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HomeMy WebLinkAbout08-3242IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA KATHLEEN A. SMITH, Individually, and as Administratrix of the ESTATE OF KATHLEEN A. CONN, 425 South Main Street Telford, PA 18969 (Montgomery County) Plaintiffs V. ERIE INSURANCE EXCHANGE 4901 Louise Drive Mechanicsburg, PA 17015 (Cumberland County) Defendant No. Dg - 3a.421 ei vi I Ierv Civil Action (X) Law ( ) Equity PRAECIPE FOR WRIT OF SUMMONS TO THE PROTHONOTARY OF SAID COURT: Please issue a Writ of Summons in the above-captioned action. X Writ of Summons shall be issued and forwarded to ( ) Attorney (X)Sheriff. Scott B. Cooper, Esquire Schmidt Kramer PC 209 State Street Harrisburg, PA 17101 (717) 232-6300 Date: ,,. za 9 /__?/ Signature of Attorney Supreme Court I.D. No. 70242 WRIT OF SUMMONS TO THE ABOVE NAMED DEFENDANT: YOU ARE NOTIFIED THAT THE ABOVE-NAMED PLAINTIFF HAS COMMENCED AN ACTION AGAINST YOU. PrAShonglaryt- Date: By: Deputy ( X ) Check here if reverse is issued for additional information D N) '- Us C: D -n r5 tP 8 SHERIFF'S RETURN - REGULAR CASE NO: 2008-03242 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SMITH KATHLEEN A ET AL VS ERIE INSURANCE EXCHANGE GERALD WORTHINGTON , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within WRIT OF SUMMONS was served upon L'OT7 TNTCTTT?hNTrP PYrWAMr-P the DEFENDANT , at 1425:00 HOURS, on the 29th day of May 2008 at 4901 LOUISE DRIVE MECHANICSBURG, PA 17055 STEPHEN GRANOFF a true and attested copy of WRIT OF SUMMONS together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing Service Postage Surcharge 61C ?/".p (?, So Answers: 18.00 12.00 Kpy` .59 10.00 R. Thomas Kline .00 40.59 05/30/2008 SCHMIDT KRAMER Sworn and Subscibed to before me this of by handing to ADULT IN CHARGE By: 4,U ) - '15, day Deputy S e iff A.D. SCHMIDT KRAMER PC BY: SCOTT B. COOPER, ESQUIRE I.D. # 70242 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Petitioner IN RE: ESTATE OF KATHLEEN ANN CONN, : Deceased, by KATHLEEN A. SMITH, Administratrix, Petitioner IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 08-3242 : ORPHAN'S COURT DIVISION SUPPLEMENTAL PETITION FOR APPROVAL OF MINOR'S SETTLEMENT FOR WRONGFUL DEATH ACTION SUPPLEMENTAL PETITION FOR APPROVAL OF MINOR'S SETTLEMENT FOR WRONGFUL DEATH ACTION AND NOW, comes the Petitioner, Kathleen A. Smith, by her counsel, Schmidt Kramer PC, and sets forth the following Petition in accordance with Pennsylvania Rules of Civil Procedure 2039 and 2206. 1. Petitioner, Kathleen A. Smith, is the Administratrix of the Estate of her deceased daughter, Kathleen Ann Conn, who died intestate on November 12, 2006, at Hershey Medical Center in Dauphin County, Pennsylvania. (See Death Certificate and Certificate of Grant of Letters of Administration attached as Exhibits A & B, respectively.) 2. Petitioner, Kathleen A. Smith, is the maternal grandmother of Aidan R. Self, a minor (Date of Birth: May 5, 2005), who is the surviving natural son of the decedent, Kathleen Ann Conn. 3. Petitioner resides at 425 South Main Street, Telford, PA 18969. 4. Justin R. Self is the parent and natural guardian of Aidan R. Self. 5. Justin R. Self, lives with Aidan R. Self, at 5001 Seneca Drive Mechanicsburg, Cumberland County, PA 17050-2575. 6. The Petitioner's decedent, Kathleen Ann Conn (Date of Birth: March 29, 1983), was involved in a motor vehicle accident on the Carlisle Pike in Hampden Township, Cumberland County, Pennsylvania, November 12, 2006, which resulted in her death. 7. At the time of the accident, Kathleen Ann Conn was a pedestrian crossing the Carlisle Pike and was struck by a vehicle owned and driven by Tegan Ritchey. (See Hampden Township Police Report attached as Exhibit C.) 8. Ms. Conn suffered traumatic injuries, and was taken from the scene by Life Lion. The decision was made to remove life support at Hershey Medical Center, and she died at approximately 8:00 a.m. that same morning. 9. Ms. Ritchey's insurer paid the available liability limit of its policy, and the settlement was distributed under the February 7, 2008, Order of this Court. Petitioner's counsel then successfully sought coverage under Justin R. Self's auto insurance policy, specifically under the Underinsured Motorists- 2 Bodily Injury coverage resulting in the current settlement. 10. Ms. Conn's funeral and burial expenses total, $12,784.16. (See Funeral and Related Billings attached as Exhibit D.) The portion of funds distributed to Kathleen Smith from the initial settlement ($5,000.00) was in reimbursement for her payment of final expenses, leaving $7,784.16, in expenses remaining. (See Previous Order attached as Exhibit E.) 11. Ms. Conn's bills for medical treatment after the accident were paid by an ERISA health plan, through Mr. Self's employer, Tyco. Tyco asserted a lien in the amount of $38,335.77, for its payment of medical bills. (See Excerpt of Tyco Summary Plan Document attached as Exhibit F.) 12. Petitioner's counsel successfully negotiated the lien to satisfaction in the amount of $25,000. (See ACS Recovery Letter attached as Exhibit G.) 13. Justin R. Self, was insured by the Erie Insurance Exchange at the time of the accident under policy number Q 10-0407835, which was effective October 4, 2006 through October 4, 2007, and included underinsured motorists-bodily injury coverage in the amount of $100,000 per person and $300,000 per accident. (See Erie Declarations attached as Exhibit H.) 14. The Erie Insurance policy also included first party coverages for funeral benefit and accidental death, in the combined amount of $7,500.00. (Id.) 15. Kathleen Conn was listed as a driver on Mr. Self's policy, and Erie determined Ms. Conn was eligible for coverage under the policy. (See Erie Correspondence attached as Exhibit I.) 3 16. Erie has offered to settle the underinsured motorists claim for $100,000, and Kathleen Smith has tentatively accepted. 17. Erie expects to pay the $7,500.00 in addition, because funeral benefits and accidental death benefits apply. Counsel will not deduct attorney's fees from the first party benefit recovery. 18. The offer exhausts the insurance coverage available from the policy. 19. It is the opinion of Petitioner and her counsel, Scott B. Cooper, Esquire, that this settlement is for the maximum recoverable from the applicable policies. Petitioner and counsel believe that the settlement, insofar as it involves minor, Aidan R. Self, is in the best interest of said minor. 20. Pennsylvania's Department of Revenue has issued a letter approving allocation to the wrongful death action. (See PA Department of Revenue Letter attached as Exhibit J.) 21. The proposed allocation, after attorney's fees and costs, is as follows: TO: ACS Recovery, to satisfy the medical lien $ 25,000.00 TO: Kathleen A. Smith (for final expenses) 7,784.16 TO: Aidan R. Self, minor son of Kathleen Ann Conn $49,400.75 22. Petitioner, Kathleen A. Smith, entered into a Contingency Fee Agreement with Petitioner's counsel, Schmidt Kramer PC. The agreement calls for a fee of 25% on any recovery obtained before trial. (See Contingency Fee Agreement attached as Exhibit K.) This results in a fee of $25,000 due Schmidt Kramer PC. Petitioner came to engage Schmidt Kramer PC by way of a referral 4 from Michael Bangs, Esquire, 429 South 18th Street, Camp Hill, PA 17011, who will receive one third (1/3, or $8,325.00) of attorney's fees. Again, counsel has calculated the fee based on the $100,000 UIM settlement, and not the $7,500.00 first party benefit payment. 23. In addition, Petitioner has incurred costs in the amount of $315.09. (See Printout of Costs attached as Exhibit L.) 24. The Petitioner requests that the amount to be awarded to the minor, Aidan R. Self, or $49,400.75, be distributed without the formal appointment of a guardian, to be added to the sequestered bank account at Commerce Bank (Account #062707487) which holds restricted funds from the third party settlement, in compliance with Pa. R.C.P. 2039(b)(2). The account in the name of the minor is restricted until the minor reaches eighteen (18) years of age. Said account shall be and is marked as follows: "This money shall be held in trust, not to be redeemed, except by Order of this Court, before May 05, 2023." 25. A copy of the proposed Release is attached hereto as Exhibit "M." 26. Justin R. Self and Kathleen A. Smith, join in this Petition. (See Joinders attached as Exhibit N.) 27. The Petitioner requests that your Court enter an Order: (a) approving the supplemental settlement and payment of first party medical benefits allocated to the wrongful death action; (b) approving disbursement to satisfy the lien; (b) approving attorneys' fees; (c) approving disbursement to reimburse Kathleen A. Smith for funeral expenses; (c) approving reimbursement of costs to Schmidt Kramer PC; and (d) authorizing the Administrator, Kathleen A. Smith, to sign the 5 Release attached to this Petition as Exhibit "M." Dated: 1)02/01 Respectfully submitted, SCHMIDT KRAMER PC By Scott B. Cooper, Esquire Attorney I.D. #70242 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Petitioner 6 VERIFICATION I, Scott B. Cooper, attorney for Petitioner, verify that I am attorney of record for the Petitioner, and that the foregoing document contains no facts within the knowledge of the Petitioner, but rather, is based upon the record or facts solely within the knowledge of the attorney; and, for that reason, I make this Verification on behalf of Petitioner. I verify that the facts contained in the foregoing document are true and correct to the best of my knowledge, information and belief. I understand that intentional false statements herein are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsifications to authorities. SCHMIDT KRAMER PC By: Scott B. Cooper, Esquire Attorney I.D. #70242 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Petitioner Date: ),,-I )) 0 I ?445 4 F _r YARNING: IT IS ILL_GAL TO ALTER TlIIS COP`( Q-7 TO D] jFL!CA _ 3Y PH- ' 0 S 7 A 7 CR Ph0- GriA?Fi. C-MHCN'NE-'H OF ?_,YNSYLYAN;A CEPAA71AE4T OF :-iFAL74 VITAL AES0RC8 LOCAL REGISTRAR'S CER T IFiCATI 'N OF DEATH OF ?,JN ?F r^, -i November 17, 20Ci CERT. NO. I.L e 49? r?!" a?a rn ?,.,. or .Ti. can,nc.ao ENT of P,ame of Decedent Kathleen Ann Conn Female 187-64-1 542 November 12, 2006 Sex Social Security No. Date of Death Date of Birth filar 29, 1983 Birthplace Philadelphia, PA Place of Death Hershey Medical Center Dauphin County Derry Township Pennsylvania Fec:iity nama C-Iy C -, 3-14- .1 :. tV Race White Occupation Student Armed Forces? (Yes or No) No Never Married Decedent's 4907 Delbrook Road, Mechanicsburg, PA 17050 Marital Status Mailing Address. N1fC9r 54aetCry i,wn Ssre Kathleen Smith Jeffrey A. Naugle' Informant Funeral Director Name and Address nt Jeffrey A. Naugle Funeral Home, 20 N. Ambler St., Quakertown, PA 18951 Funeral EstaUlishment Jeffrey A. Naugle Funeral Home, 20 N. Ambler St., Quakertown, PA 18951 . Interval Bevrveen Part L immediate Cause. Onset and Death Multiple Traumatic Injuries (a) (b) - (c) . Part II: Other Significant Conditions , Manner of Death Describe hQw injury occurred: edeStrtan vs. SUV Natural 0 Homicide Q Accident Pa ding Investigation C Suicide [1 Could not be Determined PJame and l'itle of Certifier- Patty J. °Garber, Chief Deputy 1271 South 28th St., Harrisburg, PA 17111 (UD., D.O•, Coroner, M. E.) This is to 'certify that the i formation here given is correctly copied frern an original certificate of death duly flied with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Offilce for permanent filing. 09--106 November 17. 2006 1980yKrarnmes Road Ouakertown U w f Z i G Q Y ? G C4 z .-, L r c co r ?- W ? , f L Q c^ < z t E ?- - (/) 06 U Z J Z O C E C 7 Q: Q LL n- cJ C c? ?, W o o z W 7 L C3 C7 .? W _ W W :REGISTER OF WILLS CUMBERLAND County, Pennsylvania A?o. 2007-00108 21- 0,'- 0162 Estate Of: KATHLF_FN?i;v1v(-nn1n1 Late Of: HAIVIPDEN TO1111NSHIP CU/VIBERLAND COUNTY Deceased Social Security No: 187-64-1542 W ?ERE_?S, KATHLEENANN CONK trust, ,taco/e, Last) --- ? RLe of hl- ??IPDEN TO,1/?N1SY1P CLT1 T'A 3 COUNT _r =_ed c^ th-e 12th day of liove::ber 2006 and, the C?r? t of Letters of .??. 1n1S?raL1J71 s required fcr the administration cf t,'-_e estate. T iEREFORE, T, GLENDA FARNER STRASBAUGH Re i ste? gy r of Wi,lls in and c-r CL'U'B ERL.?iVD COL'n t`i, ? n the CSP.'.Cion%eal' t:1? Of Pernsylvania, have tr_is day granted Letters of Administration Lo: KA THL EEN A SMITH has duly qualified as Ar1?lI1VTSTRTOR(RTX1 of the estate of the above named decedent and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURTHOUSE, CARLISLE, PENNSYLVANIA. 1N TEST-TIVONY WHEREOF, .1 have hereunto set n y hand and affixed the seal Of my office on the 27th day of March 2007. R'y'3IUr of / 1 i CER T !FICA TIE OF GRANT 0FL ETTERS L 't v 'S ) 1W 046, 4 7 4 COMMOiVWEALTH OF ?Vi,NSYLVANIA ` (( )' POLICE CRASH REPORTING FORM Casa Cosod Reportable Cluj-, ?Q---? /Arlr I:iL ? Yes Cvv 0'f°! O,VC ? ib0C46474 r? Crash Nun-0 -1 II J indent Nurnher _= _?,_ ' N.4Nt2006 1100382 21 103 Agr.ncf Nema S'? ' et.nct inve"I Oaf 'M!,1 00 rYY) Hampden Township ? r Glspatcfi T1mt lmaJ Arrival Tima ?mti; Inv Btpr tI 02?? 023q PT1 ?1 BRADLEY' Ud Number - SHEETZ 19] 7 b ! R41VI Witr gad Number SGT SHAUN A. 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Saturt X24 Model Year veh!c!e Ytodel (see o.erl;y) x5GZCZ23D55S3i0604 2005 VUE Ucansa Plata - RrgS-Ute Est?Spoed KfUd T1w.d _ FTR4123 rate By --- _ _J I'A 040 O Yes p Na ROADSIDE RESCUE m1V? Irrsurarrce Company - ? Nlry No QY`K Q No C. D known PROGRESS1Vr 14332664.0 ? a Tr,fill, r --j a 1=To,ving Pass. Ven d=Mob:!,NNU;Jar Hone I-Serri•Trdl!er Ta No + tm^t No. of9 U 2=Towing Truck 5=Cam 8=Cther Tay Year Tr a St Trdilin .r' per Unit :: _ 3-?cmrsg Ut7iry Tra ter 6=Full Trd,lrr 9.Unkr.Own Dlret!{cn of !V;Jrop Pesklon • I mm ae4f T/sage E y 1 -? U 1 Overlay WWII Dolor V 11 $ 06-Y !OW iver Z-11-112-U.141 MzAulcrnmle 53)4 05-ldrJe Truck C6: SU'? 2C-l'nic C 9.ede e TnC/Ci2 , LL) __J' ? - 12=Co ^mercial 3 wrvr 'G U?-Ma!orc/cle 01=Van 21=OtherPeilslrytle GC°kotApfaicah'e Carrlcr fue 08" "Gold 09.9[ Owl O?=?us 1G=5rowrnct;lle 2 O e ._I r;e .logy 101=F:re'Vvh 13=Taxi 2 C aged 1(.Crar. e 04=5rnall Tn c4 ! '02' Con I (! :p eR Porm 1 t=Faun E7oi 12=CorsUucinn E i 23nNCCC $ R ier 01=nmr lace 03=Pr1 cc 11 =Tractor Trailer 1 0 ;a'.',7It2 04zG' Y r• r' S a ,;, ?u P 13 ' ,. Za..Tran T e , , I r t er Cn erra _ 1 lurnTr der rcy » T p!e r a !er Txr C5=3ki k 1 .C!htr 9,.?Unknown (N 10 or 21Con,plita w 18 C "er Type 5xr Veh 98 Cther dente j r ror,:fipj Vtn - _ fa td C.vr;nn 17> , k yCe SraC Veh 19=0A 9) U.enrvx I 1 ,.oopll ? d S,wr t S5 l,nKrCUr 1? OC for Cn! 535 01 1 (?tmape ndlWor on I I-Urce a rage r7? i Nu e 2=F?n:tic?al Grgrllon! ) - r wm.h,;l r I (1u tom r, H:II J - - - RPR N nrntni f h . 2-Clock (o1^t 13-7op S la*Tp,cd Lfit u k 953 U I =Minor 3. bdn V g 9 J k =1r+e! 2=L iul VU0!riill I :; al ; 17 1=Ccrve r nrnn - _ , ccrn p -Unbwtir PCf?G 9 ,tA-5MA iMV) FENNDQT CO1)Y llrtp; ;Jtiv???d.clot6.state.pa.u9 icons,'PrintIma?e;,,;?;rn;File %2006113G761GUTSIIALLl9ti0... it 5330/2005 r ririi LRfi Y'Y A464 r.,, r7 ' .. COMMONWEALTH OF PENNSYL' A-m A Gish Numb j POLICE CRASH REP'ORTIN'G FORM i Prqr A 5CC 3 /-1 1>=LliVer 00=Nct .>, ?3;seryar;C<,..car.t Z=Plsier ;ar 07-D iwr - All Veric:es 7tiPedestran 02=,Frcnt Seat ttidCe Prs;ti,?r. A-c'hp( C:-Front >eat Rryht Sica =unknryn ca=Sxcr:: Row • i ef° Sine Cr Mo',Cr:fc e p3=se' ger CS=Seccrd Row • Middle ?6SCion r Cd=Seceni Row • R.rh; S,de F >'rtrra!e 07=Third Rcw Cr GreaiBr fat=.?ale Left Side U -UnAnOwn 08--Third low Cr Greater Middle ' Dc-it on 09.Third Row Of Greater - Rignt Side 1C.SJetper Section of 7,,;ckc)b C O+Ncrt rijLred 1+-In Ct-er cnJcwc 7=Killed Pa stiger Gr Cargo Vea 1"talcr !r)ury 11-tn Gpen Area JlakWderate (Back (?f P4 up' Etc) Injury 13=Trading Unit 4.. inor injury ia=Riding On V9hiGe Exterior 2 snjury, Unk I5-Bus ?aUenger 5r",erty 98-Other 9=UnknCwn if 99-Onkoc'671 Injury CC::r..ne used 1.'ict a^piicat?e C I."Ox.Ider Salt Used C ,=L-;3 Bell Used c,__ao A*d ShCulcAtr ae't U;Ad C^iIC Safety Scat Used CS=MCIOr jCe re,rret t,'Sed CSafit to u&'net U!ed lp-Sate 9ttUsed'mr.4wt'1r 1:=rhr So`e!y Seat Used Imp:cpedy 11-1-le:met Used imprcptriy 9C=Res(taint Used, Type UnknG'wn g?-Unknown FCC--None J ed /.rot Ai+Flicabie Oi=front Air Bag DepiDyed (For rhn Seat) 04=Sde Air Sag Dep(oyed (For "his Sea j C3=Cther Type Air B; Depkyed O"Muiliple A& Bags Deployed CS=MororcyC'e Eye Protein CE?i?!ist weanrg Eibcw/Kne&?ads 1C-Arr Bag Not Depoyed, Switch Cn I I.A;, Bag No: Ctplcyed. ;witch Ctt 11=Air Bag Not Ceployed, Unk jw" Sea!ng 13=A)r Bag .Rernoyed ;Prior To Crash) 1'-Unkrown If Air Bag Deployed 99=unknown G=N01^,iicaoie I=Nct l]jected 1=7Otal!y E ?tted 3=Paria.ly iJe?e $-';'Wrovrr ?I cec• .' ,,-,h C?40t E,ecied i NCI A;oiigh1e 1-T1h,r?wgh Side C_o( Opening -1 oL•gdt'Idt wl'rdow 3'iN0t.9h 'N:ndsh:eid 4-Through lack Door 5=7y40ta9h Sack Door 7ailcrate')Vn9 6=Througn Roet CoenirAj Surxaot' CcAwlibie Top yZw 7=Tmpugr. Roo! Cpering (Comer-0 Top Up) 9=Urkncwn O=Nat ADDIicaCie 1aNat Ex7ic3led 2-bIrcited By Mectianical Means 3=Freed By Non • Mechanical Mead 6-O her 9--Unknown w5 Agency: I WEST SHORE EIL1S t& L1_F? atealw( Facmty HERSHEY INfED1CAL CENTER Unit No ft =n No Date of 3 rth (,UM-DD-'yr A 9 C E F- H Ueta!e7 01 U1 O 03 - z9 -11933 WAIF Oil ;r0 rp G ? 0 U Hama / Address / Phene L _ 1 11 Op?rawr EMS TnrsPort ? San" as CO,NN, KATHLEEN A 4907 DELB ROOK, RD IMECH.ANICSBURGPA 17U'1 O Yes O NO Unlt No Perron No Date of Birth (MM-00•Y7 A 6 C G 02 01 Do 1 01 _26 - 1981 aEJ d ?1 U3E 2 aaO Name / Addrtsa / Phone ? Sama as RITCHEY,1'EGAN A 5207 DEEUIELD AVE MECHANICSBURG PA 170 EMS TranfPOr Operator Q 'yPS U NO ; Unit Ho Person No Delete? Date o Birth (MM.DD-YYVy) 02 U' Q Cti - 15 - 1982 7 E] 0 03 03 12 E 1G Oi U^ Name / Address l Phone Same as ANDItEE D1NiITR•4 CARMAN 417 RICKY ROAD hiECHANICSBURG PA 17 FMS Transport Operator O Yes O fro, unit No Person No De Date of Birth (MM-CD-y -) A B v a? =-=- ? 1 I Name / Addrem / Phone Same as Operator F]D? fM5 Transport 0 Yes 0'N0 ff Unit No Person No Dox of Birth (MP,1 DD 'mY) _ A B C? D T E f-- I H I ' 1-T_ E N? ,r DCOl J7ph o,,, F- LJ L'I -- L- _? ? _ __ _7 t?J l? ?' Same a7 _? -?-?-- - --- ---? EhN4 Transport OR9tator CD As 0 No Unit No irorson No Ddatel itdti of t iiin (Mw-Du i r rj - y -- - A fl C G G .?H ?YI u lam- = - E-_--__- r r ! [?C? Nance I Address / Phone -_ El Same as EMS Transport 7 C) Yes (D No MAW r AXZaa iiiiM PENNUOT COPY 1'(Y1?:%; «n,Y?r?.dotF.st:lte,173.us/icOrrs/Prirtlinages,!X in 1Files,/2005 113 6 76 ]GUTS HA LL 1X50,.. 1l /?0''2006 1 ire: T C S 1j(?A 64 / 4 r.4 ? l.'1 COMMONWEALTH OF P%-?4;+!SYLVAj-'qA +11 1 ?11?i i ! POLICE CRASH REPOR71NG FORM Paya Crash %knlw Ugh 0.. V- tk, a ? ?i? Aelatiar)?,y e & a , -- ?; ? Slwynattoo 7 ?r? K'latAer ConoONona Y el _ ? al?Awd Surfri(y fBn4/tksrta t6 ? 13 i ?1 17 e i r _I j 1)=NorwrllIsiCn :`rNeao Cn t An;'e ry piGF?w re d=r ll POQd::N U 1=+?dui E'd 3rA99ar'o near o??C9SN'?9 D ICF?Sf'e :ar9s??.?1 - - ;itspcirq) r-+?- {Sarno rrei;5{cn; ors --- TsFil Fxod CUjoct 9=Omer,"Jrklwr ----- 171 i=On Travel Ljr es Vlopcian 5.0,%-de Tmffcaay :anti __.-- 7=Gce* ;R.arrp +rtert4c gin ) 2 >troulCer 4•RoaCa;(?t 6.In Porklrvq'-ane 9aG0T.,o n Iq 1-Cry 1-'Net 1=i1B•yagM 2=0ark • No Creel L ( ll 1t0 A 'OT9e ondtrs 4=Duek ?iikW jHa!!) 5'?g kc??,v 60140 A Fog 2--Sand. Mud• Dlrt, "? 13-ice Pilo ds BtGtndr 3*3nlow Cowivid 501ce 7=N4V1 - SWding cr mwn 7-.alat, d Fop - 9.UnkrA+m 8-00wr UnFt No 1 =7 a ? I Ol Z ? ? ? rn 3 Pf nd In E?ro SfpvMTiJI n t7nirr 4 l_.. C Harm Eyont Z/R Mott? rUtility Ng Number Unit No t j CD ?-- --? ?- 02 z L I Hasse Put (vents in F? (D 3 SKUeotfal Order 4 0 O Nth ?y Unit No Harm Evont a??f Unit No Harm Ewe Fr. 02 O 1 01 ! 2 0o m npur ?Fd Inivml:;m ? mvipal, Han EnylrottlPMtali Aoedway 1 00 2 3 (mil l?.J DO-None 11.51 Eery Roao Ccndkt cns !IGavSnosv) 01-WndyConditicns IZNStWWnce On Roadway 02-Sudden Weather Conditions 13=r'olholes 03-011lser 1Neathev Cordhorn 14=81o(en Or Cracked Pavement U=Oeer In Roadway 15-TCO Obstructed 05-Obstacle On Roadway 15=Soh 5hDuider Or Shocloer prep Olt 06.Qther Animal in Roadway 29=Oilier Roadway Fa(-tor 07.Gtane 29=other Ent,sonmentai actor 08.i;Nork lone Related 99.Unkoown AnsfGliv Veh1de raih,rei (V) t2.*pAtS i W=Nave 05468us7 13r,0,ivvr Sui,nVCC^COl 01.T;rr% 07=Headlinh t 1 fso(f;. Doors, Hood, Etc 02•Arakc 15y7mm 08=5k?nal lighU 15.Traler witch 03=5teering System 09=01!er Lights 15=Wheels 04a5uspensic, 10-Horn 17.AU1)ag; 015. Power Traai 11 zMi Tors 13=T(ailpr Owrload-J unit Ho _ t ? Z ? 19-Unsecvelsoif!ed Tri!er Lead 2G=Improper Tcvnngg 21.Obstrvnei 1"llnd;hseld U11 It fr) 0 ?---? 99=Unknc'<n 'r t 2 t t."wc*(*4 rvstsr Pc not .7F+1+? Ns nlama:,cn on f/R V D P 0 00 0 X WIN ) AA-Vh t114UT jjI QC.No Conbibutiry Aoicn ol.DrvNWas,srar, d 02=D(i•nng Jsl(1g Hand H6C .Phwe 03=01"Wig Using Ha:ds Free Phone 04a,uakin(J Illegal 1j-Turn CSnmDfWer,Karv1co% Taiping Ob='dm;ng PrOM Wrong lane 07=P.,oC inq WiO Clearance After Stop O8=Running Step Sipge 09=RL,nning Red L'ght 10=Faikre To P_ rid To Cthrr Traff ITon! of N"Ice 11=Tailggatingq 12•Sudden Slcwm topping 13=01t9alfy 5toppr,3 Cn AcaC 14-Careless Pa5i;ny Or Uric Change 1 -Pass ng In No Fix qPort IG=Diving the Wr;ry' Vr'ay G•i 1!Nay Slrret - armfu! EwnTi'Nerm ry" 30.Hil Fence Or Will 01=Hit Urtl 1 1 31=Hit 9ur'ding 2-Hit UNI 2 ?l.Hll CJNCI 3-Hit Unit 3 0 3)-Ht Br* Pier Jr At(nment 04=Hit Unit 4 3L--H0 Parapet Erd 05-KI Unit S 35.80 Silage Hail 06-Hit Other TraNlc Jn.t 36-Hil Boulder Or Dhstac!e G7.iiit Dee( On Roadway C8•14il Dther Arimal 37=4t !mpact Atteruator 09=Collisbon 'Ntn Other Ncn 32.HIt Fire Hyerant Faed Ctwi 39=1-lit Rcadwai Equipment I I =Stn.Kk 8y unit 1 4C.Hil ?,W ?ox 124r,Uck 8y Jroi i 4t=Hit Tratfic IS'and 13.5!n ct By Unil 3 4,=Hit Snow Sank 14=5;rudk 3y'-trit 4 43--H0 ; emporary con4rucE?, r 15=SUU6 3y Und S . Srier 16.5ua(k Sy OInC Trafk Uril 18=14 (}t Yr Fay+,l, "bw ZI-Hh Tree Of SFrutbe, 49=iii! UrxrOwn Faed OL;,E- 22=Hit Emtani,-tn: 51-'.0rtrtu(rvTUI )re! 23=144 Utilil'y PGe 24.Hil Traf ic Sin 5 :St7uck 3y TI':ovm Or Fa!;rg O . 25=H.1 Suard Rail ;ec1 52=Pc: Hoies Or Other 26=Hit Guard Rail End Pavement 4Tguarix5 17.H;1 :urb 53siadnife 28 Hit Con(we Or 54-fire In Ver,!ce Longitudinal 3arner 58=0""v Ncn.Cpliwon 29114 Citch 99-Urknown Hamful Event Unit tar, r.itnr Cad. 01 ll? JI EiR is th0 yrrima Fart^! Type' lvavv 'JnR .MO ti'snk 17-carelen Or Ak9al Backing On Roadway I8=Dr,ving On "he d/rong Side O(Road 19•I'Aaking tmprcoer Er.lianc! To Higlway 20=Maknq Impruper rxq I" Highway 21=Careless Parke irvrking 22=Over/Under CnmpensAvon At Cure 23=Speedrq Z4.DrMng too Fast For Con6tions 2511 To NUmtIn Proper Speed 2E=Dnver Fleeing Polict+ Tol Ch") 27-Drne( IrvPererced Z8=r3ilure To l)se Specia'in?d Equip 92=Affected By Physical Condition 98006er Imp(ope• Driving A(;onS 99a'nkn0wn Molt o I oo z= 3= 4 Not l02 1 1 F677 Z 7-1 9 d ?--- l I tLlt y4?_Ar4!anz 03nv;Q!king - CO-K;ni Ga?PuJ,ing vehicle Ui?Fntorrki Dy t_rp:SirH3 iy SFeulied ir;Cetion ?:-_."w'r; •.•:?:,;;h7 C; LCVO-.v ,•? ?.3t 0'.=Wprurg On '?2h::¢ C2-V:a:kin2, hunninp. kr,yu?p, 07=5!ardirg Oi Play?rg 9¢ Clydr 99=.Unknov:n Unit No Unit No r 2 FQQ__1 PENNI) )T COPY ht-tp:IhrvAv.dot6.state. ?rs.us;ions;PrirltITnu??;: ?TnlFiles,'20061136761GUT5HAU19ti - 11%30/2006 ?-IinT CRS 0646474 COMNION'MEALTH OF PENINS'! IANIA POL:CE CRASH AFKATING FCRM A ?! PS?Jtl Alk 500 5 al- L4e 011Y Operator #2 stated she believes the tr attic signal was green at the time of impact and that she never saw pedestrian.#1 prior to impact. Qperator #2 stated she stopped her vehicle immediately aftsr impact with pedestrian #'. Wfness #1 was driving tier vehicle vast boun d on the Car'isie Pike when she saw pedestrian #1 running across the pike from the south side. Witness #1 then observed unit #2 strike pedestrian #1. Witness #1 stated she thinks her light was green and that she could not felt if pedestrian #1 was in the cross walk prior to impact with unit #2.. Unit #2 was charged with Driving Unregistered Veh icle and Driving Without Certificate Of Inspection VvAne# A*4xCI M PENNOCT CUPY ,'"7C^Gia ?ra?n .Jumd 1,tiT?;/i1?ww.dot6.state.pa.??s/icons`PrintIrnag s/?smIFiles") 00611.36761 GUTSHALL1950.., 111302006 )d ,,dry C' Q:R"fSs'--n. y7J9 3d? T2ritfr?T?'l'.19?;d al ? !?' ? ? ?I I ? Cs> ? }i "wc'? ? QCs ?Js1Cte'J t%A 500 F t aw " - Pa ro Raw C chmqei Ca. TrMt".or, ! 1 G»ah .VSart>y lV-1045•i' ; ? ? Tbw O Bnck or Sixk birt I? kn- W A ' 0 Miiitdry -0 Dther Fedeni AS Sag C] Caflatlut 5ld), Gravel or C + No Speclai C:) Indian.ierervation Q ?her ;urisdsa!!on O Other O Blad=p StcM 0 Unknown I CdI eAJ :y '1 Natiatal Park Q ?7 spus n.vervtf O Unitnlo n w Carr Me4v tptTi?lltt Untt Information for &a* smK mvo^ntd lr a fatal <rmh. Cc no: Went the lntormation in tre flsldf 3bo++e on m.,hipJe ;m9e!5. unit No h*?Gple bee Pont Q 0 O CD Non-Colliilon 1: 1 ` 0 Drfrerl?a?1[Ef4ru Resuictiors O il ' i Hat a Per;r;syivtnia C) O Top O1C 0:0 ed N Comp th (z) No RerarlctlorW ? CAmprii*d with Dryer Q Conskis?Jioat to I O Underrirrfage g 03 ? ^0 Q Not AppNr2hle Q CnDMpn&an ct 0 Towtd Unit 040 U n 07 06 OS LYlver I!ndCe"Wn't 0 Complied With O Not a nnsylvania Driver Pe 0 Unknown. 0 Q 0 Q Requlied - Non Compliance O? Unknown C ii Avtplda/rnr Manrutrri O NoM Raquktd zs omp ance Required liam Vnkn(mn Q Com No Avoldarv2 0 MaMYKr Braking Other Q Other Avoidirtt 0 p Evldene Maneuver P?_ Not Required for O VeNds Class Unk I C)L or CT)L Required MarysE O Brakingv• Skid ddrt O StNrlnq . ;Wdenct O Inca or )rlver Stated ndusi?e O No Valid Licertse for Clan Q Not a ?Iennsyivania Driver Braking - No Skid O Marks, Driver Stafl Q n9 Ind 8raklng C) Unknown O Not tlcarssed O Valid Llrme for n O unknow Statra U•ndewe a Stated Claim Ursolat.Rlde fixs'rator OrV4 Teif T1t+e Q Blood CD Other No Underridt or O Cndadde. Na ldt, Ot?ur ? rtmertt Q p 0 mom O Ur!ne O Unkrv»wr q Test Gvcr de V e o im Given Drug Tait - tllO'm room Rew? H T i 0 Underrlde, 0 IM./VO rtrnent UrderTlde, Unknown if Q Compartment O Underride or Intrus,on Unknavm Dxrride W G a O ven S • Amhetamirtn 1 c Ho Dru t ? t L J g prx 2. kla?i ueM . o 3 iat iat 4 o tt 6 , p 8 ¦ Dthcr 9 = Unknown Test D ? f-TM Uti Not in Emerger cy .?? 0 Both LI Q Lights Mashing O ghts and Sinn p es p es s Resuftz ILL _JJJ Use O 5iron cundirq Q Unknown Unit No i1row naltrittwou © Comp) tednMh Q Not a Pe v rylvunia Driver 0 MeNot Resione Rosttlctlons Nut O Complied With Unknown 0(pn plianct Compliance C] unknown t Q Required - Complied NnW (] Not a Pennsylvania Drhrer CD Norse Required 0 Required - Non Compliance O Unknown Compllanct c r, CarripUance Vnknnwrs 7 p 1 e O nvc rtcqu+rea nor Vehicia C14s4 Q Unk if CDL or CDL Required o Wild ucen" N O for CI -A Not a Penn Mania O ry Q Not Lxeowd . Valid ticeryt for © Driver Q Vnknown pass -T (7 Blood Q CI!her T 0 None (D Wine C-) Unknow !f 7rst Given r.' t e'i nr•zy:s -Ex, to 4c,;- +:3t?iia . o = No Test Given Am hel mi S I ? U p . e ne% 1 = No Drug Rtpatrd 6 = PCP L ) 2 . MKzlr)tne 3 rCsssain v e U •. t?ihar 9. Unknsnvn rh-t I C? 6 o Upiata Resuhs L_ TV4Qj tAA-asxrom tr? L MW- Wnt O NorKol!ision d - - 11 12 O OI - - O tp 02 G O Top O Undercarriage d 09 030 O Towed Unit Q 09 fi 4 C) .x+ ' © Unknown 0, .. 05 O © 06 O Avvklartae Ra oyr d No Avoidance Menetsver Brakin Other Q Othtr Avoidame O Uvideng © Braking • Skid M k E i e Maneuver Steering - Evidence O ar s v dent or Driver Started ?? InconcluJvc Braking - No Skid O Marks, Dave. O Steering and 9raking O Unknown Stated Eviderxt at Stated No Underride or O Urdenlde, NO Compartment trvenlde, OshcJ OOve Override Intnnlon icio Underridt, O C)mparu' e t Underride, C7 CL)rr.pannlent Unknown if O Underride cr Intruslorl Irt"jon Vnknewn Override r2tILNy Use - ,? Lights t13sh.n0 Rats l _ is 7h ar;d O O Not in Er.4ry#rv.y Use O Siren Sountl ng Si,en n Unknown PENNDOT COPY ]?ttn:!hwtr?w-dotE?,s±z?te.pA.us/icons.Prii?tzrna?;zsi'XmlFilesl20061 1 36761 GUTSI TALL 1950.. 11 /30%2006 • 1 ?' CRS ??'U•t?,i,-l?-1 pci ja 1.'1. ;? aactYi??a FORM AA 5X Ni Unit No For Answers to the barkrw (*Xcept for Engine Englnq Size Nawllv?tau? Tht j r sj l ?j i ? Passenger ('`' I 1 I MC Educa6cir) n t _ Saddle ? 8aq and/ or Trunk Trailer r?',3Cf;' r.; 1 11 i?qk C- new 1Croak Nutrtok Qianga! W'7'46-174 Size ar•d K,irst Type) U" It• fo4crwMng md*s; 'f = yes N Y NA U , '1rJr e.n C pdSxt? tcG any hLttt ? e0ummLP'out-l t4ti tit,"cw r? U EJ3 Prpte,ticr, a 0- No He:rnet I = cull ;ielrrvt I Ey*?rpQr!ion 1•?? 0 = 7(,-Qlrnet 1 = , gdClM. , 2, 314 Style 1, 9rairflz J I lCng S!e^ves 3, r'af Nelrner Sty:t ?--y U Long :sleeves 3= Ha'veiTt! k $T t_ + Long Pants ? 9 = Unknown 4elmet Slay Cn? Q Long Pants j 9- Urr cAvn ? Helmettlay On? I 1 Over Ankle Bocu l J 1 1 0 Helmet has DOT or Small ? Otter Ankle acots f'^'1 Fleirret'rs I ! Got or N-g i Designation Cesigruton II Untt No Use t$j Y = Yes PrSengtr7 ? F elmel? Unk No Ufa n N. W Y n Yes - No U a UnknCwn Head N Rear U = Unknawr Ughts7 Werors? Utill No 77 I&OIA Q fes Q No O Npt at Wersec,ort 8b*,Wl10 92&N CL'gftt Q park d Re&%C%V Q Unknown ur 01 ¦ Matked Crosswalks at 'nter &tcn 07 = At nteruc0on . No Crci5w,3&s 0,1 = Ncn•Interwtlot CroSiwaiics 04a Drneway Access 05 = In tcadway 06 . Not in Roadway 07 = Median 0$ - !Stand 09 , ShOUldtr 10 = Sidewalk 11 . c 10 Feet Cif Road 122 > 10 Feet OH Road 13 - Outside Traf Kwey 14 - Shared ?atfu/Tra is 99 a Unknown Unit L -- &tffNAl11&Ab Q Yes Q No CD NCt at Imargv.:on h4umba-aolbia, C' ugi t C> Dark CD Reiecy've 0 Unknown ? P),Mnger? L1 Hegnxt' o Head Reaff Lghtsl ? Atr!ec'o^,7 I I Of ¦ AMnrked CYxlwalks at krltWoon 02 a At !nterlectitxt • No C Vs lj cS 03 . Non•Irftrwbori Crt741walIC 04= ComwayAC-M 05 . In Roacway C6 , Not in Roadway 07 ¦ kletian Q = wand 09 • shculdor to. sidewalk 11 , c 10 Feet Off Road 12 - > 10 Feet Ott Road 13 , Cubde Traf icway 14 = Shared PatW,,ails 992 Unknown J47p i *him hill W04 Zone I ? tarv Clo"We? Consttuction 0 Before 1st work zone (Lw.g Tern) Warning Sign Ll ft Road •mth CkeA Wainteran(x Q i3hu1 Term) Q Advance Warning Area (Mark all that r? DeCU Wait on SFouke' r v Q Transition Arta 0 Yes apply. If not 1 inro rx d or Medan? Q utility Company 0 A1MV Area O Yts 0 No h or Ur know. ave ? kbii6rtiCnt t ? n9 4VCrk Q Diher ? TennirtaWn Area C] No Q uw,(,m tuank) ? FU9geT Centrop 0 Other 0 VnkncW.n ourer E] lE nwru, wA400fil(MM PENN1371 COPY httt):,'., ww-v,dot6.state.pa.as/icons, PrintImagesixinTiles/20061136761 GUTSHALL 1950... 11 !30i2006 ant CRS W00464'74 CI-d3h Number: V`1C046-474 lr,cident Number: HAM20C61100352 HLN7 p!;- Vll O ?J /'?M ?? . `AN PATT0 0RlVl? 4400 8LP ? RLISLE (l i I I ? I ? r ?;e iJ I C rl m .fs. s fGl ?'??ir?1tKS NOT To Mtn://ww-w.dot6.state.na.us/icons;'PrintImages/xm?Pilev'20061136761 GUTSIIALL1950,.. 11 /30/'7006 -1 D i _'1 7 ,h, llTH -- ..JEFFREY A. FUNERAL NOME NORTH AMBLER STREET, QUA;KERTOWN, PA 18951 -WHERE MEMORIES A,?E SHARED STATEMENT June 25, 2007 • Mrs. Kathleen Smith 425 S. Main Street Telford, PA 18969 - ?' RE: Kathleen Ann Conn Date of Death: November 12, 2006 Form o.f Received From Pu nue?nt Amouirt or Ch.eei? # nA!e PAUL paymen t t7awn Bishop .Harleysville Nat'l Bank Harleysville Nat'l Bank Harleysville Nat'l Bank Harleysville Nat-1 Bank Harleysville Nat'l Bank Harleysville Nat'l Bank Harleysville Nat'l Bank Check Check Check Check Check Check Check Ch '6000000095 6000000100 6000000105 6000000108 6000000112 6000000117 6000000120 Nov 15, 2006 Dec 28, 2006 Jan 23, 2007 Feb 23, 2007 Mar 23, 2007 Apr 24, 2007 May 23, 2007 Jun 25, 2007 2, 227.7 5 9,04 319.04 319.04 320.00 320.00 320.00 320.00 Total ofPaymrnts: $4,464,8' TotaICostofFunerat: 3G,OJO.L?2 ?? Late Fees 4,ccrved: Balance, $1,702.2 9 TERMS NET 30 DAYS. A service charge of I% per month or an ANNUAL PERCENT OF 12%?is applied to the unpaid balance beginning 30 days fronathe date appearing on the payment agreement. (SI iR Q UI R)IDIRECTOR) --(Seal) OFFICE u f f?,MILY SERVICES MAIL To; TREFFINGER HOUSE (215) 536.3343 P.O. EOX 13 7 00-; ?-? 4 , 1 24 N. AMBLER STREET l?1 :A?'Pi?7rlinini nn `,' ..nom .._._ `1_. _?_U U4: 4h V15? 1')Jt1, N.i Tr-{ ID • 8uns,A Momorfai Pa l< Cl W!l;ide Cematory Contract No. ecr?,B b"JAahin;ton Memorial Part(.. Contract CCda - ?` r r THIS AGREEMENT made this da y of by and between The `tereinrr."er called "Seller" and PURCHASER TELEPNrJ tIF- . ADDRESS r Street City , state L;p Coda ? Mama of Decoased: , S f' • ` ffV ?'VN^ ? Description of Interment Rights: ?` ?r J -- f' f - Property Owner: J'~:;•??';; ; ` Burial Rights Interment Fees r i L '. i'' 1 { t 4: r 1 Memorializatlon - Type , Size Memorial Base - Type Size Color. Memorial Installation/inspectlon Fee Outer Burial Container - Material - ? "?" plod It, Supplier Urn Type Size Flower Vase - Type Lettering Other Processing Fee Sales Tax TOTAL CASH PRICE LESS: Dcwn Payment Cash r Other Credit i Total Down Payments UNPAID BA.ANCC OF CASH PRICE 60.00 f .' Zllu'Cn;sEr agr9Ag tFijt ail riy^r,ts conveyed undor this Agreement are aubjrwt to, and P?xottasor t,o hereaNer adepteC amended or altereA,Aulas, Regulatlons and ageas to at as times c0ew terra ;x;. +r ! (-'r?'• as ro.i; 8ytaws o1.r?elier, whiff era available for ex:unina_t_im cxi in in E6tler's G'fi-w ed this day of Porches.: :??~? - ; -- r Design 11'4_1! Ua:?lb "IF ' ;?_! -- S"-1_T1 F -. (lye LAND ! t ONUMEA t k a Y. 0. Bo v,77') Qt1tl?:eztli,l?1, PA 1892 i - - ,'hone: _2 I S-??-031 S , Tax: 1 -5 ?6-.1 O90 MARKER ORDER f6- t>rde.red 2k d&e&S: I.,stall at: f' ?''`+s rr?? l+r 4 '' ?J 1 V ) ;' Alterllate Phone:: ? Dcsl`n T, - - Granite Re Ted B-v ' Granite Color: j -- Base Size: 1 ,L}Y< J'4L?7? t.?R?aSS MARKER, BEVEL MARKER ?Jarker r c Top: SERPENTINE, OVAL, FLAT Sides: ROCK, SAWN, MANTUFACTURERS CHOICE Top: POLISHED, STEELED All fl0l'al carvings will be shaped zzll ss ot?lerrk-ise sl,ecif La- out: SCALED DRAWING, FULL SCALE .DRA.'W IN G (at additional mst'l ENLACTLY AS SC.'MMITTED. FOR BEST COMPOSITION SKETCH If not idctiUca- ] to specified desigla 11LL111ber. Be sure to print clearly and place na,lles JU COITCCt position (i.e. man. on ricllt? On. Special instructio;ls: h:1.Qlllll1C'.1?t: ut1 r.f- />,"- - Other: ffi ,(?r,• S ubt1)mI Repo: It 1S Understoc,J th,a a 501% d,,1)oSit i$ rkgWi-ed at tale time o! qureenicilt ands Prior I0 r<r ?` -' a y pr?r:t aG:m or drays No store or fourdatiorl will bt ordered prios'to this. The purchaser or appoilited atent there-cf X1 i11 Ste a reduced drawing whin trust be approv4:d and sirmcd by tbein before any work will bfyill.:i11 ntemot'ihls tstilst be p.lid ill full p1"ior to installatin>_1. J-0r out of state purchaser, a pll XQ will be yell t for a 1)i r01'iil rl! 1 Pa,,'111ent received prior to im;mlliitlon- Any' add1t1011s. changes, ol- C?_)11'eCt1011S, Of el-TOI7_C4i5 data ltii?iCl1 v trt' ?]'1?rC?v rl must be r1c 1CE 1C=r prlpl f t ins',allation. It is assumed that any Mist,-J Ccs or ?rj t)l ;` ',were not according to the approx';d L'jl',:zving will be corrcetcd by the Seiler z ccc,rdin? to industr?° ?? lc It;r is. ?r11,1npal - 1b811tice"; t113t are. approved are subicct to a 2%, i7:r month flnzin,C r har` - if llljt la; r ij "o . S. i agre° to tht tern-Is of this colitl-act: , Date: '2-( 1.1: IN RE: ESTATE OF KATHLEEN ANN CONN, : Deceased, by KATHLEEN A. SMITH, Administratrix, Petitioner IN THE COURT OF COMMON PLEAS"`' CUMBERLAND COUNTY, PENNSYLVANIA NO. 10 : ORPHAN'S COURT DIVISION PETITION FOR APPROVAL OF MINOR'S SETTLEMENT FOR WRONGFUL DEATH ACTION Order AND NOW, this 7' day of February, 2008, pursuant to Pa. R.C.P. 2039 and 2206, and upon consideration of the Petition for Approval of Minor's Settlement for Wrongful Death Action, it is hereby ORDERED that the Petitioner is authorized to enter into a settlement in the gross sum of $15,000. Petitioner is authorized to sign the Release attached to the Petition as Exhibit (C' J.1) The settlement proceeds shall be distributed as follows: TO: Schmidt Kramer PC, $2,500.00 as attorneys' fees (1/3 or $835, of which, is to be paid to Michael Bangs, Esquire as a referral fee). TO: Schmidt Kramer PC, $2,138.51 as costs. The balance of the settlement is apportioned as follows: Wrongful Death Action: TO: Kathleen A. Smith (for final expenses) $5,000 TO: Aidan R. Self, minor son of Kathleen Ann Conn, $5,361.49. Said sums payable to the minor shall be invested by Justin R. Self, parent and natural guardian, for the minor. Said sum shall be deposited in compliance with Pa. R.C.P. 2039(b)(2), by Justin R. Self, parent and natural guardian. Each account shall be marked as follows: "This money shall be held in trust, not to be redeemed, except by Order of this Court, before May 5, 2023." The law firm of Schmidt Kramer PC shall oversee the execution of the preceding paragraph. BY THE COURT: J. 'J A TRUE COPY FROM RECORD / In Testimony wherot, 1 hereunto set my hand and the seal of said court at Carlisle, P A L 20 i d ay of - of court cu and County ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF In Re: ESTATE OF KATHLEEN ANN CONN, DECEASED BY KATHLEEN A. SMITH, ADMINISTRATRIX CUMBERLAND COUNTY PENNSYLVANIA NO. 21-07-0108 CERTIFICATE OF SERVICE OF ORDER ORDER DATE: JUDGE'S INITIALS: TIME STAMP DATE: IN RE: ORDER .............................................................................. SERVICE TO: SCHMIDT KRAMER PC METHOD OF MAILING: ® USPS ? RRR ? HAND DELIVERED ? OTHER MAILED: 02/07/08 ENVELOPES PROVIDED BY: ® PETITIONER ? JUDGE ? CLERK OF ORPHANS COURT ............................................................................................. SERVICE TO: METHOD OF MAILING: ? USPS ? RRR ? HAND DELIVERED ? OTHER MAILED: ENVELOPES PROVIDED BY: ? PETITIONER ? JUDGE ? CLERK OF ORPHANS COURT Deputy i Clerk of Orphans' Court I 1?'C°_Benefits A Summary of Primary and Secondary Plum This chart summarizes primary and secondary plans when both plans have a coordination of benefits provision: You Your spouse Your dspwx* t cltil mn) `flour group plan spouse's group plan Plan of patent whose ttlrthday fags first in the calsrxlar year Nan Dup i 'on of Medicare Benefits Spouse's group plan Your group plan Otlter parent's plan If you are an active employee age 65 or over and you wish to remain covered under the Tyco medical plan, the Tyco medical plant wig be your primary medical coverage and Medicare Paris A and S. d you are enrolled, will be your secondary coverage. 9 your covered spouse is age 65 or over and is covered under the Tyco plan. the same rules wig apply. You. may choose to elect Medicare instead of the Tyco medical plan. ©ection of Medicare as tie primary plan means coverage under the Tyco medical plan will termlfiate for you, and your spouse. I covered. If you or a covered dependent is covered by Medicare by reason of end stage renal disease and you are also covered under the Tyco plan as an active ernpbyee or a dependent of an active ernployee, the Tyco plan will be primary with respect to Medicare only during the first 30 months of Medicare coverage. After this 30-month period, Medicare wig be the primary plan and the Tyco plan will be secondary. In addition. the Tyco plan will pay benefits as though both Parts A and 8 of Medicare apply. K a Third Party Ls Liable Right of Subrogation You, your covered dependents fincluding your spouse. dependent children, and any covered plan member). or your legal representative may have a claim to recover money from a third party (such as an automobile insurer) for a claim that arises out of or relates to an injury for which the plan provides oenefits for you or your covered dependents. As a condition of receiving benefits under the plan. Tyco or the plan has the right to recover any claim payments it made from that third parry. This is called the right of scrbr Lion. -W -W 4ft 1? Your oenefits from Tyco's medical and dental Mans are coordinated with other benefits you may be ef9tile to receive to ensure that your total payments from au sources do not -axceec Tyco's regular berrsfi't. This is called coordination of benefits (CO81. 14f Payments that may be subject to the right of subrogation include payments from uninsured motorist coverage, underinsured motorist coverage, medical payment or reimbursement coverage, personal injury protection :;average, or payments from any other entity or source intended to compensate the covered person on account of injuries sustained as the result of the act of the third party. If Tyco or the plan is not allowed to exercise its right of subrogation or chooses not to do so. the company or the plan may still, at its discretion. choose to pay benefits under the plan. In addition. Tyco or the plan, at its discretion, may choose to exercise only the right of reimbursement under the plan. Right of Reimbursement As a condition of receivbng plan benefits, you must reimburse Tyco or the plan for any claim payments for which you or your legal representative is paid by a third parry or its insurer because of the third party's Liability for an injury or illness, up to the amount paid by the plan on the claim. This is called the right of reimbursement. Procedures for Recovery You must cooperate fully with Tyco and the plan when they exercise their subrogation and reimbursement rights under the plan and shall do nothing to prejudice those rights. In addition. you or your legal representative must inform the Plan Administrator in writing when making a claim whether or not you were injured by a third party and provide the following information in a timely manner: • The name, address, and telephone number of the: - Third party that in any way caused the injury as well as those of the attomey representing the third party; Third party's insurer; - Attorney who represents you with respect to the third party's act; • Prior to the meeting, the date, time, and location of any meeting between the third party or his or her attorney and yourself or your attomey; -All terms of any settlement offer made by the third party or his or her insurer; • All information discovered by yourself or your attorney concerning the insurance coverage of the third party; • The amount and location of any funds you recover from the third party or his or her insurer and the dates on which such funds were received: • All information related to any oral or written settlement agreement entered between yourself and the third party or his or her insurer: • All information regarding any Iegal action that has been brought on your behalf against the third party or his or her insurer; -All other information requested by the Plan Administrator. o ce eiigible to receive benefits under the pear. you or your legal representative must sign ano return a written agreement to subrogate or reimburse Tyco and/or the plan and comply with the subrogation and reimbursement terms of the plan. The plan has the right to discontinue payments and to bring legal action against yourself or your heirs, guardians. executors. or other representatives to recover benefits already paid. if benefits are paid under the plan to you or your legal representative and you or your legal representative recover a settlement, judgment. or other payment from a third party or his or-her insurer, Tyco and the plan have the right to recover from you or your legal representative an amount equal to: • The amount the plan paid, with interest at five percent per annum, or • Whatever lesser amount is recovered. Any funds that you or your legal representative recover must and are deemed to be held in trust for the benefit of Tyco and the plan to the extent of the amount of plan benefits until reimbursement is made, with yourself or your legal representative as trustee and fiduciar)4 as defined by ERISA (see page 155). Neither you nor your legal representative may retain an attorney with respect to the third party without the prior agreement of the Plan Administrator. Each covered person and that person's legal representative hereby waive, as a condition of receiving benefits under the plan. the assertion of any adomey/client privilege with regard to the third party. Neither Tyco nor the plan will be responsbe for any expenses or fees incurred in connection with any sums you or your legal representative recover from the third party. Continued Coverage Under COBRA (W-dical Coverage, Dental Coverage, and Health Cane Relmbursesnent Accounts) Under the Cor sa*MW Omrntus Reconcdation Act of 1985 (COBRA), you and your elm dependents may contnie ycxx coverage if that coverage ends under certain cimurnstances (called "qualifying events"). You and your dependents may continue coverage for a certain period of time by paying the full plan cost plus an administrative charge. You and your covered family members each have an independent right to elect continued coverage under COBRA without providing proof of good health, if you decide to continue coverage, you will receive the same coverage as active employees and their duets. You must elect continued coverage under COBRA no later than 60 days after the date of your notice. If you do not elect continued coverage within this 60-day period, you forfeit your right to continued coverage (see Electing Continued Coverage for more information). After you have elected continued coverage, you have the same rights as active employees to add dependents and make other changes to your coverage when you have a qualified change in status. You are also eligible to make changes to your coverage during annual enrollment. You, your spouse. and your eligible dependents and any children born to you or placed with you for adoption during a period of COBRA continuation coverage are qualified beneficiaries for purposes of coverage under COBRA. 151 CZI-1 ACS Recovery Services P.O. Box 4003 Schaumburg, Illinois 60168-4003 A C S October 21, 2008 Mr. Soctt B. Cooper Schmidt Kramer, PC 209 State Street Harrisburg, PA 17101 Claimant: Kathleen Conn, deceased Our Case ID: 8520347 Our Client: Tyco International (US), Inc. Date of Loss: 11/12/06 Dear Mr. Cooper: T - 847/839-7700 F - 847/839-7204 www.acs-rs.com This letter is written in follow-up to our telephone conversation today. As discussed, we maintain our position that we are entitled to full reimbursement of our $38,335.77 lien. However, in the interest of resolving this matter amicably, we are willing to accept $25,000.00 as full and final satisfaction of the lien and claim for reimbursement. Payment in this amount may be issued to ACS Recovery Services (Tax ID: 36-4129784). You have indicated that you may be in agreement with this proposal, however, I do understand that the settlement will require court approval. Pursuant to your request, I am enclosing a complete copy of the Summary Plan Description. You will note the plan's subrogation/reimbursement provision is found on Pages 149-151. If you have any questions, feel free to contact me directly. Very truly yours, Sandra J. Manaois Associate Corporate Counsel (847) 839-7748 Erie Insurance Exchange Erie Indemnity Company, Attorney-in-Fact Member Erie Insurance Group • www.erieinsurance.com Home Oftice • 100 Erie Insurance Place Erie, Pennsylvania 16530 • 814.870.2000 • Toll free 1.800.458.0811 Fax 814.870.3126 January 22, 2007 Charles E. Schmidt Jr., Esq. SK Law SchmidtKramer PC 209 State Street Harrisburg, PA 17101 Re: ERIE Claim ERIE Policy • ERIE Insured: Date of Loss: Your Client: Dear Attorney Schmidt: #010170892461 #Q10-0407835 Justin R. Self 11/12/06 Estate of Kathleen Conn I am Jeanne A. Kidder, Property & Casualty Records Coordinator for the Erie Insurance Group. I hereby certify that on November 12, 2006 the enclosed Declarations, policy forms and endorsements were in effect under ERIE Policy Number Q10-0407835. These are true likenesses of the documents issued to Justin R. Self. Sincerely, W_Y'j? anne A. Kidder & C Records Coordinator Litigation/Claims Examination Dept. (814) 870-4202 /j ak Enclosures: 1. Continuation Notice (10/4/06 to 10/4/07) 2. Pioneer Family Auto Policy, FAP (4/97) 3. UF2106 (5/01), AFPNO 1 (10/98), AFPA03 (4/03), UF2345 (7/06), AFPUO 1 (7/06), UF6853 (7/06) Sworn to and subscribed before me this A-4ay of January, 2007. NOTARIAL SEAL THOMAS J. KRILL, Notary Pubiic Cky of Erie, Erie Count' My Owwftslon Eom Mamh 24,21W Notar ublic The ERIE Is Above All In Services We commit, care and serve. IVs our true blue promise. r? ?? ERIE, Policy 010-0407835 Declaration effective 10/04/2006 ERIE INSURANCE EXCHANGE PIONEER FAMILY AUTO POLICY CONTINUATION NOTICE AA-7507 SHINER INSURANCE AGY. PC JUSTIN R SELF 4907 DELBROOK RD MECHANICSBURG PA 17050-3093 AGENT - SHINER INSURANCE AGY PC +++++ 10/04/06 TO 10/04/07 Q10 0407835 H 1001 S. MARKET STREET SUITE C AGENT PHONE - (717) 766-1200 MECHANICSBURG PA 17055 4"148 ITEM 4. AUTOS COVERED AUTO YR MAKE VIN ST TER SYM RATING CLASS DDP 1 01 HOND ACCORD EX JHMCG66871C000889 PA 4D F C13 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 254 PROPERTY DAMAGE $100M/ACC 239 FIRST PARTY BENEFITS- MEDICAL EXPENSE $5M 79 INCOME LOSS $1M/MONTH, $15M MAXIMUM 23 ACCIDENTAL DEATH $5M 3 FUNERAL BENEFIT $2.5M 1 UNINSURED MOTORISTS COVERAGE- BOD INJ $100M/PERSON $300M/ACC-UNSTACKED 15 UNDERINSURED MOTORISTS COVERAGE- BOD INJ $100M/PERSON $300M/ACC-UNSTACKED 95 PHYSICAL DAMAGE COVERAGES- COMPREHENSIVE - $50 DED 156 COLLISION $500 DED 402 TOTAL ANNUAL PREMIUM FOR EACH AUTO 1267 TOTAL ANNUAL POLICY PREMIUM $ 1,267 ITEM 6. APPLICABLE POLICY, ENDORSEMENTS, EXCEPTIONS TO DECLARATIONS ITEMS ALL AUTOS - FAP 04/97, UF2106 05/01, AFPNOI 10/98, AFPA03 04/03, UF2345 07/06*. AUTO 1 - AFPU01 071/06*. ANTI-THEFT DISCOUNT APPLIES-ALARM AUTO 1 AUTO/HOME MULTI POLICY DISCOUNT APPLIES - AMOUNT OF DISCOUNT IS $ 126 PASSIVE RESTRAINT DISCOUNT APPLIES - MULTIPLE AIRBAGS AUTO 1 ANTI-LOCK BRAKE DISCOUNT APPLIED AUTO 1 * THE SURCHARGE FOR THE 05/17/06 ACCIDENT HAS BEEN FORGIVEN * UNDER ERIE'S FIRST ACCIDENT FORGIVENESS PLAN. EXPLANATION OF ADULT &/OR YOUTHFUL DRIVER RATING CLASS AUTO ]-OWNER/PRINCIPAL DRIVER AGE 23 MISCELLANEOUS INFORMATION Policy Q10-0407835 Declaration effective 10/0412006 Page No: 2 ITEM 7. EACH AUTO WE INSURE WILL BE PRINCIPALLY GARAGED AT THE ADDRESS SHOWN IN ITEM 1, UNLESS ANOTHER ADDRESS 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* ST I JUSTIN R SELF PA 2 KATHLEEN CONN PA *IF A DRIVER IS NOT A RESIDENT RELATIVE AS DEFINED IN YOUR POLICY, COVERAGES, BENEFITS AND RIGHTS MAY BE LIMITED. REFER TO YOUR POLICY AND ITS ENDORSEMENTS FOR TERMS, DEFINITIONS, LIMITATIONS, REDUCTIONS, EXCLUSIONS AND CONDITIONS. ACCIDF OBLATIONS SUBJECT TO DEFENSIVE DRIVER PLAN (DDP) A7'FiLEEN CONN FFN ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE OR DEFRAUD ANY INSURER FILES AN APPLICATION OR CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION SHALL, UPON CONVICTION, BE SUBJECT TO IMPRISONMENT FOR UP TO SEVEN YEARS AND PAYMENT OF A FINE OF UP TO $15,000. 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. # 1 BODILY INJURY $15M/PERSON $30M/ACC 88 PROPERTY DAMAGE $5M/ACC 202 FIRST PARTY BENEFITS - MEDICAL EXPENSE $5M 48 Q10 0407835 INVOICE INFORMATION: DATE DUE PAYMENT DUE -------- ----------- 10-04-06 316.00 01-04-07 322.00* 04-04-07 322.00* 07-04-07 322.00* UGR ERIE ERIE INSURANCE EXCHANGE INSURANCE PIONEER FAMILY AUTO POLICY GROUP 100 Erie Ins. Pi. CONTINUATION NOTICE Erie, PA 16530 ME. AGENT ITEM 2. POLICY PERIOD POLICY NUMBER AA7507 SHINER INSURANCE AGY PC 10/04/06 TO 10/04/07 Q10 040.7835 H ITEM 1. NAMED INSURED AND ADDRESS ITEM 3. OTHER INTEREST JUSTIN R SELF 4907 DELBROOK RD MECHANICSBURG PA 17050-3093 AGENT - SHINER INSURANCE AGY PC ***** AGENT PHONE - (717) 766-1200 ITEM 4. AUTOS COVERED AUTO YR MAKE VIN ST TER SYM RATING CLASS DDP 1 01 HOND ACCORD EX JHMCG668710000889 PA 4D F C13 ITEM S. 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 $10OM/PERSON $30OM/ACC 254 PROPERTY DAMAGE $10OM/ACC 239 FIRST PARTY BENEFITS- MEDICAL EXPENSE $5M 79 INCOME LOSS $1M/MONTH, $15M MAXIMUM 23 ACCIDENTAL DEATH $5M 3 FUNERAL BENEFIT $2.5M 1 UNINSURED MOTORISTS COVERAGE- BOD INJ $10OM/PERSON $30OM/ACC-UNSTACKED 15 UNDERINSURED MOTORISTS COVERAGE- BOD INJ $10OM/PERSON $30OM/ACC-UNSTACKED 95 PHYSICAL DAMAGE COVERAGES- COMPREHENSIVE - $50 DED 156 COLLISION - $500 DED 402 TOTAL ANNUAL PREMIUM FOR EACH AUTO 1267 TOTAL ANNUAL POLICY PREMIUM $ 1,267 ITEM 6. APPLICABLE POLICY, ENDORSEMENTS, EXCEPTIONS TO DECLARATIONS ITEMS ALL AUTOS - FAP 04/97, UF2.106 05/01, AFPNOI 10/98, AFPA03 04/03, UF2345 07/06*. AUTO 1 -'AFPU01 07/06*. NTI-THEFT DISCOUNT APPLIES-ALARM AUTO 1 UTO/HOME MULTI POLICY DISCOUNT APPLIES - AMOUNT OF DISCOUNT IS $ 126 ASSIVE RESTRAINT DISCOUNT APPLIES - MULTIPLE AIRBAGS AUTO 1 NTI-LOCK BRAKE DISCOUNT APPLIED .AUTO 1 1001 S. MARKET STREET SUITE C MECHANICSBURG PA 17055 4748 * THE SURCHARGE FOR THE 05/17/06 ACCIDENT HAS BEEN FORGIVEN * UNDER ERIE'S FIRST ACCIDENT FORGIVENESS PLAN. ******************************************************************* EXPLANATION OF ADULT &/OR YOUTHFUL DRIVER RATING CLASS AUTO 1-OWNER/PRINCIPAL DRIVER AGE 23 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. YD SEW 09/07/06 ITEM 9. UNLESS A CO-OWNER OR LIENHOLDER IS LISTED BELOW, THE NAMED INSURED IS THE SOLE OWNER OF EACH AUTO WE INSURE. ******************************************************************************** DRIVER* ST 1 JUSTIN R SELF PA 2 KATHLEEN CONN PA *IF A DRIVER IS NOT A RESIDENT RELATIVE AS DEFINED IN YOUR POLICY, .COVERAGES, BENEFITS AND RIGHTS MAY BE LIMITED. REFER TO YOUR POLICY AND ITS ENDORSEMENTS FOR TERMS, DEFINITIONS, LIMITATIONS, REDUCTIONS, EXCLUSIONS AND CONDITIONS. kCCIDENTS/VIOLATIONS SUBJECT TO DEFENSIVE DRIVER PLAN (DDP) KATHLEEN CONN FFN. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE OR DEFRAUD ANY INSURER FILES AN APPLICATION OR CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION SHALL, UPON CONVICTION, BE SUBJECT TO IMPRISONMENT FOR UP TO SEVEN YEARS AND PAYMENT OF A FINE OF UP TO $15,000. 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. # 1 BODILY INJURY $15M/PERSON $30M/ACC 88 PROPERTY DAMAGE $5M/ACC 202 FIRST PARTY BENEFITS - MEDICAL EXPENSE $5M 48 Q10 0407835 INVOICE INFORMATION: DATE DUE PAYMENT DUE -------- ----------- 10-04-06 316.00 01-04-07 322.00* 04-04-07 322.00* 07-04-07 322.00* Kerry J. Ritchey, CPCU, AIC Ene Assistant Vice President & Claims Manager insurance" 2?2e? Branch Office 4901 Louise Drive • Rossmoyne Business Center • P.O. Box 2013 • Mechanicsburg, PA 17055-0710 717.795.8200 Toll Free 1.800.382.1304 • Fax 717.795.2315 • www.erieinsurance.com August 15, 2008 Scott Cooper, Esquire Schmidt Kramer, P.C. 209 State Street Harrisburg, PA 17101 Re: Your Client: Erie Claim No.: Erie Insured: Date of Loss: Dear Mr. Cooper: The Estate of Kathleen Conn 010170892461 Justin Self November 12, 2006 This will confirm that Erie Insurance is in a position to offer the Underinsured Motorist limits of $100,000.00 as final settlement to The Estate of Kathleen Conn. As discussed, payment of the settlement proceeds are contingent upon completion of court approval. Also, I am enclosing a copy of the proposed Release that we are requesting you include in the Petition for Court Approval. Thank you for your assistance and if you have any questions please contact me. Since , Douglas G. Kocher Claims Representative (717) 774-5007 Enclosure The ERIE Is Above All In Service°. we commit, care and serve. It's our true blue oromise. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES PO Box 280601 HARRISBURG, PA 17128-0601 November 20, 2008 Scott B. Cooper Schmidt Kramer 209 State Street Harrisburg, PA 17101 Re: Estate of Kathleen Ann Conn File Number 2107-0108 Dear Mr. Cooper: The Department of Revenue has received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 22 year old decedent died as a result of being struck by a motor vehicle. Decedent is survived by her minor son. Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the net proceeds of this action, $41,900.75 to the wrongful death claim and $ 0.00 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. §8302; 72 P.S. §9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). 1 trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Sincerely, Shannon E. Baker Trust Valuation Specialist Inheritance Tax Division Bureau of Individual Taxes Original PHONE: 717-783-5824 • Fax: 717-783-3467 • EMAIL: shabaker@state.Qa.us CONTINGENT FEE AGREENIZINT THIS AGREEMENT entered i Ito the _ day of .March, 2007, by d between SCHMIDT KR?MirR PC and Iti?THLEEN A. SMITH, Adn inistra'r.1= of the Estate of Kathleen A. Conn, hereinafter referred to as "Client." VilTNESSETH: The law firm of SCH.MIDT KRAMER PC, will act as Client's attorneyirl negotiating for a settlement, and in bringing a claim against Tegan Ritchc" arising out of an accident which occurred on November 12, 2005, Route 11 Hampden Township, Cumberland County, Pennsylvania. In addition, SCHMIDT KRaII'VIER PC, will pursue all claims for underinsured or unins_:ed motorist benefits to which the Client may be entitled under her insurance po11cy. - In return, the Client swill: 1. Promptly supply accurate information, as requested by SCH` IDT KRAMER PC, and cooperate fully, including making herself available for meetings with attorneys and for legal proceedings. Client promises all information supplied will be truthful and accurate. 2. (a) In any clairn brought on Client's behalf, to pay to SCHMIDT KPAMER PC, for its services an amount equal to twenty-five percent (25''0') of all funds or property accruing to Client as a result of SCHNIIDT KPv1MER PC's services in securing a settlement of these claims before trial,- and an amount. equal to thirty-three and one-third (33 1/30(-,) if such funds 01 property are secur?cl after start of trial . or as ,a res_.l'? of ver.uc ic. c,r?,??. Pre-Trial Cor.- -once, or v<hcll tos"n-i oriT:' 1S Ca i for tr first. In ara matter sub.-nitted to arbitration, suit. is filed when t' c a--'-tars are appointed or <xhen a Petition to Appoint Arbitrators is filed ?t l:icl.e .'e; fi-s occurs. In any matter submitted to arbitration, trial starts the first day t.e arbitrators have convened to hear testimony. (b) Client agrees not to settle or negotiate the above claim or any proceedings based thereon. (c) If Client terminates this Agreement before recovery, Client agrPes that SCHIMIDT KRA IER PC, shall be entitled to a fee based upon work d:,ne and benefit conferred. (d) Client agrees to read and follow SCHMIDT KP_-1NIER PC's 'Client Instruction Manual". 3. Client agrees to reimburse SCHMIDT ;F.ALIER PC out of ary recovery, in addition to attorneys' fees, all costs and expenses incurred on Client's behalf in order to make the claim. All such costs and expenses will be advanced by SCHMIDT KR- IMER PC as they are incurred. Such costs and expenses include, but are not limited to, filing fees, cost of medical records, copying costs, fax costs, long distance telephone costs, expert witness fees and sheriffs service costs. In the event there is no recovery, the Client will not be responsible for any costs or interest charges. Costs will be repaid to SCHMIDT KRAMER PC, out of any funds or prop rty collected either by settlement or judgment. 1. Clairrs for first Par`-V' anc: _=tCO is=>>3 C: s?.:parate lteitls. SCHIN'TIDT PC, will separate agreernent will have to be entered into for fees if a I ialor c ,Lc occurs requiring the filing of suit for these benefits. The Client has read and does understand this Agreement. Signed the day and year set forth above. WITNESS: Appro,/ed SCHi /IQTK LAMER P By Client: Kathleen A. Smith, Administra!r1 of the Estate of Kathleen A. Corn I have received a copy of this Contingent Fee Agrccri;cnt. J Initials ? o O a r o 0 m -4 0000000000000000000 t4m n M (D 0 (DC =v my CDCDM CDmmmMCDCD D O N ? ( ( ( A ? ? JC 7C'7CN 7C 7C 7C? ?? 7C'7C 7C 7Cx7C 70C y . ?' ? W m N 0 ` ` o o 0 C a C C ? O 0 w m d N d O O N <D N 7 OD OD CTNCn fT CT CTU(T LJ OD OCr CT W ?1 -? \W?W-?NNN W W D D W W W N V? N N -4 -4 N N N N N N N F3 N W W N N O N O O N N N p N 0 0 0 0 0 0 0 0 8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 O O V V O O O V O OD Co OD OD co OD W OD OD O V V V V V wow-4ww-4 N Co OD 8-988W ?to0 V NOAN OD OD O c c 0 S OWi N 33, ?(a= N 4! m w (D y ai m(mo CD aa? (A c 7 0 00, ? n ?. (D j? CaA 3' ? ??s a mM co v? v m ? O SO D o D m .N.? H O? f00 n 0) CD Cn ?D V 0 01 0 0 Cn C" cm Co Oop WO=p OD cocoAw CA Oi 4 40-4-0-40 c o (Dpc (c c c (338'' ? ?. b3 3 m Qo 7 or ? 0 lr mosum"' ag Q.8 am any CD m 0 ?cm, (D. > > ((D C (o y N N K y (D N (D a (D N M N O O 0 09 2cn m N 0 N Z N N m DDS m Ao eat DDD o O e m cncncn y m m 53 com , in m q m ca ° 5•< mvv M _4k 0 0-0 ?pX y m 7 CD Q,N = 0 wmrnm 3 m ? ti CD N ( 0 oN v 2fnD a n D m N y ( nm m N 7 3= 3 c m 0Oo y m 3 T y (Zi no !Z cr y 00m$ o m p m . 3 cnm8 o n o CD i?nQ C. rn p cmi) a W m O. w = A ?+ 4 cD W O co cn NCT Wcr W W _ 0D L" O V O W T W O O5, O O O N N A A CJi C7c to 0 0D 000 f- W !D . , OD A 0 0 W O O OACUc0fT?0Ln008C0) O(TOCA co cD O_OC>O-+co0 _00 0-000 0 w w C -` V m D W 3 d rn m d Z C 3 0) rF CD c 0 D 3 7 S w CD N `+ o O N N 3 m 3 0 D 3 0 7 y rt, CO) 2 v 70 3 m X T n OD Cfl m J CLAIM #: 010170892461 RELEASE Under policy # Q10-0407835isstied by ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY, I/We, claiming coverage for myself/ourselves or on behalf of The Estate of Kathleen A. Conn in consideration of One Hundred Thousand ($100,000.00) dollars, which I/We have received, RELEASE AND DISCHARGE ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY from any and all claims, causes of action or other rights which I/We have, have had or could have under the Underinsured Motorist coverage as set forth in said policy, which claims, causes of action or other rights arose or could have arisen as a result of a loss or accident which happened on the 12`h day of November, 2006, at or near The Intersection of The Carlisle Pike and Van Patton Drive, Hampden Township, in the county of Cumberland, in the State of Pennsylvania. I/We further understand and agree that this RELEASE is inclusive of any and all present and future liens or claims for subrogation against the payments to be made in accordance with this RELEASE. I/We understand and agree that 1/we are responsible for the payment of any liens or charges against the payments to be made hereunder should any such liens, subrogation, claims or claims for expenses and charges be asserted. This includes, but is not limited to, medical expense liens, worker's compensation liens, ERISA liens, liens asserted by any federal, state or local governmental entity or agency or any medical expense claim. Should any person or entity make claim for payment of any liens or charges against ERIE INSURANCE EXCHANGEIERIE INSURANCE COMPANY or their counsel, Fwe agree to indemnify and hold harmless ERIE INSURANCE EXCHANGEIERIE INSURANCE COMPANY and their counsel from any and all such liens, charges, fees, claims, attorney fees, costs, interests and any other sum. I/We understand that this settlement is the compromise of a disputed claim, and that the payment is not to be construed as an admission of liability on the part of the persons, firms and corporations hereby released by whom liability is expressly denied. (CAUTION: READ BEFORE SIGNING) Intending to be legally bound thereby, WITNESS my/our hand(s) and seal(s) this day of Witnessed by: (SEAL) (Administratrix of The Estate) STATE OF COUNTY OF On this day of to me known to be the person executed the same as My commission expires SS before me personally appeared who executed the foregoing instrument, and acknowledged that free act and deed. Notary Public (SEAL) NOTICE: Any person who knowingly and with Intent to defraud any insurance company or other person tiles as application for insumnee or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. Joinder in Petition I, Kathleen A. Smith, as Administratrix of the Estate of Kathleen Ann Conn, hereby state that I have read the foregoing Petition and reviewed it with my attorney, Scott B. Cooper, Esquire, and that I understand, agree, and approve the contents thereof and join in the Petition. Kathleen A. Smith, Administratrix of the Estate of Kathleen Ann Conn M Joinder in Petition I, Justin R. Self, as parent and natural guardian of Aiden R. Self, a minor, hereby state that I have read the foregoing Petition and reviewed it with my attorney, Scott B. Cooper, Esquire, and that I understand, agree, and approve the contents thereof and join in the Peen Parent and al Guardian, of Aiden R. elf, a Minor ? l f...! ? '7 ' _ y _ ? ??s .l: ?;? ? ?s l ,?_. `.tix .._? C^ ,4 r ? IN RE: ESTATE OF KATHLEEN ANN CONN, : Deceased, by KATHLEEN A. SMITH, Administratrix, Petitioner JAN 2 R 20096 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 08-3242 ORPHAN'S COURT DIVISION SUPPLEMENTAL PETITION FOR APPROVAL OF MINOR'S SETTLEMENT FOR WRONGFUL DEATH ACTION Order AND NOW, this ?a day of E6 L. , 2009, it is hereby ORDERED and DECREED as follows: (1) Pursuant to Pa. R.C.P. 2039 and 2206, and upon consideration of the Supplemental Petition for Approval of Minor's Settlement for Wrongful Death Action, Petitioner is authorized to enter into a settlement in the gross sum of $100,000.00, and accept $7,500.00 in first party benefits proceeds. (2) Petitioner, Kathleen A. Smith, Administratrix of the Estate of Kathleen Ann Conn, is given leave to sign the Release attached to the Petition as Exhibit "M." (3) It is approved that the settlement proceeds shall be distributed as follows: Schmidt Kramer PC, Attorneys' fees at 25% (1/3 or $8,325.00, of which, is to be paid to Michael Bangs, Esquire as a referral fee) ...................................................................$25,000.00 Schmidt Kramer PC, Costs incurred to date ...............................................................$315.09 cr, -- i_ `- -.. r 1 U i ' ri • - t w t - c.a .. Wrongful Death Action: ACS Recovery, To satisfy Medical Lien ........................................................ $25,000.00 Kathleen A. Smith, For unreimbursed final expenses ............................................$7,784.16 Commerce Bank, 101 North Second Street, Harrisburg, Pennsylvania to be deposited in account numbered 062707487. The account shall be marked as follows: "This money shall be held in trust, not to be redeemed, except by Order of this Court, before May 5, 2023." ...............................$49,400.75 Total ............................................................. $107,500.00 The law firm of Schmidt Kramer PC shall oversee the execution of the preceding paragraph. 2 BY THE COURT: ?1 Distribution List ?Scott B. Cooper, Esquire SCHMIDT KRAMER PC 209 State Street Harrisburg, PA 17101 Phone: (717) 232-6300 Fax: (717) 232-6467 copy a/a, joq ??q