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HomeMy WebLinkAbout09-1559IN RE: JOHN AND TONIA ULSH, COURT OF COMMON PLEAS OF PARENTS AND NATURAL CUMBERLAND COUNTY, PENNSYLVANIA GUARDIANS OF KATHRYN ULSH N AND JAMES ULSH, MINORS NO: v 9 - 1559 Cux.a -?,, PETITION FOR APPROVAL OF MINOR SETTLEMENT PURSUANT TO PENNSYLVANIA RULES OF CIVIL PROCEDURE RULE 2039 AND NOW, come Petitioners, John and Tonia Ulsh, parents and natural guardians of Kathryn Ulsh and James Ulsh, minors and petition this court for approval of minor settlement and avers the following: On December 1, 2007, John Ulsh, Tonia Ulsh and Petitioners' minors Kathryn Ulsh (age 9) and James Ulsh (age 5) were injured in a two vehicle automobile accident and all sustained injuries. See Police Report attached hereto as Exhibit "A". 2. At the time of the accident and injuries sustained, Petitioners and Petitioners' minors resided at 109 Fairway Drive, Carlisle, PA 17013. 3. As a result of the above referenced accident, Kathryn Ulsh, a minor, suffered a broken collar bone and lacerations to her mid-area requiring stitches. See medical reports attached hereto as Exhibit "B". 4. As a result of the above referenced accident, James Ulsh, a minor, suffered a broken ankle, broken collar bone and internal injuries requiring surgery. See medical reports attached hereto as Exhibit "C". 5. The accident was caused solely by the negligence of Daniel J. Martin, Jr., who died as a result of the accident. 6. Daniel J. Martin, Jr., deceased was insured by Progressive Insurance Company with the liability limits of $15,000 each person/$30,000 each accident. 7. The liability limits were tendered and distributed among the four injured plaintiffs as follows: John Ulsh $15,000 James Ulsh, minor $10,000 Tonia Ulsh $ 3,000 Kathryn Ulsh, minor $ 2,000 See undated correspondence attached as Exhibit "D". 8. After the tender of the tortfeasor's policy limits, the Ulsh's family underinsured motorist carrier, Kemper Insurance Company, tendered their UIM limits of $300,000.00 and distributed the funds as follows: John Ulsh $100,000 Tonia Ulsh $ 60,000 Kathryn Ulsh $ 40,000 James Ulsh $100,000 See correspondence dated August 15, 2008 attached as Exhibit "E". 9. Progressive Insurance Company has requested that Petitioners sign a general release in exchange for the tender of the policy limits of the tortfeasor. Said releases are attached as Exhibit "F". 10. Kemper Insurance Company, the UIM carrier, requested that the Petitioners sign a general release. Said releases are attached as Exhibit " G". 11. All liens associated with medical treatment provided to Petitioners' minor will be satisfied. See correspondence dated May 28, 2008 and December 15, 2008 attached hereto as Exhibit "H". 2 12. With respect to the court approval, Petitioners' attorneys are not requesting the court to approve any attorney's fees and costs to be deducted from the funds paid by Progressive Insurance Company and Kempt Insurance Company. 13. Payments to the minors will be deposited in into the following bank accounts: A. With respect to James Ulsh, a minor, the amount of One Hundred Ten Thousand and 00/100 ($110,000.00) Dollars will be deposited into Susquehanna Bank, 1196 Walnut Bottom Road, Carlisle, Pennsylvania 17015 in Account No. 4801056420, an account which is insured by a Federal governmental agency. No withdrawal can be made from this account until the minor attains majority except as authorized by a prior Order of Court. B. With respect to Kathryn Ulsh, a minor, the amount of Forty-Two Thousand and 00/100 ($42,000.00) Dollars will be deposited into Susquehanna Bank, 1196 Walnut Bottom Road, Carlisle, Pennsylvania 17015 in Account No. 1161808320, an account which is insured by a Federal governmental agency. No withdrawal can be made from this account until the minor attains majority except as authorized by a prior Order of Court. 14. Petitioners believe the settlement is reasonable and request the court approval the minor settlement. (IL -1). t Jo lsh, Parent and Natural Guardian of K Ulsh and James Ulsh Tonia Ulsh, Parent and Natural Guardian of Kathryn Ulsh and James Ulsh Respectfully submitted, METTE, EVANS & WOODSIDE By: Andrew H. Dowling, Esquire Sup. Ct. I.D. No. 39692 3401 North Front Street P. O. Box 5950 Harrisburg, PA 17110-0950 (717) 232-5000 - Phone J (717) 236-1816 - Fax Date: March 1/ '2009 511626v1 4 ? ?& ?? ? COMMONWEALTH OF PENNSYLVANIA F4 7--- POLICE (:RASH REPORTING FORM Case Closed Reportable Crash Page AA 500 1 CD "es Nc 40 Yes Q No HE P1398452 Crash Number Incident Number Police AgencyPatrol Zone IWTcT>,3T- i i 1,F 1,5 lo 141 Li I I I I I ; 1 1161 -??) I H 1 10132 p C Agency Name _ Precinct Investigation Date (MM-DD-YYYY) A I Q Dispatch Time (ml) Arrival Time (mil) Investigator Badge Number L 11-A 1A 6, C'D') r-r-r- FO 776 T d Reviewer Badge Number Approval Date (MM-DD-YYYY) .'r C LcA (2)7 i -®- County County Name Municipality Municipality Name ? 1? J? a o 9 'q - Day of Week 0 Sun Q Thu 41 / F. f G / cc. ' O, Crash Date (MM-DD-YYYY) Crash Time (mil) No of Units People Injured Killed* If > 00 O Mon Q Fri o lete r O;? Q O l © 1 1 ll] I Z m FO Q Tue ®' Sat F r O I Form F Q Wed Q Unk If Yes, Complete School Bus School Zone Workzone orm M 29) O Yes ® No Q Yes 0 No Q Yes ® No S cti l Notify PENNDOT Q Yes JR No , e on Re ated Related Maintenance d Intersection Tvoe Multi-Le Q 4 Way Intersection Q "Y" Intersection Q Multi-Leg Q Off Ramp Q Railroad Crossing Intersection wS ecial a o OR Midblock O "T" Intersection Traffic Circle/ Q On Ramp Q Crossover Q Other Round About Location See Overlay o Route Number/ Segment (Optional) Travel Lanes Speed Limit O North 00 O a ° O South House Number (if applicable) T T? ? Street Name Street Ending ? 40 East I I For Mid-block crashes only. Use C O West u C• ?? f? fJ /? f ® O O Unknown postal House Number and make sure Principal Roadway Street Name is filled in if using this option Route 5(gnina Q Interstate O Turnpike Q Turnpike ® State O County Q Local Road O Private Q Other/ (Not Turnpike) (East/West) Spur Highway Road or Street Road Unknown Route Number Segment (Optional) Travel Lanes Speed Limit Q North N O S h m m C out _ Street Name Street Ending ` O East T O West 77-1 m O O Unknown c Route Interstate Turnpike Turnpike State County Local Road Private Other/ Signing O (Not Turnpike) (East/West) Q Spur Q Highway Q Road O- or Street Q Road O Unknown Intersecting_Rt Num Or Mile Post Or Segment Marker O th Q No Feet E N N O I r O South 7 7 Please r ntersecting Street Name St En ding Q East v m E t m Or Miles n er Information E E O West ? m E ° 1 for BOTH , . LL v Landmarks if Using This Option 0 Intersecting Rt Num Or Mile Post Or Segment Marker c p ?1 I I O North Distance From Crash Scene to Landmark 1 C m ' . O South N Or Intersecting Street Name St Ending - O Eq?t (For Crash between G m Q West Landmark 1 and Landmark 2) o: Degrees Minutes Seconds Longitude: - Degrees Minutes Seconds Ed Latitude: EE F fful E?] P L' "MI 221 . Co 1 O Traffic Control Device Q Yield Sign Q Police Officer or Flagman Q Not Applicable O Traffic Signal Q Active RR Crossing O Other Type TCD TO Functioning Emergency 10 No Controls Q Device Functioning Q Preemptive Improperly ? Flashing Traffic Controls Signal O Stop Sign Q Passive RR Q Unknown Q Crossing Controls Signal Q Device Not Q Device Functioning Q Unknown Functioning Properly ? Lane Closed (If "Not Applicable", skip rest of the Lane Closure section) Q North and South Q All Lane Closure O North Q East p u O Not Applicable O Partially ® Fully Q Unknown DkeCU n Q South Q West ® East and West (N,S,E,W) 0 C Traffic Yes ® No Q Detoured Unknown Q a Time S.l ed O < 30 Min. Q 30-60 Min. Q 1-3 hrs ® 3-6 hrs Q 6-9 hrs Q > 9 hours Q Unknown FORM # AA-500 (12102) pni 1(^F r npv • COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM IAA 500 2 Police Use Only" o,-1714350 Fri Page: E2 111111111111111 111 Crash Number P1398452 ® Motor Vehicle in Q Hit & Run Vehicle Q Illegally Parked Q Legally Parked Q Non - Motorized Type Transport Commercial Vehicle o ' Unit Q Pedestrian Q Pedestrian on Skates, Disabled From Q Train Q Phantom Vehicle Q Q Yes ® No c in Wheelchair, etc Previous Crash " " " (If Yes, Complete Form C) (If Pedestrian or Pedestrian on Skates, in Wheelchair, etc°, Complete Form M, Section 28) Unit No First Name MI Date of Birth(MM-DD-YYM m b a rJ ?E- L- ff] 0 7 a 11(k Delete? Last Name Telephone Number - Q AA R -TZ. 0 e rJlrl ? Address / City / State Zi c P 5 C 1 5? rvtt-:tc& .CS l '7 ,,-? 3 Driver License Number State Class c R AlcohoLlDrugs Suspected Driver or Pedestrian Physical Condition Ille al Dru s Q No Q g g Q Medication A arentl Ille al Drug Q Normal y Q Use Q Fatigue Q Medication d Q Alcohol Q Alcohol and Drugs ® Unknown Had Been Q Sick Q Asleep @9 Unknown Q Drinking Alcohol Test Type p Q Test Not Given Q Breath Q Other Primary Vehicle Code Violation Char ed? 9 m v Unknown if ®Blood Q Urine Q Q Yes ® No 33o`i' ?i r Test Given > nkn Alcohol Test Results Q Test Refused ® Re ults n Driver Presence 1=Driver Operated 3=Driver Fled Scene O Q Test Given, • Contaminated Results Vehicle 4=Hit and Run F11 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=Other Municipal 98=Other Q ( 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 (? Address / City / State / Zip Vehicle Make *Make Code F Vot ??Stti1R61? ?? VIN Model Year Vehicle Model (see overlay) 3 \/ V.)16 K 1611 r'1 3p g ?' I D 1051 u-i.Tra License Plate Reg. State Est. Speed Vehicle Towed Towed By 1,61 v, r\j ( 5T41 O & , ® Yes Q No SCI icl - Qe Insurance Insurance Company Policy No o ®Yes Q No Q Un I Q C?re?-a? ?? known f ?-3 Sit 3? C Trailing T e 1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No i Tag Year Tag St Unit T il of ? Unit ? 2=Towing' Truck 5=Camper 8=Other d ra 3=Towing Utility Trailer 6=Full Trailer 9=Unknown Unit n s: 1 1 = = V . d Direction of rave I *Vehicle Position *Movement *See E EI CJ I O l pecial Usage ver ay Vehicle Color Vehicle Type 05=Large Truck 20=Unicycle, Bicycle, 12=Commercial ? O 06=Yellow 07=Silver 01=Automobile 06=SUV Tricycle 02=Motorcycle 07=Van 21 =Other Pedalcycle Passenger =Not Applicable 00 --Not Carrier 01 Fi V h 08=Gold 01=Blue 09=13rown 03=Bus 10=Snowmobile 22=Horse & Buggy 04=Small Truck 11 =Farm Equip 23=Horse & Rider = re e 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 Tye Spec Veh 98=Other (If "20" or "21 ", Complete 19=Unk ec Veh 99=Unknow T e S Vehicle 31 =Modified Veh 11 =Pupil Transport 99=Unknown . yp p n Form M, Section 27) Initial Impact Point Damage Indicator Gradient 3=Downhill Road Alignment 00=Non-Collision 14=Undercarria a g 01-12=Clock Points 15=Towed-Unit O=None 2=Functional ght 1=Minor 3=Disabling ? 4=Bottom of Hill 1=Level 5=To of Hill a 1=Strai d 5] 2=Cur 13 T 9=Unknow p 2=Uphill ve = op 99=Unknown n 9=Unknown 9=Unknown -10k' " nn_cm I1MnM nr%1 ItIc /.^12V COMMONWEALTH OF PENNSYLVANIA 7- ' POLICE CRASH REPORTING FORM Page: AA 500 2 Polli?eQUse Only $'sd? EE IIIIIVIIilllll?l?n P1398452 Crash Number ® Motor Vehicle in Q Hit & Run Vehicle Q Illegally Parked O Legally Parked O Non Motorized Type Transport Commercial Vehicle o Unit Q Pedestrian Q Pedestrian on Skates, Disabled From Q Train O Phantom Vehicle Q Q Yes ® No c ? in Wheelchair, etc Previous Crash (/f Yes, Complete Form C) (If "Pedestrian" or "Pedestrian on Skates, in Wheelchair, etc", Complete Form M, Section 28) . Unit No First Name MI Date of Birth (MM-DD-YYYY) O? o N I 7! Delete? Last Name Telephone Number O U ? ? ? yl7 ? - 5??3 Address / City / State Zi C I01 r w k ? .- t o f 1 E . . - Driver License Number State Class aas?3o ZZ G C 10 t Alcohol/Drugs Suspected Driver or Pedestrian Physical Condition I V ®No Q Illegal Drugs Q Medication Apparently Illegal Drug ® Normal O Use O Fatigue Q Medication V 2 O Alcohol Q Alcohol and Drugs O Unknown Had Been O Sick Q Asleep Q Unknown O Drinking Alcohol Test Tvpe p ® Test Not Given Q Breath O Other Primary Vehicle Code Violation Charged? u Q Blood Q Urine Q Unknown if O Yes ® No s Given Test > Alcohol Test Results Q Test Refused O Re ults n Driver Presence 1=Driver Operated 3=Driver Fled Scene Q Test Given, O ?" ? Contaminated Res lt ? Vehicle 4=Hit and Run J u s 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 Q 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 Q 0 N S (A L- -- V-k Address / City / State / Zip Vehicle Make *Make Code O `t F7A:rg WA X' S)e (24 L-727 '15 L c ra C) - A 5 `f VIN Model Year Vehicle Model (see overlay) T S 1 q .S 7 A o f 5 to r D b ?b License Plate Reg. State Est. Speed Vehicle Towed Towed By `` - ?- N ?. 7 011 P ,? J (W Yes Q No 'r 2 rC 5 /cD4 ? Insurance Insurance Company Policy No / ® Yes Q No O known tl!41 E -- Awro (3 $74,21Y9' flo ;~ 1`?S,CA. c Trailing Type 1=Towing'Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No i Tag Year Tag St Unit No. of Un ? 2=Towin6 Truck 5=Camper 8=Other 0 Trailing ? 3=Towing Utility Trailer 6=Full Trailer 9=Unknown U i u n ts: d Direction of rave ? *Vehic/e Position [a] *Movement *See O l RE Special Usage ver ay Vehicle Color Vehicle Type 05=Large Truck 20=Unicycle, Bicycle, 12=Commercial 06=Yellow 07=Silver 01=Automobile 06=SUV Tricycle 02=Motorcycle 07=Van 21 =Other Pedalcycle Passenger 00=Not Applicable Carrier 01 Fi V h 13 T i 08=Gold 01=Blue 09=Brown 03=Bus 10=Snowmobile 22=Horse & Buggy 04=Small Truck 11 =Farm Equip 23=Horse & Rider = re e = ax 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" or "2 1 18=Other Type Spec Veh 98=Other Complete 19=Unk ec Veh 99=Unknown T e S Vehicle 31=Modified Veh 11 =Pupil Transport 99=Unknown . Form m M, Section n 27) yp p Form 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 1=Minor 3=Disa g 9 1=Level 4=1ottom of Hill S=To of Hill 1=Straight 2=Curved 9=U k 2=Uphill 13=Top 99=Unknown n nown 9=Unknown 9=Unknown .,Ohl 4 &a_Gnn 119mo? Dnl IPIZ PnDv COMMONWEALTH OF PENNSYLVANIA Oq-T- POLICE CRASH REPORTING FORM Page AA 500 3 Por7 Use Only O - .X a d :; :::= J-qJ NIIVIICI?III?I?V P1398452 Crash Number Person Tae: A 1=Driver 2 P Seat Position: U 00=Not A Passenger/Occupant 01 D i All V hi l Safety Equipment One Eiedion: E 00=None Used / Not Applicable G7 O=Not Applicable h = assenger 7=Pedestrian = r ver - e c es 02=Front Seat Middle Position 01=S oulder Belt Used 02=Lap Belt Used 1=Not Ejected 2=Totally Ejected 8=Other 9=Unknown 03=Front Seat Right Side 04=Second Row - Left Side Or 03=Lap And Shoulder Belt Used 04=Child Safety Seat Used 3=Partially Ejected 9=Unknown Motorcycle Passenger 05=Motorcycle Helmet Used 05=Second Row - Middle Position 06=Bicycle Helmet Used H 06=Second Row - Ri ht Side 10=Safet B lt U d I rl Eiedion Path: C 2A., F =Female B g 07=Third Row Or Greater - Left Side y mprope y e se 11 =Child Safety Seat Used Improperly 12=Helmet Used Improperly O=Not Ejected / Not Applicable 1=Through Side Door Opening o R M=Male U =Unknown 08=Third Row Or Greater - Middle Position 90=Restraint Used, Type Unknown 99=Unknown 2=Through Side Window 3=Through Windshield o 09=Third Row Or Greater - Right Side Safe Equipment Two: 4=Through Back Door 5=Through Back Door Tailgate Opening w c l,iurv Severity: 10=Sleeper Section of Truckcab F 00=None Used / Not Applicable 6=Through Roof Opening Sunroof/ Convertible Top Down) y $ O=Not Injured 1=Killed 11=1n Other Enclosed Passenger Or Cargo Area 01 =Front Air Bag Deployed (For This Seat) 02=Side Air Bag Deployed (For This Seat) 7=Through Roof Opening (Convertible 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 4=Minor Injury 13=Trailing Unit 14=Riding On Vehicle Exterior 05=Motorcycle Eye Protection 06=Bicyclist Wearing Elbow/Knee/Pads Extrication 8=Injury, Unk Severity 15=Bus Passenger 98=Other 10=Air Bag Not Deployed, Switch On 11 =Air Bag Not Deployed, Switch Off O=Not Applicable 1=Not Extricated 9=Unknown if Injury 99=Unknown 12 =Air Bag Not Deployed, Unk Switch Setting 2=Extricated By Mechanical Means 3=Freed By Non - Mechanical Means 13=Air Bag Removed (Prior To Crash) 19=Unknown If Air Bag Deployed 8=Other 9=Unknown 99=Unknown EMS Agency: VD r 4 bc7llr- Medical Facility: //4459€Y =01,4G x)7- f Unit No Person No Date of Birth (MM-DD-YYYY) A B C D DelOete? M FRI M E F G H I Q aF(D?® Name / Address / Phone EMS Transport I Same as Operator O Yes ® No' Unit No Person No 1 Delete? Date of Birth (MM-DD-YYYY) A B C D O E F G H I O Name / Address / Phone EMS Transport Same as Operator ® Yes O No Unit No Person No O oZ O Delete? Date of Birth (MM-DD-YYYY) A B C D eOe? a_ a a ®?? d 3 E F G H I 6 3 D I ©F? Name / Address / Phone EMS Transport same as Operator o ("'rti?249 - f14-3 IS Yes O No Unit No Person No Date of Birth (MM-DD-YYYY) A B C D Delete? 113M E F G H I 51 Fo-1 Name / Address / Phone EMS Transport Same as --" F-i Operator -JArAE5 UL-,, (-_,,q F-4a7JCtLA Y be PA om ( Y _ Q-43 ® Yes O No Unit No Person No cry © Date of Birth (MM-DD-YYYY) A B C D DelOete7 _ 3 - ® ® 0 ©? E F G H I G 3 a a 511 C1 Name / Address / Phone EMS T t ranspor Same as Operator Fr L- 101 IA- t?'S A Q y ®Yes O No Unit No Person No m m Date of Birth (MM-DD-YYYY) A B C D E F G H I Delete? _ ete7 ???mm??F] L 1 Name / Address / Phone - EMS Transport Same as Operator 3 O Yes O No FORM 0 AA-500 (12/02) COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM AA 500 4 Poli a Use Only ?o ? F,47- Page as P1398452 Crash Number O=Non-Collision 2=Head On 4=Angle 6=Sideswipe 8=Hit Pedestrian Crash Description ® 1=Rear End 3=Rear to Rear 5=Sideswi 9 (Opposite Direction) i 7 B ki B Hi Fi Ob 9 O h /U k S o on) = ( ac ng) ( ame irect t xed ject = t er n nown .o a € Relation to Roadway ?`` 1=0n Travel Lanes 3=Median 5=Outside Trafficway 7=Gore (Ramp Intersection) t 2=Shoulder 4=Roadside 6=1n Parking Lane 9=Unknown c o N „ Illumination 01 1=Daylight 3=Dark - Street 5=Dawn 8=Other Lights b r 2=Dark - No 6=Dark - Unknown Street Lights 4=Dusk Roadway Lighting t Weather Conditions ? 1=No Adverse 3=Sleet (Hail) 5=Fog 7=Sleet & Fog 9=Unknown Conditions d 2=Rain 4=Snow 6=Rain & Fog 8=Other C7 V Road Surface Conditions H O=Dry 2=Sand, Mud, Dirt, 4=Slush 6=Ice Patches 8=01her Oil i 7=W ear - Stand ng 1=Wet 3=Snow Covered 5=Ice or oving Harm Event L/R Most? Utility Pole Number 1 m Harmful Events (Harm Event) 30=Hit Fence Or Wall 01 =Hit Unit 1 31 =Hit Building ® it 2 32=Hit Culvert 02 Hit U Unit No - = n F-] 0 2 m 03=Hit Unit 3 33=Hit Bridge Pier Or Abutment 04=Hit Unit 4 34=Hit Parapet End id il ge Ra 05=Hit Unit 5 35=Hit Br i ld O Ob l t Bou er r stac e 06=Hit Other Traffic Unit 36=H Please Put 3 m ? 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 ffi l d y m an c Is Unit 2 41 =Hit Tra 12=Struck B Unit 3 42=Hit Snow Bank 13=Struck B E y o Harm Event L/R Most? Utility Pole Number 14=Struck By Unit 4 43=Hit Temporary Construction 15=Struck By Unit 5 Barrier 1 m ? F ® 16=Struck By Other Traffic Unit 48=Hit Other Fixed Object 49=Hit Unknown Fixed Object T bb i h a, Unit No ree Or S ery 21 =H t ru N Q a 2 f?? 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 O E i 26=Hit Guard Rail End Pavement Irregularities 27=Hit Curb 53=Jacknife vents n Sequential 28=Hit Concrete Or 54=Fire In Vehicle Order m ? 4 0 Longitudinal Barrier - 58=Other Non-Collision 29=Hit Ditch 99=Unknown Harmful Event First Unit No Haim Event Most Unit No Harm Event - Driver Action (D) 17=Careless Or Illegal Tra rmfin f vet vent in rn 00=No Contributing Action Backing On Roadway 01=Driver Was Distracted 18=Driving On The Wrong t??ash t e rash 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 1 d a 2 3 m t ti l F t P (FJR 04=Making Illegal U-Turn Entrance To Highway 05=Improper/Careless Turning 20=Making Improper Exit Hi h 06 T i F W L F en a ac ors o ) rong g = urn ng rom ane rom way 07 P di W k 00=None 11=Slippery Road Conditions (Ice/Snow) = rocee ng /O 21=Careless Parking/Unpar ing Clearance After Stop 22=Over/Under 01 =Wind Conditions 12=Substance On Roadwa y y 02=Sudden Weather Conditions 13=Potholes sat 08=Running Stop Sign Comp Compensation At Curve 03=Other Weather Conditions 14=Broken Or Cracked Pavement 04=Deer In Roadway 15=TCD Obstructed 09=Running Red Light 23=Speeding 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=Other Animal In Roadway 28=Other Roadway Factor 25=Failure To Maintain Proper Speed 11-Tai lgatingg 26=Driver Fleeing Police (Pol Chase) 12=Sudden Slowing/Stopping 07=Glare 29=Other Environmental Factor 08=Work Zone Related 99=Unknown 27=Driver Inexperienced 13=I1legally Stoppedd On RRoad 28=Fail re To Use Specialized Equip 14=Careless Passing Or Lane ° 92=Affected By Physical Condition Ch ange I D i Oth i A ti 98 M Possible Vehicle Failures (V) 12=Wpers mproper r = er v ng ons c 15=Passing In No Passing Zone 99=Unknown E 00=None 06=Exhaust 13=Driver Seating/Control 16=Driving The Wrong Way On 0 01=Tires 07=Headlights 14=Body, Doors, Hood, Etc 1-Way Street c c3l 02=Brake System 08=Signal Lights 15=Trailer Hitch 03=Steering System 09=Other Lights 16=Wheels Unit D ® m m No 1 2 3 4 04=Suspension 10=Horn 17=Airbags a 05=Power Train 11 =Mirrors 18=Trailer Overloaded C Unit m 19=Insecure/Shifted No C7 1 (? p 2 Trailer Load 20=Improper Towing Unit ® m m m No Q 1 2 3 4 21 =Obstructed Windshield it 1 ? ? 2 m 99=Unknown N Pedestrian Action (P) 03=Working 00=None 04=Pushing Vehicle o 01=Entering Or Crossing At 05=Approaching Or Leaving Vehicle n 06=Working On Vehicle S ifi d L ti Indicated Prime Factor Unit No Factor Code pec e oca o 02=Walking, Running, Jogging, 07=Standing Do not repeat this information on multiple pages. m Or Playing 98=Other 99=Unknown E/ R V D P Unit No Cr ( Unit No 0 Q Q O O ® O If E/R is the Prime Factor Type, leave Unit No blank i 14 U 1E is vnam a as-snn rtgmgt COMMONWEALTH OF PENNSYLVANIA r POLICE CRASH REPORTING FORM /} AA 500 5 CRASH NUMBER P 1 3 9 8 4 5 2 INCIDENT NUMBER H 0 3 1 1711 8 5 0 4 See attached diagram PAGE: 101016 Witness Name Address Phone NONE KNOWN Accident Investigation Issued FX Property Damage ? Cell phone present in unit #1 and in use. Prior to this crash unit # 1 was traveling west on SR0016 and unit #2 was traveling east on SR0016. This crash occurred as unit #1 traveled from the westbound lane across the center line into the eastbound lane, into the path of travel of unit #2, at which time the left front of unit # 1 struck the left front of unit #2. Unit #1 spun 180 degrees counterclockwise and came to rest facing east in the westbound lane and unit #2 spun approximately 100 degrees counterclockwise and came to rest on the south berm with the rear of the vehicle on the top of the guardrail facing northwest. Both units were in their final resting positions upon my arrival. Physical evidence is listed on the supplemental report submitted by Cpl. Christopher PUSHART. I was assisted at the scene by Tpr. Eric CAMPBELL, Tpr. Aaron LEWIS and Cpl. Christopher PUSHART. All measurements taken at the scene are included in the supplemental report submitted by Cpl. PUSHART. Crash data was entered into the Fatal Crash system on the PSP i-net on 12/02/07. Operator # 1 was pronounced dead at the scene by Franklin Co. Coroner Jeff CONNOR at 1412. The driver's license of operator #1 was retained at the scene by CONNOR. Operator #2 and passengers in ugit #2 were unable to be interviewed at the scene due to the severity of their injuries. SP7-0015 completed for each unit. News release completed and placed in the crash attachment file. Supplemental report pending receipt of Coroner's report. Blood was drawn for toxicology tests by the Franklin County Coroner's office, f. No charges will be filed in this incident due to the death of operator #1. Scene was photographed by Tpr. Eric CAMPBELL and Cpl. Christopher PUSHART. Photographs were transferred to a CD and will be placed in the Troop-H Chambersburg Crash attachment file. LVIVI @LAn)YVtALIM Vt- Ft:NN5YLVANIA POLICE CRASH REPORTING FORM • ` • Case Closed Reportable Crash AA 500 1 0 Yes 0 No ® Yes Q No I E ?T New f ?If fQf fill ff?ff f f! {?f Crash Number Page a O Change/ n ?, 1 Continuation P Incident Number Police Agency ? Patrol Zone __ H 01311 171118 5 0 4 17771 ?g H 0] p? a p Agency Name Precinct Investigation Date (MM-OD-YYYY) C PA STATE POLICE Chambersburg 2130 ' ED - Q 0 7 1 Q Dispatch Time (mil) Arrival Time (mil) Investigator Badge Number C I. Christopher T. Pushart - 7896 F d Reviewer Badge Number Approval Date (MM-DD-YYYY) All County County Name Municipality Municipality Name Dav Qf Wee r m F J Q Sun 0 Thu 2 Crash Date (MM DD-YYYY) Crash Time (mil) No of Units People Injured Killed* *(If > 00 O MonQ Fri v , m- m m m m m Complete I I El I I T Form F) O Tue Q Sat O Wed Q Unk Workzone(If Yes, Complete School Bus O Yes School Zone Form M, Section 29) 0 Yes Q No Related O No Related O Yes Q No Not' PENNDOT Maintenance O Yes Q No c D% Intersection Tvoe Multi -Le Q 4 Way intersection Q "Y" Intersection Q 9 0 Off Ramp Q Railroad Crossing Intersection 3 r V Q Midblock 0 "T" Intersection 0 Traffic Circle/ 0 On Ramp Q Crossover Q Other Round About Location * See Overlay Route Number Segment (Optional) Travel Lanes Speed Limit Q North House Number (if applicable) a All 0 = m m ° O South T Street Name Street Ending V Q East For Mid-block crashes only. Use t 1! Q West postal House Number and make sure C _ y O Unknown m Principal Roadway Street Name is filled in if using this option n Interstate Turnpike Turnpike State County Local Road Private Other/ ? O (Not Turnpike) 0 (East/West) Q Spur 0 Highway 0 Road 0 or Street O Road O Unknown L Route Number Segment (Optional) Travel Lanes Speed Limit Q North cc b ° 0 South + ' m m = C c Street Name Street Ending 0 East k _ m °i O West T N C 0 0 Unknown r Route interstate Turnpike Turnpike State County Local Road Private Other/ SJgning 0 (Not Turnpike) O (East/West) O Spur - O Highway Q Road 0 or Street 0 Road Q Unknown Intersecting Rt Num Or Mile Post Or Segment Marker F t O O N th ee m ? N . Ell, N E Or Int r ti St t N or Q South Please a e sec ng ree ame St Ending M 0 East _ rs E Y co o Enter Information for BOTH = m ? E L.- J, 1 1 17 Q West Or Miles . O `2 v Landmarks if Using This 0 tion p Intersecting Rt Num Or Mile Post Or Segment Marker N 'c Y 0 F 0 North Distance From Crash Scene t L d k 1 c " . m „ O South o an mar G ? E Or Intersecting Street Name St Ending 0 East (for Crash between = -+ m M TT? V1?est Landmark 1 and Landmark 2) a Degrees Minutes Seconds Degrees Minutes Seconds Latitude. Longitude: I I m :I I I m m EDEE EEI • - l - L J ?L Traffic Control Device Q Yield Sign 0 Police Officer or orr in q TO Function U Flagman O Not Applicable 0 Traffic Signal 0 Active RR Crossing O Other Type TCD Device Functioning Emergency 0 No Controls O improperly 0 Preemptive Controls Flashing Traffic O Signal 0 Stop Sign 0 Passive RR O Unknown Signal O Device Not O Device Functioning 0 Unknown Crossing Controls Functioning Properly Lane Closed (if "Not Applicable ", skip rest of the Lane Closure section) Lane Closure 0 North O East Q North and South Q All o V O Not Applicable 0 Partially Q Fully Q Unknown DLmction Q South Q West 0 East and West (N,S,E,W) = C Traffic Yes Q No CD Detoured Unknown Q Time Este. Dosed 0 < 30 Min. Q 30-60 Min. Q 1-3 hrs Q 3-6 hrs Q 6-9 hrs (Q > 9 hours O Unknown FORM # AA-500L (12102) POIAC.e O RRA'?H REPORTING EC3FIM C°4[A? ?F+T ® New ?I?II?I??II'II??II?I?I?I?III Crash Number Pageo AA 500 N ' v.????"7 Conti nuation L? I J v? I Narrative and additional writnesses: z epo .ing officer: - Cpl. Chris us a --- ------ Collision Analysis an Reconstruction Unit - ---- ------- ennsy vania State Police Troop ----------- 3033 Old Harrisburg Road - -- Gettysburg, PA 17325 On December 1-,-2007, . was requested by PSP am ers urg to respond to the area o UBuc anan Trail West (SR 0016) or a two vehicle fatal cras . pon my arrival; Tme wi Troopers CAMPBELL aand CONFER who walked- me rough the cras scene. - In the area where is crash occurred, SR 0016 is a straight stretch o roadway running approximately east an west. .s divided into two lanes with a solid yellow line bordering t e wes ounn lane an a dashed yellow ine or ering a eas oun ane. o lanes ave shoulders approximately eight feet e wide. is location t roadway is bordered by arm fields to the north an south. Z .a N As we walked Tlroug the scene, noted a there was a 2002 Volkswagen C ., e a a final rest rn the westbound lane acing east. There was a 2007 cura HUX a final rest across the eastbound lane an berm with the rear o t e k vehicle on op of the southern guide rail. The Acura was acing in a northerly a direction. Both units a severe front en amage,w is showed a s ig t y offset ea -on impact. There were numerous items o debris rom of vehicles roug ou the crash scene. We also located numerous post impact scrapes an scratches on the roadway ate from the area o impact to final rest o o vehicles. Using the physical evidence a the scene, Troopers CONFER, CAMPBELL, and 1, determined a the o swagen, ni a een trave ing westbound in a westbound lane. The Acura, nit ,,11 was traveling eastbound in the eastbound lane. For an unknown reason, nit R el lane, entered Unit s lane an struck nit . The impact,cause severe damage to the front o o vehicles. FORM k AA-500N (IMM P?StJ?c..f., Cc?E'? POLICE 11CR?'S HEA?YR?OiTING ORIAAMiA E! fir- 0 New ?I?I?IIlIII?? IIi?I????ll?ll Crash Number Page Polce?JseCnly ? °? r ?.?... AA 500 N 1_'7L?? O ?j Change/ !' ?I ?? 1.= L1? 1 Continuation ttl Narrative and additional witnesses: 2 ue o t e orien a ion o -e vehicles a impact, of jehic es began to rotate in a counterc oc wise irec ion after impact. Unit rotate approximately 180 degrees before coming to rest. Unit rotated approximately 100 degrees before coming to rest. This officer took digital photographs at the scene using a Canon Digital Rebel with pee i e as require e p otographs were taken in a x format. The photographs were copied to a PSP network rive on at 1016 ours. The aster will be stored with the Troop Forensic . Services nit under reference number H07-263. A copy of the photographs was also provided to pr. CONFER for attachment to the station copy o the AA 5007 Physical evidence located at the scene consisted of Units #1 and #2, numerous items o vehicle debris, an several scrapes and scratches. The physical evidence was mare with orescent orange spray paint. A scuff N mar was located on the outside o the right rear tire of Units #1 and #2 which C confirmed at o units a rotated in a counter clockwise direction after impact. The following measurements were taken at the scene. Troopers CONFER and CAMPBELL assisted with the measuring process. Northern shoulder: 7.67 feet wide Westbound lane: 11.41 feet wide Eastbound lane: 11.66 feet wide Southern shoulder: 7.92 feet wide - Acura fog light: 98.41 feet to the northeast of the area of impact n curs o0 ornament: 104.41 feet to the southeast of the area of impact curs ea light: 56.58 feet to the 'southeast of the area of impact Plastic debris with VW symbol: 42.66 feet to the west of the area of impact FORM # AA-500N (IzRM .Pe-•..-r?n=-P*4P--ter' 0:?V.-N!ONWEALTH OF PENNSYLVA, NIA POLICE CRASH REPORTING FORM Page AA 500 N M Y z 164 _ ! b New IIIIIIIIIIIIIIIIIIIIff11111 Crash Number Change/ Ig- 0 It. ' f Continuation I ? t Narrative and additional witnesses: i ergiass debris from VW: 76.2 feet tot the west of the point of impact no -o sca e diagram was compete using Trancite Easy Street Draw versioh-73.0?317, an will be su bmitted to pr. CONFER to be attached to his d W L L M Z C M N Y1 01 C y?yL X Q I ; I a FORM # AA-500N (12mq { K ?Z- JJ Q- to mom L m w 'O E x z ? U -7 7 0 LL N C 7 C d EN C 0 x N C o s N 'C a y O , U .y a 'c r ?o W W p= m q L) .°n a O O~? ? N q Q x V O d m K N c ?a~ a I Z -w Q0 LL CL° i S D Mn L U a i U T a c 3 D F' ty` (ij New + (I III ?I?f IIIiI II I I f II Crash Number Page ?? O Continuation F(d ) I , I mil` `d _ 4 1 / .1 COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Case Closed Reportable Crash , AA 500 1 0 Yes Cj) No 4& Yes Q No t z 3 4 5 C r E E Incident Number Police Agency Patrol Zone Ewa ?; 4 16 5? 1,14 ) -,) ? p Agency Name Precinct Investigati r Hate (MM D6 YY Y} I PA ! MG' DEspitcTi time?Fit Arrival'lime (mil) Investigator Badge Number g Badge Dumber Approval Date (MM-DD-YYYY) Revie we r \ } r County County Name Municipality Municipality Name Day of Week Q Sun Q Thu e Crash Date (MM-DD-YYYY) Crash Time (mil) No of Units People Injured Killed* *(If > 00 , Q Mon Q Fri O Tue Q Sat m Complet e m_ m m m m m Form F) O Wed Q Unk E j Workzone(If Yes, Complete O Yes Q No School Bus Q Yes Q No School Zone O Yes O No Form M, Section 29) Related Related Notify PENNDOTQ Yes Q No Maintenance °i Intersection Tvoe Multi-Le9 Q 4 Way Intersection Q "Y" Intersection Q Q Off Ramp O Railroad Crossing Intersection Soecial * m Location F Q Midblock O "T" Intersection O Traffic Circle/ O On Ramp O Crossover Q Other Round About * See Overla Route Number Segment (Optional) Travel Lanes Speed Limit O North House Number (if applicable) o m m' O South - 16 Q East Street Name Street Ending c For Mid-block crashes only. Use C ` O West m postal House Number and make sure is Street Principal g C O Unknown O filled in if using t this option SiRoute a Q Interstate O Turnpike O Turnpike Q State O County O Local Road O Private O Other/ (Not Turnpike) (East/West) Spur Highway Road or Street Road Unknown d Route Number Segment (Optional) Travel Lanes Speed Limit Q North cc ?? m m O South I .U°, Street Name Street Ending w O East - w a « O West O O 71 1 Unknown N L a a ? Interstate Turnpike Turnpike State County Local Road Private Other/ { i O (Not Turnpike) , O (EastNVest) O Spur O Highway O Road O or Street O Road O Unknown Intersecting Rt Num Or Mile Post Or Segment Marker - h O Feet ? FTI 1 1 Nort s • m O South .a m m Please Enter o Or Intersecting Street Name St Ending 3 =1 E7 EQ O East O West Or Miles E ! Information for BOTH EQ m • ? v Landmarks if Using This Option ` Intersecting Rt Num Or Mile Post Or Segment Marker ^d = Ed 0 F1 I I I I I O North Distance From Crash Scene to Landmark 1 C o . '" ? O South N E Or Intersecting Street Name St Ending Q East For Crash between Landmark 1 and f0, O West Landmark 2) rr Degrees Minutes Seconds Degrees Minutes Seconds 0 Latitude: m m•m • m Longitude: - m m •m • m v Traffic Control Device Police Officer or Q Yield Sign Q O Not Applicable Q Traffic Signal O Active RR Crossing Flagman O Other T e TCD TO Functioning Emer en O No Controls O Device Improperly Functioning 0 eptive l E' yp Flashing Controls Q 9 O Stop Sign Passive RR Signal O O Unknown Signa Device Not Device Functioning Functioning O Properly Q Unknown Crossing Controls 3 Lane Closed (If "Not Applicable ", skip rest of the Lane Closure section) Lane Closure O North O East Q North and South O All p O Not Applicable Q Partially Q Fully Q Unknown Direction Q South O West O East and West (N,S,E,W) V d j Traffic Yes Q No Q Detoured Unknown Q ad• rifle Q< 30 Min. Q 30-60 Min. Q 1-3 hrs Q 3-6 hrs Q 6-9 hrs Q> 9 hours Q Unknown I F r 1 t t ? . ? . , f . . , . < ' ! ? e r ri r z .. { ?.. ,,, r?,?? {?,i i t ;,il I 1'++ i?!'e ,?+ i ! 1?2•t?, 1 i; r?+i ?r ?7 1 17 :J i :'; f r , ! ,?Of?yi.i(dA-?otil(i?J0?2) a ad {' f ,ii,i -! r? Ay A h l.di.,; ld ,ri rs{.+ ilr iiie <ii +; lr ,. Z COMMONWEALTH OF PENNSYLVANIAN " POLICE CRASH REPORTING FORM Page Aft Sao N ® New III IIIIIIIIIIIIIIIIIIIIIIIII Crash Number o Changer . Continuation Narrative and additional witnesses: t + U06- 30 jOl1 y/ i ?iS E ti. ,'?1 r J WAS f 1 q ( tt1 D y ? ??t a CI ,?' ILA?i.` V (? 1:'Vi.+?{f(? 1 p?} '' EYE ? iL t. f`.{? rr?j?{-{ Of pF f ? FA1f?` t! /' , SK ? ? ? IN I LITGny' 1...111 }? J ,/? ' i/rr Ff?I??rhuhr WIC NVES T IV N IS -frT. VAILI-011 aP Ct)Mjr3L {?1#!C T)??L, 11 11-S ULCER MEAD E .-Y?VF LOC i (t) CSI 0.1 T IV55 11100b Pup QN! T S k!-021-0 40, - '- C0. Y-CP s /'(?v, ni-m 19 &. tia G!!7 / lj 7o ?!JA) F)QU1f'Et'?!T1I (.R`? _ `)` ElLd R? I'VE -SP FIE!{'R ,'jl ' r n t?P'Tl}C? n ( ; fl!f ;f c. Ur' _ C3NI 41; 12C.?C. " I) -)D mUi''' L R Z V R M M . c 3 4 3 a ,'. . ....... ... , .'.'. s .F.? . COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Case Closed Reportable Crash 'AA 500 1 O Yes ® No 0, Yes Q No i7? III?IIf?II?II?t?I I??I'?I New Crash Number 40 Page CD Change/ Continuation MI Incident Number Police Agency Patrol Zone r b - 5 O 7 7-_77 6 w p Agency Name Precinct Investigation Date (h1M-DD-YYYY) 5 1-1 7-,E7 PC L/C t- C- ?'t'??r 's Ig u/1 G- F77 - - C 7 Q Dispatch Time (mil) Arrival Time (mil) Investigator Badge Number F,,,/'L ,eox)4C6 c6x61'-Y71U-1 d Reviewer Badge Number Approval Date (MM-DD-YYYY) - - LZI nI r) 12 .'? County County Name ? Municipality Municipality Name Day of Week Q Sun Q Thu e t = a v l-W Crash Date (MM DD YYYY) Crash Time (mil) No of Units People Injured Killed* *(If > 00, Form F) M-M-1 O Mon Q Fri O e Q Sat O Wed Q Unk Workzone'f Yes, Complete School Bus School Zone O Yes Q No O Yes Q No Section 29) O Yes Q No orm M l I I PENNDOT 0 Yes Q No e , Re ated Related Main nance Intersection Type Q 4 Way Intersection Q "Y" Intersection Q Multi-Leg Q Off Ramp Q Railroad Crossing Intersection at on j Q Midblock Traffic Circle/ Q "T" Intersection O Round About O On Ramp Q Crossover Q Other m Loc i * See Overlay Route Number Segment (Optional) Travel Lanes Speed Limit O North House Number (if applicable) e° n n c l?? m m ° O South o e Street Name Street Ending 9 O East I For Mid-block crashes only. Use Q. d 0 Wen postal House Number and make sure .S O O Unknown m Principal Roadway Street Name is filled in if using this option a signing o Interstate CD Turnpike Q Turnpike Q State O County Q Local Road O Private O Other/ (Not Turnpike) (East/West) Spur Highway Road or Street Road Unknown Route Number Segment (Optional) Travel Lanes Speed Limit Q North C cc 0 O South m m C C Street Name Street Ending' O East a r, a A O West 771 m O O Unknown z 'E GRoute nininng Q Interstate CD Turnpike Q Turnpike O State O County O Local Road Q Private O Other/ (Not Turnpike) (East/West) Spur Highway Road or Street Road Unknown 7 Intersecting Rt Num Or Mile Post Or Segment Marker p th O N Feet t I T1 El or • " 0 Or Intersectin Stre t N O South p C u Please Enter .o g e ame St Ending J E m O East O West Or Miles E c m Information for BOTH ar m o U. d -a !g Landmarks if using This Option Intersecting Rt Num Or Mile Post Or Segment Marker N p c orth 0 , Distance From Crash S L t d k 1 z ,0 R O South cene o an mar N E Or Intersecting Street, ame St Ending i 0 East (For Crash between o ED O West Landmark 1 and Landmark 2) IL ? Degrees Minutes Seconds Degrees Minutes Seconds Latitude: m M:EII.M Longitude: - m EEICE] • ED D U Traffic Control Device Q Yield Sign Q Police Officer or Flagman O Not Applicable Q Traffic Signal Active RR Crossing Q O Other Type TCD 7CD Functioning Device Functionin Emergency Q No Controls Q Functioning Q Preem tive Improperly p Controls Flashing Traffic O Signal O Stop Sign O Passive RR Crossing Controls O Unknown Signal Device Not Device Functioning O Functioning O Properly O Unknown ar = Lane Dosed (lf -Not Applicable-, skip rest of the Lane Closure section) Lane Closure O North Q East Q North and South Q All FA u Q Not Applicable 0 Partially Q Fully Q Unknown Q South Q West Q East and West (N,S,E,W) j Yes Q No Q Detoure d Unknown Q " me O< 30 Min. Q 30-60 Min. Q 1-3 hrs Q 3-6 hrs Q 6-9 hrs Q> 9 hours Q Unknown I t I I I B i s FORK #AA,500L,(1=2),. .'riii"'iwel.i+?ei?i.'.?I'. ?.'•?+?.?'?Ir?', !?,. ..,..`I?.',?' .?, ' COMMONWEALTH OF PENNSYLVANIA r, .7 III (I VIII) I II I III'IIIIII III Crash Number POLICE CRASH REPORTING FORM Page ® New AA 500 N Police Use Only Change/ ?' MI Continuation E I FORMS AA-50ON (1?JU2) . . ..... Narrative and additional witnesses: ? C.?fJ ?.`r ?U ? ! C) J i iT,C c ?'?, :"^.C;,,?? c' it _ al , _ ? ?? `r ?lr -t ??-?=•, ^, r? 4 / 1 C? 1 C C J\ i :` f j ti?? J `-s i'?i fir,, ; •l.. f, ?;_ , `? .'.? ? f r ? .'•1 /_ (.+ . r ILA 4 d A L L Z V C m a Vl d } x 3 Q 1 1 . OLI E CRASH REPORTING FORM NIA ® New III IIIIIIIIIIIIIIIIIIIIIIIII Crash Number Page `AA 500 F Polk Use Only ' O Change/ ?? ?03 - ?r Sso? P I °i 4 Continuation Road Surface Tvpe Special Jurisdiction, Q Brick or Block Q Dirt - ?, Q Military Q Other Federal Sites 24 O Concrete Slag, Gravel or No 5 ecial O Q Other ? P Q Indian Reservation O Other ® Blacktop Stone Jurisdiction Q Unknown O National Park O College/University Unknown Campus Please complete Unit Information for each unit involved in a fatal crash. Do not repeat the information in the fields above on multiple pages. Unit No Principle Impact Point O O Non-Collision 1 12 0 O [ail 1 Driver Restrictions O Restrictions Not a Pennsylvania O 10 02 O Compliance Complied With O Driver Q Top O Restrictions Not Unknown U O 09 03 ® No Restrictions/ Complied With O Compliance Undercarriage OS 04 Not Applicable O O Compliance Q Q Towed Unit Unknown 07 06 05 Driver Endorsement O Required - O Not a Pennsylvania O Unknown O O O Compliance Complied With Driver Required - Non O Unknown Avoidance Maneuver O Compliance Compliance ®None Required No Avoidance O Required - O Braking _ Other O Other Avoidance zs = Compliance Unknown Maneuver Evidence Maneuver Driver License Not Required for Unk if CDL or O Braking - Skid Steering - Evidence O Q Marks Evident O or Driver Stated 0 Inconclusive. Compliance Vehicle Class CDL Required O No Valid License Not a Pennsylvania Braking - No Skid for Class O Driver O Marks, Driver Q Steering and Braking Q Unknown O Not Licensed ® Valid License for Stated Evidence or Stated Class O Unknown Under Ride Indicator Drug Test Tvpe Underride, No Override, Other ® Blood Q Other No Underride or 0 Compartment O None * nknown if Test Override Intrusion Vehicle O Urine iven Underride,. Underride, Unknown if Drug Test Results - (Up to Four Results) F] F] 0 Compartment O Compartment O Underride or 0 = No Test Given 5 = Amphetamines Intrusion Intrusion Unknown Override 1 = No Drug Reported 6= PCP 2 = Marijuana 8 = Other Emergency Use 0 Lights Flashing 0 Both Lights and 3 = Cocaine 9 = Unknown Test ? ? Not in Emergency' Siren 4 = Opiates Results Use Q Siren Sounding Q Unknown Unit No Principle Impact Point Q !? 12 O Non-Collision X11 12 010 Driver Restrictions O Restrictions O Not a Pennsylvania O 10 02 O romp ia-7 nce Complied With Driver O Top - Restrictions Not Unknown r 09 03 O ® No Restrictions/ O Complied With O Compliance O Undercarriage Not Applicable Compliance O 08 04 O c 0 Unknown O Towed Unit 07 06 05 W Driver Endorsement Q Required O Not a Pennsylvania Q Unknown 0 O ompiance Complied With Driver o O Required - Non 0 Unknown Avoidance Maneuver C M None Required pHance ?- Compliance Com (mp No Avoidance s O Required 1 Maneuver O Braking -Other O Other Avoidance Compliance Unknown Evidence !' Maneuver Braking - Skid O Steering Evi Driver License Not Required for Unk if CDL or O Evidence Inconclusive ? Vehicle Class 0 Marks Evident or Driver Stated ? omp? _Ra- CDL Required No Valid License Braking - No Skid O for Class O Not a Pennsylvania O Marks, Driver , Q Steering and Braking C ).Unknown Q Not Licensed Valid `License for Driver Stated Evidence or Stated 311111 Class O Unknown Under Ride Indicator Drug Test Type Underride, No Q Blood Q Other No Underride or Override, Other (p Override O Compartment c) Vehicle ( None O Urine ? Unknown if Test Intrusion Given Underride, Underride, Unknown if Drug Test Results -_ft to Four Results) ? Q Compartment O Compartment O Underride or 0 = No Test Given 5 = Amphetamines Intrusion Intrusion Unknown Override 1 = No Drug Reported 6 = PCP 2 = Marijuana 8 = Other Emergency Use Both Lights and Q Lights Flashing ? 3 = Cocaine 9 = Unknown Test Not in Emergency Siren 4 = Opiates Results IV Use O Siren Sounding Q Unknown FORM # AA-500F. (12/02) oni IfIr Pnov PENN STATE 41 Milton & Hershey Medical Center College of Medicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: ULSH, KATHRYN M Patient Sex: Female Patient Location: EMER, , Visit Type: Emergency PSUHMC MRN: 7502194 Date of Birth: 3/23/1999 Visit Number: 10502194 E m e r g e n c y D e p a r t m e n t N o t e D o c u m e n t Final Document Electronically Signed by: Kimak, Mark J 12/2/2007 1:30:38 PM ED SUMMARY Name: ULSH, KATHRYN M HMC Number: 7502194 DOB: 03/23/1999 Date of Service: 12/01/2007 CHIEF COMPLAINT: Right clavicle fracture. HISTORY OF THE PRESENT ILLNESS: The patient was a belted rear seat passenger who was eight-years-old involved in a motor vehicle crash. The father and another relative was flown to the Hershey Medical Center from Hagerstown, Maryland. The sending physician noted a clavicle fracture, but stated other evaluations were unremarkable. The sending physician in Hagerstown stated that the family had wished that she and the mother be transported to Hershey, as the father and other relatives were being cared for here. As per the sending physician, she came by ground ambulance because she was stable. In route, the ground ambulance states her vital signs were stable. She currently complains of "pain over her right clavicle only. She denies difficulty breathing. She denies abdominal pain or nausea. She denies any pain in her head, face, back, arms, or legs. I was present along with the Trauma Team upon arrival. PAST MEDICAL HISTORY: Please see the triage sheet for PMH. SOCIAL HISTORY: Lives with the mother and father. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: It is otherwise negative, other than what is mentioned in the HPI. PHYSICAL EXAM: The patient is awake and alert. Her pediatric GCS is 15. The airway is patent and stable. The chest wall reveals ecchymoses over the right clavicle and tenderness in that area only. She has equal bilateral breath sounds and no audible wheezes, rales, nor rhonchi. Heart exam revealed a regular rate and rhythm with S1 and S2, and no audible murmurs, gallops, clicks, nor rubs that are obvious. When I palpate all four quadrants of the abdomen, they were ,nontender. Bowel sounds were active. She was able to move all four limbs without difficulty or asymmetry. All four limbs had no obvious deformities to palpation. There was a laceration that was repaired by the outside facility over her left leg. Date Printed: 112512008 Time Printed: 6:46 AM ?1 r]CA 11 mom 1W Milton S. Hershey Medical Center College of Medicine Patient Name: ULSH, KATHRYN M PSUHMC MRN: 7502194 E m e r g e n c y D e p a r t m e n t N o t e D o c u m e n t Final Document Electronically Signed by: Kimak, Mark J 12/2/2007 1:30:38 PM Pulses were 2+ in all four distal limbs. Neurologically, her gaze is dysconjugate. Her speech is fluent. Her smile is symmetrical. Her tongue was midline. Handgrip was full bilaterally. She could flex and extend both ankles with strength. COURSE IN THE ED: The chest x-ray was repeated which revealed no obvious hemothorax or pneumothorax, and the right shoulder films and chest x-ray revealed a nondisplaced midclavicular fracture. She was also seen by Dr. Brett Engbrecht, the Pediatric Trauma Surgery attending, and the Pediatric Trauma Team. `Course in the ED - given her stability, other relatives wished to take her home with them tonight and this was found to be acceptable. She is certainly to followup with an orthopedic surgeon for followup care of her clavicle fracture within the next week. She was to return immediately for shortness of breath, increased clavicle or limb pain, or abdominal discomfort or vomiting. 575646 Review/Sign: Kimak, Mark J, MD MJK /TLD DD: 12/02/07 DT: 12/02/07 10:01 Date Printed: 112512008 Time Printed.* 6:46 AM v PENN STATE Milton S. Hershey Medical Center College of Medicine Patient Name: ULSH, JAMES L PSUHMC MRN: 7502186 D i s c h a r g e S u m m a r y D o c u m e n t Modified Document Electronically Signed by: per contribution per contribution Signed By: Sathyendra, Vikram M (12/12/2007 9:05:52 AM); Engbrecht, Brett W (12/11/2007 4:59:38 PM) DISCHARGE SUMMARY Name: ULSH, JAMES L HMC Number: 7502186 DOB: 07/24/2003 Date of Admission: 12/01/2007 Date of Discharge: 12/09/2007 Physician: Engbrecht, Brett W Service: Peds Surgery Destination: 109 FAIRWAY DR, CARLISLE, PA 17015 Discharge Diagnosis: Multiple Trauma/MVA x Other Diagnoses: Left tib fib fracture Left clavicle fracture Traumatic bowel perforation, second jejunal perforation, second jejuna) serosal tear and mesenteric hematoma Surgical Procedures: Exploratory Laparotomy, resection of small bowel at perforation site with primary end-to-end anastomosis, primary repair of jejunal serosal tear; 12/2/07 Vaccinations Received This Hospital Stay: No vaccinations were given this hospital stay. Brief History of Present Illness: This is a 4-year-old male who was involved in a severe motor vehicle collision involving his entire family and was brought to our hospital in stable condition but with a seatbelt contusion across his abdomen and complaining of abdominal pain. In addition he had a left clavicular fracture and a left tibia and fibula fractures. Hospital Course: He was a level one trauma due to multiple patients. ATLS protocols were established and followed. Orthopedics were readily consulted. He had a CAT scan that demonstrated mesenteric and retroperitoneal edema and a mesenteric hematoma. There was a very small speck of air that did not appear to be within the lumen of bowel. There was also free fluid in the abdomen. The patient was observed with serial exams. Throughout the day his abdominal exam did not worsen and while he was under sedation for reduction of his tibia and fibula fractures he had no involuntary guarding and i Date Printed: 112312008 Time Printed: 5:26 AM PENNSTATE IV Milton S. Hershey Medical Center College of Medicine Patient Name: ULSH, JAMES L D i s c h a r PSUHMC MRN: 7502186 e S u m m a r y D o c u m e n t Modified Document Electronically Signed by: per contribution per contribution i Signed By: Sathyendra, Vikram M (12/12/2007 9:05:52 AM); Engbrecht, Brett W (12/11/2007 4:59:38 PM) s had a totally soft abdomen that was not distended. However, over the course of the night he developed fevers and a tepeat abdominal x-ray demonstrated significant free air. Dr. Engbrecht discussed with his mother the indication for exploratory laparotomy, possible need for bowel resections and possible ostomies. He discussed with her the risks including bleeding, infection, leak from anastomosis, bowel obstruction, need for other procedures. She stated that she understood and agreed that we proceed. He tolerated the procedure well and was returned to the pediatric floor in stable condition. His NG tube was placed to suction. He was NPO. He was given morphine for pain. His casted left leg was elevated and he was to wear a sling for comfort for his left arm when he was up. Physical therapy was consulted and a wheelchair was ordered. Post op day two he had moderate drainage from his NG and cares remained the same. This continued until his NG was placed to gravity drain on post op day 3.. Post op day 4 he had minimal drainage and his NG was removed late in the morning. His diet was advanced to sips on 12/6, and clear liquids on 12/7. He was tolerating a regular diet by 12/8. The patient was stable for discharge on 12/9. Exam on Discharge: On discharge, the patient's vital signs were as follows: Tmax=37.1, Tc=36.8, HR=88, BP=105/51, RR=20, Sa02=99% on 'room air. In general, he was alert, awake, and oriented. His heart was regular. His lungs were clear to auscultation bilaterally. His abdomen was soft, nontender, and nondistended with present bowel sounds. His abdominal incision was clean, dry and intact. He was all his extremities. His LLE cast was clean, dry, and intact. He was moving his toes on hiss` left foot with no discomfort. Care Instructions: 1. Keep cast clean and dry. sponge bathe only. Keep leg elevated with heel off contact, as much as possible. Do not put anything into the cast. 2. Wear your sling when you are out of bed for comfort. 3. Incisional care: i Diet Guidelines: Regular diet as tolerated, drink plenty of fluids Activity Guidelines: Stand pivot to wheelchair/chair. No standing on your left leg. You do not have to wear your sling when you are in bed. Call your doctor if: Please call 717 531-8521 and ask for the Pediatric Surgery resident on call for increasing abdominal pain, persistent vomiting, fever, diarrhea and for other concerns. You can also call us at 717 531-8342 during regular business hours. 1-.. 1Dther Instructions: i ;. i.. i ..Date Printed: 112312008 6 Time Printed: 5:26 AM A' PENNSTATE Milton S. Hershey Medical Center College of Medicine Patient Name: ULSH, JAMES L PSUHMC MRN: 7502186 D i s c h a r g e S u m m a r y D o c u m e n t Modified I Document Electronically Signed by: per contribution per contribution Signed By: Sathyendra, Vikram M (12/12/2007 9:05:52 AM); Engbrecht, Brett W (12/11/2007 4:59:38 PM) i Please come to the Pediatric surgery clinic for your post op appointment after your appointment with Dr. Fortuna; just come when you are finished with that appointment. We are on the 3rd floor of the UPC building; turn left after you get off Y the elevator always travel in cars with an appropriate child safety restraint seat. Services: Durable Medical Equipment Young's (800) 531-6200 Wheelchair Follow-Up Appointments: 1. Follow up with Dr. Fortuna at Pediatric Orthopaedic Clinic on 12/26/07 at 10:40 am . first floor south entrance of hospital; pediatric rehabilitation clinic 2. Follow up with Pediatric Surgery at UPC Suite 3200 on 12/26/07 at 11:00 am . Please just come to our clinic after your ortho appointment Date Printed: 112312008 Time Printed: 5.26 AM b PRUREIX E Andrew Dowling, Esquire 3401 N. Front St. P.O. Box 5950 Harrisburg, PA 17110 FAX: 717-236-1816 4000 Crums Mill Road, Suite 201 Harrisburg, PA 17112 TEL. (717) 540-2500 FAX: (717) 671-6458 WEB: NvivH:.progressive.coil? VIA FAX & REGULAR MAIL Our Claim Number: 075244571 Date of Loss: 12/1/2007 Your Client: John, Tonia, James, Kathryn Ulsh Dear Mr. Dowling: In reply to your 10-day time limit demand letter dated 2/14/2008, I agree this needs to be handled fast. To that end, my offers are as follows: John Ulsh: $15,000 James Ulsh: $10,000 Tonia Ulsh: $3,000 Kathryn Ulsh: $2,000 For documentation purposes of your clients' UIM carrier, I have attached my insured's declarations page verifying the policy limits amounts. If you want personal data on my insured and an affidavit of no other insurance, you must secure these from the police report and/or my insured's estate attorney Martha Walker 717-262-2185 (I am not permitted to release private data, such as social security numbers, or sign any affidavits, on my insured's behalf). The offers are for full and final settlement of any and all claims arising out of this loss. Please convey the offers to your client and advise. Cordig4y, Craig W. ssaman Casualty Representative 717-540-2502 PROGRESSIVE COMPANIES Kemper A UNITRIN BUSINESS P.O. BOX 1258, WASHINGTON, PA 15301 - PHONE: (866)407-7254 FAX: 724-229-9034 August 15, 2008 Andrew H. Dowling, Esquire Mette, Evans & Woodside 3401 North Front Street Harrisburg, PA 17110-0950 OUR INSURED: John D. and Tonia DATE OF LOSS: 12/01/07 CLAIM NUMBER: 331 AF43963:3 YOUR CLIENTS: John Ulsh, Tonia L. Ulsh Ulsh, James Ulsh, Kathryn Ulsh Dear Mr. Dowling: As discussed and agreed this afternoon, enclosed are the Underinsured Motorist Releases in the following amounts: John D. Ulsh $100,000.00 Tonia L. Ulsh $ 60,000.00 James Ulsh $100,000.00 Kathryn Ulsh $ 40,000.00 These settlement offers are inclusive of any and all outstanding liens. It is my understanding that your office will handle settlement of the medical liens. With respect to the claims of James and Kathryn, it is my understanding that you will be obtaining court approval of the settlements. In addition to the executed releases, please send me copies of the petitions and the court orders approving the minors' settlements when they become available. Very truly yours, ' 75k Doulas F. Schultz Claim Department RECYCLED G Exti:b,i? FULL RELEASE OF ALL CLAIMS WITH INDEMNITY Page 1 of 2 KNOW ALL BY THESE PRESENTS, that We, John Ulsh and Tonia Ulsh, individually and as husband and wife, for and in consideration of the sum of Fifteen-Thousand and 00/100 dollars ($15,000), the receipt whereof is hereby acknowledged, do hereby for ourselves, our heirs, executors, administrators, successors and assigns and any and all persons, firms, employers, corporations, associations, or partnerships release, acquit and forever discharge The Estate of Daniel Martin, its agents, employees, subsidiaries, and affiliates (hereinafter "Releasees") from any and all claims, actions, causes of actions, demands, costs, property damage, loss of wages, expenses, hospital medical and nursing expenses, accrued or unaccrued claims for loss of consortium, loss of support or affection, loss of society and companionship on account of or in. any way growing out of, any and all known and unknown personal injuries and damages resulting from an automobile accident which occurred on or about 12/1/2007, at or near Mercersburg, PA. It is understood and agreed that this settlement is in full compromise of a doubtful and disputed claim as to both questions of liability and as to the nature and extent of the injuries and damages, and that neither this release, nor the payment pursuant thereto shall be construed as an admission of liability, such being denied. It is further understood and agreed that the undersigned relies wholly upon the undersigned's judgment, belief, and knowledge of the nature, extent, effect, and duration of said injuries and liability therefore and is made without reliance upon any statement or representation of the party or parties hereby released or their representatives. In consideration of the payment of the sum, the undersigned further agrees to indemnify The Estate of Daniel Martin, its agents, employees, subsidiaries, and affiliates and save them harmless from any and all further liability, loss, damage, claims of subrogation and expense, arising because of any injuries and damages, sustained by the undersigned, and, if necessary in order to save them so harmless, to satisfy on their behalf any judgment against them arising in any way out of the undersigned injuries or damages. I have read this release and understand it. Sign. Witness date /y/0 Witness date Joh Iillsh date Tonia Ulsh date This document does not release any underinsured motorists claim or medical negligence claim. FULL RELEASE OF ALL CLAIMS WITH INDEMNITY Page 2 of 2 State of : County of: 71?El? On this J?CA day of , 200z__, before me personally appeared T person(s) who executed the foregoing instrument, and acknowledged this as'a free a tt and deed. IN TESTIMONY WHEREOF, I have hereto subscribed my name and affixed my seal this 3,'d day of 2ZCp My commission expires Claim No.: 075244571 COMMONWEALTH OF PENNSYLVANK Notarial Seal Deborah J. Haney, Notary Public Susquehanna Twp., Dauphin Cotmty My Commissirx, i E)dres Aug. 29, 2011 Member, Pennsylvania Association of Notaries PARENTS' RELEASE AND INDEMNITY AGREEMENT Page 1 of 2 KNOW ALL BY THESE PRESENTS: That the undersigned, individually and as legal parents and guardians of James Ulsh., a minor (hereinafter "Releasors"), for the sole consideration of Ten-Thousand and 00/100 dollars ($10,000.), receipt of which is hereby acknowledged, have remised, released, and forever discharged and covenant to hold harmless The Estate of Daniel Martin, its heirs, administrators, executors, successors, agents, employees, subsidiaries, affiliates and assigns (hereinafter collectively referred to as "Releasees"), from any and all claims, demands, damages, costs, expenses, loss of services, actions and causes of action, belonging to the said Releasors arising out of any act or occurrence up to the present time, and particularly on account of personal injury, disability, property damage, loss or damages of any kind sustained or that may hereafter be sustained by the said Releasors in consequence of an accident that occurred on or about 12/1/2007, at or near Mercersburg, PA. To procure the payment of the stated consideration, the Releasors hereby declare: that no representations about the nature and extent of the said injuries, disabilities or damages made by any physician, attorney or agent of Releasee, nor any representations regarding the nature and extent of legal liability or financial responsibility of any of the parties released, have induced the Releasors to make this Release & Indemnity Agreement; that this Release is entered into in consideration of all known and unknown injuries, disabilities and damages, and also the possibility that the injuries sustained may be permanent and progressive and recovery therefrom uncertain and indefinite, so that consequences not now anticipated may result from the said accident. The payment made to the undersigned is upon Releasors warrant that no consideration has been received heretofore from any person, firm or corporation, nor has Releasors released heretofore any person, firm or corporation from any claim or liability for the said accident. Releasors agree to indemnify and hold harmless said Releasee from any additional sum of money that Releasee may hereafter be compelled to pay on account of the injuries to said minor because of said accident. The Releasors understand that the Releasees admit no liability of any sort by reason of said accident and that said payment in compromise is made to terminate further expense and controversy respecting all claims for damages that Releasors have heretofore asserted or might personally or through personal representatives hereafter assert because of said accident. I have read this release and understand it. Signed: Witness Witness l John Ulsh, father date Tonia Ulsh, mother date * This document does not release any underinsured motorists claim or medical negligence claim. PARENTS' RELEASE AND INDEMNITY AGREEMENT Page 2 of 2 STATE OF COUNTY OF h On this .3C day ' of_, before me personally appeared S to me known to be the person (s) who executed the foregoing instrument, and acknowledged this as a free act and deed. My commission expires Notary Public Qd-? Claim No.: 075244571 COMMONWEALTH OF PENNSYLVAI?lRI, Notarial Sea' Deborah J. Haney, Notary Public Susquehanna Twp., Dauphin C=* My C.ornmission E)ires Aug. 29, 2011 Member, Pennsylvania Association of Notaries FULL RELEASE OF ALL CLAIMS WITH INDEMNITY Page 1 of 2 KNOW ALL BY THESE PRESENTS, that We, Tonia Ulsh and John Ulsh, individually and as husband and wife, for and in consideration of the sum of Three-Thousand and 00/100 dollars ($3,000), the receipt whereof is hereby acknowledged, do hereby for ourselves, our heirs, executors, administrators, successors and assigns and any and all persons, firms, employers, corporations, associations, or partnerships release, acquit and forever discharge The Estate of Daniel Martin, its agents, employees, subsidiaries, and affiliates (hereinafter "Releasees") from any and all claims, actions, causes of actions, demands, costs, property damage, loss of wages, expenses, hospital medical and nursing expenses, accrued or unaccrued claims for loss of consortium, loss of support or affection, loss of society and companionship on account of or in any way growing out of, any and all known and unknown personal injuries and damages resulting from an automobile accident which occurred on or about 12/1/2007, at or near Mercersburg, PA. It is understood and agreed that this settlement is in full compromise of a doubtful and disputed claim as to both questions of liability and as to the nature and extent of the injuries and damages, and that neither this release, nor the payment pursuant thereto shall be construed as an admission of liability, such being denied. It is further understood and agreed that the undersigned relies wholly upon the undersigned's judgment, belief, and knowledge of the nature, extent, effect, and duration of said injuries and liability therefore and is made without reliance upon any statement or representation of the party or parties hereby released or their representatives. In consideration of the payment of the sum, the undersigned further agrees to indemnify The Estate of Daniel Martin, its agents, employees, subsidiaries, and affiliates and save them harmless from any and all further liability, loss, damage, claims of subrogation and expense, arising because of any injuries and damages, sustained by the undersigned, and, if necessary in order to save them so harmless, to satisfy on their behalf any judgment against them arising in any way out of the undersigned injuries or damages. I have read this release and understand it. Signed: Witness date Tonia Ulsh date Witness date Jo?Ulsh date * This document does not release any underinsured motorists claim or medical negligence claim. FULL RELEASE OF ALL CLAIMS WITH INDEMNITY Page 2 of 2 State of: County of: On this? day of 2 , before me personally appeared f person(s) who executed the foregoing instrument, and acknowledged this as ,a free acttoand deed. IN TESTIMONY WHEREOF, I have hereto subscribed my name and affixed my seal this .day of My commission expires Claim No.: 075244571 COMMONWEALTH OF PENNSYLV Notarial Seal EDeborah Haney, Notary Public a Tv,p., 7auphin Co;mty n E xlxres Aug. 29, 2011 Member, Penns' °- "Association of Notaries PARENTS' RELEASE AND INDEMNITY AGREEMENT Page 1 of 2 KNOW ALL BY THESE PRESENTS: That the undersigned; individually and as legal parents and guardians of Kathryn Ulsh, a minor (hereinafter Releasors ), for the sole consideration of Two-Thousand and 00/100 dollars ($2,000), receipt of which is hereby aclaiowledged, have remised, released, and forever discharged and covenant to hold harmless The Estate of Daniel Martin, its heirs, administrators, executors, successors, agents, employees, subsidiaries, affiliates and assigns (hereinafter collectively referred to as "Releasees"), from any and all claims, demands, damages, costs, expenses, loss of services, actions and causes of action, belonging to the said Releasors arising out of any act or occurrence up to the present time, and particularly on account of personal injury, disability, property damage, loss or damages of any kind sustained or that may hereafter be sustained by the said Releasors in consequence of an accident that occurred on or about 12/1/2007, at or near Mercersburg, PA. To procure the payment of the stated consideration, the Releasors hereby declare: that no representations about the nature and extent of the said injuries, disabilities or damages made by any physician, attorney or agent of Releasee, nor any representations regarding the nature and extent of legal liability or financial responsibility of any of the parties released, have induced the Releasors to make this Release & Indemnity Agreement; that this Release is entered into in consideration of all known and unknown injuries, disabilities and damages, and also the possibility that the injuries sustained may be permanent and progressive and recovery therefrom uncertain and indefinite, so that consequences not now anticipated may result from the said accident. The payment made to the undersigned is upon Releasors warrant that no consideration has been received heretofore from any person, firm or corporation, nor has Releasors released heretofore any person, firm or corporation from any claim or liability for the said accident. Releasors agree to indemnify and hold harmless said Releasee from any additional sum of money that Releasee may hereafter be compelled to pay on account of the injuries to said minor because of said accident. The Releasors understand that the Releasees admit no liability of any sort by reason of said accident and that said payment in compromise is made to terminate further expense and controversy respecting all claims for damages that Releasors have heretofore asserted or might personally or through personal representatives hereafter assert because of said accident. I have read this release and understand it. Signed: Witness Witness ; JJ u,r -3-os Joh v Ulsh, father date Tonia Ulsh, mother date * This document does not release anv underinsured motorists claim or medical negligence claim. PARENTS' RELEASE AND INDEMNITY AGREEMENT Page 2 of 2 STATE OF ??, COUNTY OF On this_--'-?day of 2 ' l before me personally appeared n ?J(5 -_,to me known to be the person (s) who executed the foregoing instrument, and acknowledged this as a free act and deed. MZ commission expires Notary Public Claim No.: 075244571 COMMONWEALTH OF PENNSYLVANIA Notarial Seal Deborah J. Haney, Notary Public Susquehanna Twp., Dauphin County My Commission Expires Aug. 29, 2011 Member, Pennsylvania Association of Notaries RECYCLED [ j EXti.b'-F G Kemper A UNITRIN BUSINESS UNDERINSURED MOTORISTS RELEASE In consideration of ONE HUNDRED THOUSAND AND 00/100 Dollars ($ 100000.00 to me in hand paid by the UNITRIN AUTO AND HOME INSURANCE Company as a compromise and full settlement, the receipt of which is hereby acknowledged, it is agreed that I/we, being of lawful age, have released and discharged, and do by these presents for myself/ourselves, my/our heirs, execu- tors, administrators and assigns, release, acquit and forever discharge said Company of and from any and all actions, causes of action, claims or Underinsured Motorists Coverage attached to Policy Number HB 742945 issued to JOHN D. ULSH AND TONIA L. ULSH for or on account of any past, present, or future losses or disabilities resulting from any and all injuries, including death, suffered or sustained by JOHN D. ULSH arising out of an accident with an Underinsured automobile operated by DANIEL J. MARTIN JR, on or about DECEMBER 1ST 2007 at or near S.R. 0016, MONTGOMERY TWP., FRANKLIN CO., PA No agreements nor understandings have been made between the parties except as expressed herein and the terms of this release are contractual and not a mere recital. We hereby agree to satisfy any valid, enforceable lien asserted by any insurer, governmental entity and/or any other entity for benefits paid as a result of the alleged injuries, damages and death, including but not limited to payments made or benefits paid or payable pursuant to the Social Security Act, the Workmen's Compensation Act, or medical or other benefits paid by Blue Cross/Blue Shield, Medicare, Medicaid or any other insurer, governmental entity or any other entity, it being the express intent of this provision to absolve, protect, indemnify and hold harmless the released parties from any and all such claims. Any person v,,ho knowingly and with intent to defraud any insurance company or other person files an applica- tion for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Any person who knowingly and with intent to injure or defraud any insurer files an application or claim con- taining any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and the payment of a fine of up to $15,000. Underinsured Motorists Release.dot / 6/2006 Signed at °-?-? this 5 Witness Name Address day of State of A 4t S-,,p T ;-c o 3 X TO [AL. UL X fl JO ULSH, HUSBAND X (Seal) (Seal) (Seal) COMMONWEALTH OF PENNSYLVANIA COUNTY of DAUPHIN On this the 5th day of September, 2008, before me, a Notary Public, personally appeared John D. Ulsh and Tonia L. Ulsh, known to me, or satisfactorily proven, to be the persons whose names are subscribed to the within instrument and acknowledged that they executed the same for the purposes therein contained. I hereunto set my hand and official seal. h Notary Pubj-N COMMONWEALTH OF PENNSYLVANI Notarial Seal Betty Ann McMullan, Notary Public Susquehanna Twp., Dauphin County My Commission Expires Jan. 28, 2010 Member, Pennsylvania Aasenin,i.. _... . ?Ir 7W Kemper A UNITRIN BUSINESS UNDERINSURED MOTORISTS RELEASE In consideration of SIXTY THOUSAND AND 00/100 to me in hand paid by the UNITRIN AUTO AND HOME INSURANCE Dollars ($ 60,000.00 ) Company as a compromise and full settlement, the receipt of which is hereby acknowledged, it is agreed that I/we, being of lawful age, have released and discharged, and do by these presents for myself/ourselves, my/our heirs, execu- tors, administrators and assigns, release, acquit and forever discharge said Company of and from any and all actions, causes of action, claims or Underinsured Motorists Coverage attached to Policy Number HB 742945 JOHN D. ULSH AND TONIA L. ULSH issued to for or on account of any past, present, or future losses or disabilities resulting from any and all injuries, including death, suffered or sustained by TONIA L. ULSH arising out of an accident with an Underinsured automobile operated by DANIEL J. MARTIN JR. DECEMBER 1ST on or about 2007 at or near S. R. 0016, MONTGOMERY TWP., FRANKLIN CO.. PA No agreements nor understandings have been made between the parties except as expressed herein and the terms of this release are contractual and not a mere recital. We hereby agree to satisfy any valid, enforceable lien asserted by any insurer, governmental entity and/or any other entity for benefits paid as a result of the alleged injuries, damages and death, including but not limited to payments made or benefits paid or payable pursuant to the Social Security Act, the Workmen's Compensation Act, or medical or other benefits paid by Blue Cross/Blue Shield, Medicare, Medicaid or any other insurer, governmental entity or any other entity, it being the express intent of this provision to absolve, protect, indemnify and hold harmless the released parties from any and all such claims. Any person who knowingly and with intent to defraud any insurance company or other person files an applica- tion for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Any person who knowingly and with intent to injure or defraud any insurer files an application or claim con- taining any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and the payment of a fine of up to $15,000. Underinsured Motorists Release.dot / 6/2006 Signed at° this 5 -CV- Witness Name Address State of day of Asst S,'T ??- ao'3 X? TOXIA L. UL X p JO ULSH, HUSBAND X (Seal) (Seal) (Seal) COMMONWEALTH OF PENNSYLVANIA COUNTY of DAUPHIN On this the 5th day of September, 2008, before me, a Notary Public, personally appeared John D. Ulsh and Tonia L. Ulsh, known to me, or satisfactorily proven, to be the persons whose names are subscribed to the within instrument and acknowledged that they executed the same for the purposes therein contained. I hereunto set my hand and official seal. Notary Pub L2--o- CnMr IONWEALTH OF PENNSYLVANIA Notarial Seal r Retty Ann McMullan, Notary Public us4Llehanna Twp., Dauphin County P Al Commission Expires Jan. 28, 2010 Malt er7ennsylvanlp, Aeeoclatlon of Notarles Kemper A UNITRIN BUSINESS UNDERINSURED MOTORISTS RELEASE In consideration of ONE HUNDRED THOUSAND AND 00/100 Dollars ($ 100000.00 to mein hand paid by the UNITRIN AUTO AND HOME INSURANCE compromise and full settlement, the receipt of which is hereby acknowledged, it is agreed that ol/we,nbeing of lawful age, have released and discharged, and do by these presents for myself/ourselves, my/our heirs, execu- tors, administrators and assigns, release, acquit and forever discharge said Company of and from any and all actions, causes of action, claims or Underinsured Motorists Coverage attached to Policy Number HB 742945 issued to JOHN D. ULSH AND TONIA L. ULSH for or on account of any past, present, or future losses or disabilities resulting from any and all injuries, including death, suffered or sustained by JAMES ULSH, A MINOR arising out of an accident with an Underinsured automobile operated by DANIEL J. MARTIN JR. on or about DECEMBER 1ST 2007 at or near S.R. 0016, MONTGOMERY TWP., FRANKLIN CO., PA No agreements nor understandings have been made between the parties except as expressed herein and Lhe terms of this release are contractual and not a mere recital. We hereby agree to satisfy any valid, enforceable lien asserted by any insurer but not li governmental entity and/ t any other entity for benefits paid as a result of the alleged injuries, damages and death, including mited to payments made or benefits paid or payable pursuant to the Social Security Act, the Workmen's Compensation Act, or medical or other benefits paid by Blue Cross/Blue Shield, Medicare, Medicaid or any other insurer, governmental entity or any other entity, it being the express intent of this provision to absolve, protect, indemnify and hold harmless the released parties from any and all such claims. Any person who knowingly and with intent to defraud any insurance company or other person files an applica- tion for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Any person who knowingly and with intent to injure or defraud any insurer files an application or claim con- taining any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and the payment of a fine of up to $15,000. Underinsured Motorists Release.dot / 6/2006 Signed at y ' State of ? this day of Attgt"t S ?-/'j 20 o g Witness Name X (Seal) Address NATURAL PARENT AND GUARDIAN OF JAMES ULSH, A MIN R X (Seal) NATURAL PAR AND GUARDIAN OF JAMES ULSH, A MINOR X (Seal) COMMONWEALTH OF PENNSYLVANIA COUNTY of DAUPHIN On this the 5th day of September, 2008, before me, a Notary Public, personally appeared John D. Ulsh and Tonia L. Ulsh, natural parent and guardian of James Ulsh, a minor, known to me, or satisfactorily proven, to be the persons whose names are subscribed to the within instrument and acknowledged that they executed the same for the purposes therein contained. I hereunto set my hand and official seal. otary P lic 10MIM NWEALTH OF PENNSYLVANIA Notarial Seal Botty Ann McMullan, Notary Public swa-gushanna Twp., Dauphin County k4y 00f' MISSlon Expires Jan. 28, 2()10 .P.f, onsylVania Association of Notaries Kemper A UNITRIN BUSINESS UNDERINSURED MOTORISTS RELEASE In consideration of FORTY THOUSAND AND 00/100 Dollars ($ 40000.00 to me in hand paid by the UNITRIN AUTO AND HOME INSURANCE compromise and full settlement, the receipt of which is hereby acknowledged, it is agreed that I/we, being of lawful age, have released and discharged, and do by these presents for myself/ourselves, my/our heirs, execu- tors, administrators and assigns, release, acquit and forever discharge said Company of and from any and all actions, causes of action, claims or Underinsured Motorists Coverage attached to Policy Number HB 742945 JOHN D. ULSH AND TONIA L. ULSH issued to for or on account of any past, present, or future losses or disabilities resulting from any and all injuries, including death, suffered or sustained by KATHRYN ULSH, A MINOR Underinsured automobile operated by DANIEL J. MARTIN JR. DECEMBER 1ST arising out of an accident with an Company as a on or about 2007 at or near S. R. 0016, MONTGOMERY TWP., FRANKLIN CO., PA No agreements nor understandings have been made between the parties except as expressed herein and the terms of this release are contractual and not a mere recital. We hereby agree to satisfy any valid, enforceable lien asserted by any insurer, governmental entity and/or any other entity for benefits paid as a result of the alleged injuries, damages and death, including but not limited to payments made or benefits paid or payable pursuant to the Social Security Act, the Workmen's Compensation Act, or medical or other benefits paid by Blue Cross/Blue Shield, Medicare, Medicaid or any other insurer, governmental entity or any other entity, it being the express intent of this provision to absolve, protect, indemnify and hold harmless the released parties from any and all such claims. Any person who knowingly and with intent to defraud any insurance company or other person files an applica- tion for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Any person who knowingly and with intent to injure or defraud any insurer files an application or claim con- taining any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and the payment of a fine of up to $15,000. Underinsured Motorists Release.dot / 6/2006 Signed at ax-{" State of '?A this day of -FA J•??-t 2-00 3 Witness Name X (Seal) A, RAL PARENT AND GUARDIAN OF KATHRYN Address U SH A MINOR (Seal) NATURAL PA AND GUARDIAN OF KATHRYN ULSH, A MINOR X (Seal) COMMONWEALTH OF PENNSYLVANIA COUNTY of DAUPHIN On this the 5th day of September, 2008, before me, a Notary Public, personally appeared John D. Ulsh and Tonia L. Ulsh, natural parent and guardian of Kathryn Ulsh, a minor, known to me, or satisfactorily proven, to be the persons whose names are subscribed to the within instrument and acknowledged that they executed the same for the purposes therein contained. I hereunto set my hand and official seal. Notary UUMMUNWEALTH OF PENNSYLVANIA Notarial Seal Betty Ann McMullan, Notary Public Susquehanna Two., Dauphin County My Commission Expires Jan. 28, 2010 Member, Pennsylvanla Assoclatlon of Notaries 7Y 12/15/08 Y7:24:39 THE RAWLINGS COMPANY-> RA ngs. Company uc Subrogation Dimi n December 15, 2008 Mr. Andrew Dowling, Esq. Mette, Evans & Woodside 3401 North Front Street PO Box 5950 Harrisburg, PA 17110 Re: Our Client: Aetna Member/Patient:TONIA ULSH/JAMES ULSH Date of Loss: 12/1/2007 Our File No.: 08USH0400999 Your Client: Ulsh Dear Mr. Dowling: The Rawlings Company Page 002 16600 Sherman Way, Suite 260 Van Nuys, CA 91406-3776 Telephone (818) 908-3760 This letter will confirm our agreement to settle the above-referenced matter. We have agreed that my client's claim for medical benefits shall be settled in return for $10,666.67. Please make your check payable to The Rawlings Company and mail it to my attention at the following address: The Rawlings Company ATTN: Nancy Chan File No.: 08USH0400999 16600 Sherman Way Suite 260 Van Nuys, CA 91406-3736 If the above statement does not accurately reflect our agreement, please notify me immediately. Otherwise, I look forward to receiving payment within the next 30 days. Thank you for your cooperation in this matter. Sincerely, Ak? Nancy Chan Assistant Team Manager (818) 908-3760 ext. 234 FAX: (502) 753-6911 rd2@rawfingscompany.com 12/15/,8 17:25:2° T!-!F RAWLINGS COMPANY-> RA lings C oinpRany LLC subroptim D*ilion December 15, 2008 Mr. Andrew Dowling, Esq. Mette, Evans & Woodside 3401 North Front Street PO Box 5950 Harrisburg, PA 17110 Re: Our Client: Aetna Member/Patient: TONIA ULSH/KATHRYN ULSH Date of Loss: 12/1/2007 Our File No.: 08USH0500508 Your Client: Kathryn Ulsh Dear Mr. Dowling: The Rawlings Company Page 002 16600 Sherman Way, Suite 260 Van Nuys, CA 91406-3776 Telephone (818) 908-3760 This letter will confirm our agreement to settle the above-referenced matter. We have agreed that my client's claim for medical benefits shall be settled in return for $1,166.67. Please make your check payable to The Rawlings Company and mail it to my attention at the following address: The Rawlings Company ATTN: Nancy Chan File No.: 0SUSH0500508 16600 Sherman Way Suite 260 Van Nuys, CA 91406-3736 If the above statement does not accurately reflect our agreement, please notify me immediately. Otherwise, I look forward to receiving payment within the next 30 days. Thank you for your cooperation in this matter. Sincerely, Nancy Chan Assistant Team Manager (818) 908-3760 ext. 234 FAX: (502) 753-6911 rd2@rawfingscompany.com r D - M Q' Y1?wSCX. SOC1a S PLLC SHARON K. BROWN ATTORNEY AT LAW LICENSED IN CALIFORNIA May 28, 2008 Mr. Andrew Dowling, Esq. Mette, Evans & Woodside 3401 North Front Street PO Box 5950 Harrisburg, PA 17110 Re: Our Client: Member/Patient I)al , C T u va LV;;J. Our Files Nos.: Your Client: Dear Mr. Dowling: Aetna TONIA ULSH/JOHN ULSH i2/1/2G07 08USH0300845 (NL2) and related files John Ulsh 16600 SHERMAN WAY, SUITE 260 VAN Nuys, CALIFORNIA 91406 TELEPHONE (818) 908-3760 Exc. 232 TELECOPIER (818) 908-3761 S KB@RA WLINGSANDASSOCIATES.COM OFFICES ALSO IN: LOUISVILLE, KENTUCKY FLORENCE, KENTUCKY Our client continues to assert its recovery rights in this matter. Our client is willing to accept the following sums from the bodily injury proceeds: James Ulsh: $3,333.33 Tonia Ulsh: $1,000.00 Kathryn Ulsh: $ 666.66 John Ulsh: $5,000.00 Our client reserves its rights to recover from the uninsured/underinsured motorist proceeds in this matter. As our client has subrogation rights against Kemper Insurance, our office will continue to contact Kemper Insurance to ensure that those rights are honored. Please contact Ms. Chan or me to resolve the settlement from the bodily injury proceeds. Thank you for your professional courtesy. Sincercly, Sharon K. Brown Associate General Counsel to The Rawlings Company LLC (818) 908-3760 x232 FAX: (818) 908-3761 skb@rawlingsandassociates.com ?t "V 00 00 Ell %8b SU v w ? IN RE: JOHN AND TONIA ULSH, COURT OF COMMON PLEAS OF PARENTS AND NATURAL CUMBERLAND COUNTY, PENNSYLVANIA GUARDIANS OF KATHRYN ULSH -R-W A S ^"r T"T DIVISION AND JAMES ULSH, MINORS NO: 2009-1559 AND NOW, come Petitioners, John and Tonia Ulsh, parents and natural guardians of Katl yn Ulsh and James Ulsh, minors and petition this court for approval of minor settlement and avers the following: 1. On December 1, 2007, John Ulsh, Tonia Ulsh and Petitioners' minors Kathryn Ulsh (age 9) and James Ulsh (age 5) were injured in a two vehicle automobile accident and all sustained injuries. See Police Report attached hereto as Exhibit "A". 2. At the time of the accident and injuries sustained, Petitioners and Petitioners' minors resided at 109 Fairway Drive, Carlisle, PA 17013. 3. As a result of the above referenced accident, Kathryn Ulsh, a minor, suffered a broken collar bone and lacerations to her mid-area requiring stitches. See medical reports attached hereto as Exhibit "B". 4. As a result of the above referenced accident, James Ulsh, a minor, suffered a broken ankle, broken collar bone and internal injuries requiring surgery. See medical reports attached hereto as Exhibit "C". 5. The accident was caused solely by the negligence of Daniel J. Martin, Jr., who died as a result of the accident. 6. Daniel J. Martin, Jr., deceased was insured by Progressive Insurance Company with the liability limits of $15,000 each person/$30,000 each accident. 7. The liability limits were tendered and distributed among the four injured plaintiffs as follows: John Ulsh $15,000 James Ulsh, minor $10,000 Tonia Ulsh $ 3,000 Kathryn Ulsh, minor $ 2,000 See undated correspondence attached as Exhibit "D". 8. After the tender of the tortfeasor's policy limits, the Ulsh's family underinsured motorist carrier, Kemper Insurance Company, tendered their UIM limits of $300,000.00 and distributed the funds as follows: John Ulsh $100,000 Tonia Ulsh $ 60,000 Kathryn Ulsh $ 40,000 James Ulsh $100,000 See correspondence dated August 15, 2008 attached as Exhibit "E". 9. Progressive Insurance Company has requested that Petitioners sign a general release in exchange for the tender of the policy limits of the tortfeasor. Said releases are attached as Exhibit 'T' 10. Kemper Insurance Company, the UIM carrier, requested that the Petitioners sign a general release. Said releases are attached as Exhibit "G". 11. All liens associated with medical treatment provided to Petitioners' minor will be satisfied. See correspondence dated May 28, 2008 and December 15, 2008 attached hereto as Exhibit "H". 2 0 ? 12. With respect to the court approval, Petitioners' attorneys are not requesting the court to approve any attorney's fees and costs to be deducted from the funds paid by Progressive Insurance Company and Kemper Insurance Company. 13. Payments to the minors will be deposited in into the following bank accounts: A. With respect to James Ulsh, a minor, the amount of One Hundred Ten Thousand and 00/100 ($110,000.00) Dollars will be deposited into Susquehanna Bank, 1196 Walnut Bottom Road, Carlisle, Pennsylvania 17015 in Account No. 4801056420, an account which is insured by a Federal governmental agency. No withdrawal can be made from this account until the minor attains majority except as authorized by a prior Order of Court. B. With respect to Kathryn Ulsh, a minor, the amount of Forty-Two Thousand and 00/100 ($42,000.00) Dollars will be deposited into Susquehanna Bank, 1196 Walnut Bottom Road, Carlisle, Pennsylvania 17015 in Account No. 1161808320, an account which is insured by a Federal governmental agency. No withdrawal can be made from this account until the minor attains majority except as authorized by a prior Order of Court. 14. No Judge has ruled upon any other issue in this same matter. 15. Concurrence of counsel is not relevant in this instant action as the case settled prior to suit and no other counsel has been involved other than counsel for Petitioner's and Petitioner's minors. 16. Petitioners believe the settlement is reasonable and request the court approval the minor settlement. 3 r a v uao-'- Jo 1 h, Parent and Natural Guardian of Ka Ulsh and James Ulsh Tonia Ulsh, Pare and atural G ian of Kathryn Ulsh and James Ulsh Respectfully submitted, METTE, EVANS & WOODSIDE Date: March V , 2009 512643v1 By: Andrew H. Dowling, Esquire Sup. Ct. I.D. No. 39692 3401 North Front Street P. O. Box 5950 Harrisburg, PA 17110-0950 (717) 232-5000 - Phone (717) 236-1816 - Fax 4 ?v _ m ....1 Co ?x -,mot a ?T? i IN RE: JOHN AND TONIA ULSH, IN THE COURT OF COMMON PLEAS OF PARENTS AND NATURAL CUMBERLAND COUNTY, PENNSYLVANIA GUARDIANS OF KATHRYN ULSH AND JAMES ULSH, MINORS 09-1559 CIVIL TERM ORDER OF COURT AND NOW, this 1o day of March, 2009, IT IS ORDERED that a hearing shall be conducted on the within petition for the approval of minors' settlement at 3:00 p.m., Thursday, April 9, 2009, in Courtroom Number 2, Cumberland County Courthouse, Carlisle, Pennsylvania. Andrew H. Dowling, Esquire For Petitioners :sal e.oa rrt?.? i FU-D--OF 'r", (CE OF THE 2009 MAR 31 Ay 9: Z( CU, T Y 4? i IN RE: JOHN AND TONIA ULSH, COURT OF COMMON PLEAS OF PARENTS AND NATURAL CUMBERLAND COUNTY, PENNSYLVANIA GUARDIANS OF KATHRYN ULSH ORPHANS COURT DIVISION AND JAMES ULSH, MINORS NO: 2009-1559 MOTION FOR CONTINUANCE OF HEARING AND NOW, come Petitioners, John and Tonia Ulsh, parents and natural guardians of Kathryn Ulsh and James Ulsh, minors and files this Motion for Continuance and avers the following: 1. This Honorable court entered an Order which schedules a hearing in the above- captioned matter for April 9, 2009. The Order is attached as Exhibit "A". 2. Petitioners will be out-of-town on April 9, 2009 and returning on April 14, 2009. 3. The Honorable Edgar B. Bayley has been assigned to this matter. WHEREFORE, in light of the foregoing, the Petitioners respectfully request this Honorable court reschedule the hearing in the above-captioned case. Respectfully submitted, METTE, EVANS & WOODSIDE ?y By: ?-? Andrew H. Dowling, Esquire Sup. Ct. I.D. No. 39692 3401 North Front Street P.O. Box 5950 Harrisburg, PA 17110-0950 (717) 232-5000 Attorneys for Petitioners Date: April 3, 2009 513468v1 IN RE: JOHN AND TONIA ULSH, IN THE COURT OF COMMON PLEAS OF PARENTS AND NATURAL CUMBERLAND COUNTY, PENNSYLVANIA GUARDIANS OF KATHRYN ULSH AND JAMES ULSH, MINORS 09-1559 CIVIL TERM ORDER OF COURT AND NOW, this -o day of March, 2009, IT IS ORDERED that a hearing shall be conducted on the within petition for the approval of minors' settlement at 3:00 p.m., Thursday, April 9, 2009, in Courtroom Number 2, Cumberland County Courthouse, Carlisle, Pennsylvania. By the Csurt, Edgar B. Bayley, Andrew H. Dowling, Esquire For Petitioners sal . r. A0, 4 nA Dow Sf 00 r-4- - l C,..d j. _f. f. C3' y h i ? APR G 6 20094 IN RE: JOHN AND TONIA LSH, COURT OF COMMON PLEAS OF PARENTS AND NATURAL CUMBERLAND COUNTY, PENNSYLVANIA GUARDIANS OF KATHR ULSH C t v i L COURT DIVISION AND JAMES ULSH, MINORS NO: 2009-1559 AND NOW, this for April 9, 2009, is Courtroom No. 0 ORDER OF COURT day of April, 2009, IT IS ORDERED that a hearing scheduled D to jTbA 5 A 00 at 10 = a.m. in County Co Louse, Carlisle, Pennsylva*. ?y By the Court, Edgar V. Bayley, J. 0A co cz, j ? , g E cr% "' -ti` `i ,w RE: JOHN AND TONIA ULSH, IN THE COURT OF COMMON IN CUMBERLAND PARENTS AND NATURAL GUARDIANS OF KATHRYN ULSH 09_1559 CIVIL TERM AND JAMES ULSH, MINORS ORDER OF COURT AND NOW, this 1141 day of May, 2009, upon consideration of the petition for approval of minor settlement pursuant to Pa. Rule of Civil Procedure 2039, IT IS ORDERED that the petition is approved, that the petitioners are permitted to sign the releases requested by Progressive Insurance Company and Kemper Insurance Company and the monies will be distributed as follows: (A) The amount of $110,000 shall be deposited in a federally insured interest bearing investment at Susquehanna Bank, 1196 Walnut Bottom Road, Carlisle, Pennsylvania IN THE NAME OF JAMES ULSH, BORN JULY 24, 2003. THE ACCOUNT SHALL CONTAIN THE FOLLOWING NOTATION: "NO WITHDRAWAL CAN BE MADE PRIOR TO JAMES ULSH, BORN JULY 24, 2003, OBTAINING HIS MAJORITY EXCEPT BY AN ORDER OF A COURT OF COMPETENT JURISDICTION." (B) The amount of $42,000 shall be deposited in a federally insured interest bearing investment at Susquehanna Bank, 1196 Walnut Bottom Road, Carlisle, Pennsylvania IN THE NAME OF KATHRYN ULSH, BORN MARCH 23, 11999. THE ACCOUNT SHALL CONTAIN THE FOLLOWING NOTATION: "NO WITHDRAWAL CAN BE MADE PRIOR TO KATHRYN ULSH, BORN MARCH 23, 1999, OBTAINING HER MAJORITY EXCEPT BY AN ORDER OF A COURT OF COMPETENT JURISDICTION." 1? Andrew H. Dowling, Esquire For Petitioners :sal <'a 8 t ? 1 w lam , ?. N U Andrew H. Dowling, Esquire METTE, EVANS & WOODSIDE 3401 North Front Street P. O. Box 5950 Harrisburg, PA 17110-0950 (717) 232-5000 -Phone (717) 236-1816 -Fax ahdowling@mette.com IN RE: JOHN AND TONIA ULSH, IN THE COURT OF COMMON PLEAS OF PARENTS AND NATURAL CUMBERLAND COUNTY, PENNSYLVANIA GUARDIANS OF KATHRYN ULSH AND JAMES ULSH, MINORS 09-1559 - CIVIL TERM PRAECIPE TO SETTLE AND DISCONTINUE TO THE PROTHONOTARY: Please mark the docket in the above captioned action settled and discontinued. Respectfully submitted, METTE, EVANS & WOODSIDE ~- By. ` ~- Andrew H. Dowling, Esquire Sup. Ct. I.D. No. 39692 3401 North Front Street P. O. Box 5950 Harrisburg, PA 17110-0950 (717) 232-5000 -Phone (717) 236-1816 -Fax Attorneys for Plaintiffs Date: August 11, 2009 517925v1 Ff~~::_.,_ _ ~_. . ~ ~ ~~,; ,