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HomeMy WebLinkAbout04-1085IN RE: CORY ALEXANDER IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPIIAN'8 OOL.'Tt¥ D~ICION NO. PETITION FOR APPROVAL OF MINOR SETTLEMENT AND NOW, comes the Petitioners Tammy Burkholder and Bruce Alexander, Jr., as parents and natural guardians of minor Cory Alexander, 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 Tammy Burkholdcr and Bruce Alexander, Jr., arc adult individuals residing at 156 Chamberlin Road, Shippensburg, Cumberland County, Pennsylvania 17257. 2. Petitioners are the parents and natural guardians of minor Cory Alexander, who resides with them, and who is 17-years old, having been born on January 23, 1987. 3. Minor Cory Alexander 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 Permsylvania. 5. Nationwide Mutual Insurance Company is an insurance company incorporated in the State of Ohio, who writes and sells insurance in the State of Permsylvania. 6. On June 24, 2002, Cory Alexander was a passenger in a pick-up truck operated by Paul Gutshall, III and occupied by his friends, Eric Halter and Dustin Barmont. 298695-1 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 Cory, sustained injuries. A true 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. Cory was air-lifted from the accident scene by the Hershey Medical Center Life Lion and taken to the Hershey Medical Center where he was diagnosed with abrasions and a closed head injury. After the studies were negative, Cory was discharged on June 25, 2002 with instructions to see the pediatric surgery clinic in 2-3 weeks. A true and correct copy of the Life Lion report and hospital records are attached hereto as Exhibit "B" and incorporated herein by reference. 10. As instructed, Cory followed up with the pediatric surgery clinic at the Hershey Medical Center on July 17, 2002. Robert Cilley, M.D. noted Cory sustained a concussive head injury without structural brain injury as well as a number of scrapes and bruises. He noted Cory was troubled over the loss of his friend in the accident. Cory was discharged to return on an as needed basis and has not returned since this appointment. A true and correct copy of the treatment note is attached hereto as Exhibit "C" and incorporated herein by reference. 11. Cory has some minor scarring which is reflected on the color reprints of the photographs attached hereto as Exhibit "D" and incorporated herein by reference. He is not seeking any further treatment for the scars. 12. In addition, Cory has been suffering from depression and post-traumatic stress symptomology as a result of the accident, which resulted in his friend's death, and he has been treating with his family doctor, Babak Behta, M.D., who has prescribed medications, which are Document #298695,1 ongoing. A true and correct copy of the family doctor records are attached hereto as Exhibit "E" and incorporated herein by reference. 13. The medical bills for Cory's treatment as a result of the injuries sustained in the motor vehicle accident have been paid by Nationwide under the medical payments coverage in the amount of $10,000.00 and by Blue Shield/Blue Cross in the amount of $2,698.48. 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, nor any liens asserted. 14. At the time of the aforesaid accident, Cory 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 Barmont receiving 60% (or $9,000.00) and Cory 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 tree and correct copy of the tender letter fi.om 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, Cory was covered under his parents' automobile insurance policy with Nationwide for underinsured motorist coverage of $25,000 per person/S50,000 per accident stacked ($50,000.00 total). Nationwide consented to the settlement with Paul Gutshall, III and his liability insurer and has waived its subrogation rights against Mr. Document #298695. I Gutshall. A true and correct copy of the insurance declaration documents are attached hereto as Exhibit "H" and letter of March 17, 2003 with consent and waiver is attached hereto as Exhibit 'T' and incorporated herein by reference. 17. Nationwide agreed to make an underinsured motorist payment in the total sum of $35,000.00, out of which $30,000.00 would be placed in a structured settlement account. A true and correct copy of the letter fi.om Nationwide 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 $41,000.00, which the Petitioners, after consultation with counsel, have determined it is in the best interest of Cory 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 Cory to allocate $30,000.00 of the $41,000.00 to be transferred by Nationwide to Hartford Life Insurance Company to set up a structured settlement account, which would provide Cory with the following payments at the following respective ages: $ 7,500.00 at age 18 (January 23, 2005); $12,200.00 at age 21 (January 23, 2008); and $15,000.00 at age 25 (January 23, 2012). The lump sum payments would be tax-flee guaranteed payments and payable to Dustin or his Estate or designated beneficiary should he die before receiving all money. A copy of the Structured Settlement proposal is attached hereto as Exhibit "K" and incorporated herein by reference. 20. The structured settlement account would be through Hartford Life Insurance Company, which is rated Superior. The documents concerning the financial health of Hartford Life Insurance Company is attached hereto as Exhibit "L" and incorporated herein by reference. Document #298695.1 21. Out of the remaining $11,000.00 the sum of $483.79 will be paid to Cory's parents for the immediate benefit of Cory. 22. The remaining sum will be paid to counsel for Petitioners who were retained to represent Cory 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 Cory Alexander. 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 $10,250.00. Counsel has also incurred the following expenses on behalf of Cory: Filing Fees $ 55.50 Medical Records $ 81.83 Photocopies $ 48.63 Postage $ 18.07 Travel $ 37.23 Long Distance Phone Calls $ 9.78 Fax $ 2.00 Miscellaneous $ 13.17 TOTAL $ 266.21 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 Nationwide, under the underinsured motorist coverage, in the gross sum of $41,000.00 out of which Cory's parents will receive the sum of $483.79 for the immediate benefit of Cory, counsel will receive the sum of $10,516.21 for attorney fees and expenses and the remaining $30,000.00 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 #298695.1 26. Paul Gutshall, III through his liability insurer, State Farm, and the underinsured motorist carder, Nationwide, concur with the filing of the Petition and also seek approval of the minor settlement under thc terms set forth above. 27. Upon delivery of the upfront cash payment, Petitioners desire to discontinue this matter. 28. To the extent the Court decides a hearing is necessary, the Petitioners respectfully request that Cory 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 fimds as follows: (1) To be paid to Tammy Burkholder and Bruce Alexander, Jr., who are appointed guardians of Cory Alexander for the purposes of this Petition, the sum of $483.79 for the immediate benefit of Cory Alexander; (2) To be paid to Metzger, Wickersham, P.C. for counsel fees and expenses - the sum of $10,516.21; and (3) The balance of $ 30,000.00 to be transferred by Nationwide Mutual Insurance Company to Hartford Life Insurance Company to set up a structured settlement account. The structured settlement account will pay the following guaranteed lump sums to Cory Alexander at the following ages: $ 7,500 guaranteed lump sum, payable on 01-23-05; $12,200 guaranteed lump sum, payable on 01-23-08; and $15,000 guaranteed lump sum, payable on 01-23-12. The benefits are tax-free guaranteed benefits, which will be payable to Cory Alexander 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 Hartford Life Insurance Company. Document #298695. I METZGER, WICKERSHAM, KNAUSS & ERB, P.C. Dated: March 11, 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 #298695.1 · I · ...-,. ~.,ct c~?~.~,~o ~O,M,~.~ P0425974 Insurance Company P~ ~ ~ ~'-, "- Hi~P~srcccs ~,~ lt,~ .......... ~7o'~'173~ -,~ · f ' --t-'~ ................. ~-~ ~ ~,- ~7' COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM AA452 I 00 524 ~.ide Color ~'; '-~ ; ~ ~-' /" May Not ~ DdyeabM) 3=~ ~ 01 =Going Straight Cra~ Nurrt~ P0425974 Veh/de Ro/e ~ III OR=Trying to Avoid Anlmml, o¢ M~gin~ l=[~Yel R~4~vay ~ ~ Hi~ 09:T,,rning Right ~ 1~Turning Right 17~ ~ ~ 1~S~' '~' 12=Turning L~ [ U~ 02=Am~lar~e · 03=Police 08=Other Emergency Vehicle 3:Both St~king 0~--Not Applicable O1=Right Lane (Curb) 02=Ri ht Yum Lar~ 07:Oncoming Traflk Lane ITag State l~Taxl 21=Tra(tor Tra~ler 2~TH~e Tral~ 31 =~ir~ Veh 11 =~l~ ~ l~S~u~ ~ COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM AA 45 31 0015~,5 P'g': . . -' Leased b Driver 05=PennDOT Vehicle O ~ 02=Private ~hide Not ~ ~lCohol/Druqs Suspected ~ (~ &lcoho[ Alcohol and Drugs :~.) Unknown ~ ~iood Urine ~ Unknown if O ~ .......... Test Refused ~-~ Unknown II I Pede~t~an 5iqnal at ~ene of Oash (~ No Pedestrian S!gnal (~ Not at Inter~,egtk~ C) P~dostrian Signal Marked Crosswalks 0 at Intersection 0 Not in Roadway 0 FI MI Tela~nofl~ Nl, smb~' II I l'-II State Zip driver is not lice~sed, see manual At Interr~cl~on - No O Median Crosswalks C~ Island (~ Out~ld~ Tsaffkw~ Non*Intersection ~ S~ ~ ?, C~alks ~ Sh~ Trai~ O~veway Access ~ Sid~alk vi~at~ a~ ma~ if t~ roll B?,= (~her Municipal 00=Not Appticab!e 0~=Rentecl \;ehic!~ I I l=Oriver Operated 3=Driver Fled L__J Vehide 4=H~ ~d Run COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM B F =Femate Injury Severily: C O=Not Iniured 00=Not A I~assengerlO~cuP 02= :font ~at Middle P~ 03=.:ront ~at Right Side ~c~ Row - ~fi S~e 02=Lap Belt Used ' 03=Lap And Shouk:l~ Belt Used 04---~tld S~f~ Sea~ U~d 11 =C~lld'Sdety S~ 12.:Hel met Used ImlmN~tY gO=Restraint U~d, tYPe Unknown P0425974:.: , :: 08=Third Row Or Greater - Middle po~il~ion 99=Unknown 09:Third Row Or Greater- .~felY£aUII Right Side Passenger Or ~rgo Area 02=Si~ 1 ]=Trailing Unit i ' 98=Other l~Aif ~ NOt ~; ~ On 99=Unknown Date of Birth (MM-DD¥~YYY)______ ~ ~,-----,---~ ~ ~---~r----~ r--mA B C D E F G H I .... :--'~ .......... - -~-'~ Ii Il jill I Il I Il I Il Il Il I Un,INoPer~onNo Delete? ' ' ~ ;}~1 II I//I III ] 11 I jeJ~i ~' Un,t N0 Person INo Date of Birth (MM-DD-YYYY) ,-~ : ; L_ H : I ':'d? EMS Transport .; Ct) Ye~ ONe Unit No Person No Date of Birth (MM-OD-YYYY) A B C D N.~me ,' add.?ss_/Ph_o_n_e Unit No Person No Dateof Bi~h (MM-D~YY) A B C D E F G H . I ' Date of Bi~h (MM-DD-YYY~ A B C D E ~ Un;t r~o Person ~ Delete? ~a~e, of B~h (MM-D~YYYY) A B C D E F G H ' I 'l COMMO.W .m P0425974 POLICE CRASH REPORTING FORM W New ~ Co~'np~ete the Princit~ll Ro~d Se~t/o~ f~ all ~ of ~ ~ ~ a ~ ~ ~ ~ ~ Trave~ Lane~ ,~ Unit CZ) Unlmown (East/West) Spur Highway County Route Number Segment (Optional) Travel Lanes Speed Ltmit 5'reet N.tt~e Stll~t Ending C~ East !nte,state .r-, Turnpike :~ Turnpike (2~ State C~) Count~ C) Local Road C~ Private (Not Turnpike) ~" (E~est} Spur Highway Or lnter~ing Street Name ................ [] Lane Closure [] Wo~ o~ Shoulder [] Flagget Corneal Before Ist Work ~-) []Deter ~ Int~em ~ ~ ~ Area }' Other 5~Umh11~ Present O Yes ~ NO 0 Un~ Traffic Detoured ~ Yes (~ No' fstimated Time Closed C~ 1-3 hoots COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM AA4S6 1 Harm Event LIR Most? Utiii~/Pole Numbe~ Unit No ~ 1 0 0 12=Wlp~rs 13=Driver Seating/Control 14=Body, Doors, Hood, Ere 15=Tra~le¢ Hitch 16:Wheels 17=Ak, bags 18=Traile¢ Overloaded S4=flm In Vehkie 5~Othe~ Ne,q-Call. on 11=Tail afl 12 =Su~de~n~ing/Stopping 13=ll~gafly Stopped On Road 14=Careless Passing Or ~ne ~a~e Unit ~ -- ' .o I FI O0=No Contributing Action 17~rele~ ~,~Weg~. :"-J ~'-_-~. I ~'~ O1=Odv~ Was Distracted 02=Orivb~g U~imj Hand He/d ~=M~lng II1~1 U-Turn l~Makl~ Im~ OS=lmpr~r/~te~ss Tumlng ~=Tumi~oT=P~ingFmmw/oWr~9 ~ 2~Mak~ Im~ ~Runni~ Stop Sign O~Running R~Ug~t l~Failu~eTo R~nd To ~h~ Traffic Control ~vlce COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM P[ace emergency ~ransport, witness, and other information here. It is not required to restate Jnformatlol~ rio ~l~..the form. .~,,,~ ~',,s-';~ ~ewburg Fire ar~ Ambul. ,',,me~$1: NOr~ ~ A~lress: Witness 2: Address: Unit ! 1- Cell ~ Not preaen~ Nartat:ve. Unit # ! ~ travelinq ~,,: on the double yellc~ line and entered the bemll On' berm i~ entered a a: lea~: once and came ~ ~t faei~ ~e ~cd. All ~e ~t o~ ~e ~. .~ ~_~_._~s ~e of 14, d~d ~ ~ a ~ve~s li~ ~o ~. . : ~1s officer_ S.~e ~e cela:~ the Gift of ~e acc~ a~ r~t~tion. 0n~06~2~/_.0__2__ _~_ _r._J__ose~h Glassmire responded to the scene attached _repgr~.____T~_ooper Glassmire p~tographed the scene from the air as Well as ground ~ Both _~e~9 ..r~s~ _are__attached. m~ize~ to the parents of ~he deceased, the o~er of the veh£el'; and i 1, and pas~er~ers t 3&4. Case Pe~i .r,/~- _[_~?'_].pC_ O~ ._~__ecor?~t_.__r~c~_:_~°nis:_re~°t~' and revte-,~ ~ the Cmt3etland County Dis:crC: A:torr~_.¥s ?f~1ce w:t_n.. ~po~__sib1e C~M~MONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM AA458 1 Place emergency transport, witness, and other infor~ation here. It is not req Medk~a ~at,~e: Or:mr ! 1 ~ interviewed at the .__vhil_e traveling east on SR 641 ~a~ [rcm a clrive~ay on his tight side. He entered a yarc] an~ rolled over. 9mile spewing to c~r f 1, no [~Yoable cause ~ras~"~flt to 1 alcohol. A call to the hershey hospital foun~ no test* ~' While at the scene of the accident, n~ ht,~ U~'~'' ~ ~nt to t~ residue direly a~ ~ ~ v~icle ~ ~ fr~ ~ ~o~ ~ v~ ~ ~ bl~ ~ divvy or aro~ ~ r~i~. R~t~ att~ will '~'~ : ~ in a attar to fi~ ~o bl~ v~i~l~. · ! COMMONWEALTH OF PENNSYLVANIA I POLICE CRASH REPORTING FORM New Crash Number * : · 00 .$32 AA 45 F 1 Page: C~ Change/ Continuation ~ Concrete ~--~ Slag, Gravel or C:) other t~: ~ ~ease complete Uq:~ ~:ormaucq f~ ~ unit inVO~ in a f~ cr~sh. ~ ~ ~.~ [n'~ c~Not a Pennsylvania Driver Unknown Compliance Unknown c~Not a Pennsylvania Dr~er Uflknown Q Compl{ance Valid bcense for ~) Unknown C:) Other ~ Unknown if Te,~ Stated -Under ~cle Indicator Underride, No ~ No Underride or C~ Compartment Override Intru~on Undenlde, Underrlde, ~) Compartment C~) Compartmen{ I~rus~on Intn~ion Unknow~ Emergency Use O Lights Flashing Not in Emergency :~ Use O Siren Sounding C3 CD Unk.* .: 0 ~ CD .. QO7 06 ob C=) Principle Impac~ ~oint C~ NorkCollision C~ Top (~ Undercarriage 0 To~ed Unit C~ Unknown Avoidance Maneuver No Avoidance C~ Maneuver C-~ Braking - Skid Marks l[vident Braking - No Skid ~ Marks, Driver Stated Under Ride Indicator C~ No Underride or Override Underride, · ~ Compartment Intrusion I E_me~rqency Use Braking - Other Evidence CD Steering - Evidence or Driver Stated (~ Steering and Braking 0 Unkn°v~ Evidence o¢ Stated JJ .:~ n Other Avoidance ~ CD IncendU~Ve:: .:,~ Underride, No Override, Other Compartment (~ Vehicle Intrusion Underride, Unknovm if Compartment 0 Undenfde or Intrusion Unknown Override 8otb Ughts and Lights Flashing ~ Siren ~"'/) 7" NWEALTH __J coMMO OF PENNSYLVANIA ~o.c~ cP. AS, ~£~RT~ ~O~M 001533 AA 45 1 1 -~, v~ '~ No C30~lnuat~n ~ A e~ Name ~ PA State Model Year porky No __lI U_n_it_~_u_p~ber Delete? Type .~ Mota Vehkle in 0 Hit i Run Vehtde C) Illegall~ padded 0 Legally ~ Transport r-~ PedestTian on Skates, 0 Disabled From 0 Train ~ ~'r Unit ~ pedestrian ~-J in IArneelchair, ere previous Crash o Unit Number Owner Last Name (If pedeYtrfan, ~kip to F~ ~ 4~ 3 l) Insurance Com~ny COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Place emergency transport, witness, and other information here. It is not required to restate ~1 ~. Address: This Officer was requested colllszon And ReconstructXon ....... p_h_ho_t__o_g~_a_Dhs of this incident on Officer arrived at the location of~ this .... ?630 hours. '&he location ~', ~'~tl 'i'bK06, " Kirk PERKINS, PSP Carlisle, PatrOl'Un~t~' ~': Kodak color ~ilm (2 Rolls) 70-300mm lens, with GC400 . A uni%o'. -. T~iS and its pilot, p , , ,. ana refor tO ~n° ~'-~ -' ' Photographic lab, 1800 '~or processing only. below. ........... Re,er. to Troop H identtfXcation number 2002-0454 0446. POLIC~ CRASH REPORTING FORM AA45 1 1 y. ~ Compiny phon~ i! ~ PA State Police ~ A.ival lime (m~t~ Invesligat°r Umt Number Detete? ~ Trans~ ~-- ~'S~, ~ ~ F~ ~ Tm~ ~': '~ p~ NO insurance _~ Un- I T~~ :' Na~e (If Pedestrian, skip to ~ ~ ~ 3 1) '~ ~ ~ ~ I ~ ~ COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM 00:1536 AA4S8 I Ptace emergency transport, witness, and other information here~ It ~ This Officer was rec~tested bY C~lltsion And Recons~c~on S~a~s~ a~ ~he Location of ~h~s ~nc~en~ on 06~26~02.~[':172 .... ~----locat~on was on ~R0641 by ~hady Road, ~I0p~ell ~ber~and Co., PA. The Invest2gator PSP Carlisle, Patrol Unit. The scene was photoqraphed with a N~kon Ng0S' 28-80~ lens, Nikon SB-28 flash unit as needed. Identification unit. ~ ........ ~i~s ~o~arae~ with fo~ SP4-1~6 ~ Photographic lab, 1800'Elmerton Avenue, Harrisburg, PA z ...... ~'processing only. If photographs are neede~ Contact 5~ ~'f~-~6~ H identification numbe~ a~2-044~ COMMONWEALTH OF PENNSYLVANIA POLICE C~H RE~R~NG ~RM 00~5~T Address c Insurance Company Towe:l To Vehicle Towed FI MI Telephone Number Model Year Vehld4 Mike* Towed COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM New Cha~e/ C~tinua~ion ~ete P~e P0425975 Place emergency transport, witness, and other information here. It it not required to restate Informatlm Re~pondinq ~M5 Aqe~wy. 'M~,~ Fl~dll~fl 0 Far I COMMONWEALTH OF PENNSYLVANIA ,,I POLICE CRASH REPORTING FORM 001539 Crash Numbe~ New P0357868 11 Address VIN Owner Last Name (if Pe~sfri~, sk~e to Foil i~ 45 .~ 1) ~_..~ C~MMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM 'AA458 1 001540 Page: ~ ~ Continuatio~ CD Oelete Page Place emergency transport, witness, and other information here. It is not required to ~ .reda. ~ Responding EMS Tpr. Gar~/ Mainze~ %~__0oP H Collision Analysis and 8000 Br~tz Drive, ~arrisburg PA 17112 phone: (717) 671-7570 .Reix;c~:ing_ office~_~cO~lu~_t~]_NLa~lysia and reconstruction of this crash. . conclu.sio~s _wece~c!uring the investigation, ToW ate ba~ed on lite av~f~ble." .~£on~Lace_h~lieved~m~_~c~c~te~e an~ co~tec~ ~o a re~son~ble c~tee o~ ~' _l~_b~it_tl_was_t. ravelinq e~t on eR0641. 0 ~ .6.. _~ra~nr ~_cou]d ~ve auoi~ a ~ll{sion driu~ay to ~ ~u~ ~ br~ alone FO: detal 1.-,..re~er__ ~:z_Ger~era] Tr~veatigatton repot'l: H2-1266392. ED Tra,qnsport Note ALEXANDER, CORY L - 364633 PENNSTATE  Milton S. Hershey Medical Center College of Medicine Health Information Services HU24 * Final Report * 850 Hershey, PA 17033-0850 LIFE LION TRANSPORT NOTE PATIENT NAME: Corey Alexander PATIENT IqU~BER: 0364633 SEX: M DATE OF SERVICE: 06/24/2002 DATE OF BIRTh: 01/01/1903 FLIGHT NUMBER: 02-1064-B. DISPATCH INFORMATION: We were dispatched to Cumberland County to the Newburg area to transport what was reported to be two patients who were ejected from a pickup truck. No other information was given to us prior to our arrival and it was also relayed that they were both pediatric patients. SOURCE OF INFORMATION: John Emmons, EMT-P and physical examination. WEATHER: The weather today did not play a factor in our transport. Initially we were placed on stand-by and then placed into a response stat. HISTORY: This is a 15-year-old male patient who was involved in a motor vehicle crash involving a pickup truck with rollover. Unclear where the patient was positioned in the vehicle prior to the incident. It was reported to be a single motor vehicle accident. Initially the patient was noted to be unresponsive by bystanders but was found responsive by BLS. The patient was reported to be found approximately 20 feet from the vehicle lying in the grass. The patient was then transported to the remote landing zone. PAST MEDICAL HISTORY: Unknown. ALLERGIES: No known drug allergies. WEIGHT: Estimated at 60 kg. TREATMENT PRIOR TO ARRIVAL: The patient was received by BLS from the Shippensburg ambulance and also medic 84, paramedic John Emmons. The patient was fully assessed and placed on a long board. He had Printed by: Gridley, Laurie A Page 1 of 4 Printed on: 9/29/02 7:27 AM (Continued) An Equal Opportunity University ED Trao, sport Note ALEXANDER, CORY L - 364633 PENNSTATE cervic~,%q~tH~¥~ic~lg in place. He was on high flow oxygen~C~lc~~ther face mask. A]~iR%W~m~sm~wa~u~nitiated in the ~!~l'ght AC with a n,u. mb~r 16-gauge ,with ,lac~tated Rin~°]7033_0850 infusing at KVO. No me~canions were g~ven oezore our a . PHYSICAL EXAMINATION: Initial vital signs - heart rate was reported to be 90. Blood pressure 90/50, respiratory rate 16, Glasgow Coma Scale 4-4-6. Neuro - the patient is awake at this time and able to answer questions appropriately but amnestic to the event. The pupils are noted to be 5 mm equal and reactive to light. He is able to move all four extremities. The patient's scalp area is negative for any obvious trauma. The facial area had multiple abrasions and minor lacerations, bleeding under control at this time. Dried blood was noted in the nares and around the patient's lip. No blood noted or fluid coming from the ears. Cardiovascular - he is in a sinus rhythm on the monitor without ectopy. Has normal heart tones. Strong radial pulses bilaterally. The patient's skin is warm, dry and pink. Capillary refill is within normal limits. There is a 16-gauge angio in the right AC with lactated Ringer's at KVO. Chest wall has equal rise and fall bilaterally. The chest wall is negative for crepitus, subcutaneous air or any obvious trauma. Pulmonary - respirations are even and nonlabored. Lung sounds are noted to be clear and equal bilaterally. Airway is patent, intact and the trachea is in the midline position. The patient has no oral secretions at this time. GI the abdomen is soft and nondistended and nontender. No obvious palpable masses are noted. Pelvis is stable to compression and flexion. The right upper extremity is atraumatic. The left arm has multiple abrasions, bleeding under control. Lower extremities without any obvious trauma. SUBJECTIVE: The patient voices no complaints at this time but is amnestic to the events. LABORATORIES/X-RAYS: None. TREATMENT/PROGRESS: Permission for air transport was granted by the patient. The patient was rapidly assessed. Report was received from John, paramedic, from medic 84. This is a double patient flight. At that time, paramedic Emmons resumed care of patient while I went to assist paramedic Buck with his patient. Care rendered to secondary patient. I then transferred back to the ambulance and transferred care at that time. The patient was then transferred out of the ambulance and transferred over on the long board over to the Life Lion litter and secured with straps. He was then hot loaded to the secondary side of the aircraft and secured to the litter base. En route to Penn State Milton S. Hershey Medical Center, the patient was continually reassessed. Me was continued on high flow oxygen via a nonrebreather face mask. IV continued at KVO. Medical command was contacted at 1408 with full report given. No orders given back at Printed by: Gridley, Laurie A Page 2 of 4 Printed on: 9/29/02 7:27 AM (Continued) ED tra..nsport Note ALEXANDER, CORY L - 364633 PENNbTATE that t~.Mil~n~4~di~ed in the left forearm, ±6-gauge wxtn normal~g~~ at KVO. The patie~mh~m~en~J~ml flight to PennY'State Milton S. Hershey Medical Center and remai~o~0ert during transport and voiced no complaints. He arrived W~17033-0850 incident. TIME BP P R Cardiac Monitor SpO2 Pet C02 1406 124/62 80 16 Sinus rhythm 100% 1415 124/49 82 16 Sinus rhythm 100% 1422 78 16 Sinus rhythm 99% Dispatch times: We were placed on stand-by at 1312 and response stat, lift at 1324, arrived on scene at 1344. Patient contact at 1345. Departed the scene at 1403. Arrived at Penn State Milton S. Hershey Medical Center 1423. IMPRESSION: This is a 15-year-old male patient who was ejected from a pick-up truck which was involved in a rollover with closed head injury being transferred to Penn State Milton S. Hershey Medical Center for further care. DISPOSITION: The patient was off loaded from the helicopter and transported to trauma room 2 with report and transfer of care given to trauma team. All questions answered at that time. Both IVs were patent and intact. Total fluid infusion approximately 800 cc. No urine output noted during flight. The only valuables that were transported with the patient included a pair of boxer shorts and also a pair of work boots. EMS equipment left in the trauma bay includes long board, cervical collar, CID and straps. The patient's vital signs were stable upon my departure. PRIMARY CREW MEMBER: David Zook, RN Printed by: Gridley, Laurie A Page 3 of 4 Printed on: 9/29/02 7:27 AM (Continued) ED Trarlsport Note PENN 5TATE,, S~ECONDP[~ ~ S~.~_ .~. Medical Center 'rnomas ~a(golle~Wi~a'~dic~ne ATTENDING MD: Kym A. Salness, MD Professor & Director, Center for Emergency Medicine ALEXANDER, CORY L - 364633 Health Information Services HU24 P.O. Box 850 Hershey, PA 17033-0850 DZ/clm D: 06/24/2002 T: 06/24/2002 17:23 Printed by: Printed on: Gridley, Laurie A 9/29/02 7:27 AM Page 4 of 4 (End of Report) 24-June-~002 14:48:09 Center - ~ Services 364633 '~ REVIEW 21~ mm/sec Adult/Pediatric ~ =78 PVCa/mln = 0 PI=OFF P2=OFF CO2= SRCH IR,IRCH ~pO2= 100 NIBP=122/IO(17) TI =OFF .a~i~,i:i~iiii~!!i!~i::~ii~:::: ===================== ::::!::::!::::}-'I ....... I'"'~/'T"I ........ i"i"T'"i i i i i i i ~: Sys / Dia[ Me~ a ) ~ -- mmHg (N/B3. -- , 131/78{.)0) ,,~1.,, 119/89t102) ',1, 138 / 86(1 ~8) ":5 125/74(5) '! 125 / 83 ('171 ., 122 / 80 , , Vii 'ti Signs S,,mmlil~jr HR/PR SpO2 RR/BR ETC02 BPM % Br/M mmI-Ig 114 100 SRCH SRCH 110 100 SRCH SRCH 107 100 SRCH SRCH 86 100 SRCH SRCH 86 100 SRCH SRCH 91 100 SRCH SRCH Comments 2,i-June-2002 14:24:(~6 Hershey Medical Center - Emergency Services 'RAUMA SIXTHREFTHREE 364633 REVIEW 25 mm/sec Adult/Pediatric ~ P2 =OFF 'I¢02 = $({¢H I' BR = SRGBJ ~1~O2--1~ Jtll~J~ 1~{ 130.1.. Il=OFF ,, = 'q6 ~m ~ ~ OFE p ~ - ~ - ~ = OFF CO2 = SRCH BR = SRCH S~2 = lffi NIBP = 153/~(1~ } ~ = OFF 14:24:~ 5 i ti Signs S~mmary Sys / Dia ( ~,i~. t ) HR/PR Sp02 RR/BR ETC02 mm] ~ (Nii~ -- BPM % Br/M mmHg 153 / ??? { i ,0 ) 106 100 SRCH SRCH Comments PENNSTATE ~ Milton S. Hershey Me~__al Center College of Medicine TRAUMA PATIENT RADIOGRAPHIC "WET READS" (PRELIMINARY FINDINGS) The following radiographic studies were performed on this trauma patient, with "wet read" preliminary interpretations as indicated: '1¢ Chest ~ Q Elbow - (L) vs. (R) Q Abdomen ~,~_elvis ~-'~ [] Hip - (L) vs. (R) O Forearm - (L) vs. (R) r~ Hand/Wrist - (L) vs. (R) ~LCervica, Spine (~ n Femur- (L) vs. (R) Thoracic Spine [] Knee - (L) vs. (R) Lumbar Spine [] Foot/Ankle - (L) vs. (R) [] Skull Xrays [] Shoulder - (L) vs. (R) Other Xrays m Humerus- (L) vs. (R) ~. /? Radiologist s Signa~ ~O~S: ^~ /'~', I1 I ~-~ /1/Ang~raphic/Cardiovascular P 'nt d N m · [~/[(~/~ (,~J~)7{-~'~'~ / Interventional Radiologic procedures ri e a e ~ ~/[ / · ~ ~ ~ k ~-~'~\ O 0 are documented on other forms. Beeper#: l I ~'~ 2. All studies on this patient for whom a "wet read" was provided during the Date: f~ ( ~_..~"~ L.~/ trauma were "checked" in the appropriate boxes. 3. A "minus sign" ("-") indicates "no significant abnormality." 4. By his or her signature, the Radiologist who interpreted the studies "checked/circled" above indicates that the findings were discussed with the clinical team. MR 806 9/99 TRAUMA PATIENT RADIOGRAPHIC "WET READS" (PRELIMINARY FINDINGS) wh~e- Medical Records Yellow - Radiology PENNSTATE ~ Milton S. I-Iershey Met~..~l Center College of Medicine TRAUMA PATIENT COMPUTED TOMOGRAPHY (CT) "WET READS" (PRELIMINARY FINDINGS) The following CT studies were performed on this trauma patient, with "wet read" preliminary interpretations as indicated: Q~T - Head ~ CT - Chest E) CT - Abdomen Q CT- Pelvis Q CT - Cervical Spine (specify levels) Q CT - Thoracic Spine (specify levels) r~ CT - Lumbar Spine (specify levels) E) CT - Other Radiologist's Signature: Printed Name: Beeper : Date: ~S: iographic/Cardiovascular Interventional Radiologic procedures are documented on other forms. 2. All studies on this patient for whom a "wet read" was provided during the trauma were "checked" in the appropriate boxes. 3. A "minus sign" ("-") indicates "no significant abnormality." 4. By his or her signature, the Radiologist who interpreted the studies "checked/circled" above indicates that the findings were discussed with the clinical team. MR 807 9/99 White - Medical Records TRAUMA PATIENT COMPUTED TOMOGRAPHY (CT) Yellow- Radiology "WET READS" (PRELIMINARY FINDINGS) PENNSTATE The Milton S. ~' :hey Medical Center The College of ~,.edicme TRAUMA HISTORY AND PHYSICAL EXAMINATION Ft~ [] GSW [] Stab [] Other Airway: IV's: R.O.S. ~_-,~,~i ~ ~ (.-~ ~ Field Vitals: P: ~;;~, BP: I~//, RR: 16 . · Immobilization: Amnesia?~ ~N~, Loss o, Consoousn~sT~Yes ~ No Field Notes: ~,. ~. ~l~ ~;~ ~.: Trauma Histo~ ..... Ai~ay:~atent ~ Obstructed Intubated: ~ OT ~ N, U Breathi.g: ~ ~ ~ $rea,h Sounds: ~isability: ~Ale~ ~ Voca1 ~ Painful ~ Unresponsiw PMH: HEENT: Head: ~ Ears: TM's: Face: Maxilla: ~.,~ Nose: Mouth: Neck: Tenderness: Chest Well: Tenderness: Back: Tenderness: Head: Abdomen: Distention: Rectal: Tone: Pelvis: Stable: Vascular Exam: RightJLeft Resident S~q~t u re COPYRIGH'P', '1 ~ MR 611 Rev. 3/98 Procedures: [] NG-Tube f'J ~> [] Urinary Catheter [] A-line: ~ [] CVP(s): r"J'"'~ Chest tube: [] right [] left [] DPL: ?! /oS 2nd Vitals: Ternp:.>'o P: Eyes: Battle's: Mandible: Dentitia: Dentures: Crepitus: Crepitus: Lungs: ~¥,. ~ ~ Crepitus:  Heme: ~ ~ Q~ Tenderness: ~Radial PSH: Lest Meal: Last Tetanus: BP: I/1]~q RR: ~l~' 02sat: /o~ Trachea ML: Tenderness: Prostate: TRAUMA HISTORY AND PHYSICAL EXAMINATION ~fx--opon fracture Ab -- abmsion C --contusion Ori9 - Chart Copy- Trauma Service~ TR, ~IA HISTORY AND PHYSICAL EXAMIN/- )N ExtremltyExam ~ ~ '1 LEGEND: L --laceration Clx--closed fracture Ofx--open fracture Ab --abrasion C --contusion Cranial Nerves: Motor: Sensory: Pinprick ProprLoception DTR'SF_~ Spinal Cord Injury: 1-12 L 1-5  PTT: /'~.~~2 W/ Z'~ ALT: ABG: ALP: ECG: TEE: ~t CXR: ~ Pelvis: ~ CSpine: Lot ~ E~remities: Odontoid ~ Glasgow Cema Scale/Peals Eye Opentng Trauma Score 1 - None 2- Open to Pain Resp. Rate SBP 3 - Open to CommandNoice 0 - 0 e - 0 ~erSP°ntane°us 1 - 1-9 1 - 0-49 hal Response 2 - >36 2 - 50-69 ! - None 2 - Inc0mprehensib~e/Moans to Pain ..~ -.25-35 3 -70-90 3- Inappropriate / Cries to Pain :" 4-j/0-24 (/-;~. >90 ' - Confused / Consolable all5 -~Alert / Oriented / Ir~teracts GCS r Response 0 - 3-4 1 - None 1 - 5-7 2- Decorebrate 2 3 - Decorticate Troponin: U/A: Myoglobin: CPK: Drug Screen: Amylase: ICa: /-J/ ETOH: BHCG: Abdomen: Others: ANeflding SIgnature/Oatemme MR 611 Rev. 3/98 TRAUMA HISTORY AND PHYSICAL EXAMINATION PLNN~ IAI L Milton S. Hershey College of Mediclm. PROGRESS REPORT 'ical Center Date/Time PROGRESS NOTES: (Include Name, Title) MR 6 Rev. 6101 PROGRESS REPORT PROGRESS REPORT Date/T,~me P~.~NOTES: include Name, Title) MR 6 Rev. 6/01 PENN~TATE Milton S. Hershey College of Medicine PROGRESS REPORT 'cai Center ~" 00St Z)536 01/01/1003 Date/Time ~ PROGRESS NOTES: (Include Name, Title) ~..-. . ~ MR 6 Rev. 6101 PROGRESS REPORT PROGRESS REPORT Date/Time PROGRESS NOTES: (include Name, Title) MR 6 Rev. 6/Q1 PROGRESS REPORT PENN~TATE Milton S.~ers,h. ey College o~ rneaicmc PROGRESS REPORT Date/Time ~/~/0~_ 'ical Center ' ~:,, ~LE'~ANO~ CORY ~646) 2607~ PROGRESS NOTES: (Include Name, Title) ECs o~v MR 6 Rev. 6/01 PROGRESS REPORT PENNSTATE ~ Milton S. Hers,h. ey Medical ICollcge of M¢oicme Patient: ~EXANDER, CORY L MRN: 364635 Center Health Information Services FIowsheet Print Request Laet 240 Results HU24 ~.griB~d~fi~j: Gridley, Laurie A H=~tf~;L~OFF0~20~ 7:27 AM t39 YELLOW CLEAR NEGATIVE NEGATIVE NEGATIVE t.015 NEGAT~E 7.0 NEGATIVE 0.2 NEGATIVE NEGAT~E NONE NONE NONE NONEDE.. NONE DE... NONE DE... NONE DE... NONE DE... NONE DE.., Page I PENNSTATE ~ Milton S. Hershey Medical ~ College of Medicine Patient: ~BEXANDER, CORY L MRN: 364633 Center Health Information Set-vices glowsheet Print Request Last 240 Results P.l~r~l~d~: Gridley, Laurie A H~d~l~l~koir~2~ 7:27 AM Spiritual ... Page 2 PENNSTATE ~ Milton $. Hershey Medical Center ~ College of Medicine ~e~t~ ~nformation Services Patient: ~[~E'XANDER, CORY L FIowsheet Print Request MRN: 364633 Last 240 Results P.~r~t~j: Grldley, Laurie A H~l~i,t~qr~0~ 7:27 AM ~4.5 85.3 35.2 30.0 t3.0 06/2712... Page 3 PENNSTATE ~ Milton S. Hershey Medical Center ~ College of Medicine Health Information Services Patient: A'B~'XANDER, CORY L Flowsheet Print Request MRN: 364633 Last 240 Results HU24 P.l~rll~t~:~: Gridley, Laurie A Hc~tq4~A~O~l~ 7:27 AM ED Tran... Page 4 Pelvis XR _ (1-2 views) ALEXANDER, CORY L - 364633 PENNbTATE  Milton S, Hershey Medical Center College of Medic,ne Health Information Ser~ces HU24 * Final Report * P.o. Box 850 Hershey, PA 17033-0850 DX PELVIS1-2VIEWS PATIENT NAME: TRAUMA, 364633 PATIENT MRN: 00364633 PATIENT DOB: 01-Jan-1903 EXAM NUMBER: 509C-062402 EXAM: DX PELVIS 1-2 VIEWS ORDERING PHYSICIAN: KYM A SALNESS Exam: Exam: Exam: DX C-SPINE 2-3 VIEWS DX CHEST 1 VIEW - AP , DX PELVIS 1-2 VIEWS CHEST, PELVIS AND C-SPINE CLINICAL HISTORY: 15-year-old male ejected from vehicle in rollover motor vehicle collision. DISCUSSION: There are no prior films. FINDINGS: CHEST: The cardiomediastinal silhouette is within normal limits in size and configuration. The lungs are clear, there are no focal consolidations, effusions or pneumothoraces. The bony structures are unremarkable. PELVIS: There are no fractures. The joint spaces are within normal limits. C-SPINE: Vertebral body heights, intravertebral disc spaces, alignment and precervical soft tissues are within normal limits. There are no fractures. IMPRESSION: 1. There is no radiographic evidence of acute traumatic injury to the chest, pelvis, or C-spine. Films were reviewed with the trauma surgery service at the time they were obtained, June 24, 2002. Dr. Boal reviewed the images and discussed the interpretation with Dr. Pettinger. Pdnted by: Printed on: Gridley, Laurie A 9/29/02 7:27 AM Page 1 of 2 (Continued) Pelvis YxR (1-2 views) PENNbTATE ~ Milton S. Hershey Medical Center DI CTATj OOt~g~of Medicine Ztea~m l~orr,~o, s~ REVIEWE~%ND SIGNED: MARIA T. PETTINGER, M.D./DANIELLE K.B. 1/psc ALEXANDER, CORY L - 364633 HU2,4 ~ff)A~;~ 850. D. Hershey, PA 17033-0850 Printed by: Printed on: Gridley, Laurie A 9/29/02 7:27 AM Page 2 of 2 (End of Report) CXR (1.,-view) ALEXANDER, CORY L - 364633 PENNbTATE  Milton S. Hershey Medical Center College of Medicine Health Information Services HU24 * Final Report * P.o. Box 850 Hershey, PA 17033-0850 DX CHEST1 VIEW-AP, PATIENT NAME: TRAUMA, 364633 PATIENT MRN: 00364633 PATIENT DOB: 01-Jan-1903 EXAM NUMBER: 509B-062402 EXAM: DX CHEST 1 VIEW - AP , ORDERING PHYSICIAN: KYM A SALNESS Exam: Exam: Exam: DX C-SPINE 2-3 VIEWS DX CHEST 1 VIEW - AP , DX PELVIS 1-2 VIEWS CHEST, PELVIS AND C-SPINE CLINICAL HISTORY: 15-year-old male ejected from vehicle in rollover motor vehicle collision. DISCUSSION: There are no prior films. FINDINGS: CHEST: The cardiomediastinal silhouette is within normal limits in size and configuration. The lungs are clear, there are no focal consolidations, effusions or pneumothoraces. The bony structures are unremarkable. PELVIS: There are no fractures. The joint spaces are within normal limits. C-SPINE: Vertebral body heights, intravertebral disc spaces, alignment and precervical soft tissues are within normal limits. There are no fractures. IMPRESSION: 1. There is no radiographic evidence of acute traumatic injury to the chest, pelvis, or C-spine. Films were reviewed with the trauma surgery service at the time they were obtained, June 24, 2002. Dr. Boal reviewed the images and discussed the interpretation with Dr. Pettinger. Printed by: Pdnted on: Gridley, Laurie A 9/29102 7:27 AM Page 1 of 2 (Continued) CXR (l~view) PENNbTATE ~ Milton S. Hershey Medical Center DI CTATE~[I~ C-~[~of Medicine REVIEWE~ND SIGNED: MARIA T. PETTINGER, 1/psc ALEXANDER, CORY L o 364633 He. alth I~fornmOon Services M.D./DANIELLE K.B. HU24 Hershey, PA 17033-0850 Printed by: Printed on: Gridley, Laurie A 9/29/02 7:27 AM Page 2 of 2 (End of Report) An Equal Oppommity University C-spine~XR (2-3 views) ALEXANDER, CORY L - 364633 PENNSTATE  Milton S. Hershey Medical Center College of Medicine Health Information Services I-IU24 * Final Report * P.o. Bo~ 850 Hershey, PA 17033-0850 DX C-SPINE 2-3 VIEWS PATIENT NAME: TRAUMA, 364633 PATIENT MRN: 00364633 PATIENT DOB: 01-Jan-1903 EX~J~ NUMBER: 509A-062402 EXAM: DX C-SPINE 2-3 VIEWS ORDERING PHYSICIAN: KYM A SALNESS Exam: DX C-SPINE 2-3 VIEWS Exam: DX CHEST 1 VIEW - AP , Exam: DX PELVIS 1-2 VIEWS CHESTt PELVIS AND C-SPINE CLINICAL HISTORY: 15-year-old male ejected from vehicle in rollover motor vehicle collision. DISCUSSION: There are no prior films. FINDINGS: CHEST: The cardiomediastinal silhouette is within normal limits in size and configuration. The lungs are clear, there are no focal consolidations, effusions or pneumothoraces. The bony structures are unremarkable. PELVIS: There are no fractures. The joint spaces are within normal limits. C-SPINE: Vertebral body heights, intravertebral disc spaces, alignment and precervical soft tissues are within normal limits. There are no fractures. IMPRESSION: 1. There is no radiographic evidence of acute traumatic injury to the chest, pelvis, or C-spine. Films were reviewed with the trauma surgery service at the time they were obtained, June 24, 2002. Dr. Boal reviewed the images and discussed the interpretation with Dr. Pettinger. Printed by: Printed on: Gridley, Laurie A 9~29~02 7:27 AM Page 1 of 2 (Continued) C-spine..XR (2-3 views) PENNbTATE ~ Milton S, Hershey Medical Center D I CTAT~ Oo~I~of Medictne Health Information Services REVIEWErS'AND SIGNED: MARIA T. PETTINGER, M.D./DANIELLE K.B. 1/psc ALEXANDER, CORY L - 364633 HU24 ~'~7 8~. D. Hershey, PA 17033~0850 Printed by: Printed on: Gridley, Laurie A 9/29/02 7:27 AM Page 2 of 2 (End of Report) Head C~T (unenhanced) ALEXANDER, CORY L ~ 364633 PENNSTATE  Milton S. Hershey Medical Center College of Medicine }te~ath Information Services HU24 * Final Report * P.O. Bo~ 850 Hershey, PA 17033-0850 CT HEAD UNENHANCED-PED PATIENT NAME: ALEXANDER,CORY L PATIENT MRN: 00364633 PATIENT DOB: 23-Jan-1987 EXAM NUMBER: 515A-062402 EXAM: CT HEAD UNENHANCED-PED ORDERING PHYSICIAN: KYM A SALNESS Exam: CT HEAD UNENHANCED-PED BRAIN CLINICAL HISTORY: Multi-trauma. DISCUSSION: There are no comparison studies. TECHNIQUE: A routine unenhanced CT scan of the brain was performed. The ventricles and extraaxial spaces are within normal limits. There is no acute hemorrhage, mass, or midline shift. There are no areas of abnormal attenuation in the brain parenchyma and the bony structures are intact. The visualized paranasal sinuses are clear. These findings were discussed with the trauma team. IMPRESSION: 1. There is no acute hemorrhage or fracture. Dr. McNamara reviewed the images and discussed the interpretation with Dr. Glaiberman. DICTATED: REVIEWED AND SIGNED: /psc CRAIG GLAIBERMAN, M.D./KEVIN P. MCNAMARA, M.D. Printed by: Printed on: Gridley, Laurie A 9/29/02 7:28 AM Page 1 of 1 (End of Report) Hand XJ~ (> 3 view) ALEXANDER, CORY L - 364633 PENNbTATE  Milton S. Hershey Medical Center College of Medicine Health Information Services HU24 * Final Report * P.o. Box 850 Hershey, PA 17033-0850 DX HAND LT3 OR MORE VIEWS-LAT, OBLQ, PA, PATIENT NAME: ALEXANDER, CORY L PATIENT MRN: 00801031 PATIENT DOB: 23-Jan-1987 EXAM NUMBER: 494A-062502 EXAM: DX HAND LT 3 OR MORE VIEWS - LAT, ORDERING PHYSICIAN: ROBERT CILLEY OBLQ, PA , Exam: DX HAND LT 3 OR MORE VIEWS - LAT, OBLQ, PA , HAND CLINICAL HISTORY: Swelling S/P trauma. DISCUSSION: There are no comparison films. There is no radiographic evidence of fracture, dislocation, or acute bony abnormality. There is a moderate amount of soft tissue swelling overlying the middle finger of the left hand. The bony mineralization is age-appropriate. IMPRESSION: Soft tissue swelling overlying the middle finger of the left hand without evidence of acute bony abnormality. Dr. Kathleen Eggli reviewed the images and discussed the interpretation with Dr. Kereshi. DICTATED: 17661 REVIEWED AND SIGNED: 1/jgh TIBOR KERESHI, M.D./KATHLEEN D. EGGLI, M.D. Printed by: Printed on: Gridley, Laurie A 9/29/02 7:28 AM Page '1 of 1 (End of Report) Surg D/~C Summary ALEXANDER, CORY L - 364633 PENNbTATE  Milton S. ~ Hershey Medical Center ~ollege of Medicine ~ealth Information ServicesHU24 * Final Report * P.o. Box 850 Hershey, PA 17033-0850 DISCHARGE S UI~4AR¥ PATIENT NAME: ALEXANDER, PATIENT ~ER: 0364633 LOCATION: 7246 ~EX: M CORY L DATE ADMITTED: DATE DISCHARGED: DATE OF BIRTH: 06/24/2002 06/25/2002 01/23/1987 ADMISSION DIAGNOSES: 1. Status post motor vehicle accident. 2. Closed head injury. 3, Abrasions. DISCHARGE DIAGNOSES: 1. Status post motor vehicle accident. 2. Closed head injury. 3. Abrasions OPERATIONS OR PROCEDURES: None. BRIEF HOSPITAL COURSE: The patient is a 15-year-old male who was brought into the Trauma Bay a~ter being involved in a motor vehicle accident. Initial surveys revealed a closed head injury and multiple abrasions. Trauma films and a left hand film were all negative. Head CT was negative. The patient had an uneventful hospital stay. He had normal sodium on hospital day #2 and was discharged to home with stable vitals/tolerating regular diet/ambulating. DISCHARGE MEDICATIONS: 1. Continue home medications. 2. Tylenol and ibuprofen over-the-counter p.r.n, pain/soreness. 3. Antibiotic ointment to abrasions twice a day. SERVICES FREQUENCY: None. DISCHARGE ORDERS/INSTRUCTIONS: 1. Regular diet. 2. Activity as tolerated. 3. Antibiotic ointment to abrasions two times per day. Printed by: Printed on: Gridley, Laurie A 9/29/02 7:28 AM Page 1 of 2 (Continued) Surg D/,.C Summary ALEXANDER, CORY L - 364633 PENN bTATE greate~a~ol~of~mes Fahrenheit, conf~r~n ~m~tal status, or otherVconcerns. P.o. Box 850 . Hershey PA 1~033-0850 5. Please see the closed head injury instructions and abrasion instructions. FOLLOW-UP APPOINTMENT: Pediatric surgery clinic in two to three weeks. #265939 DICTATING MD: William B. Kilgore, MD ATTENDING MD: Robert E. Cilley, MD WBK/dts D: 06/27/2002 T: 07/02/2002 10:45 c: WP Clerk Printed by: Gridley, Laurie A Page 2 of 2 Printed on: 9/29/02 7:28 AM (End of Report) PENNSTATE  The Mi!.ton S. ~ ey Medical Center The Couege ot ~,,~aicme AMBULATORY HEALTH VISIT NAME: XANDER ~ CORY MD: C. ¥ ROSERT MR#: 801031 COB: 01123/1987 [NS: AUTO INSURANCE LOC: PESU 0OS#: 2576516 MD#; 26076 SEX: M VISIT DATE: 07117/200f [] Health Maintenance I [] Consultation Referred by/Address: Nursing [] Acute Care ,~Follow-up / Medications/Dosage 1. 2. 3. 4. 5. Signature Objective: [ Measurements: IWeight ~'-~;:i'~ Kg[ I Resp, [ [Temp.[ o/01 Length j-~ cm °C[ O[] R© Ax[~ %[ Head Circ. cm. MR 167 Lab Assessment/Diagnosis/Plan 3, 5. Next visit: SIGNATURE 4/85 AMBULATORY H EA L"~-VVl~IT \~[~ See dictation / [] Letter to M. I DATE'/'/,"-~ u'TIME PENNSTATE Milton S. Hershey Medical Center College of Medicine Robert E, Cilley, M.D. Division Chief Peter w. Dillon, M.D. Kerr:,, ill, Fagelman, M.D. Coleen P. Greeeher, M.S., R.D., Nconatal/Pedian/e Nutfitionlst Janet H. Shields, M.S.N., Beverly Shirk, R.N. Our Administrative StalT: Marcia A. Kriek Lee A. Naylor Tina Babbs Our Loeatlon~: Penn State Children's Hospital P.O Box 850 MCHII3 Hershey, PA 17033 Plmn¢: 717-531-8342 Fax: 717-531-4185 Camp Hill/Harrisburg I01 Erford Road. Suite 101 C {ill. PA 17011 P, 717-920-5200 Fax: 717-761-1320 Specializing in the Surgical Care of Infants, Children Babak Behta, M.D. 46 Walnut Bottom Road Shippensburg, PA 17257 July 17, 2002 P,~: ALEXANDER, Corey MSHMC# 801031 Dear Dr. Behta: We saw Corey in follow up after his recent injuries sustained in a motor vehicle crash on June 24,2002. He was in the bed of a pick up track which rolled at a high rate of speed and was thrown from the bed. Another child was killed in the crash. He sustained a concussive head injury without structural brain injury as well as a number of scrapes and bruises. He was amazingly unscathed. Since that time he has had no headaches, nausea, vomiting, visual changes or focal neurologic deficits. His mental status appears normal according to his mom. He has been troubled over the loss ora friend who was killed in the crash. On exam his weight is 53.5 kg. Neck is supple. Lungs are clear. Heart is regular. Abdomen is soft, flat and nontender. Extremities have a number of healing abrasions and lacerations. His left hand and wrist are entirely asymptomatic although there was some initial swelling after the crash with negative x-rays. We will plan on seeing Corey on a pm basis. He is doing fine at this time and has no need for further surgical follow up. Call us for questions. S{'n~erely, / , . .' "h'., ./ :,1,., , '~L~;{,L.~. ~ ' ¥~:-"-' · l RobErt E. Cilley, M.D. REC/asap ~;-.. 1018/02 WALK-IN-CARE .............. S! Tl~s~'~T~-~>'~'or a worker's pemfit physical. Voicing no complaints, He states he is no longer on Zolofr. All he takes is Zyrtec for allergies. States that he just didn't need the Zolofr any more. O:, Well-developed, well-nourished in no acute distress. Weight 124. BP 110/60. HEENT benign. Neck supple. Chest clear. Cot regular rote and rhythm. Abdomen is soil, nontender. Normal male external genitxt/a. Neuromuscular intact. A: Normal exam. P: Work permit completed. Advised follow up for depression as needed. HMI./jeb Alexander, Cory 10/24/02 FP S- Cory is a pt of mine with hx of depression that is doing well on Zolott 50 mg q d. Last time I had seen him on 6/13/02 for this. After that since he was doing so good he decided to get offit, but since then he was in a very serious car accident with his best friend, They were life flighted to Hershey where his, friend ended up dying and Cory survived. Since then he's having a lot of difficulty with depression, crying spells. He's been going to school. This has not affected his school performance a whole lot. Last night he really got emotional. He talked for a long time. He's been fl~ing offthe handle and gettir~' more angry and on his own, he began the Zoloft and took l tablet last night. His mom brought him to talk about options. He has been feeling suicidal on and offbut nothing recently, no plan, he just wished he had died in the accident as well. O- VS stable. Pleasant male in no acute distress. Seems fairly reasonable mood here in the offee, slightly flat affect. HEENT benign. Neck supple, no nodes. Heart/lungs clear. A/P- Fix of depression: exacerbation after traumatic injury and death of a friend. His feelings are nl with feelings of guilt and the grieving process. I reassured him about that and talked about importance of going through this process, talking it over. I think at the same time he d~s have disposition for depression. I think he is getting signs of that back as well. To help him through this, he should resnme the Zoloft 50 mg q d. 4 weeks samples given and I'll see him back in two weeks. He might need a higher dose to get a quicker response and may do that at next visit if he's not having any significant side effects. In the meanwhile, I've asked mom to talk to the teachers at school about him going through this difficult period. Also keep the lines of communication open. Cory promised he will let me know or contact anybody if he's feeling suicidal which he's not currently. I will try to find out if there are any support groups in the area that will be able to help with Cory and his family through this difficult time. Flu in 2 weeks. BB/pc ~,mp , Fulse Alexander, Coty' - . . . · 1~8/02 Family l~actioe .... . $: Cory ii.h~e, for .a...~h_..~.~.gf dep~ss~on. Sin~ the last ti~¢ I saw ~ h~ has be~n dang a little bit b~r ~th li~e Zoloft, still not back to 100% himself, lie flew offthe handl~ the other day dealing with a teacher anti did go and talk to ~e p~lwho ~ an undexstanding of wlr~t he is going tl~oug~ Tla~ w~xe thinkir~ abo~t inc~s~g ~ Z~IoR wllich I ~ is a ~ceson~ble choice. He is not having my symptoms ~om the Zoloft omx~tly and toletsling it olhexwise okay. O: His vital signs axe stable, Heaxt and lungs axe clear. Ex-ix~aities show no sig~s of edema- . · 'llsta withtheT, olofl. We decid~l to inc~se it to 100 MP: pali~nt with dea~ressi°n ~d post-h~m,~c issueS. We Y Othel~ise I will see him hackin 1 month as long ~s he i~ rog. if he has airy probl~rn with it he will let nte kn°W' He will contintte getting cotmSeling t!~ottghthe doing okay and hopefully he is goh~ to coniin~a~ to iulprove. school. BB/jcb ,..../, Alexander, Cory DOB: 1/23/87 11/12/02 WALK IN CLINIC S: 15 y/o patiem of mine with history of depression, has been on Zoloft and recently we increased him to 100 mg ~rorn 50 rog, comes here with a cold with some chills, stomach being gassy and growling and he has had diarrhea now for the last fe ~v days ,md he has bur~ T-eetingn'undown. Therefore xiecided-to me+sere frrr evaluaticm. ~t-cas done well ',vith Zolofi4n {4~e past. --0: -w-;s vita! signs erectable, t4E-E~T i~ beai~ ~ for mild ~. ~ i~4upple witheut 44tenepathy. 14~art ~nrl lung~ cr~ Clear _/klxtr~rnellJ$ falrlyb~ni~on,~:ldbr~ua~'l~q~,mrl~ NI'r~ ~n~rdingl~r re, holed. A/P: l~'mnI with what ~eem~Jike m~stJ.¥ g~qtroentedtis rather th~n reaction to Zolofl ~our~ged to pushlhe fluids. Don't take anything for the diarrhea unless it is persisting more than 7 days at which point then he should have some stool cultures or consider changing Zolot~ if that is part of the problem. Otherwise he will follow up with me as scheduled before. BB/jcb Date [ L--~',4~--~1 _~'-_ ~:mp°t~ Pu!se~ Alexander, Cory 11/14/02 WALK-IN-CAKE S: 15 y/o patient of Dr. Behta's, apparently had a syneopal episode last night. Mom says that his whole body went "limp". She estimates he was out for a minute or so. He also has diarrhe',c Seen on the 12~ of Novernber by Dr. Behta. He is having some post-traumatic stress syndrome symptoms and depression. Present medicines inclcu:le Zolof~ 100 mg qd. Mom wonders if this is too strong and that is entirely possible, When he was seen on the 12~ of November the year 2002, weight was 124 lb, 122 lb today. BP on the 12~ 98/64, BP today 92160. O: Somewhat sullen young man in no acute distress. Chest is dear. Neckis supple. Ear, nose and throat examination is ben~ The abdomen is so~ active bowel sounds, diffuse periurabilical tenderness without maas, rebound or organomegaly. Cranial nerves II-XII are grossly intact. Grip strength is equal. Biceps and triceps reflexes are intact. Gait is normal. Komberg is negative. Neck is supple without bruits. Funduseopi~ examhtation is benign. A: Post-traumatic stress syndrome. 2. Depression. 3. Ongoing enteritis. 4. Syncopal episode. P: Mom wants to decrease the Zolol~ to 50 rog, that is fine. I have given him some Lomofil 2.5 mg 2 now, 1 atter each loose stool. I've asked him to come in and see Dr. Behta next week and they'll be making an appoinUuent. Sebool excuse for yesterday and today was given to Cory. To follow up on an a~ needed basis. JAY/job Alexander, Cory I 1/20/02 Family Practice S: Cory is a patient of mine with recent post traumatic stress syndrome, history of depression, ongoing stress. We have been struggling with Zolofc on and offS0 mg, 100 mg back and forth and continue to have difficulty with it. It overall doesn't seem to be doing a whole lot and he has continued to have difficulty at school; therefore he is here with mom to possibly change his Zolof~ to something else and also consider whether he would benefit from being at h. ome and being taught at home with school teacher coming there rather than going to school for at least a period of time until this is a little bit better managed and resolved. She has talked about this with the assistant principal as well who is also in agreement. Continues to have some depressive symptoms and stress from demands of multiple teachers at school. O: His vital signs are stable. Pleasant male in no acute distress in the office. Seems in a fairly reasonable mood. Not crying. Answering questions very reasonably. A/P: Patient with depression, post traumatic stress syndrome, having stress at work and continuing to have school work suffer. We decided to change his medicine and after some discussion we decided to chose Effexor. We'll start him at 37.5 mg for 2 weeks and then increase to 75 nag. I also gave him a note for school which I think it would be a reasonable idea to consider having him being taught at home until this gets a little bit better managed and take away that stress from multiple teachers and the demands from those from him. I would like to see him back then in a month and see how he is doing with these or sooner if any other problem arises. BB/jcb wt Temp C~,(~ C/e- Pulse., ~ 0 Alexander, Cow 12/30/02 Family Practice S: Cow is here for follow up on his d~pression and post traumatic syndrome. He se~ns to be doing well with the Effexor especially since he has been going to school at home rather than havin~ to go to school. Over the near year was a little bit tough for him especially with his fiSend's birthday coming t~ but he is hansing in there, He is still getting some ootmseling. Denies any suicidal thoughts. Seems to be s611 having a httle di~culty at night but overall improving but they were wonderin~ ffhe could go up a little bit on the Effexor. O: l-Iis vital signs are stable, HEENT is fairly benign. Nook is supple without adenopathy. Heart and lungs are clear, AdP: Patient with depression and post traumatic syndrome. We certainly talked about Effexor and the pediatric use of it. He is about 15 now and that is a little bit risky situation but they understand about that and we decided to just go ahead and increase it to 150 rog. If he has any problems he will let me know right away but otherwise I don't feel comfortable going any higher than that. I will see him back then in about a month to see how he is doing, I've asked him to continue with the counseling and ffany problems let me know. BB/jcb Alexander, Cory 1/31/03 Family Practice S: Cory is here for follow up on his depression. He is doing fantastic. His grades are improving. He is on Effexor 150 mg qd and is having no side effects from that. He is eating well. He is sleeping well. Seems to be back to his usual self O: His vital signs are stable. Hem-t and lungs are clear. Extremities show no signs of edema. A/P: 1 $ y/o with post tranmatie syndrome and depression - doing significantly better. Talking more about what had happened with his friend and tolera~tg Effexor well. I've asked him to continue with the medication at tltis point indefinitely. We'll send him back to school and I think he should be able to do that. He will continue to monitor his activities and try to stay on top of his school work and ffany problem he will let me know. otherV~se ! will see hint back in 3 months. BB/jcb Alexander, Cory 2/3/03 PHONE MESSAGE This is a patient of mine with history of depression and post traumatic stress syndrome that we have been doing at home schooling with his teachers going there and teaching him and keeping up with his work. Was doing really well and doing well with his depression and he and his mom decided that he was ready to go back to school. Today was his first day back at school and they gave him 9 days of catch up work and it stressed him, he flew offthe handle and he had an exacerbation of his problem and he doesn't feel that he can handle going back to school and he really prefers to stay at home. I think that is reasonable at least for the rest of this academic year. But I told him that we need to eventually get him back into school and not just take the easy way out each time. I think since he is just starting to feel better it would be too much for him to try to work through all these issues; therefore I gave him another note to give his school for home teaching and I will see him as we have discussed before. BB/jcb ga ding: ~] Insuraflce [] Injury [] Phone Follow-up [] Rx Refill [] M~llcations [] Referral [] Test Results [] Other Phone No. Completed By Alexander, Coty 512103 Family Practice S: Patient of mine with history of depression here for a follow up. Mom also needs a driver's permit physical done on him as well. He has been doi~4~ really well on the Effexor and doing excellent being taught at home with the teaehars. His grades ~q.q~gipg great. His mood is doing well. He is sleeping well. His appetite is good. O: His vital s~n,s are stable. HEENT is benign. Neck is supple without adenopathy. Heart and lungs are dear. Abdomen is benign. Extremities show no signs of edema. Nettro - alert and oriented x 3. Cranialnerves II-XII are intact. Strength and reflexes are normal. Normal gait. A/P: Depression - doing much bet~r. We'll keep him on the Effexor. I will see hJxn back in 6 months. I gave him a refill for a year. As far as his driver's physical - appropriate forms were filled. BB/jeb ALEXANDER, ~-OR¥ ' .......... 7/5103 WALK'IN'CARE ........... $: l~¥/o~tl~ma~witb,.s~oll~n~,?,d.f~¥~r. Thi~ stated t]~ w~el<, l-Ie h~be~tlirea~th no ~,'. 0 :VS'$ st~bl~. He is ~ebrile nt th~ lime. lie ha~ ~,l~u~ ~lor~ t,he post,or pl~-yn~. Nega~ve nodes. supple. He~ ~, L~ cl. A: 1. S~S~S. P: Do.cycle 1~ mg I ~d f~ 10 ~ys. Ad~ S~ for colestid. ~ ~d ~st. K~heck ~not ~ov~d. ~G/~ Pate 8'i%05 k'~: IS wt 1~'2 BP ~ &, Dae /0 -/?- Wt,-/~.,/ BP Temp y~---~ Pulse Alexander, Cow 10/17/03 Fandly Practice S: Cory is here for a follow up cm. his depression. He is doing fantastic on Effexor. Mom decided to get h/m out of the school so that he is being now home-schooled. He is slacking off a little bit and not doing as much work as he really should be doing but we talked about that a little bit today. O: His vital signs as noted in the chat. HEENT is bemgn. Hem~ and hmgs are clear~ Extremities show no signs of edema. ....... IYPt Depressitrn--"heq. s~doing fantastically. We'll continue with the Effexor and I don't think this would be a good ........... time'for us.-to-stop4t-siiace he is doing so well. I did talk to him at length about the importance of his studies and ..... edncatim~ au&to, stay. an top of those. I will see trim back then itt 6 montlu un/ess any problems arise. BB/jcb S: This is a 16 y/o who stated last night with sudden onset of aches, pains. No t~ver. Chi/Is. Hot/cold flashes. Nausea without vomiting. Diarrhea. Some congestion. Some cough. Note that he is a tobaee0 abtlser. O: Well-developed, well-nourished in no acute distress. Afebrile. TMs ben/gn. Nares patent. Throat ben/gn. Neck supple. Chest clear. Abdomen is soft and nontender, A: Influenza. P: Increase fluids. Avoid m//k, m//k products, and solids for today. Stop smoking. Recommended Imodium over- the-counter. We'll a-eat with Tamiflu 75 mg bid, #10. HML/jcb PENNSTATE Milton $. Hershey Medical Center College of Medicine Coleen P. Greecher, M.S., R.D., N¢onatsl/Pediatric NaMtionist Janet H. Shields, M.S.N., Clinical Narse Specialist Pedlat~c Trauma Nurse Coordinator Beverly Shirk, R.N. Speclaliziag in the Surgical Care of Infants, Children and Adolescents Visit us at: Babak Behta, M.D. 46 Walnut Bottom Road Shippensburg, PA 17257 July 17, 2002 RE: ALEXANDER, Corey MSHMC# 801031 Dear Dr. Behta: We saw Corey in follow up after his recent injuries sustained in a motor vehicle crash on June 24,2002. He was in the bed of a pick up truck which rolled at a high rate of speed and was thrown from the bed. Another child was killed in the crash. He sustained a concussive head injury without structural brain injury as well as a number of scrapes and braises. He was amazingly unscathed. Since that time he has had no headaches, nausea, vomiting, visual changes or focal neurologic deficits. His mental status appears normal according to his mom. He has been troubled over the loss ora friend who was killed in the crash. On exam his weight is 53.5 kg. Neck is supple. Lungs are clear. Heart is regular, Abdomen is soft, fiat and nontender. Extremities have a number of healing abrasions and lacerations. His left hand and wrist are entirely asymptomatic although there was some initial swelling after the crash with negative x-rays. We will plan on seeing Corey on a pm basis. He is doing fine at this time and has no need for further surgical follow up. Call us for questions. '~ S~ erely, ]~ / REC/asap Delxar'anen t of Surge~ Penn Stat~ College of Medicine Milton S. Hershey Medical Center An Equal Oppommity Unlvensity CORY ALEXANDER'S MEDICAL BILLING SUMMARY PROVIDER DATE(S) AMOUNT Chambersburg ALS 6/24/02 $438.35 TOTAL $438.35 TOTAL PAID BY NATIONWIDE $438.35 OUTSTANDING BILLS $0.00 Hershey Medical Center 06/24/02 (Life Lion) 6124/02-6/25102 (hospital) TOTAL TOTAL PAID BY NATIONWIDE TOTAL PAID BY BLUE CROSS $8,873.00 $3,920.52 $12,793.52 $9,561.65 $2,328.78 Physicians Services 6/24/02 (Trauma Evaluation) $1,000.00 (Radiology Spine) $78.00 (Radiology Chest) $56.00 (Pelvis) $43.00 (CT Head) $198.00 (Office Consult) $122.00 6/25/02 (Hosp. Disc) $115.00 (Radiology Hand) $56.00 7/17/02 $50.00 TOTAL $1,718.00 TOTAL PAID BY BLUE SHIELD $369.70 TOTAL MEDICAL BILLS TOTAL PAID BY NATIONWIDE TOTAL PAID BY BLUE CROSS/BLUE SHIELD Note: clients had to pay co-pays to HMC physicians services: 10.10 co-pay 1.70 co-pay 6.50 co-pay $14,949.87 $10,000.00 $2,698.48 State Fa rm Insurance ' DEC ? 200~r 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 The undersigned is a Claim Team Manager for: [] State Farm Mutual Automobile Insurance Company [] State Farm County Mutual Insurance Company of Texas [] State Farm LIoyds, Inc. '[]] State Farm Indemnity Company [] State Farm Florida Insurance Company ONr[te in the name of the appropriate State F~.rm affiliate) Barcode Only This certifies that policy number 7227-212-,38B 88 Dodge Dakota Pickup ,wasissuedto Paul E. Gutshall , covering a and was in effect on the accident date of 6-24-02 A 15/30/5,C2 5,000 liability for this policy on that date were · The coverages and limits of State of Pennsylvania County of Frankl in Subscribed and sworn to before me this 12 day of July ,(Year) 2002 ;: :::';:I, Paul Gutshall, III, do swear and'~ffm'urrder 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 nmnber ') O&-/-- ~ I~:?wiShich provide s liability benefits in the amount of $15~ooo/~o, oo o I do not have any further liability insurance policies covering me as o£ June 24, 2002 and cio not have any type of excess or nmbrelia liability insurance. I also note that any raise statements which are made herein may he snhject to civil and crim'mal penalties as the law may ~low, 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.' ~aul Gutshali, III Subscribed and Sworn to before me this;;~ day of ~o[~ , 2002. Notary Public~)~ ~ My commission expires on: } I-'0~05- NOTARIAL SEAL : { DEBORAH WARREN, Notary Public I Shippensburg, Cumberland County ~ M..y commission Ex~kes Nov, 8, 200?| Document #: 238360.1 ~SEP 1~ '02 15:85 F~ TO ~%?S57654S P.~2784 CENTURY II AUTO POLICY DECLARATIONS Page I of 3 Those Declarer;OhS are a pa~ of the I~i cy named above and Identifl~ by p~lcy num..b~r ,pelow, Th.?¥ ~,Jj)ersede any Declarations Issued earlier. Your policy provides the coverages and limits ShOWn m me schedule,of c~3verages They apply to each Insured vehicle es Indlcatecl. YOUr DOeCy comffles with the motorists financial res~3nslblllty .~ws of your state only for vehicles for which Property Damage end ~odlly Injury Llabf(l~y ctwereges are prOv~ led. Policyholder: Policy Numl~: DB Account Number {Named Insured) 58 37 D 404003 249S67 T~ BURkT'iOLDER & BRUCE ALEXANDER Issued: 156 CHAI,~ERLIN ROAD SHI PPENSBURG, PA FE~ 07, 2002 17257-9713 Pofic¥ Period From: FL=~ 05 2002 to AUG 05 2002 b~ only ff the required pramlun~ for thleperlod has been f:~ld and only for slx month renewal periods If renewal premiums have been paid as required, This policy Is Initially effectk, e at (1) the time the application for Insurance Is competed, or (2) 12:01 a.m. on the first day of the ~x~lcy period, whichever is later. Each renewal period begins and ends a~. 12:0t a.m. standard time a! the e, ddr~.,.s of the named Insured stated herein. This policy cance~s at 12:01 a.m. at the address of the named Insured stated herein. IMPORTANT MESSAGES: C~.ANGES WE'RE PROCESSED EFFECTIVE ON OR AF'FER FEB 04__2002 EI,,~LO~E~ IS A CURRENT COPY OF YOUR POLICY DECL^RATIONS INSURED VEHICLE(S) & SCHEDULE OF COVERAGES I. 1986FOROB,~3flCO Coverages COMPREHENSIVE PROPERTY DNM4GE LIABILITY ~OOILY INJURY LIA~ILITY UNINSURE~ MOTORtSTS-~3OILY INJURY UNDERINSURi~D MOTORISTS-~ILY INJURY TOWING AND LABOR PARTY BENEFITS OPT ION 1 -MEDICAL BENEF1T OPTION 2-1NC(~IE L0~$ ~EHEFIT OPTION 3-ACCIDEN'rAL DEATH BENEFIT OPTION 4-FUNERAL BENEFIT FUt. L TORT 10 ~IF'~OJ14TSGU~80392 Limits Of Liability ACTUAL CASH VALUE L~ $ lOO 100,000 ~ ~R~E 100,000 ~ PE~ _ 300,000 ~ ~ 25,000 EACH PERSON 50,000 EACH OC~URREHCE 25,000 EACH ~Ig~ENT $0,000 EACH r'JCCtJRRI~/~:E 50 EACH DISABLEMENT 10,000 5.0~g TOTAL 1.000 MONTHLY 10.000 2.500 A~O 7100~ FRAME: C 07 Six Month Premium $ 21 .sO $ 89.20 $ 99.80 2357 $ 8.00 2358 23.20 1.80 $ 53.50 i12.50 ,t.20 ,70 TOTAL $ 31-' .30 1992 FORD EXPLORER Coveregee CO~PREHEN3 ~VE PROPERTY DAMAG~ LIABILITY BCOiLY ~NJURY L~ABIL~TY UNINSURED MOTORI$'r$.BOOtLY iNJURY UNDERINeUREO MOTORt~TS-BOOILY INJURY TO~lt,~ AND LA~OR FIRST PARTY BENEFITS OPTION 1-MEDICAL BENEFIT OPTION 2. INCOME LOSS BENEFIT OPTt0N 3-ACCIDENTAL DEATH I~ENEFIT OP'~t0N 4-FUNERAL BENEFIT FUt.L TORT Page 2 ~ 3' iD ~ll~CtJ24X0k~lk$8562 Six Moth LimEs Of UabiiRy Premium ACTUAL CASH VALUE LES~ $ 100 $ $ 100.000 EACti OCCURRENCE $ ?9.20 $ 100,000 EACH PERSON $ ~0,000 F. ACH OCCURRRt~E $ 88,80 E~DORSIg~IENT 2357 25,000 EACtt PERSON 50,000 EACH OCCURRENCE $ 8.00 E~IDORSE~ENT 2358 25,000 E~C;,I I:~RSON 50,000 EA~IOCOJRRENCE $ 23.20 50 EACH DISABLE~Ehr'Ir $ 1.80 5,000 TOTAL 1,000 MONI~LY 12.50 10,000 4.20 2,500 .70 TOTAL $ 297,80 VEHICLE CLASSIFICATIONS Premium Is Based On: 1986 FOFD 1992 FOF~3 USE OF VEHICLE ~EKLY CCI~{UTE PLEASURE 50 MILES RATEO DRIVER ADULT ADULT PRINCIPAL PRINCIPAL UNMARRIED ' ~RRIED APPLIED DISCOUNTS MULTI CAR MULTI CAR HOME & CAR HOME & CAR SPECIAL RATING FULL TORT FULL TORT Policy Fo~m & Endorsements: AU'TO 8000D 2264A 239~ Office Use: ,:EB 06, 200:~ $ 0.00 Issue~ By: NATIONWIDE PROPERTY AND CASUALTY INSURANCE COhIPANY HomeOffice*Columbue, Ohio Counte~slgne~ At: HARR1SBUF~, PA, By: R SUE DAN~ELLO FRAME-' D 07 Policy Numbe¢: 58 ~,7 0 404003 I~ued: F~ 07, 2002 T~ ~7176576545 P.04/04 CENTURY II AUTO POLICY DECLARATIONS Page 3 of 3 Pollcyhold~: (Named Inau~ed) T,V, NY BURl(HOLDER & Policy Period FEB 06, 2002 to AUG 05, 2002 LOSS PAYABLE CLAUSE ENDORSEMENT This endomement al)plies to the Comprehensive and Co,tiGlon coverag,.,s provided by this policy, it ~roteuts the llenho~der named in the p~lcy Declarations. Payment for loss w~l be made accordlnq to the interest of the po!lcyholder end IlenhoIder. Payment may be made [o both Jointly, or to ekher separately. Elfl~er way, the company will protect the Intere.~ts of both. The ilenh~ider's intere~ will be prmec~ed, except from fraud or omissions by ~ha pollcyh~dsr or the po~lcyholder's representative. If the company canc~s or r~uses lo renew the policy, the Ilent older will receive noflce a~ least 10 days before ~roteotlon of I~s InTerest will end. The Ilenhotdcr sh~lT notify the company upon foaming Of any change in ownership of the vehfcle. To the extent of payment to the Ilenho~der, the comDar~y w~l be entitled to the Iienho~der's fights of recovery. The endorsement Is issued by the Nationwide MuluaT insurance Company or NatlorrWlde Mutual Fire insurance Company, whichever has tssui~ the p~icy to which It Is e~teched, NATIONWIDE PROPERTY AND CASUALTY iNSURANCE COMPANY HOME OFFICE: COLUMBUS, OHiO 43115-2220 IMPORTANT PHONE NUMBERS Nat~onwlda 2,~-Hour Claims Number: 1-800-421-3535 Fro' QI. IF_STION$ About Your Policy, Call Your NATiONWiDE AGENT: R. DANGELLO 717-532-6478 For Hearing Impaired: '[TY 1-800622.2421 Nationwide Regional Office: 717-857-64~) FRANE: E 0 7 · * TOTRL PRGE.04 ~* 1001 Hector Street * Suite 300 * Conshohocken, PA 19428 METZGER-WICKERSHAM Clark Devere 3211 NORTH FRONT STREET PO BOX 5300 HARRISBURG, PA 17110-0300 March l7,2003 OUR INSURED: Tammy Burkholder & Bruce Alexander OUR CLAIM NUMBER: 58 37 D 404003 06242002 01 YOUR CLIENT: Cory Alexander DATE OF ACCIDENT: 06-24-2002 Dear Attorney DeVere: This letter will confirm that Nationwide Insurance Company gives consent for your client to settle with the liability carrier State Farm and we are waiving our subrogation rights. I will await Mr. Alexander's medical records and photographs of your client's scarring. NATIONWIDE PROPERTY & CASUALTY iNSURANCE COMPANY Barbara Passanisi Cla'mas Department (610)234-2726 Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. NATIONWIDE INSURANCE FACSIMILE TRANSMITTAL 5HB~T Clark IDeVare, Esq. Nationwide (610) 234-2903 (610) 234-2726 I,,8: Revised Structured Claim Settlement Proposals PROM: Barbara Pas,aNsi, Claim Represenmlive 02/0a/04 06 58 37 D 404003 062402 Cory Alexmder NOTBS/COM/~BNT$: l~nclosed a~e the updated structured dalm settlement pzopo~als that we ~ssed, ~s ~ll confi~ a mt~ ~effi~mt of }35,000 ~d~ $5,~0 payable at ~effiemmt md ~e co~t of ~e ~uiW a~ $30,000. ~e~ let me ~ow which plm i~ acceptable m ~u~ ~mt. PL~E NoTE ~T TP~SE PROPOS~ ~ ~ ~OUGH FEBRU~Y 9, 2004. if you ~d have my quesfio.~, please feel free m c~ me at (610) ~4-2726. This communlc~tlon is confidcnfi~l aaa is in~ended to be int~dcd ~eSpie~% o~ thc employee r~c~vcd ~i~ communlc~on 10111 HECTOR STRBET, SUITF. 300 CONSHOHOCKEN, PA 19424 PHONIC: (610) z~4-272fi I2AX: (ill0) :~4-2903 90/I0'd 8LP6PEELIL~6 0± SNI ]~n±~w B~IMNOI±~N ~ 8E:60 POOE £0 8B~ FEB 11 2004 10:42 FR NATIONWIDE MUTUAL INS TO ~?17234~478 P,04/05 FE~ i1 2004 0~:4~ Today's Date: Name: Date of Birth: February 11, 2004 Cory Alexander January 23, 1987 Male *HT Age: 17 Guaranteed Lump Sum Etenefits: Payable - 0t/23/2005 (age 18). Payable - 01/23/2008 (age 2~). Payable- 01/23/2012 (age 25). LUMP SUM TOTALS: TOTAL STRUCTURE AMOUNT: Cash at Settlement: TOTAL PLAN AMOUNT: Plan #2 Guaranteed Amoun.t: $7,500.00 $12,200.00 $1.5,000.00 $34,700,00 - '$34,70~.0o $5,000.00 $39,700.00 C~os.t: $30,000.00 $30,000.00 $5,000.00 $35,000.00 The Internal Rate of Return is approximately 3.03% and the Tax Equivalent Yield is 4.32%, based on a 30% tax bracket, This proposal is effective through FEBRUARY 18, 2004, This is the date that the funds for the structure must be at the annuity company or this proposal will expire, _ This is an illustratlOll, riot a contract. FEB 11 2004 10:42 FR NA?IONWIDE MUTUAL INS TO ql7172349478 P.02×0S ~'INANCJAL SETTLEMEN. T SERVI~C:£S Prorating Struccuroc] So)ut'tons' February 1 l, 2004 TO: Barbara Passanlsi RE: Cory Alexander 5837 D 404003 06/24/02 The following plans are effective until 02/1812004. They are based upon a date of birth of 01/23/1987 for Cory Alexander. Normal life expectancy is approximately 81 years. These plans are from Hartford Life Insurance Company. This Company is rated by A.M, ~est as A+ (Superior), Class Size XV. This Hartford case would include a Qualified Assignment to Hartford Comprehensive Employee Benefit Service Company (Hartford - CEBSCO), which wilI be the owner of/he policy. Financial Settlement Services will request an Evidence of Guarantee from Hartford Life Insurance Company and Ha~ord Life, Inc, (HLI), guaranteeing the obligations assigned to Hariford-CEBSCO. This guarantee is issued with the policy and is not part of the Release and Qualified Assignment. you need fine tuning of these plans, or I can help in any way, please call. Thank You Michelle Toizk. e ~0 80X ~103, W~u, wi ~1402-g103 Voi¢~ (~00) 9P3,9931 e~ ?? F~ (gOO) Olg-pl ~'/ 2004 10:4~ FN NAT;ONWIDE MUTUAL INS TO °~?172349478 DATE: As ef July 2003 TO: Financial Settlement Services (FSS) Clients SUBJECT: Hartford Ratings The following is a summary of the current ratings for Hartford Life Insurance Company. Hartford is a highly rated company I)y the various rating organizations, This Hartford case would include a Qualified Assignment to Hartford Comprehensive Employee Benefit Service Company (Hartford - CEBSCO). Financial Settlement Services will request an Evidence of Guarantee from Hartford Life Insurance Company and Hartford Life, Inc, (HLI), guaranteeing the obligations assigned to Hartford - CEBSCO. This guarantee is issued with the policy and is not part of the Release and Qualified Assignment. Hartford Life Insurance Company ratings are as follows: Rating .Organization HartfOrd LEe. (provider and guarantor) A.M. Be~t Rating & Size A+ (XV) Moody's Aa3 Standard & Poor's AA- Fitch ~ Should you need any additional information, please call FSS (800) 993-9931. TOTAL PAGE. TOTAL PAGE.OS ~ CONTINGENT FEE AGREEMENT 8, --Fcu~r,,~ ff:~rZh~l&~', individually and as parent(s) and natural guardian(s) of (~r~¢.-[ (~[e~cc~4,er , retain and authorize the law firm of Metzger, Wickersham, Knauss & Erb, P.C., to do whatever they deem necessary or desirable in order to represent my son in all claims for compensation and reimbursement for personal injuries, wage loss, and economic and other damages resulting from an accident that occurred on 1. Attorney'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 LitiRation: Actual expenses incurred on the business of the client shall be borne by the client and my attorney shall be reimbursed out of the balance, after deduction of attorneys fees, of any recovery for all legal expenses incurred in the prosecution of this claim which have not already been paid by me. We do hereby agree to pay all expenses incurred by our attorney in the preparation and presentation of this case and do understand that these expenses include, but may not be limited to, costs of medical reports and records, stenographic expenses connected with depositions, expert witness fees, photocopying charges, and mileage charges connected with the rendering of legal services. We understand that we are responsible for payment of these expenses regardless of the eventual outcome of the case and further understand that if our 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 #: 234150.1 3. We hereby further agree that our attomey 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 attomey 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 fnma shall be entitled to reasonable compensation for all work done on the case up to that point. We agree that reasonable compensation for Clark DeVere, Esquire, or any other attorney involved in the handling of this case, shall be Two Hundred Dollars ($200.00) per hour, or such higher rate as shall constitute his standard billing rate at the time that the work is performed or the agreed upon percentage fee of one-third of any ultimate recovery, whichever is greater. 8. We agree that our attorney may withdraw from this case at any time after reasonable notice to us, and we agree to keep him advised of our whereabouts at all times and to cooperate at all times in the preparation and trial of this case, to appear upon reasonable notice for depositions and Court appearances, and to comply with all reasonable requests made of us in connection with the preparation and presentation of this case. Document #: 182430,1 -2- 9. We also understand that if the investigation 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 ttmaed 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 ned below on this ~ ~clay of ~/q/-e,,~/~q~, 2002. CLIENT' ? CLIENT: METZGER, WICKERSHAM, KNAUSS & ERB, P.C. ATTORNEY: Clark DeVere, Esquire Document #: 182430.1 -3- RELEASE AND SETTLEMENT AGREEMENT The undersigned, TAMMY BURKHOLDER, individually and as the parent and legal guardian of the minor CORY ALEXANDER (hereinafter referred to as "Releasor"), declare that, for and in consideration of SIX THOUSAND and NO/100 DOLLARS ($6,000.00), the receipt of which is hereby acknowledged, for herself, her heirs, administrators, successors and assigns, and for Cory Alexander, 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 fi.om 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 no~t release, acquit or discharge any claim, actions and/or fight 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 fi.om any entity, but specifically excluding Paul E. Gutshall, Jr., Paul E. Gutshall, III and their liability insurer, State Farm Mutual Automobile Insurance Company It is understood and agreed that Releasor also specifically preserves and does not release, acquit or discharge their right to continue to make claims and/or recover for uninsured and/or underinsured motorist coverage. Document #297877.1 It is understood and agreed that Releasor specifically preserves and does not release, acquit or discharge any claim and/or action they may have against any medical provider for any treatment or lack of treatment, including malpractice. It is understood and agreed that this settlement is a compromise ora disputed claim, and that payment made is not to be construed as an admission of liability on the part of the parties hereby released, and that said Releasees deny liability and intend merely to finalize and avoid litigation and buy their peace. It is further understood and agreed that this is the complete Release and Settlement Agreement, and that there are no written or oral understandings, or agreements, directly or indirectly connected with this Release and Settlement Agreement that are not incorporated herein. It is expressly understood and agreed that this Agreement and Release shall be binding upon and inure to the benefit of the successors, assigns, heirs, executors, administrators, and legal representatives of both Tammy Burkholder, individually and as the parent and legal guardian of the minor, Cory Alexander and Cory Alexander, individually, and the Releasees. TAMMY BURKHOLDER, INDIVIDUALLY, AND AS THE PARENT AND LEGAL GUARDIAN OF THE MINOR, CORY ALEXANDER, HEREBY DECLARES THAT THE TERMS OF THIS RELEASE AND SETTLEMENT AGREEMENT HAVE BEEN COMPLETELY READ; THAT SHE HAD THE OPPORTUNITY TO DISCUSS THE TERMS OF THIS SETTLEMENT WITH LEGAL COUNSEL OF HER CHOICE; AND THAT SAID TERMS ARE FULLY UNDERSTOOD AND VOLUNTARILY ACCEPTED FOR THE PURPOSE OF MAKING A FULL AND FINAL COMPROMISE OF ANY AND ALL CLAIMS AGAINST THE RELEASED PARTIES ON ACCOUNT OF THE DAMAGES AND LOSSES MENTIONED ABOVE AND FURTHER FOR THE EXPRESS PURPOSE OF PRECLUDING FOREVER ANY FURTHER OR ADDITIONAL SUITS AGAINST THE RELEASED PARTIES BY HERSELF OR BY OR ON BEHALF OF THE MINOR, CORY ALEXANDER, ARISING OUT OF THE AFORESAID CLAIMS. This Release is executed in accordance with the Court Order dated ., 2004, in the Court of Common Pleas of Cumberland County at Docket No. and will be interpreted consistent with that Order. A copy of the Order is attached hereto as Exhibit "A" and incorporated herein by reference. Document #297877. The payment of $6,000.00 constitutes damages on account of personal injury or sickness in a case involving physical injury or sickness within the meaning of IRC § 104(a)(2). This Settlement Agreement is entered into in the State of Pennsylvania and shall be construed and interpreted in accordance with its laws. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ,2004. day of CAUTION, READ BEFORE SIGNING Tammy Burkholder, individually and as the parent and legal guardian of Cory Alexander On this day of ,2004, before me personally appeared Tammy Burkholder, known to me as the person who executed the foregoing Release, and who acknowledged to me that she voluntarily executed NOTARY PUBLIC Clark DeVere, Esquire, counsel for Tammy Burkholder, individually and as the parent and legal guardian of Cory Alexander Document #297877.1 RELEASE AGREEMENT This Release Agreement ("Agreement") is entered into among Cory Alexander, a minor, by his parents and natural guardians, Tammy Burkholder and Bruce Alexander, Tammy Burkholder and Bruce Alexander, individually; and Nationwide Property and Casualty Insurance Company (hereinafter collectively referred to as "the Parties"). The "Insured" shall collectively mean Cory Alexander, a minor, by his parents and natural guardians, Tammy Burkholder and Bruce Alexander, and Tammy Burkholder and Bruce Alexander, individually, their respective heirs, executors, administrators, personal representatives, successors and assigns; and the "Insurance Company" shall mean Nationwide Property and Casualty Insurance Company, its successors and assigns. I. RECITALS A. On or about June 24, 2002, at or near Newburg Road (Route 641), Hopewell Township, Cumberland County, Pennsylvania, Cory Alexander sustained personal injuries as a result of an automobile accident (hereinafter referred to as the "Occurrence"). In connection with the Occurrence, the Insured has asserted a claim against Nationwide Property and Casualty Insurance Company. B. The Parties desire to enter into this Agreement to provide, among other things, for certain payments in full settlement and discharge of all claims and actions of the Insured for damages arising out of or due to the Occurrence, on the terms and conditions set forth herein. NOW THEREFORE, it is hereby agreed as follows: II. UNDERINSURED MOTORIST RELEASE AGREEMENT Know all men by these presents: That, for sole consideration of the cash payment(s) referred to in Paragraph IV.A, the receipt of which is hereby acknowledged, and the promise to make the periodic payments referred to in Paragraphs IV.B.(1) and (2) from the Insurance Company, the Insured in his/her capacity as an insured does hereby forever release and discharge the Insurance Company of and from all claims of whatsoever kind and nature prior to and including the date hereof growing out of the Underinsured Motorist Coverage of an Automobile Insurance Policy number 5837 D 404003 issued by the Insurance Company to Tammy Burkholder and Bruce Alexander, and resulting from the Occurrence. III. INJURIES KNOWN AND UNKNOWN The Insured fully understands that the Insured may have suffered personal injuries that are unknown to the Insured at present and that unknown complications of present known injuries may arise, develop or be discovered in the future, including, but not limited to, subsequent death or disability. The Insured acknowledges that the consideration received under this Agreement is intended to and does release and discharge the Insurance Company for any claims for, or consequences arising from, such injudes and the Occurrence; and the Insured hereby waives any rights to assed in the future any claims not now known or suspected even though, if such claims were known, such knowledge would materially affect the terms of this Agreement. IV. PAYMENTS TO INSURED A. Cash at Settlement (and Amounts Previously Paid). The Insurance Company has paid Five Thousand Dollars ($5,000) to the Insured, and Insured's counsel, Clark DeVere, receipt of which is hereby acknowledged. This includes, but is not limited to, all out of pocket expenses, attorney fees, all medical liens, all dghts of recovery, all medical subrogation claims, all workers' compensation subrogation claims, known and unknown, and claims for general damages. B. Periodic Payments. The Insurance Company hereby agrees to pay or cause to be paid the following Periodic Payments: (1) To Cory Alexander ("Payee") the following guaranteed lump sum payments: Seven Thousand Five Hundred Dollars ($7,500) on or about January 23, 2005. Twelve Thousand Two Hundred Dollars ($12,200) on or about January 23, 2008. Fifteen Thousand Dollars ($15,000) on or about January 23, 2012. (2) Should Cory Alexander die before January 23, 2012, then the remaining guaranteed payments set forth in Paragraph IV.B.(1) shall instead be paid, as they become due, to the estate of Cory Alexander ("Beneficiary"), with the last payment to be made on or about January 23, 2012. (3) Cory Alexander shall have the right, after reaching the age of majority, to submit a request to change the Beneficiary by filing a written request with the owner of the 2 annuity. This request will be reviewed by the owner of the annuity, and if approved by the owner of the annuity and the issuing annuity company it will become effective. Said request will be made in writing by Cory Alexander. C. Nature of Payments. All sums set forth in this Paragraph IV constitute damages on account of personal injudes or sickness, adsing from the Occurrence, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. V. FINANCING OF PERIODIC PAYMENT OBLIGATION A. Assiqnment of Obliqation. It is understood and agreed by and between the Parties hereto that the Insurance Company may, as a matter of right and in its sole discretion, assign its duties and obligations to make such future payments as set forth in Paragraphs IV.B.(I) and (2) to Hartford Comprehensive Employee Benefit Service Company ("Assignee") pursuant to a "Qualified Assignment and Release," within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as amended, attached as ExhibitA. When the Pedodic Payment obligation is assigned to Hartford Comprehensive Employee Benefit Service Company, Hartford Life, Incorporated, and Hartford Life Insurance Company, have represented that they will provide written guarantees of such obligation in the forms attached as Exhibit B and C. Such assignment is hereby accepted by the Insured without dght of rejection and in full discharge and release of the duties and obligations of the Insurance Company and all Parties released by this Agreement with respect to such future payments. If the Insurance Company assigns the duties and obligations as provided herein, it is understood and agreed by and between the Parties that Hartford Comprehensive Employee Benefit Service Company, as the assignee, shall make said future payments directly to the respective payees designated in Paragraphs IV.B.(1) and (2). The Parties expressly understand and agree that, with the Insurance Company's assignment of the duties and obligations to make such Periodic Payments to Hartford Comprehensive Employee Benefit Service Company pursuant to this Agreement, all of the duties and responsibilities otherwise imposed upon the Insurance Company by this Agreement with respect to such Periodic Payments shall cease, and instead such obligation shall be binding solely upon Hartford Comprehensive Employee Benefit Service Company. The Parties further understand and agree that when the assignment is made, the Insurance Company shall be released from all obligations to make such Periodic Payments and Hartford Comprehensive Employee Benefit Service Company shall at all times be directly and solely responsible for, and shall receive credit for, the Pedodic Payments, and that when the assignment is made, Hartford Comprehensive Employee Benefit Service Company assumes the duties and responsibilities of the Insurance Company with respect to such Periodic Payments. B. Third Party Payment. It is further understood and agreed by the Parties that all future payments as set forth in Paragraphs IV.B.(1) and (2) may, solely at the option of the Insurance Company, or its assignee, Hartford Comprehensive Employee Benefit Service Company, be financed by the purchase of an Annuity Contract from Hartford Life Insurance Company (the "Annuity Contract"). When such an Annuity Contract is purchased, the assignee, Hartford Comprehensive Employee Benefit Service Company shall be the owner of the Annuity Contract and shall have and retain all rights of ownership in the Annuity Contract. For its own convenience, the assignee shall direct Hartford Life Insurance Company to make all periodic payments directly to the respective payees designated in Paragraphs IV.B.(1)and (2). Such payments will be applied against the obligation of the Insurance Company or its assignee and shall operate as a pro tanto discharge of the scheduled obligations set forth in this Agreement. C. Status of Insured. The Insured shall, at all times, remain a general creditor of the Insurance Company or its assignee and shall have no rights in the Annuity Contract nor in any other assets of the Insurance Company or its assignee. The Insurance Company or its assignee shall not be required to set aside sufficient assets or secure its obligation to the Insured in any manner whatsoever. The Insured acknowledges that the Insured has no dght to receive the present value of the payments due the Insured pursuant to Paragraphs IV.B.(1) and (2), or to control the investment of, or accelerate, defer, increase or decrease the amount of any payments required to be made to the Insured. The Insured shall only be entitled to receive the payments specified in Paragraphs IV.B.(1) and (2), as they are due. VI. NO CHANGES IN FUTURE PAYMENTS Neither Cory Alexander, his estate, nor any subsequent beneficiary or recipient of any payments or any part of the payments under this Agreement, shall have the right to, and may otherwise be prohibited or restricted under applicable law to accelerate, commute, or otherwise reduce to present value or to a lump sum any of the payments or any part of the payments due under this Agreement. Neither Cory Alexander, his estate, nor any subsequent beneficiary or recipient shall have the right to transfer, assign, anticipate, mortgage, or otherwise encumber in advance any payments or any part of any payments due under this Agreement. Any transfer of the periodic payments by the Insured may subject the Insured to serious adverse tax consequences. VII, ADEQUATE CONSIDERATION The Insured agrees and acknowledges that the Insured accepts payment of the sums that the Insured is to' receive pursuant to this Agreement as a full, complete, final and binding compromise of matters involving disputed issues regardless of whether too much or too little may have been paid, VIII. ENTIRE AGREEMENT This Agreement contains the entire agreement between the Insured and the Insurance Company with regard to the matters set forth herein. There are no other understandings or agreements, verbal or otherwise, in relation thereto, between the Parties except as herein expressly set forth. IX. READING OF AGREEMENT In entering into this Agreement, the Insured represents that the Insured has completely read all terms hereof and that such terms are fully understood and voluntarily accepted by the Insured. The Insured has been represented by counsel of the Insured's choice, ×. FUTURE COOPERATION All Parties agree to cooperate fully, to execute any and all supplementary documents and to take all additional actions that may be necessary or appropriate to give full force and effect to the terms and intent of this Agreement which are not inconsistent with its terms. XI. DRAFTING OF DOCUMENT AND RELIANCE BY INSURED This Agreement has been negotiated by the respective Parties through counsel. The Insured warrants, represents and agrees that the Insured is not relying on the advice of the Insurance Company, or anyone associated with them as to the legal and income tax or other consequences of any kind arising out of this Agreement. Accordingly, the Insured hereby releases and holds harmless the Insurance Company, and any and all counsel or consultants for them from any claim, cause of action or other rights of any kind which Insured may assert because the )egai, income tax or other consequences of this Agreement are other than those anticipated by the Insured. The undersigned, and each of them, warrant and represent that no premise, inducement or agreement not herein expressed has been made to them and that this Agreement constitutes the entire agreement between the Parties hereto and that the terms of this Agreement are contractual and not mere recitals. The undersigned, and each of them, have read the foregoing Agreement and fully understand it, and have been advised by counsel of their own choosing as to the propriety and legal effect of executing the same, and neither the Agreement nor the compromise and settlement recited herein were induced by fraud, coercion, compulsion or mistake, nor is this Agreement nor the compromise and settlement made by the undersigned in reliance upon any statement or representation of any of the Parties hereby released, or their representatives, agents or attorneys. Xll. COURT APPROVAL The Parties agree that the Insured will file petitions for all necessary court approvals, that all such petitions and orders shall be in a form satisfactory to all Parties, and that this Agreement will not be effective until such approvals have been obtained. XIII. CONTROLLING LAW This Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. Dated: Tammy Burkholder, individually and as parent and natural guardian of Cory Alexander, a minor, Insured Dated: Bruce Alexander, individually and as parent and natural guardian of Cory Alexander, a minor, Insured Dated: Duly Authorized Representative for Nationwide Property and Casualty Insurance Company Dated: Clark DeVere, Counsel for Insured APPLICABLE TO PENNSYLVANIA ONLY: For your protection, Pennsylvania requires the following to appear on this form: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Exhibit A Uniform Qualified Assignment and Release "Claimant" Cory Alexander, by his parents and natural guardians, Tammy Burkholder and Bruce Alexander "Assignor" Nationwide Property and Casualty Insurance Company "Assignee" Hartford Comprehensive Employee Benefit Service Company "Annu.ity Issuer" Hartford Life Insurance Company "Effective Date" This Agreement is made and entered into by and between the parties hereto as of the Effective Date with reference to the following facts: Claimant has executed a settlement agreement or release dated ,2004 (the "Settlement Agreement") that provides for the Assignor to make certain periodic payments to or for the benefit of the Claimant as stated in Addendum No. 1 (the "Periodic Payments"); and B. The parties desire to effect a "qualified assignment" within the meaning and subject to the conditions of Section 130(c) of the Internal Revenue Code of t986 (the "Code"). NOW, THEREFORE, in consideration of the foregoing and other good and valuable consideration, the parties agree as follows: The Assignor hereby assigns and the Assignee hereby assumes all of the Assignor's liability to make the Periodic Payments. The Assignee assumes no liability to make any payment not specified in Addendum No. 1. The Periodic Payments constitute damages on account of personal injury or sickness in a case involving physical injury or physical sickness within the meaning of Sections 104(a)(2) and 130(c) of the Code. The Assignee's liability to make the Periodic Payments is no greater than that of the Assignor immediately preceding this Agreement. Assignee is not required to set aside specific assets to secure the Periodic Payments. The Claimant has no rights against the Assignee greater than a general creditor. None of the Periodic Payments may be accelerated, deferred, increased or decreased and may not be anticipated, sold, assigned or encumbered. The obligation assumed by Assignee with respect to any required payment shall be discharged upon the mailing on or before the due date of a valid check in the amount specified to the address of record. This Agreement shall be governed by and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. The Assignee may fund the Periodic Payments by purchasing a "qualified funding asset" within the meaning of Section 130(d) of the Code in the form of an annuity contract issued by the Annuity Issuer. All rights of ownership and control of such annuity contract shall be and remain vested in the Assignee exclusively. The Assignee may have the Annuity Issuer send payments under any "qualified funding asset" purchased hereunder directly to the payee(s) specified in Addendum No. 1. Such direction of payments shall be solely for the Assignee's convenience and shall not provide the Claimant or any payee with any rights of ownership or control over the "qualified funding asset" or against the Annuity Issuer. Assignee's liability to make the Periodic Payments shall continue without diminution regardless of any bankruptcy or insolvency of the Assignor. In the event the Settlement Agreement is declared terminated by a court of law or in the event that Section 130(c) of the Code has not been satisfied, this Agreement shall terminate. The Assignee shall then assign ownership of any "qualified funding asset" purchased hereunder to Assignor, and Assignee's liability for the Pedodic Payments shall terminate. 10. This Agreement shall be binding upon the respective representatives, heirs, successors and assigns of the Claimant, the Assignor and the Assignee and upon any person or entity that may assert any right hereunder or to any of the Periodic Payments. 11. The Claimant hereby accepts Assignee's assumption of all liability for the Periodic Payments and hereby releases the Assignor from all liability for the Periodic Payments. Assignor: Nationwide Property and Casualty insurance Company By: Authorized Representative Title Assignee: Hartford Comprehensive Benefit Service Companv By: Authorized Representative Title Employee Claimant: Tammy Burkholder, as parent and natural guardian of Cory Alexander, a minor Claimant: Bruce Alexander, as parent and natural guardian of Cory Alexander, a minor Approved as toFormand Content: By: Claimant's Attorney Clark DeVere I Addendum No. 1 Description of Periodic Payments The following Periodic Payments: (1) To Cory Alexander ("Payee") the following guaranteed lump sum payments: Seven Thousand Five Hundred Dollars ($7,500) on or about January 23, 2005. Twelve Thousand Two Hundred Dollars ($12,200) on or about January 23, 2008. Fifteen Thousand Dollars ($15,000) on or about January 23, 2012. (2) Should Cory Alexander die before January 23, 2012, then the remaining guaranteed payments set forth in paragraph (1) shall instead be paid, as they become due, to the estate of Cory Alexander ("Beneficiary"), with the last payment to be made on or about January 23, 2012. (3) Cory Alexander shall have the right, after reaching the age of majority, to submit a request to change the Beneficiary by filing a written request with the owner of the annuity. This request will be reviewed by the owner of the annuity, and if approved by the owner of the annuity and the issuing annuity company it will become effective. Said request will be made in writing by Cory Alexander. Initials Claimant: Claimant: Tammy Burkholder Bruce Alexander Assignor: Nationwide Assi¢mee: Hartford CEBSCO VERIFICATION I, Tammy Burkholder, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Plaintiff's Compromise Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Plaintiff's Compromise Settlement, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Plaintiff's Compromise Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unswom falsification to author/ties. D~ed: March 10, 2004~ Tammy B/arkholder Document #298695.1 VERIFICATION I, Tammy Burkholder, as parent and natural guardian of minor Cory Alexander, 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. ][ have read the Petition for Approval of Minor Plaintiff's Compromise Settlement, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Plaintiff's Compromise Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to tmsworn falsification to authorities. Dated: l~larch 10, 2004~x"~ammyBu~l~holder, as pa~'el~t and natural guardian to Cory Alexander Document #298695.1 VERIFICATION I, Bruce Alexander, Jr., hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor PlaintifFs Compromise Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor PlaintifFs Compromise Settlement, and to the extent that it is based upon information which I have given to counsel, it is 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 tlnsworn falsification to authorities. D~ed: March 10, 2004 Bruce Alexander, Jr. ~ Document #29869§.1 VERIFICATION I, Brace Alexander, Jr., as parent and natural guardian of minor Cory Alexander, 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 PlaintiWs Compromise Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Plaintiff's Compromise Settlement, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel, I have relied upon such counsel in making this Verification. 1 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. Dated: March 10, 2004 Bruce Alexander, Jr., as pare~ffmd natural guardian to Cory Alexander Document #298695. ] VERIFICATION The undersigned hereby certifies that he is the attorney for Petitioners Tammy Burkholder and Brace Alexander, Jr., as parents and natural guardians of minor Cory Alexander, and Cory Alexander and that the facts in the foregoing Petition for Approval of Minor Plaintiff's Compromise Settlement are tree 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 Cory Alexander, by Tammy Burkholder and Brace Alexander, Jr., 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 unswom falsification to authorities. Dated: March I 1, 2004 Clark DeVere, Esquire Document #298695.1 CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and correct copy of the forgoing Petition to Seek Approval of Minor Settlement with reference to the foregoing action by first class mail, prepaid postage, this 1 lth day of March, 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 Barbara Passanisi Claims Department Nationwide Mutual Insurance Company 1001 Hector Street, Suite 300 Conshohocken, PA 19428 Clark DeV~re, E[quire Document #298695.1 IN RE: CORY ALEXANDER IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ~P~IL~Y£ CCL~IT Di¥1glON DECREE AND NOW, this zZ'~day of ¢~a,,,O,, ,2004, upon consideration of the Petition for Approval of Minor Settlement, it is hereby ORDEPdED and DECREED that the settlement for the gross sum of Forty-one Thousand Dollars ($41,000.00) 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) (2) (3) To be paid to Tammy Burkholder, who is the appointed guardian of Cory Alexander for the purposes of this Petition, the stun of $483.79 for the immediate benefit of Cory Alexander; To be paid to Metzger, Wickersham, P.C. for counsel fees and expenses - the sum of $10,516.21; and The balance of $ 30,000.00 to be transferred by Nationwide Mutoal Insurance Company to Hartford Life Insurance Company to set up a structured settlement account. The structured settlement account will pay the following guaranteed lump sums to Cory Alexander at the following ages: $ 7,500.00 guaranteed lump sum, payable on 1-23-05; $12,200 guaranteed lump sum, payable on 1-23-08; and $15,000 guaranteed lump sum, payable on 1-23-12. The benefits are tax-free guaranteed benefits, which will be payable to Cory Alexander 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 Document #298695.1 shall be designated in writing by him to Hartford Life Insurance Company. Tammy Burkholder, as parent and natural guardian of Cory Alexander, is authorized to sign the Releases and Structured Settlement Agreement, attached to the Petition, and discontinue this action upon delivery of the cash payment totaling $11,000.00 and the transfer of the remaining fimds into the structured settlement account. CC: BY THE COURT: C~/llarkDeVere, Esquire Counsel for Petition _ Heidi Sailer-Judy, Claims Representative, _~_tat.e~Farm Mutual Automobile Ins. Co. Barbara Passanisi, Claims Representative, ~ftionwide Mutual Insurance Company v . 298695-1