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HomeMy WebLinkAbout08-14-08SICARLATOS & ZONARICH LLP John R. Zonarich, Esq. Jahn B. Zonarich, Esq. N Skarlatos & Zonarich Building C7 ~ - 17 South Second Street, 6`h Floor -=,. C~ "' _ - Harrisburg, Pennsylvania ] 7101 ,_-'~~ Telephone: (717) 233-1000 ~_ ~~~- ~~ ~ ,-'~ Facsimile: (717) 233-6740 = C;.~; "' _ .~ ~ Email: jrz@skarlatoszonarich.com .. ~ - ... ~ jbz@skarlatoszonarich.com _ : ~ -r~ ~ ,~ _ ~. Attorneys for Petitioners _ -; ___:j c,.3 Terrence J. Ficco and Deborah A. Ficco, ~,~, ' Parents and Natural Guardians of C~ Abby N. Ficco, a minor IN RE: ABBY N. FICCO, a minor IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Orphans' Court Division No. `~, ~ b~ v~y3 PETITION FOR APPROVAL OF MINOR'S SETTLEMENT 'TO THE HONORABLE, THE JUDGES OF THE SAID COURT: Pursuant to Pa. R.C.P. No. 2039, Terrence J. Ficco and Deborah A. Ficco, the parents and natural guardians of minor Abby N. Ficco, by and through their attorneys, Skarlatos & Zonarich LLP, petitions this Court to enter an order permitting settlement in compromise of this action, and in support avers the following: BACKGROUND 1. Terrence J. Ficco and Deborah A. Ficco are the parents and natural guardians of the minor-plaintiff Abby N. Ficco, wha was born on February 14, 1997, and who is presently eleven (11) years of age. 2. Abby N. Ficco, the minor-plaintiff, resides with her parents and natural guardians, Terrence J. Ficco and Deborah A. Ficco, at 414 Norman Road, Camp Hill, Cumberland County, Pennsylvania. ACCIDENT AND INJURIES 3. Abby N. Ficco, the minor-plaintiff, was injured on November 30, 2007, on Route T6 (the "Pennsylvania Turnpike") in Hopewell Township, Cumberland County, Pennsylvania, when she was riding as a passenger in the vehicle driven by her father, Terrence J. Ficco, which was struck by a vehicle driven by Derek Devlin. The impact of the collision forced the vehicle driven by Terrence J. Ficco to swerve to its left and collide into the concrete medial barrier with its left front side. A copy of the Pennsylvania State Police Accident Report is attached hereto as Exhibit "1 ". 4. Abby N. Ficco, the minor-plaintiff, was transported from the scene of the accident on November 30, 2007 to the Milton S. Hershey Medical Center where she remained until January 16, 2008. The injuries sustained by Abby N. Ficco, the minor-plaintiff, were a C4 fracture and C3-4 ligamentous disruption. A copy of Hershey Medical Center's Discharge Summary is attached hereto as Exhibit " 2". 5. Abby N. Ficco, the minor-plaintiff, has not fully recovered from all of her injuries. Presently, she is living at home with her parents, Terrence J. Ficco and Deborah A. Ficco, and attending physical therapy four (4) times per week. She currently uses afour-point walker to assist with walking. She is able to perform most of her daily activities without assistance. 6. The medical expenses of Abby N. Ficco, the minor-plaintiff, relating to the accident were paid by Highmark and the Pennsylvania Department of Public Welfare. -2- LEGAL COUNSEL AND INVESTIGATION 7. On December 5, 2007, Terrence J. Ficco and Deborah A. Ficco, the parents and natural guardians of the minor-plaintiff Abby N. Ficco, retained Skarlatos & Zonarich LLP to represent Abby N. Ficco in matters arising from the November 30, 2007 automobile crash on a contingent fee basis. A copy of the Fee Contract is attached as Exhibit " 3". 8. Upon investigation, the undersigned counsel for the minor-plaintiff Abby N. Ficco determined that the defendant tortfeasor Derek Devlin, was twenty-six (26) years of age at the time of the accident and was insured by New Hampshire Indemnity ("AIG") under a policy of insurance with liability limits of fifteen thousand dollars ($15,000.00). A copy of the insurance coverage printout for Derek Devlin is attached as Exhibit "4". 9. Upon investigation, the undersigned counsel for the minor-plaintiff Abby N. :Ficco determined that the minor-plaintiff Abby N. Ficco was covered on the date of the accident by a policy of insurance issued by Donegal Insurance Group with underinsured motorist bodily injury limits of one hundred thousand dollars ($100,000.00). A copy of Donegal's insurance declaration page is attached as Exhibit "5". 10. Upon further investigation, the undersigned counsel for the minor-plaintiff Abby N. Ficco determined that the defendant tortfeasor Derek Devlin, had no additional meaningful assets from which the minor-plaintiff Abby N. Ficco could potentially recover if she were successful in a civil suit. See e.g. June 3, 2008 report of Information Network Associates, Inc. on Derek Devlin attached as Exhibit "6". 11. Donegal Insurance also conducted an investigation of the defendant tortfeasor Derek Devlin and informed the undersigned that their investigation revealed that Derek Devlin -3- had no additional meaningful assets from which the minor-plaintiff Abby N. Ficco could potentially recover if she were successful in a civil suit. PROPOSED SETTLEMENT 12. Petitioners Terrence J. Ficco and Deborah A. Ficco, the parents and natural guardians of minor Abby N. Ficco, have entered into an agreement to settle the claims in the action, subject to this court's approval pursuant to Pa.R.C.P. 2039. 13. The following settlement has been proposed: a. AIG has offered their policy limits of fifteen thousand dollars ($15,000.00) on behalf of the defendant tortfeasor Derek Devlin; and b. Donegal Insurance Group has offered their policy limits of one hundred thousand dollars ($100,000.00) on behalf of the minor-plaintiff Abby N. Ficco; to settle all claims relating to the crash in exchange for General Releases. 14. If this settlement is approved, the settlement proceeds will be deposited into a restricted, federally insured account marked "No withdrawals prior to age 18 without prior court approval." FEES, EXPENSES and LIENHOLDERS 15. Pursuant to the Fee Contract entered into between the Petitioners and Counsel, Counsel seeks reimbursement for seven hundred sixty-seven dollars and sixty-six cents ($797.66), which represents Counsel's expenses in pursing the instant litigation. See Fee Contract attached as Exhibit " 3". An itemized rendering of Counsel's expenses for which reimbursement is sought is attached hereto as Exhibit "7". -4- 16. Although Petitioners and Counsel have entered into a Fee Contract entitling Counsel to a one-third (1/3) fee on the gross settlement, Counsel is willing to voluntarily reduce his fee and accept atwenty-five percent (25%) fee on the gross settlement. Accordingly, Counsel requests a fee in the amount of twenty-eight thousand seven hundred fifty-dollars ($28,750.00), which represents twenty-five percent (25%) of the gross settlement. See Fee Contract attached as Exhibit " 3". 17. Highmark was contacted by the undersigned to determine if they have a subrogation interest. Highmark informed that they cannot subrogate for the auto accident and therefore do not have a lien on the file. A copy of Highmark's correspondence is attached hereto as Exhibit "8". 18. The Pennsylvania Department of Public Welfare was contacted by the undersigned to determine if they have a subrogation interest. The Pennsylvania Department of Public Welfare informed the undersigned that they have a medical assistance lien of $148.17. A copy of the Pennsylvania Department of Public Welfare correspondence is attached hereto as Exhibit "9". 19. Currently, there exists an unpaid medical bill from West Shore Emergency Medical Services - Chambersburg ALS in the amount of $723.00. A copy of the West Shore Emergency Medical Services - Chambersburg ALS medical bill is attached hereto as Exhibit "10". Note that the minor Abby N. Ficco's health insurance carrier paid $160.00 of the $883.00 bill leaving the unpaid balance of $723.00. CONCURRENCES 20. Petitioner and counsel seek approval of the. total settlement on behalf of the minor-plaintiff Abby N. Ficco in the amount of one hundred fifteen thousand dollars -5- ($115,000.00), because they believe that it represents a full and fair settlement of the case, equal to or greater than that which may be obtained should the matter be fully litigated. 21. Counsel for Petitioners is of the professional opinion that due to the uncertainties of litigation, the proposed compromise is reasonable and is in the best interests of the minor- plaintiff Abby N. Ficco. The basis for Counsel's opinion is that the proposed settlement is for the maximum amount of available insurance and the proposed settlement allows this case to be resolved without incurring the expense and delay of continued litigation, with uncertain outcome. It is Counsel's opinion that acceptance of the proposed settlement is in the minor-plaintiff Abby N. Ficco's best interest. 22. Petitioners Terrence J. Ficco and Deborah A. Ficco, the parents and natural guardians of minor Abby N. Ficco, concur in the proposed settlement and distribution. Petitioners further approve the proposed distribution contained in the form order attached. Their consents are attached as Exhibit "11" 23. No hearing is requested. -6- WHEREFORE, Petitioners Terrence J. Ficco and Deborah A. Ficco, the parents and natural guardians of minor Abby N. Ficco, request that this Court enter an order approving the proposed settlement and compromise; authorize them to make disbursements pursuant to the Petition, including attorneys fees and costs; and to execute all necessary releases and endorse all checks. submitted, Dated: August / / , 2008 By: ~ I ~' • ` v ~ John R. Z narich, Esq 're ' Identific ion No. 1963 ,John B. onarich, Esquire I 'cation No. 79989 Skarlatos & Zonarich Building 17 South Second Street, 6'h Floor Harrisburg, Pennsylvania 17101 Telephone (717) 233 - 1000 Facsimile: (717) 233 - 6740 Email: jrz@skarlatoszonarich.com jbz@skarlatoszonarich. com Attorneys for Petitioners Terrence J. Ficco and Deborah A. Ficco, Parents and Natural Guardians of Abby N. Ficco, a minor -7- VERIFICATION We, Terrence J. Ficco and Deborah A. Ficco, hereby certify that the facts set forth in the :following Petition are based upon information which we have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on our behalf in this matter. The language in the Petition is that of counsel and not our own. We have read the ]Petition, and to the extent it is based upon information which we 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 is that of counsel, we have relied upon counsel in making this Verification. We ]Zereby acknowledge that the facts set forth in the aforesaid Petition are made subject to the penalties of 18 Pa.C.S.A. §4904 relating to unsworn falsification to authorities. Dated: ~ ^// ~ O~ Terrence J. Fi ' o Dated: ~ ~/' a ~~ e orah A. Ficco 12/10/2i307 13:03 717-986-8749 ACCOEJNT ING COMMONWEAi.TH OF PENN51f~VANiA N • ~ POI.fCE C~idSH REPORTING FORIVi /~B e Case dosed Reportable [rash r-~~ + AA fi00 ~ Yes C:] No Yes (~ No o I t J -- PAGE 02 191111YI~INIIINI w.„..„, 1 P ~~4~~~~ - _ -~~ Police A n Patro ~ n ~ T Q ~ rJ Z 5 I L 3, 6$ T D S a 1 p ` - A an Name PreCinR tnveSt anon Da e (MM-pp-YYYY) ' ' -~ r ~ t Cgr~ Q~nle~tSY~.'<It4Nlh 5 ~. PoL- c~ /J~G.rvtt_i.l:... ~ t 1 „~ o -• ~ A o -~ ~ ~ ~ Dis atcn Tlmo (m1p grrivalTlmfefmr71 invest! afar -' Is/~ g~ a Number ~R 4d s~r w ro tv 3 5 t ~ i ~~ ~ ~ . r . . ~ ~ ~, ar T l l _. R Iavt+ar ~,{j M__... Bad a~wNUmbet Apa nofv~a) bate tMM-Db~~YrYYY) "~' ~ C~ ~~ Name ~ Munfc~ Munlctoatity Na~tre "•-~ o~ of weg~ ' ~~""~~ G 3 j ! ©Sun Q ihu ~ 1"h~ER~ ~ 2 4 V ! ~ ~ a :~ l , .-1 ~ r S . .... -. . Crash Dote MM-DD•YYYY) Gash Timedmin No al Units Pea le Ih ured Kiiled- •H a 0o Q Mon ~ Fri a? ~-~ t? - 2 p b 1 ~~ d +~ Z r~ O! Q O complete G rue p Sat F F rs o t 0 Wed [~ Unk Workzona~t Yes, _Complete O Y~ No 5chooi Bus Q Yes ~ No School tone ~ Yes Na Notli~rPENNDOt orm M Secrfon 2s Related Related Main{enance Q Yes Nn ~ g ~2lXeSR12A Tme Q 4 Way Entersection Q 'Y" interSeClion ~ jn~esse ties ~ aN Ramp (~ RaUraad Crossing 'SRetWI ~' .r (~ MidUlosk ~} 'T" Intersection {~ Traffic Circle) p a Round AbOUt ~ i7n Ramp Q Crossover Q Other See t)verla Route Number Se mint (0 tianB~ Travel Lanes Speed linilt Huse Number tit aopUcabte) Q O~~- ~ o O North Q South 1 Z- (tt ~ , :a ~ Street Nome Street f3nding ~ Q East FOrbAId.bIOCk V1<hrt Orly I.!Sa t Dostal Nauru td+ml:~r d ~ w d T ke e ^""' , ,r a n :ur es r7 t V ~ !L~ P t K JL t'" K a (= Unknown Principal Boedway 5uavr Namr i~ ~~ d i Rfl 1 l e n 1 ut rsg this opAan d rntersia[o Tumplke Q Turnpike ©State Q toasty - a lotat Road ~ Private C~ p;hao (No! Tur ike} (E35 esq Spur HI hway Road or Street Road Unknown Route Number S rrsent (Optiortall Travel. Lanes Speed t.imit ©Norih ~ m m e O 5 ih v a ~ a+ ou L~.L~J L~..L..~J d Easi ~ Str t Nam - ee e Sweet Ending ©W t es ~ o Q & Unknown s ~ ,~ BG~te tn14151at4 Q 7wrgpike 0 Turnpike Q State ~ County local Road Private DIhFr! ~ ~~ ~ (Not iumpilcm} (EasWJest) Spur Highway R°ad Q or Sheet Q Road Q Unknown ~ Intersettin Rt Num Or MRa Post or 5e ment Marker o ~ N ~ Feet ~ ~ ~ Z © , ~ ~ ~_ orth th ~~ ~ a Or frrtersectln Stree! Namn 5t Fn dPn ~ ~ PleaTe a East Or Miles Enter lnfnrrnahan for 6pi7f ~ C~7 West ~ ., ~--~-1 ^ I ( I ,~ a Wntlmarks If Using This Option y.___ ._,~_ trrtertecthrg Re Nunt Or Mite Fast ~ or ~ment Maker _ ~ p [, North ., '~ Q 3 ~ ~~~ . Distance From +: rrrsh S , . _ N ©South cene to landmark 1 or InDersect)hg Street Nartle 5t Ending ~ Q East -- ~-- w (~°r Crash between A ~ y ~ ~~_~~~ L ~J ~ a WOSr ,"J-•-~ J j Landmark t and Eandmark 21 a - ~., Degrees Minutes Seconds b saes_ Mlhutes Sewnds tatitude• 1,~ ~ p q ~ 5 (Q r ~ ~ tongiutde: - t '7 I "? I 7J ~ ~~~ . .~ TnfAe Cen rot Dnvtea Police OHic+ar arar Yieid Sign Q FI man il~ Hot Applicable 0 Traffic Signal neNve RR Grassing ~ Q Other Type TCD ~ Ti7?.$t~lltl8 Ernt;rgcn, ~} No Controls Q IJevrce Funttinning Q p,eemp'ive lmpraperiy Controls F7aSh(ng Traffic © Signal O Stop Sion Q C t~s ni g Conlrols O unknown p £ Sbinai Q FuncEloning Q prpv~ei~uncticninp 0 Unkno•.vn Iaue.SFoseid pf 'Nor ~r(fcahla•, stop rest of the lane C+osure section) lane tYac+,ro fl North Q Easr a North and South O nn d Not Applicable ~ Partielly C] fully O Unknown WlesttQa Q South ~ West ~} East and west (N.5,E wt m ,~ ~ YCT C7 NO ® ~~ Unknown q ~j~ ®< 30 Min Q 30.50 Ntin d t-3 hr f_? 3-6 hrs Q 6.9 hrs Q ~ ° hours Q Unknown F°F1M s AA-aoo (1~1 PEkNDpT CQPY 12/16/2007 13:03 717-986-8749 AGCOIJNTING PAGE 03 POU E CRA H REPORTING FORM fd1A ~~'~~~~~~~i~~~f i~~~l~ Cruvh Number r f4A 500 2 Page: Pa~ausc Only i~ J~ (~D t9 'Z p~ .1, W' U EJ ~ ~„ p ~ Motor V¢hrcla in Transport ~ 1•tii & Pun Vehtcle Q AlBgaliy }+,lrked (~ Le4a11 Parked a Cartrmarci~7 vahiUe Y n Nan ~ Motorir..ri unJi Q Pedesinan on Skates. Disabled From ~ y„r ~ +1.. ~ ©Pcdestrlan in Wheelchair, eti ~ Previous Crash ~ TrJfn C7 Phen;om Veilule Uf 'Pedestrlr7n' or "Peoiestrian o» Skates, !n wheelchair, etc', Com fete Form M. Secrlen zal (if Yes, ComprorP roan CJ tinic No First, Name ~ }- d t D .~ 'R ~~~~ i-J Delet9? last NarltB ~ r, gl~aJzollDruas Sus e cted o ~ Nn Q lllegel Dnigs ~ A,tedicalion ~' (_`a Alcohol t~ Alcohol and OrugS Q Unknown ---~ Atrohol Tast rye ~`" o` ® Tcst Not Given (~ breath Q Other (~ 9iood ~ Urine CJ 7P.nSlnGiv~eni! y Ahohpt Tess Results ~ Tcst Rslused 0 Res~-~ n __ a11e of Birth{MM-DD-YYYY) G ~{ Z..5 ! g 8 Z Tela hone Number 5ta~ Clas~ Q ~ vnvor ar aedestrlan •PhyslcaJ Can~ltlan - - • • --_ ~._ _. ® AppargntlY 1~;gd1 Krug Fat; ~ Nprma © ('~ t1ur, Mecbrnnryr~ ktad geen 0 Drinking ~ S'tk t~ Asleep ('~ ut~kt:~a.:T Prlrrtarv Vehtcle Code VlolaUon _ r hargrn?~ r --- r Pres~ance 7 #briver Op?raiecl 3=Driver Flea (f;~nR, ~ T?st Gfven, ~ Vehicle a_Hii and Run j [ontaminared Results - ~ 2~No Driver 9 r•Unknovm .. ._ _-~_ ._. __ .. . OwnelDrlvcr GD=Nor Applitahte p7,aPrivate VehiClr: tVOt 04nStatc Polke VRhitle DlxMunitipal PoRCe V^h !)':ioForf+r~.'' ;~:+ +. rl DizPrivate VehItIP Owned/ OwnedAeaSed 6y Driver 05=PENNIX37 Vehicle 08=CSrhgr IvluniClPd[ na.~(?tt~+7~ l~ascd ay Driver 03eRent¢d oohicie Ofi-Other State Gov Veh Government Vehirir. ?g=U~+f,t r,,.,t Sgma as Driver ~ this .addrtass r tt /State / ti .___.. T _ Vehlcls Make _ "Make lode VIN Model Year VehlCle Model „tt~ +n:r•rl rye Cr 2; ~ ~. t ~ -`ti ~ S M ~ 3 ~ 'Z. ~ 5 1 'R a. a G-~r~~ ~ ~. ~ ~~ U/c±ense Plate _ ~I ~ ReAg, State Lsr, Spend Vehid~ 'cawed (T'o~wed By _ ~1 ~7'_'"C r"" ~ ~ 1~r ~~_ 1 ~ t' ~ tl 'j ~"' ~ Yes Q Nn I'SDFFnt~a MD1~i1ZE. 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Bicycle. 06=SUv Trltycte 07rVan 71=01her Pgdairyde 1D.5nnwmnblle 7.7=Norse & Rupgy 71=Farm Equip )3RHgr5q ~ Rirtnr 12.1;on3trudian Equy, ~d-7r.Fin 13=ATV 25=Trouey 18=4iher Type Spec Veh 9~B=Other l9~Unk Type $pec Veh 43aUnknown d Oa7nt Aamsge tndlt:atar Gr r' t 0-NOne 7,A OO;:Non-toFliSton ra_tlndercarriage FunCttonal 1-1t!v,d 01~1Z~CIock Points 15sTawed Unit a t=Minor 3=t7isahiing 18=lop S197Unknown 4mUnknpyvn 2=Uphill t~ a 11=( rKnrtrr«.t}I h,=.as~ qet Oo=Not Applica6k r, Ittgn 01=FirBVRh 13-inn 02=ttm6ulance 21cTrr,,~~ : ,dc,: 03=PolicE 12eT~.rin Tr.u,~ 08=other Emerpenry 2d-Trinlr. railer Vehicle 31=~rl,~l+r«vi`:,: r. I IaPupif Ttanipnrl R9-+tfnt+u+n~n 3=bnwnhitl Road Ali4nmerUj -- a^BDtlnm of 11111 ~ L.,trdiq+~; StTVF Ot Hill ~ Jn[,xa:Cl 9aUnkrtnwtti 9 A I p:t: nt+u-r wwrn : M•soo lsz~yl PENNt7DT COPY 1?/10/2067 13:63 717-986-8749 ACC~Ut~#TING PRGE 04 w j C~MMDNWEAL7H OF PENNSYLVANIA ....d POLICE CRASH 6tE6~OitTING FORM Page: 5D~ ~ ra cv Uso Orsl i'a E:-.~a2 5103 ~ 0 3 ~~I~~~~~~fl~~ Crash -turnher P114~Q61 p ~ Molar Vehide 1n Q Mt & Run Vehlde (~ Illegally Parked C? le ally Parked Nnn - r~atosized TyDg Transpatt g Q Camme/tla! vohlcle unit Pedestrian on Skates. 0;gahled from Q Pedestrian Q in Vdheelchatr• etc Q Ptevttws Crash (.~ Train Q Phantom Vehicle O Yes No Y tF ^Aedesirtan" or 'Pede3trisn on skates, In Wheelchair, etc", Corn 1r:te Form M. section 28 (ff er~ Complete Form y Untt No P1rst dame Mt Data pf girth(MM•bD.YYYY) ~.~ °r ~ R R c n~ c ~. ~ a 2 ~ 8~ 4 S `i Deletrr~ Rtut FiArne_ TeteRhane Number G7 1 C C.~~1 I - -- - - ~ ~-zc-t-~~5-9Raq ~~ ~ Address /. Cf}y,( State _ _ ZI _~~ y '~ a 4 1 ~I~ +~oF.M~-~ t~~3 GrannPf~cl.~.. ~q _ ~ t}r1vLr LlcCeSe Namhtar State Class m AlcohollDrWs Suscecteal Drlv@r or F~+destrterr Physical twtdiHorr ~ No ~',~ illegal Drugs Q Medicatlpn ~ +4poar2ntty !!Segal Drug (~ Fet+qur ('~ Me+l~cahan Normal ~ Us ~' ~ Q Almhol Q Aicohof and Dr.,gs Q Unknown e HHad Been ~ Qdnking b Sick {'1 AslQep (, llnknq~vn . - - - --- r ~ q Afrnhat'Trst 7Vae ~ Test Not Given Q Breath Q Other .. .~....._ Arrmart! yrrhltfe Coda ytolagan ~ ~-~-~I Chortled ~ ~ ye [} blood (~ Urine Q Unknown if T i 1 Q Yes ~ Na ~ est G ven .J o 7. Jl-t~o~-o Uttkr~Wn LTgg~ esu/tr ()Test RQfus~ed C) RQSU#ts D_._ rArasenre tmDriver0 grated 9=Orivet FI_d Scene p ~ 'test G'nren, ~ Q t M f R l Vehicle a=Hit and Run © ontam . ater e5u is 2aNV Driver 9=Unknown OwnevYAriver 00=Not applicable ~. 02~Private vehicle Nat 09sState Polite Vehicle 07=1rtunlclpal Pallc2 Veh Og=Federal Gov V?h OtaPrivate vehlclr? Owned/ owtredneasZ+d by Oriver 05*PENNDOT Vehicle UB=Other MunicipAl 96=01her ~, t lsrased 6y Oriver 03aRenled Vehtrle 06=Other Stare Gov Vch Government Vehicle 94=Unknown Olvvner Oast Name or Bus(ness Narrrff (1f Pedestrian, sk! this section} p e ~ ~~~~ Diver ~ "yak V~}tt8 aka less ! GtY I State l ZIA Add ~ ~__~_ ~ _ VrN Model Year Vehicle Mode3 ,stic rr~ert,ry? Z W.~ ~.s.t _b 6 ors, hd 6 O ?. 9 3~ 2 r~ o c«r1~. kt~me ply Rag. 5mte Est. Speed Yehirde Fot+ved Towed B ~~ ~ l{~~ I ~~~ Q ~ O 7 ems' ®Yes O No ~v1~nJ3 1Y1p~1L>=.'SG-PN l,__ Po14ry Nn iasuraneo ineuranca Company - u ,C~ - ®Yes Q No t= knnwrr ~" t~~'+n~~ ~.. ~ ~ 1'tr~,'S '17~~ pJph (~ ~ b 3 CJ ~ ~ ~ ~ - w-- -- '~ ~~T..__ 1aTOwing Pass. Veh 4~Mobile/Motfular Hame 7~5etni•Tra'sler Tag No Tag Yenr ?og St oth (~"'~ 1 B S t_ r arnper - Rrt N4. D~ a ~ U~ ~ ~a7o> ~g rtK~ er ~~ ~ Traki ~ Ink r 9=t llr w U i U #f F fl T j ) 6 4 . ra ra no 3=Tpw t t e n ,~„ = u er Unit. `See Olrecrlon arl o •yehftte Posltten ~, `Mtsvenrent ~ """"' ~~ O dverla ^-' Snacia! Usage y Y r ~ VrNi tan -..._.~l'-.-11 V 't!e i7rne D5=Lar Truck 20=Uni rle, 81 cle, gh,L ve y ry ~ ~ t 2e[ornmescial Passenger 06e~Y411ow d ~,,,, 07o5i1ver le Tric Ot aAutcxnobite 06=SU D ~ 02~Motorcync 07=Van 21=Ocher Pedatcycfr. 00=Not Applicable Carrier 01~Fire veh t3wTaxi 08=Gold 01cBlue 09-Bra+nn 03=Bus T0~5nowmohlle 22=Horse ~ BuQgy D4=Small Truck 1 t.Farm Er~lrip 23=Horse E Bier 02=Ambulance 21=Troctor TrauEr 03cPOllce 22sxTvAn Tr}Iler 02eRed IO~range U3=White 11..Purp(r ftt "t}z ; Complete Form r2eConstructlon Equip za.Traln hf, Section 2b} 13•~47V 25=Trolley OBaOther Emergency 2a=Triple TralSer Vehcle 3t=Mtoditler4 Veh fM--Green 12=other tr5~81ack 99nltnknown 11f °yr)" or '~tt" Complete tB-~thr:r Type Spec veh 93=Other Farm M, StNon 271 19=Unk Type Saec Veh 99_Unknown rt 1 t~Punll Transport 99~Unknnwn 1nlNailrnaatr polrtt oamaaa Indicator ~ Grad!&nt 3rsDownhEll !toad Alhynmenr ~ 005NOn•Caliisian i4=Vndercania P Ini5 tS~TOwed Unltg Ol k Pr t2 Cl ~'~ OcNana 2cFUnttlonal ~ [ y '{ 4yBotiorn of Hqi J t=Minor 3~biiabling {I 1. rl tcl.evel 5=Top of Hitl ~r.7 ~ r~Srraighr y I-Curved 7 • oc = i3mTop 99=Unknown ~ gaUnknown 2=Uphrit 9=Unknown 9=Unkl+tswn wanr r an.erso trP.r~} PENNC)C7T' COPY 12/20/2007 13:03 717-986-9749 ACCCIIJNTING COMMOI'dWEAl,I~I aF PENNSYLVANIA P~Li+GE CRASH REP0R'T1NG PERM Page • AA 60d 3 '~'~'a' ~°=kSdL.5 ! ~ "~~~~ Q '~ YII~B~lIII~IW~ a 1140061 PAGE 05 Crash Numher Fwrson 'cline; Q t=Dr)ver 2=Passenger (] at>r--Nat A Passengger/pccupant 01cDirrer -All Vettttl2s ~R(f:(1~@E'IIC~~~ ~~~~ ~ 00=None se !Not 4ptrlicable (-,yTJ Not Applicable Ot=Shoulder Beh U ed 7nPedesVran Br~Dther 02=FrUr7t Seat Middle Position 03=Front Seat Right gfde s troNot Ejected o2=Lap Belt Used 2=Totallyy Ef'ened ~ 03~1ap And Shwider Belt Used 3=Partiall Elected I 9=Unknown y 04o5acand Row -Leh Side [tr Oa~Child Safety Seat Used 9=Unkna~vn Moto~ycle Passenger O5aMotorcy~te Helmet Used 05=5 d R Middl o5 P f k 6l l l ~ ~; F ryFemale ~ et:on ow • [ os e a6mSecand Raw -Right Side 01=Ttrlyd Row Or Greater - if Sid L tn . ccyytt e He met Used H Eiocr~on oath, t0=5afery Belt used tmpwperly oaNot Ejected /Not Ap lkabie 11_Child 5afery Seat US€d improperly pp t~Thrpugh Side Door O e~ri l 2 U ~ M=Male tJ ,!Unknown e e t)8=?hird Raw Crr Greater - Middle Pvsidon p ng 1 =He met sed ImpropE~rly 9CaR9svaktt Used. Type ~Jnknown Z=Through Side window 99=Unknown 3eThrough wmdsnierd o 09=Third Raw Or GrealK - Right Sidta a=Through Back Dovr S;3tery~ouiemr+nr Tvw>; S=Through QACk Poor Tailgair UpP~ting ~ o pr of injured t0@Steapor Section of Ttuckcab i tarln tither Enclosed ~ 00=None Used ! NOt Applicable 6=Through Root Openingg ISunrsuf! Deptpyed.{For This Seat) Convertible lop Dawni Ot=PrOnt Air Bag i aKitled 2=nrtai°r injury PaSSBnger• tar Gatga Area t2=1n Open Area i E d k , OZsSide Air Bafl Qeployed (For This seat} T=Tht°ugh Roof opening (~gnvert~t7lF 03aOther Typa Alr Bag Deployed TOp Up) 9=Unknown 3=Moderate Injury t7 cup, {sac FS TSJ 73+Treiling Unit 04=Multiple Air gags eployed t)5~Matorrycle Eye Protection a= inru Injury 8=injury, Unk idcRidln~ On Vehicle Extcriar 15=8us assertger o6=giryclist Wearing Elhov¢tl:nee/Pads 10-Air 80g Not Deployed. Switch On { 0-_N~Ott~ gcabfq 5ererity 9mtJnknown i! Inju 99=Other 99ml1nknown t1aAh bag Not Deployed, Switch Off taNot Extricated t2=Aft Eag Not Deployed. T-Extricated By Methan,cal MsanS Unk 5vvitih Settin ry g 3=Freed By Nan • MpK/7dnIC7! MvanS tBnAir Bag Removed {Prior To Crashl 8=Other e 19nUnknawn I{ Air Bag D eployed 9=Unknown 99=Unknown EMS agency: P~~°tSAh7'C' l~4f~ls... EN-S Madlcal Facility: f1~".~51~~1Y1~`U1CtiK. C~fL.. ~~-~ Un[t Ro person l~io OeteteT Date of Birth {MM-DD•YYYY) A B C D E F G H i Frame ! Adtlrass ! Phone •~ ,._ EM5 transport ® Soap~ataior ~ (~ Yr, s ®No Up1t ftilb Faction No a 2 v~ betete7 Data of Birth (MM•Dt)•YrrY) A gg' C to E F G H 1~ p o 2. - l $-~ `i I'~LJL'"~®o t c~ ! o ~°~1.~ f t+tame / Addresc) Phwre S ransport Same ar ~ Opurntor a k ~ O ..~ Y ~ dt Unit No P4rxon FVa o ~ a 2. Date of B it {MM•DO- ~YY-) ~-~ ~A ~ B~ C~ t7 E F r G;-~ W ~F ~o¢? a z - ~ R -L! L7 'S q t:~=1 LY.~ L~..J ~ ° ~ Q ° L!.1 ~ !. t 1 Name 1 Addcoss I Phano "' fM5 Transport Same es Qpppratvr ~1c~oR.A GeCGp y.~.~-rJtxtrv~A~ Rb.CrQr~nP1~•tl.L. 4q i~']G~t~ -tt'i-9"J5-"1'R0~ C_'lY9s ®Na Unit Na Petsnn No a 2 0 3 beleteT battr•of 131rt' (MM-DD-Ytrt'Y) SS } C D E F (G t•t nI Ca a' Z- 1 ~-~ °1 Q L:~-J 1..,x_1®° f, a 3 a o L~ J ~° U Nana /.Address !Phone •- EM5 Trnnspor! ~ ~,Ope atvr r~~~ ~ -~~ CCtS.,..~ {"'fi''T'e1~ ~ ~ Y^, C.~ No f~3. PAR,. Unit Na Pctson plo ~~ e7 bete of Bi {MM-DO-YYYY) a B C _ D E P GG H ! N2n+o /Address / Phorte EMS TranspaR Same es ^ dpara~or ~ y _._ t~ es C~ No Unity No fiP-trs~o~n N-1a .L._J L Date of 6{rsh (MM••bD•'rYYY} A it B-t~ [t-C-~J {t--+Dt~-f' E F t{-G-. ~1~ t~H 1~ 1 De~fJete? ~ - ~ - ~~ ~ t~.1 t~._t L ~ ~ U,,.~.J /~,....i .-. Name /Address !Phone Q Same 8s - - ...r...~. tDp¢ratar _ - EM5 7'ranspart __....~.. ..,...-._~ ., .._..-,~~ ~ Y25 ©NO __ par,eru,tA.uoe{taa~ PENNDt?T CORY 12/1H/2007 13:63 717-986--8749 ~ • ca+wM~onrw~a~.rM ol: PfrNt~svLVaru~,~ , Roue c~,,sH a~aoar}~u~ roam +A A 5Q4 4 ld~~~"~v2 S I ~ Crash DgscrlAHbn OeNOrt-CaUiston 2=Head C ~ t=Hear End t~ ~e ~ teack~°n g d ~ ~' ~ 1o0n Travril (.aneS -RrJarfont° RocdHrop 3~vSedian ~ ~ 2aShoutdes 4:A°adsiee c ° v ~ NJUminar!°n tmDayligM O 2~+ ark i ° 3.Dttrhk~ titt0+ LLiiu e ~ ~ sk p~ ---~-~'^~Q°lr.~ ~ 1 ~r~iHonaa 3=5teet (Hall) g c g 7 L:~.J 2•Aagt 9=snow g Road.SrrHq~eCalydltlons ~ ~,J Depry 1=1Net g~Ad, Mud, 3- new Ceve =.t i H tL =J t ~ L t J i~ J 1 ._ t Un o B ~ Z ~ ~_., _.,_ ..~ _,.~. ,.~„ ~ ~ Please Aut Events in 3 Q ~~~ _ n se~~ r ar 4 ~ _ ~ ~ ~ ~~ 4a`, S ' Hum L~eM UR Mast? Ud'1f Aatg Ntnnber ` t ~ unit No a 2 z 2 S L_J a ~~'] s 3 AJeasa Puf ; ~ Events In ~ $ ~'-` ~ ~~~_L_..~ Seqquentla! drrJer 4 ~ ^ ~ ~ "' ~"" ~" ~`~ „ Unk'Na ~ n~ ~ t Harm Bvent Untt N° Harm Event o "2 ~ j v ! 0 2. t;nvir°nmenttslFl~arlwair t srorenHat, fAcrwsr !E/R) ~ ~ Z ~'""~'"'~ 3 r"~'""~ ~ + I L....l._,,,j Op~tVone ndttioru Wi 01 d C t t a51)pppery Road Gondlti°ns ArnJSnow) adw On R 12cSuhstano = n y v DZ=Sdddt:n Weelher Condttions ; o ay 13.Potholas 03~Other Weather Conditions 14.Broken Or Cracked Pavement 04nt1¢¢r to Raadway 15r.TCb Obstructed DS-Obstac(¢ On A°ad~~~aayy 1Br_Soft Shauld6r t7r Shoulder Drt+p t)H 06=Other ahlmef M Raadwey 2t3~.Otiter Fteaadway Factor 07-Glare ZSrcOther Environmental Facts O8eWark Za"n0 Related 99.Unkriawn p-~ ~) ~i11 ~~ oni: ' ' Dti,>QExhaust 1Z-wipE7S 13-Driver SealingKonlral OteTires" D7nFlaadJtghLs 02=Brake System OB~•S;grral ti~his T a- t~o~ t)can. Hood- Etc t5~Tcat e; Hirch i6=Wheels Ot~erLig ss 03=$teedrigSystem D 04eSUSpensl°n 10^Horn 17-rUrbags 05~Pbwer TraM t iJ~tlnars 1g=Trailer Qverbaded 19rUnsecurrsdShttted r{-~•-~~ Unit ~ ~ No G { t ~ ~ Z Trall¢r toad rooer cawingg 2D~m t,....1~_I p I1.Obstructed Windshield Ho ~ '~i + T 0 ~ 2 Bt?=lJnknown ~ndl°ated Prime factor IUnI~ Da nos nprrn [ht~ ~nrMmidMl an v m~rrapb agrr. Fasto F 1 &/A V D P (~ Q ~ Q ff fJR is tAe Prtma factor 7VCa, issue Unft N° bfa»k ACCDtJN'tING PAGE 05 111 i~~~~~~~l~~~ Clash Numbnr P114na61 Page a 5 Ort a~tngla 8a5klesw~ya 8=Hk Pedessrtan 5= eswi a {5am8 ~freCtlon} (Cspp~i'e Olrectinn} 7='rttt F(xeq CrbJed 9=0lher/Unkn°wn S-Clvtalde TraH[cwEty 7-Aare (Ramp Intersection) 6cin Parking t.dna 9=Unkn°vm '.r--Fog BeHakr 8 Fog 7=519ei 8 Fog 9=Unknown B~thar I d 4=Stueh \RTia~~IMb 6~ica Patahac BmOthor 5alca ~ isw.w 7"y+'~r - 8tandin4 or ovln~ su.~LLIA~ irmrnsm~ns~. . , +.sw. _Ha-snfuJEtrenrs1rlamr Evrnrt 30aHtt Fence Or WaN DtcHit link 1 31mHit Hulldlno 42=Hit Unit 2 32.tHlt Culv¢r{ 03eiilt Unit 3 33=Hit Bridge Pier Or Abutmun; OA=Hit Urnt 4 3a=Hit Parapel find 05=Fkt Urrit 5 35aHil Bridge Rati Obeldit O,httr 7ratfic tint; 36~Hit Hwldder or Obstacle 07aHls Geer Qn Roadway ' DB=Hit Other Animal 37=Hh Impatt Rttenuatur 44=Cd1tstan Wlth Other Non 3B^Hit Flre Hydrans Fixed Ohject 39-Hit Roadway F.quipmen: t 1=Strutk 6y Unn 1 40rNlt Mal) box i2=5trvck @y Unit Z a1~H)t Traffic tsiand t3a5trtrck Hy llnir 3 aI=Hil5now Bank tQ^5truck By Unh 4 a3-Hh Temporary Cdhstnuriwr 1S=5trttck By Unit 5 Banter t6e5truck By Other TraHtc Unit dBmNit Ocher P+xed Object l1-Hit Tree OrShruhbe"ry d4=Nit Unknown Fixed Dbjec: 22=Wh P.mbankmpnt 50cOverturNRoit Aver 23~Hit Utility Pnle Ste.Struck By Thrrnvn Or FalGny 24aHtt 'raHK $I~n Q6]CCt 25pHlt Guard Rail 52aPq Hples Or t7thor 26=Nit Guard Nail end Pavement trregUtorit+es 27=Hh CvrB 53-lacknife 29~Hi1 Concrete Or 54=Fire In Vehicie Longghudmet BaniCr 5Ei=0rher NamCollisrcn 29nMlt {71trfi 99eUnknawn Harmh~l Fv¢nt acirid "• 1BoDriNngg On The tnd W¢td Phone Side O) Road rnds Free Phnne t9~Making lmprop ;s 7vnsing 2fl-Makingg Imprpper F,w; rong lane From Nlghwny i,=Carete55 ParkmgrUnparhnq Slap 'a2~OvetNnder ~n Cotnpen Sati°n A; Ctrrvc tt~~ t0=Fellure 7o Resp6nil To Other Traffic tepntrot De+riCg 2d=Ftm ng T°o Past for r.°rrditions ZSaFailurrt To M4lntatn Prober Speec t1=Teitg~Ungg 1Z=Sudden 5towingrStoppin 13dNegplty $topged On Road 26=Ottvet fleeing Police tPol Chase} 27st7rlver Inpxperie+tced Il 14-Careless Aasstng Or lgne Change Zg=F~ urp To USR SpEtialprd Egi1iA g2mAffected Hy Physical C°nnition 15rPassing In Na Passing Xane 16=Dr)v)ng The tAAvng Way On gB~Ot r Impn7per DtlvitKj Actinrs gg3Unknbwn f-way Street Mot © l t ~ z ~ 3 ~ °~ R ~ t ~ 2 ~ tt ~ c No PoderMsn acvo aD-~vonc OB-working OQ~pushlnp Vehlde 04=Entering Dr Grassing Al Spec+fi¢d Location DSr,Approaching Or leav+ng vcd,irio DDmWorking On veh~cl¢ OI=watklag, t{unning, !agginq, Or %aytng 07.Standing 48=Other Untt N4 ~ ~ ('''' L ~ ?9AUnknow Unit No n ( l 4 F n sroasu • "''600 Dam PENNbOT' COPY 12f10/2007 23:03 717-986-879 ACCQUN?I~EG COMMQNW>:AI.TW OF PEPlI+ISYLVAiVIA PQUCf: CRASH REPORTING FORM Pnge •AA 50D 5 ~~dt~v 5es2.. S 1 X03 ~,~ ~ (ef PAGE 07 aiau~iAi~~~w~ GefhN~mbcr -~ P1140062 ' °~ . , , k _f.. 1 ~ a ~ . f i { ~ ` ~, i , ~ ..i ,. } . - f ~ #. . ~ I 1 ~ { ~ i e ~ i I ~ ' { ! { ~ 1 ~ i f ~ .. __~_. '..,_.., ~ ~ j { ~ ~ ~ ~ ~ 1 i ~ ~ _ _ 1 { i F ( .._ , E i ~( ' S 7 ~ ....,, ... .~.. .._ .. 1.:.. ......, ,., ._ ~- i i ~ ~ ~ ff I 4 n ~ _j i , ' { { ~ ~ fl i ~ ~ ~ ., ~ .. ...,..... ... i_ ,. J .... ~. ,. ._ i.... .;. 1 .1. _ I .. ; i . I ~ ~ I- .. i ~ i.. ~~ ~ ~ I { ( { E i i ~ { i i E ~~ ` i .~ ~_ • ~ i j. ~ ~ . 1 .. MM' 1 r 1 i j ; i f 4 WltzfeSS Name AdiArosc Pfione ~ ~~ KNGdtyi/ . _ . Z . .. _ , _._ Narrative and additional wttstesses: AccVdettf Imestigatlon Notification fs~eJad7 ~ Proyterky Damage p ' --- ~ ; . Ia4S __ u 'o"_it_4 ~asC~s_'3"~+.a ~'~'L AI~E.+-i~ a~ tsnt-"'~ VE L,C~ ,aT~S"i "'~~~~. [ ~ !~ ^~ ~ 1. 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G`GM1~ J~1~~~ ~ ^ c R' ~ ~ ~ ofi na ~i`~2 lkC..~sa 6~3~~,I ~ o~ fi~ i.(:s g t''~ is ~M ~~ ltik ~1~r~~cC.C-~ ~ ?rn, _tn1 t~A-l~ _l~n~Etc~'. pv.oR~~ .... ~~ 7A s~ FORtA t AR•!00 (iolOi- PEHI~DOT CoiW 12/10/2007 13:03 717-986-6749 ACCOUNTING PAGE 88 ~• pauCE CitASHLitEPOrHi7 G~FOR~PI tuia Page New ~1~~11II1~~~~ Clash Number • l~1AJQd ~ ~~~i~'82. $f ~j',.~J ~ d '~ ~ Change/ P j ~ 'R p ~ _ f0~ j _I - CORLInuatlOR Nerretrve acrd additional witn~sSes: _ ~1~ r Ti anlrs-C.L e 1~ S v 7'~,f{zR 1~ ~v~.~. a ,~ J ~+` ,?'~tA ,,,! S r~,~R,. ,. .~ 'i'7~ fi'-,~c~sA-~C- $«v2f~.-~~.,_,,,_l•y~rG4nxfCr~ 77-f~ ,~SF~r,•v'~ G ~rv~v5 __ ~ .,_r e~ '~?~Ii~1S ~~ry»7A~7~ _ /ot.~oilon~5 pT,_G_yv."~~, ryP,e2,4 ~ 0~2 0~ r~a~,a.~ l tvPrS t•~i i c.R.,,~Lr~,w6.Z~ ,a-7' 7af~ SC.~,;f~ , v.~! --=---- - ~-- r 30 la'7 ea-~ r~ZO r~s___ ` __-_t~~! ~~L, C ~~,•.v,~,l ~ N L. ,_ PSP. M~u~J yr ~C 5 oPF~'To~ ~~ r~ La7~~ ~ r rf~ w i'~Z,A~ ~- r ..rc w+= ~T ~ n1 7~-f ~, L ~~ ~ _. ,u~6 r4'rW cj;eo~/ 7?-FE R~~ laa~A -4Z.3Q ! 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Q .J+ U H~ Q~ ~- ~_ 7i d !J) ~ ~~ ~4 uJ ~, ~~ J ~ M ~ ~ ~ 4 0 4 W N~"t,~~~ ~ ~ ~ ~ ~ ~ K- ~ ¢,- 4- r t""" N~ li.. }"" ~.+~ Z O tt~ C~. ~ d d ~ Q ~ '~ < Fr' t13 CL' LJJ !-' U.I U q~CpUNTINC~ PAC 09 ~ ~''': ~~ 'a'a N ..1 eI PENNSTATE Milton S. Hershey Medical Center College of Medicine Patient Nanrc•. C•tCCq_ AR$Y N Patient Sex; f crm~le Patient tocntion: 3SPR.3IGB. 01 Visit Typc, Inpati~rol Penn State Milton 5 }iershcy Mec3iarl Cemer Tel: (7 i 7) 53 t-BOSS Penn StatcCollegc orMcdicine Hrdth lnlbnnation Services. HU24 SOU Unive+sity Drive P.O L3ox 8511 1•Jcrshcy. PA f 7033-0850 PSUHMC MRN: 0793999 pate ol't3itth: 2/14/1997 Visit Number: 09265 i 711 D i s c h a r g e S u m m a r y D o c u m e n t Firra! Document Electronically Signed by: i3ramley, Harry P ll?4/?008 11:47:58 F1.1v1 DISCHARGE SUMMARY Name: FICCO, ABBY N HMG Number: 0793999 DAB: 02/14/1997 Date of Admission: 1211 S/2007 Date at Discharge: 01 /16/2008 DMI-FT'ING DIAGNOSIS: Gentraf cervical cord syndrome. D1SChiARGE DIAGNOSIS: Central cervical cord syndrome. OTHER DIAGNOSES: Neurofibromatosis and history of spinal cord tumor Abby is a 1D-year-old who was admitted to the acute care site following an MVA on 11/30107. She was a backseat passenger in a vehicle that was struck from the side. Injuries identified include a C4 wedge fracture, C5-C6 ligamentous injury with associated essential canal stenosis and contusion at C2-C5. She was sent to OR on 12/13/07 for posterior fusion. She does have a history of spinal cord tumor resection with motor deficits related to neurofibromatosis. PHYSICAL EXAMINATION: On admission showed Abby to be afebrile She was in no apparent distress, very pleasant and appropriate. Mucous membranes were moist. C-collar was in place. Heart was regular. Lungs were clear. Abdomen was soft and nontender. She was weft perfused with brisk capillary refill Neurologically, there was significant left-sided weakness noted with her upper being more weak than her tower. HOSPITAL COURSE: Abby had no complications throughout the hospital course. She received therapy from the OT and PT as wet! as music therapy and did very well From neurological standpoint, her strength on admission was around 215 to 315 and on discharge, her right upper extremity was noted to be 415, her left upper extremity was noted to be 315 Her right lotn/er extremity was around 4!5 and her left lower extremity around 415 with her right being slightly stronger than her Left. She was walking with a walker and as I stated made significant gains throughout the hospital course. Initially, upon admission, site was noted to have a urinary tract infection prior to discharge from the acute care site. She was treated with Cipro. She then was noted to have some retention of urine and it was decided to provide caching. However, she did not tolerate this and did well without cathing throughout the hospital course, There was na noted infection or difficulties. Ditropan was added to her regimen. Date Prirrled J/d/?0(JJ lime Prinrerl 5 5? ,ih! Milton S. Hershey Medlical Center College olF Medicine Patient Name: FICC'O, ABBY N PSIII•IMC MRN: 0793999 D i s c h a r g e S u m m a r y D o c u m e n t F;,~~rr Document lleetronically Signed by; Sramley, I-Iarry P 1/?420U8 l I :47:58 AM She also seemed to remain in pretty good spirits throughout the hospital course. She did have some occasional issues with anxiety, but prn Benadtyl seemed to t-elp She did well from a fluid, electrolyte, nutrition standpoint throughout the hospitat course. She took a regular diet without any difficulty. Occupation therapy saw Abby throughout the hospitat course and recommended OT service as an outpatient three times per week to address activities of daily tieing, functional mobility, neuromuscular education, range of motion, strengthening, balance, endurance. Physical therapy saw Abby two times per day throughout the hospital course. She was given hinged MAFOs and made nice progress She was discharge to home with a wheelchair and a walker. She was setup to have outpatient physical therapy three times per week. Discharge medications included senna 3 6 mg by mouth every 48 hours, t7itropan 5 mg by mouth at bedtime, emo{tients as indicated, Mirai_ax 240 ml once a day as needed for constipation, bisacodyl 10 mg rectally once a day as needed, Benadryl 25 mg by mouth every 6 hours as needed for anxiety, Tylenol 500 mg by mouth every 4 hours as needed for ain. Foliowup appointments were made with Dr. Ramer on February 25th, 2008 as well as with MealthSouth Qutpatient Rehabilitation on January 17th, 2008, for physical therapy and occupational therapy appointments. 245084 Review/Si6n: Bromley, Starry P, DO HPB /Ci:7 LSD: U1/?3/U8 I7T: Ul/?4/U8 11:11 Dare Prinrerl 3/J/?(1(13 I'in+e Nrinted S S? ~!A! r ~ ~ ~ i I"t)4'1~'1~~E2 ~)F ~iT'C'("")iZtif~:~ S C`(~\T[1{~I~:"4C;'1 t`ti:l°; :1t~t~I~:i_iii~:ti.~. 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'~)t,}'. {4~r~' ., - ~,~a _ -~ Policy Details Coverages :700505065 Page 1 of 2 Nulmbe AIGAA9829110 Prefix First Middle Last Suffix Insured ~~ ;;DEREK ~ 'DEVLIN (~~ Name I___. _.~____1~ ._. ___._._____.-__.. ~ __ ._._----------_____.._~_.___~~_.____. _----. ____!i .__ __ Second Name ~ ~ I Insured _. __ ~ _.. _ ..~. , Vehicles covered under the Pony Vehicles (001)1995 PONTIAC GRAM SE 1G2NE15MXSM539265 Vehicle I nformation Year 1995 Make VIN 1G2NE15MXSM539265 ~ License Plate Number Owner DEREKDEVLIN ~~ Lien Holder PONTIAC Model GR AM SE Class Private Passenger Garaged ""~ Zip L~.. ~ _..._._.i Code Listed Drivers Driver Number Name Date of Birth Social Security# License# License State 1 001 f DEREK DEVLIN • 04!25!1982 ~ 26223611 • Pennsylvania t Page 1 of 1 Doverage Information Coverage Eff Dt Exp Dt Dedu a Limns Warnings 1 6f 07/G7/2007 01!07/2008 0 15Ki30K wish Limited TOR T D 07/07/2007 01/07/2008 0 K/5K UMBI 07/07/2007 01/07/2008 0 15Kl30K with Non Stacked; Limited TORT UNBI 07/07/2007 * 01/07/2008 w 0 15K/30K with Non Stacked; Limited TORT FPB 07/07/2007 01/07/2008 0 K/OK _ .. 1~ Page 1 of 1 L_ __ __~ ' I Endorsement# ~ L Effective Date I I Expiration Date I I Description l ___.J https://pplcsweb.aig. com:8443/PEGS/web/LIRetrievePolicyDetailsCovera~es. do?hdnClai... 6/12/2008 Policy Details Coverages :700505065 Page 2 of 2 1 001 03/01/2006 03/01/2006 AUPA01 2 001 05/01/2004 05/01/2004 AUPA15 001 07/07/2001 01/07/2002 RETURN Premium- 001 07/07/2001 01/07/2002 Renewal 001 01/07/2002 07/07/2002 Renewal Page 1 of 6 t,tt„c•~~nnlnawPh a;u cnm~R443/PLCS/web/LlRetrievePolicvDetailsCovera>;es.do?hdnClal... 6/12/2008 ATLANTIC STATES I NSUREDS COPY 1NSURA.+VCE COMPANY A Donegal Company RENEWAL OF POLICY PAG 3 0 3 0 60 6 Marietta, PA ~ 7547-0302 PERSONAL AUTO POLICY - SUPERIOR XL AUTO PROGRAM RENEWAL CERTIFICATE r~r~r~r;~~r1 vr; 1 L: U 1 A. M PAG 3030606 10/30/07 10/30/08 ATLANTIC STATES INS. CO. ~000362~0( ~ rc~/ t73/-L.S~L --- FICCO TERRENCE & DEBORAH MOSCHETTI INSURANCE AGENCY 0: 414 NORMAN ROAD 331 S MAIN STREET CAMP HILL PA 17011 GREENSBURG PA 15601 VEHICLES COVERED UNIT ST TER YR MAKE MODEL SERIAL NUMBER SYM CLASS MAX LT CHG DATE 001 PA 015 02 HONDA CIVIC LX 2HGES16602H602933 14 885220 10/30/0; 002 PA 015 98 HONDA CIVIC LX 1HGEJ6671WL054779 13 889120 10/30/0; INSURANCE IS PROVIDED WHERE A PREMIUM IS SHOWN FOR THE COVERAGE COVERAGE LIMITS OF LIABILITY PREMIUMS UN I T 1 2 LIMITED TORT OPTION APPLIES TO THIS POLIGY YES YES SPLIT LIABILITY LIMITS PP0309 0486 BODILY INJURY LIABILITY $100,000 EACH PERSON $300,000 EACH ACCIDENT 40.Op 37.00 PROPERTY DAMAGE LIAB,I,LITY $50,000 EACH ACCIDENT 29.00 26.04 UNINSURED MOTORIST BODILY INJURY PER PERSON $50,000 PER ACCIDENT $100,000 16.00 16.00 UNDERINSURED MOTORIST BODILY INJURY PER PERSON $50,000 PER ACCIDENT $100,000 39.00 39.00 MEDICAL EXPENSE COVERAGE $10,000 8.00 7.00 WORK LOSS COVERAGE $1,000 MONTH/$5,000 TOTAL 3.00 3.00 FUNERA:G EXPENSE COVERAGE $1,500 1.00 1.00 OTHER THAN COLLISION LOSS LESS $100 DEDUCTIBLE 49.00 40.00 PL-2 (9188) President 09/26/07 CONTINUED ON REVERSE SIDE REFER TO FINAL PAGE FOR BILLING NOTICE ATLANTIC STATES INSUREDS COPY INSURDanega~COMPANY RENEWAL OF POLICY PAG 3030606 Marietta, PA 77547-03D2 PERSONAL AUTO POLICY - SUPERIOR XL AUTO PROGRAM RENEWAL CERTIFICATE EFFEC`PIVE 1Z;U.l. A.M PAG 3030606 10/30/07 10/30/08 ~ ~ L ~ ~ ~~~ FICCO TERRENCE & DEBORAH 414 NORMAN ROAD CAMP HILL PA 17011 ATLANTIC STATES INS. CO, 000362 O( 0 :I 15601 l/L4j t3S/"LS~L MOSCHETTI INSURANCE AGENCY 331 S MAIN STREET - GREENSBURG PA BELOW YOU WILL FIND IMPORTANT INFORMATION REGARDING TMESE POLICY DECLARATIONS. COVERAGE FUR RENTED AUTOS IF YOU PURCHASED COLLISION COVERAGE ON YDUR OWNED AUTOS} UNDER THIS POLICY, COVERAGE EXTENDS TO COLLISION DAMAGE TO A PRIVATE PASSENGER AUTO THAT YOU OR A RESIDENT RELATIVE MAY RENT. THIS COVERAGE IS EXCESS OVER OTHER AVAILABLE INSURANCE AND APPLIES WHEN SUCH AUTO IS RENTED FOR 30 CONSECUTIVE DAYS OR LESS. IF YOU HAVE A COLLISION LOSS WITH THE RENTED AUTO, YOU MAY NAVE TO PAY THE LDWEST COLLISION DEDUCTIBLE AMOUNT SHOWN ON THE DECLARATIONS. BECAUSE THERE ARE MANY DIFFERENT AUTO RENTAL CONTRACTS, YOU SHOULD READ SUCH CONTRACTS CAREFULLY BEFORE REJECTING "COLLISION DAMAGE WAVER COVERAGE" OFFERED BY AN AUTO RENTALAGENCY. (SEEYOUR POLICY FOR COVERAGE DETAILS.} PL-2 (9/88) __ ~~_ President CONTINUED ON REVERSE SIDE REFER TO FINAL PAGE FOR BILLING NOTICE ATLANTIC STATES INSUREDS COPY INSURANCE COMPANY A f~onegal Company RENEWAL OF POLICY PAG 3 0 3 0 6 0 6 Marietta, PA 17547-0302 PERSONAL AUTO POLICY - SUPERIOR XL AUTO PROGRAM RENEWAL CERTIFICATE - EFFECTIVE 12:01 A.M PAG 3030606 10/30/07'_10/30/081 ATLANTIC STATES INS. CO. I000362~Oi .,~.,. FICCO TERRENCE & DEBORAH 414 NORMAN ROAD CAMP HILL PA 17011 ~lc~t! ts3!-L35L MOSCHETTI INSURANCE AGENCY 331 S MAIN STREET GREENSBURG PA 15601 INSURANCE I5 PROVIDED WH COVERAGE COLLISION LOSS LESS $250 TOWING & LABOR $50 LIMIT PACE PROTECTOR TOTAL BY UNIT 304.00 256.00 TOTAL TERM PREMIUM ~ $560.00 A $54.00 EXTRA EDGE DISCOUNT HAS BEEN DEDUCTED IN DETERMINING YOUR TOTAL PREMIUM A $601.00 ACCOUNT CREDIT HA5 BEEN DEDUCTED IN DETERMINING YOUR TOTAL PREMIUM 15% ANTI-THEFT DISCOUNT APPLIED TO UNIT 1 30% PASSIVE RESTRAINT DISCOUNT APPLIED TO UNITS 1,2 PL-2 (9(88} ~ ` - ' , ~~/ Q ,"~oL !~,µq.J President Q9/26/07 CONTINUED ON NEXT PAGE ERE A PREMIUM IS SHOWN FOR THE COVERAGE LIMITS OF LIABILITY PREMIUMS UNIT 1 2 DEDUCTIBLE 115.00 83.00 4.00 4.00 INCL INCL 0 REFER TO FINAL PAGE FOR BILLING NOTICE ATLANTIC STATES I NSUREDS COPY INSURANCE COMPANY A Donegal Company RENEWAL OF POLICY PAG 3 0 3 0 6 0 6 Nf3riiett2, PA 17547-0342 PERSONAL AUTO POLICY -- SUPERIOR XL AUTO PROGRAM RENEWAL CERTIFICATE ' Err'L''.C'1'1V~; iL:Vi A.M ! PAG 3030606 10/30/07 10/30/08 ATLANTIC STATES INS. CO. 000362 O( ~ ~ ~ i~~. 724 837-2352 FIC:CO TERRENCE & DEBORAH MOSCHETTI INSURANCE AGENCY 0: 414 NORMAN ROAD 331 S MAIN STREET CAMP HILL PA 17011 - GREEN5BURG PA 15601 i DR'.IVER ID DRIVER NAME LICENSE NUMBER BIRTH DATE 41 TERRENCE ON FILE 02/18/57 02 DEBORAH ON FILE 02/19/59 APPLICABLE FORMS FORM # DATE UNIT FORM # DATE UNIT FORM # DATE UNIT FORM # DATE UNIT PP0001 06/94 ALL PPD0151 03/05 ALL IL0910 01/81 ALL PAE001 12/89 ALL PP1301 12/99 ALL PP0309 04/86 001 PP0338 47/90 001 PP0422 07/90 001 PPD042.3 05/06 001 PP0418 07/90 001 PPD0419 05/06 001 PP0303 04/86 001 PP0551 06/94 001 AAACF 02/92 001 PPD9012 05/06 001 PP0.309 04/86 002 PP0338 07/90 002 PP0422 07/90 002 PPD0423 05/06 002 PP0418 07/90 002 PPD0419 05/06 002 PP0303 04/86 002 PP0551 06/94 002 AAACP 02/92 002 PPn9012 05/06 002 PP0305 08/86 002 LOSS PAYEE FOR UNIT #00.2 PA STATE EMPLOYEES C.U. 1 CREDIT UNION PLACE HARRISBURG PA 17110 09/26/07 PL-2 (9198} ~yup,f,~~~~~n,~,~4.,J President ----- STATEMENT OF ACCOUNT ----- ------- PAYMENT PLAN ------- PAG3030606 02 2] TOTAL PREMIUM $560.00 INSTALLMENT PLAN / DUE 10/27/07 $119.00 * ** AMOUNT DUE 12/30/07 $119.00 TOTAL AMOUNT RECEIVED $0.00 FULL PAYMENT PLAN/ DUE 1U/27/07 $560.00 ACCOUNT BALANCE $560.00 * INCLUDES $7.00 SERVICE CHARGE ** ALSO 3 ADDITIONAL INSTALLMENTS .ATI.1~-NTIC STATES INSUR.~NCE C®MPANY NOTICE TO NAMED INSUREDS NAMED INSURED FI CCO TERRENCE & DEBORAH AGENTMOSCHETTI INSURANCE AGENCY POLICYNUMBER PAG 3030606 02 AGENCY NUMBER 0003623 This notice is being sent to you as required by the Pennsylvania Vehicle Code Title 75 Section 1791.1(a). The laws of the Commonwealth of Pennsylvania, as enacted by the General Assembly, only require that you purchase liability and first-party medical benefit coverages. Any additional coverages or coverages in excess of the limits required by law are provided only at your request as enhancements to basic coverages. This notice is to provide you with the minimum coverage limits and corresponding premiums. $15,000/$30,000 Bodily Injury Liability $5,000 Property Damage Liability and $5,000 First-Party Medics{ Benefits $ 43.00 $ 50.00 $ 13.00 Total $ 106.00 THIS IS NOT YOUR BILLING NOTICE. PLEASE REFER TO COVER LETTER WHICH INCLUDES PREMIUM INVOICE FOR AMOUNT DUE. We urge you to contact your insurance agent to thoroughly discuss your insurance needs before making any changes to your policy. PLOF-207A (Ed. 08-91) ATLANTIC STATES INSURANCE CaMPANY IMPORTANT NOTICE REGARDING CHOICE OF TORT OPTIONS The laws of the Commonwealth of Pennsylvania give you the right to choose either of the following two tort options: A.. "Limited Tort" Option-- This form of insurance limits your right and the rights of members of your household to seek financial compensation for injuries caused by ether drivers. Under this form of insurance, you and other household members covered under this policy may seek recovery for all medical and other out-of-pocket expenses, but not for pain and suffering or other nonmonetary damages unless the injuries suffered fall within the defini#ian of "serious injury," as set forth in the policy, or unless one of several other exceptions no#ed in the policy applies. B. "Full Tort" Option-This form of insurance allows you to maintain an unrestricted right for yourself and other members of your househo{d to seek financial compensatinn far injuries caused by other drivers. Under this farm of insurance, you and ether household members covered under this policy may seek recovery for a!I medico! and other nut-of-pocket expenses and may also seek financial compensation for pain and suffering or ether nonmonetary damages as a result of injuries caused by other drivers. If you wish to change the tort option that currently applies to your policy, you must notify your agent, broker nr company and request and complete the appropriate farm, PLOF-208A (Ed. 7-90) +~~{ ~,._,.~'` Investigate Protect Secure Mr. John R. Zonazich, Esq. Skarlatos & Zonarich, LLP 17 S. 2`~ St., 6"' Floor Harrisburg, PA 17101 Re: Derek L. Devlin DOB: 04!25! 19$2 SSN: 121-76-xxxx Dear John: Information Network Associates, Inc. 5235 North Front Street Harrisburg, PA 17110 www.ina-inc.com (800) 443-0824 • (717) 599-5505 (717}599-5507 June 3, 2008 This report summarizes Information Network Associates, Inc.'s ("INA") efforts to date to establish details of any assets for the above-captioned individual against which your client may execute in order to collect a potential judgment. INA's investigative research has established that your subject has resided solely at 1 Main St., P. O. Box 225, Blairs Mills, PA 17213 since Apri12002. This address is located in Huntingdon County (PA). INA has conducted a nationwide database search of corporate records on file at various Secretaries' Of State (SOS) offices, including Pennsylvania, and determined that your subject is not currently affiliated with any business entities. Following is a summary of the results of our asset searches in Huntingdon County (PA) for the name "Derek L. Devlin" for the period of January 1, 1998 to May 26, 2008: INDEX SEARCHED Civil Suits (Plaintiff & Defendant) Judgments (Plaintiff & Defendant) Federal /State Tax Liens Tax Assessment Office Property Ownership Property Transfers within last yeaz Mortgages RESULTS No Record No Record No Record No Record No Record No Record No Record Mr. John R. Zonarich, Esq. June 3, 2008 Page 2 A search of bankruptcy and civil records at the U.S. District Courthouse for the Eastern, Middle and Western Districts in the Commonwealth of Pennsylvania has revealed the following information concerning Derek L. Devlin as of May 30, 2008: INDEX SEARCHED RESULTS Bankruptcy Petitions No Record Civil Actions No Record Criminal Convictions /Judgments No Record The information contained in this report and the attached documents is self-explanatory; however, if you have any questions, or if you require additional investigative research services, please call me. Thank you for using INA to help fulfill your information and investigative requirements. Very truly yours, Information Network Associates, Inc. ~f Daniel P. Ryan, CPA DPR:wj Counsel's Expenses In Re: Abby N. Ficco, a minor 8/12/2008 Postage, Federal Express, B/W Copies ChartONE, Inc. -Medical Records Less partial payment from Terrance Ficco Record Reproduction Services -Med. Records INA -~ Asset Search Hershey Medical Center -Medical Bills Cumberland Cty. Reg. of Wills -Filing Fee $119.50 $460.88 ($200.00) $260.88 $122.28 $250.00 $15.00 $30.00 Total Expenses $797.66 Jul 22 08 05:37p OPL Recovery Fax Cover Sheep 724212-3015 p.1 ~rIIGHMNZKm To: John Zonarich From: Jacki Ross Fax #: 717 - 233 - 1016 Fax #: Phone #: Date: July 22, 2008 RE: Abby Ficco cc: No. of pages (including cover): 1 Date of accident: 11/30/2007 ID # 103-869-399-001 Please be advised, vde cannot subrogate for the above referenced auto accident, therefore, we do not have a lien on file_ Thank you. Have a nice day_ NOTICE OF CONFIDENTIALITY This transmission is intended only for the use of the individual or entity to which it is addressed. It may contain information that is privileged or confidential. if the reader of this transmission is not the intended recipient, or the employee or agent responsible for delivering the transmission to the intended recipient, you are notified that any dissemination, distribution or copying of this transmission is strictly prohibited. COMMONWEALTH OF PENNSYLVANIA DEPARTN~NT OF PUBLSC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF 7HIR0 PARTY LIABILITY CASUALTY UNIT P.0.00X 8486 HARRISEiURG, PA 97905&l86 July 30, 2008 SKARLATOS & ZONARICH LLP JOHN B ZOI+TAFZICH ESQI7IRE 17 SOUTIi SECOND STREET 6 TH FLOOR HARRISBURG PA 17101-2039 Re: ABBY FICCO (minor) CIS #: 370149693 Incident Date: 11/30/2007 Dear Attorney Zonarich: Pursuant to our previous correspondence, please be advised that our lien against your client's personal injury award is detailed on the attached statement of claim. Social Security Act §1902(a)(7) requires that this recipient information be safeguarded, used by you solely to recover funds that we provided. Disclosure for other purposes is subject to criminal and monetary penalties. Please contact this office well in advance of settlement so that we can provide you with an updated statement of claim. In the event that the ]7epartment continues to provide your client with. medical and/or cash assistance, the. amount of our claim will increase accordingly. This statement does not include any other claims which may exist. If copies of bills are needed, please Contact the providers directly. Refer them to the Medical Assistance Bulletin, Na. 99-98-01 (Effective Date 02/01/97). Checks should be made payable to the Department of Public Welfare and sent to my attention at the above address. W~ request that with all transzni.ttal o£ funds, you provide the Department with a copy of the final distribution sheet. Please advise us of your position regarding payment of the Department's claim in this matter, as well as the present status of this case. Tf you have any further questions, please contact me. Thank you for your cooperation in this matter. sincerely, ~~ ~ ~~~~ Angela D. Carter Claims Investigation Agent 717-772-6612 717-772-6553 FAX Enclosure I COMMONWEALTW OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX -8486 WARF:ISBURG PA 17905.8488 July 30, zoos STATEMENT OF CLAiM SUMMARY FICCO, A88Y 370 149 693 w y, ~'- +~ ~~-1~ CLAIMS 907.78 146.17 CURRENT SdC -- .00 ... ,,.,, ...._ __...... y , - ,3~ _ ~ 948.17 _~ July 30, 2008 STATEMENT OF CLAIM F1000, ABBY 370149 693' HEALTHSOUTH OF MECHANICSBURG PO BOX 2016 PA 17055 04/25108 - 04!26!08 07/15/08 08175F778800001 48175F77fi800001 138.00 g,3g DIAGNOSIS 1 : Vb789 REHABILITATION PROG NEC DIAGNOSIS 2 : 95200 C1-C4 SPIN CgRD INJ NOS PROC CODE : 97110 THERAPEUTIC PROCEDURE, ONE OR MORE AREAS 05108/08 - D51081D8 07f15lOS 08175FT75900001 08175F778900001 136.00 33.50 DIAGNOSIS 1 : V6789 REHABILCTATION PROC NEC DIAGNOSIS 2 : 95200 C1-C4 SPIN CORD INJ NOS PROC CODE.: 97112 THERAPEUTIC PROCEDURE, ONE OR AAORE AREAS • HEALTHSOUTH OF MECHANICSBURG REHAB 268.00 41.88 >~.. 100002779 OD03 NRI: July 3Q 2008 STATEMENT OF CLAEM < FIGCO, ABBY s ~ - ' 370149 693 FAMILY HOME MEDICAL 1 SPRINT DR 02/05106 - 02!05108 DIAGNOSIS 1 : 9529 PRO~C CODE : E0978 02/05/08 - 02105!08 DIAGNOSIS 1 : 9529 PRO+C CODE : E2807 ozlo.5/oa - o2los/a8 DIAGNOSIS 1 : 9529 PROC CODE : E0992 02105!08 - 02105/08 DIAGNOSIS 1 : 9529 PROC CODE : K0004 02105108 - 02!05!08 DIAGNOSIS 1 : 9529 PROC CODE : E0971 PA 17016 06!09!08 27081346216830001 27081346216830001 SPINAL CORD INJURY NOS BELT, SAFETY WITH AIRPLANE BUGKLE, WHEEL 06109!08 27081356122210001 27081355122210001 SPINAL CORD INJURY NOS SKIN PROlPOS WC CUS WD a221N OB10@!08 27081356122300001 27081366122300001 SPINAL GORD INJURY N05 SOLID SEAT INSERT 06/09108 27081356122430001 27081356122430001 SPINAL CORD INJURY NOS HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR 06!09108 270813Sfi122760001 27081356122760001 SPINAL CORD INJURY NOS ANTI-TiPPIN(3 DEVICE WHEELCHAIR 75.00 376.00 8o.s8 90.00 17.90 3.37 fi7.00 1s.18 18.00 1.74 FAMILY HOMO MEDICAL 639.78 106.29 25 001731529 0004 NPI: 1700857661 WSEMS -Chambersburg ALS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011 Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 PATIENT NAME: ABBY FICCO INSURANCE: HIGHMARK DONEGAL INSURANCE 003096008 TERRANCE RCCO 414 NORLAND RD CAMP HILL, PA 17011 PATIENT NUMBER: CALL NUMBER: ZAH103869399001 DATE OF CALL: PAGPA01070018682 TIME OF CALL: CALLER: FROM: TO: REASON{S) FOR TRANSPORT INVOICE a~ ~~~ ~~~ :n.~E~cr ;JCV n~~~r?rc~aL s~r,vrc~s 67361 EXIN 003096008 11 11 /30/2007 04:54 PM Police/Fire/911 MILE MARKER 203 STAT MEDEVAC Paralysis MOTOR VEHICLE ACCIDENT DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT PARAMEDIC INTERCEPT S0207 1.0 797.87 797 87 EKG ELECTRODES (1) A0396 1.0 1.24 1.24 INF CONTROL GLOVES (PR) A0382 1.0 3.65 3.65 GLUCOSE BLOOD A0394 1.0 6.74 6.74 PERIPHERAL IV A0394 2.0 36.75 73.50 Total Charges $$3.00 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Total Credits 0.00 PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~ RETURNED CHECK FEE - X31.00 $883.00 PATIENT NAME: FICCO, ABBY N PATIENT NUMBER: 67361 DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT AMOUNT DUE 883.00 CALL NUMBER 003096008 AMOUNT $ BILLING DATE: 07/31 /2008 ENCLOSED NO PAYMENT HAS BEEN RECEIVED ON THIS CLAIM. PLEASE CONTACT YOUR INSURANCE COMPANY IMMEDIATELY. y~ VISA Mas ~ ~ .j ~ AND MASTER CARD ACCEPTED WSEMS -Chambersburg ALS 205 GRANDVIEW AVE CAMP HILL, PA 17011 CERTIFICATION OF PARENTS AND NATURAL GUARDIANS We, Terrence J. Ficco and Deborah A. Ficco, hereby certify that we are the parents and natural guardians of the minor plaintiff, Abby N. Ficco, who is presently eleven (11) years of a~;e. We have reviewed and discussed with counsel the proposed settlement and distribution as sett forth in the foregoing petition including the proposed order and schedule of distribution. We have signed this certification, concur with and join in this petition and we recommend that the court approve this settlement and distribution schedule. We understand that this certification is made pursuant to provision 18 Pa. Cons. Stat. § 4904, relating to untold falsification to authority. Dated: ~ ~~ -® r~ Terrence J. Fi Dated: ~ ~~~(~ ~ , ~ , / C', Deborah A. Ficco t CERTIFICATE OF SERVICE I, Sherry L. Devlin, an employee with the law firm of Skarlatos & Zonarich LLP, hereby certify that I this day served a copy of the foregoing PETITION FOR APPROVAL OF MINOR'S SETTLEMENT upon the person(s) indicated below by depositing a copy of the same in the United States Mail, postage prepaid, at Harrisburg, Pennsylvania, and addressed as fi~llows: Terrence J. Ficco and Deborah A. Ficco 414 Norman Road Camp Hill, Pennsylvania 17011 ,~ Date: August 13, 2008 Sherry L. e lin Legal Assistant