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HomeMy WebLinkAbout08-6156ANGINO & ROVNER, P.C. David L. Lutz, Esquire Attorney ID# : 35956 4503 North Front Street Harrisburg, PA 17110-1708 (717) 238-6791 FAX (717) 238-5610 Attorneys for Plaintiff(s) E-mail: dlutz@angino-rovner.com IN RE: PAMELA WENERICK, mother and natural guardian of KERRI WENERICK, a minor, Petitioner IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA NO. D P. G l?G C?,;zP T PETITION FOR COURT APPROVAL OF A COMPROMISED SETTLEMENT D THE DISTRIBUTION OF PROCEEDS OF A THIRD-PARTY SETTLEMENT ON BEHALF OF MINOR PETITIONER. KERRI WENERICK PURSUANT TO Pa R C P 2039 The Petition of Pamela Wenerick, mother and natural guardian of Kern Wenerick, a minor, respectfully represents: 1. Kern Wenerick is the daughter of Pamela and Thomas Wenerick. Kerri Wenerick is 17 years old, having been born on April 12, 1991. Kerri resides with her parents, Pamela and Thomas Wenerick, in New Cumberland, York County, Pennsylvania. 2. On December 12, 2007, at approximately 10:20 p.m., Kern was injured in a motor vehicle collision that occurred on Limekiln Road in York County, Pennsylvania. 3. At that time and place, Kerri was driving east on Limekiln Road. She was within a few hundred yards of her home. 390196 4. Nathaniel Sherwood was driving west on Limekiln Road and lost control of his vehicle at a high rate of speed and caused a head-on collision. Attached as Exhibit A is the Fairview Township Police Department report. 5. Nathaniel Sherwood was arrested and attached as Exhibit B is a York County Juvenile Probation Notification Form listing the numerous offenses. The disposition of the criminal matter was transferred to Cumberland County. In fact, if there was going to be a third- party lawsuit, it would have been filed in Cumberland County inasmuch as Mr. Sherwood resides in Mechanicsburg, Cumberland County. 6. As a result of the aforesaid collision, Kerri sustained injury. Fairview Township EMS were called to the accident scene and immobilized her, preparing her for a flight to Hershey. Attached as Exhibit C is the Fairview Township EMS records. Attached as Exhibit D are the Lifeflight records. 7. Kerri was hospitalized at the Hershey Medical Center from December 12, 2007, until December 19, 2007. 8. On December 14, 2007, Kerri underwent an open reduction internal fixation of a left femur fracture with an intramedullary rod. She also had a partial plantar fascia avulsion of the right foot. Attached as Exhibit E is the Hershey Medical Center Patient Discharge Instructions, as well as Dr. Edward Vresilovic's December 14, 2007, Operative Report. 9. After discharge from the Hershey Medical Center, Kerri treated at the orthopedic clinic. Attached as Exhibit F is the March 19, 2008, outpatient note wherein Dr. Vresilovic indicates that "the patient appears to have healed her femur fracture and the rods in place without difficulty." Dr. Vresilovic released Kerri to return to full activities without restrictions and released her to return to her part-time job. 390196 2 10. Nathaniel Sherwood is insured by Erie Insurance Company. Accordingly, a claim was made to Erie Insurance Company. Melissa Cover, an Erie liability insurance adjuster, eventually notified Petitioner's counsel that Erie was going to tender its policy limits of $100,000. Attached as Exhibit G is Melissa Cover's July 30, 2008, correspondence and enclosures documenting the tender of limits, Mr. Sherwood's Erie policy limits, and providing a proposed release, as well as Ms. Cover's August 14, 2008, letter with the Sherwood declaration page. 11. At the time of the subject motor vehicle collision, Kerri's parents, Pamela and Thomas Wenerick, were also insured with Erie Insurance Company. Therefore, in order to preserve Kerri's ability to make an underinsured motorist claim, Petitioner's counsel corresponded with Mr. Douglas Kocher, an Erie claims adjuster monitoring the underinsurance claim, and obtained Erie's consent to settle and waiver of subrogation. Attached as Exhibit H is Douglas Kocher's August 14, 2008, correspondence. An underinsurance claim will be filed once the third-party claim is resolved. 12. Additionally, Erie, Mr. and Mrs. Wenerick's first-party benefits insurer, paid $10,000 of first-party benefits for medical expenses. Once the $10,000 of medical expenses were exhausted, Mr. Wenerick's health insurance paid accident-related medical bills. Petitioner's counsel has received correspondence from the Strategic Recovery Partnership indicating that there is an "ERISA lien." Attached as Exhibit I is Attorney Russell Bowman's April 1, 2008, correspondence and Petitioner's counsel's April 9, 2008, correspondence requesting documentation confirming that Strategic Recovery Partnership was entitled to seek subrogation given the provisions of 75 Pa. Cons. Stat. Ann. §1722. Attached as Exhibit J is Jennifer Murphy's April 10, 2008, correspondence providing documentation indicating that the 390196 3 health insurance plan is a self-funded ERISA health plan. Attached as Exhibit K is Jennifer Murphy's August 1, 2008, correspondence documenting an "ERISA lien" in the amount of $48,400.64. 13. The Wenericks also made a claim to the Victim's Compensation Assistance Program and attached as Exhibit L is Robin Shea's June 5, 2008, correspondence documenting an award of out-of-pocket losses of $882.21, and Robin Shea's June 12, 2008, correspondence documenting an award of out-of-pocket losses of $415.03. The total award was $1,297.24 as reflected in Steven Turner's letter of July 31, 2008, attached as Exhibit M. Attached as Exhibit N is Edward Katz's August 13, 2008, letter setting forth the basis of the aforesaid statutory right of subrogation. 14. Pamela Wenerick, as mother and natural guardian of Kerri Wenerick, retained the services of the law firm of Angino & Rovner, P.C., to prosecute this action. Typically, the Angino & Rovner contingency fee contract provides that the attorneys are to receive, for professional services, 30% of the gross amount recovered. However, Angino & Rovner, P.C., has reduced its fee to 25% of the gross amount recovered (i.e., $25,000). The Angino & Rovner, P.C., modified Power of Attorney and Fee Agreement is attached as Exhibit O. 15. Angino & Rovner's out-of-pocket expenses totals $993.78. A print-out of expenses is attached as Exhibit P. A proposed Distribution Sheet is attached as Exhibit Q. 16. Accordingly, the net proceeds of $24,308.34 is to be placed into the New Cumberland Credit Union, a deposit which is insured by Federal Government, in an account that provides no withdrawal will be made until Kerri Wenerick reaches majority (age 18), except as authorized by Court Order. 390196 4 WHEREFORE, the Petitioner, Pamela Wenerick, mother and natural guardian of Kerri Wenerick, a minor, respectfully requests this Honorable Court approve the settlement and authorize payment of $100,000 whereby the net proceeds of $24,308.34 is to be placed into the New Cumberland Credit Union; $25,000 to be paid to Angino & Rovner, P.C. for attorney's fees; and $993.78 for out-of-pocket expenses to be reimbursed to Angino & Rovner, P.C. The Petitioner also respectfully requests that $1,297.24 be escrowed in Angino & Rovner's escrow account pending negotiations with the Victims Compensation Assistance Program with regard to the lien asserted. Likewise, $48,400.64 also be placed in the escrow account of Angino & Rovner pending any negotiations of the "ERISA lien." ANGINO & ROVNER, P.C. Date: ??, ? D - 0? David L. Lutz I.D. No. 35956 4503 N. Front Street Harrisburg, PA 17110 (717) 238-6791- phone (717) 238-5610 - fax dlutz@angino-rovner.com Attorney for Petitioner 390196 5 PETITIONER'S COUNSEL CERTIFICATE I, David L. Lutz, Esquire, Petitioner's counsel, do hereby affirm that the proposed $100,000 settlement, representing a tender of limits, in my professional opinion, is reasonable and in the best interest of the minor given the fact that an underinsured motorist claim will be made. It is also counsel's professional opinion that distribution of the proceeds as set forth in the aforesaid Petition is in the best interest of Kerri Wenerick. ANGINO & ROVNER, P.C. Date: 1?-??- U DMd V Lutz I.D. No. 35956 4503 N. Front Street Harrisburg, PA 17110 (717) 238-6791- phone (717) 238-5610 - fax dlutz@angino-rovner.com Attorney for Petitioner 390196 VERIFICATION I, Pamela Wenerick, as mother and natural guardian of Kerri Wenerick, hereby verify that the facts set forth in the foregoing document are true and correct to the best of my knowledge, information, and belief. I understand that any false statements therein are made subject to the penalties of 18 Pa. Cons. Stat. Ann. §4904, relating to unsworn falsification to authorities. WITNESS: Dated: l©/ 7LO Pamela Wenerick 390196 COMMONWEALTH OF PENNSYLVANIA ' 01 OLICE CRASH REPORTINGVMK4 - _ Page Case Closed Reportable Crash AA 500 1 CD Yes fED No -4g) Yes Q No Q P1300962 Crash Number " Incident Number Police Agency Patrol Zone 11 Z O c? t c u 19 p C Agency Name _ Precinct Investigation Date (MM-DD-YYYY) ®-/ a --5o v a Dispatch Time (m ll) Arrival riim e Investigator Bade Number (miil) V ^ ?/ `t i1 ?7 c•? R V G G r i O d J Reviewer _ Bad Number Approval Date (MM-DD-YYYY) R County County Name Municipality Municipality Name O NX of Week O Sun O Thu (} S FASRuiFt 3 Tw P. 12 V_ Crash Date (MM-DD-YYYY) Crash Time (m il) No of Units People Injured Killed* *If > 00 Mon Q Fri u =-=. a O Q f t O o? () H] © p EB Form F Wed O Unk Workzone (If Yes, Complete School-Bus School Zone lorm M, Section 29) O Yes ® No Related O Yes ( No Related O Yes 40 No Noti PENNDOT Maintenance O Yes ®No Intersection Tvoe Q 4 Wa Intersection Multi-Ley y O °Y" Intersection O O Off Ramp O Railroad Crossing Intersection , ecial U ® Midbloc:k Q "T" Intersection O Traffic Round Circlet About O On Ramp O Crossover O Other * See Overly Route Number Segment (Optional) Travel Lanes Speed Limit O North House Number (if applicable) 1 :5 S U 3 S .1 O South q Street Name Street Ending c ® East For Mid-block crashes only. use a. MI ` , °-' O West ?, = m K. = L IV R L O Unkno postal House Number and make sure Principal Roadway Street Name is .C wn filled in if using this option Route Interstate Turnpike Turnpike CD_ State County Local Road Private Other/ ?jgnma o (Not Turnpike) O (East/West) O Spur Highway ' O_ Road ® or Street O Road O Unknown "a a Route Number Segment (Optional) Travel Lanes Speed Limit Q North e O South m m c _ Street Name Street Ending 1 O East m ? O West O O Unknown c ° Sieana O Interstate O Turnpike O Turnpike O State O County O Local Road O Private O Other/ N (Not Turnpike) (East/West) Spur Highway Road or Street Road Unknown Intersecting Rt Num Or Mille Post- Or Segment Marker ?- c th O N Feet A E 7 '0 ? f d O I t ti St t N or O South Please r n erse r c ng ee ame St En ding O East u Or Miles Enter Information !? -' P N H 1 6 1 t< + m = L 1 ;= a O west m a °p for BOTH L d k . y LL an mar s v if Using This Option Intersecting Rt Num Or Mile Post Or Segment Marker N r c J C) North Distance From Crash Scene to Landmark 1 W Q So th y N E Or Intersecting Street Name St Ending- :) O East (For Crash between is C IS IL 11 T If }-? 1- L! I I I I = I R l? . O West Landmark 1 and Landmark 2) W H ? Degrees Minutes Seconds Degrees Minutes Seconds 5 3 Longitude: - Latitude: F70 FTM : j 7 3 ?. Ez " u Traffic Control Device Q Yield Sign Q Police Officer or Not Applicable Flagman O Traffic Signal O Active RR Crossing O Other Type TCD Device Functioning Emergency O O Preemptive IM No Controls Improperly Flashing Traffic Controls O Signal O Stop Sign O Passive RR Q unknown Crossing Controls Signal o Device Not O Device Functioning O Unknown Functioning Properly 3 Lam( Of "Not Applicable', skip rest of the Lane Closure section) Lane Closure O North O East O North and South O All p O Not Applicable O Partially 'Fully O Unknown ? 49 Qkmcliw Q South Q West East and West (N,S,E,W) W 0 C Traffic Yes O No 1W Detoure d Unknown Q EFU. rpm 514 O < 30 Min. Q 30-60 Min. ® 1-3 hrs O 3-6 hrs O 6-9 hrs O > 9 hours O Unknown FORM M AA-500 (12/02) POLICE COPY ??h1 b f )_ 1 - +T `? * COMMONWEALTH OF PEMNSYLVANIA -J` 4POLICE CRASH REPORTING FORM AA 500 2 Police Use Only EKI fIIIII?IIIIIIflII?R Page: Pi3oossz Crash Number 7 o C rjr6e M Vehicle in hi Ille ailed O Le all Parked (4 Trar por? eft p e?/ ga& 9 Y CD Non -Motorized { Commercial Vehicle D c DisableFrm Unit Pedestrian Pedestri n on Skates, o in Wheelchair, etc Previous Crash CD Train o PhantomVehicle CD Yes ,Fc No (If "Pedestrian" or 'Pedestrian on Skates, in Wheelchair, -etc, Complete Form M, Section 28) (if Yes, Complete Form C) Unit No First Name MI Date of Birth (MM-DD-YYYY) I /v,aTk-l D NS 0 I s 9$ 9 Last Name Telephone Number Delete? o S H F P- w 10 © D Address / C' /State Z• c 3613 LzssuR 70g1 CH04ojleSBuR Aq I -1 a S S I Driver License Number State Class 2$S 14 y309 ]PIRI Alcohol/Druas Suspected Driver or Pedestrian Phvsical Condition m CD Illegal Drugs Q Medication ? No Apparently Illegal Drug ? o (::) Fatigue Q Medication Normal Use 41P Alcohol CD Alcohol and Drugs o Unknown Had Been ® o Sick Q Asleep Q Unknown Drinking Alcohol Test Type .C p Q Test Not Given Q Breath o Other Primary Vehicle Code Violation Char ed? 9 d u Unknown if o Blood Urine ® Test G iven 3 10 Yes o No 3 s nkno Alcohol Test Results CD Test Refused ® Re ultswn Driver Presence 1=Driver Operated 3=Driver Fled Scene o Test Given, Contaminated Results Vehicle 4=Hit and Run I ? _ 2=No Driver 9=Unknown Owner/Driver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh 01=Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=0ther Municipal 98=Other ?. Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown Same as Owner First Name Owner Last Name or Business Name-(ff Pedestrian, skip this Section) Driver Address / City / State / Zip Vehicle Make *Make Code F I CHfV 2101 VIN Model Year Vehicle Model (see overlay) ! G ? IvD5 arA3x I 10 954h 1 9 mf4Lr.b License Plate Reg. State Est. Speed Vehicle Towed Towed By G w B 3 9 t S a I I 1 1 ® Yes o No t/fnJ s Sg2v3C? NjF Insurance Insurance Company Policy No 0 Yes CD No o known Cws 5 11 .30()(660a , p C Trailing Type 1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No Tag Year Tag St Unit T No. of Unit ? 2=Towing Truck 5=Camper 8=Other ili d ra ng Units: 3=Towing Utility Trailer 6=Full Trailer 9=Unknown V Direction of Vehicle Position O *Movement -7 *See O l Special Usage ver ay Vehicle Color Vehicle Type 05=Large Truck 20=Unicycle, Bicycle, 12=Commercial 06=Yellow Q (? 07=Silver - { 01=Automobile 06=SUV Tricycle 02=Motorcycle 07=Van 21 =Other Passenger 00=Not Applicable Carrier 01 Fi h 08=Gold 01=Blue 09=Brown 03=Bu5 10=5nowmobile 22=Horse & & Buggy Buggy 04=Small Truck 11 =Farm Equip 23=Horse & Rider = re Ve 13=Taxi 02=Ambulance 21 =Tractor Trailer 02=Red 10=Orange 03=White 11 =Purple (If "02" Complete Form 12=Construction Equip 24=Train M, Section 26) 13=ATV 25=Trolley 03=Police 22=Twin Trailer 08=Other Emergency 23=Triple Trailer 04=Green 12=Other 05=Black 99=Unknown 18=Other Type Veh 98=Other (If or "21 " Complete 19=Unk Type Spec Spec Veh 99=Unknown Vehicle 31 =Modified Veh 11 =Pupil Transport 99=Unknown . Form m M, Section 27) Initial Impact Point Damage Indicator Gradient 3=Downhill Road Alignment 00=Non-Collision 14=Undercarriage V ?- 01-12=Clock Points 15=Towed Unit O=None 2= Functional 1=Minor 3=Disablin 3 9 4=Bottom of Hill © 54--Bottom of Hill 1=Level 1=Strai ht ® 2=Curved 9=Unknown 2=Uphill n 13=Top 99=Unknown 9=U known 9=Unknown FORM # AA-500 (12/02) POLICE COPY COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page: AA 500 2 Police Use Only [H?] 1111111111111111111111111111 Crash Number 7 P1300962 G ?. Moto?Vehicle in r ed O Legally Parked Q Non Motorized Type ! Transport © klif &?iu?i ehic? _ 70 ?Ilegally A Commercial Vehicle 0 Unit Pedestrian on Skates, Disable m F Q Pedestrian O Q Train Q Phantom Vehicle Yes ! No O c in Wheelchair, etc Previous Crash " " " (if Yes, Complete Form C) (If Pedestrian or Pedestrian on Skates, in Wheelchair, etc", Complete Form-A4, Section 28) Unit No First Name MI Date of Birth (MM-DD-YYYY) a lKLIP-lid-ill ® o t Last Name Telephone Number Delete? O W £ -3 £ t, IT I C K -7/ 7- 770- &0 q Address / City / State Zi c 534 Alm I-rMT-LT-1 to 1) k t> CU 0) t F Ph I 1 -7 U-7 Driver License Number State Class C A Alcohol/Drugs Suspected Driver or Pedestrian Physical Condition , N Illegal Drugs o O O Medication % Apparently Illegal Drug Normal O Use O Fatigue Q Medication 113 d Q Alcohol Q Alcohol and Drugs Q Unknown Q Had Been O Sick Q Asleep Q Unknown Drinking Alcohol Test Type p QR Test Not Given Q Breath Q Other Primary Vehicle Code Violation Charged? a Q Blood Q Urine Q Unknown if Q Yes Q No r Test Given > Alcohol Test Results Q Test Refused O Resultswn Driver presence 1=Driver Operated 3=Driver Fled Scene Test Given, ?• Q Contaminated Results ? Vehicle 4=Hit and Run 2=No Driver 9=Unknown OwnerlDriver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal-Police Veh 09=Federal Gov Veh 01=Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98=Other d Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown Same as Owner First Name Owner Last Name or Business Name (if Pedestrian, skip-this Section) Driver O I-rklolmIdsl W£ N is R= C K Address / City / State / Zip Vehicle Make *Make Code 93y ?1r'Y)fK£Lt?1 koez), L 2 N A t7U70 bdlb GZ-] VIN Model Year Vehicle Model (see overlay) f 8 3 (o K 3P, r" 11 6-1 o [[g 9 SPzIZs-r License Plane/ Reg. State Est. Speed Vehicle Towed Towed By Q NO Yes 5 K d I (D lS Kf+VS SrZVJCE Cf+u] F Insurance Insurance Company Policy No s Q& Yes Q No O known T2-£ Q o O 113 3 H A I Trailin4 Type 1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag-No Tag Year Tag St Unit No. of ? unit ? 2=Towing Truck 5=Camper 8=Other T ili 0 m ra ng 3=Towing Utility Trailer 6=Full Trailer 9=Unknown Unit V s: m Direction of rave a *Vehicle Position *Movement *See (? I Q O l Special Usaae ver ay - Vehicle Color Vehicle Tvpe 05=Large Truck 20=Unicycle, Bicycle, 761 12=Commercial FO m3 06=Yellow (? 07=Silver 01=Automobile 06=SUV Tricycle 101 11 02=Motorcycle 07=Van Van 21 =Other Pedalcycle Passenger 00=Not Applicable Carrier 08=Gold 01=Blue 09=13rown 03=Bus 10=Snowmobile 22=Horse & Buggy 04=Small Truck 11 =Farm Equip 23=Horse & Rider 01 =Fire Veh 13=Taxi 02=Ambulance 21=Tractor Trailer 02=Red 10=Orange 03=White 11 =Purple (If "02" Complete Form 12=Construction Equip 24=Train M, Section 26) 13=ATV 25=Trolley 03=Police 22=Twin Trailer 08=Other Emergency 23=Triple Trailer 04=Green 12=Other 05=Black 99=Unknown (If "20" 18=Other Type Spec Veh 98=Other or "21 Complete 19=Unk Type S ec Veh 99=Unknown Vehicle 31 =Modified Veh 11 =Pupil Transport 99=Unknown Form m M, . p Section n Form 27) Initial Impact Point Damage Indicator Gradient 3=Downhill Road Alignment 00=Non-Collision 14=Undercarriage 01-12=Clock Points 15=Towed Unit O=None 2=Functional ? 3 1=Minor 3=Disabling 4=Bottom of Hill 1=Level 5=To of Hill © 1=5traieht T 2=Curve 9=Unkno n p 2=Uphill 13=Top 99=Unknown w 9=Unknown 9=Unknown FORM # AA-500 (12/02) POLICE COPY COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page AA 500 3 Police Use Only EKI III IIIIIIIII 111111111111111111111 Crash Number ?1300962 Person Twe: A 1=Driver Seat Position: D 00=Not A Passenger/Occupant ?uipment One: E Safery 00=None Used / Not Applicable E' i n: G O=Not Applicable 2=Passenger 01=Driver - All Vehicles 01 =Shoulder Belt Used 1=Not Ejected 7=Pedestrian 02=Front Seat Middle Position 02=Lap Belt Used 2=Totally Ejected 8=Other 03=Front Seat Right Side 03=Lap And Shoulder Belt Used 3=Partially Ejected 9=Unknown 04=Second Row - Left Side Or 04=Child Safety Seat Used 9=Unknown Motorcycle Passenger 05=Motorcycle Helmet Used 05=Second Row - Middle Position 06=Second Row - Right Side 06=Bicycle Helmet Used 10=Safe Belt Used Improperly H Ejection Path: C ?€X: F =Female B M=Male 07=Third Row Or Greater - Left Side ? 11=Chit Safety Seat Used Improperly 12=Helmet Used Improperly O=Not Ejected /Not Applicable 1=Through Side Door Opening +• m U =Unknown 08=Third Row Or Greater - Middle Position 90=Restraint Used, Type Unknown 99=Unknown 2=Through Side Window 3=Through Windshield o l i S i 09=Third Row Or Greater - Right Side 10= Slee er Section of Truckcab Safe Equipment Two: F 00 N n d / N li U t A bl 4=Through Back Door 5=Through Back Door Tailgate Opening 6=Through Roof Opening Sunroof/ C m n urv ever ty. O=Not Injured C p 11=1n Other Enclosed = o e se o pp ca e 01 =Front Air Bag Deployed (For This Seat) Convertible Top Down) 7=Through Roof Opening (Convertible CL 1=Killed Passenger Or Cargo Area 02=Side Air Bag Deployed (For This Seat) Top Up) 0 d 2=Major Injury 3=Moderate 12=ln Open Area (Back Of Pickup, Etc.) 03=Other Type Air Bag Deployed 04=Multiple Air Bags Deployed 9=Unknown Injury 13=Trailing Unit 05=Motorcycle Eye Protection 4=Minor Injury 8=Injury, Unk 14=Riding On Vehicle Exterior 15=Bus Passenger 06=Bicyclist Wearing Elbow/Knee/Pads 10=Air Bag Not Deployed, Switch On ric ti n: O=Not Applicable Severity 9=Unknown if 98=Other 99=Unknown 11 =Air Bag Not Deployed, Switch Off 12=Air Bag Not Deployed, 1=Not Extricated 2=Extricated By Mechanical Means Injury Unk Switch Setting 13=Air Bag Removed (Prior To Crash) 3=Freed By Non - Mechanical Means 8=Other 19=Unknown If Air Bag Deployed 99=Unknown 9=Unknown EMS Agency: ?afRJ kt P ??,`?? Medical Facility: yan ,.I: No?Px Unlit No Person No HI Delete? Date of Birth (MM-DD-YYYY) A B C D E F G [61F1 0 5q J UIE® Fo Name / Address / Phone EMS Transport- ® Same as Operator C& Yes CD No Unit No Person No o f U a Delete? Date of Birth (MM-DD-YYYY) A B C D E F G- H I o 3- ! 9 -u 9 9 F ?H q t?3 oo ®00F Name / Address / Phone EMS Transport Same as Operator LYNHNAJ Si i1N(`?£1 FLm `r, jvfr0 urn f2LI?}Nl) t %7' -58g1 ®Yes CD-No Unit No Person No Date of Birth (MM-DD-YYYY) A B C D E F G H I Delete? 9/ FLIFF®? J 9 C a [9 El ® Name / Address / Phone EMS Transport Same as Operator (AD- Yes o No Unit No Person No mm Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I o -m ???mmm000 Name / Address / Phone E1R5 Transport Same as Operator o Yes C) No Unit No Person No mm Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I o m-m ??0mmm?0? Name / Address / Phone EMS Transport Same as Operator o Yes o No Unit No Person No m m De Date of Birth (MM-DD-YYYY) A B C D E F G H I 0eT m-m El El El ??F Name / Address / Phone EMS Transport Same as Operator o Yes CD No FORM 4 AA-500 (12/01) POLICE COPY COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM . AA 500 4 Police Use Only n ilea Sri Crash Number Page P1300962 Crash Description © O=Non-Collision 2=Head On 4=Angle 6=Sideswipe 8=Hit Pedestrian 1=Rear End 3=Rear to Rear 5=Sideswipe (Opposite Direction) e 0 0 (Backing) (Same Direct ion) 7=Hit Fixed Object 9=Other/Unknown E a Relation to Roadwav 1=0n-Travel Lanes 3=Median 5=Outside Tralficway 7=Gore (Ramp Intersection) 0 0 2=Shoulder 4=Roadside 6=1n Parking Lane 9=Unknown ' N illumination ® 1=Daylight 3=Dark -Street 5=Dawn 8=Other Lights 2=Dark - No 6=Dark - Unknown Street Lights 4=Dusk Roadway Lighting C Weather Conditions 1=No Adverse S=Fo 7=Sleet & Conditions 3=Sleet (Hail) 9 Fog 9=Unknown ate, E 2=Rain 4=Snow 6=Rain & Fog 8=Other ?w v Road Surface Conditions El 0--Dry 2=&nd, Mud, Dirt, 4=Slush 6=lce Patches 8=Other Uu a 7=W Mter - Standing 1=Wet 3=Snow Covered 5=lce or giving Harm Event L/R Most? Utility Pole Number 1 Harmful Events (Harm Event) 30=Hit Fence Or Wall 01 =Hit Unit 1 31=Hit Building it 2 32=Hit C l 02 t Hit U Unit No u ver = n 2 m 03=Hit Unit 3 33=Hit Bridge Pier Or Abutment 04=Hit Unit 4 34=Hit Parapet End 05=Hit Unit 5 35=Hit Bridge Rail 06=Hit Other Traffic Unit 36=Hit Boulder Or Obstacle Please Put ? 3 O E i 07=Hit Deer On Roadway 08=Hit Other Animal 37=Hit Impact Attenuator vents n Sequential 09=Collision With Other Non 38=Hit Fire Hydrant Order 4 Fixed Object 39=Hit Roadway Equipment 11=Struck By Unit 1 40=Hit Mail Box y Unit 2 41 =Hit Traffic Island 12=Struck B Unit 3 42=Hit Snow Bank 13=Struck B E y 0 Harm Event L/R Most? Utility Pole Number 14=Struck By Unit 4 43=Hit Temporary Construction ,. ' 1 ( ? ® 15=Struck By Unit 5 Barrier 16=Struck By Other Traffic Unit 48=Hit Other Fixed ObjeOb 49=Hit U k Fi d t Hit T Sh 21 O bb 6 Unit No n nown xe jec ree r = ru ery W .10 2 6 1 `! 22=Hit Embankment 50=Overturn/Roll Over 23=Hit Utility Pole 51 =Struck By Thrown Or Falling 24=Hit Traffic Sign Object 25=Hit Guard Rail 52=Pot Holes Or Other Please Put 3 m E t i F 26=Hit Guard Rail End Pavement Irregularities 27=Hit Curb 53=Jacknite ven n s Sequential 28=Hit Concrete Or 54--Fire In Vehicle Order q m [:] 0 Longitudinal Barrier 58=Other Non-Collision 29=Hit Ditch 99=Unknown Harmful Event First Unit No Harm Event Most Unit No Harm Event - Driver Action (D) 17=Careless Or Illegal R armful 0 1m!} ful m/ v nt V 2. NEW, o (- 00=No Contributing Action Backing On Roadway d 18=Driving On The Wrong 01=Driver Was Distract the Crash tee trash e 02=Driving Using Hand Held Phone Side Of Road Do not repeat this information on multiple pages 03=Driving Using Hands Free Phone 19=Making Improper Environmental /Roadwav P t ti l F M t 1 d 2 m 3 m 04=Making Illegal U-Turn Entrance To Highway 05=Improper/Careless Turning 20=Making1mproper Exit 6 T o en a ac ors ( ) 0 = urning From Wrong Lane From Highway 00=None 11 =Slippery Road Conditions (Ice/Snow) 07=Proceeding W/O 21 =Careless Parking/Unparking Clearance After Stop 22=Over/Under 01=Windy Conditions 12=Substance On Roadway 02=Sudden Weather Conditions 13=Potholes 03 h h 08=Running Stop Sign Compensation At Curve 09=Running Red Light 23=Speeding =Ot er Weat er Conditions 14=Broken Or Cracked Pavement 04=Deer In Roadway 15=TCD Obstructed 10=Failure To Respond To 24=Driving Too Fast For Conditions Other Traffic Control Device 05=Obstacle On Roadway 16=Soft Shoulder Or Shoulder Drop Off 06 Oth r A i l I R d 28 Oth R d F 25=Failure To Maintain Proper Speed 11=Tailgatingg 26=Driver Fleeing Police (Pol Chase) = n ma n e oa way = er oa way actor 07=Glare 29=Other Environmental Factor 12=Sudden Slowing/Stop ing 27=Driver Inexperienced 13=I1legally Stopped On Road e o 08=Work Zone Related 99=Unknown 28=Failure To Use Specialized Equip 14=Careless Passing Or Lane 92=Affected By Physical Condition Ch o- - Possible Vehicle Failures (V) 12=Wipers ange 15=Passing In No Passing Zone 98=Other Improper Driving Actions 99=Unknown 00=None 06=Exhaust 13=Driver Seating/Control 16=Driving The Wrong Way on 14=Bod , Doors, Hood, Etc 01 =Tires 07=Headlights 1-WaY Street ? 02=Brake System 08=Signal Lights 15=Trailer Hitch 03=Steering System 09=Other Lights 16=Wheels Wheels Unit m m No 1 2 a 3 ? 4 04=Suspension 10=Horn 17=Airbags v d a 05=Power Train 11 =Mirrors 18=Trailer Overloaded = U° 19=Unsecure/Shifted Not V 1 m Trailer Load C? d 20=Improper Towing Unit No 0:] 1 m 2 m 3 m 4 m 21 =Obstructed Windshield Unit Q Q m 99=Unknown 1 2 ? Pedestrian Action (P) 03=Workin g 00=None 04=Pushing Vehicle - No 01 =Entering Or Crossing At 05=Approaching Or Leaving Vehicle 06=Working On Vehicle S ifi d L ti pec e oca on Indicated Prime Factor Unit No Factor Code 02=Walking, Running, Jogging, 07=Standing Do not repeat this information on multiple pages. U ' m Or Playing 98=Other 99=Unknown E/R V D P Q Q ® CD If E/R is the Prime Factor Unit No Unit No m m m m Type, leave Unit No blank 19 FORM # AA-500 (12M) POLICE COPY COMM©NWEALWH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page -PA 500 5 Police Use Only IIIIIIRIIIIIIIIIIM Crash Number P 1300962 ....................................................................... ........... ........... ........... ........... ........... ........... ..... ................................... ...... ........... ........... ........... ........... ...........i. ........ ...... ......................................... ...... .................. ................... ... ....... .............. ........... ......... ..... , ... ... .... .: ........................................... . . . ... . . . . . ..... . . . . . ..... .. . . ... ..... . . ..... ..... ..... ..... ..... ..... 20 . . . . . . . : . . . . . . . . . . . . . . . . . . . . . . . . . . . .. c ...................... ........... ........... ...._ ....... .......... .......... ........... ........... ........... ........... ........... ........... ..... ...... ........... ........... ........... ........... ........... ..... ..... ..... ..... ..... ..... ..... ... .. ..... ..... ..... ................................................................................ ......................... ..... .............. ... .............. . .. .............. ... .............. ..... ..... ..... ... .......... ..... ... ... ...... ...... ...... .. ... Witness Name Address Phone 21 1 2 Narrative and additional witnesses: Accident Investigation Notification Issued? O Property Damage O tv i ONE &jA-S ` 0 £M N R o A b WF-IT 0- C- d D. T TW UA WI ST !:m7l4-rLNV Z3 ':16 T 0 b. AZ r TI()lTE V:4 si u TmA\j -F 2T (?, `' G C 7H ?- ^'ko a> SuR?;cv I F T ?i - T T TH m 2o? w -? '''r -c-) I t TtoTo THE a ? a 4 fL ti iJ'T i ?> T 4 '? !?a N4 T C -' r- z } T wo 0i i oT ;? `Nf oPi o Su c z ?o a z 7C 2 5 ? u a m C 3 ?iJf2. F -T 1RANSPo2'T2 L ) Hiasnz? F cP? FNS i NI-, bal,JiQ r- NTT O lflv?NSPD(Z71'ib -10 t iZ S N f - ri C4 tv ? 2 a" Hicin)pTni RoTN LkN L T S 5 ??L 2F '-,f v z a z T)?}rhetG £ ,57 Z TlYI l? ACT P -T 'I Po l2v7c (fr3TF FORM # AA-500 (12/02) POLICE COPY CASE NUMBER: PAGE: 1 OF 1 EV Vehicle 1 a !Y V C ?q d Vehicle 1 _ 'J approximate J Y J co O O f O I? Right Rear Yaw Left Front Yaw i - j Vehicle 1 \ z Right: Front Yaw :• ` I? li i? Vehicle 1 I Vehicle 1 ' Vehicle 1 at Impact - 1 - , Vehicle 2 at Impact Debris Field I fit. e . i Pre-Impact Skid i i Vehicle 2 Vehicle 1 - - Tree ! ? i Vehicle 2 Final Rest I Vehicle 1 -- ; 41 Post Impact Skids ?' g E Wheel Gouge f Vehicle 1 Final Rost - 0 10 20 30 40 50 60 70 80 90 100 ft FA IRVIEW TOWNSHIP POLICE DEPARTMENT INVESTIGATOR: K. GORM ,N LOCATION: 900 BLK LIMEKILN RD COUNTY: YORK WEATHER: CLOUDY RCI:D COND.: DRY DATE DRAWN: 12/13/2007 TIME OF INCIDENT: 2118 HRS DRAWN BY: KVG DATE: 12/12/2007 SCALE: SEE ABOVE YORK COUNTY JUVENILE PROBATION NOTIFICATION FORM Juvenile: Nadel 8,d Probation Officer: Ted Balker ,TADL#: CP76 7nW-3.94M8 Offense(s) & Date: DUI.3 a 1 DUI 3802 d Sault b DI 12/12/07 Date of Disposition: 7/8/08 Date of Notification: 711;0!08 Disposition Notifications- Scat To: Police Wm Iftm h.jCjp P_A Address 145: UMMA IM Stye ftwunaftam PA 1'78'ti Atty. McPate Address 35 E. aflA St, York, R 17401 DA -Woodward Address . Judicial Cettitrar victim ICerri Weateclc. Address _ 934 W. Limekiln Rd New Ciand, PA 17070 ..:...... . Disposition of case: Warned and counseled at intake Informal Adjustment ?x Charges were t t d by the Court Arm Assault by MV i_e &V1 ? ' Dx I'`ef ete Charm were withdrawn Found not to l'.ave ca emitted the offense + Consent Dee Aditdit+e, 0eliisgtttt/Ctitr# Action: Fonda( Probation Intensive Probation Plsceizient, Location Commun4 based services Restitution (tails section for victims only) X Other D §mMtion lxmftred.to hg1 The above child has been ordered to pay the restitution amouritt of If the gild is in placenent,the attetnlat.to soli t tept will bo delayed Every effort will be mada,19.xastttre your lass, but mw=j*,4a. y varies: For informatidm 6fi the status tsfyour case, contact: the J er a Prob a Idpartcrumtat77 . • When the Court dines fat the cor tInent of a delinquent Cbild to a residential placement the most appropriate disposition, a treabnant plan is developed(. If it seems consistent with public safety and treatment plan, a horse pass May be scheduled to facilitate tie achievement of spe fiic goals. A home pass is a scheduled temporary roktm of the child to the community. Current standards provide that you may request to be informed by the Juvenile Probation Depatumt of all authorized home passes. Please indicate below if you wish to be so informed It Do response is reeeimd 110 working days, we WIN ac me that jowdo not wish to be ttWw& : , ?frs„ I do wish too. be informed of aii borne passes for this offender. ;, No, t do itot Nvish to be informed of home passes forlhis offender. sigtre?3: , Late:. +6341 Provides that marts it;? t strait ed'that acts ascribed tb the child were not committed by ffie dO% *a btrft shall direct that the firignprints and phut DpT#s be immedlattly destroyed by law enforcement agencies: tf applicable, destroy said recap, and return this signed document. Rev. 10/2005 ennsylvania EMS Report Service Name Station Unit Name & No. PCR No. Date AMB 68-02 - 6700702 0712031 12/12/2007 Fairview Township EMS, Inc. Incident Location Municipality & Incident Zip PSAP Incid. No. Fairview Township, 17070 #•900blk. Limekiln Road, New Cumberland, Pa. Receiving Agency LIFE LION - Hershey Med. Ctr. Crew Patient Name Kerri A. Wenerick C #1 Hauck, M atthew E. E 118085 Street Address d R l C#2 Hawkins, Hollie.l. E 118535 4" oa n #934 Limeki C #3 City New Cumberland State Zip PA 17070 C #4 r? S. Female Age DOB 16 Years 04/12/1991 Phone No. (717) 770-1629 Times .PW 0 Patient Number Social Sec. No. Pt Weight 911 Dispatch 21:18 125 kg. Enroute 21:19 Private Physician Driver's License Arrive-Scene 21:23 Contact 21:25 Transporting Assist Units Assist OS Out On-Scene Dest. In Depart Scene Arrive Available 22:40 A Response Outcome Medical Command Physician M Quarters 22:40 Care Transferred Chief Complaint: Left Leg And Right Ankle Pain -> Secondary To A Motor Vehicle Accident Current Meds: AlI gra Allergies (meds): Secore PMHx Diabetic, HTN, Seasonal Allergies Level of Consciousness Speech Neurological Skim, Temperature & Color Q Conscious Q Oriented x 4 ©'Coherent ? No Complaint Q Dry Pink Mottled ? ? © Alert Uncooperative ? Incoherent ? Headache ? Numbness ? Moist ? Pale Cyanotic ? Lethargic ? Combative ? Silent ? StiffNeck ? Weakness ? Diaphoreti c ? Flushed ? Yellow- [D Confused C] Altered ? Crying ? Neck Pain 0 Dizzy Ashen Other ? ? ? Unconscious ? Hysterical ? Slurred ? Dysphasia ? Gait-Unsteady Hot O Warm O Cool O Cold O ? Infant ? Aphasia Facial Droop - L O R O Respiratory Breath Sounds Cardiovascular P-upils [] PERL E SENT Eyes ? No Complaint ?? No Complaints t P L R Chest Pain ? ? L R Blurred Vision - L ? R ? resen Airway Patent ? No Complaint Size Q Double V ision - L ? R Symmetrical Absent ? ed Clear ? L b El ? Severity _ Pinpoint ? ? ?? photophobia - L?R? or a ? Constant ? Intermittent Dilated ?? Retractions Diminished ? ?? E] Sharp ? Burning Fixed ?? Ears ? No Complaint ? Stridor Wheezes ? ? ? Dull ? Pleuritic Slush ggi 01:1 - L?R? Pai Crac Crackles ? Nasal Flaring ? ? ? Heavy [] Radiating Non-Reactive [In n e - LQR? char Di nchi Rho Cough 1:1 El Known Anomaly?? g s d - LOR? Bl Q No Complaint Asymmetric ? ? ? Capillary Refill oo i Productive - No O Nose E] No Complaint Yes O Nasal Congestion Throat ? No Complaint ? Nasal Drainage - ? Sore Throat ? Dysphasia Deviation - L O R O ] R o Epistaxis - L[ ? Drooling ? Swelling/Edema i ? JVD ? Deformity Printed On: 12/13/2007 10:45 EM.Stat Reporting(c) 1998-2007, Med-Media, Inc. All Rights Reserved a Provider Page: 1 of 4 O O J C1 O O N ennsylvanWEMS Report Service Name Unit No PCR No. Date Fairview Township EMS, Inc. AMB 68-02 - 6700702, 071203 ] 12/12/2007 i Patient Name Date of-Birth Social Security Number PSAP IKerri A. Wenerick 04/12/1991 ?? No Complaint ? Nausea ? Vomiting ? Diarrhea ? Constipated Area(s) Effected ? LUQ ? RUQ ? LLQ ? RLQ Pain ? Soft ? Finn ? Guarding ? Bowel Sounds Absent Distended - No O Yes O Tender No O Yes O ? Constant ? Intermittent ? Burning ?? Sharp ? Dull Radiating - No O Yes O ? No Complaint ? Urgency ? Frequency ? Pain ? Burning ? Incontinent ? Retention ? Foley Total Output _ Extremities ? No Complaints LA RA Paralysis ? ? Paresthesia ? ? Pulse ? ? LL RL LA RA LL RL ? ? Pain ? ? ? Q ? ? Pallor ? ? ? ? ? ? Edema ? ? ? ? Reproductive ?? No Complaints Female Male ? Vaginal Bleeding ? Discharge ? Penile Discharge Pregnant -No O Yes O ? Testicular Pain Gravida _ Para _ Week _ ? Fetal Movements Fetal HeartTones _ Narrative Dispatched to said incident location: Limekiln Road and Spanglers Mill Road, class one (1) along with D.D.R.E. Fire Department, Fairview Twp. Fire Department, Fairview Twp. Police Department, Community Life Team (ALS ),Lower Allen EMS. For a motor vehicle accident with entrapment. Weather Conditions: Cloud Cover: Cloudy, Wind: Slight Breeze, Temperature: Lower thirties (30's). BLS 68-02 Responded: From #522 Locust Road, class one (1). Upon BLS Responding: YCC advised that you are going to have a two (2) car motor vehicle accident with one (1) vehicle over the embankment approx. ten (10) feet and entraprament. EMT #118085 advised YCC to place aeromedical on stand-by status, and to dispatch a second (2nd) BLS unit. Upon BLS Arriving: SCENE SURVEY: Road Conditions: Clear and Dry at this time. One (1) vehicle was still on the roadway, and this vehicle sustained moderate to heavy front right damage. The windshield was spidered, and at this time there was only one (1) occupant in this vehicle. F.T.P.D. directed the crew from ambulance 68-02 to the vehicle that was over thg- Printed On: 12/13/2007 10:45 EMStat Reporting(c) 1998-2007. Med-Media. Inc. All Rights Reserved Provider Page: 2 of 4 O h+ N O W v o> O O N 'ennsylvania EMS Report Service Name Unit No PCR No. Date Fairview Township EMS. Inc. AMB 68-02 - 6700702 0712031 12/12/2007 Patient Name Date of Birth Social Security Number PSAP IKeni A. Wenerick 04/12/1991 embankment. EMT #118535 did a rapid trauma assessment of the patient in vehicle one (1) and gave a cervical collar to the F.T.P.D. officer to apply onto the patient of vehicle one (1). Vehicle two (2) was off the roadway and down the embankment approx ten (10) to twelve (12) feet, and up against a fence post. This vehicle was a four (4) door sedan type vehicle. This vehicle sustained heavy front end damage, and the windshield was spidered. Interior survey showed: Steering- wheel was distorted, Airbag was deployed. There was approx. four (4") of intrusion on the drivers side. At this time it was unclear if this vehicle rotated after impact. Speed at this time was unclear, It was unclear at this time, if this patient was wearing a seat-belt at the time of the accident. See EMT #077407 patient care report for the patient in vehicle one (1). Patient Interview: EMT #118085 When asked what had happened this evening? Patient voiced, " I was in a accident ". When asked did you loose any consciousness at any time? Patient voiced, " No ". When asked do you remember the entire accident? Patient voiced, " Yes ". When asked what hurts or bothers you at this time? Patient voiced, " My right ankle and my left leg ". When asked did you hear anything snap,crack or pop? Patient voiced, " Not that I know of ". When asked do you have any chest pain or chest discomfort? Patient voiced, " No ". When asked do you have any shortness of breath or difficulty breathing? Patient voiced, No ". Treatment: EMT #118535 crawled into the vehicle through a window on the right rear drivers side. EMT #118535 controlled manual cervical spinal immobilization. EMT #118085 made several _attempts to apply a cervical collar, but the patient's neck girth was to large to apply a cervical collar, so EMT #118535 contunided to control manual cervical immobilization. F.T.F.D. initiated extrication at 21:34, the extrication was complete at 21:44. During the extrication the patient voiced, " I. can not feel anything below my waist ". At this time EMT #118085 advised fire command to fly ' aeromedical. Patient was placed onto our long spine board and placed into the F.T.F.D. stokes basket. Once up onto the roadway, the spider straps were applied starting at the feet and working towards the head. CID's were applied and secured with the cid straps. EMT #118085 gave a verbal report to flight medic " C. Wood ". Patient was transported to the helicopter with the assistance of the F.T.F.D. staff. *** $iS crew was not able to obtain base line vital signs or to obtain a spo2 on this patient, since tflis patient was entrapped and the heavy coat she was wearing at the time of the extrication. Once this patient was extricated and the with the temperature being in the lower thirties (30's), EMT #118085 did not want to remove any clothing from this patient since this patient could become hypothermic.*** Time P R B.P. %Ox. ET C02 Glasgow Rhythm Treatment Provider Response/Comments Printed On: 12/13/2007 10:45 EMStat Reporting(c) 1998-2007. Med-Media. inc. All Rights Reserved Provider Page: 3 of 4 v N O W Vt 01 O D ftJ- ennsylvania EMS Report !Service Name Unit No PCR No. 1 Date I Fairview Township EMS; Inc. AMB 68-02 - 6700702 0712031 12/12/2007 i i Patient Name Date of Birth Social Security Number PSAP 'Ketri A. Wenerick 04/12/1991 Time P R B.P. ° o Ox. ET C02 Glasgow Rhythm Treatment- Provider Response/Comments 21:27 C-Spine Stabilize C2 21:44 i Full Spinal Immobilization CI C2 CO 21:44 Extrication C1 C2 CO Right Ankle Pain Left Leg Pain Anterior Posterior N I? J 0 N Printed On: 12/13/2007 10:45 Provider EMStat Reporting(c) 1998-2007, Med-Media, Inc. All Rights Reserved Page: 4 of 4 1/11/2008 11:19 Remote ID Imprint ID D 2/6 Request #: 0712-0452-A Svc Date: 13/1 Type: Helicopter Air-jOn-scene Priority: Emergent Dispo: Patient Transported Name: York County Comm York, PA 17401 Location: 40°12.WN x 076°53.90V Loc County: York PA Loc CSZ: New Cumberland, PA 17070 Wan K Name: Penn State Hershey-Med Center Hershey, PA 17033 Unit Emergency Department Rec MD: Kimak, Maric Crew 1: Wood, Clayton CHW- Crew 2: Kennedy,-Ella EMK Crew 3: Crew 4: Pilot 1: Woolman, Scott Dispatcher. Focht, Linda Med Ctrl: Kimak, Mark Ident: N600LL --Mauphin 365-N3) Name: Wenerick, Karrie Addr: VU W Limekiln Road New Cumberland, PA 17070 Ph: 717-770-1629 DOB: 04/1211991 Age: 16 yrs. Sex F Race: SS: 197-72.9237 Next of Kin: Call Rcvd: 21:33 on 1211212007 Notify Plt 21:33 on 1211212007 Wx Confirm: 21:33 Respond: 21:35 Ar Bedside: 21:54 Liftoff: 21:40 Dp Bedside: 22:(W Ar ive 1: 21:50 Depart 1: *22:06 Arrive 2: *22:14 i Depart 2: 22:14 Dispatch: 0 Arrive 3: 22:16 Wx Check 0 Depart 3: 22:57 Liftoff: 5 Arrive 4: 23:09 Response: 7 Fly to Pt 10 Fly with Pt 7 Other Fit 14 Tot Leg Time: 31 On Scene: I& Bedside: 12 Total Crew: 98 Loaded Miles: 13 sm _(PtoP); Actual: 13 sm In Service: 23:13 Total Miles: 54 sm Completed: 23:13 on 1211212007 Category: Pediatric- Trauma Pt weight 110 kg Diagnosis: Multiple Trauma Mechanism: Motor Vehicle Accident /lUergles: Ceclor 1/11/2AOO 1°-:^.9 Remote 11) Imprint ID ? 3/6 Hip pain - S/P MVA Date & Time of Injury/ Onset: 12/1212007 21:33- Two vehicle MVA. Patient reportedly the restrained-driver of a vehicle which collided head-on with another vehicle at an unknown rate of speed. Patients vehicle then proceeded to leave the roadway and travel down an embankment into several trees. Patient was found confined in her vehicle with CC decreased sensation in her legs and non-specific hip pain. She denied losing consciousness. Damage to patients vehicle was extensive to include a displaced windshield and marlwd-deformities of both the dashboard and steering wheel / column. There was airbag deployment Treatment prior to Lifelion contact-consisted of_extric ation onto a LSB and application of a CID. Due to patients large size and neck structure, a rigid cervical collar could not be fitted. She was subsequently extricated up the embankment to a cleared area where contact was made with the flight team @ 2154 hrs. SKIN: "Within Defined Limits" HEENT:'Wthin Defined Limits" ** CARDIOVASCULAR: ' Within Defined Limits" RESPIRATORY: "Within Defined Limits" "ABDOMEN / GU: "Within Defined Limits" ** EXTREMITIES: Abrasion/contusion-R leg, Abrasion/contusion-L hand, exam otherwise - "Within Defined Limits" ' SPINE: ' Within Defined Limits!'- as reported by EMS prior to immobilization * NEURO:' Within Defined Limits" '* Other: Abrasions noted along sternum - no deformity palpated, assessment of anterior /lateral chestwalls otherwise "within defined limits" none Introduced staff, Assessed.patient - report received from EMS 68, Obtained Wtransp consentfrom parents on scene, Moved patient to litter, Patient covered, Patient secured to fitter, patient transferred to aircraft where she was secured into the primary position, Attached monitors, oxygen continued at 15 Ipm via NRB mask, peripheral N initiated, medical command contacted with-a-report - no further orders received, during the short flight no marked change in patients condition was noted - patient remaining asymptomatic during flight, arrived HMC ECU without incident - TOVTOC to trauma team. Report given to trauma team by Wood, Clayton. none 21:55 / 110 16 x. . 1:1 R1111 0 22:06 137/89 106 106 18 100% 0 22:09 227/149 100 16 100% 0 Questionable ¦IBP - patient flexing arm during reading 1/11/2008 11:19 Remote ID Imprint ID D 416 Place EKG Strip Here Clayton Wood EMT-P E. Kennedy RN Total Intake (Pre-Transport) 0 (During Transport) 100 Total Output (Pre-Transport) 0 (During Transport) 0 2/21/2P?9 11:29 Remote ID Imprint ID ? 5/6 1/11/2009 11:19 Remote ID Imprint ID D 6/6 Insurance Screen: Not Screened A-Son resp >6 Stand-by Sex? Oovs! I'll go fix it 10 N51ton S. whey Medica-fir 'ae of Medic Patient Name: WENERICK, KERRI A PSUHMC MRN: 1241879 D/ G I n s t r u c t i o n F o r m D o. z u m e n t Final Document Electronically Signed by: Biggio, Cheryl L 12/19/2007 11:28:06 AM PENN STATE MILTQN S. HERSHEY MEDICAL CENTER 1-717-531-8521 PATIENT DISCHARGE INSTRUCTIONS If you have any questions, please contact your physician. Date of Admission: 12/12/2007 Date of Discharge: 12/19/2007 Physician: Dillon, PeterW Service: Peds Surgery Discharge Diagnosis: Left Displaced Closed Midshaft Femur- Fracture Other Diagnoses: Partial plantar fascia avulsion of right foot Surgical Procedures: 12/14/07 - Left femur-IM nail Dr. Vresilovic Vaccinations Received This Hospital Stay: No vaccinations were given this hospital stay. Date Printed: 111912008 Tune Printed: 3:49 AM (4 Milton & Hwshey Medical Cuter College of 1V1ed3dne Patient Name: WENERICK, KERRI A D/ C I n s t r u c t i o n F o r m D o c u m e n t Final Document Electronically Signed by: Biggio, Cheryl L PSUHMC-MRN: 1241879 12/19/2007 11:28:06 AM Discharge Medications: Marfie2 inn Dose Snecial Instructions noxaparin INJECT 0.4 ML SUBCUTANEOUSLY enoxaparin 40 mg/0.4 mL soln) DOSE=40MG ) EVERY DAY FOR THREE WEEKS xycodone 10 mg by mouth every 12 hours, as Take until 01/02/08. Ox ontin needed for <None> ocusate 100 mg by mouth 2 times daily Take until 01/18/08. Colace cetaminophen-codeine tab by mouth every 4 hours, as Take until 01/02/08. T lenol with Codeine #3 oral tablet) n eeded for Pain - Moderate spirin see Instructions 25 mg Care Instructions: 1. Keep incision dry. 2. Use stool softener of choice while taking-pain medication. 3. NO SMOKING or use of any products containing Nicotine. 4. NO Nonsteroidal Anti-inflammatory Medications Such as - Advil, Motrin, Ibuprofen, Aleve, Naproxen 5. Please return to your pre-surgical medications as directed. 6. Lovenox for 3 weeks, then daily aspirin (325mg) for 3 weeks WHEN DONE WITH LOVENOX. Diet Guidelines: Regular- encourage liquids Activity Guidelines: 1. Use crutches or a walker to assist-with walking, weight Bear as-instructed (For your procedure weightbearing as tolerated to left lower extremity). 2. Elevate leg above level of the heart when-not active. 3. Eat a well balanced diet. 4. Do not kneel, run, jump, lift heavy objects or activities that stress the leg. 5. No Driving while on pain medication. 6. Do not get incision wet. 7. Use cam boot walker on the right foot during walking for stability/support. Date Printed: 11912008 lime Printed: 3:49" Af ton &Hamhey l icnl. Cater College of MmUdne Patient Name: WENERICK, KERRI A PSUHMC MRN: 1241879 D/ C I n s t r u c t! --a n F o r m D o c u m e n t Final Document Electronically Signed by: Biggio, Cheryl L 12/19/2007 1128:06 AM Call your doctor if: Dept of Orthopaedic Services at 717-531-5638 with any questions concerning, fever greater than 101, chills, pain, swelling, cramps. Other Instructions: Wear your lap and shoulder seat belt for all travel,snugly fastened. Follow-Up Appointments: Prnvirlor I nnatinn Date Time Remarks Dr. Vresilovic's clinic PC suite 400, phone 531- weeks-- will be called at home with 638 -ate/time, or call to confirm by theend of is week. Dr. Juliano UPC suite 400, phone 531- weeks, will be called at home with 638 ate/time, or call to confirm by theend of his-week. Discharging Provider: Agarwal, Siddharth Date Printed: 11912008 Time Printed: 3:49 AM Mon & E hpy Medical QnWr Cake of Medicine, Penn State Milton S. Hershey Medical Center Tel: (717) 531 4055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: WENERICK, KERRI A Patient Sex: Female Patient Location: 7MBW, 7266, 01 Visit Type: Inpatient PSUHMC MRN: 1241879 Date of Birth: 4/12/1991 Visit Number: 10502243 O D e r a t i v e N o t e D o c u m e ru t I Final Document Electronically Signed by: Vresilovic, Edward J Name: WENERICK, KERRI A HMC Number: 1241879 DOB: 04/12/1991 Date of Service: 12/14/2007 OPERATIVE REPORT SURGEON: Edward Vresilovic, MD ASSISTANT(s): Michael Stauff, MD PREOPERATIVE DIAGNOSIS: Left mid shaft femur fracture which was closet- POSTOPERATIVE DIAGNOSIS: Same. 12/28/2007 1:26:11 AM OPERATION PERFORMED: Open reduction internal fixation of left femur fracture with intramedullary device. ANESTHESIA: General endotracheal anesthesia. INDICATIONS: OPERATION: The patient was brought to the operating room and identified as Kerri Wenerick. She was indicated for surgery when she suffered a motor vehicle accident in which she suffered a-mid shaft closed left femur fracture. Because of the instability in this fracture, she was consented for surgery and brought to the operating room. She was identified as Kerri Wenerick. She was then induced with a general endotracheal anesthesia. When an adequate level of anesthesia was obtained, she was placed in the right lateral decubitus position with the left side up. The left leg was then sterilely prepped and draped free for rod placement. A starting incision was made approximately 6 cm in length over an area proximal to the greater troch, approximately 5-6 cm above the greater troch. Sharp dissection was carried down to the right neck. The layered muscle was split to allow entrance into the piriformis fossa area. The piriformis fossa was opened with an awl after a guidewire was placed, and then a guidewire was passed under fluoroscopic examination through the fracture site. This was under fluoroscopic guidance in two planes. The guidewire was extended down to the neo-epiphyseal scar. After this, the femoral canal was sequentially reamed in 0.5 mm increments to 12 mm in diameter. Date Printed: 11912008 lime Printed: 3:49" Mon S. Eks* laical Center Cade of llane Patient Name: WENERICK, KERRI A PSUHMC MRN: 1241879 O p e r a l i v e N o t e D o c u -m e n t Final Document Electronically Signed by: Vresilovic, Edward J 12/28/2007 1:26.11 AM The femur was then measured by using a fluoroscopic guide, and an 11 x 380 mm Synthes rod was selected. This was then impacted across the fracture site under fluoroscopic examination. After this was complete, using perfect circles technique, the distal femur was locked to the rod with screws of 50 and 62 mm, the 62 more-distal using perfect circles technique. The rod was then impacted across the fracture site. The alignment of the patella and hip were assessed and the proximal end was fixed using a proximal guide through another incision that was approximately 3 cm in length. The screws proximally were 52 and 40 mm in diameter. With all screws in place and the rod locked proximally and distally, all wounds were copiously irrigated. T he fascial layer was closed with interrupted 2-0 Vicryl suture. The subcutaneous tissues were approximated with 2-0 Vicryl suture and staples were then placed at the 6 cm proximal wound. The next most proximal was the 3 cm wound and the two distal 1 cm incisions. Sterile compressive dressings were then applied. The patient was returned to the supine position and awakened from anesthesia having tolerated the procedure well and returned to the recovery room in stable condition. #576593 Review/Sign: Vresilovic, Edward J, MD EJV /RMH DD: 12/17/07 DT: 12/17/07 13:24 Date Printed: 11912008 lime Printed: 3:49 AM NIIton S. fey AMM LAMr Calege of Mane Patient Name: WENERICK, KERRI A PSUHMC MRN: 1241879 O u t p a t i e n t N- -o t_ P D o c u m e n t 1 Final Document Electronically Signed by: Vresilovic, Edward J OUTPATIENT NOTE Name: WENERICK, KERRI A HMC Number: 1241879 DOB: 04/12/1991 Date of Service: 03/19/2008 4/3/2008 2:44:38 PM Patient comes in today now 3 months status post fracture of her left femur. She was showing a delay in her healing and we dynamized the femur with removal of the one of the proximal screws. She comes in today without complaint. On examination her wounds are well healed without swelling or erythema. Leg shows full motion at the hip and knee. She does note some stiffness with range of motion. X-ray examination shows a healing fracture with now bridging callus. DISCUSSION: The patient appears to have healed her femur fracture-and the rodsin place without difficulty. PLAN: At this time would be the patient can return to full activities without restriction, and we will plan to see the patient back on a p.r.n. basis for any exacerbation or new complaint. The patient was-out-of work from her injury 12/12/2007 to 3/19/2008, and I have released her to return back to full work related activities. 583402 Review/Sign: Vresilovic, Edward J, MD EJV /CO DD: 03/19/08 DT: 03/20/08 03:28 Date Printed: 511512008 Time Printed: 10:44 PM Erh?6.4? ERIE KERRY J. RITCHEY, CPCU, AC Claims Manager ERIE INSURANCE GROUP Branch Office • 4901 Louise Dr. • Rossmoyne Business Center • P.O. Box 2013 • Mechanicsburg, PA 1 7055-07 1 0 (717) 795-8200 • Toll Free 1-800-382-1304 • Fax (717) 795-2315 - www.erieinsurance.com July 30, 2008 David Lutz, Esq. 4503 North Front Street Harrisburg, PA 17110 RE: ERIE Claim #: 010170954002 Date of Loss: 12/12/07 ERIE Insured: April & Nathaniel Sherwood Your Client: Kerri Wenerick Dear Mr. Lutz: Pursuant to our phone conversation of July 28, 2008, Erie Insurance Group is tendering its policy limit of $100,000 under the auto policy of April Sherwood relative to injuries your client sustained in this loss. Please have your client and her parents execute the enclosed Release. Once we have received a copy of the Petition, Court Order approving the settlement and the executed Release, we will issue the settlement check. A certified declarations page will be forwarded under separate cover. Thank you for your patience in regard to the handling of this claim. Sincerely, 'OA)JA Melissa Cover Liability Adjuster Harrisburg Branch Claims 866-331-3602 Enclosure: Release cc: M Cover/File The ERIE Is Above All In SERNCE® • Since 1925 GENERAL RELEASE CLAIM #. 010170954002 For the consideration of ONE HUNDRED THOUSAND DOLLARS---------------------?--~-""--"- ----MM -_-------001100 dollars ($ 100,000.00 receipt of which is hereby a k lonc wW edged; I/we release and discharge, and for myself/ourselves my/our heirs, representatives, executors, administrators, successors and assigns, do hereby remise, release and forever discharge APRIL SHERWOOD; NATHANIEL SHERWOOD hereinafter referred to as the releasee(s), his/her/their/its heirs, executors, administrators, insurers, successors and assigns, and any and all other persons, firms, corporations, associations, of and from any and all causes of action, suits, judgments, claims and demands of whatsoever kind, in law or-in-equity, known and unknown, which I/we now have or may hereafter have, and/or which the minor KERRI WENERICK now has or may hereafter have, especially the claimed legal liability of releasee(s) which liability releasee(s) expressly deny(ies), arisingfrom or by reason ctany andall -bodily or personal injury and/or property damage known and and unknown, foreseen and unforeseen which heretofore has/have been or which hereafter may be sustained by y ear me/us or the minor aforementioned arising out of the accident on or about DECEMBER 12 RT 114, FAIRVIEW TWP , in the County of YORK at or near in the State of PENNSYLVANIA , in which the minor aforementioned sustained personal injuries and/or property damage. I/We agree that the consideration set forth is specifically applicable to and paid to me/us with respect to any and all damage to any property, either real or personal, of mine/ours or the minor aforementioned, and with minor res ours or the ther of, alown as ntioned, whether or unk own anyforeseeand all whichf mayelsubseque tly developoandethe consequencepresentl or , arising from the aforementioned accident. I/We further agree that the consideration set forth above is specifically applicable to and paid to melus with respect to any right of contribution that I/we or the minor aforementioned may have against the releasee(s), his/her/their/its heirs, executors, administrators, insurers,-successors and assigns relative to claims of others that may be brought against me/us or the minor aforementioned by reason of said accident. I/We further agree that the consideration set forth above is specifically applicable to my/our agreement that [/we or the minor aforementioned -will not join nor attempt to join the releasee(s), his/her/their/its heirs, executors, administrators, insurers, successors and-assigns in any capacity, in any action that may be brought against me/us or the minor-aforementioned arising-out of said accident. In consideration- of the aforesaid payment, I/we for myself/ourselves and my/our heirs, representatives, executors, administrators, successors, and assigns do hereby; (1) agree to indemnify and hold forever hanntess the releasee(s) and his/herlits/their/representatives, administrators, or assigns, against loss from -any and all further claims, demands or actions that may hereafter be made at any time or brought against the releasee(s) by me/us or the minor aforementioned, or by anyone in our behalf for the purpose of enforcing a further claim, for which this release is given; (2) warrant that I/we have received no money or other valuable consideration from any other person or persons by-reason of any causes of action, suits, covenants, agreements, judgments, claims and demands- of whatsoever kind, which I/we now have or may hereafter have, for injuries to person or property-arising-out of the aforementioned accident or for the other matters for which this release is gqiven. Intending ro be legally bound thereby, WITNESS my/our hand(s) and seal(s) this day of ' (Year WITNESSES: ather-Guarolan (Seal) (Seal) - Mother (Seal) - Minor C-41M (R) 04105 y111. Erie AW Insurancee Kerry J. Ritchey, CPCU, AIC Assistant Vice-President & Claims Manager Branch Office 4901 Louise Drive- • Rossmoyne Business Center P.O. Box 2013 Mechanicsburg, PA 17055-0710 717.795.8200 Toll Free 1.800.382.130-4 • Fax 717.795.2315 • www.erieinsurance.com It ' David Lutz, Esq. 4503 N. Front Street Harrisburg, PA 17110 RE: ERIE Insured: April Sherwood ERIE Claim #: 010170954002 Date of Loss: 12/12/2007 Your Client: Kerrie Wenerick t V. I ' Dear Dave: August 14, 2008 Enclosed is a notarized copy of April Sherwood's declarations page. .. Since i Melissa Cover Liability Adjuster 866-331-3602 Enclosures: r Declarations page • cc: file 01 i •. :.R The ERIE Is Above All In Service'. We commit, care and serve. It's our true blue promise. Ppge: 1 Document Name: untitiec< - ------ ----- .PICV Qll 3008803 04 0002 113007 ISS EFF RSN ERIE INSURANCE EXCHANGE FAMILY AUTO POLICY CONTINUATION NOTICE AA7367 FETROW INS ASSOC LLC APRIL SHERWOOD 3013 LISBURN RD MECHANICSBURG PA 17055-4825 11/30/07 TO 11/30/08 Qll 3008803 H AGENT - FETROW INS ASSOC LLC 5299 E. TRINDLE RD. AGENT PHONE - (717) 766-3200 MECHANICSBURG PA 17050 3552 srirGitrt "ift PATRaA sHEFwELD,idiay Pubic eo%, Date: 7/29/2008 Time: 9:54:18 AM Page: l Document Name: untitled PICV Qll 3008803 04 0003 113007 ISS 8FF RSN * CONGRATULATIONS! A PIONEER EXPERIENCE RATING CREDIT HAS * BEEN APPLIED TO YOUR POLICY PREMIUM. ITEM 4. AUTOS COVERED AUTO YR MAKE VIN ST TER SYM RATING CLASS DDP 1 99 CHEV MALIBU 1G1ND52M3XY109547 PA 4D 8 ALAS-M FS41 2 01 FORD- TAURUS SES 1FAFP55SX1A178755 PA 4D C AlBL-M FS41 ITEM 5. INSURANCE IS PROVIDED WHERE A PREMIUM, OR INCL, IS SHOWN FOR THE COVERAGE. COVERAGES-, LIMITS AND ANNUAL PREMIUMS ARE AS FOLLOWS- M EQUALS THOUSAND $ #1 #2 *****GOOD DRIVER RATES APPLY***** --- THE FULL TORT OPTION LIABILITY PROTECTION- BODILY INJURY $100M/PERSON PROPERTY DAMAGE $100M/ACC FIRST PARTY BENEFITS- MEDICAL EXPENSE $5M INCOME LOSS $1M/MONTH, $15M APPLIES TO ALL PRIV. ?300M/ACC 95 77 36 MAXIMUM 9 ?ATE PASSENGER VEHICLES. 114 93 42 10 Sate: 7/29/2008 Time: 9:54:32 AM Page: 1 Document Name: untitled PICV Qll 3008803 04 0004 113007 ISS EFF RSN ACCIDENTAL DEATH $5M 1 2 FUNERAL BENEFIT $2.5M 2 2 UNINSURED MOTORISTS COVERAGE- BOD INJ $25M/PERSON $50M/ACC-STACKED 13 13 UNDERINSURED MOTORISTS COVERAGE- BOD INJ $25M/PERSON $50M/ACC-STACKED 46 46 PHYSICAL DAMAGE COVERAGES- COMPREHENSIVE - $100 DED 31 47 COLLISION - $500 DED 136 TOTAL ANNUAL PREMIUM FOR EACH AUTO 310 505 TOTAL ANNUAL POLICY PREMIUM $ 815 ITEM 6. APPLICABLE POLICY, ENDORSEMENTS, EXCEPTIONS TO DECLARATIONS ITEMS ALL AUTOS - FAP 03/07*, UF2106 05/01, AFPF01 03/07*, AFPA03 11/07*, UF2345 10/06*. AUTO 1 - AFPU01 03/07*. AUTO 2 - AFPU01 03/07*. PASSIVE RESTRAINT DISCOUNT APPLIES - DUAL AIRBAGS AUTO 1 PASSIVE RESTRAINT DISCOUNT APPLIES - DUAL AIRBAGS AUTO 2 Date: 7/29/2008 Time: 9:54:41 AM K-SO Erie Alit W Insurance° Kerry J. Ritchey, CPCU, AIC Assistant Vice President & Claims Manager Branch Office 4901 Louise Drive • Rossmoyne Business Center • P.O. Box 2013 • Mechanicsburg, PA 17055-0710 717.795.8200 Toll Free 1.800.382:1-304 • Fax 717.795.2315 • www.erieinsurance.com August 14, 2008 David Lutz, Esquire Angino & Rovner, F.C. 4503 North Front Street Harrisburg, PA 17110-1799 Re: Your Client: Erie Claim No.: Erie Insured: Date of Loss: Dear Mr. Lutz: Kerri Wenerick 010170954099 Thomas & Pamela Wenerick December 12, 2007 In response to your request that Erie provide written consent to settle. Be advised, Erie will waive its subrogation rights versus April -&-Nathaniel Sherwood and consents to the settlement with their carrier Erie Insurance in the amount of their $100,000.00 policy limits. By providing consent to settle,-Erie-does not waive, invalidate or forfeit any other terms or conditions under policy Q03-0113273. If you have any questions please contact me. Si ely4G.Kocher uglClaims Representative (717) 774-5007 bh"o tl- The ERIE Is Above All In Service. We commit, care and serve. It's our true blue promise. STRATEGIC RECOVERY PARTNERSHIP INC. 208 N. Easton Road Tuesday, April 01, 2008 Willow Grove, PA 19090 Tel. 215.784.1616 David L. Lutz, Esq. Fax: 215.784.1772 4503 N. Front St. Harrisburg, PA 17110 Re: Your Client: Wenericly, Kerri Date of Loss: 12/12/2007 Our File #: 08AMH23732 Dear Mr. Lutz: I am writing on behalf of our clients, The GWB - S - NE Union #2 Health Plan and their claims administrator, which has processed at least $1,000.00 in medical claims on behalf of your client. This amount is not final. These claims were made as a result of your client's accident on or about 12/12/2007. Kindly advise if our information regarding the date of loss is incorrect. If we do not hear from you, we will assume the information we have is consistent with your understanding of the date of loss. Other related claims may be also under consideration, which could cause the lien to increase. Please request a final lien amount and supporting documentation from us only when your client`s case has reached a pivotal juncture or is concluding. If you have claims to submit, or questions regarding claim payment including timeliness, amount and/or discounts, then please refer directly to the plan's claims administrator, whose address you can find on your client's insurance card. Otherwise, please cease all contact and direct all future correspondence regarding the plan's subrogation interest to me at the above address as we are the sole representative of their interest in this matter. Due to our intent to put the third parry on notice directly, I would also appreciate: 1. The status of any negotiations (if applicable) 2. The name/address/claim # of defendants liability carrier Thank you, in advance, for your cooperation in this matter. If you have any questions, please do not hesitate to give me a_call. Ve y yours, Russell D. Bowman, Jr., Esq. bh? b;i i ANGiNo & RoVNER, P.C. 4503 NORTH FRONT STREET HARRISBURG, PA 171101799 717/2386791 FAX 717/2385610 RICHARD C. ANGINO MICHAEL E. KOsIK NEIL]. ROVNER RICHARD A. SADLOCK JOSEPH M. MELILLO LISA M. B. WOODBURN DAVID L LUTZ DARYL E. CHRISTOPHER W W W.ANGINO•ROVNER.COM EMAIL: DLUTZ@ANGINO-ROVNER.COM April 9, 2008 Russell D. Bowman, Jr., Esquire Strategic Recovery Partnership Inc. 208 N. Easton Road Willow Grove, PA 19090 RE: My Client: Kerri Wenerick Your File No. 08AMH23732 D/L: 12/12/07 Dear Attorney Bowman: Receipt of your April 1, 2008, correspondence is acknowledged. As you are aware, Kerri Wenerick was injured in a-motor vehicle accident. Given the provisions of 75 Pa.C.S.A. 1722, would you please advise me the basis of which your client is seeking a subrogation lien? Your prompt written response would be greatly appreciated. Thank you. Ve truly yours, *DavL. Lutz DLL/kat 381603 VIA FAX ONLY (no cover page attached) Thursday, April 10, 2008 David L. Lutz, Esq. Via Facsimile: (717) 238=5610 Re: Your Client: Wenerick. Kerri Date of Loss: 12/1212007 Our File #: 08AME123732 Dear Mr. Lutz: STRATEGIC RECOVERY PARTNERSHIP INC. 208 N. Easton Road Willow Grove, PA 19090 Tel. 215:7-84A-616 Fax: 215.784.1772 I have received your letter dated April 9, 2008. Please nofe that my client is a self-funded ERISA health plan and as a condition of accepting benefits under- this health plan, your client agreed to reimburse the health plan 100% of all accident related benefits paid out in the event of a recovery. I have attached a copy of this plan language for your review. Please contact me regarding any additional-questions or concerns. Very truly yours, - "" er Mdrphy (SUN) APP 13 2008 23: 43/ST. 23 : 39/No. 681 62 C nvL -RR AIYD GENERAL INF-0 Name and Address of the Employer and Plan Sponsor Stroehmana Bakeries, L.C. 255 Business Center Drive, Suite 200 Horsham, PA 19044 (215) 672-8010 Name and Address of the Plan Admintswator Stroehmann Bakeries, L.C. Employee Benefits Committee 255 Business Center Drive,'Suite 200 Horsham, PA 19044 (215) 672-8010 Name and Address of the Designated Agent for Service of Legal Process General Counsel Stroehmann Bakeries, L.C. 255 Business Center Drive, Suite 200 Horsham, PA 19044 (215) 672-8010 Name and Address of the Designated Claims Payor for the Medical Plan Ameriklealth Administrators 720 Blair Mill Road P.O. Box 975 Horsham, PA 19044 1-800-480-5034 Name and Address of the Designated Claims Payor for Prescription Drug Coverage PCS Health Systems, Inc- PCs Claims Department 9501 East Shea Blvd. Scottsdale, AZ 85260 Name and Address of the Designated Claims Payor for Mail Order Drug Coverage PCS Managed Mail Service P.O. Box 2879 Pittsburgh, PA 15230 Internal Revenue Service and Plan identification Number The corporate tax identification number assigned by the Internal Revenue Service is 23-,2826739. The pin number is 501. Plan Year The plan year is the 12-month fiscal period for Strochmann Bakeries, L.C. beginning January Land ending December 31. October 29, 1998 41 STRS9i-t.D0C FROM CS OTHER IMPORTANT-PLAN PROVISIONS Assignment Of Benefits All benefits payable by the, plan may be assigned to the provider oUservices or supplies at your option except if you receive care in Pennsylvania, New Jersey or Delaware from a I .; -Payments made in accordance with an assignment are made in good faith and release the plan's obligation to the extent of the payment. Payments will also be made in accordance with any assignment of rights required by a state Medicaid plan. Special Election For Employees And Spousa Age 65 And Over if you remain actively employed after reaching age 65, you or your spouse may choose to remain-covered-under this plan without reduction fbr Medicare benefits or designate Medicare as the primary payor of benefits. If you choose to remain covered under this plan, this plan will be the primary payor of benefits and Medkare will be secondary. If you choose Medicare as primary, coverage under this plan will end. If you do not specifically choose one of the options, this plan will continue to be primary. If you are under age 65 and your spouse is over age 65, he or she can make his or her own choice. . ?( Acts Of Third Parties This provision applies whenever someone else including your own insumc; nder an automobile or other policy) is legally responsible or agrees to compensate you or an illness or injury su Fred by you or your dependent(s). In that case, you must reimburse the plan for any benefits it paid relating ta_that_illness or injury, up to the fall amount of the compensation received from the other party (regardless of how that compensation may be characterized). The reimbursement required under this provision will not be reduced to refit Vany costs or attorneys' fees incurred in obtaining compensation unless separately agreed to, in writing, by the plan administrator in the exercise of its sole discretion. Benefits relating to such illness or injury will not be payable by the plan until you sign and return a statement, provided by the plan, acknowledging your obligation to reimburse the plan under this provision.-(That obligation will arise upon the payment of any plan benefits relating to the illness or bjury, whether or not you sign such a statement) Right To Receive And Release Necessary Information The plan may, without the consent of or notice to any person, release to or obtain front any organization or person, information needed to implement plan provisions. When you request benefits-you must furnish all the information required to implement plan provisions. Recovery Of Excess Payments Whenever payments have been made in excess of the amount necessary to satisfy the provisions of this plan, the plan has the right to recover these excess payments from any individual (including-yourself), insurance company or other organization to whom the excess payments were made or to withhold payment, if necessary, on future benefits until the overpayment is recovered. Further, whenever payments have been made based on fraudulent information provided by you, the plan will exercise its right to withhold payment on future benefits until the overpayment is recovered. October 29, 1998 24 STRS98-i.DOC °40M ' t Method Of FmWing Benef b (SUN) APR 13 2008 23 : 44/ST. 23 : 39/No. 68 Health benefits arc self-fynded froth accumulated assets and are ptmded directly from the PAW qW W The total level of fundinfrwill W4 F, mined by the aggregate stopioss policy. taking into cow the number of employees covered each t• Payments out of the plan to health care provk rs on behalf of the covered person will be based on the provisions of the plan. October 29, 1999 42 snts99-t.°Oc CgpM (SUN)APP 13 2008 23:44/ST.23:39/No.6815204155 freeERISA.com - Instant View Page 1 of 2 Quickllnks Now Search Form SS00 I Schedule A (1) 1 Schedule A (;) Schedule A (3) 1 Schedule A (4)1 Schedule A (5) 1 Schedule A (6) 1 Schodule A 171A I71?1 gdm&ft (n 1 1(sclladllla A (12) 1 Schedule A (11)1 Schedule A (1211 Sched•• e A .lei 1-Schedule A (14) [Schedule A (1S)1 Schedule A (16) 1 Schedule A (17) 1 SchedaN A_(1.S) I $t:htldafe A (1O) I schedule A. (20)1 Schedule A (21) I Schedule A (22)1 Schedule W11 Other Doeuman a I St)OYIt ALL H Ms. efin owre Offlolorlive OnIV Form 5500 Annual ReWiviliMilo 1278=008G DspWbnwd of Ow Tmnwy This fond le ragYMadb be atw udder aadiWAI-W& lend 4E of do ERplOyes ldo. RsvwmBervice RodrowetdbuxuaeftNEWApteftal4-)lendeeaalewaasm9wis,- -- Dap.ranwderr Labor Ibb and ?MM of 90 MbrrlM Ibesesa cede glee code). 2004 Pension wN wseara B.rralas Cogllele aE e I IM In aoaerdease wile Farsrl ?s oven to AdmW.Yw«, on blatltletaas to tlla Fong liaii. Thla S Pa isapOP" Pubic Fix" Monslll cues" corpora Bar Part I Annual Report Identli cation Inforin on For the coloodar plan year 2004 or 1lecd plan yesr' -- ' g Janesry 01, ?n?n, and endbB t ^em*? - ?, , ?rn?n A This roll-kelpod Is (1) ® a muM wnpk ysr plan; (3) 1:1a m Mplsimpbyer Plan: for (2) ? a aingla•ampioyer pin (otiur than a mulapWanploYS (4) 11a DFE (spscty) plan); a This rewrNroporl Is: (1) ? the find ro Urrrhepixt fled for to plan; (3) ? the &W raUnhaportMd for Ne plan; (2) ? orb amended .wn .pert; (4) ? a .host plan yes, W. %W (leas tun 12 months)- C If Via plan is a cofieeWey-bargained plan, ehadr here ? D If you Ned for on solonslon of tins to tie, elnee I t» box and aMadn a copy of to erdaasion-application Part H Basic Plan hildrillive On - antler al requesiod irlf mallorn. 1 a Nano of plan Y 1b pion number{PN) a^^?^ta F'ER..^?' . Mp? ?'1 1C g eddy deb of pWr(mo., day, yr.) January 01, 2003 20 Plan sponsor's name and addrosa (employs. i fora single a n yer Flan) 2b---Employer bend Number (ON) (Address should include room or suMs m) 22-3319,6179-- 2C s ldsphofm number vi:5 ivc+ i:"79 6 'w6. 9'e kL pi.niv 215-572-8010 _ :.:: - -, ..: .... 2d Business oodr(see bdmw -) 255 BUFTNFSS CENTER DP.)VF °1.9.17 F?OASHAM, PA 19044-3421 Caudon: A panda for the lab or imm?lplala Bing of this rawmlrepmt wE be assessed unless reasonable cerm3s eelatiahed. Under perutiss of perjury and other penalties set f b M in Ow lnelrrrn tons, I 'I A tut 1 hew exarNned trs nhnnhOW, inchAng sorampwWft adudules. sbdenunts and etbchmsnla, and to the bast of my luw l dge and beaef, t is true. corded. and oompNW . Signahae of plan administ aW Dab Typed or plinbd name of individual signing as plan adinth WrM- "irT Signature of empbyar/plan sponas/DFE Deb Tye or prNbd nerved indkiduel sbrdn9 as employs Plan sponsor or DFE as appic" For Papswwi Raductbn Act MaUce and OMB Control Nernbsre, see the Nalnrctlone for Forre WOO. v2.3 Form 5500 (tow) +3a Plan admini.tralors name and address (1 sane as plan sponsor, enbf 5srrie-) 3b Adminiatrolora EIN N-Ac 3t: Adminisbadoes ldsphoru nuwdw 4 M the name and/or EIN of are plan sponsor has changed since the last rowm/report fled for We plan. ~ the name. EIN and tns plan number hom the lest rohmWeport below; a Sponsors name hV://www.freeerisa.com/5500/InstantView.asp?mainlD=15832299 b EIN C PN 11/13/2007 MEMEN ror?M freeERISA.com - Instant View S Preparar tnfomwtion (optional) a Name (irchrdinp firm name, f appicabis) and aadaws 6 TaW number of partldpanb at the baphft of the plan year 7 Number d participaMS mot the end of the plan year (waNare plans eanpleia only lines 7a, 7b, 7c, anti 7d) a ANNA Pa Upt - b R46 or soparat - parlidpards repelving benefit C Oawr refsad or sapaabd pMicipanb enflaod b future benefit d Subww. Add tm.s 7a6 7b, and 7C a Deceased pwft pant whose bens iaeries are racoiving or are enured to mome bera to TaW. Add tines 7d and 7* 6816204165 Page 2 of 2 b EAt C Telephone no. 6 t,;,-7 a 7,811 b 1,065 C d e. s^F 9 f ;,uy6 g Number of parddpank wNh account balances as of No end dew plan _year (only defined oonlribnrgon plans complete g thin bm) h Number d parddpanb tat larrniwbd employment during the plan year wflh accrued bwwft that ware Was than h IW%veebd 1 lfany p«Wparo(s) sepaabd ftn swvioa with a defined vesbd brwfif, eater the number d sWnftd patldpenb i requiad fo bo raporle , on a Schedule SSA (Form 550tt) 1 Bawfib provided under the plan (oornplele Be Through 8e, as applia I a) a ? pmM n.Dssrt?(tt. (dwek this bore g the plan provides tamaion benefits and wftr the appgeaWs pension taNure codes flan the list of Ran ChemcWM= Codas (prided In 1he indrucbons)): b ® lvw. iwnwft (cheek gate boor jr tha plan provides walla, benefda and enter to applic" wd km feature codes from the list of Pion Chaacbrlsice Codes (prWad in the in*ucdons)): 4a 46 4E, 4E 4H 6a Ran nrndkv arrangement (check all that apply) 9b Plan bwAM aranpemwat (fled( all that apply) (1) ? insurance (1) ? insurance (2) ? Section 4 im insurance =*acb (2) ? Se d on 412(1) iwraana conbaeb (3) ? Trust (3) ? Trust (4) ® Gains' assets or Yne sponsor (4) l p pa t'_`! General seta dllw sponsor 10 Sdneddes eftchad (Check al appkahle bowa and, where indkabd, enter the nlanbar attedod-Sao done.) a Pea U 0ellewl aohedalea R (RedmmentPlan lnfomwtion) (1) b FWAndsl adwdu" (1) 8 H (Financial W mwllen) (2) T (Quafad Pension Ran Coverage hnlamwdom) B (2) 1 (finaneid idform don - Snwll Plug N a Schedule T is not.tladt 1 because We plan is (3) " A O nsumnoa Wbrm lleM retying on oo- - ps ' infor nagon for a prior (4) C (Sarvke Provider Irdorme0n) year. anier the year (e? D (DFEJPartidpalnp Plan Information) B (Aebwrial Worma6m) (3) (6) G (F rAncid TImmo tlon S OMU) (4) E (ESOP Annual infamalm) ? (71 P (Trust Fidudayl Inlbnrwtlon) (S) SSA (Sepsralled Vested PaAdvadt Information) http.//www.freeeris&com/55001IngtantView.asp?mainlD=15832299 11/13/2007 S'T'RATEGIC RECOVERY PARTNERSHIP INC. VIA FAX ONLY (no cover page attached) Friday, August 01, 2008 David L. Lutz, Esq. Via Facsimile: (717) 238-5610 Re: Your Client: Wenerick. Kerri Date of Loss: 12/12/2007 Our File #: 08ANIH23732 Dear Mr. Lutz: 208 N. Easton Road Willow Grove, PA 19090 Tel. 215.784.1616 Fax: 215.784.1772 As requested, please find attached a copy of the payout report, reflecting a lien in the amount of $48,400.64. This lien is only final if your client has not received accident related treatment since 3/19/08 and is not scheduled to do so in the firture. Please provide a settlement offer and details at your earliest convenience. Thank you for your cooperation. I ry trul yours, Jenni urphy Jmurphy@srp m _ Date• August 1, 2006 Agreement Number: 01378071 Patient: Vlfeneddc Kern A L3 M I N I S T K A T O R S- Claim Numlber Date of Service Prom?der w 8!Id: _ Paid, 01041923300 12112 - 13/07 Radiology Dept - HMG 444tV;VU- w +?.? + 01041923301 12/12/07 Radiology Dept - HMC $117.00 $76.05 01042254200 12112107 Div of Emergency Room $384.00 $-249.60 01042254600 12/12/07 Anesthesia Dept $135.00 $72.75 9907897010 12112/07 Hershey Medical Center $12,814.00 $4,026.35 99080468800 12/12 - 19/07 Hershey Medical Center $33,204.85 $26,363.88 01042254300 12/13/07 Pediatric Surg Division $202.80 $202.80 01042254100 12/14/07 Anesthesia Dept $2,058.00 $1,337.70 01042254500 12/14107 Orthopedic Surg Div $6,808.00 $4,425.20 01042254400 12/15 - 19/07 Pediatric Surg Division $512.00 $332.80 01041923100 12/17/07 Div of Emergency-Room $64.00 $41.60 01041923200 12/18/07 - Radiology Dept - HMC $60.00 $39.00 A0330638000 112 - 30108 Healthsouth Rehab $3,089...00 $1,503.95 A0336518100 01/31 - 02/28/08 Healthsouth Rehab $2,553.00 $1,239.15 A0286245200 02106108 Radiology Dept- HMC $62.00 $15.00 A0288215600 02/06/08 MS Hershey Medical $183.00 $122.00 A0291112300 02114/08 Radiology Dept - HMC $62.00 $12.00 A0292167000 02114108 Radiology Dept - HMC $1,798.00 $339.42 A0330692600 02/14/08 Anesthesia Dept $1,325.00 $650.00 A0331527700 02/14/08 MS Hershey Medical $9,311-35 $6,136.45 A0333938000 02/14/08 Anatomic Pathology Dept $22.00 $8.00 A0336566900 02/28/08 Radiology Dept - HWIC $620 $15.00 A0337453300 02128/08 MS Hershey Medical $183.00 $117.42 A0357255400 03103 - 13/08 Healthsouth Rehab $1,587.00 $782.85 A0360815900 03/19/08 MS Hershey Medical $183.00 $117.42 A0360815900 03/19/08 Radiology Dept- HMC $62.00 $15.00 Page 1 /-a,m-e.ri "Qa.!th. A D M I N I S T R A T O R S- Date: August 1, 2008 Agreement Number: 01378071 Patient: Wenerick, Kerd Claim Number: Date of Service :. Provider: Hided Paid. Page 2 p y '4 lc-rl..Ms compF1TSA IC} ASSISTANCE `ls'i2O( E-A { _; ) -- 3-2.33q HARRISBURG, IA 17108-11.67 (717) 787-4306 AX Jute S, 2008 as ?a *F< ':% 17070 Re: Claim No.: 200802340 victim-. K to A. Wrnernck E)ear Thomas S. Wenerick: - -k d isa copy of the Proms"s decision in the claim you filed which is referenced above. This decision will become final 34 `-e the date if :his le=. A. IF YOU AGREE WITH THE DECISION. you do not have to return any forms or take any f "ier action. If you were a any ro mey in this decision that is payable to you, enclosed is an initial payment issued from our advancement account: (compensation awwds are not taxable). The balance will be mailed to you directly from the Treasury Deparnnent (approximately d rear-fo€u w=eeks from the date of this decision). If money is due to the Providers, payments will be shade direzly to tern ftom the Treasury Department. If you submitted losses which wem not considered in this decision sir y u have additional losses, these may be considered in. a supplemental award. It is not necessary to complete the Request for Reconsideration form for additional bills to be considered. B. IF YOU DO NOT AGREE WT7TI THE PREX.iRANf S DECISIC)N and you want the Program to change its decision, you roust complete and return the used Ruction of Decisions acrd Request for Reconsideration fort, List on that :Conn each decision you think the Program made in error. If a check is enclosed and you reject the Progranfs decision, you must return the check in order for the decision to be-reconsidered. A= FAILURE TO FILE A REQUEST FOR RECONSIDERATION WITHIN 30 DAYS FROM THE URQBT DATE OF THE DECISION WILL CAUSE THE DECISION TO BECOME FINAL, AND YOU WILL .HAVE NO FURTHER RIGHT OF APPEAL. C. ATn, ] RNirY F IyFS_ If en attorney resented you _in filing this claim, please be advised that an attorney -shall not collrct fe s m € t anyor 4clse foz with a claim rep iless vftlae or tc _ : Attorney tees are in addition to awards made to victims and are only paid if there is an actual award of money (18 F.S. § 11.31'2(3)). The attorney is not entitled to lees if no award is made. An attorney may petition the Program for fees after the award is )said. Sincerely yours, Robin Shea compensation specialist Enclosures cc: Faith 1. Uhler-Myers t(? ?? L ?-h 'orker117: Robin Shea - F It7: R1%DWlD7 PENNSYLVANIA COMMISSION ON CRIME AND DELINQUENCY OFFICE OF XTICTI'MS` SERVICES VICTIMS COMPENSATION ASSISTANCE PROGRAM Victim: Kerr' A. Wenctick Claimant: Thomas S. Wenerick :address: 934 Limeklin Road New Cumberland, PA 17070 Claim :No.: 2002340 Date of Incident: December 12, 2007 Review and Determination OUT-OF-POCKET LOSSES Provider Name/rDate of Service Anmnt ,. w . . Claimant Provider 1. Mileage to MS Hershey Med. Ctr (01104;2008-03/19/2008) (5 Visits) S78.25 S0.00 .Ian. 4, 10, Feb. 6, and 28 @,A& 5 cents per mile, Mar. 19 50.5 cents per mile. All @ 32 miles round trip. ' - Wa1-M fi (Of. /09/2008) $1.94 $0.00 Bayer tablets 3. Minium and Kearns Orthodontist (04/06/2008) $200.00 $0.00 New Essix Appliance ($75) and new RetaineriRawley Appliance (5125) 4. Total Vision Care (04/10/2008) $99.00 $0.00 5. Rite Aid Phan-nacy (12/26/2007) $9.50 $0.00 6. Mileage to Physical therapy (12/27/2007-03/13/2008) (33 Visits) $163.52 $0.00 Dec. 27, 27, 31, 2007. Jan_ 2, 3, 7, , 10, 14, 17, 18, 21, 23, 24, 28, 30, 31, Feb. 4.6, 7, 11, 18, 20, 21, 25, 26, 28, Mar. 3, 4, 6, 10, 12, and 13, 2008. (10.24 miles per trip (? $0.485imile) 7. Heafthsiouth Rehab of Mechanics (12127!2007-03/13/2008) $50.00 S400.00 Provider is considered paid in full. ($280.0 Out-of-Pocket Loss: $602.21 .00 TOTAL OUT-OF-POCKET LOSSES: $1,002,21 Rental $200.00 Medications $11.44 Physical Therapy/Chiropractic $330.00 Replace Glasses Frames $49.50 Replace Glasses Lenses S49.50 Trarvortation/Meals $241.77 The wwdmum payable for out-of-pocket losses is $35,000.09. AWARDABLE OUT-OF-POCKET LOSSES: $882.21 AWARDABLE TOTAL LOSS OF EARNINGS: $0100 AWARDABLE TOTAL LOSSES: $882.21 Worker ID: Robin Shea CWM #: 2(W02340 Fbrrr IM rXWT5 PENNSYLVANIACt?MMISSION ON CRIME AND DELINQUENCY OFFICE OF VICTIMS' SERVICES VICTIMS COMPENSATION ASSISTANCE PROGRAM RESTITUTIONXIVIL SUITS Restitution Ordered: Unknown Amount applied to this Review and A t Ordered: $0_014 Determination-- $4.00 The laN,- requires that any pa tints received or to be received by the claimant as a result of the injury shall be paid,to this agency until the compensation that this agency awarded to you. is paid back in full. This regWmme:nt covms not only restitution that the Court orders the offender to pay, but a.lso.ins .trance paym s or civil AV*& }paid by.or on behalf of the offender, This requirement also covers insura e payments or civil awards paid by or on behalf of a third party on a claim retying"to the crime ihideM. `If you have already received any such payments, or receive any in the future, you are required to reimburse this agency for those payments. The chdmtant is required to nod y the Program about the ultimate disposition of any civil suit Less Payment to the Clamant for Restitution: ($0.00) Lis Reductions for Contribution of 00%: $0.00 Other Reductions: ONE DETERMINATION With this award of $$8211 and prior award(s) of $0.00, the Program has awarded a total to date of $882.21. Claimant: 5602.21 Provider(s): $280.00 Arriount of enclosed check: $602.21 To be issued in 3 to 4 weeks: $0.401 Providers identified as being paid in full as indicated in the Out-of-Pocket Losses Section an Page 1 cannot bill the victim/claimant for any remaining balance according to the Crime Victims Act, as a€r a ded. Please contact the Program if you are billed for any remaining balances from these identified providers. Upon receipt of the required information, the following losses can be considered on a future award:. Verification forms have been sent to Milton Hershey Medical Center and Stroehmanu Bakeries. Those losses Worker iR: Robin %ea ctaim #: 200902,140 Form ID-. RNM215 IT IS.HEREBYDETERIVITNED that the claimant, Thomas S. Wenerick, be compensated regarding the above claim in the amount of S882.2 1, payable as follows: PENNSYLVANIA COMMISSION ON CRIME AND DELINQUENCY OFFICE OF VIC'TIMS' SERVICES VICTIMS COMPENSATION ASSISTANCE PROGRAM can be processed as Soon as the forms are completed and returned.. Please-submit a copy of the K-Mart receipt for the wheel chair gloves. The slate is not risible on the copy that was submitted previously. Kerri's Loss Of Etu ings was calculated by dividing her 2007 earnings (53,743.61) by 30.84 (the creeks she worked at Karns) for an average weekly gross of S 121.39. Subtracting taxes of 15% ($18.21) gives an average weekly net wage of $103.18. Kerri missed 14 weeks of work, for $1,444.52 in total Loss Of Earnings. However, Kerri has been reimbursed by Erie Insurance for $1,877.80. Since that amount is greater than her losses, the Program has no LOE to consider for Kerri. Date: June 5, 200$ SIGNED. Robin Shea. Compensation Specialist Enclosures ac: Faith I. Uhler-Myers Worker 0: .Rabin; Shea Claim M I-ON F2340 Ftmn CLb; X215 PENTNSY VAANIA COMMISSION ON CRIME AND DELINQTiE X Y Office 0f Victims` Services Victims Compensation Assistance Proms wn PENNSYLVANIA CO VIMIIS91ON ON CRIME AND DELINQUENCY Office of V'ictims' Services Victims Compensation Assistance Ptogram Victim: Kerry` A. Wenerick Claim No.: 200802340 Claimant Thomas S. Wenerick I Review and Deteirmtination ORDER AND NOW, this 5th day of June, 2008, the Office of V'ictims' Services, Victims Compensation Assistance Program, do b by approve the Determination submitted in the above-captioned matter; and, _.... _.... . ....... . _. , . _ _._ _ Y - a able as t`o?1.0 IT IS HEREBY ORDERED that the claimant is awarded the sum of, 280.00, PAYEE AMOUNT 631105923 $280.40 Healthsouth. Rehab of Mechanics 175 Lancaster Blvd Mechanicsburg, PA 17,055-3562 These amounts may be changed by administrative action of the Program if additional information is received verifying payments by the offender or a third party to either the claimant or a provider. SIGNED: Robin. Shea Compensation Specialist. W06mr ir>: Kuhn Shea Faam ID, RNDO(3303 aennsytvar a VICTIMS COMPENSATION ASSISTANCE PROGRAM (SW) 233-2339 E P.O. ll;Ox r167 ( 793-5153 KARRIS-RURG, P-A 171.08-1.167 (71.7) 7974306 FAX June 12, 2008 Thomas S. Wenerick 934 Limeklin Road New Cumberland, PA 17070 Re: Claim No.: 200902340 Victim: Ketri A. Wenerick Dear -(bonus S W enerick: Enclosed is a copy of the P'rogram's decision in the claim you filed which is referenced above, This decision will becorne final ail days from the date of this letter. A. IF YOU AGREE WITH THE DECISION you do not have to return any forms or take any further action.. If you were awarded any money in this decision that is payable to you, enclosed is an initial payment issued from. our advance account (ctanipensation awards are not taxable). The balance will be mailed to you directly from the Treasury Department (approximately three-four weeks from the date of this decision.). If money is due to ft pravidws, payments will be made directly to them froth the Treasury Department. If you submitted losses which were not considered in this decision or you have additional losses, these may be considered in a supptez tai awe d. It is not necessary to complete the-Request for Reconsideration form for additional bills to be couddere B. IF. YOU DO NOT AGREE WITH THE PROGRAM'S ,-)E Q.S ON, and you want the Program, to change its decision, you must complete and return the enclosed Rejection of Decision and Request for Reconsideration form. List on that form each decision you think the Program made in error. If a check is enclosed and you reject the Program's decision, you must return the check in order for the decision-to be reconsidered. IMFORTANT: FAILURE TO FILE A REQUEST FOR RECONSIDERATION WITHIN 30 DAYS FROM THE DATE OF THE DECISION WILL CAUSE THE DECISION TO BECOME FINAL, AND YOU WILL HAVE NO FURTHER RIGHT OF APPEAL. C. ATTORNEY FEES: If an attorney represented you in filing this claim, please be advised that an attorney shall not collect fees ftein a claim t flr anyone else-for helping with a claim regardless of the outcome. Attorney fees are in t . -t r? , c '. i'l?r addition to swsrua »c W V aid a L. Or'll °r i v of 'may (IR P.q- 51 La 1. 2 ? attorney is not entitled to fees if no award is made. An attorney may petition the Program for fee after the award is paid- Sincerely yours, Robin Shea Compensation Specialist Enclosures cc: Faith 1. Uhler-Myers Wo*er ID: Robin sbea Fom 0- iLM3Kl 107 PENNSYLVANIA COMMISSION ON CRIME AND DELINQUENCY OFFICE OF V`ICT1,MS' SERVICES VICTIMS COMPENSATION ASSISTANCETROCRAM Victim: Kerri A. Wenerick Claimant: Thomas S. Wenerick. Address: 934 Limekli.n Road New Cumberland, PA 17070 Claim No.: 200802340 Irate of Incident: December 12, 2007 Review and Determination OUT-OF-POCKET LOSSES Provider Name/Date of Service Claimant Provider L K-Mart (01/01 /2008-01/11/2008) $15.98 $0.00 Hot/cold wrap purchased 1/11/08, $9.99. Wheel chair ,gloves purchased 1/] /08, $ 5.99. 2. Giant Pharmacy (02/14/2008) $10.00 $0.00 3. Hershey Medical Center (02/14/2008-02/19/2008) (1 Visit) $75.00 $0.00 4. Milton S Hershey Med Ctr (12/12/2007-12/19/2007) 50.00 $15.00 Providers is considered paid in full. ($10.50) 5. MS Hershey Medical Center (12/12/2007-12/19/2007) 0.00 $250.00 Provider is considered paid in full. ($175.00) 6. Thomas' lost wages (12/13/2007) $128.55 $0.00 Maximum Lass of Earnings is 5642.75 net per week, or $128.55 per day. Out-of-Pocket Loss $229.53 $265.00 TOTAL OUT-OF-POCKET LOSSES: 5494.53 Doctor $10.50 Hospital $250.00 LOE-HC-Attu Medical Appt. $128.55 Medical Equipment & Supplies $15.98 Medications 510.00 The maximum payable for ow-of-pocket losses is $35,000 AWARDABLE OUT-OF-POCKET LOSSES: $415.03 AWARDABLE TOTAL LOSS OF .EARNINGS: $0.00 AWARDABLE TOTAL LOSSES. $415.03 Worker IA: Robin St" Claim # 200802340 Form 1A: R.N,I304#215 PENNSYLVANIA COfMMISSION ON CRIME AND DELINQUENCY OFFICE OF VICTIMS' SERVICES VICTIMS COMPENSATION ASSISTANCE PROGRAM RESTITUTION/CIVIL SUITS Restitution Ordered: Unknown Amount applied to this Review and Amount Ordered: $0.00 Determination: SO.00 The law requires that any payments received or to be received by the claimant as a- result of the injury shall be paid to this agency until the compensation that thhis agency awarded to you is paid back in full. This requirement covers not only restitution that the Court orders the offender to pay, but also insurance payments or civil awards paid by or on behalf of the offender. This requirement also covminsurarice you have already received any such payments, or receive any in the future, you are required to reimburse this agency for those payments. The claimant is required to notify the Program about the ultimate disposition of f any civil suit. Less Payment to the Claimant for Restitution: ($0.00) Less Reductions for Contribution of 0°l(: $0.00 Other Reductions: NONE DE'T'ERMINATION With the award of $415.03 and prior award(s) of $882.21, the Program has awarded a total to date -of $1,297.24.. IT IS HEREBY DETERMINEII that the claimant, Thomas S. above claim in the amount of $415.03, payable as follows: Claimant: $229.53 Amount of enclosed check: $229.53 To be issued in 3 to 4 weeks: $0.00 Wenerick, be compensated regarding the . Provider(s): $185.50 Providers identified as being paid in full as indicated in the Out-of-Pocket Loss Section on Page 1 cannot bill the victim/claimant for any remaining balance according to the Crime Vim Act, a Please contact the Program if you are billed for any remaining balances from these identified provis. Loss of Earnings awards are limited to the average weekly net wage as determined by the DepartmW of Labor and Industry. The current amount is $642.75, which we divided by 5 to got the emu allowable Worker ID: Rabin Shea Clain #: 2OM2340 F am ID: FFd+tr i5 PENNSYLVANIA COMMISSION ON CRIME AND DELINQUENCY OFFICE OF VICTIMS-' SERVICES VICTIMS COMPENSATION ASSISTANCE PROGRAM per day, or $128.55.. Date: June 12, 2008 SIGNED: Robin Shea Compensation Specialist cc. Faith. I. Uhler-.Myers Worker ID- Rollin Shea Claim #: 200502340 Fam JD-. € ND D0215 PENNSYLVANIA` COMMISSION ON CRIME AND DEUN!Q ENCY Office of Victims' Services - Victims Compensation Assistance Program PENNSYLVANIA COMMISSION ON CRIME AND DELINQUENCY Office of Victims' Services Victims Compensation Assistance Program Victim: Ferri A. Wenerick f Claim No.: 200802340 Claimant Thous S. Wenerick 1 Review and Determination ORDER AND NOW, this 12th day of June, 2008, the Office of Victims.' Services, Victims Compensation Assistance Program, does hereby approve the Determination submitted in the above-captioned matter; and, .. '7'1?.?..2.7'?1? (1D it ? D Cl"1 tl.. a ?t a. Y r.. 'a.",'?S?$?`?.'???? t O J .? V ?J? ?1?... _ _. .....,_._........._ .....?........._... PAYEE 251854772 MS Hershey Medical Center P.O. Brix 643291 Pittsburgh, PA. 15264-3291 AMOUNT $175.00 PAYEE 251857435 Milton S Hershey lvMed Ctr Physicians Group Billing Services Pty Box 854 Hershey, PA 17033-0854 AMOUNT $10.50 These amounts may be changed by administrative action of the Program if additional infbrmat on is received verifying payments by the offender or a third party to either the claimant or a provider. SIGNER: Robin Shea Compensation Specialist Worker ID: Robin Shea Form Ia. RNDOG303 GOVERNOR'S OFFICE OF GENERAL COUNSEL July 31, 2008 David Lutz, Esq. Angino & Rovner, P.C. 4503 North Front Street Harrisburg, Pa 17110-1799 Dear Mr. Lutz: VIA FAX: 238-5610 Re: Kerri A. Wenerick Claim #200802340 Thank you for your correspondence of July 30, 2008 to the Victims Compensation Assistance Program (VCAP) acknowledging our subrogation rights under the Crime Victims' Act, at 18 P.S. § 11.1301. To date; VCAP has paid a total of $1,297.24 on this claim. Attached is the financial log and breakdown of payments. If you or the Court have any questions, please contact my assistant, Cynthia Minnich, at (717) 265-8518. Thank you for keeping this agency informed in this matter. Sincerely yours, Steven V. Turner Chief Counsel OFFICE OF CHIEF COUNSEL I PCCD 3101 North,Front Street HARRISBURG, PA 17110 pennsylvania Ph: 717-265-8517 1 Fx: 717-214-9585 www.pccd.state.pa.us i COMMISSION ON CRIME AND DELINQUENCY .•,?` "1 ?'? ?3t Bcnc?i?,?cfcnu?iia _ ,, ? ? ,-, Out of Pocket ? $1,496_7d $35,000.00 51,29'.24 533,?02.?6 - Replace Glasses Frames - $200.00 $49.50 $49 .50 $150 .50 Replace-Glasses L - - ? $49 50 $800.00 x $49.50 ( $750.50 ?- enses Hospital $325.00 $35,000.00 $250.00 $34,750.00 Doctor 115.00 ? $35,000.00 $10.50 $34,989.50 Medications $35,000.00 $2144 $21.44 34,978.56 Physical, ytChiropractic IThera _ $450.00 j $35,000.00 F ( $330.00 $34,670.00 -- p Dental $200.00 $35,000.00 $200.0034,800.00 F- I Medical Eq*pment & Supplies $15.98 $35,000.00 $15.98 $34,984.02 ransportation/Meals $241.77 _ $35,000.00 $34,758.23 $241.77 --- r -- LOE-HC-Attend t Medical A - r------------- $128.55 $35,000.00 _ ? $128.55 $34,871.45 I ?- . pp Totals $1.496.'4 -; $35,x.00 S1,297.24 $33,702.76 k., .Overdue ? wbragelion, pemsyWam Cf MSON ON CRIMIE AND DEMQUENCY VICTIMS COMPENSATION ASSISSTANCE PROGRAM P.O._BOX 1167 HARRISBURG, PA 17108-1167 August_ 13, 2008 David Lutz, Esquire Angino &Bovner 4503 North Front Street Harrisburg, PA 17110 Dear Attorney Lutz: (800) 233-2339 (717) 783-5153 (717) 787-4306 FAX I am the Financial Resource Coordinator of the Pennsylvania Commission on Crime and Delinquency (PCCD) and its Office of Victims' Services (OVS). PCCD is an executive agency of the Commonwealth of Pennsylvania. Among other missions, OVS uses public funds to compensate victims of crime who have limited resources through the Victims Compensation Assistance Program (VCAP). The VCAP is a payor of last resort, restoring lost earnings or lost support and paying medical providers where there is no other immediate source of recovery. Your client, Thomas S. Wenerick, applied to this Program for compensation incurred as the result of a crime incident that occurred on 12/12/2007. Thomas S. Wenerick indicated on the claim form that you would be providing representation in a civil lawsuit or insurance action. Therefore, I would like to inform you of the subrogation rights of the VCAP. As part of the application process, your- client signed a reimbursement agreement in which, as a condition for receiving compensation, agreed to pay-the Commonwealth back if another source makes an award or payment relating to the crime in question. This includes any-restitution your client may receive from the offender. In addition to the contractual obligation, the Crime Victims Act, at 18 P.S. § 11.1301, gives OVS a statutory right of subrogation. OVS takes the position that a crime victim who was compensated in his or her time of need should reimburse the Commonwealth in f ffifa recovery is eventually obtained. Your client has or will be receiving compensation from this agency. Therefore, please keep this office i><uormed of the status of any civil suit or insurance action. Thank you for your attention to this matter. Sincerely yours, 14 Edward A. Katz Financial Resource Coordinator Victims Compensation Assistance Program cc: Thomas Wenerick York Co. Victim/Witness Services, Faith I. U 6h1 Worker ID: Robin Shea bl'i Form ID: ATT00100 POWER OF ATTORNEY AND FEE AGREEMENT BY SIGNING THIS AGREEMENT, I (WE) ACKNOWLEDGE THAT I (WE) HAVE ENGAGED THE LAW FIRM OF ANGINO & ROVNER, P.C. (HEREINAFTER A & R), TO REPRESENT ME (US) UNDER THE FOLLOWING TERMS AND CONDITIONS: A & R may on my (our) behalf secure medical, work and other similar records, conduct an investigation, negotiate, d if necessary start suit a ainst anyone responsible for my (our) injuries and losses with respect to -C 1 ZW , with full power and authority to appear on behalf of the undersigned in any Court-of re&rd or in any administrative or other proceeding, to do and perform all and every act and thing whatsoever that may be requisite and necessary to be done in connection with the above claim as fully as the undersigned might or could do if personally present; hereby ratifying and confirming all that said attorneys shall lawfully do or cause to be done therein by virtue of this power of attorney. I (we) understand that so long as the case is handled by an A & R attorney, I (we) will not be responsible for any fees and/or expenses unless a recovery or benefit is obtained. If my (our) case is handled to a successful completion by an A & R attorney, I (we) agree to pay A & R all reasonable out-of-pocket expenses without the payment of interest, plus a fee for time expended as follows: A & R An (US) a. SETTLEMENT PRIOR TO STARTING SUIT Z 5 0 70% b. SETTLEMENT FOLLOWING SUIT BUT PRIOR TO TRIAL OR 36 65% ARBITRATION c. SETTLEMENT OR VERDICT AT TRIAL OR ARBITRATION, AFTER TRIAL, ARBITRATION, OR APPEALS OR SHORTLY BEFORE 3$ / 60% TRIAL AND AFTER CASE HAS BEEN TOTALLY PREPARED 0 d. IF NO-FAULT RECOVERY OR NON-MONETARY BENEFIT: RICHARD C. ANGINO ($500); NEIL J. ROVNER ($450); ASSOCIATES ($400) PER HOUR BUT NOT TO EXCEED 40% OF TOTAL RECOVERY OF VALUE OF BENEFIT e. OTHER CASES 4. If my (our) case was forwarded/referred to A&R by another attorney or law firm, A&R may pay a portion of its fee to forwarding counsel. You will not pay a larger fee because of the fee splitting arrangement. If for any reason I (.we) take my (our) case to another attorney or law firm including a former A & R attorney or handle it myself (ourselves), I (we) recognize that A & R has, in good faith, expended money and time for my (our) benefit and I (we) therefore agree to `pay, or have my (our) new attorney pay, immediately, upon severing the A & R attorney/client relationship, all the out-of-pocket expenses incurred on my (our) case plus interest at the rate of 6% per annum from the date of each expenditure. In addition, when the case is successfully concluded, I (we) agree to pay or to direct my (our) new attorney to pay as a fee 20% of the gross recovery to A & R. 6. In the event that any settlement is made on a structured or deferred payment basis, A & R shall be entitled to receive their percentage based on the present value of the structured settlement, if paid as a lump sum at the time of settlement. If by settlement or operation of law, benefits are to be paid periodically in the future, the attorneys' fee due to Angino & Rovner, P.C., on such benefits will be calculated by taking the present value of such future payments at the time of the award based upon the then existing federal funds discount rate and will be paid in a lump sum to the attorneys at the time of settlement or verdict. I (we) agree not to settle or discuss settlement of my (our) case without the written consent of A & R- 208219 (revised 8106) '. thf'o 0 r?? PLEASE COMPLETE SECTION BELOW PERSONAL INFORMATION Receiving Support from-Dept of Welfare or Public Assistance (Including Cash) Yes o (circle one) Receiving Medicare/Medicaid Yes o (circle one) Under child support order? Yes o (circle one) Are you in arrearages with child support? Yes o (circle one) Injured's Name W z4rC Injured's Social Security Number Injured's Date of Birth ?- Z - Address Street p G?? / City, State, Zip rV1 C (?tid Jy • / / ? 4 7?D E-Mail Address Telephone Home -77 0 -16 ? Work / a+-0 S Cellular 512- - ? BY SIGNING THIS AGREEMENT, THIS Z 1 DAY OF )-e? , 20DJ I (WE) ACKNOWLEDGE THAT I (WE) HAVE READ, UNDERSTOOD, AND RECEIVED A COPY OF SAME AND AGREE WITH ITS TERMS AND CONDITIONS. WrFNESS(ES): (:-J:h Vi ?) CLIENT(S): (SEAL) (SEAL) I recognize that in order to investigate my claim, Angino & Rovner, P.C., will obtain my medical records and other personal medical information. I understand Angino & Rovner may disclose my medical information to experts, insurance carriers, defendants, other attorneys and/or other individuals necessary to pursue my case. I have been informed that I have the right to privacy in my medical records under the Health Insurance Portability and Accountability Act, 42 U.S.C. § 1320, et seq. If this Act would be deemed to apply to disclosures made by Angino & Rovner, I hereby waive any rights I may have under the aforementioned Act and hereby hold g' & fovner, P.C., harmless for any actions which may be affected by HIPAA or the regulations thereunder. Client's initials I understand that Angino & Rovner will retain my file for a period of five years after the conclusion of my case. I further acknowledge that Angino & Rovner will destroy my file at the end of the five year period. Exceptions to this policy may include cases involving minors, annuities/structured settlements, and worker's compensation cases settled by partial compromise and release. I have/rp e: pectation that my file will be retained permanently. iierit's initials I (We) acknowledge that pursuant to Act 109 of 2006 which became law on July 7, 2006 that a statutory lien has been created by the Pennsylvania Legislature which requires me (us) to provide information concerning any Orders or Agreements to pay child support and any arrearages that may be due at the time of settlement or verdict. I (we) also recognize that the law requires the law firm of Angino and Rovner, P.C. to verify with the Pennsylvania Department of Public Welfare whether there are any arrearages in my (our) support obligation at the time of settlement. I (we) understand that the law requires my attorney pay the amount of the arrearages to the Pennsylvania State Disbursement Unit prior to the distribution to me of the net proceeds of any settlement or award to me in any case where the net proceeds to client exceed $5000.00. I acknowledge that if there are child support arrearages owed at the time of settle t ?r verdict that it is statutory lien which Angino and Rovner, P.C. must confirm and honor. tint's Initials 208219 (revised 8/06) Angino & Rovner, P.C. ** CASE/ACCOUNTING REGISTER ** FILE NUMBER ............: 08004 CLIENT .................: WENERICK, PAMELA FOR KERRI DATE IN OFFICE.........: 12/21/2007 TYPE OF CASE...........: A DEFENDANT(S)...........: NATHANIEL SHERWOOD ATTORNEY IN CHARGE.....: DLL FORWARDER ..............: REFERRAL ...............: SPECIAL NOTE(S)........: W-9 PREPARED: 10/01/2008 PAGE: 1 ----------------------------------------------------------------------------------- *** FILE EXPENSES *** DESCRIPTION DATE QUANTITY UNIT/PRICE AMOUNT PERSON FAX CHARGES (PER PAGE) 12/21/2007 1.00 1.00 1.00 FAX CHARGES (PER PAGE) 7/30/2008 1.00 1.00 1.00 EXPENSE TYPE TOTAL: FAX CHARGES (PER PAGE) INVESTIGATION TIME EXPENSE INVESTIGATION TIME EXPENSE INVESTIGATION TIME EXPENSE INVESTIGATIONTIME EXPENSE INVESTIGATION TIME EXPENSE INVESTIGATION TIME EXPENSE INVESTIGATION TIME EXPENSE EXPENSE TYPE TOTAL: INVESTIGATION TIME EXPENSE DIGITAL PHOTO C.D.'S DIGITAL PHOTO C.D.'S EXPENSE TYPE TOTAL: INVESTIGATION EXPENSE LONG DISTANCE EXPENSE TYPE TOTAL: LONG DISTANCE MAS - MILEAGE MAS - MILEAGE EXPENSE TYPE TOTAL: MILEAGE COLOR COPIES 12/12/2-007 2.00 70.00 12/26/2007 1.00 70.00 1/21/2008 .50 70.00 2/19/2008 .75 70.00 6/05/2008 .50 70.00 6/12/2008 .25 70.00 7/02/2008 .25 70.00 12/21/2007 6/05/2008 10/01/2008 12/26/2007 6/04/2008 12/21/2007 100.00 .50 2.00 140.00 MAS 70.00 MAS 35.00 MAS 52.50 MAS 35.00 MAS 17.50 MAS 17.50 MAS 367.50 * 6.00 6.00 ------------ 12.00 * 5.00 ------------ 5.00 * 3.88 6.00 9.88 50.00 uh( lklip Angino & Rovner, P.C. ** CASE/ACCOUNTING REGISTER ** PREPARED: 10/01/2008 FILE NUMBER ............: 08004 PAGE: 2 CLIENT ........... ......: WENERICK, PAMELA FOR KERRI ---------------------- ---- ------------------------------------------- COLOR COPIES ADDL ----------------- 1/22/2008 -- 43.00 .25 10.75 COLOR COPIES 6/05/2008 26.00 .50 13.00 COLOR COPIES ADDL 8/13/2008 13.00 .25 3.25 PHOTOCOPIES 10/01/2008 100.00 .25 25.00 PHOTOCOPIES 10/01/2008 765.00 .25 - 191.25 ----------- 293.25 EXPENSE TYPE TOTAL: PHOTOCOPIES POSTAGE 10/01/2008 42.90 ------------ 42.90 EXPENSE TYPE TOTAL: POSTAGE SUB-TOTAL ----- 732.53 ** ----------------------------------------------- *** ---------------------- CHECK EXPENSES *** DESCRIPTION DATE CHECK# AMOUNT FAIRVIEW TOWNSHIP EMS 1/23/2008 75092 10.00 CHARTONE, INC. 1/23/2008 75096 72.55 HERSHEY MEDICAL CENTER 1/30/2008 75167 15.00 CHARTONE, INC. 3/11/2008 75470 32.97 FAIRVIEW TOWNSHIP POLICE 3/17/2008 74845 15.00 CHARTONE, INC. 5/28/2008 76148 37.23 SUB-TOTAL 182.75 ** TOTAL EXPENSES ------------------ 915.28 *** -- ------------------------------------------------------------------ xxxxx RECEIPTS ***** SOURCE REASON DATE AMOUNT RECEIPTS TOTAL -------------- .00 *** -- ---------------------------------------------------------------------- * OUTSTANDING INVOICES CUSTOMER NAME INV# INV DATE $BILLED $PAID $DUE OUTSTANDING INVOICE TOTAL .00 *** TOTAL... 915.28- ---------------------------------------------- ------------------------------------- ** END OF FILE ** -- 3i5"18 + fefi -oon f eL 78-50 + 493 - 78 AN GINO & RovNER, P.C. 4503 NORTH FRONT STREET HARRISBURG, PA 17110.1799 717/23&6791 FAX 717/238-5610 W W W.ANGINO-ROVNER.COM EMAIL: DLUTZ@ANGINO-ROVNER.COM RICHARD C. ANGINO MICHAEL E. KosIK NEIL J. ROVNER RICHARD A. SADLOCK JOSEPH M. MELILLO LISA M. B. WOODBURN DAVID L. LUTZ DARYL E. CHRISTOPHER PAMELA WENERIC - Mother and Natural Guardian of KERRI WENERICK, a Minor v. NATHANIEL SHERWOOD DISTRIBUTION SHEET TOTAL AMOUNT OF SETTLEMENT DEDUCTIONS: Attorney's Fee (25%%) Balance Reimbursement of expenses paid by attorneys to others for records, experts, etc. Balance Less Escrow for outstanding liens: ERISA $48,400.64 PCCO $ 1,297.24 BALANCE TO CLIENT PLUS ANY INTEREST EARNED WHILE HELD IN BANK ESCROW FINAL DIVISION: Attorney's Fee '$25,000.00 Client's Balance $24,308.34 Reimbursement of Expenses $ 993.78 Escrow for outstanding liens $49,697.88 $100,000.00 $ 25,000.00 $ 75,000.00 $ 993.78 $ 74,006.22 $ 49,697.88 $ 24,308.34 This settlement/verdict may be taxable. We recommend that you consult your accountant or tax attorney for the calculation of your tax liability and any deductions to which you may be entitled. WARRANTY AND NOW, this day of , 2008, we acknowledge that we have read, understood, approved and obtained a copy of this Distribution Sheet. We further acknowledge that the above balance constitutes my total reimbursement for medical expenses, wage losses, pain and suffering and any other losses sustained or claims resulting from our accident. We warrant that if there are any outstanding medical bills, child support arrearages or claims other than as set forth above, they will be our responsibility; we further warrant that we will pay any outstanding Blue Cross, Blue Shield, Public Assistance, Medicare/Medicaid, medical subrogation liens-or any other liens and expenses not noted above. WITNESS PAMELA WENERICK, Mother and Natural Guardian of KERRI WENERICK, a Minor 394557 a 1?6,?? ?{ ? ? s?o?? Q, ..,? V? U ? d -0 ? ??? t? ? ? ?? D era ``' --? ?" c,? w ;; e? p?= 0 IN RE: PAMELA WENERICK, mother IN THE COURT OF COMMON PLEAS OF and natural guardian of KERRI CUMBERLAND COUNTY, PENNSYLVANIA WENERICK, a minor 08-6156 Civil Term ORDER OF COURT AND NOW, this Z day of October, 2008, a hearing on the within petition shall commence at 10:30 a.m., Monday, November 3, 2008, in Courtroom Number 2, Cumberland County Courthouse, Carlisle, Pennsylvania. By the Edgar B. B AD/avid L. Lutz, Esquire For Petitioner :seal /n _ fy u N?5 S./ C"t • fi ANGINO & ROVNER, P.C. David L. Lutz, Esquire Attorney ID# : 35956 4503 North Front Street Harrisburg, PA 17110-1708 (717) 238-6791 FAX (717) 238-5610 Attorneys for PlaintiMs) E-mail: dluu@angino-rovner.com OCT: 15 2008 (A IN RE: PAMELA WENERICK, mother and natural guardian of KERRI WENERICK, a minor, Petitioner IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA NO. 0% - (of Qp Civil ler-nl ORDER OF MINOR SETTLEMENT AND NOW, this V day of A"kL , 2008, upon consideration of the Petition for Court Approval of a Compromised Settlement and the Distribution of Proceeds of a Third-party Settlement and Pursuant to Pa.R.C.P. 2039, IT IS HEREBY ORDERED AND DECREED that the Petition is granted and that Petitioner, Pamela Wenerick, may execute a Release whereby Erie Insurance Company will issue a $100,000.00 settlement check. IT IS ALSO ORDERED that payment of $24,308.34 due to the minor is directed to be made and deposited in the New Cumberland Credit Union, a deposit which is insured by the federal government, and no withdrawal will be made from such account until the minor attains majority (age 18), except as authorized by Court Order. THE COURT ALSO ORDERS that payment of attorney's fees in the amount of $25,000.00 and reimbursement of counsel's out-of-pocket expenses in the amount of $993.78 is approved. THE COURT ALSO ORDERS that $1,297.24 is to be escrowed in Petitioner's counsel's escrow account pending settlement negotiations with the Victims Compensation Assistance Program with regard to its lien. Secondly, $48,400.64 is to be escrowed in Petitioner's counsel's escrow account pending settlement negotiations with regard to any "ERISA lien." Any proceeds that remain after negotiation of the aforesaid two liens are to be deposited in the New Cumberland Credit Union on behalf of the minor, Kerri Wenerick. 390196 The Court also hereby authorizes the Petitioner to execute a Release on behalf of the minor for the benefit of Nathaniel Sherwood and his insurer, Erie Insurance Company. Counsel shall provide the Court with an Affidavit of Depos t evidencing the deposit of $ 4,308.34 to be made in the New Cumberland Cre it UnionrG40 ky- C4&/^k BY THE RT: tu Coq J. Distribution: David L. Lutz, Esquire, 4503 N. Front Street, Harrisburg, PA 17110; phone - 238-6 ; fax - 238-5610; dlutz@angino-rovner.com Ms. Melissa Cover, Liability Adjuster III, Erie Insurance Group, 4901 Louise Drive, P.O. Box 2013, Mechanicsburg, PA 17055; phone - 264-2356; fax - 264-2589 390196 $s? 6? :01 WV E- AON $DOZ 3?`1311J ANGINO & ROVNER, P.C. David L. Lutz, Esquire Attorney ID# : 35956 4503 North Front Street Harrisburg, PA 17110-1708 (717) 238-6791 FAX (717) 238-5610 Attorneys for Plaintiff(s) E-mail: dlutz@angino-rovner.com IN RE: PAMELA WENERICK, mother and natural guardian of KERRI WENERICK, a minor, Petitioner IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA NO. 08-6156 Civil Term PETITION FOR COURT APPROVAL OF A COMPROMISED SETTLEMENT AND THE DISTRIBUTION OF PROCEEDS OF AN UNDERINSURED MOTORIST SETTLEMENT ON BEHALF OF MINOR PETITIONER. KERRI WENERICK PURSUANT TO Pa R C P 2039 The Petition of Pamela Wenerick, mother and natural guardian of Kerri Wenerick, a minor, respectfully represents: 1. Kerri Wenerick is the daughter of Pamela and Thomas Wenerick. Kerri Wenerick is 17 years old, having been born on April 12, 1991. Kern resides with her parents, Pamela and Thomas Wenerick, in New Cumberland, York County, Pennsylvania. 2. On December 12, 2007, at approximately 9:20 p.m., Kerri was injured in a motor vehicle collision that occurred on Limekiln Road in York County, Pennsylvania. Nathaniel Sherwood, an Erie insured, caused the collision. 3. A third-party claim was made to Erie and in an Order dated November 3, 2008, attached Exhibit A, Judge Bayley approved the third-party settlement. 390196 4. An underinsured motorist claim was made to the Wenericks' insurer, also Erie Insurance Company. After a series of negotiations, Mr. Douglas Kocher, an Erie claims representative, extended a UIM settlement offer of $75,000.00. Attached as Exhibit B is Douglas Kocher's November 10, 2008, correspondence and proposed Release. 5. The Wenericks' Erie Insurance contract provides that underinsured claims that are not amicably resolved are to be litigated in the Court of Common Pleas. It was counsel's plan to proceed with litigation in the Court of Common Pleas of Dauphin County had the $75,000.00 offer not been made. It is counsel's professional opinion that the $75,000.00 UIM settlement offer should be accepted as it is possible that a Dauphin County jury would award less than $175,000.00 (it is assumed that the Court would mold the $100,000 paid on behalf of the tortfeasor). 6. Kerri attends Cedar Cliff High School and works part-time. As such, she is required to drive to and from work after school. Unfortunately, her car is in need of repairs. Accordingly, it is respectfully requested that $1,000.00 of the $75,000.00 settlement be paid directly to Kerri for car repairs. 7. Pamela Wenerick, as mother and natural guardian of Kern Wenerick, retained the services of the law firm of Angino & Rovner, P.C., to prosecute this action. Typically, the Angino & Rovner contingency fee contract provides that the attorneys are to receive, for professional services, 30% of the gross amount recovered. However, Angino & Rovner, P.C., has reduced its fee to 25% of the gross amount recovered (i.e., $18,750). The Angino & Rovner, P.C., modified Power of Attorney and Fee Agreement was attached to the Petition for the $100,000 third-party settlement as Exhibit O. 397683 2 8. Angino & Rovner has expended approximately $100.00 of expenses since the third-party settlement and attached as Exhibit C is a print-out of out-of-pocket expenses. Also, attached as Exhibit D is a proposed Distribution Sheet. 9. Should the Court approve the $1,000 payment to Kerri for car repairs, the remaining net proceeds of $55,150.00 is to be placed into the New Cumberland Credit Union, a deposit which is insured by the Federal Government, in an account that provides no withdrawal will be made until Kerri Wenerick reaches majority (age 18), except as authorized by Court Order. WHEREFORE, the Petitioner, Pamela Wenerick, mother and natural guardian of Kern Wenerick, a minor, respectfully requests this Honorable Court approve the underinsurance settlement and authorize payment of $75,000 whereby $1,000 of the net proceeds will be paid to Kerri for car repairs; $55,150.00 is to be placed into the New Cumberland Credit Union; $18,750 to be paid to Angino & Rovner, P.C. for attorney's fees; and $100.00 to be reimbursed to Angino & Rovner, P.C., for out-of-pocket expenses. ANGINO & ROVNER, P.C. Date: ??,1 9davld I,. Lutz I.D. No.35956 4503 N. Front Street Harrisburg, PA 17110 (717) 238-6791- phone (717) 238-5610 - fax dlutz@angino-rovner.com Attorney for Petitioner 397683 3 PETITIONER'S COUNSEL CERTIFICATE I, David L. Lutz, Esquire, Petitioner's counsel, do hereby affirm that the proposed $75,000 underinsurance settlement, in my professional opinion, is reasonable and in the best interest of the minor given the fact that a Dauphin County jury could award less than $175,000. It is also counsel's professional opinion that distribution of the proceeds as set forth in the aforesaid Petition is in the best interest of Kerri Wenerick. ANGINO & ROVNER, P.C. Date: (- ?? - ?l Uabvic L'. Lutz I.D. No. 35956 4503 N. Front Street Harrisburg, PA 17110 (717) 238-6791 -phone (717) 238-5610 - fax dlutz@angino-rovner.com Attorney for Petitioner 390196 VERIFICATION I, Pamela Wenerick, as mother and natural guardian of Kerri Wenerick, hereby verify that the facts set forth in the foregoing document are true and correct to the best of my knowledge, information, and belief. I understand that any false statements therein are made subject to the penalties of 18 Pa. Cons. Stat. Ann. §4904, relating to unworn falsification to authorities. WITNESS: Dated: Pamela Wenerick 390196 ANGINO & ROVNER, P.C. David L. Lutz, Esquire Attorney ID# : 35956 4503 North Front Street Harrisburg, PA 17110-1708 (717) 238-6791 FAX (717) 238-5610 Attorneys for Plaintiff(s) E-mail: dlutz@angino-rovner.com OCT IN RE: PAMELA WENERICK, mother and natural guardian of KERRI WENERICK, a minor, Petitioner IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA NO. p$ - tot Qp 0,-1v t- t Ie r M ORDER OF MINOR SETTLEMENT AND NOW, this ?d day of _9""k _, 2008, upon consideration of the Petition for Court Approval of a Compromised Settlement and the Distribution of Proceeds of a Third-party Settlement and Pursuant to Pa.R.C.P. 2039, IT IS HEREBY ORDERED AND DECREED that the Petition is granted and that Petitioner, Pamela Wenerick, may execute a Release whereby Erie Insurance Company will issue a $100,000.00 settlement check. IT IS ALSO ORDERED that payment of $24,308.34 due to the minor is directed to be made and deposited in the New Cumberland Credit Union, a deposit which is insured by the federal government, and no withdrawal will be made from such account until the minor attains majority (age 18), except as authorized by Court Order. THE COURT ALSO ORDERS that payment of attorney's fees 'in the amount of $25,000.00 and reimbursement of counsel's out-of-pocket expenses in the amount of $993.78 is approved. THE COURT ALSO ORDERS that $1,297.24 is to be escrowed in Petitioner's counsel's escrow account pending settlement negotiations with the Victims Compensation Assistance Program with regard to its lien. Secondly, $48,400.64 is to be escrowed in Petitioner's counsel's escrow account pending settlement negotiations with regard to any "BRISA lien." Any proceeds that remain after negotiation of the aforesaid two liens are to be deposited in the New Cumberland Credit Union on behalf of the minor, Kerri Wenerick. 390196 The Court also hereby authorizes the Petitioner to execute a Release on behalf of the minor for the benefit of Nathaniel Sherwood and his insurer, Erie Insurance Company. Counsel shall provide the Court with an Affidavit of Deposit evidencing the de os't of $24,308.34 to be made in the New Cumberland Cre it Union.,-L',4,1 4-- C,?,) .,4 BY THE GURT: J. Distribution: David L. Lutz, Esquire, 4503 N. Front Street, Harrisburg, PA 17110; phone - 238-6, fax - 238-5610; dlutz@angino-rovner.com Ms. Melissa Cover, Liability Adjuster III, Erie Insurance Group, 4901 Louise Drive, P.O. Box 2013, Mechanicsburg, PA 17055; phone - 264-2356; fax - 264-2589 TRUE V"y nay hand u in Testimony whereof, i and the seal of said Court at Cariis;e, Pa. This ........... day of...'ev'ov........ ..........re.. ..-? ?. Prothonotary 390196 Erie Zj Insurance' Kerry J. Ritchey, CPCU, AIC Assistant Vice President & Claims Manager Branch Once 4901 Louise Drive • Rossmoyne Business Center • P.O. Box 2013 • Mechanicsburg, PA 17055-0710 717.795.8200 Toll Free 1.800.382.1304 • Fax 717.795.2315 • www.erieinsurance.com November 10, 2008 David Lutz, Esquire Angino & Rovner, P.C. 4503 North Front Street Harrisburg, PA 17110-1799 Re: Your Client: Kerri Wenerick (minor) Erie Claim No.: 010170954099 Erie Insured: Thomas & Pamela Wenerick Date of Loss: December 12, 2007 Dear Dave: This will confirm that we have reached a settlement agreement with respect to Kerri Wenerick's Underinsured Motorist Claim in the amount of $75,000.00. Enclosed is the proposed Release that I am requesting you include with the petition for court approval. Upon receipt of the court order, I will issue the settlement proceeds and direct them to your office is said amount. Thank you for your assistance and if you have any questions please contact me. iSinc ly, ugl G. he / Koc * *?a Claims Representative (717) 761-7475 Enclosure The EME Is Above All In Services. We commit, care and serve. It's our true blue promise. ?,hb?f3 CLAIM #: 010170954099 RELEASE AND AGREEMENT Under policy # Q03-0113273 issued by ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY, I/We, claiming coverage for myself/ourselves or on behalf of Kerri A. Wenerick (minor) in consideration of Seventy Five Thousand ($75,000.00) dollars, which I/We have received, RELEASE AND DISCHARGE ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY from any and all claims, causes of action or other rights which I/We have, have had or could have under the Underinsured Motorist coverage as set forth in said policy, which claims, causes of action or other rights arose or could have arisen as a result of a loss or accident which happened on the 12th day of December, 2007, at or near Route 114, Fairview Township, in the county of York, in the State of Pennsylvania. In consideration of such payment, I/We agree as follows: 1) to assign Erie Insurance Exchange/Erie Insurance Company to my/our rights of recovery against any person(s) or party(ies) legally liable to me/us, to the amount of and for the purpose of the payment noted above; 2) that I/We have not and will not make any separate settlement with nor give any separate release to any person(s) or party(ies) who caused or are alleged to have caused the above mentioned loss or accident; 3) that suit may be instituted by Erie Insurance Exchange/Erie Insurance Company in my/our name; 4) to execute all papers required to commence such suit; and 5) to cooperate in prosecuting any or all actions which Erie Insurance Exchange/Erie Insurance Company may bring to recover from any person(s) or party(ies) for the claims or causes of action which I/We have growing out of said loss or accident. It is expressly understood and agreed that, out of any amount recovered, costs of collection, including by not limited to counsel fees, shall be first paid to ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY. Except in states which apply comparative negligence in determining legal liability, any recovery in excess of collection costs shall be paid to me/us, up to the full extent of my/our loss. In states which apply comparative negligence, any recovery of my/our loss, in excess of collection costs, shall be reduced by a factor equal to the percentage of my/our negligence which contributed to cause the above mentioned accident, before it is paid to me/us. I/We further understand and agree that this RELEASE AND AGREEMENT is inclusive of any and all present and future liens or claims for subrogation against the payments to be made in accordance with this RELEASE AND AGREEMENT. I/We understand and agree that I/we are responsible for the payment of any liens or charges against the payments to be made hereunder should any such liens, subrogation, claims or claims for expenses and charges be asserted. This includes, but is not limited to, medical expense liens, worker's compensation liens, ERISA liens, liens asserted by any federal, state or local governmental entity or agency or any medical expense claim. Should any person or entity make claim for payment of any liens or charges against ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY or their counsel, Uwe agree to indemnify and hold harmless ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY and their counsel from any and all such liens, charges, fees, claims, attorney fees, costs, interests and any other sum. I/We understand that this settlement is the compromise of a disputed claim, and that the payment is not to be construed as an admission of liability on the part of the persons, firms and corporations hereby released by whom liability is expressly denied. (CAUTION: READ BEFORE SIGNING) Intending to be legally bound thereby, WITNESS my/our hand(s) and seal(s) this Witnessed by: STATE OF COUNTY OF On this day of to me known to be the person _ executed the same as My commission expires day of SS (Parent/Legal Guardian) (SEAL) (SEAL) before me personally appeared who executed the foregoing instrument, and acknowledged that free act and deed. Notary Public NOTICE: 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 the person to criminal and civil penalties. Angino & Rovner, P.C. ** CASE/ACCOUNTING REGISTER ** PREPARED: 11/12/2008 FILE NUMBER ............: 08004 PAGE: 1 CLIENT .................: WENERICK, PAMELA FOR KERRI DATE IN OFFICE.........: 12/21/2007 TYPE OF CASE...........: A DEFENDANT(S)...........: NATHANIEL SHERWOOD ATTORNEY IN CHARGE.....: DLL FORWARDER ..............: REFERRAL ...............: SPECIAL NOTE(S)........: LIENS W-9 ---------- -------------------------------------- *** -------------- FILE EXPENSES --------- *** -------------- ------------ --- DESCRIPTION DATE QUANTITY UNIT/PRICE AMOUNT PERSON CREDIT FROM PRIOR SETTLEMENT 11/12/2008 993.78- EXPENSE TYPE TOTAL: CREDIT FROM PRIOR SETTLEMENT --- --------- 993.78-* FAX CHARGES (PER PAGE) 12/21/2007 1.00 1.00 1.00 FAX CHARGES (PER PAGE) 7/30/2008 1.00 1.00 1.00 EXPENSE TYPE TOTAL: FAX CHARGES (PER PAGE) --- --------- 2.00 INVESTIGATION TIME EXPENSE 12/12/2007 2.00 70.00 140.00 MAS INVESTIGATION TIME EXPENSE 12/26/2007 1.00 70.00 70.00 MAS INVESTIGATION TIME EXPENSE 1/21/2008 .50 70.00 35.00 MAS INVESTIGATION TIME EXPENSE 2/19/2008 .75 70.00 52.50 MAS INVESTIGATION TIME EXPENSE 6/05/2008 .50 70.00 35.00 MAS INVESTIGATION TIME EXPENSE 6/12/2008 .25 70.00 17.50 MAS INVESTIGATION TIME EXPENSE 7/02/2008 .25 70.00 17.50 MAS EXPENSE TYPE TOTAL: INVESTIGATION TIME EXPENSE --- --------- 367.50 DIGITAL PHOTO C.D.'S 12/21/2007 6.00 DIGITAL PHOTO C.D.'S 6/05/2008 6.00 DLL - EXPENSES 10/20/2008 22.00 EXPENSE TYPE TOTAL: INVESTIGATION EXPENSE --- --------- 34.00 LONG DISTANCE 10/01/2008 5.00 EXPENSE TYPE TOTAL: LONG DISTANCE --- --------- 5.00 MAS - MILEAGE 12/26/2007 3.88 Angino & Rovner, P.C. ** CASE/ACCOUNTING REGISTER ** PREPARED: 11/12/2008 FILE NUMBER .... ........: 08004 PAGE: 2 CLIENT ......... ----------------------------------------- ........: WENERICK, - PAMELA FOR KERRI MAS - MILEAGE ------------------ 6/04/2008 ------------ -------- -------------------- 6.00 EXPENSE TYPE TOTAL: MILEAGE ------------ 9.88 COLOR COPIES 12/21/2007 100.00 .50 50.00 COLOR COPIES ADDL 1/22/2008 43.00 .25 10.75 COLOR COPIES 6/05/2008 26.00 .50 13.00 COLOR COPIES ADDL 8/13/2008 13.00 .25 3.25 PHOTOCOPIES 10/01/2008 100.00 .25 25.00 PHOTOCOPIES 10/01/2008 765.00 .25 191.25 PHOTOCOPIES 11/12/2008 263.00 .25 65.75 EXPENSE TYPE TOTAL: PHOTOCOPIES ------------ 359.00 POSTAGE 10/01/2008 42.90 POSTAGE 11/05/2008 2.00 .42 .84 POSTAGE 11/12/2008 13.15 EXPENSE TYPE TOTAL: POSTAGE 56.89 ------------------------------------------------ --------------- SUB-TOTAL -------- - 159.51-** *** CHECK EXPENSES - ----------- *** ---------------- DESCRIPTION DATE CHECK# AMOUNT FAIRVIEW TOWNSHIP EMS 1/23/2008 75092 10.00 CHARTDNE, INC. 1/23/2008 75096 72.55 HERSHEY MEDICAL CENTER 1/30/2008 75167 15.00 CHARTONE, INC. 3/11/2008 75470 32.97 FAIRVIEW TOWNSHIP POLICE 3/17/2008 74845 15.00 CHARTONE, INC. 5/28/2008 76148 37.23 PROTH OF CUMBERLAND COUNTY 10/09/2008 77266 78.50 SUB-TOTAL 261.25 ** ------------------------------------------------ ------------- TOTAL EXPENSES 101.74 *** ***** ----------------------- RECEIPTS ***** ---------------- SOURCE REASON DATE AMOUNT ------------------------------------------------ ------------ -- RECEIPTS TOTAL ---------- .00 *** ------------------------ * OUTSTANDING INVOICES ---------------- CUSTOMER NAME INV# INV DATE $BILLED $PAID $DUE OUTSTANDING INVOICE TOTAL .00 +** ' Angino & Rovner, P.C. ** CASE/ACCOUNTING REGISTER ** PREPARED: 11/12/2008 FILE NUMBER ............: 08004 CLIENT .................: WENERICK, PAMELA FOR KERRI ---------------------------------------------------------------------------------------------------- ------------ TOTAL... 101.74- ---------------------------------------------------------------------------------------------------- ** END OF FILE ** PAGE: 3 101 •`i4 + 112•JES ANGINO & ROVNER, P.C. 4503 NORTH FRONT SrREET HARRISBURG, PA 17110.1799 717/238,6791 FAX 717/238.5610 RICHARD C. ANGwo MICHAEL L KOSIK NEEL J. ROVNER RICHARD A. SADLOCK JOSEPH M. MELILLO LISA M. R WOODBURN DAVID L. LUTZ DARYL L CHRISTOPHER W W W.ANGINO-ROVNER.COM EMAiu DLUTZ@ANGINo6ROVNER.COM PAMELA WENERICK. Mother and Natural Guardian of KERRI WENERICK. a Minor v. ERIE INSURANCE EXCHANGE DISTRIBUTION SHEET TOTAL AMOUNT OF SETTLEMENT $75,000.00 DEDUCTIONS: Attorney's Fee (25%) $18,750.00 Balance $56,250.00 Reimbursement of expenses paid by attorneys to others for records, experts, etc. totals $112.74; however only taking a reimbursement of $100.00 (includes credit of $993.78 subtracted from third party settlement) 100.00 BALANCE TO CLIENT PLUS ANY INTEREST EARNED WHILE HELD IN BANK ESCROW $56,150.00 FINAL DIVISION: Attorney's Fee $18,750.00 Client's Balance $56,150.00 Reimbursement of Expenses $ 100.00 This settlement/verdict may be taxable. We recommend that you consult your accountant or tax attorney for the calculation of your tax liability and any deductions to which you may be entitled. WARRANTY AND NOW, this day of . 2008, we acknowledge that we have read, understood, approved and obtained a copy of this Distribution Sheet. We further acknowledge that the above balance constitutes my total reimbursement for medical expenses, wage losses, pain and suffering and any other losses sustained or claims resulting from our accident. We warrant that if there are any outstanding medical bills, child support arrearages or claims other than as set forth above, they will be our responsibility; we further warrant that we will pay any outstanding Blue Cross, Blue Shield, Public Assistance, Medicare/Medicaid, medical subrogation liens or any other liens and expenses not noted above. WITNESS 397940 PAMELA WENERICK ea CD _ r m dG NOV 18 2008C4 ANGINO & ROVNER, P.C. David L. Lutz, Esquire Attorney ID# : 35956 4503 North Front Street Harrisburg, PA 17110-1708 (717) 238-6791 FAX (717) 238-5610 Attorneys for Plaintiff(s) E-mail: dlutz@angino-rovner.com IN RE: PAMELA WENERICK, mother and natural guardian of KERRI WENERICK, a minor, Petitioner IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA NO. 08-6156 Civil Term ORDER OF MINOR SETTLEMENT AND NOW, this day of , 2008, upon consideration of the Petition for Court Approval of a Compromise Settlement and the Distribution of Proceeds of an Underinsured Motorist Settlement and Pursuant to Pa.R.C.P. 2039, IT IS HEREBY ORDERED AND DECREED that the Petition is granted and that Petitioner, Pamela Wenerick, may execute a Release whereby Erie Insurance Exchange will issue a $75,000.00 settlement check. IT IS ALSO ORDERED that payment of $55,150.00 due to the minor is directed to be made and deposited in the New Cumberland Credit Union, a deposit which is insured by the federal government, and no withdrawal will be made from such account until the minor attains majority (age 18), except as authorized by Court Order. IT IS ALSO ORDERED that payment of $1,000.00 to be made to Kerri Wenerick is approved for car repairs. THE COURT ALSO ORDERS that payment of attorney's fees in the amount of $18,750.00 and out-of-pocket expenses of $100.00 to Angino & Rovner, P.C., is approved. The Court also hereby authorizes the Petitioner to execute a Release on behalf of the minor for the benefit of Erie Insurance Exchange with regard to the unde ' ed motorist settlement proposal. Counsel shall provide the Court with an Affi o evidencing the deposit of $55,150.00 to be made in the New Cumberland Cre ' nio . B HE CO . c J. Pistribution: /David L. Lutz, Esquire, 4503 N. Front Street, Harrisburg, PA 17110; phone - 23 -6791; fax - 238-5610; dlutz@angino-rovner.com ? Mr. Douglas Kocher, 4901 Louise Drive, P.O. Box 2013, Mechanicsburg, PA 17055-0710; phone - 761-7475; fax - 795-2315; no e-mail address known COP I -es rn?u LC / 390196 ? W:;? -?- . ? ? +r 7 r ;;,, ? ? y. ??Lf"`° ? ,??{y- t1- ?. ??+ ? ,( ti ANGINO & ROVNER, P.C. David L. Lutz, Esquire Attomey ID# : 35956 4503 North Front Street Harrisburg, PA 17110-1708 (717) 238-6791 FAX (717) 238-5610 Attorneys for Plaintiff(s) E-mail: dlutz@angino-rovner.com IN RE: PAMELA WENERICK, mother IN THE COURT OF COMMON PLEAS and natural guardian of KERRI CUMBERLAND COUNTY, PA WENERICK, a minor, Petitioner NO. 08-6156 Civil Term AFFIDAVIT OF DEPOSIT The undersigned, counsel for Pamela Wenerick, as mother and natural guardian of Kerri Wenerick, a minor, hereby certifies that the net settlement amount of $24,308.34, as set forth in this Court's Order dated November 3, 2008, was deposited by Pamela Wenerick into a restricted, federally insured account on November 20, 2008, account no. 089604. Proof of deposit is attached hereto as Exhibit A. ANGINO & ROVNER, P.C. Date: - U? David L. Lutz I.D. No. 35956 4503 N. Front Street Harrisburg, PA 17110 (717) 238-6791 -phone (717) 238-5610 - fax dlutz@angino-rovner.com Attorney for Petitioner t ? r ?o 00 OIN O N r? M d F? N ? ?t10 r- l? 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L .. u CD `° t-j L1jm Q Z ro O 3 M: g Li! <C C >. m ' i :D _t m Q-' LU CO L2_ LT {, I M 7 LLj m Lt£ LLJ CA Cn YOB Z ? ? ? O m Y m CJ co m ui f - L f i L3 7 W L) L3 -i c Q Q CA y I j ? e ?..? OOL SOW NOISIAIO 3'JV-LlM2H/103tlIO OuvnoNW 3 t--?Vt ? If+ -4 r ANGINO & ROVNER, P.C. David L. Lutz, Esquire Attorney ID# : 35956 4503 North Front Street Harrisburg, PA 17110-1708 (717) 238-6791 FAX (717) 238-5610 Attorneys for Plaintiff(s) E-mail: dlutz@angino-rovner.com IN RE: PAMELA WENERICK, mother IN THE COURT OF COMMON PLEAS and natural guardian of KERRI CUMBERLAND COUNTY, PA WENERICK, a minor, Petitioner NO. 08-6156 Civil Term AFFIDAVIT OF DEPOSIT The undersigned, counsel for Pamela Wenerick, as mother and natural guardian of Kerri Wenerick, a minor, hereby certifies that the net settlement amount of $55,150.00, as set forth in this Court's Order dated November 19, 2008, was deposited by Pamela Wenerick into two restricted, federally insured accounts on December 9, 2008, account no. 089604. 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