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HomeMy WebLinkAbout04-0814IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: DUSTIN E. BARMONT ORPIIAN'S COURT DIVISION PETITION FOR APPROVAL OF MINOR SETTLEMENT AND NOW, comes the Petitioners Ted and Angela Barmont, as parents and natural guardians of minor Dustin Barmont, and petitions this Court for approval of a settlement of a minor's case in accordance with Pa.R.C.P. No. 2039 and in support of the Petition avers as follows: 1. Petitioners Ted and Angela Barmont, husband and wife, are adult individuals residing at 432 Newvill¢ Road, Newburg, Cumberland Cotmty, Pennsylvania 17240. 2. Petitioners are the parents and natural guardians of minor Dustin Barmont, who resides with them, and who is 17-years old, having been bom on December 7, 1986. 3. Minor Dustin Barmont has selected Petitioners, as his parents and natural guardians, to represent his interest in this Petition. 4. State Farm Mutual Automobile Insurance Company is an insurance company incorporated in the State of Illinois, who writes and sells insurance in the State of Pennsylvania. 5. Erie Insurance Exchange is an insurance company incorporated in the State of Pennsylvania, who writes and sells insurance in the State of Pennsylvania. 6. On June 24, 2002, Dustin Barmont was a passenger in a pick-up truck operated by Paul Gutshall, III and occupied by his friends, Eric Halter and Cory Alexander. Document #295819.1 7. On the aforesaid date, the pick-up truck crossed a double yellow line and rolled, throwing all four passengers from the vehicle. 8. As a result of the aforesaid accident, Eric Halter died and the other passengers including Dustin, sustained injuries. A tree and correct copy of the Police Accident Report for the motor vehicle accident is attached hereto as Exhibit "A" and incorporated herein by reference. 9. Dustin was transported from the accident scene by ambulance and taken to the Chambersburg Hospital Emergency Room where he was diagnosed with abrasions and a questionable fracture of the right wrist. A true and correct copy of the ambulance report and emergency room records are attached hereto as Exhibit "B" and incorporated herein by reference. 10. Following orthopedic consults, Dustin was diagnosed with a right wrist scaphohinate ligament tear and underwent surgery on October 14, 2002, which involved the placement of anchors and pins in his wrist. A true and correct copy of the hospital records for the surgery are attached hereto as Exhibit "C" and the orthopedic records are attached hereto as Exhibit "D" and incorporated herein by reference. 11. On December 12, 2002, Dustin's right wrist radiographs showed the scapholunate interval to be intact. Dustin was released to full activities and he was discharged from orthopedic care on January 17, 2003. 12. In addition, Dustin has been suffering from post-traumatic stress symptomology as a result of the accident, which resulted in his friend's death, and he has been seeing Vic Cardinale, Clinical Psychologist. A true and correct copy of the psychologist report is attached hereto as Exhibit "E" and incorporated herein by reference. Document #295819.1 13. The medical bills for Dustin's treatment as a result of the injuries sustained in the motor vehicle accident have been paid by Erie Insurance Exchange under the medical payments coverage in the amount of $5,069.51. Attached hereto as Exhibit "F" is a Medical Billing Summary showing the amount of bills and the source of payment of those bills. At the time of this Petition, there does not appear to be any outstanding medical expenses. 14. At the time of the aforesaid accident, Dustin was not employed and there is no wage loss claim on his behalf. 15. On the date of the aforesaid accident, Paul Gutshall, III was covered under a motor vehicle liability policy, which provided liability coverage of $15,000 per person/S30,000 per accident. Since there were three victims, $15,000 of the policy was paid for the death claim on behalf of Eric Halter and the remaining $15,000 was agreed to be divided 60/40 with Dustin receiving 60% (or $9,000.00) and Cory Alexander receiving 40% (or $6,000.00). The undersigned counsel represented the Estate of Eric Halter, Dustin Barmont and Cory Alexander and the respective clients agreed to this division. A true and correct copy of the tender letter from State Farm, Certificate of Coverage and Affidavit of No-Other Insurance are attached hereto as Exhibit "G" and incorporated herein by reference. 16. At the time of the aforesaid accident, Dustin was covered under his parents' automobile insurance policy with Erie Insurance Exchange for underinsured motorist coverage of $100,000 per person/S300,000 per accident stacked. Erie consented to the settlement with Paul Gutshall, III and his liability insurer and has waived its subrogation rights against Mr. Gutshall. A true and correct copy of Erie's letter of October 14, 2003 and insurance declaration documents are attached hereto as Exhibit "H" and letter of January 13, 2003 with consent and waiver is attached hereto as Exhibit 'T' and incorporated herein by reference. Document #295819. l 17. After some investigation, Erie agreed to make an underinsured motorist payment in the total sum of $58,500.00, out of which $50,000.00 would be placed in a structured settlement account. A true and correct copy of the letter from Erie confirming the settlement is attached hereto as Exhibit "J" and incorporated herein by reference. 18. The total proposed settlement and the gross sum of the recovery is $67,500.00, which the Petitioners, after consultation with counsel, have determined it is in the best interest of Dustin to accept and seek Court approval of the amounts at this time. 19. The Petitioners, after consultation with counsel, determined it would also be in the best interest of Dustin to allocate $50,000.00 of the $67,500.00 to be transferred by Erie Insurance Exchange to Erie Family Life Insurance Company to set up a structured settlement account, which would provide Dustin with the following payments at the following respective ages $I0,000.00 at age 18 (December 7, 2004); $20,000.00 at age 25 (December 7, 2011); and $35,152.00 at age 28 (December 7, 2014) The lump sum payments would be tax-free guaranteed payments and payable to Dustin or his Estate or desi~ated beneficiary should he die before receiving all money. A copy of the Structured Settlement proposal is attached hereto as Exhibit "K" and incorporated heroin by reference. 20. The structured settlement account would be through Erie Family Life Insurance Company, which is rated A. The documents concerning the financial health of Erie Family Life Insurance Company is attached hereto as Exhibit "L" and incorporated herein by reference. 21. Out of the remaining $17,500.00 the sum of $383.67 will be paid to Dustin's parents for the immediate benefit of Dustin. Document #295819. ] 22. The remaining sum will be paid to counsel for Petitioners who were retained to represent Dustin on a contingent fee basis of 25% plus expenses, which fee is fair and reasonable for the time and effort expended on behalf of minor Dustin Barmont. A copy of the fee agreement is attached hereto as Exhibit "M" and incorporated herein by reference. Counsel's attorney fee at 25% would be $16,875.00. Counsel has also incurred the following expenses on behalf of Dustin: Filing Fees $ 55.50 Medical Records $ 87.18 Photocopies $ 48.92 Postage $ 18.71 Travel $ 4.55 Long Distance Phone Calls $ 10.54 Fax $ 9.00 Miscellaneous ~ 6.93 TOTAL $241.33 23. Petitioners respectfully request that this Honorable Court approve of the settlement with Paul Gutshall, III and his liability insurer, State Farm as well as the payment by Erie Insurance Exchange, under the underinsured motorist coverage, in the gross sum of $67,500.00 out of which Dustin's parents will receive the sum of $383.67 for the immediate benefit of Dustin, counsel will receive the sum of $17,116.33 for attorney fees and expenses and the remaining $50,000.00 will be allocated to a structured settlement account. 24. The Petitioners request for the balance to go into a structured settlement account is in accordance with Pa.R.C.P. No. 2039 and in particular No. 2039(b)(3). 25. Upon approval, the Petitioner will sign the Releases and Structured Settlement Agreements, a copy of which is attached as Exhibit "N" and incorporated herein be reference. Document #295819.1 26. Paul Gutshall, III through his liability insurer, State Farm, and the underinsured motorist carrier, Erie, concur with the filing of the Petition and also seek approval of the minor settlement under the terms set forth above. Upon delivery of the upfront cash payment, Petitioners desire to discontinue this 27. matter. 28. To the extent the Comrt decides a hearing is necessary, the Petitioners respectfully request that Dustin be excused from attending because of the psychological effect and other reasons personal to the family. WHEREFORE, Petitioners respectfully request that this Honorable Court approve of the minor compromise settlement and enter a Decree distributing the funds as follows: (1) To be paid to Ted and Angela Barmont, who are appointed guardians of Dustin Barmont for the purposes of this Petition, the sum of $383.67 for the immediate benefit of Dustin Barmont; (2) To be paid to Metzger, Wickersham, P.C. for counsel fees and expenses - the stun of$17,116.33; and (3) The balance orS 50,000.00 to be transferred by Erie Insurance Exchange to Erie Family Life Insurance Company to set up a structured settlement account. The structured settlement account will pay the following guaranteed lump sums to Dustin Barmont at the following ages: $10,000 guaranteed lump sum, payable on 12-7-04; $20,000 guaranteed lump sum, payable on 12-7-11; and $35,152 guaranteed lump sum, payable on 12-7-14. The benefits are tax-free guaranteed benefits, which will be payable to Dustin Barmont at the specified ages and if he should die before the payments are made, to his Estate or to such other persons or others as shall be designated in writing by him to Erie Family Life Insurance Company. Document #295819.1 METZGER, WICKERSHAM, KNAUSS & ERB, P.C. Dated: February ~q , 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 Document #295819.1 ' /"'" o%-s:~a ''''~ ~ '~ CO~IMONWEALTH OF PENN'~YLVANIA /~'~I. ICE CR~ R.~IRT. I~i.G FORM il~ N~w P0425974 --1! ?.i ~ ':"i ~ I Vehide ,~:-~ (If Y~ Com~wt~ ~xn~ AA 45 C 'Il Crash Hum~¢ '~ ._J COMMONWEALTH OF PEN NSYLVANIA '~ ' ,.o.~ ~.^~..~,.o..,.~ ~O.M ~ ~ P0425974 ...... 'r- .... C~j~/ -" gl=Going Straight 02--gowing/StoppincJ in Lane $oe~ial UM~ 22=H~ a~ Bu~y ~ Ap~ka~e 23=Ho~e and Rider 01=~ire V~ COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM ~.. P0425974 Change/ ~) Continuation MI Number Last Name IIIIIIII .......... . ......... .... ~ ~ ....... ~ ,- .,~ ~ o ~ ~ode 01=Private Vehicle ~n~/ ~SUte ~ice Veh~e --~" Leased by O,iver OS=Penn~T VehUe O ' ~ 02=Pfivate Vehicle Not ~=~her S~te ~v Veh~ OwnS/Leased by Ddver 07=Mun~ ~ice Veh~ ~Unk~ Ad~ress N~ Illegal Drugs , '~ M~icatJon ,._.., ~ ~ti~ Signal ' ~ at I~e~ion ~ Not in Ro~w~ > 10 ~ - ~iOod Udne ~ Unknown if 0 At Intron - No ~ M~n Te~t Given R~u~ · C~swalks 0 S~r 0 S~r~ P~ :~. 0 -- Test Given. ~ 0 Sid~alk 0 Un~ ~,~o/ '~d-~'r ~Pfl s~calCondton VeflideC~ ~t anyVehicle~d~ _J COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM AA4S4 1 Cr~h Numbe~ P0425974 A l:D,-iver D 00=NotAPassenger/O<cup~nt E C 0=Not Injured o 2=Major Injury 02= :font Seat Middle Position1 02=lJp ~elt U~ed 03=*:font Seat Right Side I A~d $~;~lde~ ~ ~ ~oto~ Pas~ger ~ ' 05=~d Row* M~e P~ ~=~ond R~ - ~ght ~ 09=~ird Row Or Greater - · , Passenger Or Cargo Area 02=S~ Air ~ h~ ~ ~k ~0 12=in O~n Area (Back Of Pickup, E~.) ~Mu~ ~ ~ Ii=Trailing Unit 9~Other l~Air ~ Not ~; $~ On 99=Unkno~vn 1 l=~r ~ ~ ~, S~h ~ Unk S~ ~ 8=~ 13=Air ~ R~ ~r To ~ash) ~Unk~ un,~ No Person No Delete? Date of _8~irth (MM-OD-vyYy) A B C D E F .... ~---, ....... 2 {J{ II II 11 I I[ { Il I,.ll. I/ll COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM I New P0425074 Sect )n. ff you have a midblo~k crash, you should e~te~ blq~rma~on in t~e 'Distmlal ~ I.~qdma~' A Serf. lan in the P6ncipal Road area, Coun.~! Route Number Segment (OpUo~al) Travel Lanes Street Name ".i'"', ~ ...... ~-' ' -'; Inter.re r~ Tum~Je 0 Tum~ke I Stite ~ (Not Turnpike} ~ (Ea~I) S~r H~ : County Route Number Segment {OptianaO Travel Lanes i111 ' interstate ~j Turnpike :~ Turn,kc O ~ ~ ' (Not Turnpike) (~est) S~r H~hway Inter~;n9 Rt Num Or Mile Post ~ ~ment ':'="' '' 7"~-": ......... '--'~--' ~JllJll 5top Sign Crossing Controls No Controls ~' Impm~eHy C~ ~ ~ i Functioning ~ Propedy C~ th-dm~m ~o._o~ ~/~._~.(,:,,.~ iff 'Not a Work Zone', sk:p rest of Work Zone se~ion) Work Zone (Ma~ afl ~at apply) .] COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM /LA 4S 6 1 c --' O=Non-Cotlision 2=Head On Harm Event LIR Most? Utility Pole Number Sequent~a! 0 O ~ 12=wlpers 13=Driver Seating/Control 14=Body, Doors, Hood, Err 15:Trai~e¢ Flitch 16:Wheels 17=Ah'bags 18=Trailer Overloaded tg=U~ecure/Shi~ted 11~m~k B 1al ~awme~ m~ui ~ ~ V~ R.Ngh~ ' 02=Odvlng U~ing Hand Held Phone 03=Driving U~g Ha~s ~ ~T~ ~m Wr~g ~ne 2~ 07=~ing W/O ~unni~ Stop Sign ~=~un~ R~Ught l~Fai~re To R~nd To ~ T~afflc ConSol 12=Su~d"~wing/S~ppiog · I COMMONWEALTH OF PENNSYLVANIA I POLICE CRASH REPORTING FORM AA 45 7 ~ 0015;~9 ,.,.: *COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM AA45 8 1 PJace emergency transport, witness, and other information here. R is not required to restate information f ~rgD,.the ?rm. - ~ -:":,_ . ;.,..: Unit ! 1- Cell ~ NOt pre, est Narratrve. ............. Unit _i 1 was traveling -n~t om the double yellow limn and entered the berm it entered a yard, the fro~t passenger side'tf~:d%~: at least once and came to rest facin~ east/north east half on the the 7~r~_: All four passengers were thrown fr(~ the,~Vehi~le; the rear of the truck. Oper ! 1 and paeaenger ! 2 Were in the"cab* belt. Passenger % 2&4 were flow~ to Her~ Medical-Center. the Chambersburg Hospital. pa_~--enger % 3 was also t~a~po~ed."~0 Passenger ~ 2 was pronounced brain'Dead At ~ershey Medical Center ~ :ar~va~ Clean Message 129617, File 3, was sent in accor~lce with FR-6-4 on.06/28/02 at 0252..hfs .T~_.~.. d.e~_~a___s~:td_._,_due _to hi? age o~ 14, dxd not. have a dr[ve~o license to secure. ~ni~ off~ce~__~2P_ke with r,iea a Potletger off the Dnuphtn ~ounty Oo~one~ She related the Gi~t ot ~i~e ~ g~ven pe~on to harvest o~jnn~ g~0m copy o~.the_cp~_o_n~_~'~ F__e~o~t i~ nttached. ?notca taken and retained _.0~___06_/_~.~70_.2 T,z__o:~:~r C, ar~, Main~__er o~ Troop-,-~arri~burg respor~ad tO the the acci_de~.t_, a__.n~__~_econ~_truction, case pending the receipt of said report. -, · oD_ ,06./2_6/_0_2 _.__T~3j~pe_ r J_osep~._G!a~ssmtre cesponded tO the scemn and phot0grai~ed attached..._r_epg~.____Trooper Glass, ire photographed the scene from the aft as ground~ Bot~_ reports are attached. SP7-O015 were mailed to the parents of the deceased, the owner of the Vehicle; an~ and passengers # 3&4. Case pendi .ng ?ce~p~ 0.~ _R_~e~'o_ nstructioniet reDort, and review by ~ Cumberland County OistcicC Attot-n?¥s ?ffice 't'~.t:_~. _possible_ _c.._ha__rge_~b~_~i?:J__~.iled. £~M~MONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM AA4581 o I, :IX' Place emergency transport, witness, and other information here. It is not required to restate informa~on fr0m interviewed at the while traveling east .on sa 641 fron a driveway on hia right aide. He While ~Deaking to oper f 1, no v~c;~able.caUSe was":butlt oc' alcohol, a ca1! t:o t:he hershey ho~ital f°tmcl, n° teet[wa~ D~hile at the scene of the acci~n~-, r,~ bli~.'~al~t~;~'is~qq ~ent to the residence directly accoas from vehicle had cc~e from an~ found nobody vas __hy~e_ _ andn°blue Z ~c dive--ay or around the residence. Re~eated ~ _i_n__a_a__~ t~o~in~ the blue vshicle. COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM ~ Ne~ 00'1532 Change/ AA 4.5 F 1 "ag~: J:lJoJJ CD Continuation ~ Concrete ~ Slag. Gravel or P!ea~e :amplete Ur];t ~forma~c~ f~ ~ unit in~N~ in Unknown No Valid License for Class Valid License for Class Not a Pennsylvania Driver Unknown Compliance O Unk I! CDL or CDL Required ~-~ Not a Pennsylvania Driver (~; Unknowz~ © Other .~ Unknown if Test Given Emerqency Use Not in Emergency Use Principle Im~ct Point 0 Nan-Collision O Top C~ Undercarriage O Towed Unit C~ Unknown Avoidance Maneuver c~NO Avoidance Maneuver C~ Braking - Skid Marks Evident 8raking - No Skid C) Marks, Driver Stated Under Ride Indicator C) No Underride or Override C~ Underride, Compartment Intrusion £_me_n:lency Use Crash Number I '1o Iv I,'1 17.1',' I Override, Other Under~ide, No C:) Compartment C~ Vehicle Intrusion Undeffide, Unkno,~n if 0 Comp~rlmem 0 Underrlde or InU'usion Unkno~ O~errld~ - Both Lights and Lights Flashing C~ Siren COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM 001533 Page: ~ County Coun~ Name Crash Dat~e (MM-OD-YYYY) Delete? Owner Last Na_m_e_(!f Pedestrian, skip to Form AA 45 3 l) Policy No 11 Unit Number Owner Last Name (ff Pedestrian, skip to Form AA 45 3 I) ............... :'---~=-----¥---7---~- I I ' Address '~ YiN Model Year ~E .............. ~ License Pla~e ......... ~ .... 7-= Insurance Com~ny P~ . .~ .... ,, II ~,cl,~]'~e~ ........... ,COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM AA45 8 1 Cominuetlo~ Delete I~age Place emergency transport, witness, and other information here. It is not required to r~ This officer was requested ' col I:LS:TLOn And Reconstruction : S Decla~ls.t.t ........ p_h_ho_t~oqraphs of this incident on Officer arrived at the location of-'th~ - at 16~JO--hours. The location .... Hop~ell__Twp. ~ _Cu~L~erlaz~LCo. Kirk PERKINS, PSP Carlisle, Patrol on~t~ 153 70-300mm lens, with GC400 Kodak color f~tm (2 Ro11: "--to be retained by Troop H, Identificat~on unit. . Ttl.i=. wa~able to photograph the econo w~th bbc assist"nee 3 and its pilot, Tpr. Jeff BRAID, PSP Aviation Un[t~ .............. _Film _wa~ fn~vflr~d vtth fO~m~' $D4-1~'6 eO Photographic lab, 1800 Elmerton Avenue, Harrisburg, for processing only. If p~otograp~s are nee~e~ H,___Z~ntj~e~t~o~ t~nJ~ ~n~ refer ~ t~ ~v-t I.D. below ............ Re£er._tc~T_roop ~ Ident~fic~tion n~)mher 0446. 2002-0454 COMMONWEALTH OF PENNSYLVANIA 'POLICE CRASH REPORTING FORM AA451 1 ~_, Y~S C~ No Number ~ (mia ~ ~al ~ (mi8 Iflv~or New County County Name ~ I~-i ...... ~'~ /"" :' ~;;sh Date (MM-DD-YYYY) CLash ~ ~Mil~ ~ Re~ Cr~h ~ H~flway Ma~t~e ~ ~ ~ :.: Unit Number O Motor Vehkfe in O HE&RunV~ O I~P~ O ~ city Modd Ye~' II Towed 8y Unit Number ~ Motor vehide in C~ Hit & Run Vehide (~ I~1~ Parked 0 Legally p~ced C~ Non-'~ Oelete? Type ~ Transport pedes'bi~n off Skates, O Dtsab~l From O Train O etumtme Vehlde ..~, Un/t m~ Pedestrian 0 in Wheel(hair. ate I~-ev~ou~ O~ Owner Last Name (If Pedestrian. skip lo Fo~m AA 45 .t 1) Addr~s ' City WN License Plate Ill Insurance Company Un- ~ Towed TO FI MI Telephone Number I ': state Zlp:.:..~-: .. -: O;Y~: '~ ~el Year ~ NO ~ ~Y ~ ; , AA45 8 1 COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM 001536 Omminua~ion Place emergency transport, witness, and other information ?his Officer was requested by Collision And Reconstruction Specialist ..... of fht.~._:Ln.~.td~,nt on 06/2fi/02 a~ 1~3R at the location of this incident on 06/26/021 -- --The--location was on -".R0641 by Shaay Roma, Cumberland Co., PA. The Investigator PSP Carlisle# ~atrol Unit. · .. ~.;;' :,'-- ~'~*T;~-~': · he scene vas pho~og:aphe~ ~bb a. ~kon ~908 ....... ~I.O~-f-Li~Rolls). Nogatives robe ' Y Identification unit. - ........... ~-~S lo.arid with fo~ Spa-1 ~ ~n PRp ~arrtsbu~g~,~ ~ Photographic lab, 1800'Elmerton AVenue~ Harrisburg; PA i ....... ~-processin9 only. I~ photographs are neea~ con~ac~ ...... H~.~nt~L~nit and refer to I.D. U~ft nvm~r be]ow, COMMONWEALTH OF PENNSYLVANIA _~ Lkense Plate c ~ -"F'-~ '. Insurance Company Insurance Policy No ~) v. !ED No ~; know. j ............. To~veJ To Tow~4 By Vehicle Tow~ {~ Moto~ Vehide in 0 Hit & Ruff Vehlde 0 ul~llY P~ked 0 ~mgallY II~Fged 0 ~ - ~ ; ~nef ~st Na~ (if ~es~n, skip to ~ ~ 45 3 1) R MI T~ ~ Addr~s O~ S~ ~ ' ~ ~ YIN ~ Year Ve~e M~' ........ __ COMMONWEALTH OF PENN~,, LVANIA POLICE CRASH REPORTING FORM · 001535 J New Change/ C~ ContJnualion C~ De~ete Page P042S97S Place emergency transporL witness, and other information here. It is not required to restate Inform~Uon M~dlc~l On 06/28/02 this officer vent to Shi[~e _r~m~ PA 17257 and rec~ested him to sign ~ Troo~r Ga=y ~tainzer of Trooo B-Barrisbur9 ccatld ~ner of the vehicle si~n said search and Tpt* ~ainzer vas provi~d =earch. Searchefl performed. Case penclinq the repo~c frc~ T~. co~y_9f the waiver. COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM 001539 0 New AA45 1 1 ©T*~ (~ ~ ~ , ~ ~ '~ .~ ~_~ Ye~ ~No County N~me Crash Date (MM-OO-YY~Y) I 1 Delete? . . Mod,~ Year V,ddd~ Make~ Unit Number t Delete? O~er L~sX Name ~f l~fest~f~ skip to ~ ~ 45 3 f) MMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM ~ ~ 'aaas8 oo:l. Sao ",': o ,,.,.,..,. Place eme~gen(y transport witness, and other information here, It is ~ required Respondin~ EMS Agenof: [1~ 1~3'1~. :~., Address: Address: Ti~. Gary ~ainzer TrOOp It Collieion lmalvsie and 8000 Bre~z Drive, Barrisbum P~ 17112 p~one: (717) 671-7570 _Repotting_ o[[icec__colld~l;e~_an ajlalysis and reoonstruction of this clash. The follovinq"! co~clueto~mece reachea o'urtn9 t. he investigation. ~ey ate based on the available, i.n~'~ .ma~*£o~id_.areJ~e/tevefl to be ~ccurate and co~¢ec~ to a reaaonable deqre~ of tnVea~lqaEl~'& · ..certainty: ~ .1,._OniLil~as~traveling east on Sa0641, ~= .2....UniLJl vas_.tr&v~t ~n initial speed of approximately 58 mph, ~_3._ Nei~her__operat~r_ll_no~ the front-seat pa.~senger w~ wearing a seat belt, .i .4. Operatoc.ll..loat_.control_of unit tl clue to excessive ~/~ ~ at~rt~ in~t. 0 ~ 5. ~ra~r ..ill~l~of sight ~ld ~ve ~itt~ him to ~e a v~icle enteri~ ~_~~iv~ay Eo the ~ for a dis~*n~ of at l~t 819', ~ .6.. ~a~ t1 .~t~l~ h~ve avoi~ a ~llision wi~ a v~icle enteri~ ~1 f~ ~e ~iv~ay to ~ ~ ~ b¢~ al~e .... Foc detail~ refen I-n _C.-eaez'ai Trt,/eatigation report H2-1266392. Pennsylvania EMS Report Cumberland Valley EMS Co. 53 2100303 0200745 CC# 9657 ] 0024/2002 ~Incldent Location MC'rD . Receiving Facility Rt 641 and Shady Rd 21911 Chamber~l~urg Hospital Patient Name Phone No. A~e Date of Birth Social Sec. No. [Sex.. ~ Dustin Barmont (717)423-6024 15 12/07/1986 -- ! lvl~te ~ Street Address Crew Titans ~'~ 432 N~ville Rd A#11Kintzler, Steven EMT 144914 Dispatch 13:24 q~ City State Zip A#2~ Dangler, Klm EMT 047671 Earouta 1J:24 P^ m4o n#3tMy s,Bc.j.min ^*r ^r eSccoe n;32- ~ Arrtve Faclllt~14:14 ~,~ Private Physician Out On-Scene De~t. In Available 15:28 38516 38532 38550 38562 In Quarters .: I Medical Command Phyaician MCC Chief Complaint: [ i~one Current Med~: { none Allert, le~ ~meds): J none PM~Ix: /Vt~x VlOW I"ICO~D I-]^BP ~]Diab. ["~Cnnc~r ~b[oaeKnovr~ Narrative At 13:24 Arab 3-53 was dispatched by CC as thc 4th Amb due to an MVA with quadmpal e~ecfion with toll over at the inte~ectlon of Rt 041 and Shady RdinHop~wcllTownahip 17240. AO$ Arab 3-53 staged behind Squed 15, Rosune 51, Englne 2-51. Medlc84. AsAmb 3-53 was a~vlngAmb's 1 and 2 53 wcro leaving thc scene with pta in aansit to the landing zone for Life Lion. Al asked A3 to grab a Ix~ard ~lld C][D's while Al got the ~ b. ag and walked up to thc triage area wber~ thea'e ware two mor~ p~ being ~reat~ Walking up the thc pta A1 wdik~, by what appeared to be a compact ptck- up which was cn'bbed and shown signs of a low speed roll-over with heavy crashing damage to the cab and engine compamuant but not much to the bed. Therewasaisonotearingoftheshectmetalandveryllttioparts Onthnroad. Al was shown whexa his pt was andtoldthattheotherptwasin~e ca. of Arab 11-8. A1 ptwas a 15 y/o mwb, o was CAOx3 laying on the ground stadng that hewantedto stsadupandl~ave. Pt stated that he had oo injuriec other than a few serspos and that his grandfather h~d been called and was on his way to get him. Al asked pt what had happened and pt explained the accident. Pt stated that they had been on their way to get fishing worms when the driver ew~'w'ed the ttllck to avoid hitting a car, The truck thon hit aa ~mhankmant turning On its side then rolling over completely. Pt stated that he had be~m siillng in the bed of the ~ruck duling the a~cideut and whun the vehicle stzuck the hank and relied onto its side pt s~ated that he rolled fi'om the truck to the g~und. Pt snared that he rolled because he had been not secure ia the bed and that ther~ was no drop b~weea the truck and the ground R was on the same l~'el due to file mn~t. Pt stated that he had covered his face.a~d rolled along the grass until he stopped. Pt stated that he had not come in contact with t~e. tmck afinr tolling outofit. Pthadno, obvious injudes other thansomevery.m/noshrushbUmandscralga fzom.thogruss. Pt was also v~.~'dustyanddirty.fi~m rollingon the emhankmanL Pi stated that/~ soon as he stopped rolling be got up and went to the others involved. Pt rated thai he n~ver lost ~onac/oos-noss nor ' did he have pain at anytime. Al was confidant in allowing pt to be released into the care of pt grandfatlgr ~ he arrived and stated that ho would take pt to Chambersburg Hospital just to be checked but he would pick up pt mother from work fmc A2 stated that the idea was fine and would also allow grandfather to sing for the pt. A~ Al, A3, and FF Garmeo war~ walking expaipment and pt back to the Arab to compioto pap~nunrk Trooper Perk~ stopped pt and asked whero he was going. Al explained that pt was going back to the Arab to completo ~ork and release pt to grandfather. Trooper asked if pt was in tho vohicio Al r~plied that he was in dead and explained the situation. Tronper otderod that Arab 3-53 transpoR pt to Chernl~sburg Hospital for treamaant and would not allow grandfather to sigo for pt beoaose he was not immediate family. A2 explained to Trooper that she was ok with grandfather signing and that she was the director of the Arab service. Trooper stated that grandfather would not be aloud to sign for pt and that pt must be tshen by Arab. Al stated that they would ~ransport and walked pt to Arab whea~ Al iustmc~ pt to lie down on Iongbeard and plac~ a C-collar oR pt and szoured pt with s~xaps and CIDs. Pt grandfather was instructed to collect family and meet at the at tho hospital. Pt vitals were hr 82, bp 132/80, r 20. Pt was given a head to toe physical ~t which did not revile any injurlas that wa~e obvious. Pt clothing was ditty but no dirt had pa~ed to pt skin. Pt had no bruising, bloeding~ or deformifi~ anywhere. A3 used steriln water and 4x45 to cleca dirt from pt skin. Pt was also placed On 10Lpm 02 blow-by as ~ precaution tod protoeall not beck. os* pt was having t~uble Ineathing. Pt stated that he was still having no complainis in any way. Al radioedtlghespitalandnxplainedtlgattr~asport was due to Tmolgr Perkins and that pt hed uo injudes at alL Upunarrival at Chambemburg pt vitals were hr 100, bp 124/76, r 18. Pt again ashed to be tskea offofthe board and walk into the hospital, A1 explained that · doctor wouldAn ~.~5~o Clret~m~h~ toC-spinr, eiwiec~b~a fwO ~'2:e.wo uld be taken off of the board. Pt w~s placed on n litteI Cupyright, 2000 Med-Media, AIl Righta Rezorved Page: 1 of 2: ~ rain ERGENCY CARE UNIT RECORD ,~ ~ HPI 4: LOCATION S EVERri~' E £/C, f EKG ABG room UA KNEE TRAUMA PACK SERUM PREGNANCY UAC~ HIP PED PROFILE AMYLASE SPIRAL CT FORE. ARM PORT C-SPINE ~cea ieen dot on chart.) EKG / MONI fOR X4~AYS - W~ I READ PULSE OX: I--INI [~ HYPOXIC MED PREPACKS vd o.~ [] Transfer Name: BARMONT,DUSTiN E CE~eMr~ Cam UnitlA~endir~ tOArSSOCTime NotiCed '~'~0~ Pt Phone: (717)423-6024 t~,.1,~<~/. ,&Chambersbu.r~. Emer Notify: (717)423-6024 Date Family D(~tor ,~. . Il .e,~._.~_~ MR No: H329813 ~S'~x ~M Time Refe~ed to Ooct0r ECU Record DOB/AGE: 12/07/1986 15 : 1419 Date Tdage Time ~ie~ ~m~iR~ HPI ~ Pain Score Otherconcerns []No ~None ~None Arthritis ~1 Appendectomy Asthma [] Cardiac CA ~ Chol~yste~omy Cardiac ~ Hysterectomy COPD ~ Other OB/GYN CVA ~ Prostate Diabetes ~ Tonsillectomy Hy~ension ~ Hernia repair Psychosocial Seizures ~ Smokes ~ Subs~nce Abuse Medications, Herbs, & Vitamins: /~one ~1 Unknown AJlergies: ~NKDA Reaction: Vital Signs Arrival Mode: Time T P R BP 02 sat% [~ Walk I~1W/C Triage i ~.~// []ALS /.~LS  0~¢ ~ ~ Carried ' ~ Police /ql ootho, ~ Family ~ Other ~nguage spoken other ~han English: Airway/Breething Mental Status Speech Able to speak Aled __ /~AAssisted *~Oriented X__ -{~"~ANpC ~ ams~lc ~1 Labored [] Unresponsive [] Slurred [] Shallow [] Confused ~1Apneic Behavior Conversation Ideation uOOperative [~oherent [] NA (Not Applicable) ncooperative ~J Silent [] Harmful to Self [] Calm [] Overralkative [] Harmful to Others ~1 Agitated [] Incoherent [] Violent ~1 Crying Visual Acuity: OS OD []CorreCted [~ Not Corrected LMP Vt[ Tetanus: [] Within 5 yrs r-I >5 yrs Peal Immunization: ~ Never [] UTD [] VIS given prior to Td [] Not UTD [] VIS given prior to Td Emotional / Safety / Religious Issues: [] No [] Domestic Violence / Abuse Referral [] Yes Ct SS Referral [] Chaplain Referral [] Yes [] No Age appropriateness Rjr Growth and Development_< 17 years [~ N/A PRE-HOSPITAL CARE: Vital signs: BP: P: Rhythm: Oxygen Airway: {~ Nasal [] Oral [] ET Tube # Taped @ cm ~'Cervical Collar ALS MEDS ,~[Longboard [] Albuterol reed neb ..~ID [] NTG x ~ Splint ~ ~six ~ CPR Begun ~ ~ Morphine -- ~ Blood Sugar. ~ Dextrose 50% ~ I,V. ~ ~her [] N/A [] Atropine [~ Epinephrine [] Udocaine Emer Notify: ~1'~723-6024 Sex: Triage RN Signature . ~ ~ ECU Triage Assessment &Chambersbur. g. White - Chart Copy Yellow - Physician Billing Pooos4c lo 4/c~1 ' CHAMBERSBURG · CHAI~IBERSBURG, PA 17201 BARMONT,DUSTIN E 432 NEWVILLE RD NEWBURG,PA 17240 Ob'P'ITAL EMERGENCY DEPARTMEr Chart Copy {7171423-6024 STUDENT SP 06/24/02 1425 CA 15 SSN 203-62-5516 BARMNONT,ANGIE 432 NEWVILLE RD NEWBURG,PA 17240 BLUE CROSS CUSTOM BLUE .0s0×775223 HARRISBURG,PA 17177-5223 ~ _Mv~ ~ Lebow M.D., Howard M i i:~~ ACbambersb~r.g. H00013267877 ER H329813 CITIZENS BANK W ORANGE ST (717)532-2151 186-58-4776 BARMONT.SHERRY MO PRH186684776 PRH366 (717}530-5117 {717)423-6024 CUMBERLAND VALLEY EMERG A$SO Lebow M.O., Howard M {717)530-5117 Other Doctor Information: Patient Name: BARt, fONT, DUSTIN Account #: HO00! 3267877 Med Rec#: H329813 Admit Date: 06/24/02 CONSENT FOR EXAMINATION, TREATMENT. AND PROCEDURE I agree and give my consent to any examination, treatment, or procedure that the attending physician or his/her assistants may deem necessary or advisable during my stay or visit in this Hospital. It is understood that this consent does not include operation or surgical procedures which may be found necessary. If such operations or surgical procedures are required during my hospitalization/visit, I understand that I will be asked to give specific consent for these operations or procedures. Witness . Patient Signature Dace Authorized Person Relationship to Patient ~?~.~/~ ~ * When a patient is a minor, incompetent, or unabie to sign, the signature of the person authorized to give consent is required. AUTHORIZATION FOR RELEASE OF INFORMATION & ASSIGNMENTS OF BENEFITS I authorize The Chambemburg Hospital to release such information as may be necessary for the completion of insurance claims relative to this hospitalization visit. I understand that the Hospital or my physician may disclose and release all or any part of my medical record to any person or corporation which is or may be liable under a contract to the Hospital or physician, or to the patient or family member or employer of the patient, for all or part of the Hospital's charges or physician's charges. This includes, but is not limited to, HIV related information, drug and alcohol treatment information, mental health treatment information and other information of a sensitive nature to hospital or medical service companies, insurance companies, workmen's compensation carriers, wetfare funds, or the patient's employer. I hereby authorize payment directly to The Chambersburg Hospital for the hospital benefits otheP, vise payable to me, but not to exceed the Hospital's regular charges for this period of hospitalization. I understand that I am financially responsible to the Hospital for charges not covered by this assignment. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim for payment of my benefits. If covered by Medicare, I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I request payment of authorized Medicare benefits for me or on my behalf for any services furnished to me, by or in the Hospital (including physician services) to be made to The Chambersburg Hospital. I authorize any holder of medical and other information about me to be released to Medicare and its agents any information needed to determine these benefits or benefits for related services. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize the physician or organization to submit a claim to Medicare for payment of my benefits. I understand that I am financially responsible to the Hospital for charges not covered by this assignment. If covered by Medica~ Assistance, I certify that the information I have provided is true, correct, and accurate. ~ understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements, documents or concealment of material facts may be prosecuted under applicable Federal and State laws. Provider: The Chambersburg Hospital Patient Signature Date I was offered a Patient's Bill of Rights brochure Authorized Person * Date d udng registration at The Chambersburg Hospital.Relationship tO Patient Jz~/~.~,~'~ ~'~-~ atient'a Initials For patients with Medicare: ~ was given a Beneficiary Right to Know card during registration. Patient's Initials ALL AUTHORIZATIONS I'fUST BE SIGNED BY THE PATIENT OR BY AN AUTHORIZED PERSON IN THE CA~E OF A fqlNOR OR WHEN A PATIENT IS PHYSICALLY OR kIENTALLY INCOI'IPETENT. /~ Keep clean and dry ~lressing for next ~ day(s). ~I.E] Following th~s time period, remove dressing, wash wound with soap and warm water, dry thoroughly and cover with appropriate bandage, Repeat dally unfil the wound has healed. I"']Return here for wound check in __ day(s). Date: f-I Have sutures removed in day(s). Date: []__ time(s) a day, wash bums thoroughly with soap and water; then reapp~y Silvadene cream and redress, Keep dressing clean and dry. [3 Your wound has been closed with Steri-strips, They must be kept clean and dry. Leave Steri-strips in place until they fall off spontaneously in five to seven days. [] Warm water soaks or compresses for 15 minutes four times daily. "~] Return immediately to the Emergency ~/Department or your family doctor ,/if signs of infection deve op - increasing redness, swelling, pus, foul odor, red streaks, fever. ORTHOPEDIC & BACK INJURIES [] Apply ice intermittently to the affected area for the next 48 hours and keep elevated to reduce swelling. [] Rest affected area day(s) or until pain-free. [] Use crutches; do not bear weight until able to stand without pain; then slowly return to normal activities. [] You may remove elastic bandage and/or splint every day(s). If affected area is still painful, reapply and continue use until pain-free. []Bed rest for the next __day(s). [] Wear elastic bandage and/or splint for day(s). [] If the extremity below any bandage becomes increasingly painful, numb, blue, or swollen, remove it or loosen it immediately and contact the Emergency Department. []Use air cast according to the ElffERGEN~'Y C/ ~ UNIT PATIENT INSTRUCTIONS m ~'-Tergent [] Nonemement BARMONT,DUSTIN E ?,:) 267-7146 ;~,~ H00013267877 MR#: H329813 The treatment you have received has been rendered on an emergency basis only. It is important that you follow discharge instructions and receive follow-up care. Follow the instructions below that are checked and any additional instructions given, WOUND CARE MEDICATION INSTRUCTIONS FOLLOW-UP CARE INSTRUCTIONS [] Get prescription filled; take or [] Return to the Emergency Department apply medicine as directed on label, in day(s). Date: Discontinue medication if allergic Time: reaction occurs (rash, trouble [] Call Dr, breathing or other sudden, unexpected Telephone: symptoms) and contact Emergency for follow-up appointment in Department immediately. __ day(s). [] Take 2 - 3 Advil/Nuprin/Ibuprefen every [] Driving restrictions: 4 - 6 hours as needed for pain or fever [] DO NOT drive for the next greated than 101 degrees. __ hours/days (circle one) [] Take with food. [] DO NOT drive until evaluated [] Take two Tylenol every four hours for by Dr. pain or fever greater than 101 degrees, [] Worker's Compensation: Return to ~]Continue current medicine. See medication information provided: the Eme~Jency Department or call [] Antibiotics [] Muscle relaxants your company's designated [] Anfi-inflammatories [] Decongestants/ physician if you develop new [] Narcofics/sedatives Antihistamines symptoms, if your symptoms have GENERAL INSTRUCTIONS not improved in day(s), or []Increase fluid intake if any aspect of your condition []Take only small amounts of clear should suddenly worsen. fluids overnight. [] Return to the Emergency Department [] Gradually resume a normal diet, or call your family doctor Carbohydrates such as toast, plain rice, immediately if you develop new applesauce may be helpful. Dairy symptoms, if your symptoms have products may make your symptoms worse, not improved in day(s), or if [] Use vaporizer or cool mist humidifier, any aspect of your condition [] For pain or temperature over 101 suddenly worsens. degrees use aspirin-free medication ADDITIONAL INSTRUCTIONS (Tylenol, Tempra, Acetaminophen, etc.) [] Your x-rays have received by following schedule, a preliminary interpretation CHILOREN'S ACET~MINOPHEN DOSAGE RECOMMENOATIONS by the Emergency physician Age 4-11 12-23 2-3 4-5 6;8 9-10 11 12-14 and will be reviewed by the G~3~p Mos. Mos. Yrs. Yrs. Yrs. Yin. Yrs. Yin. radiologist within 24 hours. Weight an~ Please call the Emer~.ency ({bs.l 12-17 13-2324-3538-47 48.59~0471 71.95 over D~e ~ Department in 24 houm for Ac. etarnk~ohen 80 120 160 240 32O 4OO 480 64O final interpretation. (in mi.) rog. rog. rog. rog. rog. rog. rog. rog. []'3 Eye instructions: Return Drops to the Emergency Department (80mgm. Stol) I 1.s 2 - - or call your eye doctor Elkir immediately if increasing I1S0mg S.~) pain, redness, discharge, tsp. full 0,5 0.75 1 1.5 2 2.5 3 or blurred vision develops, c~ [] While in the Emergency Room, TatYets (80rog each) 1.5 2 3 4 5 6 your blood pressure was found Jr, St~eflgth to be elevated, This may be Swallow-able due to the stress of an Tablets _ _ Emergency Department visit. (160rog each) 2 2.5 3 4 We recommend your blood Repeat dose every 4 hours as needec, pressure be rechecked by Do not bundle child in blankets, your family doctor within one [] For pain or temperature over 101 degrees use Children's week. instruction sheet. ,'~ ~. Motrin by following schedule. Take every 6 hours as needed, [] A culture specimen has been See additional Instruct ~s ~L~ obtained to test for bacteria, ~ ~\.~ Age 12-23 2-3 4-5 8-8 9-10 11-12 Adult Please call the Emergency provided: ~ ~ s- 11 r-I Head Injury \~L~' ~ ;L~ ~r~ GmU~ Mos. MOS' Yrs' YrS. YrS. Yrs. Yrs. Department in 3 days for [:] Animal bite ' ~-~' ,,',-' Weiqht(Ib~s.) 13-17 18-23 24-35 36-47 48-59 80-71 71-95 - results. E] Tetanus immunization serie~ . Dosage in tsp 0.5 1 1.5 2 2.5 3 4 4 [~ Stop smoking. OTHER: ~- -~- '. , ' .": ~ ~ ,,,', · - ,F ?~ ,' ~: ~- -". ' I hereby a~cknowledge receipt and understanding of the above instructions including the additional instruction sheets. .z' ~ ./,~,; ¢ -, .. ,-. ,- -'. '~ ..... ...- ~ Date: , /: {,..&"~ ! I':' '!--'~' Time: /,. C ~. AM / P~vl Patient's or ResponsibJe Party's Signature - /"~, ~ ' lr~orms Physician's Signature: t ' ~ (,) ~ .~ -~% ~ -_ ' ' ,~"' ' ~ ~- ' Pp338 PHYSICIAN COP'Rurse s S~gnature THE CHAMBERSBURG HOS~ t12 North Ssventh Street Charhbersburg, PA 17201 (717)267-7149 SUMMIT HEALTH C ER Rhonda Brake Shreiner Women's Center Summit Diagnostic Services Departments of Chambersburg Hospital NAME: BARMONT, DUSTIN E PATIENT#: H00013267877 DOB: 12/07/1986 RADIOLOGIST: Kevin M Cregan M.D. PATIENT LOCATION: CER REPORT #: 0624-0333 ADMITTING DIAGNOSIS: MVE REASON FOR EXAM: ORDERING PHYSICIAN: Anderson, Thomas E M.D. MEDICAL RECORD #: H329813 PATIENT TYPE: DEP ER ROOM/BED: PATIENT PHONE: (717)423-6024 FINANCIAL CLASS: SP ORDER #: 0624-0237 DIAGNOSTIC IMAGING REPORT STATUS: Signed DATE OF SERVICE: 6-24-02 HISTORY: 15 year old male with trauma. RIGHT WRIST IMPRESSION: 1. Soft tissue swelling along the volar aspect of the distal radius without evidence of an associated fracture. COMMENT: Three views of the wrist are obtained. There is soft tissue swelling along the volar aspect of the distal redid! metadiaphysis. There is no evidence of an associated fracture. The prenator quadretus fat pad is preserved. 959.3 <Electronically signed by Kevin M Cregan M.D.> Dictating Physician: Kevin M Cregan M.D. TR NAME: DONNA M SHETTER DICTATED: 06/24/02 TR DATE: 06/24/02 CC: Howard M Lebow M.D.; Kevin M Cregan M.D.; Thomas E Anderson M.D. HIM Copy Medical Records DEPARTMENT: DIAGNOSTIC IMAGING 73110 Page 1 of 1 MR#:'H329815 Name: B~MO~T, DUSTIN E Acct: H~00t3267877 Phone: (717)423-6024 Priority: Stat STATUS ~.EG ER ORDER # PL~F~MONIC 1. 0624-0237 ~FRZ~T *Reason For Exam: TRAUI4A Left Or Right Side?R Comments: MVA Date Ordered: 06/24/02 Time Ordered: 1518 Service Date: 06/24/02 at ~517 DOB: 12/07/1986 Ordering Phys: Anderson M.D., Thomas E Pt. Room/Bed: DESCRIPTION Entered By: PIERRETTE CUMMINGS REQUISITION 9: 02-72443 ============================================================================================ EMERGENCY DEPARTMENT RF~%DING . NO IFICANT ABNOPd4ALITY !~'~] ANDE BOYLER HEINE_ CORIALE. MARX CONNOR OATMAN SENECAL STEVENS WILLWERTH__ RESIDENT___ R.J~IOLOGIST READING AGREE NO SIGNIFICANT ABNORMALITY __DISCREPANCY ED NOTIFIED: (TIME/PERSON): PS199meditech RADIOLOGIST SIGNATURE ERILL CHING CREGAN D'AMELIO. FANG LEVIN THANE .J :~'~[~".'} I'1 ~d~llabo[ed [] Labored [] Sffidor D Retractions ~ rway patent [] Accessory muscles [] Nasal fladng ~- Symme~cal [] Shallow [] Audible ralos ,; .. [:3 Cough: [] No0-producgve [] Productive O Lung sounds: Clear ~ Absent/Decreased [3 L _~ Rales [] R [] L j ~- Rhonchi [] R [] L w Wheezes [] R [] L , Other I-1 ~Alert & oriented Pupils ~ [] Headache lmm 2mm 3mm 2: ri Neck pain · · · -- ri Facial droop [] R [] L 5mm 6mm 7mm -I [] Dysphasia < [] Numbness ~ m Weakness O r-1 Dizzy Size Prompt reaction 0 ao~. r3 Ur~teady Gait [] Stead ::3 Hand Gras , > ~ Deviated ~: [] Other Fixed Sluggish Non-reactive rl [] Denies < Nausea []Yes [] No Vomiting []Yes [] No ~ Alt color [] Diarrhea [3 Constipation [] Dysphagia ~ ~r~e nt [] Absent -' ,' [] Hypoactive :' · ' [] Hyperactive 0 Last BM ~?.~: I-1 Location/Assessment ~ '-~'=~'* ~ of Injury ~'~iJ'~!ii' ~ Distal Capillary refill: ~-!~ J['] ~ O [] Wound cleansed [] Ice applied __ n Extremity elevated I ~ m [] BloWing controfl~:~ ~ m [] Dressing applied O< ~ O [] Other I E] Eyes [] N/A [] R [] L i ~ [] Blurred vision ~;..~i .;~>~~Z n Double vision ~,!~,~.;~ ~_ [] Photophobia · ,,, [] Other 4mm R L mm mm [] [] [] [] r'l [] [] [] [] [] [3 [] [] Distended [] Tender [3 Firm [] ~in Pulses Z~Wa Cap Refill ~ k [] Regular rm [] < 3 sec. z [] Pale [] Irregular [] Dry [] > 3 sec. · [] Cyanotic [] Bounding [] Cool "~ [] Ashen [] Weak [] Clammy ~ [] Mo~ged D Absent [] Ecchymosis 0 [] Flushed Radial [] R [] L [] Edema ~, ~ Jaundiced pos1Tibial [] R [] L ac Pedal [] R [] L o DR DL [] Denies ,~ [] Denies [] Urgency ~ [] Vaginal Bleeding Onset [] Frequency __z [] Discharge Descdbe [] Burning [] Cramping [] Foley in place EDC FHT G P [] Pressure [] Pain Fetal Movement (Per Mother) ~ Y ~ N ~ Other Neuro(sensation) Distal Pulse [] Intact [] Present [] Deficit [] Absent [] Intact [] Present [] Deficit [] Absent [] Intact [] Present [] Deficit [] Absent [] Intact [] Present [] Deficit [] Absent [] <3 sec. [] >3 sec. [] Wound clean & dry [] Drainage [] Redness [] Wound weft approximated [] Sutures intact Ears [] N/A [] Itch [] Pain [] Burn [] Drainage [] Red [] Other [] Drainage PN- ~[] [] Driver [] Passenger [] Pedestrian [] Auto -- [] Motorcycle [] All terrain [] Bicycle [] Gun shot wound ~ ~: [] Stabbing [] Fall ~ [] Ejected [] Restrained [3 Unrestrained o ~. [] Helmet [] Unknown [] Other 0 R ~ L Nose N/A Throat D NIA ~ R ~ L ~ Sol throat ~ Bleeding ~ Dysphagia ~ Drainage D Dr~gng ~ Other ~ ~her MoNT,DUSTIN E ABcAcct:R H00013267 B77LOC: CER MR#: H329813 ADM DT: 06/24/02 PC Phy' LaboW M.D., Howard M DOB/A~e: 12/071398B ~5 Sex: M pat Phone: (717)4.23-6024 ~f'ne~ NotiN: (717)423'6024 . Chambersb.u. Chambersburg ECU NURSING ASSESSMENT Page POO993 Monitor Strip Rhythm r~ 12 Lead EKG r~ Cardiac Monitor TfME 02 Type: Pulse Oximeter: CPR: TEST PROCEDURES INITIALS TIME TEST Glucose Hemastix; + Hemocult: + mg/dl INITIALS P R O~ PAIN BP SAY GCS SCAt. E I & O BARMONT, DUSTIN E Acct: H00013267877 LOC: CER MR#: H329813 ADM DT: 06/24/02 PC Phy: Lebow M.D., Howard M DOB/Age: 12/0711986 15 Se:<: M Pat Phone: (717}423~6024 MEDS NURSING OBSERVATION, INTERVENTION & EVALUATION Cham~burg Pege 2 TIME T ' P R BP 02 PAIN I & O SAT GCS SCALE ONT,DUSTtN E BARM___~_~ ?L~oc: CE~ Acct: HOp_~J~78?'ADM DT; 0612A/02 PC Phy: Leb 7~;[~S6 15 Sex: DOB/Age. ~7171423-6024 Pat Phone: , 24 MEDS NURSING OBSERVATION, INTERVENTION & EVALUATION l Chambersburl - Chambemburg ECU NURSING ASSESSMENT Page 3 02 PAIN TIME T P R BP SAT GC$ SCALE I & O MEOICATION [] Safety Measures: [] Side rails x with verbal consent obtained. [] Papoose Board [] History of Falls [] Restraints [] Family/significant other present Name/Relationship: Pag~ 4 NURSING OBSERVATION, INTERVENTION & EVALUATION .: ,~, [] Admit: Report called to: Room Number Time to Unit [] Transported to Critical Care with ACLS trained RN, monitor, and essential emergency supplies as appropriate. · -:: ~ ' [] Old Records Sent :"~'~:'~.-".' .--';.~: [] Transferred to: Via Report called to: Room Number Time leaving [] ECF Notified Time Name [] Family Notified Time Name and Relationship E] Police Notified Time [] Children in Youth Time [] Morgue Time [] WIN Notified Time '" ~-Discharge: ~Ambglatory []W/C []Carried []Stretcher []Ambulance Time: i~!~.:~l Status: ~]~2Alert &oriented []Other Accompanied by: ~: ~ischarge instructions given with verbalized understanding of treatment regimen for home care. [] Rx given [] Medication instructions given [] Head injury instructions given [] Orthopedic instructions given [] Dermabond instructions given [] Explained by interpreter [] Other BARMONT,DUSTIN E Acct: H00013267877 LOC: CER MR#: H329813 ADM DT: 06/24/02 PC Phy: Lebow M,ID., Howard M DOB/Age: 12/07/1986 15 Sex: M Pat Phone: (717)423-6024 Emac Notify: {717)423-6024 [] Crutches fitted with return demonstration [] Left AMA [] Left without instructions/follow-up completed [] Discharged by physician [] Instructed not to drive [] Splint [] Suture [] Knee immobilizer removal [] Ace wrap [] Dressing [] Sling THE CHAMBERSBURG HOSPITAL 112 North Seventh Street Chambersbur.q, PA 17201 (717) 267-3000 NAME: BARMONT, DUSTIN E PATIENT#: H00013267877 PHYSICIAN: Thomas EAnderson M.D. ROOM/BED: SERVICE DATE: 06/24/02 MEDICAL RECORD #: H329813 PATIENT TYPE: DEP ER DOB: 12/07/1986 REPORT #: 0626-0096 REPORT STATUS: Signed EMERGENCY ROOM REPORT CHIEF COMPLAINT: Motor vehicle accident. HISTORY OF PRESENT ILLNESS: This 15-year-old male was in the back of a pickup truck that apparently rolled over. He says he was thrown from the pickup truck and he cornplains of pain only around his right wrist area and some abrasions to his left arm. He denies any other injuries. Denies injury to the head or neck,chest, abdomen or extremities other than the right wrist. He says he has fractured that right wrist in the past. Patient was up and ambulatory at the scene, but when ambulance arrived, he was placed on a back board and cervical collar. Brought to the emergency department for evaluation. PRESENT MEDICATIONS: None. PAST MEDICAL HISTORY: Negative. REVIEW OF SYSTEMS: General: No fevers, chills or weight loss. Eyes negative, ENT: Denies facial injury. Respirations: He is not short of breath. CV: Denies chest pains, Gl: No abdominal pain, nausea or vomiting. Musculoskeletal: Only injury as outlined above. Skin: No laceration, Neure: Denies bead injury, denies headache, neck pain or back pain, extremity weakness or numbness. PHYSICAL EXAM: AJert, normal mental status and vital signs. Blood pressure is 145/71, pulse 98, respirations 18. Eyes: Conjunctivae mildly injected. ENT: There is no facial tenderness or swelling. Does have mud about the face, but no abrasions or swelling. Heart rate without murmur. Lungs clear to auscultation. No chest wall tenderness. Abdomen is soft. There is no guarding, tenderness or masses. Musculoskeletal: There is moderate swelling and tenderness and limited range of motion of the distal right radius and ulnar area. No elbow tenderness. The left extremity shows superficial abrasions, but no bony tenderness or swelling. He has a few very superficial abrasions over the left knee as well, Neuro: Skull is atraumatic. Neck is in cervical collar. This was removed. He has no posterior cervical or spinal tenderness, No thoracic or lumbar spinal tenderness, Skin: Abrasions as outlined above. No other lacerations seen. DIAGNOSTIC STUDIES: X-ray of the right wrist: I do not see obvious fractures. Could have a growth plate fracture. This cannot be ruled out. EMERGENCY DEPARTMENT COURSE: His abrasions were cleaned. Bacitracin ointment applied and a dressing. Splint applied to the right wrist. MEDICAL DECISION MAKING: Patient presents after a motor vehicle accident. I do not see signs of intracranial, pulmonary, abdominal or neurologic injuries at this time. I am concerned about a possible occult fracture to the right wrist or growth plate fracture. DIAGNOSIS: 1. Status post motor vehicle accident, 2. Abrasions of the left arm. 3. Question fracture right wrist. PLAN: Treatment as above. Patient put on Dr. Wolfe's follow-up list for tomorrow. Change dressings on the abrasions once a day. Watch for signs of infection. Return to ER if any problems or any new symptoms develop. DEPARTMENT: CHAMBERSBURG HIM Page 1 of 2 THE CHAMBERSBURG HOSPITAL 112 North Seventh Street Chambersburg. PA 17201 (717) 267-3000 NAME: BARMONT, DUSTIN E MEDICAL RECORD #: H329813 PATIENT #: H00013267877 ROOM/BED: TR NAME: DEBORAH HAFER DICTATED: 06/24/02 TR DATE: 06/26/02 CC: Howard M Lebow M.D, Medical Records' copy Medical Records EMERGENCY ROOM REPORT <Electronically signed by Thomas E Anderson M.D.> Dictating Physician: Thomas E Anderson M.D. DEPARTMENT: CHAMBERSBURG HIM Page 2 of 2 C H A M B E~.~ii~3 U R G . O~iii~A L CHAMBERSBuRG, PA 17201 BARMONT,DUSTIN E (717}423-60:24 432 NEWVILLE RD NEWBURG,PA 17240 AUTO[ 10/14/02 , BARNIONT,TEDDY E 432 NEWVlLLE RD e.t- NEWBURG,PA 17240 ERIE INSURANCE GROUP ERIE INSURANCE GROUP P O BOX 2013 MECHANICSBURG,PA 17055 10-14,OP,RT. WRIST UGAME Lebow M.D. Howard M ss~ 176-72-4494 CA 15 12/07/1986 OCC COOE REL~TI0 N TO PATIENI~ 162-54-4852 BARMONT,TEDD¥ E. (717)530-5117 STUDENT UNKNOWN FA 010170621395 Wolfe M.D., Raymond M Lebow M.D., Howard M FA (717)423-6024 (717)264-6211 (717)530-5117 Other Locations: CPAT OUTPATIENT DISCHARGE INSTRUCTIONS 1. DO NOT d,l,c ut oDezatc h,u~,,dous machincry fo, 24 h,~m~. 2. DO NOT make important personal or business decisions for 24 hours. 3. - DO NOT drink aichoholic bc¥'ciages for 24 hours. Drink water and carbonated beverages (cola, 7-up, etc.) as tolerated. 4. Eat light foods. (Jell-O, soups, etc.) as tolerated. 5. If your bandage becomes saturated with bright red blood, place another pad over it. Do not remove the odginai bandage. Call your surgeon for further instructions. A small amount of bright red blood is expected. 6. Repoa the following signs or any questions regarding your physical condition to your surgeon immediately: excessive swelling on or around your incision redness · t~mperamre of 101½ F or above · excessive pain 7. You may take Tylenol for pain as needed and tolerated. 8. You have had an intravenous catheter removed from your arm or hand. It is very important that special care be given by you in order to prevent infection. The following general measures should be followed: · keep band-aid on arm or hand for s~ to eight hours. · if you must bathe or shower, remove Band-Aid first; then bathe or shower. DO NOT KEEP WET BAND-AID ON AT ANY TIME! Observe for signs of infeetion such as redness, pain, or swelling. If these symptoms occur, see your surgeon or retom to the Chambersburg Hospital Emergency Care Unit. 9. If you are unable to pass your urine within eight hours after your arrival home, please call your surgeon. Special instructions/medication: 3. Physici&gna r~e~ ~ate P04228 7/92 INSTRUCTIONS GIVEN BY: P~~WLEDG~qT: (Patlenffs~gmficant other's signature) Date: Time: FOLLOW.UP ~PPOINTMENT: Date: ~ toeOz. Time: CALL d~,q-<,,2 tt FOR APPOINTMENT TIME. NAME: BARMONT,DUSTIN E PATIENT #: H00014030217 ADMISSION DATE: PHYSICIAN: Raymond M Wolfe M.D. THE CHAMBERSBURG HOSPITAL 112 North Seventh Street Chambersburg, PA 17201 (717) 267-3000 MEDICAL RECORD #: H329813 PATIENT TYPE: PRE SDC DOB: 12/07/1986 ROOM/BED: REPORT#: 1014-0095 HISTORY AND PHYSICAL HISTORY DATE OF SURGERY: 10/14/2002 CHIEF COMPLAINT/REASON FOR ADMISSION: Right wrist pain. HISTORY OF PRESENT ILLNESS: The patient is a 15-year-old gentleman who had fallen out of a pickup truck and sustained an injury to his right wrist. Despite nonoperative treatment and casting, the patient failed to get better. He eventually underwent an MRI that showed a tear of the scapholunate ligament in his right wrist, and he presents now for surgery. PRESENT MEDICATIONS: None. ALLERGIES: No known drug allergies. RELEVANT PAST MEDICAL HISTORY: Denies. PAST SURGICAL HISTORY: Denies. RELEVANT FAMILY HISTORY: Noncontributory. RELEVANT SOCIAL HISTORY: The patient is a 15-year-old gentleman who lives at home, currently in the vo-tech program. Denies any history of drug or alcohol use. REVIEW OF SYSTEMS: Noncontributory. RELEVANT PHYSICAL EXAMINATION GENERAL: Physical examination shows a healthy appearing teenage male in no apparent distress. HEENT: Within normal limits. LUNGS/CHEST: Clear. HEART: Regular rate and rhythm. ABDOMEN: Soft, nontender. EXTREMITIES: Intact except for the right wrist which shows a painful and palpable crepitation with radioulnar deviation and axial load. He has weakness in the right wrist as compared to the left. Radiographs show a mild widening of the scaphotunate ligament interval. MRI confirms a tear of the ligament. IMPRESSION: Right wrist scapholunate ligament tear. PLAN: Repair of the ligament. Patient understands the risks and benefits and wishes to proceed. Page 1 of 2 DEPARTMENT: CHAMBERSBURG HIM NAME: BARMONT, DUSTIN E MEDICAL RECORD #: H329813 PATIENT #: H00014030217 ROOM/BED: THE CHAMBERSBURG HOSPITAL 112 North Seventh Street Chambersburg, PA 17201 (717) 267-3000 HISTORY AND PHYSICAL Raymond M Wo fe~M.D~ TR NAME: MARY ANN STARR DICTATED: 10/14/02 TR DATE: 10/14/02 CC: Raymond M Wolfe M.D. Medical Records' copy Medical Records DEPARTMENT: CHAMBERSBURG HIM Page 2 of 2 NAME: BARMONT, DUSTIN E PATIENT #: H00014030217 PHYSICIAN: Raymond M Wolfe M.D. ROOM/BED: THE CHAMBERSBURG HOSPITAL 112 North Seventh Street Chambersburg, PA 17201 (717) 267-3000 MEDICAL RECORD #: H329813 PATIENT TYPE: REG SDD DOB: 12/07/1986 REPORT #: 1015-0161 .::2 OPERATIVE REPORT SURGERY DATE: 10/14/2002 PREOP DIAGNOSIS: Right wrist scapholunate ligament tear. POSTOP DIAGNOSIS: Same. OPERATION: Repair of right wrist scapholunate ligament. SURGEON: Raymond M Wolfe M.D. ANESTHESIA: General. INDICATIONS: The patient is a 15-year-old gentleman who had fallen offofa truck several months ago. He injured his right wrist, and eventually an MRI was performed that confirmed the above injury, and he presents now for surgicat treatment. DESCRIPTION OF PROCEDURE: The patient taken to the operating room and placed supine on the operating room table. After general anesthesia was performed, and IV antibiotics were given, a tourniquet was placed over the right upper arm but not inflated, and the right arm was propped and draped in standard surgical fashion. Attention was turned to the right wrist to where a incision was made approximately 4 cm long over the radius-scapholunate interval, and the incision was carried down through skin and subcutaneous tissue. Subcutaneous tissue was bluntly dissected, and hemostasis was obtained. The wrist joint was then entered between the third and fourth domal compartments down to the level of the wrist capsule, and the wrist capsule was elevated exposing the scapholunate ligament quite well. A probe revealed that the ligament was completely detached from the scaphoid, although it was still attached in its most distal insertion dorsally. The scaphoid was then debrided with a rongeur and curet to expose the bleeding bone surface, and then the ligament was repaired back down to the bone using two 2.4 mm anchors and horizontal mattress sutures from the most distal pole up the dorsum in 3 mm increments. The scaphoid was then reduced on the lunate as confirmed by x-ray, and then a single 0.062 pin was drilled from radial to ulnar through the scaphoid and lunate. Satisfied with the roduction with the pin, the sutures wero then tied, and another pin was placed into the scaphocapitate. Satisfied with the procedure, the wound was irrigated. HemostasJs was obtained after the tourniquet was released. Capsule was repaired with 2-0 Monocryl interrupted suture. The skin closed with 2-0 and 4-0 Monocryl subcuticular sutures and Steri-Strips. The patient was then placed in a well-padded sugar-tong splint, awakened from anesthesia and taken to the rocovery room in stable condition. Raymond M Wolfe M.D. TR NAME: DEBORAH a DESHONG DICTATED: 10/14/02 TR DATE: 10/15/02 CC: Raymond M Wolfe M.D. Medical Records' copy Medical Records DEPARTMENT: CHAMBERSBURG HIM Page 1 of 2 NAME: BARMONT,DUSTIN E MEDICAL RECORD #: H329813 PATIENT #: H00014030217 ROOM/BED: THE CHAMBERSBURG HOSPITAL 112 North Seventh Street Chambersburg, PA 17201 (717) 267-3000 OPERATIVE REPORT DEPARTMENT: CHAMBERSBURG HIM Page 2 of 2 ACbambersb?.& PACU STANDING ORDERS FOR PATIENTS AGE 12 AND OVER 112 North Sevenga St~et P.O. Box 6005 Chambetsburg, PA 17201-6005 717-267-3000 ROUTINE MONITORING A. tVfi.lrrual momitoring to include I~G, BR respirations, t~mperamre, and oxygen saturation. B. Blood pressure and pulse to be r~corded on admission and q 5 minutes until patient is awake and slabie; then q 15 minutes C. Respirations are to be taken on admission and at q 15 minme intervals. D. Oxygensaturafiontoberecordndq 15 miuntes onfil discharge. E. Temtxramm w be recorded on admission end q 30 miunte~ if below % or abov~ 99 or with/n one degee of pm-op temperamr~ OXYGEN THERAPY A. 3-5 LPM Oxygen via nasal carmula or as determined by anesthesiologist. B. Wean patient off oxygen slowly. C. May discontinue oxygen when saturation is maintained above 90% on room air or same as pn~.enesthetic levels. IV FLUID 2 ccJkg~r of intraoperative fluid or as ordered by the anesthesiologist. PAIN MEDICATION A. PS I-II and 60 years of age or less Fantanyl 25-50 ug IV; may repeat q 5 minutes until pain score is less than 5. LOC 3 or 4; total dose not to exceed 200 ug. B. PS I-II and over 60 years of age Fantanyl 25-50 ug IV; to~al dose not to exceed 150 ug. C. PS Ill-IV Fentanyl 25-50 ug IV; may repeat q 5 minutes as above; total dose not to exceed 150_uw. - D. Rescue Medication Morphine 2-$ mg IV q 5-10 minutes until pain score, is < 5 ca', LOC 3 or 4 for inpafients only; total dose not to exceed 30 nag unless approved by anesthesiologist. Contact supervising unea~thesiologlst re: outpatient~. NAUSEA AND VOMITING Regian 10 mg IV for recta'rent nausea and/or vomiting (not in Parkinsou's). If unrelieved may give Zofran 4 mg IV. ACTIVITY Inpatient - as per suvgenn's order Outpatient - elevate head of bed as tolerated; gradual progressio~ of activity as tolerated. DISCHARGE NOTIFY ANE$1HESIOIOGIST IF May discharge to home, room, or Same Day Services A. Systolic BPbelowg0mmHg ~--~ when meets discharge criteria(on backofthis form). If B. Diastolic BP above 100 mmHg . a ~ -0,~~- / ,~oxygen saaimtion below 90% and patient otherwise C. Il_earl: rate below 50 or above 120 /~'/~ ~ ~f///'re.~ar~af. cli~'sch~e maintain on oxygen via cannula at 3 ~ ,v t¥,'ZT>~/I/ '.-fEPM untiF0700. May discontinue nasal O if natient BARMONT,DUSTIN E Acct: H00014030217 LOC: MR#: H329813 ADMOT 10/14/02 Dr: Wolfe M.D., Raymond M DOS/Age: 1210711986 15 Sex: M 0 - Wide awake; alert I - Drowsy; eyelids droop; responds to verbal stimuli 2 - Dozing intermittently; responds to mild physical and verbal stimuli 3 - Mostly slenping; responds to moderate/strong physie~sfimuli 4- $o~. t'~.~r~ble P04234(0: I 0t96, R:7/001 2. 3. 4. 5. 6. 7. Discharge Criteria Par Score 8 or greater Dressing intact; drainage appropriate to procedure. IV site unremarkable; IV dc'd if applicable. Minimal or no nausea/vomiting. VAS SCore of 5 or less. Skin color & temperature same as preanesthetic level procedure appropriate. Responsible adult to accompany (outpatients only). SURGICAL PREOPERATIVE SCREENING PHYSICIAN'S ORDERS PatientName: ~(.d ~>/.r] ~ ~'ZT. t4V'DtO'L~ Surget~Date: P.A.T. Appointment Date: e~ 6/'7/0~ ,~.'~4C._h Admission Date (Inpatient Surgeries Only): Patient Diagnosis: ~ (..l./t.,,..~- ~A~e~,',~.~°~d- ~ 'q/pe of Anesthesia: Patient Allergies: CBC PtPtt Amy HBSG HiVAB TAS OBTAS Udne (Comprehensive Blood Count) (PT + Ptt) (Comprehensive Metabolic Panel) (Basic Metabolic Panel) ~ (Liver Function Studies) (Amylase) (Hepatitis B Surface Antigen) (H~V) (Type + Screen only) (C-Sections-OB Type + Screen) (Type + Cross) # units (Urinalysis) (Urine Culture) EKG - to be read by Dr. Chest X-ray Other * EKG, Chest X-rey, and Lab Requirements - see back of this form BARMONT,DUSTIN E Acct: H00014030217 LOC: MR#: H329813 ADMDT 10114/02 Att Dr: Wolfe M.D., Raymond M DOB/Age: 12/07/1986 1 § Sex: M SAM~DAY SERVICES ORDERS: ~l~Antibiotics: Give in SDS OR/~ OTHER MEDS: Give in SDS . OR Clip area: [3 No Clip [3 N/G: Insert in SDS OR . [3 Foley: Insert in SDS OR ri Knee High AES O Thigh High AES [3 SCD Pump: Start in SDS __ PACU Right Left O Bi-valve Cast in SDS [3 Other Surgeon's Si~nature Date Pre-oR T,eachi~g ?on:y Dale Faxed to Central Suppty Date Time p04141 (O'OND,R:4d0I) Ag~ 0 to 6 months 6 months to 10 years 10 years to 40 years 40 years to 50 years 50 years to 64 years 65 years to 74 years 74 years or older Male H/H (Hemoglobin and Hematocrit) None None ECG (Electrocardiogram) ECG (Electrocardiogram) YAH (Hemoglobin and Hematocrit) ECG (Electrocardiogram), BUN (Blood Urea Nitrogen), Glucose I-I/H (Hemoglobin and Hematocrit), ECG (Electrocardiogram), BUN (Blood Urea Nitrogen), Glucose, Chest X-Ray? Female H/H (Hemoglobin and Hematocrit) None H/H (Hemoglobin and Hematocrit) Pre~mancy Test? IqJH (Hemoglobin and Hematocrit) Pregnancy Test? H/H (Hemoglobin and Hematocrit), Pregnancy Test? ECG (Electrocardiogram) H/H (Hemoglobin and Hematocrit), ECG (Electrocardiogram), BUN (Blood Urea Nitrogen), Glucose H/H (Hemoglobin and Hematocrit), ECG (Electrocardiogram), BUN (Blood Urea Nitrogen), Glucose, Chest X-Ray? * Laboratory studies that are 90 days old or less and ECG/Chest X-Rays that are no more than one year old are acceptable for asymptomatic patients who have had no interval change in health or intercurrent infection. * Chest X-Rays are to be elective for all cases, depending on the patient's history and physical. BMP (Basic Metabolic Panel) Carbon Dioxide Chloride, blood Creatinine, blood Glucose, quantitative Potassium, serum Sodium, serum Urea Nitrogen, quantitative Anion Gap, calculated Calcium, total Lyre (Electroglytes Panel) Carbon Dioxide Chloride, blood Potassium, serum Sodium, serum Anion Gap, calculated CMP (Comprehensive Metabolic Panel) Albumin, serum Bilimbin, total Calcium, total Chloride, blood Creatinine, blood Glucose, quantitative Phosphatase, alkaline Potassium, serum Protein, total Sodium, serum Transferase, Aspartate Amino (AST/SGOT) Urea Nitrogen, quantitative Liver (Hepatic Function) Albumin, serum Bilirubin, total + direct Phosphate, alkaline Transferase, Aspartate Amino (AST/SGOT) Transferase, Alanine Amino (ALT/SGPT) Preoperative Eva~uatJon: Patient was iden~ed before surgs~y ~ ~ No Image atudiee and/or wflt'len ar verbal mpc~ indlcam ,~lde to be opem~d o~: .... O L ~J~-R I~NA The procedure will be perfomled on the: ....................... i-I L,~I/ [~'J~lt $~de I-I NA Date: r~/~(,,.,Time: /~'/' ~/o~natu~}~- Type of Anesthesia: Estimated Blood Loss: Significant Findings: Complications: .. ~ Condition of Patient: Date: /~/,//~ Time: BARMONT, DUSTIN E Acct:H00014030217 LO C: MR#:H329813 ADM DT 10/14/02 Att Dr: Wolfe M,D., Raymond M DOB/Age: 12/07/1986 15 Sex: M Signature PRE & POST PROCEDURE PROGRE~.~ NOTES :~*~ ,. ~i~'? **THIS SIDE TO BE COMPLETED BY ANESTHESIA** ·~-~-~-~'~'-~-' :''', -~- "~, ~.~: /. '?~ ~ ?.~?~*DATA (only Items as applicable) ~ * ~ ~'* ~ ~/:~*TM ~.~..: h' -~ ~.-..,,.., . - PT CO2 :: ~"~2 ' P~ Glu :~ Base OTHER OTHER Bun/er 02 Sat Above reviewed by Special Considerations: ;: A.S.A. Physical Status' ~ 2 _~.:3. :..4; 5 , E ,.~*," ,-" - ~ ¢..~-:~ ~ .><: Phw ~-.~ F~am ~,~, Nn~ ' Ahnn~ ,~ ~nmm~nte .~ - :'-' ~ Anes~etlc choices and ns~ e~laln~ to patient ~d }~. ;~ - -..,~, ..-, ,.,*. . .-~,, .. ~r.-~..~, ,.. - ,, , ,. ,.?~ ~ All questions ~swered ., ...: ~ ' ' r ' ig ature ~'~ .... - '*(aalampa, ~) Date ~-/~- Z Time POST ANESTHETIC EVALUTiON (Circle when applicable) No Sequelae or problems Nausea & Vomiting ~"~' ':~ · Numbness/VVeakness c/o Sore Throat Headache Damaged Teeth Commen~ Signature Dat/~//~,_ Time ,,,~1~ QUESTIONS · . r,. Pharmacist (TRGPH) ;¢o~ Dietary (TRGDI)~ · ':~' O- PT (TRGPT) -,~ ,: ~' ~/~ ~ ET (TRGRT~ _ .'~ *... ~ -.' Chapl.a~n (TRGCH) i~;~.;.ET Nurse.('TRG._ET). ;-~: i ~ -.Crises. Intervention '£.¢ ;A: Diabetic Pediatric/Adolescence Age Spemflc AssessmentI Head Ci fe~ t ) · * .... mum o 18 months Tetanus: >5y~-"'~know~ Immunizations up to date? ('Y'es ~,) No f no, mmun zat on material provided· Yes Spina Bifida (latex) YesJ'No~ ~ · Cleft Palate Yes ~ · ~- GROWTH AND DEVELOPMENT REVIEW Check (If applicable) ' ~-=;~ [] Infant Birth - 3 months · ~ [] Can turn head from side when prone [] Lifts head momentarily from bed [] VOCalizes to familiar voice [] Set, iai smile in response to vanous stimuli [] Toddler -1-2-years [] Walks without help [] Feeds self with cup with little spilling :~"[] Pulls and pushes toys [] Seats self on chair ;:~:~.~ -- [] Ceases crying when parent enters room :-"~ ' [] Locates sound by turning head to side and looking n same direct on "2' ~;~ ~.:<~.O Plays peekaboo .~ ', - ' .....~..- * ~' ' , [] Infant 8-12 months [] Sits steadily unsupported o Fear of strangers [] Starts holding on to furniture [] Begins to show fear of going to bed and being left alone [] Crawls by putting self forward with hands [] Says "dada" and "mama" [] Walks holding on to furniture [] Can hold a crayon to make a mark on paper BARMONT,DUSTIN E Acct: H00014030217 LOC: MR#: H329813 ADM DT10/14/02 Att Dr: Wolfe M.D,, Raymond M DOS/Age: 12/07/1986 15 Sex: M [] Picks up object without falling [] Speaks short, simple sentences ~:~?~ [] Names one color ...... - ~ ~ .~:.~..' '" [] May have daytime bowels and bladder control *~"' [] Pre-School 3-5 ye~ars [] R des tricycle ,-~; r~;~ · [] Uses complete sentences of three to four words Catche~ ball roliably~:~ ~- -" - Kn~s simple songs ~ Nam~,~'~oins(nickel, dime, etc) identifies With parent of the same sex [] School ~ge 6-12 years ~ - [] Takes bath without supervision · ~?~-'-~; I ght '* "~'~ ~[] Reads clock correctly to nearest quarter hour [] BnJshes and combs hair acceptably without help [] Helps with routine household tasks [] Repeats days of the week and month in order [] Reads for practical information or enjoyment [] Fond of friends ~;loleacenca 13-17 years [] Discusses general news. sports, and events [] Takes part in games/sports [] Performs responsible routine chores without [] Able to generally use mone.y with commonsense [] Attends activities with persons of own age without adult direction [] Experience conflict over independence- dependence ~ ~'~J- . ;' This is to certify that I, ~2T'Crsigned, assum~ll resp~3~i~ilit~' -~ ,, my ~tems of clpthi~¢, val'~l~s, and perusal possessions, '~ :~ "' - ,Eatient'(Relative'br Frie¥1dif Patient is unable to Siqn) ~ ~ For TBA In or 23~,~atien~: ~:~ ~'~ ~:: · : ¢ - I hereby give my volunta~rY Consent for the use of two .'gular (circle one) -, ? '~ side mils to be u~'f&~:"n~ ~ri~/enlence. ':: '~ .,gu ar_ ;~ ;. ;._:;. :~ ,;;~;~m;.: ~,~..~...,. .. - S~gnature' ~ . ' ~.T~:~ ~'<~"~' ;Date L Witness " Chairbound* :, Bedbound* Walker Cane :-: : Fair ' Poor Dysphagia ..'o ~r~ ntentior~a[~Ne!~'~Ep~ :~t.~ Geriatric Su[gical Location/Score 1~10 .... .: ~ ~'~ ~' 5. CULTURAL-~[ryOU have any religio~s O.r cultural preferences which w iI affect care? 4p ' , ~.-:/;-" 7. SOCIAL: 9. COMMUNICATION: ' ': Hearing Deficit: ' Language Barrier: 10. LEARNING: ! ~IMEDICATION' Dose, Do e someone to sta, anything else y~_think I should ~now. '-,' ;-:'.. . . :~r*~ ~..~.. ,.. ;[~~.,~ ~ (describe) out Caregiver · Date RN Assessment /0 ' Date Muscle Disease I RESPIRATORY I Asthma .... ~_ Croup ..f2[.~-'..' ~." {' Smoke - Years ' t ?~, Emphysema : : .;~Chronic Bronchitis '.~ COPD· ' "' ~;.2'i Sleep with head of bed up }:i'm ^N£STHESlA QUESTIONNAIR£ ' :~/Dear Patient, ;': '-Tohelpus,~0~. ~ care r,~ i~r~; pletethenext,'"5q~estons. Thankyou. ,X Pabent s name: ~.~.~ ~(~ ~, ~ MEDICAL HI~ORY~ ~:'~ : ~ .1. To your knowledge do you have, or ~ve you ever ~ad ~y of ' following? (Please d~e} ~. -'-~ . · .2~2~;/,~27 L 2 ' % ~Q,2~ ~}~'} ~ ~': Blo~ Clot Hiatal Hernia B~a~ Surge~ Ul~m [,- -?,-,~,wc,.,~, ~'. - High Bl~d Pressure Reflux Hea~ Affack Liver Disease Mu~ur Diabetes · I~utar Hea~ Seat ~[~Ic 5' ~ 3, Please list any previous surgeries. Ankle~eg Swelling ~yroid Disease ' - Chest Pain MUSCULO~KEL~AL Sho~ne~ of Breath on ~e~ion ~ Problems A~ficial Hea~ V~ve N~k Problems Mitral Valve Prolapse ~ ~ ~f Falls Stroke Seizum~Epilepsy Histo~ of ~loed~ Migraines BI~ Tra~fusion Di~ine~ Caner Facial Dr~p ~ .A~I . 4. Have you had any problems with ~esthesia? YES .-. R~fiona Drags If i ,~:. HIV/AIDS-~ :-; ,-~.,~,~,. ,~' ~,-~."'L":;T'''~'' ' Nausea Vomiting .; Hiao~ 9f Depre~ion Headache Damaged Teeth ~ ~%~ei~Ps Dise~e ....... Numbnes~eakness Sore ~roat :; - -'-: 5. U~ ~'b~ '%' relative o~ ever had any problem with Bl~y Sp~um ~ ~eeze ~J Use O~gen at Home e Ha~ of Headng If yes, ple~ explain: ~ Difficulty dudng sleep Kidney/Bladder Disease Ca~-s/Bddge/Dentures Dialysis Loose Teeth Ostomy Other Illnesses or Discomforts Prostate Frequency/Urgency Pregnant ,;* [] Breast Feeding MEDICAL STAFF NOTES: BARMONT,DUSTIN E Accr: H00014030217 LOC: MR#: H329813 ADMDT 10/14/02 Att Dr: Wolfe M.O., Reymond M Notify; BARMONT,TEO(~y E (717)423-6024 ,~-.~.. CHAMBERSBURG HOSPITAL ~'~ ANESTHESIA RECORD ~: ~ ~EC~E: ~AI~AY~U~TIO : ~,..,v~ ~ ~ E~L -- ' H000140nn~,~ I~ ~- MR#: H329813~'~.,../.. LOC: Art Or: Wolfe M D/~M DT 10114/02 DOS/Age: 12/07/1986 O~,~T ~ ~~'~ MENTAJ- 8TA~J~ ~'~ PAGE: N~4E: BARMONT,DUSTIN E PHONE#: (717)423-6024 DIAGNOSIS: 10-14,OP,RT. WRIST LIG~ENT TENOR BIRTH DATE: 12/07/1986 AGE: 15 ATTENDING P~YSICI~: Wolfe M.D., Raymond M MRS: H329813 ACCT#: H00014030217 SEX: M LOC: COR Ordered Tests: HH, HGB $, HCT $ COLL: 10/07/02 1550 REC: 10/07/02 1607 PHYS: Wolfe M.D,, Raymond M Copies se~t to: Lebow M.D., Howard M (1007:H00441R) TEST RESLrLT REFERENCE P~ANGE HGB 13.3 10.3-16.0 ~/dL HCT 38.9 35-44 % Date Recvd: FOLLOW-UP: B~RMONT,DUSTIN E Date Reviewed: Report Printed: 10/07/02, 2231 PAGE: 1 **EA~D OF REPORT ** SURGICAL SITE IDENTIFICATION FORM Circle appropriate side: L = Left, R = Right and sign verification. If an INCONSISTENCY is noted at any point, the Attending Surgeon is paged immediately to see the patient. PRE-OPERATIVE / PRE-PROCEDURE states side to be operated on: ............ L ~ History and physical states side to be operated on: ....... L Order for procedure states side to be operated on: ........L OR Posting Schedule states side to be operated on: ...... L When witnessing consent, verify: AT TIME OF THE PROCEDURE ~verify: Arlesthesia provider states side ,o be operated on'. ...... ....~.'.'~L ~ ,~- ~/'~'~e'-~ RN M.D,ICRNA A Chambersbur. . CONSENT FOR ADMINISTRATION OF ANESTHESIA (OR) (Do not ,¥~km a'ilhotd Name: .......... [)ate: ]~.l{,l~a2 Time: I understand that I have been scheduled to have a diagnostic and/or operative procedure. I request that a tbrm ut' anesthesia be provided for relief ut'and protection t'rom pain during the course of the planned procedure. Anesthesia may be general, regional, local, and/or sedation depending on the anesthetic agent, the method followed, and the area of the body to be anestt~etized. The type ut*anesthesia chosen will depend on the medical condition of the patient, the nature of'the procedure to be per fl.)treed, and when possible, the pret'erences of the patient and surgeon. Geofanesthesia chosen for this procedure: neral anesthesia is a tbrm of anesthesia in wbich thc, patient' is "put to sleep" (rendered unconscious) by injection and/or by breathing anesthetic gases through a mask or tube. [] Re~ional anesthesia is a tbrm ut'anesthesia in wbich an anesthetic agent is injected into the spinal sac, the space outside the spinal sac, the axil la, ora vein causing an area of the body to be insensitive to pain (numb). This is frequently combined with some/btm of sedation. [] Local anesthesia involves tbe injection oFan anesihctic agent near tbe area to be operated on to reduce or eliminate pain in that liraited area. [] Sedation may be accomplished by various combinatiuns ut'drags administered intravenously, intramuscu- larly, and/or by moutb. The goal is to reduce anxiety and awareness during the planned procedure. I understand that all types ut'anesthesia involve some risk and that complications illzly result/'rom the use of any anesthetic agent, These include, bu! are out l inlited to. respiratory problems, drug reactions, paralysis, weakness, brain damage, and, rarely, death. Common consequences seen Ibllowing the nse of general anesthesia include minor discomfort, generalized aching, tiredness, sore throat, injury to the voice box. teeth, crowns, bridge work. dentures, or eyes. Additional risks associated with spinal or epidural anesthesia include headache and/or chronic pain. I have been given an opportunity to discuss my conditinn, the types of anesthesia suitable t'or my condition, the risks, and benefits of the various anesthetics available. I realize that the anesthetic management may need to be altered during the course of the procedure sbould ibc circumstances warrant it. I have read (or had read to mc) and understand the above inlbrmation. [~es [] No I have been given adequate opportunity to ask questions about the Anesthetic procedure. ~Yes [] No [ consent to the administration of anesthesia and to thc associated procedures thai may be uecessary or appropriate for 8ARMONT,DUSTIN E Acct: H00014030217 LOG: MR#: H329813 ADM DT 10/14/02 Att Dr: Wolfe M.D., Raymond M DOR/Age:12/07/1986 '15 Sex: M ==*?:~'~-'~t Name: ~(~ . u$'rlN E ~:-Account #: H00014~)-302 ! 7 Mad Re¢ #: H329813 Arimit Date: 10/14/02 CONSENT FOR EXAMINATION, TREATMENT, AND PROCEDURE I agree and give my consent to any examination, treatment, or procedure that the attending physician or his/her assistants may deem necessary or advisable during my stay or visit in this Hospital. It is understood that this consent does not include operation or surgical procedures which may be found necessary. If such operations or surgical procedures are required during my hospitalization/visit, I understand that I will be asked to give specific consent for these operations or procedures. W'~ness/~~ ~ Patient Signature ~ Date ~ho~.~ed Person / * When a patient is a minor, incompetent, or unable to sign, the signature of the person authorized to give consent is required. AUTHORIZATION FOR RELEASE OF INFORMATION & ASSIGNMENTS OF BENEFITS I authorize The Chambersburg Hospital to release such information as may be necessary for the completion of insurance claims relative to this hospitalization visit. I understand that the Hospital or my physician may disclose and release all or any part of my medical record to any person or corporation which is or may be liable under a contract to the Hospital or physician, or to the patient or family member or employer of the patient, for all or pert of the Hospital's charges or physician's charges. This includes, but is not limited to, HIV related information, drug and alcohol treatment information, mental health treatment information and other information of a sensitive nature to hospital or medical service companies, insurance companies, workmen's compensation carriers, welfare funds, or the patient's employer. I hereby authorize payment directly to The Chambersburg Hospital for the hospital benefits otherwise payable to me, but not to exceed the Hospltars regular charges for this period of hospitalization. I understand that I am financially responsible to the Hospital for charges not covered by this assignment. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim for payment of my benefits. If covered by Medicare, I certify that the information given by me in applying for payment under Title XVlll of the Social Security Act is correct. I request payment of author~ed Medicare benefits for me or on my behalf for any services furnished to me, by or in the Hospital (including physician services) to be made to The Chambersburg Hospital. I authorize any holder of medical and other information about me to be released to Medicare and its agents any information needed to determine these benefits or benefits for related services. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize the physician or organization to submit a claim to Medicare for payment of my benefits. I understand that I am financially responsible to the Hospital for charges not covered by this assignment. If covered by Medical Assistance, I certify that the information I have provided is true, correct, and accurate. I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements, documents or concealment of material facts may be prosecuted under applicable Federal and State laws. Provider: The Chembersburg Hospital I was offered a Patient's Bill of Rights brochure during registration at The Chambersburg Hospital. Patient's Initials Patient Signature ~e~[atio.~h,p to Patient For patients with Medicare: I was given a Beneficiary Right to Know card during registration. Patient's Initials ALL AUTHORIZATIONS MUST BE SIGNED BY THE PATIENT OR BY AN AUTHORIZED PERSON IN THE CASE OF A MINOR OR WHEN A PATIENT IS PHYSICALLY OR MENTALLY INCOMPETENT. P00521 medforms (O:OND.R:10/01) Natrle: : Do not sign wd~i'b'ut reading My doctor ~,~ ,g~ ~,~,O/'~/~'~...D has recommended that I have a name of physician describe the procedure My doctor has told me how the procedure will be done and what to expect. ,)~Yes [3 No My doctor has explained why this procedure was recommended to me. /)~-Yes [3 No My doctor has explained the available alternatives and choices to this procedure, as well procedure done. '~-Ye s These include, but are not limited to: as the risks of not having the My doctor has provided an explanation of the known and recognized risks to this procedure. Specific risks include, but are not limited to: ,~Yes [3 No My doctor has given me an opportunity to ask questions. /5~Yes {~ No My doctor has answered my questions and I believe I have all the information I need to fully agree to this procedure. .A~Yes [3 No 9. I consent to the procedure. I have read and understood this form and have truthfully answered all the questions. ~Yes [3 No BARMONT,DUSTIN E Acct: H00014030217 LOC: MR#: H329813 ADM DT 10114/02 Att Dr:Wolfe M.D., Raymond M DOB/Age:12/07/1986 15 Sex: M Notify: 8ARMONT,TEDDY E (717)423-6024 & Chambersbtt ,rg. CONSENT FOR SURGERY/INVASIVE PROCEDURE THE CHAMBERSB' - q HOSPITAL - - - Pi~-OPERATIVE T~ACHING RECORD __ Inpatient __ TBA ~"~/Outpatient __ 23-Hour Observation CHAMBERSB~'~3PENNSYLVAN IA~. '~. EXplain in ways patient will understand Explanation and Nurse Demonstration (check items which apply): _~,/Coughing ZCpeep Breathing linting of Incision .__~Leg Exercises ~ Truiger Test (Outpatient only) ~ Oth~ Received from patient: order sheet .~ patient database form consent, if not completed, notify physician discharge planning questionnaire (inpatients & TBAs) II. Return Patient Demonstration: use as apply (G) Good, (F) Fair, (P) Poor .~a~e explain in space provided if problem is identified. Coughing --~Dnep Breathing ~ Splinting of Incision --(.d Leg Exercises ~ Truiger Test (Outpatient Only) ..~ Other IlL Explanation of (check items which apply): ~-~NPO after midnight, or -- NPO after breakfast -- NPO after clear liquids ~ Pre-up medication .~/Poat-Anesthesia Care Unit --..dOxygen routine use/Incentive Spirometry -.~I.V. Therapy .~T, urning (in-house or TBA patients)/Body Mechanics ~/Early ambulation (in-house or TBA patients) -- Physical Therapy ~Availability of pain medication-- PCA -- Epidural .--/No Smoking --.~Preparation for surgery (possibility of skin prep, urinary catheter, AES hose, enema, nasogastric tubes) -- Pain Scale (use of for assessment of post-up pain) l IV. Verbalizes understanding of instructions ~'JYes __ No (/fno, explain): Other For TBA/Outpatients Onlv 1. Advise patient of the following: a. Wear comfortable clothing to the hospital. b. Expect a call between 1:00 p.m. and 3:00 p.m. the day prior to surgery with the scheduled time to come to the hospital c. You must have someone available to drive you home and to stay with you for at least 12 hours. 2. Phone number where patient can be reached. Before.,adm_j.ss~ion: /'~)..-)- (aO--~-ig Afterdiseharge: 3. Allergies: 4. Pediatric Patients Only: __ cc Pru-op mix given to parent/guardian Child's weight: BARMONT,DUSTIN E Acct: H00014030217 LOC; MR//: H329813 ADM DT 10/14/02 Att Dr: Woffe M.D., Raymond M DOE/Age: 12/07/1986 15 Sex: M Notify: BARMON~,7~-DO¥ E {717}423-§024 Date: / --~ ~'~'-'p Time: ~/' Patient's Signature Signature of person completing form, if other than R.N.) Completed/Reviewed by: ~9)~ R.N. Time/Date: #1 #2 Surgical Procedure: POST-OPERATIVE ASSESSMENTS T, P R B/P Position: Supine Prone R Side L Side Skin: Warm Dry Cool Moist Skin Breakdown: Yes No Braden Scale* Pain: 0 I 2 3 4 5 6 7 8 9 10 Deep Breathing: Good Fair Poor N/A Breath Sounds: (describe) Leg Exercises: Good Fair Poor N/A 'Bowel Sounds Abd. Distention (describe) T P R B/P. Position: Supine Prone R Side L Side Skin: Warm Dry Cool Moist Pain: 0 I 2 3 4 5 6 7 8 9 l0 Cough: Good Fair Poor N/A Deep Breathing: Good Fair Poor N/A Leg Exercises: Good Fair Poor N/A #3 T P R B/P Position: Supine Prone R Side L Side Skin: Warm Dry Cool Moist Pain: 0 1 2 3 4 5 6 7 8 9 10 Cough: Good Fair Poor N/A Deep Breathing: Good Fair Poor N/A Leg Exercises: Good Fair Poor N/A L.O.C.: Awake/Alert/Oriented/Sedated/Disoriented Other (describe): Dressing: Voiding: Comments: Signature: L.O.C.: Awake/Alert/Oriented/Sedated/Disoriented Other (describe): Dressing: Voiding: Comments: Signature/Title: L.O.C.: Awake/Alert/Oriented/Sedated/Disoriented Other (describe}: Dressing: Voiding: Comments: Signature/Title: Chambersburg, PA ~4 T P R B/P_ Position: Supine Prone R Side L Side Skin: Warm Dry Cool Moist Pain: 0 I 2 3 4 5 Cough: Good Fair Poor N/A Deep Breathing: Good Fair Poor N/A Leg Exercises: Good Fair Poor N/A Current Functional Status (complete for surgical TBA patient) Needs Recent Independent Assistance Decline ~ating [] [] [2 ~/ 3athing [] V1 f'tO Dressing [] [] V]O Coileting [] [] []O tomemaking [] El VI O 3ed Mobility [] [] []00 A/alk/ng/Balance [] [] []OO Fransfers [] []OO ~ History of Falls/Fa, .sk (Complete Fall cation Assess.) L.O.C.: Awake/Alert/Oriented/Sedated/Disoriented Other (describe): Dressing: Voiding: Comments: Signature/Title: Key: 0 - OT ch -SLP O - PT Orientation to Environment [] Room/Bathroom [] Side Rails [] No Smoking [] Telephone System [] Visiting Hours [] Bed Control [] Nurses Station [] Call System [] TV/Education Channel *Complete for Patients who are: Call Bell in Reach [] yes [] no Signature Date Time__ [] Bedbound [] Chairbound, , [] Inability to ~, ~.,~'ition p09173 (O: I/g0. R: 7/07) !eof ~S.~.,~H..~m [] Gl LAB [] MATERNITY '~E CATE 3CEDURE 112 North ~vend~'S[~cet · RD. Box ~5 ~ MINOR SURGERY IN SDS ) ~DVANCE ~b~, PA 17201~5 · (717) 267-3~ '~ SURGERY IN O.R. REGIST~ TION TO 3E CO~P~TED ~ p~*S~CIA~S OFFICE ~ rs m~ SU~RE mE RESET OF ~ r~ D~S ~0 ONS~ OF I~E~ OA~ PERSON CARRYING PRIORY INSURANCE / IF NO INSU~NCE, PERSON RESPONSIB~ FOR ~NSURANCE- P~SEA~ACHA COPY OF CARD ; MEDdlE NUMBER J J MEDIAL M~I~E ~ ~ HOS~ P~A ~ ~ GOVE~GE FORM NO. ~4~ (R~. ~) T~A~NG~D~T~cEPH~EC~FR~MY~URBED~DE~NE*Y~UW~NEEDAcA~NGCARD~ME~NEAT~M~T~AC~E~HARGES THE CHAMBERSBURG HOSPITAL 112 Nodh Seventh Street Chambersburg, PA 17201 (717) 267-7149 SUMMIT HEALTH CEN ~ Rhonda Brake Shreiner Women's Center Summit Diagnostic Services Departments of Chambersburg Hospital NAME: BARMONT,DUSTIN E PATIENT #: H00013891403 DOB: 12/07/1986 RADIOLOGIST: Kevin M Cregan M.D. PATIENT LOCATION: CMRI REPORT #: 0918-0381 ADMITTING DIAGNOSIS: RT WRIST PAIN REASON FOR EXAM: ORDERING PHYSICIAN: Wolfe, Raymond M M.D. MEDICAL RECORD #: H329813 PATIENT TYPE: REG CLI ROOM/BED: PATIENT PHONE: (7t 7)423-6024 FINANCIAL CLASS: AUTO ORDER #: 0917-0020 REPORT STATUS: Signed DIAGNOSTIC IMAGING DATE OF SERVICE: 9/17/02 HISTORY: 15 year old male, ligament tear. MRI RIGHT WRIST: IMPRESSION: 1. Tear of the scapholunate ligament. 2. Intact triangular fibrocartilage and lunotriquetral ligament. Technique: Coronal T1, FSE T2 and stir images were obtained along with 3D volume acquired gradient images, sagittal T2 weighted images, and T1 and FSE T2 fat saturated axial images, A dedicated wrist coil was utilized. COMMENT: There is widening of the scapholunate interval. The ligament is well seen on the thin section coronal images and is tom. The scaphoid insertion appears to have avulsed. The lunotriquetral ligament and triangular fibrocartilage complex am intact. The bone marrow demonstrates normal signal intensity. The flexor and extensor tendons have a normal appearance. The flexor retinaculum is normal in thickness. The median nerve demonstrates normal size and signal intensity. There is no evidence of a joint effusion or mass lesion. (Thank you for referring this patient to us.) DEPARTMENT: DIAGNOSTIC IMAGING 73221 <Electronically signed by Kevin M Cragan M.D.> Dictating Physician: Kevin M Cregan MD. Page I of 2 NAME: BARMONT,DUSTIN E MEDICAL RECORD #: H329813 PATIENT #: H00013891403 ROOM/BED: DATE OF SERVICE: 09/17/02 REPORT#: 0918-0381 THE CHAMBERSBURG HOSPITAL 112 North Seventh Street Chambersburg, PA 17201 (717) 267-3000 DIAGNOSTIC IMAGING REPORT STATUS: Signed TR NAME: MARYWOODCOCK DICTATED: 09/18/02 TR DATE: 09/18/02 CC: Howard M Lebow M,D.; Kevin M Cregan MD.; Raymond M Wolfe M.D. Additional copy DEPARTMENT: DIAGNOSTIC IMAGING 73221 Page 2 of 2 TELEPHONE: (717) 264-621 FAX NO. 264-0406 ORTHOPAEDIC ASSOCIATES ROBERT N. RICHARDS, SR., M.D. JOHN D. ASHBY, M.D. ROBERT N RICHARDS, JR., M.D. SHABBAR HUSSAIN, M.D. RAYMOND M. WOLFE, MD. 1035 WAYNE AVENUE CHAMBERSBURG, PA 17201~2988 Name Address Charge to Address Occupation Diagnosis, Provisional Diagnosis, Final Date June 25, 2002 Dustin E. Barmont 432 Newville Rd. Newburg Case No. ~15310 S. M. W. D. Age 12/7/86 Phone No. 423-6024 Referred by ER right wrist 6/25/02 - This patient is a 15 year old white male who was a passenger in a car that was involved in an MVA yesterday. There were three other passengers one of whom is in critical condition at Hershey Medical Center. This patient sustained contusions to the right forearm and multiple abrasions of his left forearm. X- rays were negative. EXAM: Reveals some tenderness in the junction of the middle and distal third over the radius of the right forearm, but x-rays reveal no evidence of fracture. May discontinue the sling and the splint which is only on for comfort, but he is more comfortable without it, Return in 9 days for followup. J.D.A. 7/11/02- Patient now has full range of motion of the right forearm but it is still painful on full pronation and supanation. There is no special local- ized tenderness at this time. I think this is a healing bruise. Resume normal activity as tolerated but should be seen one more time before discharge in about two weeks. JDA:sak Dustin E. Barmont - Page 2 7/25/02 - This patient is improving, although he still has a small amount of swell- ing over this distal third of the radius. I think this is probably a resolving hematoma under the periosteum. But I don't see any treatment for it at this time if at all. Resume normal activity. I explained all of this to the patient and his mother, both of whom were concerned about the fact that the swelling was still present, even though diminished. Discharged unless problems remain. I told them that if they were still concerned in 2-3 weeks, they were to call, and I would be glad to see him again. J,D,A ~ist. ~is time the pain is in the volar aspect rather than over the radial styloid. E~: Reveals full range of motion. He makes a complete fist. There is no swel- ling. No redness. No tenderness over the pressure of the radial styloid which he complained of at his last visit. ~at has resolved. I can't find anything wrong with this ~ist. New x-rays are no~al. No suspicion of navicular fracture. But I felt that they might prefer another opinion, so I reco~ended a foilow~p appointment in ~wo weeks with another doctor. If he is c~mpletely improved by then, I asked the father to cancel the appointment, othe~ise keep it for another opinion. I have nothing more to offer. J.D.A. Dustin Barmont - 09/12/02 - Dustin is here for follow-up of his right wrist. He has new onset of bruising and pain in the previously injured area. He was seen by my partner Dr. Ashby over the last several months for this injury. PHYSICAL EX~4: Shows tenderness over his piciform bone as well as some ecchymosis in that same area. He also has palpable subluxation of his radius scapholunate joint with Watts and Clunk maneuver. IMPRESSION: Chronic right wrist pain status post significant trauma. PLAN: Given the fact that the x-rays are normal and his exam is abnormal I have recommended that he obtain an MRI looking for a subtle ligament and / or possible occult fracture. He is to follow- up after the M~I is performed. RMW/mmm 09/19/02 - here for follow-up of the MRI that confirms scapholunate ligament tear. No other abnormalities are noted. We had a long discussion with mother and recommended that he have it repaired. We discussed the short and long term consequences of both repair versus non-repair. The fact that he is 15 and is right hand dominant and works in the labor field and is currently in Vo-Tech and will probably end up being a carpenter or mechanical position, I strongly recommend that he strongly consider having this fixed. He understands. They are going to go home and speak with the father and decide on when to have this. They will get back in touch with us for a time. RMW/mmm 10/14/02- REPAIR OF RIGHT WRIST SCAPHOLUNATE LIGAMENT. RMW Dustin Barmont - Page 4 10/25/02 - Pmiem is here for follow-up offs fight figamem repot 11 days out, distally and neurovascularly intact. Splint was removed and ind~on was clean, dry and intact. Short arm cast was applied. Radiograph shows the pins and anchors in excellent posRion. PLAN - see ~m back in 4 ~ee~.~o~se-xra~ a~_~ .rech~· RMW/wfl 11/26/02- Here for follow up of his right wrist surgery. No complaints of pain. Cast'removed. Pins were removed without difficulty. There is no evidence of infection. His swelling andinfection is well healed. Range of motion is excellent despite being in a cast. He has about a 40° arch. PLAN: Protection in wrist splint with twice a day range of motion exercises. I will see him back in 2 weeks for recheck and re x-ray. RMW:sak 12/12/02 - Dustin is here for 8 week followup from his right scapholunate liga- ment repair. No complaints of pain. His range of motion is limited to about 45° are which is better than expected. His incision is well healed. There is no evidence of infection, erythema, or swelling. He is distally neurovascu- larly intact. Radiographs show scapulolunate interval to be intact. PLAN: We will begin range of motion exercises and see him back in a month for recheck. He is to wear the brace outside or if he is going to do any lifting in VoTech. R.M.W. Dustin Barmont - Page 4 10/25/02 - Patient is here for follow-up of his fight ligament repair 11 days out, distally and neurovascularly intact. Splint was removed and incision was clean, d~ and intact. Short arm cast was applied. Radiograph shows the pins and anchors in excellent position. PLAN - see him back in 4 weeks for re-xray and recheck. RMW/wfl 11/26/02- Here for follow up of his right wrist surgery. No complaints of pain. Cast removed. Pins were removed without difficulty. There is no evidence of infection. His swelling andinfection is well healed. Range of motion is excellent despite being in a cast. He has about a 40° arch. PLAN: Protection in wrist splint with twice a day range of motion exercises. I will see him back in 2 weeks for recheck and re x-ray. RMW:sak 12/12/02 - Dustin is here for 8 week followup from his right scapholunate liga- ment repair. No complaints of pain. His range of motion is limited to about 45° arc which is better than expected. His incision is well healed. There is no evidence of infection, erythema, or swelling. He is distally neurovascu- larly intact. Radiographs show scapulolunate interval to be intact. PLAN: We will begin range of motion exercises and see him back in a month for recheck. He is to wear the brace outside or if he is going to do any lifting in VoTech. R.M.W. ~1~10~ - ~stin is ~er~ ~o~ foHow-u~ o~s ~st su~e~. ~e oo~]~s o~o ~. ~e ~: ~0~ tod~y ~s ~e~sio~ to ~bout 60 deNe~s, ~o~ ~sBy ~B as ~p~ to t~ ot~ ~st. ~e ~ p~ ~t~ ~0~ ~o ~ ~ r~di~ ul~ d~tio~ ~o t~ad~ss or ~ellin~ ~: Co~t~u~ ~i~ ~ tol~. ~e w~ ~ ~d~s to ~ork o~ ~s ~ ~io~. THE CH~RSBURG HOSPITAL 112 NErth Seventh Street Chambersburg, PA 17201 (717) 267-7149 SUMMIT HEALTH CEN ~ Rhonda Brake Shreiner vVomen's Center Summit Diagnostic Services Departments of Chambersburg Hospital NAME: BARMONT,DUSTIN E PATIENT#: H00013891403 DOB: 12/07/1986 RADIOLOGIST: Kevin M Cregan M.D. PATIENT LOCATION: CMRI REPORT#: 0918-0381 ADMITTING DIAGNOSIS: RT WRIST PAIN REASON FOR EXAM: ORDERING PHYSICIAN: Wolfe, Raymond M M.D. MEDICAL RECORD #: H329813 PATIENT TYPE: REG CLI ROOM/BED: PATIENT PHONE: (717)423-6024 FINANCIAL CLASS: AUTO ORDER #: 0917-0020 DIAGNOSTIC IMAGING REPORT STATUS: Signed DATE OF SERVICE: 9/17/02 HISTORY: 15 year old male, ligament tear. MRI RIGHT WRIST: IMPRESSION: 1. Tear of the scepholunate ligament. 2. Intact triangular fibrocartilage and lunotriquetral ligament. Technique: Coronal T1, FSE T2 and stir images were obtained along with 3D volume acquired gradient images, sagittal T2 weighted images, and T1 and FSE T2 fat saturated axial images. A dedicated wrist coil was utilized. COMMENT: There is widening of the scapholunate interval. The ligament is well seen on the thin section coronal images and is tom. The scaphoid insertion appears to have avulsed. The lunotdquetral ligament and triangular fibrocartilage complex are intact, The bone marrow demonstrates normal signal intensity. The flexor and extensor tendons have a normal appearance. The flexor retinaculum is normal in thickness. The median nerve demonstrates normal size and signal intensity. There is no evidence of a joint effusion or mass lesion. (Thank you for referring this patient to us.) <Electronically signed by Kevin M Cregan M.D.> Dictating Physician: Kevin M Cregan M.D. TR NAME: MARY WOODCOCK DICTATED: 09118/02 TR DATE: 09/18/02 CC: Howard M Lebow M.D.; Kevin M Cregan M.D.; Raymond M Wolfe M.D. Ordering Physician's copy Wolfe M.D., Raymond M DEPARTMENT: DIAGNOSTIC IMAGING 73221 Page 1 of 2 THE CHAMBERSBURG HOSPITAL 112 North Seventh Street Chambersburg, PA 17201 (717) 267-3000 NAME: BARMONT, DUSTIN E PATIENT#: H00014030217 PHYSICIAN: Raymond M Wolfe M.D, ROOM/BED: MEDICAL RECORD #: H329813 PATIENT TYPE: REG SDC DOB: 12/07/1986 REPORT#: 1015-0161 OPERATIVE REPORT SURGERY DATE: 10/14/2002 PREOP DIAGNOSIS: Right wdst scapholunate ligament tear. POSTOP DIAGNOSIS: Same. OPERATION: Repair of right wrist scapholunate ligament. SURGEON: Raymond M Wolfe M.D. ANESTHESIA: General. INDICATIONS: The patient is a 15-year-old gentleman who had fallen off of a truck several months ago. He injured his right wrist, and eventually an MRI was performed that confirmed the above injury, and he presents now for surgical treatment. DESCRIPTION OF PROCEDURE: The patient taken to the operating room and placed supine on the operating room table. After general anesthesia was performed, and IV antibiotics were given, a tourniquet was placed over the right upper arm but not inflated, and the right arm was prepped and draped in standard surgical fashion. Attention was turned to the right wrist to where a incision was made approximately 4 cm long over the radius-scapholunate interval, and the incision was carried down through skin and subcutaneous tissue. Subcutaneous tissue was bluntly dissected, and hemostasis was obtained. The wrist joint was then entered between the third and fourth dorsal compartments down to the level of the wrist capsule, and the wrist capsule was elevated exposing the scapholunate ligament quite well. A probe revealed that the ligament was completely detached from the scaphoid, although it was still attached in its most distal insertion dorsally. The scaphoid was then debrided with a rongeur and curet to expose the bleeding bone surfaco, and then the ligament was repaired back down to the bone using two 2.4 mm anchors and horizontal mattress sutures from the most distal pole up the dorsum in 3 mm increments. The scaphoid was then reduced on the lunate as confirmed by x-ray, and then a single 0.062 pin was drilled from radial to ulnar through the scaphoid and lunate. Satisfied with the reduction with the pin, the sutures were then tied, and another pin was placed into the scaphocapitate. Satisfied with the procedure, the wound was irrigated. Hemostasis was obtained after the tourniquet was released. Capsule was repaired with 2-0 Monocryl interrupted suture. The skin closed with 2-0 and 4-0 Monocryl subcuticular sutures and Steri-Strips. The patient was then placed in a well-padded sugar-tong splint, awakened from anesthesia and taken to the recovery room in stable condition. Raymond M Wolfe M.D. TR NAME: DEBORAH A DESHONG DICTATED: 10/14/02 TR DATE: 10/15/02 CC: Raymond M Wolfe M.D. Dictating Physician's copy Wolfe M.D., Raymond M DEPARTMENT: CHAMBERSBURG HIM Page 1 of 2 ATTENDING PHYSICIAN'S REPORT Date ~ 1. Patient's Address Patient Dustin Barmont Date of Accident June 24, 2002 File Number 432 Newville Road, Newburg, PA 17240 2. History of. occurrence as described by patient 3. D, iagnosis an~d concurre, nt condit~ons-n-n-n-n-n-n-n-n~gJ~' 4. ~en did s~ptoms first appel? Date: Has p~ent ever had sine or simil~ conditions, st~en ~fibe: 5. 6. Is the accident a factual cause in bringing about this condition? If no, explain: 7. Prognosis: 8. Is the patient still under your care for this condition? 9. What is the anticipated frequency and duration of the treatment you are providing? Please indicate 10. List diagnostic tests performed and results: 289416-1 12. Will patient have any kind of permanent or residual problems because of injuries sustained in the motor vehicle accident on June 24, 2002? 289416-1 MEDICAL BILLING SUMMARY FOR DUSTIN BARMONT Medical Provider(s) Cumberland Valley EMS Date(s) 06/24/02 TOTAL TOTAL PAID BY ERIE Amount(s) $ 526.00 $ 526.00 $ 348.80 Chambersburg Hospital 06/24/02 09/17/02 10/07/02 10/14/02 TOTAL TOTAL PAID BY ERIE $ 564.00 1,171.00 39.50 5,329.00 $7,103.50 $2,958.73 Chambersburg Imaging Associates 06/24/02 09/17/02 TOTAL TOTAL PAID BY ERIE $ 32.00 241.00 $ 273.00 $ 81.01 Orthopaedic Associates 06/25/02 07/11/02 07/25/02 08/29/02 09/12/02 09/19/02 10/14/02 10/25/02 11/26/02 12/12/02 01/07/03 $ 83.00 55.00 55.00 134.00 55.00 55.00 1,308.00 79.00 79.00 79.00 nc TOTAL $1,982.00 TOTAL PAID BY ERIE $1,254.27 Chambersburg Anesthesia 10/14/02 TOTAL TOTAL PAID BY ERIE $1,125.00 $1,125.00 $ 166.70 Vic Cardinale 06/25/03 07/09/03 08/06/03 09/03/03 TOTAL TOTALPAIDBYERIE $ 65.00 65.00 65.00 65.00 $ 260.00 $ 260.00 TOTAL MEDICAL BILLS TOTAL PAID BY ERIE $11,269.50 $ 5,069.51 *Dustin Barmom reserves the right to supplement this Medical Billing Summary. Document #: 247689.1 State Fa rm Insurance DEC Companies December 11, 2002 State Farm lnsurance 1134 Kennebec Drive PO Box 6001 Chambersburg, PA 17201 Clark Devere POB 5300 Harrisburg, PA 17110 RE: Claim Number: Date of Loss: Our Insured: Your Client: Dear Clark: 38-J968-776 June 24, 2002 Paul E. Gutshall Cory Alexander and Dustin Barmont This letter serves a follow up to our telephone conversation of today wherein we discussed the case noted above. Enclosed please find copies of Dustin Barmont's medical records. After review of the medical records I have on both parties, it is my opinion that a 60/40 split of the available limits in the favor of Barmont would be a reasonable resolution to this matter. Please let me know your position. Sincerely, ' e~i~i Saller- Judy~PCU Claim Representative (717) 261-4805 State Farm Mutual Automobile Insurance Company HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 CERTIFICATE OF COVERAGE Barcode Only The undersigned is a Claim Team Manager for: [] State Farm Mutual Automobile Insurance Company [] State Farm County Mutual Insurance Company of Texas [] State Farm Lloyds, Inc. [] State Farm Indemnity Company [] State Farm Florida Insurance Company ONdte ~n the name of the appmprlate State F~.rm affiliate) This certifies that policy number 7227-212-,38B 88 Dodge Dakota Pickup , was issued to Paul E. Gutshal! Jr. , covering a and was in effect on the accident date of 6-24-02 liability for this policy on that date were A 15/30/5,C2 5,000 · The coverages and limits of State of Pennsylvania County of Frank! in Subscribed and sworn to before me this 12 day of Ju!y ,(Year) 2002 . Notary Public JUL ! JUL 2. 6 201 · : : ':-I, Paul Gutshall, III, do swear and '~ffirm'under' oath that the.only-liability insurance policy which covered me as of June 24, 2002, was my liability insurance policy with State Farm Mutual Automobile Insurance Company, policy number '~ 0&~ ~ 2 l~.-3,gw~aich provides liability benefits in the amount of $ I ~ooo! ~too o I do not have any further liability insurance policies covering me as of June 24, 2002 and do not have any type of excess or umbrella liability insurance. I also note that any false statements which are made herein may be subject to civil and criminal penalties as the law may allow. I also note that this Affidavit is being executed as part of a personal injury claim made by George and Melinda Hager and they are relying on this Affidavit in negotiating, settling and/or prosecuting the personal injury claims for the Estate of Eric B. Halter. FPaul Gutshall, III Subscribed and Sworn to before me this;t~ day of cYo/~ , 2002. My comm/ssion expires on: I ~-~0~-05~ NOTARIAL SEAL DEBORAH WARREN, Nota~/Public Shippensburg, Cumberland County M..y Commission Expires Nov. 8, 2005~ Document It.. 258560.1 ERIE INSURANCE EXCHANGE Erie Indemnity Company, Attorney-in-Fac1 · Members Erie Insurance Group Home Office · 100 Erie ~nsurance Place · Erie, Pennsylvania 16530 · (814) 870-2000 · Toll Free 1-800-458-0811 October 14, 2003 Clark DeVere, Esq. Metzger, Wickersham, Knauss & Erb, PC 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 Re: ERIE Claim ERIE Insured: Date of Loss: Your Client: ~010170621395 Teddy E. Barmont & Angela M. Barmont 06/24/02 Dustin E. Barmont, A minor, et aL Dear Attorney DeVere: As requested in your letter dated December 6, 2002 directed to Don Bottini at our Mechanicsburg, Pennsylvania office, enclosed is a copy of the information found on Teddy E. Barmont & Angela M. Barmont's Declarations Page for ERIE Auto Insurance Policy #Q04-2106730 on the listed loss date. A copy of the Tort Options Selection form completed for this policy, is also enclosed. Mr. & Mrs. Barmont's Uninsured Motorists coverage limits and Underinsured Motorists coverage limits are equal to their limit of Bodily Injury Liability with stacking, therefore there are no waivers or sign down forms to provide. Angela M. Barmont is also insured under her own Pioneer Family Auto Policy with ERIE Policy #Q10- 2504970. I have enclosed a copy of the information on her Declarations Page in effect on the date of loss. As Angela M. Barmont selected the Full Tort Option and her Uninsured Motorists coverage limits and Underinsured Motorists coverage limits are equal to her limit of Bodily Injury Liability with stacking, there are no waivers or sign down forms to provide. Also enclosed is a copy of the information found on Teddy E. Barmont's Declarations Page for his HomProtector Extracover Policy (Q59-2103803). Sincerely, Brandi S. Bissell P & C Records Coordinator Litigation/Claims Examination Dept. (814) 8704864 /bsb N?,c~ Enclosures: , t~.~'~ 1. Continuation Notice 04/21/02 to 04/21/03 for Teddy and Angela Barmonts AutoPolicy #~-2106730 2. Tort Options Selection Form for Policy gQ04-2106730 3. Continuation Notice I0/25/01 to 10/25/02 for Angela Barmont's Auto Policy gQ 10.2504970 4. Continuation Notice 11/21/01 to 11/21/02 for Teddy Barmont's HomeProtector Policy #Q59-2103803 The ERIE Is Above All In sERvIcE~ · Since 1925 B2B ERIE NSUPJ~NCE EXCHANGE PIONEER FAMILY AUTO POLICY CONTINUATION NOTICE AA7401 CARL L CRAMER INS. LLC 04/21/02 TO 04/21/03 Q04 2106730 H TEDDY E BARMONT & ANGELA M BARMONT 432 NEWVILLE RD NEWBURG PA 17240-9376 AGENT - C/MRL L CP~AMER INS. LLC AGENT PHONE - (717) 530-8600 833 W. KING STREET SHIPPENSBURG PA 17257 9201 ITEM 4. AUTOS COVERED AUTO YR MAKE 1 96 GMC SIERRA1500 VIN ST TER SYM 2GTEK19M5T1528296 PA 4F E RATING CLASS DDP A2BL-M MM40 ITEM 5. INSUR/L~CE IS PROVIDED WHERE A PREMIUM, OR INCL, IS SHOWN FOR THE COVERAGE. COVERAGES, LIMITS AND ANNUAL PREMIUMS ARE AS FOLLOWS- #1 *****GOOD DRIVER RATES APPLY***** --- THE LIMITED TORT OPTION APPLIES TO ALL PRIVATE PASSENGER VEHICLES. --- LIABILITY PROTECTION- BODILY INJURY $100M/PERSON $300M/ACC PROPERTY DAMAGE $100M/ACC FIRST PARTY BENEFITS- MEDICAL EXPENSE $10M INCOME LOSS SiM/MONTH, $15M MAXIMUM ACCIDENTAL DEATH $5M FUNERAL BENEFIT $2.5M UNINSURED MOTORISTS COVERAGE- BOD INJ $100M/PERSON $300M/ACC-STACKED UNDERINSURED MOTORISTS COVERAGE- BOD INJ $100M/PERSON $300M/ACC-STACKED PHYSICAL DAMAGE COVERAGES- COMPREHENSIVE - $50 DED COLLISION - $500 DED OPTIONAL COVERAGES- ROAD SERVICE 70 73 34 11 2 2 13 67 76 139 4 TOTAL ANNUAL PREMIUM FOR EACH AUTO TOTAL ANNUAL POLICY PREMIUM 491 $ 491 ITEM 6. APPLICABLE POLICY, ENDORSEMENTS, EXCEPTIONS TO DECLARATIONS ITEMS ALL AUTOS - FAP 04/97, UF2106 05/01', AFPN01 10/98, AFPA03 10/98. AUTO 1 - AFPU01 04/99. MULTI POLICY DISCOUNT APPLIES - AMOUNT OF DISCOUNT IS $ 21 PASSIVE RESTRAINT DISCOUNT APPLIES - SINGLE AIRBAG AUTO 1 ANTI-LOCK BRAKE DISCOUNT ~ 0LIED AUTO 1 * FIRST ACCIDENT FORGIVENESS APPLIES. THE FIRST SURCHARGE FOR A * * FUTURE AT-FAULT ACCIDENT WILL BE WAIVED. * EXPLANATION OF ADULT &/OR YOUTHFUL DRIVER RATING CLASS AUTO i-TO WORK 11-14 MILES ONE WAY, 8,501 OR MORE MILES ANAK3ALLY MALE, MARRIED, AGE 40-44 MISCELLANEOUS INFORMATION YD JLW 03/20/02 ITEM 7. EACH AUTO WE INSURE WILL BE PRINCIPALLY GARAGED AT THE ADDRESS SHOWN IN ITEM 1, UNLESS ANOTHER A]DDRESS IS SHOWN BELOW. ITEM 9. UNLESS A CO-OWNER OR LIENHOLDER IS LISTED BELOW, THE NAMED INSURED IS THE SOLE OWNER OF EACH AUTO WE INSURE. DRIVER 1 TEDDY EUGENE BAR/~ONT 2 ANGELA M BARMONT ST LICENSE NUMBER PA 19022441 PA 21313667 BIRTH DATE 04/11/60 o7/ii/67 ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMP~qY OR OTHER PERSON FILES ANAPPLICATION 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 ~ SUBJECTS THE PERSON TO CRIMINAL ~ CIVIL PENALTIES. YOUR COLLISION COVEP3tGE ~ DEDUCTIBLE APPLY TO PRIVATE PASSENGER AUTOS YOU OR A RESIDENT RELATIVE RENT FOR 45 DAYS OR LESS. THIS IS SUBJECT TO LIMITS, TERMS AND CONDITIONS IN THE POLICY. THE LAWS OF THE COMMONWEALTH OF PENNSYLVANIA, AS ENACTED BY THE GENERAL ASSEMBLY, ONLY REQUIRE THAT YOU PURCHASE LIABILITY AND FIRST-PARTY MEDICAL BENEFIT COVERAGES. ANY ADDITIONAL COVERAGES OR COVERAGES IN EXCESS OF THE LIMITS REQUIRED BY LAW ARE PROVIDED ONLY AT YOUR REQUEST AS ENHANCEMENTS TO THE BASIC COVERAGES. BELOW ARE ANNUAL PREMIUMS FOR THE MINIMUM REQUIRED COVERAGES AND LIMITS FOR LIMITED TORT. PLEASE NOTE THAT THE LIMITED TORT OPTION MAY NOT BE AVAILABLE ON CERTAIN VEHICLES. BODILY INJURY $15M/PERSON $30M/ACC 39 PROPERTY DAMAGE $5M/ACC 61 FIRST PARTY BENEFITS - MEDICAL EXPENSE $5M 27 Q04 2106730 INVOICE INFORMATION: ~TE DUE PAYMENT DUE 04-21-02 122.00 07-21-02 126.00' 10-21-02 126.00' 01-21-03 126.00' APPLICANT: TEDDY E BA~MONT PAGE: B AA7401 - CARL L. cRAMER Bndr No: Q98 1103405 01 NOTICE TO ~ INSUREDS A. "Limited Tort" Option- The laws of the Commonwealth of Pennsylvania give you the right to choose a form of insurance that limits your right, and the right of members of your household to seek financial compensation for injuries caused by other drivers. Under this form of insurance, you and other household members covered under this policy may seek recovery for all medical and other out-of-pocket expenses, but not for pain and suffering or other nonmonetary damages unless the injuries suffered fall within the definition of "serious injury" as set forth in the policy, or unless one of several other exceptions noted in the policy applies. The annual premium for basic coverage as required by law under this "limited tort" option is $180. Additional coverages under this option are available at an additional cost. B. If you wish to choose the "limited tort" option described in paragraph A, you must sign this notice where indicated below and return it. If you do not sign and return this notice, you will be considered to have chosen the "full tort" coverage as described in paragraph C and you will be charged the "full tort" premium.,I wish to choose~e "limit~d-~ort3 ~p~on described in paragraph A: Signature Line I. ~ ~ %.2_~~II ~f~'{~7 N~e~/m~sured Dst e C. "Full Tort" Option- The laws of the Commonwealth of Pennsylvania also give you the right to choose a form of insurance under which you maintain an unrestricted right for you and the members of your household to seek financial compensation for injuries caused by other drivers. Under this form of insurance, you and other household members covered under this policy may seek recovery for all medical and other out-of-pocket expenses and may also seek financial compensation for pain and suffering and other nonmonetary damages as a result of injuries caused by other drivers. The annual premium for basic coverage as required by law under this "full tort" option is $210. Additional coverages under this option are available at an additional cost. If you wish to choose the "full tort" option described in paragraph C, you may sign this notice where indicated below and return it. However, if you do not sign this notice where indicated below and return this notice, you will be considered to have chosen the "full tort" coverage as described in paragraph C and you will be charged the "full tort" premium. Signature Line II. Named Insured Date E. You may contact your insurance agent, broker or company to discuss the cost of other coverages. An Independenl Agent Repre~nling ERIEINSURANCE GROUP B2B009 12 ANGELAM BARMONT 054598B135 CONTINUATION NOTICE ERIE INS~CE EXCHANGE PIONEER FAMILY AUTO POLICY AA7401 CARL L CP~kMER INS. LLC 10/25/01 TO 10/25/02 Q10 2504970 H ANGELAM BARMONT 432 NEWVILLE RD NEWBURG PA 17240-9376 AS LISTED BELOW AGENT - CARL L CRAMER INS. LLC AGENT PHONE (717) 530-8600 833 W. KING STREET SHIPPENSBURG PA 17257 9201 * CONGRATULATIONSl A PIONEER EXPERIENCE RATING CREDIT HAS * * BEEN APPLIED TO YOUR POLICY PREMIUM. * ITEM 4. AUTOS COVERED AUTO YR MAKE 1 00 TOYO 4RUNNERLTD VIN ST TER SYM JT3HN87R3Y9042231 PA 4F P RATING CLASS DDP A3AS-M FM30 ITEM 5. INSURANCE IS PROVIDED WHERE A PREMIUM, OR INCL, IS SHOWN FOR THE COVERAGE. COVERAGES, LIMITS AND ANNUAL PREMIUMS ARE AS FOLLOWS- #1 *****GOOD DRIVER RATES APPLY***** --- THE FULL'TORT OPTION APPLIES TO ALL PRIVATE PASSENGER VEHICLES. --- LIABILITY PROTECTION- BODILY INJURY $100M/PERSON $300M/ACC PROPERTY DAMAGE $100M/ACC FIRST PARTY BENEFITS- MEDICAL EXPENSE $10M INCOME LOSS SIM/MONTH, $15M MAXIMUM ACCIDENTAL DEATH $5M FUNERAL BENEFIT $2.5M UNINSURED MOTORISTS COVERAGE- BOD INJ $100M/PERSON $300M/ACC-STACKED UNDERINSURED MOTORISTS COVERAGE- BOD INJ $100M/PERSON $300M/ACC-STACKED PHYSICAL DAMAGE COVERAGES- COMPREHENSIVE $100 DED COLLISION - $500 DED 81 78 31 12 1 1 15 79 160 298 TOTAL ANAK3AL PREMIUM FOR EACH AUTO 756 TOTAL ANNUAL POLICY PREMIUM $ 756 ITEM 6. APPLICABLE POLIC' ENDORSEMENTS, EXCEPTIONS ALL AUTOS - FAP 04/97, USz106 05/01', AFPN01 10/98, AUTO 1 AFPU01 04/99, AMMMN 05/88. DECLAP~ATIONS a£PA03 10/98. ITEMS ANTI-THEFT DISCOUNT APPLIES-ALARM AUTO 1 PASSIVE RESTR3IINT DISCOUNT APPLIES - DUAL AIRBAGS AUTO 1 ANTI-LOCK BRAKE DISCOUNT APPLIED AUTO 1 EXPLANATION OF ADULT &/OR YOUTHFUL DRIVER RATING CLASS AUTO 1-TO WORK 15-20 MILES ONE WAY, UP TO 12,500 MILES ANNUALLY FEMALE, MARRIED, AGE 30-34 MISCELLANEOUS INFORMATION ITEM 7. EACH AUTO WE INSURE WILL BE PRINCIPALLY GARAGED AT THE ADDRESS SHOWN IN ITEM 1, UNLESS ANOTHER ADDRESS IS SHOWN BELOW. ND WFS 09/22/01 031009 12 ANGELA M BARMONT 054598B135 ITEM 9. UNLESS A CO-OWNER OR LIEN-HOLDER IS LISTED BELOW, THE NAMED INSURED IS THE SOLE OWNER OF EACH AUTO WE INSURE. LIEN-HOLDER FOR AUTO 1 FIFTH THIRD BANK FIFTH THIRD AUTO LEASING 38 FOUNTAIN SQUARE DEPT 778 CINCINNATI OH 45202-3191 ADDITIONAL INSURED FOR AUTO 1 FIFTH THIRD B]~NK FIFTH THIRD AUTO LEASING 38 FOUNTAIN SQUARE DEPT 778 CINCINNATI OH 45202-3191 DRIVER 1 ANGELAM BARMONT 2 TEDDY E BARMONT ST LICENSE NUMBER PA 21313667 PA 19022441 BIRTH DATE 07/11/67 o4/i /6o ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INS~CE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSUP_ANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFOPd~ATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME D~ND SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES. YOUR COLLISION COVERAGE AND DEDUCTIBLE APPLY TO PRIVATE PASSENGER AUTOS YOU OR A RESIDENT RELATIVE RENT FOR 45 DAYS OR LESS. THIS IS SUBJECT TO LIMITS, TERMS AND CONDITIONS IN THE POLICY. THE LAWS OF THE COMMONWEALTH OF PENNSYLVANIA, AS ENACTED BY THE GENERAL ASSEMBLY, ONLY REQUIRE THAT YOU PURCHASE LIABILITY AND FIRST-PARTY MEDICAL BENEFIT COVERAGES. ANY ADDITIONAL COVERAGES OR COVERAGES IN EXCESS OF THE LIMITS REQUIRED BY LAW ARE PROVIDED ONLY AT YOUR REQUEST AS ENHANCEMENTS TO THE BASIC COVERAGES. BELOW ARE ANNUAL PREMIUMS FOR THE MINIMUM REQUIRED COVERAGES AND LIMITS FOR LIMITED TORT. PLEASE NOTE THAT THE LIMITED TORT OPTION MAY NOT BE AVAILABLE ON CERTAIN VEHICLES. BODILY INJURY $15M/PERSON $30M/ACC 40 PROPERTY D~24AGE $SM/ACC 56 FIRST PARTY BENEFITS - MEDICAL EXPENSE $5M 20 Q10 2504970 INVOICE INFORMATION: DATE DUE PAYMENT DUE 10-25-01 189.00 01-25-02 192.00' 04-25-02 192.00' 07-25-02 192.00' B2B006 07 TEDDY E BA~RMONT 042687B139 CONTINUATION NOTICE ERIE INSURANCE EXCHANGE HOMEPROTECTOR POLICY EXTRACOVER AA7401 CARL L CRIER INS. LLC 11/21/01 TO 11/21/02 Q59 2103803 H TEDDY E BARMONT 432 NEWVILLE RD NEWBURG PA 17240-9376 AS LISTED BELOW OR ON REVERSE SIDE AGENT - CARL L CRAMER INS. LLC AGENT PHONE - (717) 530-8600 833 W. KING STREET SHIPPENSBURG PA 17257 9201 COVERAGE BEGINS AND ENDS AT 12.01 AM STANDARD TIME AT THE LOCATION OF THE INSURED PROPERTY. UNTIL TERMINATED, THIS POLICY WILL CONTINUE IN FORCE. LOCATION OF RESIDENCE PREMISES IF OTHER THAN STATED IN ITEM 1 OR IF SPECIFIC DESIGNATION IS NEEDED. ZIP CODE - 17240 HOPWEL TWP, CUMBE CO PROPERTY INFORMATION - PRIMARY RESIDENCE, YEAR OF CONSTRUCTION 1960, FRAME, PROTECTION CLASS C. PROPERTY IS OVER 2000 FEET FROM A FIRE HYDR_A_NT AND WITHIN 2 MILES OF A RESPONDING FIRE DEPARTMENT. AUTOMATIC ADJUSTMENT OF COVERAGE WAS APPLIED. YEARLY INCREASE ON DWLG IS 5%. COVEEAGE IS PROVIDED ONLY IF A SPECIFIC AMOUNT OF INSURANCE IS SHOWN. SECTION I - PROPERTY PROTECTION DWELLING OTHER STRUCTURES PERSONAL PROPERTY LOSS OF USE AMOUNT OF INSUP~ANCE PREMIUMS $ 117,000 $ 340.00 $ 17,800 $ 12.00 $ 83,300 $ 4.00C LOSS SUSTAINED NOT TO EXCEED 12 CONSECUTIVE MONTHS SECTION II - HOME AND FAMILY LIABILITY PROTECTION PERSONAL LIABILITY EACH OCCURRENCE $ 500,000 MEDICAL PAYMENTS TO OTHERS EACH PERSON $ 1,000 PREMIUM CHARGE FOR INCREASED LIABILITY LIMITS FULL TERM PREMIUM FOR THIS RESIDENCE ...... FULL TERM ADDITIONAL COVERAGE PREMIUM ..... TOTAL PREMIUM FOR THIS POLICY ......... SECTION I DEDUCTIBLE $ 100. APPLIC~_BLE FORMS - 2003 02/01', HP-PA 02/01', UF9013 04/01', UF3189 12/00', UF3226 04/01', HP-BD 02/01', UF2106 05/01'. $ 20.00 $ 368.00 $ 9.ooc $ 359.00 UF-8705 06/96', UF-6523 08/98', ENDTOM, HP-AA_N 01/97, PRIM3~RY RESIDENCE-MORTGAGEE LN 0015332299 MELLON BANK PO BOX 5954 SPRINGFIELD OH & E' 45501-5954 ?OM SEE REVERSE SIDE AGTMC Y 10/06/01 031006 07 TEDDY E BARMONT 042687B139 NO BUSINESS PURSUITS ARE CONDUCTED AT THE PREMISES, EXCEPT AS FOLLOWS ADDITIONAL COVERAGES PREMIUMS OTHER STRUCTURES ABOVE INCLUDES AN INCREASE OF $ 6100 SHOWN ABOVE YOUR BASIC DWELLING PREMIUM REFLECTS YOUR OPTIONAL DEDUCTIBLE INCL ABOVE PREMISES ALARM SYSTEM - TYPE 2 $ 19.00CR REPLACEMENT COST SETTLEMENT - PERSONAL PROPERTY $ 50.00 MULTI-POLICY DISCOUNT APPLIES $ 40.00CR ENDORSEMENT OM IT IS AGREED THAT THE PRIMARY RESIDENCE MORTGAGEE IS AMENDED TO READ - MELLON BANK ATTN 0015332299 ITS SUCCESSORS AiqD/OR ASSIGNS ATIMA ERI 1 5 200'3 ERIE INSUFIANCE GFIOVP Branch Office · 4901 Louise Dr · Rossmoyne Business Cenlor · PD. Box 2013 · MechanicsBur0, PA 1705,~0710 (717) 705-8200 · Toll Free 1-800-382-1304 · Fax (717) 705-2315 · http:#www.erio-insurance.com Date: January 13, 2003 Clark DeVere, Esquire Law Offices 3211 N. Front Street PO Box 5300 Harrisburg, PA 17110 Erie Claim #: 010170621395 Erie Insured: Ted & Angela Barmont Date of Loss: 06/24/2002 Your Client: Dustin Barmont Dear Mr. DeVere: You have requested Erie Insurance Company supply you with written consent to settle the Bodily Injury claim of Dustin Barmont with the Third Party tort-feasor, Paul E. Gutshall, III. Consent is requested so that your client can pursue an Underinsured Motor/st claim with Erie Insurance under the above referenced claim number. Erie Insurance will waive its subrogation rights versus Paul E. Gutshall, III and consents to the settlement with his carrier, State Farm Insurance Company, in the amount of $9,000.00. The information provided by State Farm Insurance Company confirms the liability limit of their policy is $100,000.00 and that there is no umbrella policy available to their insured. Erie Insurance waives its right of subrogation for payments made under our Underinsured Motorist coverage. By providing our consent to settle, Erie Insurance does not waive, invalidate or forfeit any of the other terms or conditions of said policy. Sincerely, Claim Representative (717) 795-2251 The ERIE Is Above All In sERvIcE® . Since 1925 ERIE INSURANCE GROUP Branch Office · 4901 Louise Drive · Rossmoyne Business Center · Mechanicsburg, PA 17055 · (717) 795-8200 Adjuster Mailing Address · P.O, Box 396 · Mechanicsburg, PA 17055 · Adjuster Direct Line: (717) 774-5088 * Fax: (717) 795-2315 Date: November 5, 2003 Clark DeVere, Esquire Law Offices 3211 N. Front Street PO Box 5300 Harrisburg, PA 17110 Erie Claim #: 010170621395 Erie Insured: Ted & Angela Barmont Date of Loss: 06/24/2002 Your Client: Dustin Barmont Dear Mr. DeVere: I am sending this as a follow up on the above referenced claim to confirm settlement of $58,500.00 in your client's Underinsured Motorist claim. It is my understanding that your client wishes to place $50,000.00 of the settlement proceeds into a structured settlement through Erie Family Life pending review of the structured settlement quotes which will show payouts at age 19, 25 and 28. If, after review of the quotes, there is no interest in a structured settlement, please advise and I will forward the appropriate release. As you are aware, since this settlement involves a minor, we will require the settlement to be court approved. Thank you for your cooperation in this matter, and if you have any questions, please do not hesitate to call. (717) 774-5088 The ERIE Is Above All In sERvIcE." Since 1925 RINGLER ASSOCIATES (412) 263.2228 (800} 22%2228 Fa.x (412) 2634288 Individually Designed Settlement Dustin Barmont DIO/B 12/7186 GUARANTEED BENEFIT COST YIELD Immediate Cash $8,500 $8,500 Guaranteed Lump Sums $ 10,000 atAge 18 9,705 10,000 $ 20,000 at Age 25 15,5t7 20,000 $ 35,152 at Age 28 24,778 35,152 $58,500 $73,652 The enclosed figures are for illustrative purposes only and should not be construed as a contract. All figures are subject to approval by the life insurance carrier prior to contract issuance. THRF~ GATEWAY CENTI~, 16 NORTH * PI'I-fSBUROH, PA 15222 www.RinglerAS.~: iates, eom JAN.08'2004 15:35 412 263 2288 Ringlet Assoc #3799 ?.001/004 RINGLe;R ASSOCIATES, INC. FACSIMILE TRANSMITTAL SHEET TO; Chex.dc Whit,sob FROM: FJ%.X NO.: 717-234-9478 DATE: CC: FAX NO.: CC; FJ~'< NO.: Janis K. S~rope, Case Administzator Januxr~' 8, 2004 3i[S: Dmfia Bartr~o~t, a m/not CLALM NO.: 010170621395 TOTAL # OF Pt\G~$ INCLUDING COVI~R:4 [] URG;'~NT X I~OR RI;¥II*;W X I'J,I~,ASI'~ COMMi,;NT [] PI,I,',ASI',' RI~PI,Y [] PLEASE RJ",CYCI.ll At Dan Vic.kovic's request, attached is the financial profile for Erie Family Life .Insurance Company. Please note that while Erie Family Life is rated A by A.M. Best Company, Erie Insurance Exchange and/or Erie Indemnity Company guarantee the payments in the structure and both of these companies are part of the Erie Insurance Group which is rated If you have any questions or need any .fi.rrther irtfonnatiou, please do not hesitate to call our office. Thauk you for your assistance in this matter. 3 GATEWAY CENTER, 16N; PITTSBURGH, PA PHONE_: 412-263-2228 F~X: 412-263-2288 15'222 JAN.08'2004 15:35 412 263 2288 Kingler Aesoc #3799 P.002/00~ Life Insurer Financial Profile Company RaCings/Rank*'::*,..: , :'* ."* '!=' :*:~ A.M. Best Company (Sest's Rating, 15 ratings)" Standard & Poor's (Financial Strength. 20 ratings) Moody's (Financial Strength, 21 ratings) Weiss Ratings (Safety Rating, 16 ratings) Comdex (Percentile in Rated Companies) Erie Family A (3) Apl (6) B (5) 81 * These ratings te fled[ the opinions of the rating agencies and are not implied warranties of the company's ab~lty to meet ~ contractual obligations. All re0ngs shown em currant es of December 01. 2003. *" Relative financial sfA3i~gth and op~ra~tflg performance in cemdeflson with Industry norms. IASseW'& Liabii!tles' ' :'" " Total Ads,ed Assets Total Liabilities Separate Accounts Total Surplus & AVR As % of General Account Asseta [l.n~ested Asset Distrlbu.t on & Yield:. ':':[..:i : Total Invested Assets Bonds (%) Stocks (%) Mortgages (%) Real Estate (%) Policy Loans (%) Cash & Short-Term (%) Other Invested Assets (%) Net Yield on Mean Invested Assets 200Z (Indust~ Average 6,42%) § Year Average (Industry Average 7.05%) INon-Perform!ng Assets a,s s~:!3f Surplus; ,&.',AVE Bonds In or Near Defautt Problem Mortgages Real Estate Acquired by Foreclosure Total Non-Performing Assets As a Percent of Invested Assets I '~' ". ';' ' '.'.i ' ;' .. Bond Quality ' ,:; ,::: :., Total Value of Bonds Class 1-2: H~ghest Quality Class 3-5: Lower Quality Class 6: In or Near Default Weighted Bond Clasti ncome & Earni.n, gS ::.. Tota~ Income Net Premiums Written Earnings Before Dividends and Taxes Net Operating Earnings 1,225,$89 1,t32,270 0 94,598 7,7% 1,183,171 82.2% 6.3% 0,6% 0.1% 0.8% 8,8% 1.4% 6,64% 6,95% 4.5% 0.0% 4,5% 0.4% 1,034,995 95.5% 4.1% 0.4% 302,811 224,325 10,906 5,479 Data for Year-End 2002 from the life insurance COmpanies' stet~iop/annual statements, All dollar amounts are in thousands, Page 1 of 1 JAN.08'2004 15:35 412 263 2288 ~in~ler Aesoc #3799 P.003/004 04283 - Erie Insurance Group A.M. Seat #: 04283 View a [L~t_p._f..gr.q~p mer~be__~_ 'Re#ngs as of f2/04/2OO5' f ~ :f T: 4 f AM E.$. T. A+' (superior)* ~in ~..n.c_i.a. I S i~_e .C_~.t~.. g _o_~. XV ($2 billion or more) Rating Category (Superior): Assigned to comp;hieS that }la~e. in out oplnk>n, a Sul~edor ability to meet their ongoing obllgetion9 ~o point,em, Impotent Notice: Beet's Ratings ~e~ our opinion based on a comprehensive quantitative and qualitative evaluatfon of a ~m~any's balance sheet strength, operating peEormance and business pm~Je. These ratings a~e not a wa~mn~ of an i~surer's current or ~u~ ability to meet i~s contr~tual obligations. ~ew our ~[~ n_g3jg~ ~r a complete details. Companies Interested in placing a Beet's SecUrity Icon on their web site to promote their financial strength may f_egist__er o_.__n/!.ne, Copyright © 2003 by A,M~ Be~; Cgm~.a_n. yj.J.n.c__.. ALL RIGHTS RESERVED No part of this information may De distributed in any eleu-tronlc form or by any means, or stored in $ database 9~ retrieve! system, without [he prior wfltten permission oftheA.M. Baa Company Re~t to out t~. ,.F~. se;[gsa for add ~Jona dgta s. h~:~www3~ambestc~m/rat~n~s/ra~inm~sp?AMBNum~42g3&Re~nur33=~42~&$i~e---r~ ].2/4/2003 JAN,08'2004 15:35 4i2 263 2288 Ringler Assoc #3799 P,004/004 Company Profile I Where We're Located I Newsroom I Investor Relations Home > About US > Investor Relations > Indemnity ERIE Indemnity Company tmnity Corn~a, nv, , , N~SDAQ: ERIE... Last Trade: $ 41.10 . . . Change: + Related Top · News Rel, · Upcomin! Question Erie Indemnity Company (NASDAQ: ERIE) is a Fortune 500 company providing sales, underwriting and adreinistrative services to Erie · Insurance Exchange, a reciprocal insurance exchange, The company Is 2003 Ear also engaged in property/casualty insurance through its three subsidiaries and retains common stock in Erie Family Life, an affiliated ~n-~--W~ life insurance company. Together with the Exchange, Erie Indemnity Company and its subsidiaries and affiliates operate collectively under the name Insurance Group. With a network of Independent agents in 1 ] states and the District of Columbia, The ERIE seeks to insure standard and preferred risks, primarily in private passenger auto, homeowners and small commercial lines Including workers' compensation. Read more about the history, progress and management of Erie Indemnity Companywlth these highlights from the 2002 Annual Re pO~..'~: Managem. e_.n.~ TO Our Shareholders jeff Ludrof - An Intervie~ ~j[h.._E.R.!.E'~..New CEO A Singular Purpose A Distinct Culture A Firm Foundation A Steadfast Commitment _q..~s~!~.n.s..and Financlals: · Fundame Reports , SEC Filin~ $~q?_k__Qu- Dividend First Call Zacks Contact Information Questions: Karen Kraus Phillips, manager and vice president, Corporate Communications and Investor Relations 1-800-458-0811 ext. 4665 or $14-870-4665 http://www, arieinsurance.com/AboutUs/InvtrRelatiordlndemnity/De£ault.htm 12/4~2003 CONTINGENT FEE AGREEMENT 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 an accident that occurred on 1. Attomey's Fees: The fee of the attorneys shall be contingent as follows: (a) Twenty-five percent (25%) of gross recovery; (b) 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 w/th 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 attorney deems it necessary, we may be asked to advance these costs prior to the incurring of any such expenses or the scheduling of any deposition. Document #: 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 circumstance 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 rote 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 this case at any time after reasonable notice to us, and we agree to keep him advised of our whereabouts at all tunes 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 reveals that a parent is contributorily negligent in causing the accident the attorney's representation will 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/expenses, 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 ]J~a~tay of jkJ~,~Odll['~gd', 2002. CLIENT: CLIENt. METZGER, WICKERSHAM, KNAUSS & ERB, P.C. ATTORNEY: Clark DeVere, Esquire Document Il: 182430. I RELEASE AND SETTLEMENT AGREEMENT The undersigned, TED BARMONT and ANGLE BARMONT, individually and as the parents and legal guardians of the minor DUSTIN BARMONT (hereinafter referred to as "Releasor"), declare that, for and in consideration of NINE THOUSAND and NO/100 DOLLARS ($9,000.00), the receipt of which is hereby acknowledged, for themselves, their heirs, administrators, successors and assigns, and for Dustin Barmunt, his heirs, administrators, successors and assigns do forever release, acquit and discharge PAUL E. GUTSHALL, JR., PAUL E. GUTSHALL, III and STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, their predecessors, heirs, successors and assigns, and their officers, directors, owners, employees and agents (hereinafter collectively referred to as "Releasees"), of and from any and all actions, causes of actions, claims, demands, damages, costs, loss of services or use, expenses and compensation of whatever kind or nature on account of or in any way growing out of any and all personal injury and property damage and consequences thereof, and for any damages which may develop at some time in the future, and for any and all unforeseen developments arising from known or unknown injuries or property damage, resulting or to result from an accident which occurred on or about June 24, 2002 in Shippensburg, Cumberland County, Pennsylvania. It is expressly understood and agreed that this release and Settlement Agreement is intended to apply to and does apply to not only all known injuries, losses and damages, but further operates to release, acquit and forever discharge any and all claims or actions for any further injuries, losses and damages which arise from or may be related to the occurrence set forth hereinabove, even if said injuries, losses, and damages are unknown at this time and develop in the future. It is understood and agreed that Releasor specifically preserves and does not release, acquit or discharge any claim, actions and/or right they have to first party benefits through their own insurance policies; social security disability benefits; or any other source for recovery of income loss, work loss, medical benefits, health insurance, disability benefits from any entity, but specifically excluding Paul E. Gutshall, Jr., Paul E. Gutshall, 1II and their liability insurer, State Farm Mutual Automobile Insurance Company Contract. Payments under this Annuity Contract shall be made to Dustin Barmont in accordance with the following schedule. $10,000.00 guaranteed lump sum, payable on December 7, 2004; $20,000.00 guaranteed lump sum, payable on December 7, 2011; and $ 35,152.00 guaranteed lump sum, payable on December 7, 2014. ERIE shall provide to Releasors evidence of the purchase of said Annuity Contract. IlL Guaranteel Payments in Event of Death All payments to be made under this Release & Agreement shall be guaranteed by ERIE and/or Erie Indemnity Company in the event of any default on the Annuity Contract by Erie Family Life Insurance Company. Further, in the event of the death of Dustin Barmont prior to ail payments being made as required by this Release & Agreement, the remaining payments shall be made to the beneficiary(ies) named on the Direction of Payments Form. Should Releasors fail to designate a beneficiary, any remaining payments shall be made to the intestate heirs of, or in accordance with the Last Will & Testament of Dustin Barmont. IV. Riohts with Re~ard to Payments All payments made under and in accordance with this Release & Agreement are being made on account of personal physical injuries or physical sickness sustained by Dustin Barmont, The Releasors or Payees under this Release & Agreement shall have no rights of control over the periodic payments. Neither the payments to be made in accordance with this Release & Agreement, nor any of the assets of ERIE are subject to execution or any legal process. Specifically, the Releasors acknowledge that Dustin Barmont is the certificate holder of the Annuity Contract referenced herein. ERIE is the owner of the annuity. The periodic payments to be made under this Release & Agreement cannot be accelerated, deferred, increased or decreased by the Releasors or any Payee. Neither the Releasors nor any Payee have the power to sell, assign, mortgage, encumber or anticipate the periodic payments or any part thereof in any manner whatsoever. Any attempt by the Releasors or any Payee to sell, assign, anticipate, mortgage or encumber any of the payments hereunder or any part thereof shall not be recognized by ERIE. Document #295556.1 2 VERIFICATION I, Ted Barmont, 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 PlaintifFs Compromise Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Plaintiffs Compromise Settl~nent, 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 unswom falsification to authorities. ~ocument #295819.1 VERIFICATION I, Ted Barmont, as parent and natural guardian of minor Dustin Barmont, 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 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 unsworn falsification to authorities. Dated: o.~/~:~ ~ '~Tff~~//)~'~/ T~ed Barmont, as parent and natural guardian to Dustin Barmont Document #295819.1 VERIFICATION I, Angela Barmont, 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, infom~ation, 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 relat'mg to unsworn falsification to authorities. Document #295819.1 VERIFICATION I, Angela Barmont, as parent and natural guardian of minor Dustin Barmont, 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 Plaintiffs 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 unswom falsification to authorities. gu~.~n to~O~J~?d natural Document #295819.1 VERIFICATION The undersigned hereby certifies that he is the attorney for Petitioners Ted and Angela Barmont, as parents and natural guardians of minor Dustin Barmont, and Dustin Barmont 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 Dustin Barmont, by Ted and Angela Barmont, his parents and natural guardians, 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 unsworn falsification to authorities. Dated: Document #295819.1 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 the forgoing Petition to Seek Approval of/VI/nor Settlement with reference to the foregoing action by first class mail, prepaid postage, this ~q ~day of February, 2004 on the following: Paul Gutshall, III c/o Heidi Sailer-Judy Claims Representative State Farm Mutual Automobile Insurance Company P.O. Box 6001 Chambersburg, PA 17201-6001 Erie Insurance Group P.O. Box 396 Mechanicsburg, PA 17055 ATTN: Donald Bottini, Claims Representative Clark De~'ere,-VEsquire Document #295819.1 IN RE: DUSTIN E. BARMONT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA OR~HA~w'~ ~uo~* uiw$iON No. DECREE AND NOW, this 2~_ day of V~. ~J z. L1 ,2004, a ~C~/,~C) ,is scheduled for the ]~' day of t0~,, ,2004 at// :/z9 ~c.m. in ! ~z/~-~gz~-~ ~'~0. [ before Judge ~(~. ~'.(~ rStt~ r.~. The minor Dustin Barmont is not required to be preserlt for the hearing., L BY THE COURT: CC: Clark DeVere, Esquire - counsel for Petitioners ~ ~ ,~-~/-0'~ Heidi Sailer-Judy, Claims Representative, State Farm Mutual Automobde Ins. Co. Donald Bottini, Claims Representative, Erie Ins,urance Group Document #295819. I IN RE: DUSTIN E. BARMONT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DECREE AND NOW, this [~t_ day of /~ ~o c ', [ ,2004, upon consideration ofthe Petition for Approval of Minor Settlement, it is hereby ORDERED and DECREED that the settlement for the gross sum of Sixty-Seven Thousand Five Hundred Dollars ($67,500.00) is APPROVED. Counsel fees and expenses are found to be fair and reasonable and also approved as set forth below. The distribution is directed as follows: (1) To be paid to Ted and Angela Barmont, who are appointed guardians of Dustin Barmont for the purposes of this Petition, the sum of $383.67 for the immediate benefit of Dustin Barmont; (2) To be paid to Metzger, Wickersham, P.C. for counsel fees and expenses - the sum of $17,116.33; and (3) The balance of $ 50,000.00 to be transferred by Erie Insurance Exchange to Erie Family Life Insurance Company to set up a structured settlement account. The structured settlement account will pay the following guaranteed lump sums to Dustin Barmont at the following ages: $10,000 guaranteed lump sum, payable on 12-7-04; $20,000 guaranteed lump sum, payable on 12-7-11; and $35,152 guaranteed lump sum, payable on 12-7-14. The benefits are tax-free guaranteed benefits, which will be payable to Dustin Barmont at the specified ages and if he should die before the payments are made, to his Estate or to such other persons or others as shall be designated in writing by him to Erie Family Life Insurance Company. Document #295819.1 Ted and Angela Barmont, as parents and natural guardians of Dustin Barmont, are authorized to sign the Releases and Structured Settlement Agreement, attached to the Petition, and discontinue this action upon delivery of the cash payment totaling $17,500.00 and the transfer of the remaining funds into the structured settlement account. BY THE COURT: CCi Cla. r.k. DeVere, Esquire - counsel for Petitioners . _~-~_ ~ ~- o/- o ~' Heldi Sailer-Judy, Claims Representative, State Farm Mutual~Automobile Ins. Co. % ' Donald Bottini, Claims Representative, Erie Insurance Group Document #295819.