LR/DS/,45N~/DS.gN$ WO/KVO/Infuse at , mis/hr [ ]Obtam old records [ ] Td [ ] Protocol illltiated for Inltmla __ Signature _ RN~MA Initials_ $~gnature RN/MA Dictated Half [ ] Completed/(~>~ CRITIC/~L CARE hfs Diagnostic ImpmsslO~ ~' _~2t.Az~ ~'~ ~ Signature- M.~/DOICRNP Date Time 1 "~ C,~' C t L'" ::,£ L L "'lEu ~r[. Date FMD ,,, Patient Name '/ Log ~n hmo ~ Tnage T~me I I ;~ T,me to exam room ~'~ VIt~[.~.ig n $ Pulse ~ Resp._~ Wt. kg Est ( scale Pain Assess Location h~tens~tyr /10 [] Adult (%10) [] WonglBaker Duration and frequency __ ._~e'~tilatlon tear Obstructed gl Labored gl Non.labored [] Apnea Intubated Circulation gl Pulses gl Present gl absent gl Regular rq irregular gl Strong gl weak Comment Onset of sx/T~me of Injury Chief Coml Related Assessment Tx sarrlvel ALS Ambulatory [] Carned Other __ ~NKGIES/reactlon DA Latex allergy L~ yes ri ~rtor to Ararat Screening ri Exposure to messfes, ch~ckenpox, or TB m past d~rectlves Q no E.) yes attached ,~ no gl yes gl Speaks no Enghsh Language Translahon by Character gl Sharp r~ Ache 0 Pressure Q Bummg [] r~on- radlabng r~ radiating What relieves para? Time PMH Triage Reaasessment Imtlal ___El Oondmon same ~ Condlbon char~ed, see notes__ __.O Cond~on same Q Cond~bon changed, see notes Last tetanuS_ LMP Childhood ~un~zatlon O UTD ~1 not UTE) Adutt./Chdd abuse. Do you feel safe?___ ~ Lin usual/suspicious marks 0 e burns, welts, bruises, lacerabons, punctu res) gl Potential Sexual Abuse ~ Potential Domestic V~olence gl n/a El Bhnd ~) HQH gl Other Medications O See attached hat L~ No Idenhf/ed Needs [~ Taaged to Radiology @ gl N/A for_._.. deformity gl no [] yes drstal pulses gl present rq absent edema gl no ri yes area_.. ecchymosts gl no Q yea arse~ skin color gl WNL ~ cyanobc gl moffied skin tamp gl warm gl cool Interventions completed at TriaGe: Intervention Time Initial gl me pack [~ sam sprat ri elevation El c-cella r gl med~cabon (see Dr order sheet) gl other Tna~e Notes, Holy Spent Hosp~[al Camp Hdl, PA 17011 John R Dletz ECU Nursing Assessment CHART COPY Appe~3ranca Neuro ~'~A nheadac~e ~.IPERL R L EYES MOTOR RESPONSE VERBAL f t ' ~Jef~al Status , Gastrolnt eStlna I,~['NIA GU 1 GYN F1 dear CJslndor r~wheezmg L I R Trauma ~NIA~ C0rbPleted '6yl /~ L J.A ,,¢_~L.,¢¢~ RN T me ~ Holy Sprat HOSpltat Camp Hd[, PA 17011 John R D~etz ECU Nursing Assessment/Notes CHART COPS' Imt~al S~gnature [nmal Time Notes - '"~T~RANSFER OR DISCHARGE .~di~c~arged/acc~mpamed by ~ ~ambulata~ ~w/cJ ~ambu~an~ EMERGENCY CENTER URG! CENTER DISCHARGE INSTRUCTIONS HOLY SPIRIT HOSPITAL (717) 763-2316 ~'~ (717) 763;2424 A --~ ~ ---~ ding to package msfruct~ons for age, weight 2 3 FOLLOW-UP Th~s IS our recommendabon for fo,ow-up ri your Insurance (HMO} requires a physic{an referral (or specialty consultal~on, IT IS YOUR RESPONSIBILITY' TO OBTAIN THE NECESSARY APPROVAL HOLY SPIRIT HOSPITAL EMERGENCY CENTER $03 NORTH 21ST STREET CAMP EIILL, PA 17011-2288 (7t7) 763-~316 ~bent or Responsible Person Physm~an ~ '~I ' M D J D Q.. Nurse RN ( ) Va~ldqa Abrahax~, M D 038840L ( }Thoma~ Aldous. MD 017075E :SPRAINS, STRAINS, BRUISES, FRACTURES ( ) Elevate ttle injured pert for~days to reduce swelhng ( ) Apply Ice packs Intermglentiy for__days to reduce swelkng ( ) Ace wrap ~or support for__ days y moist heat ,~or._./~ rain ~tes ~ bfftes dally beglnnl~c,~ In ~.~1 ~.~ hours Wear eye palch for, hours I1 nose bleed recurs, pinch nosa firmly for 5 minutes continuously, return fl bleeding not controlled The pcescr~be~l ant~btOtlC may reduce the effectiveness of HOLY SPIRIT HOSPITAL EMERGENCY CENTER 503 NORTH 21ST STREET CAMP HILL, PA 17011-2288 (717) 763-2316 t ) Vanttha Abra~am~ M D 038840L I I Jon Dubm D O OS 00699[L 3 ( } The lollowlng n~ed~c~nes may cause drowalness DO NOT DRIVE OR OPERATE MACHINERY WHILE TAKING FOLLOW-UP This is our recommendation lot follow-up If your MD /0 C~:,Nurse RN ( ~ Lawrence p~ul, M D 039524-L ( ) Thom~.s Aldous, M D 017075E ~ ) Salvalore Alfano, M D ~Y25502E SIONA'tUKE M D/D 0 ) Marlys Ha~son, M D 072553L )John P dud~on, MD 038368.E / ) Howa~i Rudmck, M D 040862-L ( ) Raajana Sharraa, MD 0312§5-E DEA# REFILL TIMES CONTINGENT FEE AGREEMENT ~, ~m~c, C-~lc~.o~l( , individually and as parent(s) and natural guardian(s) of ~e_e.,~ (~--~d~o~ , retain and authorize the law firm of Metzger, Wickersham, Knauss & Erb, P.C., to do whatever they deem necessary or desirable in order to represent my son in all claims for compensation and reimbursement for personal injuries, wage loss, and economic and other damages resulting from za~ accident that occurred on I. Attome¥'s Fees: The fee of the attomeys shall be contingent as follows: (a) Twenty-five percent (25%) of gross recovery; Co) SHOULD THERE BE NO RECOVERY BY SUIT OR SETTLEMENT, SAID ATTORNEYS DO NOT HAVE ANY CLAIM AGAINST US OF ANY KIND FOR LEGAL SERVICES RENDERED. 2. Expenses of Litigation: Actual expenses incurred on the business of the client shall be borne by the client and my attorney shall be reimbursed out of the balance, after deduction of attorneys fees, of any recovery for all legal expenses incurred in the prosecution of this claim which have not already been paid by me. We do hereby agree to pay all expenses incurred by our attorney in the preparation and presentation of this case and do understand that these expenses include, but may not be limited to, costs of medical reports and records, stenographic expenses connected with depositions, expert witness fees, photocopying charges, and mileage charges connected with the rendering of legal services. We understand that we are responsible for payment of these expenses regardless of the eventual outcome of the case and further understand that if our a~lomey deems it necessary, ~ve may be asked to advance these costs prior to the incurring of any such expenses or the scheduling of any deposition. Document ii: 234130.1 3. We hereby further agree that our attorney may charge us reasonable additional compensation if it is necessary to try the case more than once, if the case is appealed, or if proceedings in other courts are necessary because of the change of cimumstance of a party or for other reasons. 4. We hereby further agree that our attorney is hereby authorized to bring suit or to settle and compromise the claim, to execute all documents pertaining thereto, and to do all lawful acts requisite for effecting the claim on our behalf. 5. We further authorize our attorney to pay out of any proceeds of settlement or trial any unpaid medical bills for treatments or services made necessary by the injuries sustained in this accident and any workers' compensation liens. 6. We agree that our attorney accepts this employment on the condition that he will investigate this claim, and if it appears to be a recoverable claim, he will proceed to handle the claim; but if, after investigation, the claim does not appear to be :recoverable, said attorney shall then have the right to rescind this Agreement. 7. We hereby further agree that if we decide to terminate this authority before any settlement is offered or any award is obtained the firm shall be entitled to reasonable compensation for all work done on the case up to that point. We agree that reasonable compensation for Clark DeVere, Esquire, or any other attorney involved in the handling of this case, shall be Two Hundred Dollars ($200.00) per hour, or such higher rate as shall constitute his standard billing rate at the time that the work is performed or the agreed upon percentage fee of one-third of any ultimate recovery, whichever is greater. 8. We agree that our attorney may withdraw from tiffs case at any time after reasonable notice to us, and we agree to keep him advised of our whereabouts at all times and to cooperate at all times in the preparation and trial of this case, to appear upon reasonable notice for depositions and Court appearances, and to comply with all reasonable requests made of us in connection with the preparation and presentation of this case. Document #: 182430,1 -2- 9. We also understand that if the investigation reYeals that a parent is contributorily negligent in causing the accident the attorney's representation V~[ll solely be limited to representing the injured minor and there will be no representation of the parent. I also waive any conflict of interest that may arise by my meeting with the attorney to discuss the case. 10. I understand and agree that in the event that my account is turned over for collection because of unpaid fees and/or costs/expeuses, I will be responsible for payment of the costs of suit as well as reasonable attorney fees incurred in the collection of the monies owed to Metzger, Wickersham, Knauss & Erb, P.C. 1N WITNESS WHEREOF, I have signed below on this ltg~-day of ~J'~/e~,~ ~ ,2002. CLIENT: METZGER, WICKERSHAM, KNAUSS & ERB, P.C. ATTt~R~k Dever~, Esquire Document #: 182430.1 -3- PARENT-GUARDIAN RELEASE AND INDEMNITY AGREEMENT FOR AND IN CONSIDERATION of the payment to me/us of the sum of TWO THOUSAND FIVE HUNDRED AND 00/100 ($2,500.00), the receipt of which is hereby acknowledged, I/we, the undersigned parents and/or guardian of MEGAN E. CALDWELL, a minor, do hereby release acquit, discharge and covenant to hold harmless, BRIAN SPONAR and COUNTRY INSURANCE & FINANCIAL SERVICES, its insurer, their heirs, successors and assigns of and from any and all actions, causes of action, claims, demands, damages, costs, loss of services, expenses and compensation, on account of, or in the auy way growing out of any and all known and unknown personal injuries and property damage which we may now or hereafter have as the parents and/or guardian of said minor, and also all claims or rights of action for damages which the said minor has or may hereafter have, either before or after he/she has reached his/her majority, resulting or to result from a certain accident which occurred on or about the 9th day of November, 2001, at or near the "T" intersection of Main Street (S.R. 114) and McCormick Drive in Lower Alien Township, Cumberland County, Pennsylvania. It is further understood and agreed that this settlement is 'Ihe compromise of a doubtful and disputed claim, and that this payment is not to be construed as art admission of liability on the part of BRIAN SPONAR and COUNTRY INSURANCE & FINANCIAL SERVICES, its insurer, by whom liability is expressly denied. I/we further state that I/we have carefully read the forego:lng release and know the contents thereof and Fwe sign the same as my/our own free act. WITNESS, our hands and seals this __ day of ., 20 ln the presence off (SEAL) LINDA A. CALDW'ELL, as parent and Natural Guardian ofMegan E. Caldwell (SEAL) LINDA A. CALDWELL, individually and in her own fight (SEAL) BRIAN CALDWELL, as parent and Natural Guardian of Megan E. Caldwell (SEAL) BRIAN CALDWELL, individually and in his own right Page 1 of 2 On this __ day of , 20 , before me appeared LINDA A. CALDWELL AND BRIAN CALDWELL, to me personally known, and who acknowledge the execution of the foregoing instrument as their free act and deed, for the consideration set forth herein. SWORN TO AND SUBSCRIBED BY ME ON THIS DAY OF ,200__. NOTARY PUBLIC Page 2 of 2 VERIFICATION I, Linda Caldwell, as parent and natural guardian of minor PlaintiffMegan Caldwell, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Plaintiffs Compromise Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Plaintiffs Compromise Settlement, and to the extent that it is based upon information, which I have given to counsel, it is Ixue and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Plaintiffs Compromise Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Plaintiffs Compromise Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unswom falsification to authorities. Dated: Li~nda C~ ~. ~d~U~ / ~ -{95- 03 ' dwell, as parent and natural guardian to Megan Caldwell VERIFICATION I, Linda Caldwell, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Plaintiff's Compromise Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Plaintiff's Compromise Settlement, and to the extent that it is based upon information, which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Plaintiff's Compromise Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsifi,:ation to authorities. Dated: / o3 VERIFICATION I, Brian Caldwell, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approvtd of Minor Plaintiff's Compromise Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel and not my own. I have read the Petition for Approw~ of Minor Plaintiff's Compromise Settlement, and to the extent that it is based upon information, which I have given to counsel, it is tree and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby aclmowledge that the facts set forth in the aforesaid Petition for Approval of Minor Plaintiff's Compromise Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unswom falsifilcation to authorities. Dated: 12-5-03 ~ ~--~ ~ -~~-~7~ Brian Caldwell VERIFICATION I, Brian Caldwell, as parent and natural guardian of minor PlaintiffMegan Caldwell, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Plaintiff's Compromise Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Plaintiff's Compromise Settlement, and to the extent that it is based upon information, which I have given to counsel, it is tree and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby ~,clmowledge that the facts set forth in the aforesaid Petition for Approval of Minor Plaintiff's Compromise Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unswom falsification to authorities. Dated: 12-5-03 Brian Caldwell, as parent and natural guardian to Megan Caldwell VERIFICATION The undersigned hereby certifies that he is the attorney for Plaintiff Megan Caldwell, by Linda Caldwell, as Megan's parent and natural guardian and that the facts in the foregoing Petition for Approval of Minor Plaintiff's Compromise Settlement are true and correct to the best of his knowledge, information and belief, and that said matters relating to the Petition for Approval of Minor Plaintiffs Compromise Settlement are as known to the undersigned as to the clients minor Plaintiff Megan Caldwell, by Linda Caldwell, as her parent and natural guardian, said knowledge being based upon information contained in the attorney's file in this matter, and further states that false statements herein are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unswom falsification to authorities. Clark DeVere, Esquire Dated: /_~ CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a tree and correct copy of Plaintiff's Petition for Approval of Minor Plaintiff's Compromise Settlement with reference to the foregoing action by first class mail, postage prepaid, this o~t~-day of January, 2004 on the following: Brian Sponar 7 Surrey Lane Mechanicsburg, PA 17055 Jennifer Hunter, Esquire Mintzer, Sarowitz, Zeris, Ledva & Meyers 1528 Walnut Street, Suite 1500 Philadelphia, PA 19102 Clark ~[uire MEGAN E. CALDWELL, a minor, by : LINDA A. CALDWELL, her mother and : natural guardian and LINDA A. : CALDWELL in her own right, : Plaintiffs : : VS. BRIAN C. SPONAR, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 03-5624 CIVIL ACTION - LAW JURY TRIAL DEMANDED ORDER AND NOW, this ~ day of ~'e 1'-o ,2004, upon consideration of the Petition for Approval of Minor Plaintiff's Compromise Settlement, it is hereby ORDERED and DECREED that the settlement for the gross sum of Twenty-Five Hundred Dollars ($2,500.00) is APPROVED. Counsel fees and expenses are found to be fair and reasonable and are also approved as set forth below. The distribution is directed as follows: (1) To be paid to Linda Caldwell, as parent and natural guardian of Megan Caldwell, for the purposes of this Order, to be placed in an insured savings account or certificate of deposit, to be marked "not to be withdrawn, assigned, negotiated, or otherwise alienated until Megan Caldwell reaches her maturity on March 14, 2009, except upon prior Order of the Court" - $1,785.08; (2) To be paid to Metzger Wickersham, P.C. for counsel fees and expenses - $ 714.92. Linda Caldwell, is authorized to execute the Release that is attached to the Petition and discontinue this action upon filing of the proof of deposit of the sum for the minor as set forth above. cc: Clark DeVere, Esquire - counsel for Plaintiffs Jennifer Hunter, Esquire - counsel for Defendant OF THE pgoTHONOIA~ MEGAN E. CALDWELL, a minor, by LINDA A. CALDWELL, her mother and IN THE COURT OF COMMON PLEAS OF CUMBERLAND Col mr'ex,- ...... MEGAN E. CALDWELL, a minor, by LINDA A. CALDWELL, her mother and natural guardian and LINDA A. CALDWELL in her own right, Plaintiffs VS. BRIAN C. SPONAR, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 03-5624 CIVIL ACTION - LAW JURY TRIAL DEMANDED PROOF OF DEPOSIT In accordance with Pennsylvania Rule of Civil Procedure 2039 and Judge J. Wesley Oler, Jr.'s Order of February 6, 2004, the undersigned is filing a phc,tocopy of the Time Certificate of Deposit of $1,785.08 of the settlement proceeds in the above matter which were deposited on March 19, 2004 at Commerce Bank in the name of the minor Megan Caldwell, Court Ordered Account, "not to be withdrawn, assigned, negotiated or otherwise alienated until Megan Caldwell reaches her maturity on March 14, 2009, except as authorized by a prior Order of this Court." The photocopy of the Time Certificate of Deposit is attached hereto as Exhibit "A". METZGER, WlCKERSHAM, KNAUSS & ERB, P.C. By: Clark DeVere, Esquire Attorney I.D. No. 68768 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorney for Plaintiffs Dated: April ~', 2004 302306-1 J Time Certificate of Deposit Financial InstitutiOn: CO~IMERCE BANK/HARRISBURG, NA, CEDAR CLIFF 1120 Carlisle Read, Camp Hill, PA 17011- Account Name: LINDA A CALDWELL as Custodian for MEGAN E CALDWELL Under the Pennsylvania Uniform Transfers to Minors Act OWNERSHIP TYPE: Custodian for Minor 12000O529 SSN/TIN: 191-72-6541 120000529 March 19, 2004 $1,785.08 60 Months March 19, 2009 Rate Information: This Account is an interest bearing account. The interest rata on the account is 1.98% with an annual percentage yield of The interest rate and annual pementage yield will not change for the term of the account. The interest rate will be in effect until March 19, 2009. Interest begins to accrue on the business day you deposit noncash items (for example, checks). Interest will be compounded daily and will be credited to the account monthly, interest on you; account will be credited by adding the intarest to the principal. The annual percentage yield assumes interest will remain on deposit until maturity. A withdrawal will reduce earnings. Balance Information: We use the daily balance method to calculate the interest on the account. This method applies a daily periodic rate to the pdncipal in the account each day. We will use an interest accrual basis of 365 (or 366 in leap year) for each day in the year. You must maintain a minimum balance of $500.00 in the account each day to obtain the disclosed annual percentage yield. Limitations: You must deposit $5(~.00 to open this account. You may not make additional deposits into this account. You may not make withdrewals from your account until the matudty date. Time Account Information: Your account will mature on March 19, 2009. If you withdraw any of the principal before the maturity date, we will impose a penalty of 180 days loss of interest. We will use the rate in effect on the date of withdrawal. If the account is closed bef~e interest is credited, you will not receive the accrued interest. This account will ~ 10 days after the maturity date to withdrew funds without penalty. NON TRANSFERABLE - NON Nf ,and has ~ words "we", for norseash items (such as ehccks converted to U.S. funds as of the ISSUE DATE. If you open wes made at the opening of the next t INH~-iEST RATE. The based upon the interest accrual basis ( AUTOMATIC RENEWAL POLICY. If the / has not bean withdrawn will automaflcelly renewed accounts will be calculated at the funds from your Account, you must notify us d EARLY WITHDRAWAL PENALTY. You have part of the funds from your Account pnor o; granted, the penalty as specified above will apply. , and rules that are s the words means th we receive credit the Account. Deposits of foreign currency will be open, we will consider that the transection compounding ("interest Rate"), and is Deposit Amount and all earned interest that interest on you wish to withdraw Until the IVratudty Date ofyour Account. Any withdrawa of a or We will consider requests for early withdrawal end, if ......Minimum Required Pena ly f you withdraw money w th n six (6 days after .the date c f deposit., the Minim. um R m[ed' pene~ ~s' seven ,da ,YS~_si_m_P~.!,n,t~.e~....t,~o~ the Wl!~,d,_raw. n,[u,n~ds. If,partial .eady ..w~.hcl. r~wal~)s) ere permitted,, we ~skra required to impose th~eC~inlmum Required Pene~ ~. ,,~ a,,.,.uun~tS) w.[[nuraW, n w!!.m .n s~x t,o) aays aner eac.n., parmu withdrawal. The early withdrawal penalty may be more than the Minimum Reau red ~n~en~. j.ou.~p_{y.~_n._e_~ny ~w_~more_w...~al pen. a!ty .by fo,..d, elfing p.arl ct.the ~c~ued interest on the Account. If your Account has not earned er~ough .... , u~. mu ..e[~-,~[ naS oeen pale, we l~Ke [ne oln~rence from the pnnclpal amount of your Account. Exceptions. We may let you withdrew money from your Account before the Maturity Date without an early withdrawal penalty: (1) when one aO~l ~n~i~i~fuYa~edt~=mO~r n~ ~e~teor~ni~fl~l~g~ easll~a~[~emdP~nfeaotccbery~ ~OcUrt ...or.,_~h..e,r ?~d~ministretive body of c~mpetent junsdiction; or (2) when the Account is ~. .~ e ce Whn ~o U~ 408 and the money s paid within seven (7} days after the Account is opened; or (3) when the Account is a Keogh Plan (Keogh), f you forfeit at least the interest ea~ed on the withdrawn funds; or (4) it the Account is an ?,A.o.r a Keogh ~ia.n established pursuant to 26 UStC 408 or 26 USC 401, when you rea~.h age 59 1/2 or become disabled; or (5) within en epp~ceme grace pacco (if any). .,we re. ay xe ...our d .h.t ct setoft or sesuri / ot e t age,nsf any and a, of your Accounts (except - ,..~-'~. p,a. aHu ~u~t ,'.~,~(~.Unl~) WRIIOU[ nOffi~e, .~or an~v IlalOlfl~y or eaot of any of you, wnethar joint er individual, whether direct or contingent, wnemer now or hereafter existing and whether arising ~rom overdrafts endorsements aranfees cans attachmen r~eys f~., or other obligations. If the Account ~s a ~oint or multip..l.eT.-parfy account, each joint or muit~ple-perty account holder authorizes us to exercise our right of setoff agemst any and all Accounts or each Account Holder. OTHER ACCOUNT RULES. The following rules also apply to lhe Account. .$urren, de..r of I.natrl~.m. en.t. We re.ay require you t? endorse an~ surrender this Agreamect to us when you wthdraw funds, transfer or close your ~coum. ~r you ~ose m~s P, greemem, you agree to s gn any affidawt of lost instrument, or other Agreement we may require, and agree to hold us harmless from liability, prior to our honoring your withdrawal or request. Death of Account Holder. Each Account Holder agrees to notify us immediately upon the death of any other Account Holder. You agree that we may hold the funds in your Account until we have received all required documentation and instructions. Indemnity. If you ask us to folfew instructions that we believe might expose us to any cl~dm, liability or damages, we may refuse to follow your instructions or may require a bond or other protection, including your agreement to indemnity us. Page 1 of 2 Pledge. You agree not to pledge your Account without our prior consent. You may not withdraw funds from ~our Acco~Jnt until all obligations secured by your Account are satisfied. SURRENDER OF TIME DEPOSIT CD # 1200OO529 This certificate Is hereby surrendered. Date: Number of Signers Required: Any one (1) of the Authorized Signers(s) shown below. ACCOUNT HOLDER: X. X LINDA A CALDWEU., Custodian LINDA A CALDWELL, Cuatodisn Page 2 of 2 Page: i Document Name ~ untitled TDDIAV ( FWD ACCOUNT NUMBER 0120000529 TITLE MEGANE CALDWELL D]-I~J~ DATE OPEITED 03/19/04 LAST DEPOSIT DATE/AMOUNT ENTER Y FOR DETAIL TD DISPLAY AVAILABLE BANK 0184 ) BRANCH 0012 T]~PE 35 60-120 MO, RENEWABLE STATUS FROZEN 03/22/04 1,785.08 CURRENT BALANCE TOTAL HOLDS TODAY ' S ACTIVITY ATM ACTIVITY TODAY TELLER TERMINAL ACTIVITY TODAY ACCRUED INTEREST P~lqD ING ACCRUALS UNPOSTED ITEMS TODAY CONTING~CY WITHHOLDING AVAILABLE BALANCE 1,785.08 .00 .00 .00 1.3S .00 .00 .00 Page: 1 Document Name: u~titled TDDIAV ( LST ACCOUNT NUMBER 0120000529 TD DISPLAY AVAILABLE TITLE MEC4%NE CALDWELL UTTMA BANK 0184, ) SEQ TY EXPIRES AMOUNT 01 3 12/31/15 .00 02 3 12/31/15 03 3 121~111s .oo 04 3 12/31/15 .00 05 3 12/31/15 ,00 DESCRIPTION CD FROZEN DUE TO COURT ORDER DO NOT NEGOTIATE UNTIL MEGAN REACHES THE AGE OF 18. MUST H~VE RELEASE DOCUMENT FROM THE CO'URT FOR THIS TO OCCUR. CLW12 SPECIAL INSTRUCTION TYPES 1 - STOP PAYM~IFr 2 - HOLD 3 - SPECIAL INSTRUCTIONS ACCOUNT BAL;~CE INFORMATION CURRENT BALANCE 1,785.08 HOLDS .00 PRESS ENTER TO RETURN TO TD DISPLAY AVAILABLE. CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and correct copy of Plaintiffis' Proof of Deposit with reference to the foregoing action by first class mail, postage prepaid, this ~"~k-day of Apr/l, 2004 on the following: The Honorable J. Wesley Oler, Jr. Court of Common Pleas of Cumberland County Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 Jennifer Hunter, Esquire Mintzer, Sarowitz, Zeris, Ledva & Meyers 1528 Walnut Street, Suite 1500 Philadelphia, PA 19102 Megan and Linda Caldwell 804 Lisburn Road Camp Hill, PA 17011 METZGER, WICKERSHAM, KNAUSS & ERB, P.C. Clark DeVere, Esquire 302306-1 MEGAN E. CALDWELL, a m/nor, by : L/NDA A. CALDWELL, her mother and : natural guardian and L/NDA A. CALDWELL in her own right, : Plaintiffs : : VS. BRIAN C. SPONAR, Defendant 13I THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTy, PENNSYLVAN/A NO. 03-5624 CIVIL ACT/ON __ LAW JURY TRIAL DEMANDED PRAECIPE TO SETTLE, DISCONTINUE THE CIVIL ACTION AND END TO THE PROTHONOTARY OF CUMBERLAND COUNTy: In accordance with the Court's Order of February 6, 2004, kindly mark the entire above- captioned case, settled, discontinued and ended. By: evere, Esquire 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110 (717) 238-8187 Attorney for Plaintiffs Dated: April 12, 2004 302377.1 CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a tree and correct copy of Plaintiffs' Praecipe to Settle, Discontinue and End with reference to the foregoing action by first class mail, postage prepaid, this 12th day of April, 2004 on the following: Jennifer Hunter, Esquire Mintzer, Sarowitz, Zeris, Ledva & Meyers 1528 Walnut Street, Suite 15013, Philadelphia, PA 19102 Megan and Linda Caldwell 804 Lisbum Road Camp Hill, PA 17011 METZGER, WlCKERSHAM, KNAUSS & ERB, P.C. Clark De erV~, Esquire - 302377-1