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HomeMy WebLinkAbout09-1562SKARLATOS & ZONARICH LLP John R. Zonarich, Esq. John B. Zonarich, Esq. Skarlatos & Zonarich Building 17 South Second Street, 6 h Floor Harrisburg, Pennsylvania 17101 Telephone: (717) 233-1000 Facsimile: (717) 233-6740 Email: jrz@skarlatoszonarich.com jbz@skarlatoszonarich.com Attorneys for Petitioners, Ronald L. & Susan L. Woolf, Parents and Natural Guardians of Dale C. Woolf, a minor, Kathi A. Woolf, a minor, and Aimee S. & David R. Woolf, Jr., Parents and Natural Guardians of Skyler A. Woolf, a minor IN RE: DALE C. WOOLF, KATHI A. WOOLF, SKYLER A. WOOLF IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. O PETITION FOR APPROVAL OF MINOR'S SETTLEMENT TO THE HONORABLE, THE JUDGES OF THE SAID COURT: Pursuant to Pa. R.C.P. No. 2039, Ronald L. Woolf and Susan L. Woolf, his wife, the parents and natural guardians of minors Dale C. Woolf, and Kathi, A. Woolf; and David R. Woolf, Jr. and Aimee S. Woolf, his wife, the parents and natural guardians of minor, Skyler A. Woolf, by and through their attorneys, Skarlatos & Zonarich LLP, petitions this Court to enter an order permitting settlement in compromise of this action, and in support avers the following: BACKGROUND Ronald L. Woolf and Susan L. Woolf, his wife, are the parents and natural guardians of the minor-plaintiffs Dale C. Woolf, who was born on February 5, 1995, and Kathi -1- A. Woolf, who was born on January 25, 1998. Dale C. Woolf is presently fourteen (14) years of age and Kathi A. Woolf is presently eleven (11) years of age. 2. David R. Woolf, Jr. and Aimee S. Woolf, his wife, are the parents and natural guardians of the minor-plaintiff, Skyler A. Woolf, who was born on February 14, 2000, and who is presently, nine (9) years of age. 3. Dale C. Woolf and Kathi A. Woolf, the minor-plaintiffs reside with their parents and natural guardians, Ronald L. Woolf and Susan L. Woolf, at 200 West Main Street, Walnut Bottom, Pennsylvania 17266. 4. Skyler A. Woolf, the minor-plaintiff resides with her parents and natural guardians, David R. Woolf, Jr. and Aimee S. Woolf, at 405 Pidgeon Hill Road, Branchville, NJ 07826. ACCIDENT AND INJURIES 5. Dale C. Woolf, Kathi A. Woolf, and Skyler A. Woolf, the minor-plaintiffs, were injured on Saturday, May 19, 2007, at the intersection of Oakville Road and Spring Road, Cumberland County, Pennsylvania, when they were riding as passengers in the vehicle driven by Ronald L. Woolf, which was struck by a vehicle driven by Shawn D. Strite. The impact of the collision forced the vehicle driven by Ronald L. Woolf, to flip over several times before coming to rest on its side. A copy of the Pennsylvania State Police accident report is attached as Exhibit «1,? 6. Dale C. Woolf, the minor-plaintiff, was transported from the scene of the accident on May 19, 2007, by helicopter to Hershey Medical Center. It was suspected that Dale had a punctured lung, road rash up his back, a gash on his right elbow, scratches, bruises, and a hair -2- line fracture of his right shoulder. A copy of Hershey Medical Center's Discharge Summary is attached hereto as Exhibit "2". 7. Kathi A. Woolf, the minor-plaintiff, was transported from the scene of the accident on May 19, 2007, by Shippensburg Area EMS to Carlisle Regional Medical Center. Kathi received bruises on her face; swelling of her nose, a forehead contusion, and a bruise on her right temple. Kathi experienced headaches and dizziness. A copy of Carlisle Regional Medical Center Discharge Summary is attached hereto as Exhibit "3". g. Skyler A. Woolf, the minor-plaintiff, was treated at Carlisle Regional Medical Center. Skyler received cuts, bruises on the right side of her face, bruises on the left side of her cheek bone to the top of her lip, a bruise and cut on the left side of her jaw bone. Skyler also received a bruise on her right hip, and was having headaches and nightmares. A copy of Carlisle Regional Medical Center Discharge Summary is attached hereto as Exhibit "4". 9. Dale C. Woolf, the minor-plaintiff, has fully recovered from injuries. Dale still intermittently complains of shoulder pain since the accident. 10. Kathi A. Woolf, the minor-plaintiff, has recovered from her injuries. 11. Skyler A. Woolf, the minor-plaintiff, has fully recovered medically from the injuries she received from the accident. Skyler does continue to have bad dreams about the accident from time to time. LEGAL COUNSEL AND INVESTIGATION 12. On May 23, 2007, Ronald L. Woolf and Susan L. Woolf, and Aimee S. Woolf retained Skarlatos & Zonarich LLP to represent Dale C. Woolf, Kathi A. Woolf, and Skyler A. Woolf in matters arising from the accident on May 19, 2007. Although Skarlatos & Zonarich -3- LLP has been retained to represent the minor children, the firm has elected not to take a fee for their services. 13. Upon investigation, the undersigned counsel for the minor-plaintiffs, Dale C. Woolf, Kathi A. Woolf, and Skyler A. Woolf, determined that the defendant tortfeasor Shawn D. Strite was insured by Nationwide Insurance Company under a policy of insurance with bodily injury liability limits of twenty five thousand dollars ($25,000) each person, fifty thousand dollars ($50,000) for each occurrence. A copy of the insurance coverage printout for Shawn D. Strite is attached as Exhibit "5". 14. Upon further investigation, the undersigned counsel for the minor-plaintiffs Dale C. Woolf, Kathi A. Woolf, and Skyler A. Woolf determined that the minor-plaintiffs were covered on the date of the accident by a policy of insurance issued by Unitrin. A copy of the insurance declaration page is attached as Exhibit "6". The insureds policy carries only a LIMITED TORT OPTION. 15. Upon further investigation, based upon the minor injuries incurred by plaintiffs, Dale C. Woolf, Kathi A. Woolf, and Skyler A. Woolf, Plaintiffs are precluded from seeking financial compensation for injuries caused by Defendant Shawn D. Strite, such as pain and suffering and nonmonetary damages. 16. Also based upon counsel's investigation there exists no exception to the limited tort upon which Plaintiff's can sue for reasonable non-economic compensation. PROPOSED SETTLEMENT 17. Despite the limited tort provisions of all minors parents' insurance policies, the undersigned counsel has been able to obtain settlements from the Defendant's insurance carrier, Nationwide, as follows: (See attached letter from Nationwide Insurance as Exhibit "T'). -4- a. Dale C. Woolf - $1,500.00 b. Kathi A. Woolf - $1,000.00 c. Skyler A. Woolf - $1,000.00 If the settlements are approved the settlement proceeds will be deposited into restricted, federal insured accounts marked "No withdrawals prior to age 18 without prior court approval". FEES EXPENSES and LIENHOLDERS 18. As stated previously, the undersigned counsel has agreed not to take any fees in this case. CONCURRENCES 19. Petitioners and counsel seek approval of the individual settlements on behalf of the minor-plaintiffs Dale C. Woolf, Kathi A. Woolf, and Skyler A. Woolf. 20. Counsel for Petitioners is of the professional opinion that due to the uncertainties of litigation, and in light of the limited tort options of all parties that the proposed compromise is reasonable and is in the best interest of the minor-plaintiffs. 21. Petitioners, Ronald L. Woolf, Susan L. Woolf, the parents and natural guardians of minors Dale C. Woolf and Kathi A. Woolf, and Petitioner, Aimee S. Woolf and David R. Woolf, Jr., the parents and natural guardians of Skyler A. Woolf , concur in the proposed settlement and distribution. Petitioners further approve the proposed distribution contained in the form order attached. Their consents are attached as Exhibit "8". 22. No hearing is requested. -5- WHEREFORE, Petitioners, Ronald L. Woolf, Susan L. Woolf, the parents and natural guardians of minors Dale C. Woolf and Kathi A. Woolf, and Petitioners, David R. Woolf, Jr. and Aimee S. Woolf, the parents and natural guardians of minor Skyler A. Woolf, request that this Court enter an order approving the proposed settlement and compromise; authorize them to make disbursements pursuant to the Petition, and to execute all necessary releases and endorse all checks. Respectfully submitted, Dated: -fllQ - Q q By: Jo1Sn R. " onaricti, uire Identif, at-ion No. 19 &mtificationNo. Zonarich, Esquire 79989 -6- Skarlatos & Zonarich Building 17 South Second Street, 6th Floor Harrisburg, Pennsylvania 17101 Telephone (717) 233 - 1000 Facsimile: (717) 233 - 6740 Email: jrz@skarlatoszonarich.com jbz@skarlatoszonarich. com Attorneys for Petitioners Ronald L. Woolf and Susan L. Woolf, Parents and Natural Guardians of Dale C. Woolf and Kathi A. Woolf, a minor, and Petitioners, David r. Woolf, Jr. and Aimee S. Woolf, Parents and Natural Guardians of Skyler A. Woolf, a minor VERIFICATION We, Ronald L. Woolf and Susan L. Woolf, hereby certify that the facts set forth in the following Petition are based upon information which we have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on our behalf in this matter. The language in the Petition is that of counsel and not our own. We have read the Petition, and to the extent it is based upon information which we have given to counsel, it is true and correct to the best of my knowledge, information and belief. To the extent that the content of the Petition is that of counsel, we have relied upon counsel in making this Verification. We hereby acknowledge that the facts set forth in the aforesaid Petition are made subject to the penalties of 18 Pa.C.S.A. §4904 relating to unsworn falsification to authorities. Dated: Z - `? !6 Ronald L. Woolf i?pir Dated: 2 - ZS C?Y1 Susan L. Woolf VERIFICATION We, David R. Woolf, Jr. and Aimee S. Woolf, hereby certify that the facts set forth in the following Petition are based upon information which we have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on our behalf in this matter. The language in the Petition is that of counsel and not our own. We have read the Petition, and to the extent it is based upon information which we have given to counsel, it is true and correct to the best of my knowledge, information and belief. To the extent that the content of the Petition is that of counsel, we have relied upon counsel in making this Verification. We hereby acknowledge that the facts set forth in the aforesaid Petition are made subject to the penalties of 18 Pa.C.S.A. §4904 relating to unworn falsification to authorities. Dated: U J, 3)a Dated: 4id Woolf, Jr. Aimee S. Woolf COMMONWEALTH OF PENNSYLVANIA JA ' V,, POLICE CRASH REPORTING FORM Page Case Closed Reportable Crash • AA 500 1 r v- r-n r r„ 90k Yes r-1 No I of 1__l 1111111111111111111111 CrashNumber P 1257161 incident Number Police A gem Patrol Zone s ' p Precinct Investigation Date (MM•DD-YYYY) Agency Name er r Dis ch rime (mrn Arrival Time (min Investigator Badge Number - 7 S 2I- 5 1 a S?V?1>ti- L a Reviewer Badge Number A naval Date (MM-DD-YYYY) Court county Name Municipals Municipality Name Q?v of Weak Q Sun O Thu O Mon O Fri O Crash Time (mil) No of Units Pea le Injured 101led* *0> 00 Crash Date (MM-DD-Y" Q Tue 42 Sat s ZLA Form F Q Wed Q Unk Workzone /?f Yep, Complete ©Yes No School Bus O Yes ®o ReSdoo?2one O Yes ® No M e TQ Yes @ No n 29) Re cti S F u e o orm l l Nttemcdon trvne ®4 Way Intersection O `Y- Intersection O inter lion O Off Ramp O Railroad Crossing L S O MkNock Traffic Circle! Q 'T" Intersection O Round About O On Ramp Q Crossover O Other * See Dveria Route Number Segment (Optional) Travel Lanes Speed Limit O North House Number (if applicable) b 3 C> ?-, i ® South a Street Endin .9 0 East For Mid-block crashes only use g A f Name Street y O West postal House Number and make sure Principal Roadway Street Name Is ? O Unknown Y filled in if using this option p ? Signft Interstate Q Turnpike Q Turnpike State Q County 0 Local Road O Private 0 Other/ Q (Not Turnpike) (EZ' esU Spur Highway Road or Street Road Unknown o M Route Number Segment (Optional) Travel Lanes Speed Limit Q North 3 3 3 ® C7 o South 10 Street Name Street End O East ing West is O unknown Route -- Interstate O Turnpike O Turnpike O State County O Local Road O Private O Other/ O (Not Tumpike) (East/West) Spur Highway Road or Street Road Unknown Intersecting Rt Num Or Mile Post Or Segment Marker Feet ?? . ? 4 O North O South E E q o Or Intersecting Street Name St Ending O East Or Miles Please En ter a O West a I I I ormalion tn( . a E for BOTH Landmarks if Using Intersecting Rt Num Or Mile Post Or Segment Marker t? North Distance From Crash Scene to Landmark 1 C This Opiron r L ! m Q South (For Crash between A c Or Intersecting Street Name St Ending 91 O East Landmark t and l a L O West Landmark 2) m T Degrees Minuttees: . Seconds Degrees Minutes Seconds Latitude.- y a ? C7 1'i "? longitude: - : E5 Z p naffic ott oLDRzke Q Yield Sign O Police Officer or Emergency Flagman 0 No Controls O Device Functioning O Preemptive O Not Applicable Traffic Signal Active RR Crossing Improperly (::) C ls s O Other Type TCD Signal tr e u s- o on Flashing Traffic ® Stop Sign Passive RR 0 Device Not I& Device Functioning O Unknown O Unknown Functioning Properly l p g O Signa Crossing Controls a l (if "Not Appikable ; skip rest of the Lane Closure section) Land l O North O East O North and South tW All (N_S-E.W) o O Not Applicable O Partially 40 Fully Q Unknown Direction O South O West O East and West 9 u Traffic Yes-? No O Est O 30 Min ti 30-60 Min Q 1-3 hrs Q 3-6 hrs f0 6-9 hrs O > g hours O Unknown aetctured unknown Q FoRU it A"up (12m) PENNOOT COPY COMMONWEALTH OF PENNSYLVANIA 111111101 Crash Number J POLICE CRASH REPORTING FORM Page: P1257161 AA 500 2 Poke LV-M"L- )/Z5 W101 EIS ® Motor Vehicle in 0 Hit & Run Vehicle 0 Illegally Parked O Legally Parked 7(0::) on -Motorized Commercial Vehicle I?C, ' e Transport Q Yes AS No Unit 0 Pedestrian 0 Pedestrian on Skates, 0 Disabled From 0 Train hantom Vehlde in Wheelchairetc Previous Crash {if Yes Complete Form C) kte Form M, Sa) ? a? .?.?Y..r...• ... •oe.re Fen nn Slrares_ in Wheelchair etc'. ComP Unit No First Name MI 10 H Delete? Last Name 0 % (?sfi 0 E c A ,t i a. A a r Z-"76I w aasvv " W Alcohol/Drugs Suspected IS No O Illegal Drugs O Medication O Alcohol 0 Alcohol and Drugs C} Unknown Date of Birth(MM-DD-YYYY) cry --> -La?dg 15-1 Telephone Number o l zip b 1 i. o State class N relntly o I ri Drug 0 Fatigue 0 Medication 0 Had Been Q Sick O Asleep Q Unknown Alcohol Test Type Primary Vehicle Code Violation Charged? a Test Not Given Q Breath O Other if n ii - -3 `Z,3 6 430 yes O No 0 Blood Q Urine O Te s[ Give Alcohol Test Results O Test Refused Q R nnown Driver Presence 1=Driver Operated Vehicle 3=Driver Fled Scene 4=Hit and Run ? (T1 Test Given, Q i a 9=Unknown • Contaminated Results ver 2=No Dr OwnedDriver 00=Not Appkable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh 094ederal Gov Veh r 01h 98 01=Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 06=Other State Gov Veh 08=0ther Municipal Government Vehicle e = 99-Unknown d Leased by Driver 03=Rented Vehicle same as Owner First Name Driver OFF-1 I Address 1 City I State /Zip ' Vehicle Make *Make Code 1Z)17 rrY ? 10 VIN Z i Model Year ;, Z -e Vehicle model (see overlay) g+ 3 p 10 5 Z G 2 - ,: - o" License Plate Reg. State Est Speed Vehlde Towed Towed By " P N 1 1 1-) 1 I = I a Yes ONO ?j c:7 Insurance Company Policy No Insurance N Un- - 1 t S ?s / ?1 o c (ig Yes 0 ? o known w r. .?. e -- e Trani o U No. of D Tralkng m Units: V T e 1=Towing Pass, Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No Tar Tag St =1 n2=Towing Truck 5=Camper B=Other -JI I 3=towing Utility Trailer 6=Full Trailer 9=Unknown Direction of • Vehicle Position ?., ram a L`?J J Spedal Usage 12=Commercial Passenger 00-Not Applicable carrier 01=Fire Veh 13=Ta3i 02-Ambulance 21=Tractor Trailer 03=Police 22=Twin Trailer 08=0ther Emergency 23=Triple Trailer Vehicle 31=Modified Veh I 1=Pupil Transport 99=Unknown 05-Black 99-Unknown Form M, Section 27) a ype Initial h?act Point Damage indicator Gradlen 3=Downbli Road Allynment 00=Non-Collision 14=Undercarriage 0=None 2=Functional 4=Bottom of Hill f=Straight FIT] t=Minnr 3=Disabling © 1=Level 5-Top of Hill ? 2=Curved 01 12=Clock Points 1 5=Towed Unit 9=Unknown 2=Uphill 9:Unknown 9=Unknown i 13=Top g4dinknown Owner Last Name or Business Name 'Movement p , '? Overlay Vehicle Color Vehicle Tvoe 05-Large Truck 20-Unicycle. Bicycle. ® 06=Yellow 07 07=Sihrer 01=Automobile ?$ 02=Motorcycle 06=SUV 07=Van Van Tricycle 21=Other Pedaky & Bu 22 H 118=Gold 03=Bus 10=Snowmobile ggy y = orse 2 01=Blue 02=Red 09=Brown 10=Orange 04=5mak Truck (if '027, Complete Form 11 --Farm Equip 12=Construction Equip 1r 23=Horse Be R 24=Train 03=White 11=Purple h M, Section 26) 13=ATV e 25=Trolley 04=Green er 12=Ot Of 120' or '21, Complete 19 Unk T S Veh 99=Unknown Fonts.AA-SW (t2 ) PENNDOT COPY COMMOF4WEALTH OF PERNSYLVANDA POLICE CRASH REPORTING (FORM P125,161 Page: AA 500 2 rotce vie v .y r„ f 6 L7 Motor Vehicle in C) Hit & Run Vehicle O Illegally Parked lie ® Transport 10 ?, Unit Pedestrian on Skates. Disabled From = Q Pedestrian in Wheelhair. etc Previous Crash of 'Pedestrian" or 'Pedestrian On Skates, in Wheelchair, etc', t O Legally Parked O Non - Motorized Q Train Unit No First Name MI Delete? Last Name 0 W z? L- 0 % OF O Phantom Vehicle 1,9 t !v 6 im O m V m Gash Number Commercial vehicle (:).Yes @P No (if yes, Complete Form 0 Date of Birth (MMI-00-yyyy) i ? ) I 1 s Tef nne Number Zf state Class AlcohoW nws Suspected ® No (::) Illegal Drugs C) Medication Cb Q Alcohol C) Alcohol and Drugs C) Unknown C) Used Drug (::) Fatigue Q Medication C] Sick Q Asleep C) Unknown Alcohol Test Tit Primary Vehide code Violation Charged? ® Test Not Given C) Breath 0 Other _ C) Yes Q No Q Blood Q Urine T? t GGi enif Aloohof Test Results 0 Test Relused C) Results Driver Presertce 1=Driver Operated 3=Driver Fled Scene Hif and Run 4 Test Given, a. 0 Contaminated Results = Vehicle 2=No Driver 9=Unknown Own MlDriver 00=Not Applicable D2=Private Vehicle Not i D4=State Police vehicle 07=Municipal Pbice Veh PENNDOT Vehicle 06=Other Municipal 05 09=Federal Gov Veh 98=Other of =Private vehicle Owned/ i ver Owneduased by Dr 03=Rented Vehicle = 06=0ther State Gov Veh Government Vehicle 99=Unknown •? ver Leased by Dr same as I1 f Owner Driver I f Address I City I Owner Last Name Model Year VIN h k2 -1X% .34_',S AG= )'4IS ?7 1?5?i 1 License Plate Reg. State Est. Speed vehicle Towed y N 3 F? I I ® -7 s 'P Yes 0 No Insurance Insurance Company 1.y Polity No Un- own ? W s= ?- ?? Ty+ C'`J }1? %4 0 i ? C-,4 73L ® Yes 0 No CD kn Vehicle Make `Make Code Vehicle Model (see overlay) (L k- TTowwedd-By I `n?yCEGsr?'G??? o? c m Type f failing g 1=Towing Pass. Veh Towing Truck Z 4=Moble/Nlodular Home 7=Semi-Trailer 5=Camper 8=0ther Tag No Tag Year Tao No, o Trading - 3=Towing Utility Trailer 6=Full Trailer 9=Unknown J Units: Vi ction of © 'vehicle Position ? (, rT `Movement 1 11 I 11 *see Overlay speda! Usage I Z> 12=Commerdal _Vehide Color Vehicle Type o5=Large Truck V S 20=Unicyde, Bicycle, Tricycle bl l Passenger r r C cJ 06=Yellow 07=Silver 01=Automobile 02=Motorcycle 06= U 07=Van 21=Other Pecialcycle e & Buoy H 22 ica e 00-Not App 01 =Fire Veh ar ie 13=Taxi l 08=1jold 03=Bus 10=Snowmobile ors = 02=Ambulance 21=Tractor Trai er 01=Blue 0_ town e 04=Small Truck Complete Form (if -02' 1 i=farm Equip 12=Construction Equip 23=Horse & Rider 24=Train 03=Police 22=Twin Trailer 08=0ther Emergency 23=Triple Trader 02=Red 10=0rang 03=White 11=Purple , M, Section 16) 13=A1V 18=0ther Type Spec Veh 25=Trolley 98=0ther Vehide 11=Pupil Transport 31 =Modified Veh 99=Unknown 04=Green 12=Other 05=Black 99=Unknown (if "20' or '21, Complete Form M, Section 27) 19=Unk Type Spec Veh 99=Unknown lnklaJ impact Point h dercarriage U 14 i Damage indicator D=None 2=Functional 1 Grate nit l 3=Downhill 4=Bottom of Hill Road AUonment 1=Straight d n = on is 00=Non-Go Ck Points 15=Towed Unit t I n1 17 ? 3 1=Minor 3=Disabling 41 Z=Uph Uphih 5=Top of Hill 9=Curve 9=Unknown . - = 9=Unknown 9=Unknown 1R:Tee 99=Unknown " FORM 0 AA-500 (12102) PENNDOT COPY COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM 1111111111111 P1257161 Page AA 5OO a ?: i6G s66 Crash Number 7 Seat Fbsftion: '(N Jnme?rr : one AQ river p 00=Not A Pa dOccupmt E 00=None Used / Not Applicable 01=Shoulder Belt Used All V i ('] Applicable 1?t E'eded I 2=Passenger 7=Pedestrian 8=Other es ver - 01-Dr 02=front Seat Middle Position 03=front Seat Right Side 02=Lap Belt Used 03=Lap And Shoulder Belt Used 2=TotaB Eed 3=Partially ected 9=Unknown 04--Second Row - Left Side Or Motorcycle Passengw Position - Middl d R 04=Child Safety Seat Used 05=Motorcycle Helmet Used 06=81cVde Helmet Used 4=Unknown H crion Path: i Female B e ow 05=Secon 06=Second Row - Right Side 07=Third Row Or Greater - 1 D=Safety Belt Used Improperly 11=Child Safety Seat Used Improperly erl ro d I U l w e D--Not Ejected / Not Applicable 1= Through Side Door Opening M=Male c « U =Unkno n Left Side =Third Row Or Greater - y p mp se met 12:He 90=Restraint Used, Type Unknown 2=Through Side Window 3=Through Windshield w rd Middle Position 09--TNrd Row Or Greater - 99-Unknown 4=Through Back Door 5=Through Back Door Tailgate Opening 0=No Right Side I O=Sleeper Section of Truckcab 11dn Other Enclosed f 6=Through Roof Openiknnqg (Sunroof/ F 00= ne Used/ of Applicable Convertible Top Down) 01 =Front Air Bag Deployed (For This Seat) 7=7hrough Roof Opening (Convertible 1-Killed 0 2=Major Injury ° Passenger Or Cargo Area 12=in Open Area Etc) Of Picku c B 02=Side Air Bag De (For This Se 03=Other Type Air ag Deployed 04=Multiple Air Bags Deployed at) Top Up) 9=Unknown 3=Moderate a In))u 4=fvlkI Injury k p. a ( 13-TraiBrtg Unit 14- icing On Vehicle Exterior 05-Motorcycle Eye Protection 06=Bicycist Wearing Elbow/Knee/Pads Extdration : ( B=1ury Unk 15=Bus Passenger 48?ther Io=Afr Bag Not Deployed, Switch on 11"r Bag Not Deployed, Switch Off 0=Not Applicable i=Not Extricated 9=Unknown vn if Injury 99=Unknown 12=Air Bag Not Deployed, Unk Switch Seth Kerr=rior To Crash) 13=Air Ba 2=Extricated By Mechanical Means 3=Freed By Non - Mechanical Means 8 Oth g 19=Unknown If Air Bag Deployed = er 9=Unknown 99=Unknown EMS Agency: J Medical Facility: f .G Unit No Person No Date of Birth (MM-DD-YYYY) A B C 6111 DOe? ?_m -mm?®? [-5M- DE F G H I IS 3 a 5©© is Name / Address / Phone EMS Transport Same O Yes I* No Operator Unit No Person No p 1 Delete? Date of Birth (MM-DD-YYYY) A B CC eOeT m^m_???aLJ D E F G H I ?? aa? Name I Address / Phone EMS Transport Same Operatto or ® Yes C7 No Unit No Person No m © L Date of Birth (MM-DD-YYYY) A B C DeO ? r,. -?- 5 ?00 D E F G H I ° 3 a aizz? 1a Name / Address / Phone EMS Transport Same as E' \'.." '.Le< 'L a? W ty 1iy'11 S ? W ?`N? r- ?:? i"t^oi... ?? F1. 1WYes 0 No operator Unit No Person No ? 3 Date of Birth (MM-0D-YYYY) A t8 C DelOete7 l- 5 - C? L_J 1? M D? { E F nG HH I P `y 0 d t r t L=J Name / Address / Phone EMS Transport Some as Operator 40 Yes (::) No Unit No Person No 2 y Delete? Date of Birth (MM-DD-YYYY) A -B C D E ??F ??II I G H I o F-IF -I- E FgFP F ° C?1®P] Name / Address / Phone Same as t1 r 51NL.i?'i?- \,ao ?f ?(? M ty 1+.+ ?? EMS Trans port v 1??ti ® 0 No T'e'a Yes Operator -' Unit No Person No m W C D E Fm G H I Delete? Date of Birth (MM-DD-YYYY) A F CD m- ? L-l C? L? t_.__.E._.J FIE] Name / Address / Phone EMS Transport Sauer Operator O Yes 0 No Form 0 AA-00 (12M) PENNDOT COPY COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page AA 500 4 1 &C, 5 dl 111111111111111 Crash Number P1257161 (6 is O=Non-Colision 2-Head On 4=Angle 6=Sideswipe 8=Hit Pedestrian site Direction) crash 1)escriotlon _ id??g ? t=Rear End 3=Beat imago Rear 5= same Dkeclion) 7 Object 9.-0herNnknown o ti c on) 0 1=On Travel Lanes 3=Median 5=Outside Traflirway 7=Gore {Ramp Intersec Relation to Roadwav Lane 9=UnlvtoNrtt 6=In ParkYr id d g e s 2-Shoulder 4.Roa 5 tl ll i 1=Dayllght 31fi - Street 5=DDawn 8=Other i hts k M A na um on f ® g 6=(?d m rww 2=Dark - No Street is 4=Dusk V N C 3 1=Nopdrse 3=Sleet {Hall) 3-Fog 7=Sleet & Fog 9=Unknown Weather conditions CondHbns g] 2=? 4--Snow 6=Rain 8 Fog 8--Other =D 2-?OiI d, Mud, Did, 4?IUSh 7B==lceg Patches =w Road Surface conditions 8=Other Stung I o 5 ce = r Mow 1 et 3-Snow Covered Harm Event L/R Mos0 U rty PO a Num r 1 El m r HaM ul Events (Harm Event) 30=Hit Fence Or Wall 01=Hrt Unit 1 31=Hit BuilrtAg 02=Hit Unit 2 32=Hit CUNert Unit No 03=Hi1 Unit 3 33-HR Bridge Pier Or Abutment 1 2 m 04=Hit Unit 4 34=Hit Parapet End it Unit 5 35=Hit Bridge Rail or Obstacle ld i B H er t ou 06-Hit Other Traffic Urnl 36=H On Roadway a O m Please Put 3 i Deer 07 08=?1i1 Other Other Animal 37=Hit Impact ttenuator 38=Hit Fire Hydrant n Events L_ L J Sequential 094oNtsion With Other Non Fixed Object 39=Hit Roadway Equipment v Order m 4 Q TTT1 11=Struck By Unit 1 40=Hit Tratl Box c Wand 12=Struck BY Unit 2 41=Nit Traffic 13=Struck By Unit 3 42=Hit Snow Bank i 6 on 14=5truck By Unit 4 43=Hit Temporary Construct b ., Harm Event L/R Most? Utility Pole Number 0 15=Struck By Unit 5 Barrier 16=Struck By Other Traffic Unit 48=1-111, Other Fixed Ob ect 49=Hit Unknown Fixed Object Shrubber t Tree Hi 21 d Unit No y 50=Overtunilitoll over 22== Hlt Embankment F1 C] 2 23=Hit Utility Pole 51-Struck By Thrown Or Falling 24=HK Traffic Sign Object z 25=Hi1 Guard Red 52=Pot Hales Or Other Please Put 3 f 1 J i 26=Hh Guard Rail End Pavement Irregularities 27=Hit Curb 53=n e 54=Fire Fire In Vehicle _ n Events Sequential 28=Hh Concrete Or Longitudinal Barrier 58=Other Non-Collision order 4 O 29=Hit Ditch 99=Unknown Harmful Evert i7 First Unit No Harm Event Most Unit No Harm Event armful )ful O vent in ti J =Careless Or Illegal Driver Action (D) 17 Racking On Roadway 00=No Conltibuting Action 18=Dmmsg The Wrong On Oi=Driver Was Distracted ?? n i, enTZ?sh a :h Side Of ad 02=Driving Uwg Hand Held Phone Ro 19 Ro i Ph F d P OPer . ou mr repeat d?a WANW4 "an ffl hok pNes ree one s 03=Driving Using Han =e al UTurn To Highway Makin Ille 04 g = g Exit 20=Making Turnin 05 b Environmental/Roadwav tors (EIR} t 2 3 L l F i , trwa g = npr From ar O6=Turnirig ing From Wrong Lane From ifighway ac a Potent 01=Proceeding 21=Careless ParkingNnparking (ice/Snow) 00=None t i =SlipDeY Road Conditions R d tleararxe Al let ter Stop 22=Over/Under At C i i ' oa way 01=Windy Conditions 12-Substance on 02=Sudden Weather Conditions 13=Potholes urve n Compensat on Stop S 08=Run 09=Ru rmg Red 1 t 23-Speeding 03=Other Weather Conditions 14=9roken Or Cracked Pavement 10=Failure To Respond To 24-Drrvrng Too Fast For conditions l D i 04=Deer in Roadway 1 S=TCD Obstructed ev Other Traffic Contro ce 25--Failure To Maintain Proper Speed 05=Obstacle On Roadway 16=Soft shoulder Or Shoulder Drop Off 11=Ta ting 26-Driver Fleeing Police (Pot Chase) 06-Other Animal to Roadway 28=Other Roadway Factor 07=Glare 29=Other Environmental Factor 12 n S topping 27=Ddw Inexperienced 13=illegally StoloppeOri Road 28=Failure To Use Specialized Equip re ? 08=Work zone Related 94=Unknown 14aCareless Passing Or Lane 92=Affected By Physical Condition hectors er Drivin 98 I ro 01h ? a° q Possible Vehicle F.Hures M 12=Wipers i /C l g = mp p er ln NO Pass' Zone 15= assing i 99=Unknown On The Wron a Drivi 16 0 ng ontro 00-None Oft-Exhaust 13=Driver Seat 01=Tires 07=HeadR9hts 14=900y, Doors. Hood, Etc T g y = ng 1 Way Street rader 02=8rake System 0--mal Lights IFWAF = tem 099=otOther tights 16=Wheells S Unit 3 4 ' JI 0 No f pW 1 2 ys 03=Steering 04=Strspensian 10=Hom 17=Airbags 18=Trailer overloaded -?-- J ? ,v 05=power Train 11 -mirrors L d L d T il Unit 2 C3 I) e oa Unit 2 er oa ra i 1 0 2 20=Improper Towing '? No No Q L $ No ! Windshield -Obs ki 03 W ^? 99 Unit 2 = o ng Pedestrfan Action {pJ 00=None 04 Pushing Vehicle Or Leaving Vehicle P A i No 4 ?? ng t ? W 01=Entering Or Cross Specified Location Unit No Factor Code lrrdicat; Prime Factor r-T-n Do rid repeat this om+iion °^ I,r y 1 `571 02=Walk , Running. Jogging. 07=Standing Or Playing 98=0ther Unknown 99=Unknown 19 ? l O rm,nrpie pages. E/ R V D P Unit No Unit No ?r m i 0 {r3 if E/R is the Prime Factor Type, leave Unit No blank _. FORM +M-900(12102) PENNDOT COPY . COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page AA 500 5 "°"- "°i ;. - 14 C. S4 4,/ liiiiiiiiiiiiii Crash Number r 1257161 d. vl? : s : i t { ' i i i s i -f -t ` i } .. 9 g I { S-le 1XIS 1 s S i . 5i ... { E ' { { j ! i i i t a Wltness Name Address Phone t gQ-4? ui a 2 q SP4-x MCL Si{r v -) i•1-4 Z'L-} 664 2 t,=96&-- =444-- *4 7c=? 11?cts?'?Crt?,. lE n r ?? J --) n ?, . Narrative and additional witnesses: Accident Investigation Notification Issued? O Property Damage O V r c.r ,s- ?RA'y -•?tiG \+a.Es r ou Sgg-r,, c?Fri-4n V? sr r 'Z.. ?.+ ps \ 0 ?U?t'?Y S?y?1•. fh.Y V ?LI+E' iL0 }fir \ 1? .?. .? w ? ? c ,.? rs c v? ? ? U V r c." ? 1 ?, '(?-.J1.t `C' _ ?1.1L7 ??-n\,?(i??i? ? p? _? S 1G??J??!n?` ? a .,,c' V ?.a s r ? z 04>?,?s a Vt.. <av r(-16j;^ }?.Q0.3Cv?jr star T11? a cox jQi? uT? W r? y r" v. ps'^" S 't.-31ST' ?! S' ?o K?© s'' 1t ou ?r ?suc..ri ?v• ,a,Ec. ?s? 5?+ h ? ?u ? Ptity se.'-? Rp ? ? P. • ?- t?. ? ?? SP r r?r ?Lt? 'Ci•?.v r' 'w??Et~1 ?'E W? \?Sr 4 ?1 raT1t E?- c•*4` \ SVC r6r 4? s?v tEtiP? > ?Mi?f FORM 0 AA-00 0XIM PENNDVT GVVY COMMONWEALTH Pa ® New 111111111mull Gash Rumber POLICE CRASH TOF PENNSYLVANIA ?-4e AA 500 N ' 144 s "? co ?ae?.a. p '2. 41 1 1 ? ? 2: Narrative and additional witnesses: \;,, ?'ss QitPctt.?l %JvJN i1 w s' c- vsm- r- c r?"U = =iv 25- t" 23'ZS' IiRS ?? -s r'Pr?r3 s ?? 5 r7 s.... 5- o y?-ytiti- 1666 d a z 13 b d R Q FORM 1 AAA0N nMM PENNDOT COPY 0 PENNZ TRTE Milton S. Hershey Medical Center College of Medicine Patient Name: WOOL.F, DALE C PSUHMC MRN: 7500908 D i s c h a r g e S u m m a r y D o c u .m e n t Filial Document Electronically Signed by: Engbrecht, Brett W 5/23/2007 4:49:39 PM DISCHARGE SUMMARY Name: WOOLF, DALE C HMC Number: 7500908 DOB: 0210511995 Date of Admission: 0512012007 Date of Discharge: 05/2012007 Physician: Engbrecht, Brett W Service: Peds Surgery Discharge Diagnosis: Motor vehicle accident Surgical Procedures: None Vaccinations Received This Hospital Stay: No vaccinations were given this hospital stay. Brief History of Present Illness: The patient is a 12-year-old male who presents status post MVA. The patient was an unrestrained front seat passenger in a truck that was involved in a rollover MVA. The patient was self-extricated.. There is a questionable loss of consciousness; he was amnestic to the event. He complains mainly of right shoulder pain and right scapular pain. He had stable vital signs en route to the hospital. Hospital Course: Dale was admitted to the Pediatric Surgery service for observation Official CAT scan reads of the head, chest, abdomen, pelvis, cervical spine, thoracic spine, lumbar spine, upper and lower extremities bilaterally were free from abnormalities. Dale continued to complain of right shoulder and c-spine tenderness. Orthopaedics evaluated Dale and recommended a shoulder sting • Flexion and extension radiographs were obtained of the cervical spine to defiatively rule out injury, and results were negative for abnormalities. Dale's diet was advanced for which he tolerated well, and his pain was controlled, He was ambulating without difficulty. Dale's vital signs remained stable, and he was afebrile. Dale was discharged in stable condition. Exam on Discharge: Alert, and in no distress. Heart was regular. Lunges were clear. Abdomen was soft, non-tender, non-distended, with bowel sounds present. Date hinted 612712007 lime Printed 9 59 Abp PENNSTATE Milton S Hershey Medical Center College of Medicine Patient Name: WOOLF, DALE C PSUHMC MRN: 7500908 D i s c h a r g e S u m m a r y D o c u m e n t Filial Document Electronically Signed by, Engbteeht, Brett W 5/23/2007 4:49:39 PM Minor abrasions over right scapular region. Care Instructions: All radiographs were normal. If right shoulder pain persists, you may follow up with Pediatric Orthopaedics in two weeks, Please call (717) 531-5638 to schedule appointment. You may use the shoulder sling as needed for pain. Diet Guidelines: No restrictions Activity Guidelines: No restrictions. Call your doctor if: You experience worsening shoulder pain, fever > 101.5, persistent nausea or vomiting, or any other questions or concerns. Please call (717) 531-0000 and ask for the Pediatric Surgery resident on call Other Instructions: There is no need to follow up with Pediatric Surgery. Follow-Up Appointments: No Follow-Up Appointments have been scheduled. Date Printed 611712007 rInte Primed 9.591W ••. _ - -- Milton & Hershey rvk iW Center ® College of Medicine Patient Name: WOOLF, DALE C PSUHMC MRN: 7500908 D i s c h a r g e S u m m a r y D o c u m e n t First Document Electronically Signed by: Engbrecht, Brett W 5/23/2007 4:49:39 PM #310031 Review/Sign: Brett W Engbrecht, MD Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Andreas Meier, Kerry Fagelman, Brett Engbrecht Coleen Greecher MS RD CNSD,.Janet Shields MSN CRNP CS, Lynn Simmons MSN CRNP BWE /L.MW DD: 05/20/07 DT: 05/23/07 11:46 Dare Printed 6127120117 Time hated 9 59 AA•I Carlisle Regional Medical Center -- Er tency Department Wool, AM A 361 Alexander Sadna Rd Carlisle, PA 7 1013 -- (717) 960.1695 5120/0112:15am 000818159 DISPOSITI901 SUMMARY Patient: Woolf. Kathi A Aqe/DOB: SS #: Current Ph: CURRENT Address: Medical Record: 000818159 City. Zip: Arrival: 512010712:15am Disch: 5120/07 12:50am Disposition: MD ED: Cliff Cloonan. MD PMD: Res/PA/NP: PMD Ph: Dx #1: MVA (Unspecified) ICD-9 #1: E819 9 #1 Dx Engl: MOTORVA.ESW #1 Dx Span: MOTORVA.SSW Dx #2: Facial Contusion/bridge of nose, forehead 1CD-9 #2: 920 #2 Dx Engl: CONTUS.ESW #2 Dx Span: CONTUS SSW Rx #1: Motrin Suspension (Ibuprofen) 100mg15mi Take 3 teaspoonfuls by mouth every 6-8 hours as needed 4 ounces Follow-up: YOUR FAMILY DOCTOR F/U MD Ph: FiU D/T: 4 Days Other Instr: Follow up with your primary care doctor in next 3 - 5 days as needed for persisting svmptoms. Return to ED for fainting/near fainting, dill. breathinq/shortness of breath, abdominal pain, severe/unrelived headache, recurrent vomitinq May return to work/school: Monday Restrictions: No contact sports for next 2 weeks. MY SIGNATURE BELOW INDICATES: > I have received and understood the oral instructions regardinq my current medical problem > I will arrange follow-up care as instructed above. > I acknowledge receipt of the written instructions as outlined on this and any previous page(s). I will ad and review these instruc' s X A X A>-'? et"/ Patient (or Legal Guardian) Signature Staff ( mess) Signature q? O M 9 N n a n Carlisle Regional Medical Center -- En encv Department Woolf vier 361 Alexander Sarina Rd Carlisle. PA 1'rtJ13 -1717) 960-1656 512010712:12am 1061617 DISPOSITION SUMMARY Patient: Woolf, Skyler Age/DOB: SS #: Current Ph: CURRENT Address: Medical Record: 1061617 City: Zip: Arrival: 5120107 12:12am Disch: 5/20107 12:13am Disposition: MD ED: K.J Miller, MD PMD: Res/PAINP: PMD Ph: Dx #1: Motor Vehicle Accident-Passenger ICD-9 #1: E8191 #1 Dx Engl: MOTORVA. ESW #1 Dx Span: MOTORVA.SSW Dx #2: Conlusion, Face ICD-9 #2:920 #2 Dx Engl: CONTUS.ESW #2 Dx Span: CONTUS.SSW N.I. !!. r Follow-up: KREBS,STEPHEN J 804 BELVEDERE STREET CARLISLE, PA FIU MD Ph: 71 7 243 1 94 3 FIU D/T: Other Instr: tylenol or ibuprofen for discomfort. You must wear your seatbelt at all times in a vehicle. Any concern call your doctor or return. MY SIGNATURE BELOW INDICATES: > I have received and understood the oral instructions regarding my current medical problem. > I will arrange follow-up care as instructed above > I acknowledge receipt of the written instructions as oen d any vious page(s). will read and view these ins 4A X ?Q ?. X Patient (or Legal Guardian) Sign to Staff (Witness) Signature 6,-,- 7174125049 nationwide Nationwide Insurance 12:53:35 p.m. 10-20-2006 2 /3 NATIONWIDE AUTO POLICY DECLARATIONS These Declarations are a part of the policy named above and Identified b Page 0. of 02 su any Declarations Issued earner. Your poly provides the coverages nnumber sin fn They U19 0 sc covenges. They apply to each insured v1loolla as Indicated. Your polio y compiles with the cover" a slbility 241 of your state only for vehicles for which Property Damage and Bodily injury Liability ' ancial provided, Policy NumbePolicyholder. s8 37 D 778068 (Named Insured) Issued: 20 1 T{ECK RD 172 U DEC 07 PA 2006 17201.9711 Policy Period From: DEC 31, 20C6 to JUN 30, 2007 but onl?r If the required premium for this riod has been id rwd ord for six month renewal for !F renewal pnmittme have been paid as required. 'fhia policy is tnpa(1 j the tone the apf n insurance Is oomplehd, or (2) 12:01 a.m on the first day of the NICT period, whichever Is later. Each renewal period begins and ends at 12:01 a.m. standard time at the address of he named Insured stated herein. This poiloy cancels at 12:01 a.m at the add.aaa „f ?ka ?.• .wr ,,,vMIPM Oiamw 1pri8U1. fiP IWPOLbI YSFORM TO V-000376 SEE ENCLOSED NOTICE FOR PREMIUM DETAIL INSURED VEHICLE(S) & SCHEDULE OF COVERAGES 1. 2006 DOW 2600 $LT ID #31)702=00192628 Coverages COMPREHENSIVE AND 1 600 OUS 12ARTION N Limits Of Liability ACTUAL CASH VALUE LESS $ 100 PSix remium $ 229 COLLISION AND S RATION ACTUAL CASH VALUE LESS $ 600 $ ,70 526.00 E ?NLI ABILITY TY 26,00 28, 00 P $ 232.40 UNINSURED MOTORISTS-BODILY INJURY ) 0 (NON-STACKEDJ 26 000 EAt $ 122.40 UNDERINSURED MOTORISTS-BODILY INJURY , I PEi N (NON bT02K OOC $ 3.60 50,000 P LOSS OF USE BROAD FORM ! 3022 S 18.38 800 PE DA R `? pj ? R?p F A2 - D3F 8 9E1I T = IDENT 5 0 0 "' Ei IT 0 TOTAL , 00 h?NT 1 $ 53.30 L IM I TEED 70R ?' BENEFIT HLY ,,5600 1 0 4.20 LIENHOLDER-DC FIN SVCS AMER LLC. TOTAL LIEN EXPIRES ON JUN 30, 2013 $1, 192.70 INSURED DRIVERS: Driver # Name 01 SHAWN STITE Birth (_Ylarital Date Status 08/02/85 SINGLE v_1 nn_a 7174125049 nationwide Nationwide Insurance 12:54:01 p.m. 10-20-2008 313 Page 02 of 02 APPLIED DISCOUNT3: PASSIVE RESTRAINT SAFE DRIVER NEW VEHICLE FARM BUREAU MBABER Policy Form & Endorsements: V0378 3272 3328 Office Use: JUL 10, 2006 $ 0.00 Issued By: NATIONWIDE INSURANCE COMPANY OF AMERICA 25453 Home Office - Columbus, Ohio Countereigned At. HARRISBURG, PA. By: ANDREW L SHOEAfAKER LUT IMPORTANT PHONE NUMBERS Nationwide 24Hour Claims Number. 1.800421-3630 For QUESTIONS About Your Policy, Call Your NATIONWIDE AGENT : ANDREW L SHOEMAKER For Hearing Impaired: TTY 1-swe22-2421 717-7767229 Nationwide Regional Office: eoo-79s-7783 0 UNIIRIN Kemper I `?AUTOAND HOMH BRATTON INSURANCE AGENCY PO BOX373 MILLERSTOWN, PA 17062 Agency Phone(717)589-3278 Insurance Provided By UNITRIN AUTO AND HOME INSURANCE COMPANY 5210 Belfort Road - Jacksonville, FL 32256-6017 Named Insured and Mailing Address Policy Number Policy Period 0000511 SP -SNGLP T7 3 436417266-970600 CV 834949 Effective: 04-28-2007 Expiration: 10-28-2007 Producer Code 12:01 a.m. standard time. RONALD L WOOLF 29-3086 SUSAN L WOOLF Agent/Customer ID 200 WEST MAIN STREET WOOLR01 WALNUT BOTTOM, PA 17266-9706 POLICY DECLARATIONS - AUTOMOBILE POLICY SUMMARY OF COVERED VEHICLE(S) AND PREMIUM(S) Term' Premium No. Year Make Model Vehicle Identification No * 1 1999 DODGE RAM 2500 3B7RF2365XG145897 $ 363.00 2 1991 SUBARU JF2BJ63COMB903997 $ 132.00 TOTAL POLICY PREMIUM $ 495.00 LIMITED TORT COVERAGE OPTION APPLIES COLLISION COVERAGE PROVIDED BY YOUR POLICY EXTENDS TO RENTAL VEHICLES SUBJECT TO THE CONDITIONS AND LIMITATIONS IN YOUR POLICY SUCH AS COVERED TERRITORY, LENGTH OF TIME OR ANY DEDUCTIBLES. PAYMENT EXPECTED FROM INSURED I R-11 DETAILS CONCERNING SPECIFIC COVERAGES AND PREMIUMS FOR YOUR AUTO(S) CAN BE FOUND ON THE FOLLOWING PAGES. COVERAGE APPLIES ONLY IF A PREMIUM OR LIMIT OF LIABILITY IS SHOWN FOR THE COVERAGE. AK ?0 4 (08 00) 9e was made to your pol"6-ONTINUED ON REVERSE 000324 1 0000511 (E) ss On Your Side' Victoria Insurance P.O. Box 2655 " 1000 Nationwide Drive " Harrisburg, PA 17105 January15, 2009 John R Zonarich Esquire 17 South Second 6th Floor Harrisburg, PA 17101 OUR INSURED : Shawn Strite OUR CLAIM NUMBER : 58 37 D 778068 05192007 01 YOUR CLIENT : Skylar Woolf, a Minor, Kathy Woolf, a Minor & Dale Woolf, a Minor DATE OF LOSS : 05-19-2007 Dear Mi Zonarich. As per our telephone discussion I agreed to resolve the minor's claims as follows: Dale Woolf - $1,500.00 Kathy Woolf - $1000.00 Skylar Woolf - $1000.00 I will diary my file for receipt of signed court approval from Cumberland CCCP. Sincerely, Nationwide Insurance Company of America Barbara J Noce (PA-02-19) Claims Department (717)671-3526 Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. Nationwide Insurance Allred Insurance Natbmvlde Agribusiness Titan Insurance CERTIFICATION OF PARENTS AND NATURAL GUARDIANS We, Ronald L. Woolf and Susan L. Woolf , hereby certify that we are the parents and natural guardians of the minor plaintiffs, Dale C. Woolf, who is presently fourteen (14) years of age and Kathi A. Woolf, who is presently eleven (11) years of age. We have reviewed and discussed with counsel the proposed settlement and distribution as set forth in the foregoing petition including the proposed order and schedule of distribution. We have signed this certification, concur with and join in this petition and we recommend that the court approve this settlement and distribution schedule. We understand that this certification is made pursuant to provision 18 Pa. Cons. Stat. § 4904, relating to untold falsification to authority. Dated: D- - a 5 -,r -% Dated: o7 - aS - U) Ronald L. Woolf Susan L. Wool CERTIFICATION OF PARENTS AND NATURAL GUARDIANS We, David R. Woolf, Jr. and Aimee S. Woolf, hereby certify that we are the parents and natural guardian of the minor plaintiff, Skyler A. Woolf, who is presently nine (9) years of age. We have reviewed and discussed with counsel the proposed settlement and distribution as set forth in the foregoing petition including the proposed order and schedule of distribution. We have signed this certification, concur with and join in this petition and we recommend that the court approve this settlement and distribution schedule. We understand that this certification is made pursuant to provision 18 Pa. Cons. Stat. § 4904, relating to untold falsification to authority. Dated: U Dated: r David R. Woolf, J . IYAZ Aimee S. Woolf CERTIFICATE OF SERVICE I, Sherry L. Devlin, an employee with the law firm of Skarlatos & Zonarich LLP, hereby certify that I this day served a copy of the foregoing PETITION FOR APPROVAL OF MINOR'S SETTLEMENT upon the person(s) indicated below by depositing a copy of the same in the United States Mail, postage prepaid, at Harrisburg, Pennsylvania, and addressed as follows: Ronald L. Woolf Susan L. Woolf 200 West Main Street Walnut Bottom, PA 17266 David R. Woolf, Jr. Aimee S. Woolf 405 Pidgeon Hill Road Branchville, NJ 07826 Date: to e ev Ay- Legal Assistant C: - I, D --a 000 R? 00 ?? 00 ?? { 0 0 Cjrl, 116 SKARLATOS & ZONARICH LLP John R. Zonarich, Esq. John B. Zonarich, Esq. Skarlatos & Zonarich Building 17 South Second Street, Ob Floor Harrisburg, Pennsylvania 17101 Telephone: (717) 233-1000 Facsimile: (717) 233-6740 Email: jrz@skarlatoszonarich.com jbz@skariatoszonarich.com Attorneys for Petitioners, Ronald L. & Susan L. Woolf, Parents and Natural Guardians of Dale C. Woolf, a minor, Kathi A. Woolf, a minor, and Aimee S. & David R. Woolf, Jr., Parents and Natural Guardians of Skyler A. Woolf, a minor KATHI A. WOOLF, SKYLER A. WOOLF IN RE: DALE C. WOOLF, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. 09-1562-Civil Term AMENDMENT TO PETITION FOR APPROVAL OF MINOR'S SETTLEMENT TO THE HONORABLE, THE JUDGES OF THE SAID COURT: A Petition for Approval of Minor's Settlement was filed on March 12, 2009. 2. This Amendment is provided to ensure compliance with local rule 208.3(a). 3. There have not been any other rulings in this matter or a related matter. 4. No lawsuit has been filed in this matter and no counsel has entered their appearance on behalf of Shawn D. Strite the driver of the vehicle insured by Nationwide Insurance. 5. Nationwide Insurance Company has agreed to settle the minors' claims as evidenced by Exhibit 7 of the Petition, and since there are no other parties involved, there is no need to obtain a concurrence. -1- Respectfully submitted, Dated: 03/18/09 By: John Zonarich, Esqui e denti cation No. 19632 Zonarich, Esquire Identification No. 79989 Skarlatos & Zonarich Building 17 South Second Street, 6`h Floor Harrisburg, Pennsylvania 17101 Telephone (717) 233 -1000 Facsimile: (717) 233 - 6740 Email: jrz@skarlatoszonarich.com jbz@skarlatoszonarich.com Attorneys for Petitioners Ronald L. Woolf and Susan L. Woolf, Parents and Natural Guardians of Dale C Woolf and Kathi A. Woolf, a minor, and Petitioners, David r. Woolf, Jr. and Aimee S. Woolf, Parents and Natural Guardians of Skyler A. Woolf, a minor -2- 1 %. CERTIFICATE OF SERVICE I, Sherry L. Devlin, an employee with the law firm of Skarlatos & Zonarich LLP, hereby certify that I this day served a copy of the foregoing AMENDMENT TO PETITION FOR APPROVAL OF MINOR'S SETTLEMENT upon the person(s) indicated below by depositing a copy of the same in the United States Mail, postage prepaid, at Harrisburg, Pennsylvania, and addressed as follows: Ronald L. Woolf Susan L. Woolf 200 West Main Street Walnut Bottom, PA 17266 David R. Woolf, Jr. Aimee S. Woolf 405 Pidgeon Hill Road Branchville, NJ 07826 Date: 03/18/09 C3 .,ca c i -'- r -t MAR 16 20Qg? IN RE: DALE C. WOOLF, KATHI A. WOOLF, SKYLER A. WOOLF IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. DA - ?5(yA 0,1V iI Term ORDER AND NOW, this 2,1 day of hay , 2009, upon consideration of the Petition for Approval of Minors' Settlements, it is hereby ordered that the Petitioners are authorized to enter into the individuals settlements of. Dale C. Woolf, one thousand five hundred dollars ($1,500.00), Kathi A. Woolf, one thousand dollars ($1,000.00) and Skyler A. Woolf, one thousand dollars ($1,000.00) The settlement amount shall be distributed as follows: TO: Ronald L. Woolf and Susan L. Woolf, as Parents and Natural Guardians of Dale C. Woolf ($1,500.00) and Kathi A. Woolf ($1,000.00), minors, totaling $2,500.00 to be deposited into separate restricted, federally insured accounts for each minor marked "No withdrawals prior to age 18 without prior court approval." TO: David R. Woolf, Jr. and Aimee S. Woolf, as Parents and Natural Guardians of Skyler A. Woolf ($1,000.00), a minor, to be deposited into a restricted, federally insured account marked "No withdrawals prior to age 18 without prior court approval." TOTAL AMOUNT OF DISTRIBUTION: $3,500.00 i91t i!''a?w tv. ? nn, Counsel shall provide to the Court, within ten (10) days from the date of this order, proof of such deposit. Petitioners are authorized to sign the necessary releases and other documents to conclude the Minors Dale C. Woolf, Kathi A. Woolf, and Skyler A. Woolf's claims arising from the May 19, 2007 motor vehicle crash. By the Court: J.