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Home My WebLink About04-1795MORRIS & ADELN3~N, P.C- BY: JAMES W. ADEIXq3UN, IDENTIFICATION #02604 P.O. BOX 30477 Philadelphia, Pennsylvania (215) 568-5621 '11J15 ~S AN ANSITPATION CASE A~:,,.~.~VlENT OF DAMAGES HF.,~ NOT REO~JIRED ESQUIRE ATTORNEY FOR PLAINTIFF Donegal Companies 19103-8477 'Donegal Companies 1195 River Road Marietta PA 17547-0302 vs. Adin Kenes 429 Bernheisel Bridge Road Carlisle PA 17013-9025 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION : : : : : : No. Oq --lqgJ COMPLAINT CIVIL ACTION NOTICE TO DEFEND You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any .money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORN3~TION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ~LBLE TO PROVIDE YOU WITH INFOR/q3~TION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 2 Liberty Av Carlisle PA 17013 717/249-3166 kwa0419.2 1. Plaintiff is Donegal Companies, an insurance company duly authorized to issue insurance policies in the Commonwealth of Pennsylvania. 2. Defendant 3. Plaintiff, is Adin Kenes. COUNT I at the request of Defendant, or Defendant's authorized agent, a true and correct copy of the application for the policy is attached hereto, incorporated herein and marked Exhibit "A", issued a Worker's Compensation and Employer's Liability policy naming Defendant as the insured. A true and correct copy of the policy is attached hereto, incorporated herein and marked Exhibit "B". 4. The total annual estimated earned premium for the insurance year set out in the policy was $9,304.00. In accordance with the rules, rates and classifications of the Pennsylvania Worker's Compensation Bureau (PWCB) and the premium endorsement, the estimated premium is subject to increase or decrease in accordance with the actual payroll figures established by the insured but not available at time of policy issuance. 5. Plaintiff was permitted to audit the true and correct books and records of the Defendant. -1- k~a0419.2 6. AS a result of Plaintiff's audit of Defendant's payroll, an adjusted premium of $13,252.60 became due and owing Plaintiff by Defendant for insurance year as set forth on the final earned premium adjustment endorsement, a true and correct copy of which is attached hereto, incorporated herein and marked Exhibit "C". 7. Ail credits to which Defendant is entitled are set forth on the statement of account, a true and correct copy of which is attached hereto, incorporated herein and marked Exhibit "A". 8. By virtue of the foregoing, Defendant is indebted to Plaintiff in the amount of $13,252.60 for an additional premium. 9. Although Plaintiff has made demand upon Defendant for $13,252.60, Defendant has failed and refuses to pay the same or any part thereof. WHEREFORE, Plaintiff claims there is now justly due and owing by Defendant(s) the sum of $13,252.60 with interest at 6% from August 27, 2003 and costs on Count II. COUNT II 10. Paragraphs t through 9 are incorporated by reference. -2- 11. On or before August 27, 2003, Plaintiff provided insurance services to Defendant at the times, of the kinds, in the quantities, and for the premiums set forth in Plaintiff's books of original entry, true and correct copies of which are shown as Exhibits "A", "B" and "C". 12. Defendant received and accepted the insurance services shown on Exhibits "A", "B" and "C", and benefitted thereby. 13. These insurance services have a reasonable worth of $13,252.60. 14. Defendant received the benefit of the insurance services from Plaintiff and it is unconscionable for Defendant receive those benefits without making restitution to Plaintiff. to 15. It can be inferred from the acts in the light of the surrounding circumstances that Defendant implied it would pay Plaintiff for the insurance services. 16. Under the circumstances of the case, the ordinary course of dealing and the common understanding of mean, there is shown a mutual intention by Plaintiff and Defendant to sell and pay for these insurance services. 17. Ail conditions precedent to the present action have occurred or been performed. kwa0419.2 Daniel J. Wagner, CPA Vice President & Treasurer of Donegal Mutual Insurance Company · and that the fac~s set forth in the foregoing COMPLAINT ~e his knowledge, information and belief, and statement is made subjec= to the penalties of 18 Pa. C.S.A. relating to unsworn fa!sification to au=horities. and correct to t_he best of t_hat this 4904 Dated: March 30, 2004 Vice President & Treasurer , CORD® WORKERS COMPENSATION APPLICATION ! [~.~,~. E~}~:~.I~ ) 6~ 7 = 19 ~8 I :°""~' ~.":'~"*'"'~" FAX (717)697-7~52 DONEGAL NUTUAL INSURANCE CO. i Bob Smith :UMBERLAND VALLEY INSURANCE East Main Street ~.O. Box 451 Jew Kingstown, PA 17072-0451 10/05,/1999 KENES, ADIN APPUCANT T/A ADIN KENES BUILDER NAME MAILIN~ 41 Golden Rod Drive ADDRE~ ~p, nC,um.coae~ Carlisle, Cumberland County, PA 17013 ............................. YRS IN BUS SIC i X INDIVIOUAL i CORPORA"~ON i OTHER: ~ODE; PACUMBIO I :: : 00001430. 25-1838004 .OCATIONS i 4'1' d6~'~l'~" ~6~ '~F~'~ 'i oo001 Carlisle Cumberland County PA 1701~ lO/OZ/Z999 ~0/01/2000 ~ COMPeNS4TmON(~) ............................................ ~ ALL OTHER PA : s 100 000 ~CH A~ [ ~ED~ [ ~ U.S.L ~ H. .................................................................................... : [XC[~ PA AND ........ ~ S 500,000 ~S~SE-~L~ LIM~ MONO~LISTIC IN~MN~ ~ ~ V~UmA~ ~NSA~ :: S 100 m 000 ~S~E-~CH EMPLOYEE [ ~ : ~ ........................ : ........................................................................................................................................................... ......~ ................................................ L.....~ ................................................. ~m:~ prevSous employees ~ W~K, SU~O~A~S. ME~A~-MER~AN~, ~ERS. ~LIVERI~. SERV~E-~E. L~T~. FAR~ACR~GE. ANIMAl. MACHINERY, SU~*~S. Framing - new homes ~XPLAIN ALL "YEt RESPONSE~ YES:: NO EXPLAIN ALL 'YES" RESPONSES ::YESi NO 8. IS A F~MAL ~F~ PR~RAM IN ~RA~? X :: COMMERCIAL INSURANCE APPLICATION ACORD® APPLICANT INFORMATION SECTION 08,,'J2, I,)99 qO~UCCR ~.~o B.t (7]7)697-19SR CARRIER UNI)FRWN TER _.~., ,/.,~. FAX (717)697-7552 DONEGAL MUTUAL TNSURANCE CO. [ Bob Smith ~UMBERLAND VALLEY INSURANCE I East Hain Street ...................................................... ~'"'"': .................................................................................................... '.O. Box 451 : ~ PROPERTY ....... INSTALLATK~N/BUILDERS RISK VEHICLE SCHEDULE lew Kingstown, PA 17072-0451 ....... ! GLA~AND~IGN : ELECTRONIC DATA PRCC "'"" BOiLER&MACHINERY ...................................................... : ............................................................... i VALUABLE PAPERS !...._.? GENERAL LIABILITY ...... 00001430 ' ! mANS[mORTAI1ON/ ' : ~ MOTOR TRUCK CARGO TRUCKERS X li~i~ ..,-...~ 10/01/1999 10/01/2000 .... :ENES, AD'rN ~/A ADIN KENES BUILDER ~1 Colden Rod Drive Carlisle PA 17013 ~"T iii6~;l~i~ .......... r'""}' '~ii;~'"'""::'"'"'i '~i~' '~-' i~i~:i~i&i ............................................................................. i'"'"Ti~ '~'~'"'"' '~' ~' i~' ~- ~ PARTNERSHIP ~ ~ ~1~ VE~RE :: NSPECTION CONTACT ~ PHONE (~,.~, ~)~ ~ ~ NO E~ ~ (7~7) ~19-0600 . ACCOUNTING RECORDS CONT~T ~ PH~E Adin Kenes ~E~"t~ '~"~'~" ' ~"~'~"~'~"~ ~ ~'~ "~"~"~[~' ~ '""~["~"'[~'" ::4~ Golden Rod Drive ~INSIDE ~ ;~NER )0001~ ~ Cumberland County ~ ~s~ [ ~NA~ ~ [Carlisle PA 17013 ....... .............. :: ............... ~ .................................................................................................................. ~ ......................... ~..._..~ ................................. ................................................................................... :arpen~ry - New hom~ construction EXPLAIN ALL "YES" RESPONSEB ::YES NO [ EXPLAIN ALL "YBS" RE,SPQNBE$ ANY PERSON WHO KNOWINGLY AND WITH THE INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CON- CEALS 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. APPLICANT'S SIGNATUP. E DATE (MM/DD/YY) DONEGAL COMPANIES MARIETTA, PENNSYLVANIA 17547-0302 STANDARD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY COVERAGE IS PROVIDED BY DONEGAL MUTUAL INSURANCE COMPANY INFORMATION PAGE - STANDARD WC000001A Amended Policy Effective: 10/01/2002 POLICY NUMBER WC 0025525 04 1. NAMEDINSURED AND MAILING ADDRESS Adin Kenes D/B/A Adtn 6~11Westover Drive Mechanicsburg PA 17050 OTHER WORKPLACES NOT SHOWN ABOVE: SEE LOCATION ADDRESS FEIN# 251838004 RISK ID.#OO3094616 CARRIER CODE 15636 AGENTNAMEANDADDRESS Cumberland Valley Insurance 31E Main St P 0 Box 451 New Kingstown PA 17072 AGENT NUMBER 0004254 OO PHONE NUMBER (717)697-1956 POLICY PERIOD FROM 10/O1/2OO2 TO 10/O1/2OO3 12:01 A.M. STANDARD TIME AT THE NAMED INSURED'S MAILING ADDRESS SHOWN. FORM OF NAMED INSURED'S BUSINESS: SUPERSEDES ANY PREVIOUS POLICY BEARING THE SAME NUMBER AND POLICY PERIOD Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the States listed here: PA B. Employers Liability Insurance: Part Two of the policy applies to work in each State listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ ]. 0 0,0 0 0 Bodily Injury by Disease $ '10 0,0 0 0 Bodily lnjury by DIsease $500,000 each accident each employee policy limit Other States Insurance: Part Three of the policy applies to the States, if any, listed here: S - Specific ALL OTHER STATES EXCEPT PA AND MONOPOLISTIC STATES D. See attached schedule for list of endorsements forming a part of this policy. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All Information required below is subject to verification and change by audit. Premium adjustment shall be made annually. Classification Code Premium Basis Description NO. Total Estimated Remuneration Carpentry - Detached One or Two Family Dwellings 652 77,381 Clerical Office Employees NOC 953 27,290 RatePer Estimated $1000f Term Remune~tion Pmmlum 12.57 $9,72? .42 $115 MINIMUM PREMIUM: $1,395 9885 MERIT RATE ADdUSTMENT 0063 PREMIUM DISCOUNT STATE: PA .95 -$492 -$489 EXPENSE CONSTANT: $140 O938 - EMPLOYER ASSESSMENT (0.0337): $303 TOTAL ESTIMATED POLICY PREMIUM: $9,304 DEPOSIT PREMIUM: $9,304 PREMIUM CHANG E THIS ENDORSEMENT: $2,900- .~ ~ ' I /] President 01/15/03 Copynght 1987 National Councd on Compensabon insurance ~-'~ f~,-- ~ ~ CL-4 9/99 DONEGAL COMPANIES Workers Compensation MARIETTA, PENNSYLVANIA 17547-0302 POLICY NUMBER: WC 0025525 04 STATE PA LOC. 1 EXTENSION OF INFORMATION PAGE LOCATION ADDRESS 611 WestoveP Drive MechantcsbuPg PA 17050 FORMS AND ENDORSEMENTS CONTAINED IN THIS POLICY WC OOOOOOA (4-92) Workers Comp. and Employers Liab, Ins. Policy WC 000419 (O1-O1) Premium Due Date Endorsement WC 370402 (4-92) Pennsylvania Const. Class. Prem Ad] Endt. WC 370405 (8-96) Pennsylvania Merit Eating Plan Endt. WC 370601 (4-84) Special Pennsylvania Endt-Insp. of Manuals WC 370602 (4-84) Pennsylvania Notice WC 370603A (8-95) PA Act 86 1986 Endt - NonRen Notice of Premium Change THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EFFECTIVE DATE OF CHANGE 10/01/2002 EFFECTIVE FOR THE FOLLOWING REASON(S): Policy Amended LDC I Class Co~e Added LOC I Class 652 - Change of Payroll(s) ~ I /] President 01/15/03 Copyright 1987 National C0unc~l on Compensation Insurance C~,-- ~ ~ CL-4 9/99 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 19 (Ed, -01) PREMIUM DUE DATE ENDORSEMENT This endorsement is used to amend: Section D. of Part Five of the policy is replaced by this provision. PART FIVE PREMIUM D. Premium is amended to read: You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. The due date for audit and retrospective premiums is the date of the billing. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The Information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No, Endorsement No. Insured Pmmiurs $ insurance Company Countersigned by WC000419 (Ed.-01) Copyright, 2000 National Council on Compensation Insurance, Inc. DONEGAL COMPANIES MARIETTA, PENNSYLVANIA 17547-0302 STANDARD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY COVERAGE IS PROVIDED BY DONEGAL MUTUAL INSURANCE COMPANY INFORMATION PAGE - STANDARD POLICY NUMBER WC 0025525 03 1. NAMED INSURED AND MAILING ADDRESS Adtn Kenes D/B/A Adtn 6111 WeB'cover DPtve I~echan lcsbuPg PA 17050 OTHER ~NORKPLACES NOT SHOWN ABOVE: SEE LOCAT[0N ADDRESS FEIN # 251838004 RISK ID. # POLICY PERIOD FROM IO/O1/2OO1 TO 10/01/2002 12:01 A.M. STANDARD TIME AT THE NAMED INSURED'S MAILING ADDRESS SHOWN. Amended Policy Effective: 10/01/2001 CARRIER CODE 15636 AGENTNAMEANDADDRESS Cumberland Valley Insurance 31E Main St P 0 Box 451 New Ktngstown PA 17072 AGENT NUMBER 0004254 OO PHONE NUMBER (717)697~1958 FORM OFNAMEDINSURED'S BUSINESS: SUPERSEDES ANY PREVIOUS POLICY BEARING THE SAME NUMBER AND POLICY PERIOD Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the States listed here: PA B. Employers Liability Insurance: Part Two of the policy applies to work In each State listed In Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ ]. 0 0,0 0 0 Bodily Injury by Disease $10 0,0 0 0 Bodily Injury by Disease $ 50 0,0 0 0 each accident each employee policy limit Other States Insurance: Part Three of the policy applies to the States, If any, listed here: S - Specific ALL OTHER STATES EXCEPT PA AND MONOPOLISTIC STATES D. See attached schedule for list of endorsements forming a part of this policy. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All Information required below Is subject to verification and change by audit. Premium adjustment shall be made annually. Classification Code Premium Basis Description No. Total Estimated Remuneration Carpentry - Detached One or Two Famtly Dwellings 652 36,718 Rate Per Estimated $1000f Term Remuneration Premium 10.85 $3,984 MINIMUM PREMIUM: $1,225 STATE: PA EXPENSE CONSTANT: 0938 - EMPLOYER ASSESSMENT (0,0337): TOTAL ESTIMATED POLICY PREMIUM: DEPOSIT PREMIUM: PREMIUM CHANGE THIS ENDORSEMENT: $140 $139 $4,263 $4,263 $754 /~ ~ I /] President 12/18/01 Co~vn(~ht 1987 Nabonal Council on Compensation Insurance ~J-4~./~ ~ CL-4 9/99 DONEGAL COMPANIES Workers Compensation MARIETTA, PENNSYLVANIA 17547-0302 POLICY NUMBER: WC 0025525 03 STA'fE PA LOC. 2 EXTENSION OF INFORMATION PAGE LOCATION ADDRESS D/B/A Adin 6111Westover Drive MechanicsbuPg PA 17050 FORMS AND ENDORSEMENTS CONTAINED IN THIS POLICY WC OOOOOOA (4-92) Workers Comp. and EmployePs Llab. [ns. Poltcy WC 000419 (04-O1) Premium Due Date Endorsement WC 370402 (4-92) Pennsylvania Const. Class. PPem Adj End±. WC 370405 (8-96) Pennsylvania Me, it Rattng Plan Endt. WC 370601 (4-84) Special Pennsylvania Endt-Insp. of Manuals WC 370602 (4-84) Pennsylvania Notice WC 370603A (8-95) PA Act 86 1986 Endt - NonRen Notice of PPem~um Change THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EFFECTIVE DATE OF CHANGE 10/01/2001 EFFECTIVE FOR THE FOLLOWING REASON(S): .Policy Amended LOC 2 'Class 652 - Change of Payroll(s) ,~ '~' I J/ President 1~/1Rlnl r~nn,,rmhi 1~R7 N.~t,nn.~l Count, il nn Cnm~ensatlon Insurance ~-~ ~J-~ ~ ~ CL-4 g/99 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 19 (Ed. -01) PREMIUM DUE DATE ENDORSEMENT This endorsement is used to amend: Sec[ion D. of Part Five of the policy is replaced by this prevision. PART FIVE PREMIUM D. Premium is amended to read: You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. The due date for audit and retrospective premiums is the date of the billing. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The Information below is required only when this endomerneet is Issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Premium $ Insurance Company Countersigned by WC000419 (Ed.-01) Copyright, 2000 National Council on Compensation Insurance, Inc. DONEGAL MUTUAL INSURANCE ~ ~ , WORKERS COMPENSATION LU-182 AUDIT INVOICE 3/91 The estimated premium on the policy is hereby adjusted in accord with the audit for the period indicated. POLICY PERIOD FROM 10/01/2001 TO DESCRIPTION CODE Carpentry - Detached One 652 or Two Family Dwellings 10/01/2002 DATE UNITS PREMIUM EFFECTIVE RATE PAYROLL EARNED 10/01/01 10.85 77,381 8,396 Clerical Office Employees NOC 953 10/01/01 .37 27,290 101 Premium Discount Expense Constant Employer Assessment Charge 0063 -381 0900 140 0938 .0337 278 EARNED PREMIUM LESS DEPOSIT PREMIUM $8,534 $4,263 TOTAL BALANCE DUE: r'-] iNSURED ~'1 COMPANY $4,271 Additional Premiums due Company are payable upon receipt of this premium adjustment endorsement. Return Premiums due Insured are payable provided the Estimated Deposit Premiums are paid in full. This premium adjustment is for the policy period indicated and forms a part of Policy Number WC 0025525 issued to: Adin Kenes Adj. Computed at u~,--;~t~, ;,A Date 12/04/02 Agent Cumberland Valley Insurance - 0004254 DONEGAL COMPANIES AUDIT SUMMARY BATCH NUMBER INFACS CODE INVOICE NUMBER INS Code L# STATE LOCATION 1 PA Mechanicsburg CODE CLASS ~.~_~_.~ Carpentr?-Detached Dwellings Policy Name WORKERS COMPENSATION Company Name Adin Kenes D/B/A Westover Drive Contact's Name Adin Kenes Street Address 6111 Westover Drive city Mechanicsburg State PA zip 17050 Policy Date 10/0112001 To 10/0112002 Reporting Date 1010112001 To 10/01/2002 Auditor Joe Gilmartin Completion Date 10/10/2002 Phone 679-7702 TOTAL ADJUSTED PREVIOUS DELTA TOTAL BASIS lO4,671.o0 ~1~,671.oo ~ 36,718 186.07% SPLIT 1 TOTAL SPLIT 2 TOTAL AUDIT TOTAL ! ADJUSTED TOTAL TOTAL BASIS TOTAL DELTA Description of Operations INSURED IS A CARPENTRY CONTRACTOR BUILDING NEW HOMES ONLY. DOING MOST OF THE CONSTRUCTION WORK WITH HIMSELF AND A GROWING CREW OF 2-9. USING SUBS ON PLUMBING, ELECTRICAL, EXCAVATING ETC. _ _nfacs ~tvme Ogce 11 Pafill Drive, Marietta, Pennsylvania 17457 (71 7) 426-1904) DONEGAL COMPANIES FEDERAL ID. ~'~ ~' ' ~ ,~ SUMMARY DETAIL BATCH NUMBER INFACS CODE iNVOICE NUMBER INS Code .... rj~ I~; I PolicyNumberWC 0025525 03 Policy Name WORKERS COMPENSATION Company Name Adin Kenes D/BIA Westover Drive Street Address 6111 Westover Drive c~y Mechanicsburg State PA Zip 17050 Policy Date 10101/2001 To 1010112002 Reporting Date 1010112001 To 1010112002 Auditor Joe Gilmartin Completion Date 1011012002 Phone 679-7702 N# L.#' Code Title Name/Group I 1 65201 Carpenters {2-9) Total Adjusted Description Function 104,671.00 104,671.00 NEW CONSTRUCTION AND RE Employee Source of Data Verification I,NSURED I ~941 I II I Lo,iai Entity ISole Proprietor Was There I Subcontractor Amount Gross Overtime Period Totals 10~I/2001 To 1~/31/2001 8~428 O1~1/2002 To 03/31/2002 '~ 9,783 O4/01/2002 To 0§~30/2002 26,614 0710112002 To 09/30/2002 49,848 To TO TOTAL 104,671 DONEGAL COMPANIES Class Description Summary BATCH"NUMBER INFACS CODE INVOICE NUMBER INS Cods NAME # TITLE NAME/GROUP 1 Carpenters (2-9) 0025525 03 Policy NameWORKERS COMPENSAT Company NameAdin Kenes D/B/A Westover Drive Street Address6'l '~ 1 Westover Drive c~yMechanicsburg StatePA ZipPI7050 Policy Datel0101/2001 To 1010112002 Reporting Date'1010112001 To 1010112002 Auditor Joe Gilmartin. Completion Date10110~2002 DESCRIPTION OF DUTIES NEW CONSTRUCTION AND REMODELING Sunday, October 13, 2002 acs 17t,mcOffiwc, IIPA,I~ILLDRIVE,~V~4J~IETT4. PENNgYLI!4JVIA 17547 (717)426-1904 Insured Adin Kenes D/BIA Westover Drive DONEGAL COMPANIES E~CLASSlFICATION CHANGE NOTES Policy Number WC 0025525 03 Policy Date 1010112001 Infacs Code 200201701 E]ENTITY CHANGE NOTES E-]ADDRESS CHANGE NOTES ~CTUAL EXPOSURES AS COMPARED WITH ESTIMATED EXPOSURES VARY BY MORE THAN 25% E~EMPLOYEE LEASING IS DISCLOSED E]UNINSURED AND UNDERINSURED SUBCONTRACTOR EXPOSURE FOUND AT TIME OF AUDIT [--[AUDIT DATA QUESTIONABLE ~]COMMENTS NOTES 185% iNCREASE IN PAYROLL FROM ESTIMATE AMOUNT. DONEGAL MUTUAL INSURANCE COMPANY WORKERS COMPENSATION AUDIT INVOICE LU-182 ~91 Theestimatedpremium~nthep~icyisherebya~ustedina~rdwiththeauditf~rtheperi~dindic~ed~ POLICYPERIODFROM 10/01/02 TO 03/05/03 CANC, DESCRIPTION CODE CARPENTRY-DETACHED ONE 652 OR.TWO FAMILY DWELLINGS MERIT RATE ADJUSTMENT 9885 DATE UNITS PREMIUM EFFECTIVE RATE PAYROLL EARNED 12.57 $112,993. $14,203.00 .95 - 710.00 EXPENSE CONSTANT 0900 60.00 PREMIUM DISCOUNT 0063 -932.00 EMPLOYER ASSESSMET 0938 .0337 425.00 This premium adjustment is for the policy period indicated and forms a part of Policy Number EARNED PREMIUM $13,046. LESS DEPOSIT PREMIUM $ 9,304. TOTAL BALANCE DUE: [] INSURED [] COMPANY $ $ 3,7~,2. Additional Premiums due Company are payable upon receipt of this premium adjustment endorsement. Return Premiums due Insured are payable provided the Estimated Deposit Premiums are paid in full. WC 0025525 04 issuedto: ADIN KENES Adj. computedat Marietta, PA Dme 05/23/03 Agent CUMBERLAND VALLEY INSURANCE (AUTHORIZED REPRESENTATIVE) DONEGAL COMPANIES 1195 River Road · P.O. Box 302 · Marietta. Pennsylvania 17547-D302 ADIN KENES D/B/A ADIN 6111 WESTOVER DRIVE MECHANICSBURG PA 17050-2373 h,,llhh,h,,h,hllh,,,,Ih,,,lllh,,,h,hlh,,,Ih,h,II CUMBERLAND VALLEY INSURANCE 31 E MAIN STREET P 0 BOX 451 NEW KINGSTOWN PA 17072 PHONS(717)697 - 1958 0004254 Dear Policyholder: The attached amended Declaration has been issued to reflect the recent changes made to your Insurance Policy. If we can be of any further service or if you have any questions concerning your policy, please do not hesitate to contact your agent for assistance. WC 0025525 BACK OF PAGE CONTAINS BILLING A $10 LATE FEE WILL BE ASSESSED IF PAYMENT IS RECEIVED AFTER DUE DATE ADIN KENES 0523 WC 0025525 04 AUDIT $13,252.60 METHOD OF PAYMENT [] ADDRESS CHANGED? ~LEASE DONEGAL MUTUAL INS PLEASE SHO~ ~ : ~ i75a'7~030;0 ; i AD~RE~$ ~HA",NGE: P 0005 WCZOD25525 04 0004254 WCZ 00001325260 030617 00001325260 8 DONEGAL COMPANIES AUDIT SUMMARY BATCH NUMBER INFACS CODE INVOICE NUMBER INS Code Po,,cyNum ,WC 0025525 04 Policy Name WORKERS COMPENSATION Company Name Adin Contact's Name Adin Kenes Street Address 6~11t Westover Drive City Mechanicsburg State PA Zip 17050 Po[icy Date 10/01/2002 To 10101/2003 Reporting Date '10/01/2002 To 0310612003 Auditor Joe Gilmartin Completion Date 0511~;/2003 Phone 732-7741 L# STATE LOCATION CODE CLASS TOTAL ADJUSTED PREVIOUS DELTA TOTAL BASIS I PA Mechanicsburg arpentry- Detached Dwlngs 112;993,00 ~"~2,9 ~- 104,671 7.0B% 1 PA Mechanicaburg ~lerical Office Employees o,~o J j SPLIT 1 TOTAL SPLIT 2 TOTAL AUDIT TOTAL ADJUSTED TOTAL TOTAL BASIS TOTAL DELTA I Description of Operations INSURED IS A CARPENTRY CONTRACTOR BUILDING NEVV HOMES ONLY. DOING MOST OF THE CONSTRUCTION WORK WITH H~MSELF AND A GROWING CREW OF 2-9. USING SUBS ON PLUMBING, ELECTRICAL, EXCAVATING ETC. acs Home Office, 11 Pa.]H/Drive, Marietta, Pennsylvania 17457 (717) 426-]904) DONEGAL COMPANIES FEDERAL ID. ~ ~' ~' SUMMARY DETAIL BATCH NUMBER INFACS CODE INVOICE NUMBER INS Code Policy Number WC 0025525 04 Policy Name WORKERS COMPENSATION Company Name Adin Street Address 6111 Westover Drive city Mechanicsburg State PA Zip 17050 Policy Date 1010112002 To 10/0112003 Reporting Date 1010112002 To 0310512003 Auditor Joe Gilmartin Completion Date 0511512003 Phone 732-774'1 N#' L# Code Title Name/Group t I 65201 Carpenters 2 1 05301 Clerical Total Adjusted Description Function 112,993.00 112,993.00 REMODELING AND NEW CONST Employee 5,00 0.00 NO EXPOSURE Employee Source of Data Verification IINSURED i iuo-2 I II Legal Entity Subcontractor Amount Iso,e Proprietor Was There Gross Overtime Period Totals 10/01/2002 To 12/31/2002 67,928 O1/O112003 To 03/31/2003 45,065 To acs To To To TOTAL ~12,993 DONEGAL COMPANIES Class Description Summary BATCH NUMBER INFACS CODE INVOICE NUMBER INS Cod~ NAME # TITLE NAME/GROUP PolicyN~Jl~berWC 0025525 04 Policy NameWORKERS COMPENSAT Company NameAdin Street Address61 11 Westover Drive c~yMechanicsburg StatePA Zip 17050 Policy Date10/01/2002 To 10101/2003 Reporting Date1010112002 To 03105/2003 Auditor Joe Gilmartin Completion Date0511512003 DESCRIPTION OF DUTIES Carpenters REMODELING AND NEW CONSTRUCTION 2 Clerical NO EXPOSURE Monday, May 19, 2003 acs DONEGAL INSURANCE COMPANIES 1195 River Road, EO. Box 302 Marietta, Pennsylvania 17547-0302 (717) 426-1931 www. donegalgroup.com August 13, 2003 Adin Kenes DBA Adin 6111 Westover Drive Mechanicsburg, PA 17050-2373 RE: Policy No.: WC 0025525-03/04 Balance Due: $13,252.60 Dear Policyholder: Our records indicate there is an outstanding balance, in the amount of $13,252.60 due on the above-referenced policy. This premium results from an audit of $4,271.00 for the 10/01/01 to 10/01/02 policy term, and earned premium of $13,046.00, plus service changes and late charges totaling $34.00, less payments of $4,098.40 for the 10/01/02 to 03/05/03 policy term. Enclosed you will find copies of documentation supporting the above. If you have any questions regarding this premium, please contact Janis Parduski, 717--426-3529, extension 7535. Please forward your payment of $13,252.60 prior to August 27, 2003. Thank you in advance for your cooperation. Sincerely, DONEGAL M~,ITUAL INSURANCE COMPANY Daniel d. Wagner, CPA~ Vice President & Treasurer Enclosure PC: ~4254 - Cumberland Valley Insurance epaud Adin Kene$ DBA Adin 6111 Westover Ddve Mechanicsburg, PA I7050-2373 STATEMENT OF ACCOUNT September 29, 2003 Policy No.: WC 0025525-03 10/01/,01 to 10/01/02 Deposit Premium Endorsement, 12/01 Audit, 10/02 Audit Credit, 12/02 Total Due: 3,539.00 754.00 6,905.00 (2.634.00) [8,554.ool Paymen~ Return Premium Check (882.25) (882.25) (531.35) 2,634.00 (665.72) (665.71) ~665.72~ 10/11/01 11/02/01 11/23/01 12/05/02 04/03/02 06/06/02 08/05/02 Total Paid: Total Due: 8,905.00] Policy No.: WC 9025525-04 10/01 ~02 to 03/05/03 Deposit Premium Endorsement, 11/02 Endorsement Credit, 01/03 Late Charges Cancellation Credit Audit, 05/03 Total Due: 4,718.00 7,528.00 (2,900.00) 20.00 (28.00) 3.742.00 13,080.00 I (1,176.00) (2,634.00) (2.922.40) 6,347.60] Paymen~ 10/07/02 t2/06/02 01/10/03 Total Paid: Total Due: GRAND TOTAL DUE DONEGAL MUTUAL SHERIFF'S RETURN - CASE NO: 2004-01795 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND DONEGAL COMPANIES VS KENES ADIN REGULAR SF~AATNON SUNDAY , Cumberland County, Pennsylvania, says, the within COMPLAINT & NOTICE KENES ADIN DEFENDANT at 1432:00 HOURS, at ONE COURTHOUSE SQUARE CARLISLE, PA 17013 ADIN KENES a true and attested copy of COMPLAINT & NOTICE Sheriff or Deputy Sheriff of who being duly sworn according to law, was served upon the on the 3rd day of May , 2004 by handing to together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 18.00 Service .00 Affidavit .00 Surcharge 10.00 .00 28.00 Sworn and Subscribed to before me this ~ day of ~ ~/ A.D. So Answers: R. Thomas Kl±ne 05/03/2003 MORRIS & ADELMAN By: ' Deputy Sheriff' I hereby certify that the above names are correct and Precise Business Address of the judgment creditor is Address : 1195 River Road : Marietta PA 17547-0302 Address of Defendant : 429 Bernheisel Bridge Road : Carlisle PA 17013-9025 MORRIS & ADELFLAN, P.C. BY: JAMES W. ADELM_AN, ESQUIRE ATTORNEY FOR PLAINTIFF IDENTIFICATION 902604 P.O. Box 30477 Donegal Companies Philadelphia, Pennsylvania 19103-8477 (215) 568-5621 Donegal Companies 1195 River Road Marietta PA 17547-0302 vs. Adin Kenes 429 Bernheisel Bridge Road Carlisle PA 17013-9025 COURT OF COMMON PLEAS CUMBERL~kND COUNTY CIVIL DIVISION NO. 04-1795 CIV ORDER FOR ENTRY OF JUDGMENT AND ASSESSMENT OF DAMAGES TO THE PROTHONOTARY: Enter judgment in favor of the Plaintiff, Donegal Companies, and against the Defendant(s), Adin Kenes, in the above-entitled proceeding in the sum of $13,960.42 for failure to file an Answer, and assess damages as follows: Amount of Claim $13,252.60 Interest from August 27, TOTAL D~ages ~ss.~s d~ Above: Prothonotary 2O03 $ $13 607.82 JAMES W. ADELMAN, ESQUIRE Attorneys For Plaintiff JWA0601.4 ~ORRIS & ADELMA_N, P.C. BY: JA/~ES W. ADELM3~N, ESQUIRE IDENTIFICATION #02604 PO BOX 30477 Philadelphia, Pennsylvania 19103-8477 (215) 568-5621 ATTORNEY FOR PLAINTIFF Donegal Companies Donegal Companies 1195 River Road Marietta PA 17547-0302 VS. Adin Kenes 429 Bernheisel Bridge Road Carlisle PA 17013-9025 COURT OF COMMON PLEAS CUMBERLA/qD COUNTY CIVIL DIVISION NO. 04-1795 CIV AFFIDAVIT OF NON-MILITARY SERVICE COM}{ONWEALTH OF PENNSYLVANIA COUNTY OF PHILADELPHIA :SS . JAMES W. ADELMA/q, Esquire, being duly sworn according to law, deposes and says that the above-named defendant(s), to the best of his knowledge, the Armed Forces of the United States G, Sworn To And Subscribed Befo~ Me This ~)'~ Dayz Notary Publi~J My Co~ission Expgre$1 COMMO~L~ OF PE~SYLVANIA NOTARIAL SEAL PATEICIAA ~ENZIE Nota~ C~ ~ ~l~ig, ~lla M~ C~ F,~ Unr~ 23, 2~ information and belief, ~ernm~ / / is or are not members of ESQUIRE JWA0601.4 MORRIS & ADELMAN, P.Co BY: JA/~ES W. ADELMAN, ESQUIRE ATTORNEY FOR PLAINTIFF IDENTIFICATION #02604 P.O. Box 30477 Donegal Companies Philadelphia, Pennsylvania 19103-8477 (215) 568-5621 Donegal Companies 1195 River Road Marietta PA 17547-0302 vs. Adin Kenes 429 Bernheisel Bridge Road Carlisle PA 17013-9025 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION NO. 04-1795 CIV CERTIFICATION I hereby certify that I sent a Notice Of Intention to file a default judgment to Defendant(s) by mail pursuant to Pa. R.C.P. 237.1, a true and correct copy of which is attached hereto as Exhibit "A". /&~ ,/ P.C. "~~ oE Sr n eW~sA~Eo r~p 1 'a iEn tS iQ~RE MORRIS & AJDELMAN, P.C. BY: JAYMES W. ADELMA-N, ESQUIRE ATTORNEY FOR PLAINTIFF IDENTIFICATION #02604 P.O. Box 30477 Donegal Companies Philadelphia, Pennsylvania 19103-8477 (215) 568-5621 Donegal Companies 1195 River Road Marietta PA 17547-0302 vs. Adin Kenes 429 Bernheisel Bridge Road Carlisle PA 17013-9025 COURT OF COM}~ON PLEAS CUMBERL~ND COUNTY CIVIL DIVISION NO. 04-1795 CIV TO: Adin Kenes 429 Bernheisel Bridge Road Carlisle PA 17013-9025 DATE OF NOTICE: May 24, 2004 IMPORTANT NOTICE YOU A_RE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEA~J~NCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEA/~ING AND YOU MAY LOSE YOU SHOULD TAKE THIS PAPER TO YOU LAWYER AT ONCE. IF YOU DON'T HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION A_BOUT HIRING A LAWYER. IF YOU CAN NOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE INFORMATION A~OUT AGENCIES THAT MAT OFFER LEGAL'S~RVICE~TO/~LIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. / LAWYER REFERENCE SERVICE Cumberland County Bar Associati~ / 2 Liberty Av ~ / vv / Carlisle PA 17013 (Sight,re of Plaintiff or Attorney) JWA0520.2 OFFICE OF TItE PROTHONOTARY COURT OF COM/VION PLEAS CUMBERLAND COUNTY TO: ADIN KENES 429 Beraheisel Bridge Road Carlisle, PA 17013-9025 DONEGAL COMPANIES 1195 River Road Marietta, PA 17547 VS. Al)IN KENES 429 Bemheisel Bridge Road Carlisle, PA 17013-9025 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION NO. 04-1795-CIV NOTICE Pursuant to Rule 236 of the Supreme Court of Pennsylvania, you are hereby notified that a Judgment has been entered against you in the above proceeding as indicated below. Prothonotary ( ) Judgment Agaln~t Garnishee ( ) Complaint (Confession of Judgment) ( ) Judgment transferred from another jurisdiction (X) Judgment by Default ( ) Money Judgment ( ) Judgment in Replevin ( ) Judgment for Possession ( ) Judgment on Award of Arbitrators ( ) Judgment on Verdict ( ) Judgment on Court Findings IF You HAVE ANY QUESTIONS CONCERNING THIS NOTICE, PLEASE CALL: ATTORNEY: JAMES W. ADELMAN, ESQUIRE At this telephone number: 215-568-5621 MORRIS & ADELMAN, P.C. BY: JB/4ES W. ADELMAN, ESQUIRE ATTORNEY FOR PLAINTIFF IDENTIFICATION #02604 Donegal Companies P.O. Box 30477 Philadelphia, Pennsylvania 19103-8477 (215) 568-5621 Donegal Companies 1195 River Road Marietta PA 17547-0302 VS. Adin Kenes 429 Bernheisel Bridge Road Carlisle PA 17013-9025 COURT OF COM}{ON PLEAS CUMBERLAND COUNTY CIVIL DIVISION NO. 04-1795 CIV ORDER TO SATISFY JUDGMENT TO THE PROTHONOTARY: Please mark the judgment in the above-entitled case satisfied upon payment of your costs only. So Ordered As Above: Prothonotary J%~A0621.2