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HomeMy WebLinkAbout09-2125Metzger, Wickersham, Knauss & Erb, P.C. By: Andrew W. Norfleet, Esquire Attorney I.D. No. 83894 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 Attorneys for Petitioners (717) 238-8187 awna,mwke.com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: JONATHAN RITZ, a Minor : NO. ?- S aJ, 4e- frt PETITION FOR APPROVAL OF MINOR SETTLEMENT AND NOW, come the Petitioners, David Ritz and Jennifer Ritz, as parents and natural guardians of minor Jonathan Ritz, and petition this Court for approval of a settlement of a minor's case in accordance with Pa.R.C.P. No. 2039 and, in support of the Petition, avers as follows: 1. Petitioners, David Ritz and Jennifer Ritz, husband and wife, are adult individuals residing at 10 Burns Road, Spring Grove, Pennsylvania. 2. Petitioners are the parents and natural guardians of Minor Petitioner Jonathan Ritz ("Jonathan'), who resides with them, and who is 14 years old, having been born on January 8, 1995. 412596-1 3. Jonathan has selected Petitioners, as his parents and natural guardians, to represent his interests in this Petition. 4. On April 14, 2007, Jonathan was a passenger in a 2004 Chevrolet Malibu Sedan owned and operated by David Ritz. 5. On the aforesaid date, David Ritz, Jennifer Ritz and Jonathan were traveling north on Interstate 83, New Cumberland Borough, Cumberland County, Pennsylvania. 6. On the aforesaid date and place, Donald Cross-Cook approached stopped traffic on Interstate 83. Donald Cross-Cook failed to stop his vehicle, causing him to strike the rear of two vehicles, including the Ritz vehicle. A true and correct copy of the police accident report is attached hereto and incorporated herein by reference as Exhibit "A". See, photographs showing damage to the 2004 Chevrolet Malibu occupied by Minor Petitioner which are attached hereto and incorporated herein by reference as Exhibit "B." 7. Following the motor vehicle collision, Jonathan complained of neck pain. He was transported to Hanover Hospital where he was treated and released the same day. Jonathan was diagnosed as suffering a cervical strain/sprain and a thoracic strain/sprain. Jonathan was allowed to take Tylenol for pain and instructed to follow up with his family physician. See, medical records from Hanover Hospital which are attached hereto and incorporated herein by reference as Exhibit "C." 8. On April 23, 2007, Jonathan was examined at Jefferson Family Medicine. The note from April 23, 2007 confirms the diagnosis at the emergency room and notes "no head trauma" as well as "no symptoms presently." See, medical records from Jefferson Family Medicine which are attached hereto and incorporated herein by reference as Exhibit "D." 412596-1 9. On October 25, 2007, Jonathan was examined at the Chirocare Center for intermittent mild to moderate pain in the left and right neck area. The diagnosis of cervical strain and sprain was confirmed. Jonathan had additional treatment dates of November 2, 2007 and November 16, 2007. See, medical records from Chirocare Center which are attached hereto and incorporated herein by reference as Exhibit "E." 10. Jonathan has not received any additional needed treatment since November 16, 2007 and his symptoms have resolved. 11. No further needed care for Jonathan is planned. 12. The medical bills for Jonathan's treatment as a result of the injuries sustained in the accident have been paid by the automobile insurer State Farm Insurance who insures his parents. The medical bills total $736.00. There are no outstanding medical bills or liens. See, a copy of the medical bills attached hereto as Exhibit "F." 13. State Farm Insurance, also the provider of liability coverage, has offered $1,700.00 to the Petitioners to resolve the liability claim against their insured as a result of this incident. See, tender letter from State Farm Insurance which is attached hereto and incorporated herein by reference as Exhibit "G." 14. Petitioners, David Ritz and Jennifer Ritz, after consultation with counsel, have determined that it is in the best interest of their son, Jonathan, to accept State Farm's offer and seek Court approval of the settlement. 15. Counsel was retained by Petitioners to represent the Jonathan on a contingent fee basis of 25% of gross recovery. A true and correct copy of the Fee Agreement is attached hereto and incorporated herein by reference as Exhibit "H." 412596-1 16. Counsel has agreed to accept an attorney fee of 20% or $300.00. In addition, counsel has also incurred expenses in the total amount of $186.08 in pursuing this claim on behalf of Jonathan Ritz. See, itemization of these costs which are attached hereto and incorporated herein by reference as Exhibit "I." 17. After consultation with counsel, including a review of the attached medical records and consultation concerning litigation in this matter, the Petitioners respectfully request that this Honorable Court approve the compromise settlement of this claim with State Farm Insurance in the total gross sum of $1,700.00 out of which Petitioners will receive the sum of $1,213.92 on behalf of Jonathan, and counsel will receive the sum of $486.08 for attorney fees and costs. Petitioners also seek permission to execute an appropriate Release of Claims on behalf of their son. 18. Petitioners propose to place their son's settlement proceeds in a federally insured restricted savings account or certificate of deposit at a bank, credit union or savings and loan association organized or existing under laws of the Commonwealth of Pennsylvania in the name of their son. Said account will be marked "No withdrawals prior to age 18 without prior court approval." 19. After a review of the medical records, medical billing, and the future prognosis of the minor child, undersigned counsel believes it is in the best interest of the minor child to settle his claim for personal injuries in this matter. 20. State Farm Insurance, on behalf of its insured, concurs with the filing of this Petition and also seeks approval of the minor's settlement under the terms set forth. 21. None of the Parties to this Petition are requesting a hearing before this Honorable Court. 412596-1 WHEREFORE, Petitioners respectfully request that this Honorable Court approve of the minor settlement and enter a Decree distributing the funds as follows: (1) To be paid to David and Jennifer Ritz, parents and natural guardians of Jonathan Ritz, the sum of $1,213.92, to be placed in a federally insured and restricted savings account or certificate of deposit, to be marked "not to be withdrawn, assigned, negotiated or otherwise alienated until Jonathan Ritz reaches his majority on January 8, 2013, except upon prior Order of the Court"; (2) To be paid to Metzger, Wickersham, P.C., for counsel fees and expenses the sum of $486.08. It is further requested that an Order be entered granting David Ritz and Jennifer Ritz, as parents and natural guardians of Jonathan Ritz, authorization to sign the Releases attached to the Petition. Dated: CI A tot 6 METZGER, H AUSS ERB C. By: W Andrew W. orfleet, Es Attorney I.D. No. 83894 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 Attorneys for Petitioners 412596-1 VERIFICATION I, David Ritz, as parent and natural guardian of Jonathan Ritz, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Settlement, and to the extent that it is based upon information which I 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 for Approval of Minor Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities. Dated: 3 /Z4, 1 412596-1 of Jonathan Ritz VERIFICATION I, Jennifer Ritz, as parent and natural guardian of Jonathan Ritz, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Settlement, and to the extent that it is based upon information which I 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 for Approval of Minor Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unworn falsification to authorities. /'v-- Je? Ri, as pare d natural guardian of nathan Ritz Dated: .. L& 0q 412596-1 VERIFICATION The undersigned hereby certifies that he is the attorney for Petitioners, David Ritz and Jennifer Ritz, as parent and natural guardian of minor Jonathan Ritz, and that the facts in the foregoing Petition for Approval of Minor Settlement are true and correct to the best of his knowledge, information and belief, and that said matters relating to the Petition for Approval of Minor Settlement are as known to the undersigned as to the clients, Jonathan Ritz, by David Ritz and Jennifer Ritz, his parents and natural guardians, said knowledge being based upon information contained in the attorney's file in this matter, and further states that false statements herein are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unworn falsification to authorities. Dated: 412596-1 CERTIFICATE OF SERVICE I, Andrew W. Norfleet, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and correct copy of the foregoing Petition for Approval of Minor Settlement with reference to the foregoing action by first class mail, prepaid postage, this -30e_ day of f 2009, on the following: Patricia Wise State Farm Insurance PO Box 953 Frederick, MD 21705 G? Andrew W. f4orfleet, Es 412596-1 .?- ???,? J COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM ,? 500 1 Case Closed Reportable Crash' Page (0 Yes Q No (Z) Yes Q No az] IIVINIINVIIIIM?N Cr...,.., P 1223508 " Incident Number Police A en Patrol Zone MOW i- ! a! d7 Q m %ncy a me Precinct Investigation Date (MM-OD-YYYY) ,,,, w C N1 ? ? _ ?. Q D[ In Time (mil) Arrival rime (mil) Inve ti ator Badge Number Revie er Badge Number A roval Date (MM-DD-YYYY) -? 7 CountIl Coun Name Muniupali Municipality Name ICU VD J DB,y of Week Q Sun Q Thu 0 1 , Ak, V t) -1 Crash Date (MM-DD-YYYY) Crash rime (mil) No of Units People Injured Killed' `If > 00 t, -1 2 1 12 ED Mon Q Fri , ? ? Form F Q 0 ? 0 r= 0 Q Wed Q Unk F Work:one (I Yes, Complete School Bus School Zone Form M, Section 29) Q Yes (5D No Related C] Yes ®No Related Q Yes No Nati PENN Mai to enance DOT 01 No 0 Yes InWnKdon D= Q 4 Way Intersection Q "Y" Intersection Q Multi-Leg Q Off Ramp Q Railroad Crossing Intersection -SRg181 ® Midblock Traffic Cirde/ Q "T" Intersection O Round About O On Ramp Q Crossover Q Other L,? 0 ' see Overla Route Number Segment (Optional) Travel Lanes Speed Limit ® North House Number (if applicable) h ° O S 1610156-1? © ?, ? out a 1 qq Street Name Street Ending O East For Mid-block crashes only. Use l Hou r N mb nd m k sure t a se u a e a e a a O West pos dwa O O unknown filled nel'Roaing thistoP name is ® Interstate O Turnpike O Turnpike O State O County O Local Road O Private O Other/ (Not Turnpike) (East/West) Spur Highway Road or Street Road Unknown 0 Route Number Segment (Optional) Travel Lanes Speed Limit Q North m O South Street Name Street Ending V 0 East I II I I I I I I I I I I I I m O CD West ! Q Unknown a Si alnin es O Interstate O Turnpike O Turnpike O State O County O Local Road O Private o Other/ (Not Turnpike) (East/West) Spur Highway Road or Street Road Unknown Intersecting Rt Num Or Mile Post Or Se ment Marker F t rth Q N ee ro N •? A ? ? .? m o Q South I ti O i S N V w Please r n terse ct ng treet N ame St Ending Q East ?t 3 Enter Information e q 0 West Or Miles m ? m for BOTH e :V Landmarks $ if Using This Option Intersech Rt Num Or Mile Post Or Segment Marker a 0 ! ?? El North 0 . Distance From Crash Scene to Landmark 1 . 10 O South +M N E Or Intersecting Street Name St Ending O East (For Crash between O e 3 m Q West Landmark 1 and Landmark 2) Degrees Minutes Seconds Degrees Minutes Sec nds o r l . ! C? Latitude: ® ®;®. E p Longitude: - 1 ' ! If' „I ? ;1 1I J 1 "J=J L_?„?? a V Traffic Contra! Device Q Yield Sign Q Police Officer or (21 Not Applicable Flagman © Traffic Signal Active RR Crossing Other Type TCp Device Functioning Emergency No Controls Q Q Preemptive Improperly Controls Flashing Traffic Q Stop Sign O Passive RR Q Unknown 0 Signal Crossing Controls Signal Device Not Device Functioning O O Q Unknown Functioning Properly Lane a2Wd (!f "Not Applicable ", skip nest of the Lane Closure section) Lane 005 ® North 0 East Q North and South Q All p Q Not Applicable Q Partially (B Fully Q Unknown Q South Q West O East and West (N,S,E,W) V I jiaffic Yes (0 No Q Detour Unknown Q Erbil Mm Q < 30 Min. (Z 30.60 Min. Q 1-3 hrs 0 3-6 hrs Q 6-9 hrs Q > 9 hours O Unknown FORM N AA-5W f12Ml PENNDOT COPY COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING (FORM / •/' Page: AA 504 2 PNS)P'y/LS-? Lo? nNMIIIINIIN Crash Number P1223508 o Motor Vehicle in O Hit & Run Vehicle Q Illegally Parked 0 Legally Parked QNon -Motorized ® Commercial vehicle ? Transport ? O Yes (Xf No unit Pedestrian on Skates, Disabled From Train O Phantom Vehicle Pedestrian O Q Previous Crash in wheelchair, etc (!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) Tele hone Number Last Name Delete? c C / CD -mg? e Address / City I State rip w '? i _Driver License Number State class - `J ® O c AlcohoYDrugs Sus Driver or Pedestrian Physical Condit/on (Z No Q Illegal Drugs Q Medication Apparently Normal Q Illegal Drug Q Fatigue Q Medication Q Alcoh& O Alcohol and Drugs O Unknown Q Had Been Q Sick Q Asleep Q Unknown Drinking Alcohol Test Type h h O Primary Vehicle Code Violation Charged? er Ot Test Not Given Q Breat f W Yes 0 No ?f r Q Blood Q Urine O Test Givenr /' > Alcohol Test Results Q Test Refused e? Resultts Driver Presence 1=Driver Operated 3=Driver Fled Scene / Vehicle 4=Hit and Run O Q Test Given, M Q kn wn U 9 J? Contaminated Results • n o = 2=No Driver OwnerJDriver 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=01her Municipal 98=Other Q Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown Owner First Name Owner Last Name or Business Name Of Pedestrian, skip this Section) lame as Driver Address / City / State ! Zip Vehicle Make 'Make Code 14 L91 I I IV 1 VIN Model Year Vehicle Model (see overlay) U T 10 P Ics?r`-?R License Plate Reg. State Est. Speed Vehicle Towed Towed By ® c ? 15 1 (Er Yes O No ?T ? K I J _ insurance Insurance Company Policy No e ` ( Yes Q No O Un- known l" n c r J /J .? l a = z Trailing 1=Towing Pass. Veh 4=Mobile/Modular Home =Semi-Trailer Tag No T^ a9 Year , Tag St r I it 2=Towing Truck 5=Camper 8=Other Unit No. of u • n "? Trailing Q 3=Towing Utility Trailer 6=Full Trailer 9=Unknown Units: Direction of --- `Vehicle Position O ' `Movement ® 'See Overla Special Usage ve ravT y Vehicle Color Vehicle Type 05=Lar a Truck 20=Unicycle, Bicycle, 12=Commercial Passenger 06=Yellow FCR 07=Silver 01=Automobile 06=SUV Tricycle 02=Motorcycle 07=Van 21=Other Pedalcyde FoTT & B 00=Not Applicable Carrier 01=Fire Veh 13=Taxi 08=Gold 01=Blue 09=Brown uggy 03=Bus 10=Snowmobile 22=Horse 04=Small Truck 11 -Farm Equip 23=Horse & Rider 02=Ambulance 21 =Tractor Trailer 03=Police 22=Twin Trailer 02=Red 10=Orange (if "02", Complete Form 12=Construction Equip 24=Train 08=Other Emergency 23=Triple Trailer 03=White 11=Purple M, Section 26) 13-ATV 25=Trolley Vehicle 31 =Modified Veh 04=Green 12=OtheT U k 9 (if "20" or 121", Complete 18=Other Type Spec Veh 98=Other Type Spec Veh 99=Unknown 19=Unk 11 =Pupil Transport 99=Unknown nown n 9= 05=Black . Form M, Section 27) Initial impact Point Damage indicator Gradient 3-Downhill Road Alignment ® 00=Non Collision 14=Undercarriage 15=Towed Unit k Poi 01 12 Cl ? O=None 2=Functional 1=Minor 3=Disabling 1=Level 4=Bottom of Hill S=Top of Hill 1=Straight T2=Curved oc nts - = 13=Top 99=Unknown 1 ,/- 1 9=Unknown 2=Uphill 9=Unknown 9=Unknown FORM rr nn.500 (112102) PENNDOT COPY COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM AA 500 2 P us? o?ly?(Q? Page: m lS.ZD 1111111111311 Crash Number P 1223508 o Motor Vehicle in Q Hit & Run Vehicle O Illegally Parked 0 Legally Parked Q Non - Motorized commercial vehicle • - T ort P Q Yes (5Z)No L Pedestrian on Skates, Disabled From unit etc Previous Crash Q Train Q Phantom Vehicle Q Pedestrian Q in Wheelchair Complete Form C) (If Yes ? , (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) © I's I T N aaa?t Delete? Last Name Tele hone Number 7? -- 3 ?`?? o - Address / Ci /State 1 ?F-773 ? 3 r 0 L SKI K i Driver License Number State Class a AlcohoUdruas Suspected Driver or Pedestrian Physical Condition (X) No Q Illegal Drugs Q Medication Co NoPmalntly Q IUseal Drug Q Fatigue Q Medication IL Q Alcohol O Alcohol and Drugs Q Unknown Q Had Been Q Sick Q Asleep Q Unknown Drinking Alcohol Test Type Primary Vehicle Code Violation Charged? p Test Not Given Q Breath Q Other Q Yes (J? No Q Blood Q Urine Test Given if ADA/ Alcohol Test Results Q Test Refused Q R known sults Driver Presence 1=Driver Operated 3=Driver Fled Scene Vehicle 4=Hit and Run O Q Test Given, ? known ?L?••• 9 U • Contaminated Results n = 2=No Driver 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=0ther Municipal 98=Other Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown owner First Name Owner Last Name or Business Name (If Pedestrian, skip this Section) Same as Driver Address ! City / State ! Zip Vehicle Make *Make Code R 1 VIN Model Year Vehicle Model (see overlay) m u '7 ?C o Islu 9 a t a 1 ?] Buz-, -- 77 r I r _ License Plate Reg. State Est. Speed Vehicle Towed Towed By 1A P Ij ® d (R) Yes Q No IS-1 F r AS Insurance Insurance Company Policy No 0 Un- W Yes Q No CJ kn own 12 ' Trailin TJ.pe r 1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No Tag Year Tag St nit No. of unit 0 2=Towing Truck 5=Camper 8=01her li - T ro rai ng 3=Towing Utility Trailer 6=full Trailer 9=Unknown v Units: rech'on of a "Vehicle Petition Dl "Movement Ov*See erla L??J Y Special Usage a Vehicle Color Vehicle Tvpe 05_Lar e Truck 211=Unicycle, lic/cle, 9 12=Commercial Passenger 06=Yellow 07=Silver (? 01=Automobile 06-SUV Tricycle t ?t 02=Motorcycle 07-Van 21=Other Pedalcycle 00=Not Applicable Carrier 01=Fire Veh 13=Taxi 08=Gold I LLI 03-Bus 10=Snowmobile 22=Horse & Buggy 02=Ambulance 21 =Tractor Trailer 01=Blue 09=Brown 04=Small Truck 11 =Farm Equip 23=Horse & Rider 03=Police 22=Twin Trailer 02=Red 10=Orange (If "01", Complete Form 12=Construction Equip 24=Train 08=Other Emergency 23=T(ple Trailer 03=White 11 =Purple A Section 26) 13=ATV 25=Trolley Vehicle 31=Modified Veh 04=Green 12=Other 99 U k ()f "20" or '21", Complete 18=Other Type Spec Veh 96=Other Type Spec Veh 99=Unknown 19=Unk 11=Pupil Transport 99=Unknown nown = n 05=Black , Form M, Section 17) Initial !m ct Point Damage Indicator Gradient 3=Downhill Road Alignment 00=Non-Collision 14=Undercarriage ts 15=Towed Unit k P i 1 Cl 12 O=None 2=Functional 1=Minor 3=Disabling 1=Level 4=Bottom of Hill 5=Top of Hill r 1=Straight ? 2=Curved L- o n - oc = 0 13=Top 99=Unknown A 9=Unknown 2=Uphill 9=Unknown 9=Unknown FORM ? AA-500 (12!02) PENNDOT COPY COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM NA AA 500 2 Page: 0-41 1111111111111111 Crash Number _? i» ? Motor Vehicle in Q Hit & Run Vehicle Q Illegally Parked Q Legally Parked Q Non - Motorized Commercial Vehicle Type Transport Q Yes ?Er No Unit Pedestrian on Skates, Disabled From -- Q Pedestrian Q Q Q Train Q Phantom Vehicle in Wheelchair, etc Previous Crash Complete Form Q (lf Yes (If "Pedestrian" or "Pedestrian on Skates, in Wheelchair, etc", Can lete Form M, Section 18) , Date of Birth (MM-DD-YYYY) Unit No P Nam* " © ? ?JI 119 7 d 1(L;/?Il 1? Delete? Last Name Terlle7 jhone Number Address / Ci / State Zip a t a 1 dE, Driver License Number state Class 1= RE i -I A - w AlcohoUDnras Suspected Driver or Pedestrian Physical Condition _ ($ No Q Illegal Drugs Q Medication Apparently O Illegal Drug Q Fatigue CD Medication N l orma >L Q Alcohol Q Alcohol and Drugs Q Unknown Q Had Been Q Sick Q Asleep Q Unknown Drinking Alcohol rest Tyne Primary Vehicle Code Violation Charged? el Test Not Given Q Breath Q Other Q Yes Q No d v Blood Urine Q Unknown if Q Q Test Given N© Alcohol Test Results Q Test Refused Q Unkn swn Driver Presence 1=Driver Operated 3=Driver Fled Scene ` Vehicle 4=Hit and Run MED Test Given, k i U 9 wn -????•••JJJ......??...... Contaminated Results no ver n = 2=No Dr Owner/Driver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehide 07=Municipal Police Veh 09=Federal Gov Veh 01=Private Vehicle Owned/ Owned/Leased by Driver 0S=PF.NNDOT Vehicle 08=Other Municipal 98--Other Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown Owner First Name Owner Last Name or Business Name (if Pedestrian, skip this Section) Same as - Driver (Z ]I I 1 1 1 L I I L I j 1 1 1 1 t T1 - Address / City / State / Zip Vehicle Make *Make Code VIN Model Year Vehicle Model (see overlay) H ) 14 1::0 1191 7L-I oo 1 A/71q),01 ) License Plate Reg. State Est, Speed Vehicle rowed rowed B Yes Q No . 1 1 Insurance Company Policy No Insurance Yes Q No Q Un- known 1 2 traili» 1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No Tag Year Tag St Other Unit No, i Unrt ? 2=Toying Truck 5=Camper 8= di "- T ` m n ng ra 3=Towing Utility Trailer 6=Full Trailer 9=Unknown V Units: rection ci © 'Vehicle Position D' D "Movement (??1 *S a ove Special Usage a y Vehicle Color Vehicle T m 05=large Truck 20=Unicycle, Bicycle, 12=Commercial Passenger 06=Yellow 07=Silver 01=Automobile 06=SUV Tricycle 02=Motor cle 07=Van 21 =Other Pedaicycle cy & 00=Not Applicable Carrier 01=Fire Veh 13=Taxi 08=Gold 01 =Blue 09=6rovm Buggy 03=Bus 10=Snowmobile 22=Horse 04=Small Truck 11=Farm Equip 23=Horse & Rider 02=Ambulance 21 -Tractor Trailer 03=Police 22=Twin Trailer 02=Red 10=Orange (if "02", Complete Form 12=Construction Equip 24=Train 08=Other Emergency 23=Triple Trailer 03=White 11=Purpie M, Section 26) 13-ATV 25=Trolley Vehicle 31 =Modified Veh 04=Green 12=Other Unknown 99 1 (If "20" or "21", Complete 18=Other Type Spec Veh 98=0ther pe Spec Veh 99=Unknown 19=Unk T 11 =Pupil Transport 99=Unknown = ack 05=8 . y Form M, Section 27) tl Point Initial Impa Damage Indicator Gradient 3=Downhill Road Alignment _ --?--^? 00=Non-Collision 14-Undercarriage I nll _ I 01-12=Clock Points 1 S=Towed Unit Z2 M 0=None 2=Functional 1=Minor 3=Disabling 1=Level 4=Bottom of Hill 5=Top of Hill hill 2 U 1=Straight Q 2=Curved ti, 13=Top 99=Unknown 9=Unknown = p 9=Unknown n 9=Unknown FORM x AA-500 (17102) PENNDOT COPY ..J• COMMONWEALTH OF PENNSYLVANIPOLICE CRASH REPORTING FORM ?rPage AA 500 3 Pob se ry / L=.?iZJ 11111111111111 Crash Number P 1223508 Seat Position: Q 1=D ? OQ=Not A Passenger/Occupant 2=Passenger 01 =Driver -All Vehicles --fete rin,SLotn nt One: F.?Ci4Q? E 00=None Used / Not Applicable G 0--Not Applicable 01=Shoulder Belt Used 1=Not Ejected 7=Pedestrian 8=Other 02-Front Seat Middle Position 03=Front Seat Right Side 02=lap Belt Used 2=Totally Ejected 03=Lap And Shoulder Belt Used 3=Partially Ejected 9=Unknown 04-Second Row - Left Side Or Motorcycle Passenger 04=Child Safety Seat Used 9=Unknown 05=Motorcycle Helmet Used • 05-Second Row - Middle Position 06=Second Row - Right Side 06=Bicycle Helmet Used H Election Path: 10=Safety Belt Used Improperly O==Not Ejected / Not Applicable F =Female M=Male 07=Third Row Or Greater - Left Side 11 =Child Safety Seat Used Improperly 1=Through Side Door Opening 12=Helmet Used Improperly 2=Through Side Window U =Unknown 08=Third Row Or Greater - Middle Position 90=Restraint Used, Type Unknown 3=Through Windshield 99=Unknown 4=Through Back Door O 09=Third Row Or Greater - Right Side S=Through Back Doer Tailgate Opening $?fpty a Moment Two: 6=Through Roof Opening (Sunroof/ Y m lniurv Severity: 0--Not Injured 10=Sleeper Section of Truckcab 11=1n Other Enclosed 00=None Used ! Not Applicable Convertible Top Down) 01=Front Air Bag Deployed (For This Seat) 7=Through Roof Opening (Convertible Thi S l d Q 1=Killed Passenger Or Cargo Area (For s oye 02=Side Air Bag Oep eat) Top up) 0 d 2=Major Injury 3=Moderate 12 =In Open Area (Back Of Pickup, Etc.) 03=0ther Type Air BB, Deployed 9=•Unknown 04=Multiple Air Bags Deployed Injury 4=Minor Injury 8=Injury Unk 13=Trailing Unit 14=Riding On Vehicle Exterior IS=Bus Passenger 05=Motorcycle Eye Protection 06=Bicyclist Wearing ElbowlKneeMads Extrication: 10=Air Bag Not Deployed, Switch On O=Not Applicable , Severity 9=Unknown if 98=Other 99=Unknown 11=Air Bag Not Deployed, Switch Off I Not Extricated 12=Air Bag Not Deployed, 2=Extr(cated By Mechanical Means Injury Unk Switch Setting 3-freed By Non - Mechanical Means 13=Air Bag Removed (Prior To Crash) 8=Other 19=Unknown if Air Bag Deployed 9=Unknown 99=Unknown 3 EMS Agency: IK YI W -p Erns Medical Facility: Unit No Person No Date of Birth (MM•DO-YYYY) A B C D E F G H I Delete7 F6 - Name / Address / Phone EMS Transport Same as Yes (Z) No Operator Unit No Person No o.? o f d 1 Delete? Date of Birth (MM-DD-YYYY) A 8 C D E F G H I o -o?- c?oaF Name / Address / Phone EMS Transport Vame as O Yes O No Operator ?Unit No Person NNo Date of Birth (MM-OD-YYYY) A 8 C D E F G H I Delete? Name / Address / Phone j l Same as 1146L L ni1QO Operator /?+?? _ EMS Transport AOL S(? k. 1?? ?r Yes (?JNo Unit No Person No a r? 3 Date of Birth (MM-DD-YYYY) A 8 { CC D E F G H T Delete? e? (--7-? a D o b ©?t?r Q 14 4N a a It n /? Name / Address / Pho e EMS Transport Same as ) L (tir T / f 7T Q Yes J?a No Operator Unit No Person No Delete? Date of Birth (MM-DO-YYYY) A 8 C D E F G H I 71 c) Fo oC 7- a b ?Maa Name / Address / Phone EMS Transport Same as Operator IL ZW Q Yes (0 No Unit No Person No Delete? Date of Birth (MM-DO-YYYY) A ?8 CC D E F G H ?I 19- 17 10 M7 L 1 Name / Address / Phone EMS Transport 'Same as Operator fD Yes ($ No FORM 0 AA-500 (I M2) PENNOOT COPY COMMONWEALTH OF PEdlNSYLVANI POLICE CRASH REPORTING FORM /YY page AA 5W P P61 /) ! n)-yl n, ?? ? j:rer New 11111111111111 Crash Number co Changel I Continuation Unit No Person No Date of Birth (MM-DD-YYYY) A B ?C D ?E F G H I 1?.C1?J LU 6C 1 Se? ?- 11-71 - Name / Address / Phone EMS Transport n Same as Operator O Yes (3) No unit No Person No Date of Birth (M-M---DDD-,YYYY) q Q A B C DD EE F G H I Lv_JLJ Delete? = i { ?tv1_JJ©1®a Name / Address / Phone 1' J EMS Transport mA CJ Yes Q?`No Ope ator W&Z Unit No Person No DateofBirth (MM-OD-YYYY) A B C D E F G H I --7---? DeiOete? -m _ F: o m m F- a a Nawme / Address! Phone EMS Transport Same as Operator Q Yes Q No Unit No Person No Date of Birth (MM-DD-YYYY) A B C D E F G H I DOiete? 1- ? - ? a a m o a ? Name / Address / Phone EMS Transport Same Operator I- I 0 Yes Q No ?U'niit?ITN?oPerson No Date of Birth (MM-DD-YYYY) A B C D E F ??'G?1 H I L? I Delete? 0 0 D L I FT] Name / Address / Phone EMS Transport same as operator Q Yes Q No Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I cry c? o ?ooc?mcmoaa d Name //A dress /Phone EMS Transport Q Same as Operator r - - J l Q Yes ONO Unit No Person No Date of Birth (`MME-DD-]YYYY) A ?8 ] C mD E F G H I m m Delete? - W 1] ]ET] W m I J ?FT? H Name /Address /Phone EMS Transport c Same as Operator Q Yes O No Unit No Person No Delete? Date of Birth (MM-DO-YYYY) A B C D E F G H I m [?`?_1--? l__ 0- W U? W m?-Q-?? Name ) Address i Phone EMS Transport Sas OOpeerrator ' O Yes O No Unit No Person No Delete? Date of Birth (MM-DD-YYYY) [ AA B C D E F G HH I m O -CD L__J l C? Q? CIS ?D FU1 1 Name I Address I Phone EMS Transport operator 0 Yes Q No Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I ca m CD 0El0 ma o Name / Address / Phone EMS Transport Same as O Yes O No Operator FORM • AA-500 r (12MA PENNDOT COPY COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM / Page AA 500 4 f..?? 1111111111111111 Crash Number v 1223508 tlon O=Non-Collision 2=Head On 4=Angle 6=SideswiQe B=Hit Pedestrian Crash Descri_ p U I c _ 1=Rear End 3=Rear to Rear 5= '?deswi Q (Opposite Direction) ? o (Backing)Same ?rrection) 7=Hit Fixed Object 9=C„herNnknown Relation to Roadway (? 1=0n Travel Lanes 3=Median 5=Outside Trafficway 7=Gore (Ramp intersection) (? 2=Shoulder 4=Roadside 6=1n Parking Lane 9=Unknown t Illumination 1=Daylight 3=Dark - Street 5=Dawn 8=Other „ p R lark No Lights 6= ark - Unknown ? treet V hts 4=Dusk oadwa U Mi ; d Weather Conditions 3=Sleet (Hail) 6--Fog 7=Sleet & Fog 9=Unknown 1=NC oo And itiondver s s is c 2=Rain 4=Snow 6=Rain 8r Fog 8=Other v Load Surface Conditions 0=Dry 2= fond, Mud, Dirt, 4=Slush 6=Ice Patches 8=Other 7=or t r -Standing 1=Wet 3=Snow Covered 5=Ice or moving Harm Event L/R Most? Utility Pole Number `Z 1 ® HarmfW Events (Harm Event) 30=Hit Fence Or Wall 01 =Hit Unit 1 31=Hit Building Q Unit No 02=Hit Unit 2 32=Nit Culvert 2 03=Hit Unit 3 33=Hit Bridge Pier Or Abutment 04=Hit Unit 4 34=Hit Parapet End e Rail Hit Unit 5 35=Hit Brid 05 = g 06=Hit other Traffic Unit 36=Nit Boulder Or obstacle Please Put 3 Events in ? 07=Hit Deer On Roadway 08=Hit Other Animal 37=Hit impact Attenuator , LLL Sequential 09=Collision With Other Non 38=Hit Fire Hydrant c u Order 4 Z $ © 0 Fixed Object 39=Hit Roadway Equipment 11 =Struck By Unit 1 40=Hit Mail Box m 12=Struck By Unit 2 41 =Hit Traffic Island Unit 3 42=Hit Snow Bank 13=Struck B £ `o 5 Harm Event C/R Most? Utility Pole Number y 14=Struck By Unit 4 43=Hit Temporary Construction 15=Struck By Unit 5 Barrier ., 1 ® 16=Struck By Other Traffic Unit 48=Hit other fixed Object 49 Hi k Fi d Ob Unit No nown = t Un ject xe 21 =Hit Tree Or Shrubbery 2 a Q 22=Hit Embankment 50=Overturn/Roll Over 23=Hit Utili Pole 51=Struck By Thrown Or Falling Object 24=Hit T Si ff ra ic gn 25=Hit Guard Rail 52=Pot Holes Or Other Please Put E ent i 3 1:1 Q 26=Hit Guard Rail End Pavement Irregularities 27=Hit Curb 53= Jacknife v n s 5equentlal 28=Hit Concrete Or 54=Fire Fire I n Vehicle Order 4 m Q Longitudinal Barrier 58=Other Non-Collision 29=Hit Ditch 99=Unknown Harmful Event first Unit No Harm Event Most Unit No Harm Event }emful m ® >?fin ® ^ veni inin veF-'ni fn ? Driver Action (D) 17--Careless Or illegal 1Backing On Roadway 00=NO Contributing Action 8=Drivin on The Wron D i CJ e ash the t msh g g r 01= ver Was Distracted 02=Driving Using Hand Held Phone Side Of Road fb nol repeat this information on multiple pages 03=Dr ving Using Hands Free Phone 19=Making improper Environmental /Roadway Potential factors (E/R) 1 V b 2 3 m 04=Making Illegal U-Turn Entrance To Highway 05=Improper/Careless Turning 20=Making Improper Exit 06=Turnin From Wron Lane From Hi hw g g g ay 07=Proceedin W/0 21 C l P k N 00=None 11 =Slippery Road Conditions (ice/Snow) g = are ar ess ing nparking Clearance After Stop 22=Over/Under 01=Windy Conditions 12=Substance On Roadway 02=Sudden Weather Conditions 13=Potholes 08=Running Stop Sign Compensation At Curve 09=Running Red Light 23=Speeding 03=Other weather Conditions 74=Broken Or Cracked Pavement r In Roadwa 04=D 15=TCD Ob t d 10=Failure To Respond To 24=Driving Too Fast For Conditions y s ee ructe 05=Obstacle On Roadway 16=Soft Shoulder Or Shoulder Droo Off r Animal In Road 06=Oth 28 Oth R F d t Other Traffic Control Device 25=Failure To Maintain Proper Speed 11=Tailgatingg 26=Driver Fleeing Police (Pol Chase) way e = or er oa way ac 07=Glare 29=Other Environmental Factor 12=Sudden Slowin Stopping 27=Driver Inexperienced 13=1llegafly Stop On Road e 08=Work Zone Related 99=Unknown 28=Failure To Use Specialized Equip 14=Careless Passing Or Lane 92=Affected By Physical Condition Ch Possible Vehicle Failures (10 12=Wipers ange 98=Other improper Driving Actions 15=Passing In No Passing Zone 99=Unknown 00=None 06=Exhaust 13=Driver Seating/Control 16=Driving The Wrong Way On 01=Tire5 07=Headlights 14=Body, Doors, Hood, Etc 1-Way Street ? 0=Brake System 08=5ignal Lights 15=Trailer Hitch 033=Steering System 09=Other Lights 16=Wheels i b Unit ® m No 1 2 3 4 O I q S r ags 04=Suspension 70=Horn 7=A 05=Power Train 11 =Mirrors u ?- r--, 19=Un Shifted Non L? f 1 2 m Trailer iler Load 1 Q 20=Improper Towing Unit ® m No 1 C? d 2 3 4 Unit N Eil ? 21=Obstructed Windshield 99=Unknown 1 Q p 2 m Pedestrian Action (f) 03=Workin g 00=None 04=Pushing Vehicle o 01=Entering Or Crossing At 05=Approaching Or Leaving Vehicle tion 06=Working On Vehicle S ifi d L Indicated Prime Factor Unit No Factor Code oca pec e 02=Walking, Running, Jogging, 07=Standing Oo not repeat this information on multiple pages. j ® Or Playing 98=Other 99=Unknown E/R V D P if ElR i h P F 5 Unit No Unit No m m m m Q e rime actor ? Q G s t Type, leave Unit No blank FORM 4 AAAW (12/02) PENNDOT COPY J • COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM M SO0 4 o ?t?5 S?r? Now Crash filumber Page Change/ __R Continuation 31SIO Crash Descriat ion o ; E $ Relation to Roadway o ? •F V c s N a Jllumination i V rv m Weather Conditions Road Surface Conditions 0--Non-Collision 2=Head On ? i=Rear End 3=Rear to Rear (Backing) 1=0n Travel Lanes 3=Median ? 2=Shoulder 4=Roadside 1=Daylight 3=Dark • Street lark Li ahu ret L ights 4=D 4dVt rse usk '=onlbons 3=Sleet (Hail) 2=Rain 4=Snow ? 0--Dry 2- nd, Mud, Dirt, it 1=wet 3=8now Covered Unit No 1 1 F1 W ®2?J DOI Please Put EvenCS in 3 m O Sequential p Order 4 m 6 o c Harm Event L/R Most? Utility Pole Number 1 m Unit No CTS 2 ?I ? 0 1 ^7 Please Put Events in 3 0 Sequential Order 4 m F-1 0 (1 c 0 A E First Unit No Harm Event Most Unit No Parmful vnrn N-ent m m ? Hann Event m h am-0-ash Do not repeat this information an multiple pages Environmental Roadway 1i Potential Factors (E)R) m 2 m 3 m 00=None 11=Slippery Road Conditions (Ice/5now) 01=Windy Conditions 12=Substance On Roadway 02=Sudden Weather Conditions 13=Potholes 03=Other Weather Conditions 14=Broken Or Cracked Pavement 04=Deer In Roadway 15=TCD Obstructed 05=0bstade On Roadway 16=Soft Shoulder Or Shoulder Drop Off 06=0ther Animal On Roadway 28=Other Roadway Factor 07=Glare 29=Other Environmental Factor 08=Work Zone Related 99=Unknown Pbss/ble Vehicle Failures M 12=Wipers 00=None 06=Exhaust 13=Driver Seating/Control 01=Tires 07=Headlights 14=Bod , Doors, Hood, Etc 02=Brake System 08=Signal Lights 15=Trailer Hitch 03=Steering System 09=Other Lights 16=Wheels 04=Suspension 10=Hom 17=Airbags 05=Power Train 11=Mirrors 18=Trailer Overloaded Unit 2 19=Unsecure/5hifted Trailer Load No 1 m (? 20--Improper Towing 21=Obstructed Windshield Unit 99=Unknown No 1 m 2 m Indicated Prime Fador Do not repeat this information on multiple pages. E/R V D P O CD O 0 Unit No Factor Code m ff E/R is the Prime Factor Type, leave Unit No blank 4=Angle pe 5=(Same R e rectifxt) 5=Outside TratRcway 6=1n Parking Lane 5=Dawn R=nnrlr - I lnknnu 5=Fog 6=Rain & Fog 4=Slush 5=Ice 6=Sldeswi(re 8--Hit Pedestrian (Opposite Direction) 7=Hit Fixed Object 9=0therNnknown 7=Gore (Ramp Intersection) 9=Unknown 7=Sleet & Fog 8--Other 6--Ice Patches 7=W t r - Stal or?tovino Harmful Events (Harm Event) 01 =Hit Unit 1 02=Hit Unit 2 03=Hit Unit 3 04=Hit Unit 4 05=Hit Unit 5 06=Hit Other Traffic Unit 07=Hit Deer 08=Hit Other Animal 09=Collision With Other Non Fixed Object 11 =Struck By Unit 1 12=Struck By Unit 2 13=Struck By Unit 3 14=Struck By Unit 4 15=Struck By Unit 5 16=51ruck By Other Traffic Unit 21=Hit Tree Or Shrubbery 22=Hit Embankment 23=Hit Utility Pole 24=Hit Traffic Sign 25=Hit Guard Rail 26=Hit Guard Rail End 27=Hit Curb 28=Hit Concrete Or Longitudinal Barrier 19=Hit Ditch Driver Action (D) 00=No Contributing Action 01=Driver Was Distracted 02=Driving Using Hand Held Phone 03=Driving Using Hands Free Phone 04=Making Illegal U•Turn 05=Improper/Careless Turning 06=Turning From Wrong Lane 07=Proceeding W/0 Clearance After Stop 08=Running Stop Sign 09=Running Red Light 10=Failure To Respond To Other Traffic Control Device 11=Tailgatingg 12=Sudden Slowing/Stopping 13=Illegally Stopped On Road 14=Careless Passing Or Lane Change 15=Passing In No Passing Zone 16=Driving The Wrong Way On 1-Way Street 9=Unknown B--Other 30=Hit Fence Or Wall 31=Hit Building 32=Hit Culvert 33=Hit Bridge Pier Or Abutment 34=Hit Parapet End 35=Hit Bridge Rail 36=Hit Boulder Or Obstacle On Roadway 37=Nit Impact Attenuator 38=Hit Fire Hydrant 39-Hit Roadway Equipment 40=Hit Mail Box 41=Hit Traffic Island 42-Hit Snow Bank 43=Hit Temporary Construction Barrier 48=Hk Other Fixed Obiect 49=Hit Unknown Fixed r 50=0vertum/Roll Over 51=Struck By Thrown Or Falling Object 52=Pot Holes Or Other Pavement Irregularities 53=Jacknife 54=Fire In Vehicle 58=Other Non-Collision 99=Unknown Harmful Event 17-Careless Or Illegal Backing On Roadway 18=Drivingg On The Wrong Side Of Road 19=Making Improper Entrance To Highway 20=Making Improper Exit From Highway 21=Careless Parking/Unparking 22=Over/Under Compensation At Curve 23=Speeding 24=Driving Too Fast For Conditions 25=Failure To Maintain Proper Speed 26=Driver Fleeing Police (Pal Chase) 27=Driver Inexperienced 28=Failure To Use Specialized Equip 92=Affected By Physical Condition 98=Other Improper Driving Actions 99=Unknown Noi1 ® 1 2 m 3 m 4 Noi1 m 1 m 2 C? 3 m 4 m PedesVian Action (P) 03=Working 00=None 04=Pushing Vehicle 01=Entering Or Crossing At 05=Approaching or Leaving Vehicle Specified Location 06=Working On Vehicle 02=Walking; Running, Jogging, 07=Standing Or Playing 98=Other 99=Unknown Unit No m Unit No FORM 0 Aa-oorrtd® PiENNDOT COPY 11111111H111111111 Crash Number P 1223508 COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page AA 500 5 Z P4 jEjjaqt4 7 lL S 00, COOP ALL I f 1- 736-0q Narrative and additional witnesses: Accident Investigation Notification Issued? W Property Damage Q THIS CRASH OCCURRED AS UNITS 1, D 3 WERE ATRAVELING N.B. ON -83 IN THE RIGHT LANE. UNITS 2 AND 3 WERE ST-9PPED WITH TRAFFIG. UNIT 2 WAS BEHIND UNIT 3. UNIT 1 WAS BEHIND UNITS 2 AND 3. THE OPERATOR OF UNIT 1 FAILED TO NOTICE THE TRAFFIC IN FRONT OF HIM SLOWING. E)PERATOR 1 SWERVED TO THE RIGHT. THE PASSENGER SIDE FRONT OF UNI 1 STRUCK IHE EAST WALL OF THE ROADWAY- IHFN THE DIRIMER SIDE QF UNIT 1 IMPACTED THE PASSENGER SIDE OF UNIT 2. THE FRONT END OF UNIT 1 m AGAINST THE WEST WALL OF THE ROADWAY. A PI IV61CAL EVIDENCE OBSERVED AT T' !EseENE CONSISTED eF t2 m APPROXIMATELY 5OFT OF TIRE MARKS LEFT BY UNIT 1 IN THE RIGHT LANE LEADING TO THE POINT OF IMPACT WITH THE EAST WALL. THERE WAS A TIRE MARK AND SeRAPES ON THE EAST WALL LEFT BY UNIT 1. THE OPERATOR OF UNIT 1 WAS INTERVIEWED AT THE SCENE. OPERATOR 1 NOTICE THE T-R-A.r=.rmlr-- S-1, 01212ED IN FRON'T OF HE 1.-R.lr-=-n T- -0 S-I.A.IERVE TO THE RIGHT TO AVOID A CRASH. HE HIT THE WALL AND CRASHED. I ON THE BERM AND HIT HIS TRUCK. THE GREEN TRUCK THEN CRASHED INTO 'ORM • M-6001121021 PENNDOT COPY POCOMMONWEALTH OF LICE CRASH REPORTING FORM PENNSYLVANI i? Pge ® New Gash Number app AA 500 N ?o eA"iy ?' 0 Change/ I/ Continuation Narrative and additional witnesses: THE OPERATOR OF UNIT 3 WAS INTERVIEWED AT THE SCENE. OPERATOR 3 TRUCK - I-83. SWERVED AND HIT THE WALL. IT THEN CRASHED INTO THE BACK OF UNIT 3. a ? a A M b Y a FORM 0 AA-600N p? PENNOOT COPY !?? Y?( ?x ? ? ? ' ? ? Al - ? • i 4YY?yy1Y i aA A? ?- ,?SbY• a. r e i f h I i AN4 1-51 -l9 ` -Zl - aIr . Alb J* ExAiLl'+ C- CERTIFICATION The copies of records for which this certification is made are true and complete reproductions of the original or microfilmed medical records of (print name of medical provider) The original records were made in the regular course of business at or near the time of the matter recorded. The certification is given pursuant to 42 Pa.C.S. Ch. 61 Subch. E (relating to medical records) by the custodian of the records in lieu of his or her personal appearance. Patient: Jonathan Ritz SSN: XXX-XX-8059 DOB: 1/8/1995 Medical Record No.: Number of Pages: Dated: *10 1 Subscribekand Sworn to before me this 7 day of 2007. Notary Public q My commission expires on: ?Y1 7, 2a I COMMONWEALTH OF PENNSXLVAN!A NOTARIAL SEAL DIANNE L. ALBIN, wtay v Public Hanover Born: York County M Commission Expires May 17, 2009 15-17?h C, t r, ?, /C& Print Name: !ll ANOVERHV SPITA L1 JD 0 Comment Entered 300 HIGHLAND AVENUE /7, ?/? NANnVFR PA 17331 .Y . L>$t4 Time - O FC Location Mode of Arrival Registrar Age irthdate Veil Niter 1141..., 1926 R E....:. AUTO ER EMD.DLS 12 01/08/1995 vQp38591 Patient Name Insura Card? Sex MS Race RITZ,JONATHAN D Y No M S CA ElB' Address Addr Discharge Date 10 BURNS ROAD City, State, Zip Phone Alternate one Social Security No. SPRING GROVE,PA 17362 (717)229-8761 Reason for Service Accident Date Accident Time Occur Code MVA-NEC PAI 1 04/14/07 1012 01 Attending Wan Family Physician Other Physician PHYSI AN ER KINZINGER,BRUCE C MD Next Kin Rd. Address Phone RITZ,JENNIFER MO 10 BURNS ROAD HM 1717)229-8781 Person to Notify Rel. Address Phone RITZ,JENNIFER MO 10 BURNS ROAD HM (717)229-8781 Patients Employer Occupation Address Phone CHILD CHILD Guarantor Guarantor SS# Address Phone RITZ,DAVID 10 BURNS ROAD (717)229-8761 Guarantor Employer Occupation Address Phone YORK AUTOMOTIVE SALES MANAGE Ins. Mnemonic Insurance Company PollcylCertificate Group No. Subscriber Rel. Subscriber DOB Subscriber SSN AUTO STATE FARM INSURANCE 51 7956 F19 380 0018590005 RITZ,DAVID B FA 09/21/1967 BC BLUE CROSS 366 CAC186568457 0018590005 CZ,DAVID B FA 09/21/1967 rrogress notes fi/ 7&?, ( - HIPAA )940 0 No V for MR#11ED(REV.02W) CHART COPY PHARMACY EMERGENCY ROOM REEVALUATION AT TIME O -MANSFER OR DISCHARGE SD ED: at 'l S Verbalizes understanding of D/C instructions 4 51 ine lock D/Vd ? Site dear ? Catheter intact bulatory ? Ambulance ? Carried ? w/c reaction to medication ? Pain scale TRANSFER TO: at Via COBRA ? Copies: ? Chart ? Labs ? X-mys/CT ? EKG Report given to: Valuables List: ? Yes ? No Valuables with ? ALS ? BLS ADMITTED: Called at Room /i Report called to: at Valuables List: ? Yes ? No Valuables with Transported via at With: ? Cardiac Monitor ? 02 ? RN ? AMA ? Elopement Time EXPIRED: ? Organ Donation Form ? Body to morgue at CODE: Y N P(? n SIGNATURE: 17 MVC DATE: ? 1 _ _ ROOM: /a _ EMS Arrive/ HISTORIA acien family EMS _UNAB?-E TOO AIN HISTORY DUE TO: HPI chief complaint: MVC Injury to: duration: just prior to ardvof on le: I ('a driver sse er (root odc What made you come in today? context: car colli ' overturned vehicle single-car acct ent fatality at the scene (last controi / (ell asleep I seizure I fainting /chest pain / polpitodom / troubk breathing/unknown cause ) location of pain / -- in car ribs hand ribs hand shldr hip shldr hip head face mouth € arm thigh arm thigh chest abdomen elbow knee elbow knee bat upper mid lower I f-arm leg f-arm leg radiating to (R / L) thigh /leg wrist ankle wrist ankle foot € foot severltv of ain: associated symptoms: Eild lost consciousness / dazed duration moderate remembers: severe impact coming to hospital became dizzy / fainted seizure site of impact: restraints, ? "P" = primary "S" = secondary none lap shoul r doesn't re car seat air bag deployed thrown from vehicle force direct glancing ambulated at scene rear ended / t-boned / head on long extrication d l < 15 spee ow mod 15 -50 high > 50 ROS _ ----- loss feelin /power arms /legs ; troubl breathing / chest pain ; memory I s ; loss of adder function ; headache / k pain ' skin rash ' double Sion ! hearing loss - nausea fey r /illness abdomina nausea / omi in n r preg t confirmed w/ home test ; LMP ; ? all systems net except as marked- ; r----------------------------------------------r ; SOCIAL HX s leer drugs ; alcohol (recent /heavy/ asionaQ living situa ' n alone sp a family friend ; FAMILY H -negative ; ---------------------------------------------- ? RITZ,JONATHAN D 04/14/07 101/08/1995 12 M PHYSICIAN ER KINZINGER,BRUCE M000158722 V00002366692 11111 W Alma I PAST HX heart isease d' tes Type 1 Type 2 se M lung dis a diet oral/inwlm hx osuppression neuro di kidnef( dis ase AIDS steroids cancer transplant liver ease splenectomy GI dis []Tetanus immun. UTD Me ir,rimns VFione see nurses note Allergies KDA ASA NSAID clopidogrel warfarin see nurses note heparin o anti ants Iff Nursing Assessment Reviewed it+el vital Signs Reviewed BP HR RR Temp Pulse Ox o/, _RA _02 per NC / mask Interp -nml _hypoxic PHYSICAL EXAM eEEXAM LIMITED BY: General Appearance _c-collar (PTA /in ED) / backboard well ars t -mild / moderate / severe distress _ ec -anxious / lethargic combative behavior -smells of ETON To -see diagram o evidence of -Raccoon eyes /Battle's sign trauma NECK (Z a -non-tender oint-tenderness p _painless ROM - muscle spasm / decreased ROM trachea midline _ Fwn on movement of neck -Nexus criteria neg _ midline tenderness / distracting injury - altered mental status / neuro deficits(injury)- recent ETOH 1 u EX P _unequal pupils R--mm L-_rmn .fPERRL -EOM entrapment / palsy ?EOMI _subconjunctivai hemorrhage ENT _hemotympanum_ external _TM obscured by wax inspection -clouted nasal blood io dental injury dental injury / malocclusion -ml occlusion - _pain / crepitance -instability of maxilla mandible RESP -see diagram (on reverse) lest non-tender -tenderness / seat belt bruising /io ecchymosis / subcutaneous emphysema - :ltfeath sounds nml -splinting / paradoxical movements splinting -decreased breath sounds _wheezes / rales / rhonchi CVS -tachycardia bradycardia eart sounds nmi ABDOMEN / GI -see diagram ( on reverse) ion-tender -tenderness / guarding / rebound !o organomegaly -mass / organomegaly distention FHT's _pelvis sable to distraction / compression 0 1996 - 2006 T-S stem, Inc. Circle or check affirmatives, backskuh negatives. Hanover Hospital EMERGENCY PROVIDER RECORD MRS 490 04/00, 07/01, 05/03, 10/06, 01/07 MENT - Cl NO TRIAGE TO TREATMENT AREA / ._ To 13t rteti From ?xIINI 02 IM m o t4 Cl r,(-W-0 A_10 < Z It f n no (j? MR Tetwm: r"` LMP, Sal mr. 0y,0 .4ini emh os PMH: O None `r A v^Q f 7>k priorao arrty? Wa* 0111111111111111W - Tumbmw O Aatr MOR O DM IM © kin ? Eieawce 7D: Area D ? XraY ©--?Time RN Class: 12 3 PRE-INWITAL CAII: O ALS O BLS /A Vital signs: BP: P: R: Rhythm: Airway: Oxygen: 02 Sat O ET Tube # Taped 0 cm O Cervical Collar ALS MEDS O Longboard O Albuterol med neb O Morphine O CID O Atropine O NTG x O Splint O Dextrose 50% D Blood Sugar O I.V. O Lasix O Other WA NEURO/THOINW PROCESSES: ooperative O Oriented x _ ZJb66S_ ous Eye Contact: O Y O N O O Agitated0 Combative O Confused O Hallucinations O Delusions O Suicidal/Homicidal HEAQ A10 FACE: O HQAEJ Denies O Hematome/Swelling O Deformity O Laceration ion 17 Loss of Consciousness . D O O Hematoma/Sweiling O Deformity O Laceration0 Abrasion L O PhotophWa Visual Acuity: O$_ OIL_ 0 Corrected O Not Corrected O Em: 11 O Hematoma/SwellingO Deformity O LaceraWnO Abrasion O Obfta O Earache O Nose: ies O Hematoma/Swelling O Deformity O LacerationO Abrasion O hinorhea Q Epista)ds O Moulh/Throat Cr Fenies O Normal O Hematoma/Sweiling ? Deformity O Laceration O Abrasion O Sore Throat O Dental Pain Descd O SKI •O rdC arm O of O Diaphoretic O Pale O Cyanotic EC C O Denies O Hematoma/Swelling O Deformity O Laceration Abrasion <r3fi'ain lat imited Motion Describe ?k c l wy- - O EXTREME TM8: I O Edema O Hematoma/Swelling O Deformity O Laceration Abrasion Describe RITZ,JONATHAN D 04/14/07 0110811995 12 M PHYSICIAN ER KINZINGER,BRUCE VOOOo2366592 M000158722 O Cardin O COPO O CVA MEDICATIONS UST: O DepressWArodely O Dlabotes O Hypertension O Hypothyroid O Seizures O Substance abuse (.-,o Safe at home? O Other O UNKNOWN O ? CIRCULAT Rr C Sheet Pulse; ular ? Irregular ? Weak Cap Refill ? a/Swelling O Deformity ? Laceration ? Abrasion DyRiTendemess ? CHE es ? ? Sternal Tendemess O Seatbelt Marks DO LUNGS: CI-Qffes ? Clear ? honchi/Rales ? Wheezing ? Cough ? Retractions Describe ? ABDOMEN: ies ? Hematom welling ? Laceration ? Abrasion ? Seatbelt Marks ? Distensio ? Soft ? Rigid O Nausea ? Vomiting Tender. O LUQ O RUG O U.0 O RLO Bowel Sounds: ? Y O N O Diarrhea O Constipation O Last BM: Describe O PELVIS/011111: D s O Hematoma/ (ling O Laceration O Abrasion O Tenderness D Frequency Urgency O Retention O Dysuria O Hematuria Describe Reproductive: rus: LMP O Pregnant -weeks FHT G_ P __9B_ O Vag Bleeding O Vag O/C Describe O PAIN: (Circle scale used) O Denies Loca 9 _ O Provoked O Quality O Radiationn O tI C Severity (0-10) O Timing )ascribe 1• X ?? I I I I I I I I 11 NO PAM MODBNTE PAN SEVERE PAN 2. 00 00 00 0® 0? =few 2-Hu 4-Hurts a 6-Hurts 8-Hurts a 10-HuAs as nwh just a little bk even more whole lot as you can Ins oe, doesn't hurt little b more although you dorn at an have to be crying to 3. FLACC Scal this bW. RN Signature limel ED TRIAGE/NURSING ASSESSMENT RECORD MR. q. roa0., ? y a? y y y ? y y y y y y y CHART-ORIGINAL. COPIES: PHARMACY EMERGENCY DEPT ? ? ? ? ? ? 4n 4§ 4w 4x 40 40 4a 40 ALLERGIES: «NkA O UNKNOWN LATEX: O Y 6w_r Time T P R BP NARRA VE C ? nn 62 Lj\\? L Q %J -j L Q 02 ? BGM (65-99 mg/dl.) by (Reference Range) y ne% ificarl of rritiral rrpc1 dtc at by EKG shown to at by Time stop Stan Stop Dose Route Pain Taken Before Init Time Reeval Start 1me?oF MEDICATIONS Dow Route Pain Terre Init Time Rwval Ti- ?`"' ?`°p site Size SOLUTIONIVOLUME Rate tntt Time NTAKE UTPUT ORAL IV URINE OTHER SIGNATURE INIT 'SIGNATURE IN SIGNATURE INIT SIGNATURE INIT ? Indwelling Foley Inserted Time Size Balloon Initial Urine Output RITZ,JONATHAN D 04/14/07 01/08/1995 12 M VER_7O` 7?/'f L M000158722 V00002366592 ED PROGRESS NOTES .., ...._,_..._ ................_... CHART COPY PHARMACY EMERGENCY ROOM MR #11 CONT (REV. 02/07) HANOVER HOSPITAL Emergency Services 300.Highland Avenue Hanover, PA 17331 717-633-2000 mate: Saturday, April 14, 2007 at 07:51 PM Patient: Johnathan Ritz Doctor: Michael Denney DO The following instruction(s) should be read carefully: NECK PAIN OR INJURY: There are several different causes for neck pain, which is a very common problem. A "whiplash" injury is a sprain of the cervical (neck) ligaments occurring from extreme flexion or hyperextension of the neck. We see this commonly after motor vehicle accidents, but it is also frequent in falls and sports injuries. The pain and stiffness may not develop until several hours after the injury occurs. Muscle strains of the neck may occur with the above injuries. Sometimes, there is only the history of turning the head or waking up with pain. There may be muscle spasm, causing the head to be held in an abnormal position. The evaluation of neck pain often includes x-rays to look for a neck fracture or other bony abnormality. Any symptoms of numbness or weakness must also be carefully considered. Resting the neck is very important in the treatment of acute neck pain. This means lying down or reclining so that the neck is not doing any work of holding the head up. A cervical collar is sometimes used to help support the head when the person is up - but this is not a good substitute for true neck rest. Pain medicine, muscle relaxants, and anti-inflammatory drugs are often used as III. Ice packs initially, followed by heat after 2-3 days is often very helpful. Other physical therapy may be indicated, especially symptoms do not gradually improve after several days. Neck sprains often take several weeks to heal completely. You will need follow-up with your doctor if you are not gradually getting well. NOTIFY YOUR DOCTOR or return to the Emergency Department in case of the following: - Persistent or increasing pain. - Numbness or weakness. - Prolonged or high fever. - Severe or worsening headache. - Change in mental status - too sleepy, confused, short of breath, irritable, slurred speech, difficulty walking. The following note(s) should be read carefully: Follow-up with your private physician within 3 to 5 days. If your condition worsens and your private physician is not available, return to HANOVER HOSPITAL Emergency Services. I understand that the treatment I have received was given on an emergency basis only. I understand that further treatment may be necessary. I have been given a copy of the above instructions. I understand these instructions and I will arrange for follow-up care as outlined above. If my condition worsens, I will call my doctor or return to the hospital. Emergency Department phone 1mber: 717-633-2000. in the event you have a "managed care insurance," you need to call your primary care physician on the next business day to have the proper paperwork forwarded to your insurer. Signed: V 1J Relation to Patient Johnathan Ritz Hanover Hospital Page 2 Witness: About Your Visit to Hanover Hospital About the Physicians The Emergency Department at Hanover Hospital is staffed by physicians from Emergency Physician Associates of Pennsylvania, P.C. Emergency Physician Associates of Pennsylvania, P.C. is a group of physicians who specialize in Emergency Medicine. They are experienced in treating patients needing emergency medical care. About Your Bill The charges for your visit to the Emergency Department today include: * Charges from the services provided by the physician Separate charges for the use of the facility, x-rays, supplies, medicines, etc. These charges will be billed separately. That is, you and/or your health insurance provider will receive SEPARATE bills: one (1) from Emergency Physician Associates of Pennsylvania, P.C. for emergency room physician services, one (1) from the Hospital, and possibly others from physicians who were involved in interpreting tests that might have been conducted. ? ou have any questions about your bill from Emergency Physician Associates of Pennsylvania, P.C., please call 1-888-952- 6772. We will be happy to assist you. If you have any questions about your bill from the Hospital, please contact the Hospital Billing Department at (717) 633-8877. We are not a participating provider with Aetna Health Insurance. Therefore, you may be responsible for any or all charges incurred during this visit. NUTRITION NOTES: p 1 Concerns or questions regarding nutrition, please contact Nutritional Services at (717) 633-2263. ?? S 0 a' PAIN CONTROL: / Tylenol (acetaminophen) or Advil (Ibuprofen) should be used for pain control unless otherwise advised by your physician DICATIONS: Your medicines are important to us. We need to know what medicines you are currently taking to take better care of you when you are a patient here in the Emergency Department whether you are admittted or discharged. Whenever you come to Hanover Hospital Emergency Department, please bring all of the current bottles of medicine with you so we can have the accurate dose and frequency. It will help us to help take care of you. You can bring a list of medicines instead as long as it includes the dose and frequency. Johnathan Ritz Hanover Hospital Page 3 Thank you. ,anover Hospital Emergency Department Staff i April 25, 2007 Hanover Hospital ATTN: Medical Records Custodian 300 Highland Avenue Hanover, PA 17331-2297 RE: Patient : Jonathan Ritz DOB : 1/8/1995 L SSN : XXX-XX-8059 Dear Sir or Madam: 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 717-238-8187 Fax: 717-234-9478 Other Offices Lancaster Mechanicsburg 717-431-0138 717-691-5577 Shippensburg York 717-530-7515 717-843-0502 Wilkes-Barre 570-825-7500 This law firm has been retained to represent the above-referenced individual for injuries sustained in an accident on April 14, 2007. At this time, we are hereby requesting copies of any and all records from April 14, 2007 to the present, pertaining to our client. The records requested include, but are not limited to, any and all physician reports, chart notes, correspondence, test results, consultation reports, memoranda, billing records, medical records and correspondence from other health providers, etc. Enclosed is a Release of Records Authorization allowing you to release to us the records. Please also complete and return to me with the records the enclosed Certification pursuant to 42 Pa.C.S.A. §6151 et seq. By returning the completed Certification, we may be able to avoid the personal appearance of the records custodian at trial. We will reimburse you at the legal rate for the reproduction costs associated with complying with my request. However, should the records be voluminous, please telephone the undersigned for verbal approval to proceed with reproduction. If you require prepayment, please contact us or, if you prefer, note the amount required here: ($?; and return this letter to us. We would appreciate receiving these records within ten (10) days from the date of this letter. Thank you for your prompt attention to this request. Sincerely, ME ZGER, WICKERSHAM, KNAUSS & ERB, P.C. i Kam M. Hertzler James F. Carl KMH?kmh Edward E. Knauss, IV* Clark DeVere' Enclosure Francis J. Laffert}; IV Andrew W. Norfleet cc: Patient Billing (w/encl.) Robert P. Grubb Of Counsel Doc# 375565.1 " Board Certified in civil trial lau+and advocacy I nul by the National Board ?/ANOVERHOSPITAL When performance counts. 300 Highland Avenue Hanover, PA 17331-2297 717-637-3711/1-800.673.2426 www.hanoverhospital.org MEMORANDUM FROM: Release of Information Specialist At your request we are forwarding the accompanying documents which contain information from Hanover Hospital which is confidential and/or legally privileged. The information is intended only for your use. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or taking of any action in reliance on the contents of this information is strictly prohibited and all of the enclosed should be returned to this hospital immediately. In this regard, if you have received this in error, please notify us by telephone (717-633-2231) immediately so that we can arrange for the return of the documents at no cost to you. THE FOLLOWING STATEMENT APPLIES TO ALL PAGES OF THE ENCLOSED! CONFIDENTIAL Federal Regulations (42CFR Part 2) prohibit you from making any further disclosure of these records without the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. GEN# 151 10/98,11/04 .? }c?j ?' ? STAR-MED Certification of Medical Records Date: .5=dA -07 Patient Name: SGrow-han. ('tZ Facility: , 7C rinn As the Release of Information Specialist at the above mentioned facility, I certify that the attached f pages are true and accurate photocopies of the original medical record as specified by the patient's authorization or as directed as of ,- 2,9 -e,7 (Date copied). :Y?aa -67 LZ Date Release of Information Specialist )cation, i ration, t .odifying ins and s 'chronic Name: •..>: DOB: ?I yr a r severity, context, s, associated nu OR status MS. - .. .. ?Ia 0 0 0 Date: `f' D1 . H: W:.- T:.._._ __....: P: Age: BM I Chief Complaint, -(u - m ypq 'r A`.13 D O A i°? -- J 0 Mods Reviewed `1 Allergies Reviewed k /?1Q ? Recent jAb y3 Acute Mods: MA Signature HPI: CQ C) ;7 14 4; /- , 0 ' le /-"7? 7 Musc O CJ Skin/breasts ? Q!. Neuto ? O. t Psych' O w Endb ? a. Hem/lymph O C1a Past! CI ? , a Skin Nburo a ?- v? ZJ Y SV1611 /U U g" ? C Ste- a -4-?r Jexbfh Follow Up: Days _ Weeks Montt.,. Pm ' Couns/coord > 50% 0 I Total time: min. Provider Signature ; Couns/coord tithe: min, Ex4ib,f E Jonathan D. Ritz Chart: 2007-00599; DOB: 01/08/1995 Thursday, October 25, 2007 Progress Notes Page 1 of 3 Initial Conference: The above captioned patient presented in this office for evaluation and consideration of possible treatment. A detailed problem focused chief complaint was discussed and an extended history of the patient's present illness was obtained. Additionally, an extended review of systems was performed and a brief past, family and social history was gathered. Examination: A detailed examination of this patient's affected body area(s) and other related or symptomatic area(s),was performed. See below for further information. Level of Medical Decision Making: Low Complexity. PFSH: I confirm that I have reviewed the Medical Health History Questionnaire which includes review of systems, past medical, social and family history. Subjective: The patient enters the office today with a report that he is feeling intermittent mild to moderate pain in the left and right neck area. In addition, he states that he has been suffering mild to moderate intermittent spasticity'of the neck muscles bilaterally. This patient further stated that he has been feeling moderate pain in tfre`middle back area bilaterally. Jonathan finally reports that he has been feeling occasional moderate pain bilaterally in the lower back area. The patient reported to the office complaining of severe back pain in several regiong`as the result of a motor vehicle accident that occurred on April 14, 2007. The patient completed an accident questionnaire detailing the events (see file). He and his family were stopped in traffic when his vehicle was stuck from the rear by another vehicle traveling 60 mph. He was evaluated at a hospital the day of the acciddKt and released. Objective: Functional segmental motoricity was checked and there was a moderate fixation of the spinal joints at C2-C6, T4-T5, T7-T9, 1-3-1-4, the left ilium-the right ilium, the left ilium and the right ilium noted. There is a moderate amount of muscle tightness in the suboccipital muscles bilaterally, cervical paraspinal muscles bilaterally, upper thoracic muscles bilaterally, mid thoracic muscles bilaterally, lower thoracic muscles bilaterally, lumbar paraspinal muscles bilaterally and gluteal muscles bilaterally elicited on palpation. On palpation examination there was elicited a medium level of pain at C2 to C6, T4 to T9, L2 to L5, and the left ilium to the right ilium bilaterally with a moderate edema at C2 to C6 bilaterally. Jonathan's right hand is his dominant hand. He is 5 feet and 5 inches tall. He weighs 111 pounds. His Temperature was taken and measured as 98.1 degrees. Pulse was 120 BPM and respiration was 16 per minute. Jonathan's blood pressure was taken in a sitting position with the following results: Left A'rm: 126/84 Observation of the ears, nose and throat found that the ears, nose, and throat appear normal. The heart was observed to be normal. The following tests were performed. Jackson's Test is positive bilaterally, and Adson's Test is positive on the right. Kemp's Test was negative bilaterally. Myotomal, reflex and sensory evaluations of the C5-T1 and U-Si nerve roots were bilaterally symmetrical and unremarkable. No pathological reflexes were present in the upper or lower extremities. Today's appointment included ROM measurements. The results were: Normal (Degree) Patient (Degree) CERVICAL ROM: Flexion 50 Normal Extension 60 Normal Right Lateral Flexion 45 25 Left Lateral Flexion 45 21 Right Rotation 80 60 ChiroCenter • 2595 South George Street • York, PA 17403 • 717.741.4848 Jonathan D. Ritz Progress Notes Chart: 2007-00599; DOB: 01/08/1995 Page 2 of 3 Left Rotation 80 45 Normal (Degree) Patient (Degree) LUMBAR ROM: Flexion 60 Normal True Lumbar Extension 25 15 Right Lateral Flexion 25 Normal Left Lateral Flexion 25 Normal Assessment: Acute condition with active symptomatology under an acute/intensive pain reduction phase of care. Plan: The patient is scheduled to return twice a week for two months. A re-evaluation will take place thereafter to deter ine the medical necessity of additional treatment. Manual adjustment was administered today to cor s . I misalignment in the neck area, thoracic area, lumbar region, and area of the pelvis. 11,2 imber , Friday, November 2, 2007 Conference/Counseling: On today's visit, a medical conference was held to discuss the results of this patient's recent examination procedures. Positive neurological, orthopedic, palpatory, chiropractic and other physical findings were reported. Treatment options and alternatives were reviewed. Potential risks inherent to treatment, where applicable, were also discussed. The length of face-to-face time for this procedure was fifteen (15) minutes. Subjective: On today's appointment, Jonathan reported that he has been feeling mild to moderate intermittent pain bilaterally in the neck area. Additionally, he states that there is intermittent mild to moderate spasm of the neck muscles bilaterally experienced and he is experiencing moderate pain bilaterally in the area of the thoracic spine. This patient also reported that he is feeling occasional moderate pain bilaterally in the lower back. Objective: On examination of the spinal joints, a moderate loss of joint function at C2-C6, T4-T5, T7-T9, 1-3-1-4, the left ilium-the right ilium, the left ilium and the right ilium was detected. Palpation of the muscles revealed a moderate degree of hypertonicity in the suboccipital muscles bilaterally, cervical paraspinal muscles bilaterally, upper thoracic muscles bilaterally, mid thoracic muscles bilaterally, lower thoracic muscles bilaterally, lumbar paraspinal muscles bilaterally and gluteal muscles bilaterally. A medium level of pain at C2 to C6, T4 to T9, L2 to L5, and the left ilium to the right ilium bilaterally was found on palpation of the spine. Further palpation revealed a medium amount of swelling at C2 to C6 bilaterally. Assessment: Acute condition with active symptomatology under an acute/intensive pain reduction phase of care. Plan: Two visits a week are recommended for 4 weeks. A re-evaluation will take place thereafter to determine the medical necessity of additional treatment. In order to correct subluxation and reduce vertebral fixation, manual spinal adjustment was administered to the cervical area, area of the thoracic spine, lumbar spinal area, and pe ip area. mbe Friday, November 16, 2007 Subjective: On today's visit, the patient reported he has been feeling mild to moderate intermittent pain bilaterally in the neck area. He further reports he has been experiencing intermittent mild to moderate spasticity of the neck muscles bilaterally. Jonathan states that he is feeling moderate pain bilaterally in the middle back. He also reports that he has been feeling occasional moderate pain bilaterally in the lower back area. ChiroCenter • 2595 South George Street • York, PA 17403 • 717.741.4848 Jonathan D. Ritz Chart: 2007-00599; DOB: 01/08/1995 Progress Notes Page 3 of 3 Objective: There is a moderate amount of spinal joint fixation at C2-C6, T4-T5, T7-T9, 1-3-1-4, the left ilium-the right ilium, the left ilium and the right ilium found on spinal evaluation. In checking for muscle rigidity, a moderate amount of muscle tightness in the suboccipital muscles bilaterally, cervical paraspinal muscles bilaterally, upper thoracic muscles bilaterally, mid thoracic muscles bilaterally, lower thoracic muscles bilaterally, lumbar paraspinal muscles bilaterally and gluteal muscles bilaterally was determined. A digital inspection of the spinal area was performed. A moderate pain level at C2 to C6, T4 to T9, L2 to L5, and the left ilium to the right ilium bilaterally was found. Inspection also showed a swelling of a medium severity at C2 to C6 bilaterally. Assessment: Acute condition with active symptomatology under an acute/intensive pain reduction phase of care. Plan: The patient is scheduled for one treatment a week for 4 weeks. A re-evaluation will take place thereafter to determine a medical necessity of additional treatment. Manual chiropractic adjustment was given to the neck area, thor cic area, lumbar spinal area, and area of the pelvis. The effect is to improve spinal mobility and correct 7:b s lignmen . ? ??? imberl M. Caro C ChiroCenter - 2595 South George Street - York, PA 17403 - 717.741.4848 Jennifer Ritz presented on 10/25/07 with neck and mid-back pain, bilateral shoulder pain, bilateral wrist pain and some low back pain. Objective findings indicated moderate muscular and ligamentous damage, with radiating pain at the L1/L2 nerve root level. She has had four visits thus far, and has responded well to her care. Her treatment plan includes chiropractic manipulation of the full spine, flexion/distraction therapy for the lumbar spine, inter-segmental traction, EMS and manual therapy of the shoulder and thoracic region with extremity manipulation of the wrists. Muscular and ligamentous stabilization and rehabilitation will commence within the next week. I anticipate her release within the next 12 weeks. Diagnosis: 847.0 Strain/sprain, cervical (whiplash) 723.3 Cervicobrachial syndrome (diffuse) 847.1 Strain/sprain, thoracic (whiplash) 739.2 Subluxation, thoracic 847.2 Strain/sprain, lumbar (whiplash) 353.4 Lumbar nerve root impingement Jon Ritz, (DOB 1/8/1995) also presented on 10/25/07 with generalized low-back and neck pain with diffuse muscular hypertonicity throughout the cervical, thoracic and lumbar spine. His treatment plan consists of chiropractic manipulation of the full spine, manual therapy and where appropriate, stretching and strengthening exercises for the cervical, thoracic and lumbar regions of the spine. I anticipate his release within the next 12 weeks. Diagnosis: 847.0 Strain/sprain, cervical (whiplash) 739.1 Subluxation, cervical 847.1 Strain/sprain, thoracic (whiplash) 739.2 Subluxation, thoracic 847.2 Strain/sprain, lumbar (whiplash) 847.2 Strain/sprain, lumbar spine if you have any further questions about the care of these patients, please feel free to contact me at 717-741-4848 x] 19. Sincerely,/ Kimberly WC-arozzi, DC E l„drt F HANOVER HOSPITAL, -?_ 2 3 PATIENT CONTROL NO. HANOVER HOSPITAL VAN77349 131 300 HIGHLAND AV E 5 FED. TAX NO. i 7 COV D. 8 N-C D. 9 C-1 D. 10 L-R D. 11 HANOVER PA 17331 2297 23-13608511 04140710414071 0 0 12 PATIENT NAME 13 PATIENT ADDRESS ^TTZ,JONATHAN D 1 10 BURNS ROAD SPRING GROVE PA 17362 THDATE 15 SEX 18 MS 21 D HR 22 STAT 23 MEDICAL RECORD NO. 31 01081995 M S104140 7 1191 11 7 20 01 M000158722 32 K s •- • x OWA , • V-0 37 h11 , - 1 . A Ol 041407 1 1 1 RITZ,DAVID W&W •? 10 BURNS ROAD 8 SPRING GROVE PA b 17362 C d 42 REV. CD. 43 DESCRIPTION 41 HCPOS I RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-0OVERED CHARGES 49 450 EMERGENCY ROOM GENERAL 99282 041407 1 14$00 j S I I ? r S 1 f 1 TAL CHARGE 4 i 1 f 7 14800 i e i 0 ' ; ; 50 PAYER 51 PROVIDER NO. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 STATE FARM INSURANCE 390233 p BLUE CROSS 366 390233 0 I 57 1 'I •? Q 56 INSURED'S NAME 59 P.IEL 80 CERT. - SSN - MC. - ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO. RITZ,DAVID B 19 38L209996 517946F19380 RITZ,DAVID B 19 QAC1$6S68457 BLUE CROSS 366 0018590005 E 63 TREATMENT AUTHORIZATION CODES 61 ESC 65 EMPLOYER NAME 86 EMPLOYER LOCATION 1 I E 87 PRIN. DIAG. CD. am am 76 ADM. MG. CD. 77 E CODE 78 8470 7231 O 9 P.C. 80 C DE ALP ROCEDDRTE K ATTflOl4fl?MY8 D 8 E74079 DENNEY,MICHAEL R DO t a ago 04M D 8 t 34 REMARKS ONO Ism D 282N0000OX X'T KIT,' 9-92-CFA-1450 APPROVED OMB NO. 0099-0279 Printed on Recycled Paper OCR/ORIGINAL I cormy 711E CERyw" ILLER 043007 ON THE REVERSE APPLY TO THIS BILL AND ARE YAOE A PART HEREOF. HOSpital 300 HIGHLAND AVE. A MEMBER OF HANOVER HEALTHCARE PLUS NETWORK GUARANTOR RITZ,DAVID 10 BURNS ROAD SPRING GROVE PA 17362 SERVICE BY ANESTHESIOLOGISTS, CARDIOLOGISTS, PATHOLOGISTS AND RADIOLOGISTS ARE NOT INCLUDED IN THIS BILL. PATIENT BILLING - (717) 633-8877 TOLL FREE 1-800-673-2426 BILLING OFFICE HOURS - 7:00 AM - 4:30 PM MONDAY THRU FRIDAY FEDERAL TAX I.D. ra-1360661 RITZ,JONATHAN D V00002366592 04/14/07 04/14/07 04/21/07 FINAL DETAIL BILL 1 *** 450 EMERGENCY ROOM GENERAL *** 04/14/0 10204 EMERGENCY DEPT-EXAM II\LIMIT 1 148.00 148.00 V000012366592 148.00 N+? ?a rt1= nm tSVR.- F } } FF ' F HANOVER HOSPITAL • 300 HIGHLAND AVE. • HANOVER, PA 17331-2297 • (717) 633 8877 ( SAVE THIS PORTION } FOR TAX PURPOSES RjG-;5-2JU7 ? D_02:30 AM Physician Billing patient Name 1ATHAN DAVID RITZ Account Number 3 000430411 FAX NO, 7178516904 Billing Date 08/].5/2007 PHYSICIAN BILLING CUS'T'OMER SERVICE HOURS ARE MON - THURS 8:00am - 4:30PM, FRIDAY 7:30am - 4:00PM THIS IS YOUR BILL FROM WELLSPAN MEDICAL GROUP 23-2730785 INVOICE#:6748103 04/23/2007 99213 PATIENT VISIT /KINZINGER MD 06/26/2007 AUTOMOBILE INS PAYMENT - 06/26/2007 CONTRACTUAL ADJUSTMENT Due From Patient Current Insurance Information SOUTH CENTRAL PREFERRED 3 000430411 Insurance ID## *****873 P. 02 Questions? 717-851-6816 800-839-1404 69.00 62.35 6.65 0.00 Total Balance Due 0.00 DAVID RITZ 10 BURNS RD l'' u i?-Gvv( W;-J Uu;3U AM Physician Billing SPRING GROVE,PA 173,62 Page 1 FAX NO, 7178516904 P. 03 WELLSPAN MEDICAL GROUP C/O PHYSICIAN BILLING SERVICE 1803 MT ROSE AVE SUITE B3 YORK PA 17403 HUG` U1i i r WD Uv: K AM ? by s i c i an B i 111 i n g FAX NO, 7178516904 P. 01 1803 ML'. Rose Avenue Suite B3 FAX COVER SHEET York, PA 17403 WellSpan Medical Group Phone: (717) 851-6816 Physician Billing Service "%A&U SPAN Medical Group TO: NAME: PHONE: FAX:. 1_? - ?12'3y - c-t L-(,1 S. FROM: NAME: PHONE: FAX: Amy 717.851.6858 717.851.6904 SENT ON: PAGES (w/cover sheet): ? SUBJECT: -czc COMMENTS: Confidentiality Note: The documents accompanying this transmission may contain confidential health information that is legally privileged. This information is intended for the use of the named recipient(s). The authorized recipient of this information is prohibited from disclosing this information to any other patty unless required to do so by law or regulation and is required to destroy the information after its slated need has been fulfilled, if you are not the intended recipient, you arc hereby notified that any disclosure, copying distribution, or salon taken in reliance on the contents of these documents is strictly prohibited. If you receive this fax in error, please notify the sender immediately to arrange for return of destruction of the documents. Thank you. Ch/rioCare center, PC 2595 South George Street Suite 7 „york, PA 17403 ?17) 741-4848 Fax (717) 741-3501 Jonathan D. Ritz 10 Burns Rd. Spring Grove, PA 17362 Date CPT Modifier Description 10-25-2007 99203 -25 Evaluation/Management, New Patient 10-25-2007 98941 Spinal Manipulation 11-02-2007 99213 -25 Evaluation/Management, Est. Patient 11-02-2007 98941 Spinal Manipulation 11-16-2007 98941 Spinal Manipulation 11-28-2007 Insurance Payment 11-28-2007 Insurance Write Off 11-28-2007 Insurance Payment 11-28-2007 Insurance Write Off Payments Office Adjustments Amount 85.00 50.00 60.00 50.00 50.00 (120.44) (14.56) (95.44) (14.56) Total Services 295.00 0.00 215.88 215.88 0.00 29.12 Balance 0.00 50.00 50.00 Ex va a a.n vct vcJ. .L0 's/ G/ GVva J : VG : JG YL•1 YHlrr. G/ VU/- .CrJ x nul*vur COPY Claim central - Complex PO Box 142 April 1, 2009 Concordville, PA 19331-0142 Andrew Norfleet Metzger Wickersham P.C. 3211 North Front St. Harrisburg, PA 17110 RE: Claim Number: 20-6248-400 "- Date of Loss: April 14, 2007 Our Insured: Donald P Cook Your Client: Jonathan Ritz Dear Mr. Norfleet: This letter will confirm our written offer of settlement in the amount of $1,700.00, in accordance with the terms of Pa. R.C.P. 238. If this offer is acceptable to your client, we will promptly issue a draft upon receipt of an executed release. This offer will remain in effect for ninety (90) days from the date of this letter or until January 18, 2015 when the statute of limitations is due to expire, whichever occurs first. Sincerely, Patricia L. Wise x7435191 Claim Representative (888) 713-4694 State Farm Mutual Automobile Insurance Company HOME OFFICES: BLOOMINGTON, ILLINOIS 61710 C?, 1614460, ONTIFEE AGREEMENT We, DPWI _ J ;ete,NU!pRretain and authorize the law firm of Metzger, Wickersham, Knauss & Erb, P.C., to do whatever they deem necessary or desirable in order to represent us in all claims for compensation and reimbursement for personal injuries, wage loss, medical expense and other damages resulting from M V A 1. ATTORNEY'S FEES: The fee of the attorneys shall be contingent as follows: (a) Thirty-three and one-third percent (33 1/3%) of gross recovery; (b) SHOULD THERE BE NO RECOVERY BY SUIT OR SETTLEMENT, SAID ATTORNEYS DO NOT HAVE ANY CLAIM AGAINST US OF ANY KIND FOR LEGAL SERVICES RENDERED. 2. EXPENSES OF LITIGATION: We acknowledge responsibility for all expenses incurred on our behalf to pursue our claim/case and our attorney shall be reimbursed out of the balance, after deduction of attorneys fees, of any recovery for all legal expenses which have not already been paid by us. We do hereby agree to pay all expenses incurred by our attorney in the preparation and presentation of this case and do understand that these expenses include, but may not be limited to, costs of medical reports and records, stenographic expenses connected with depositions, expert witness fees, photocopying charges, and mileage charges connected with the rendering of legal services. We understand that we are responsible for payment of these expenses regardless of the eventual outcome of the case and further understand that if our attorney deems it necessary, we may be asked to advance these costs prior to the incurring of any such expenses or the scheduling of any deposition. 3. APPEAL: We hereby further agree that our attorney may charge us reasonable additional compensation after consultation with us if it is necessary to try the case more than once, if the case is appealed, or if proceedings in other courts are necessary because of the change of circumstance of a party or for other reasons. Page 1 of 3 4. AUTHORITY: We hereby further agree that our attorney is hereby authorized to bring suit or to settle and compromise the claim, to execute all documents pertaining thereto, and to do all lawful acts requisite for effecting the claim on our behalf. 5. MEDICAL EXPENSES AND LIENS: We further authorize our attorney to pay out of any proceeds of settlement or trial any unpaid medical bills or liens for treatments or services or workers' compensation liens made necessary by the injuries sustained in this accident, or back child support payments owed to Pa.SCDU. We understand that our attorney is not guaranteeing the payment of any medical bills or liens, and they remain solely our responsibility. 6. INVESTIGATION OF MERITS OF CASE: We agree that our attorney accepts this employment on the condition that he will investigate this claim, and if it appears to be a recoverable claim, he will proceed to handle the claim; but if, after investigation, the claim does not appear to be recoverable, said attorney shall then have the right to rescind this Agreement. 7. EARLY TERMINATION: We hereby further agree that if we decide to terminate this authority before any settlement is offered or any award is obtained the firm shall be entitled to reasonable compensation for all work done on the case up to that point. We agree that reasonable compensation for Andrew W. Norfleet, Esquire, or any other attorney involved in the handling of this case, shall be Two Hundred Dollars ($200.00) per hour, and other employees One Hundred Dollars ($100.00) per hour, or such higher rate as shall constitute his/her standard billing rate at the time that the work is performed, or the agreed upon percentage fee in paragraph one of this Agreement, whichever is greater. 8. WITHDRAWAL: We agree that our attorney may withdraw from this case at any time after reasonable notice to us, and we agree to keep him advised of our whereabouts at all times and to cooperate at all times in the preparation and trial of this case, to appear upon reasonable notice for depositions and Court appearances, and to comply with all reasonable requests made of us in connection with the preparation and presentation of this case. Page 2 of 3 IN ITN WHEREOF, we have signed below on this '2007. day of f CLI T: v?J ,?i=?!}1.P oG' ?DicJ Jo NA.?iahl CLIENT: METZG A' p- Oleo. Andrew N Page 3 of 3 KNAUSS & ERB, P.C. C x ?I bif .Z 1RRR Jonathan Ritz c/o David and Jennifer Ritz 10 Burns Road Spring Grove, PA 17362 RITZ, JONATHAN v. Cook Jonathan Ritz v. David Cook METZGER, WICKERSHAM, KNAUSS & ERB, P.C. P.O. BOX 5300 HARRISBURG, PA 17110-0300 (717) 238-8187 TAX I.D. 23-2871395 March 30, 2009 Billed through 03/30/2009 Invoice# 0 AWN Our file# 000084 00673 Balance forward as of invoice dated January 01, 1900 $0.00 Payments received since last invoice 0.00 A/R adjustments made since last invoice 0.00 ............................ Accounts receivable balance carried $0.00 DISBURSEMENTS P160 05/02/2007 $30.64 05/02/2007 HANOVER HOSPITAL, medical records. 30.64 P160 05/25/2007 $20.18 05/25/2007 STAR-MED LLC, medical records from Wellspan - Jefferson Family Medicine. 20.18 P140 12/10/2007 $23.29 12/10/2007 CHIRO CENTERS, prepayment for medical records. 23.29 P160 02/11/2008 $20.20 02/11/2008 STAR-MED LLC, fee for copies of duplicate records from Jefferson Family 20.20 Medicine. P101 03/30/200 $2.34 03/30/2009 Photocopies. 2.34 P110 03/30/2009 $5.23 03/30/2009 Postage. 5.23 P120 03/30/2009 $0.70 000084 00673 AWN Invoice# 0 03/30/2009 Long Distance phone calls. PI,22 03139 03/30/2009 Fax. f -433130 9 $78.50 03/30/2009 CUMBERLAND COUNTY PROTHONOTARY, fee for Minor Settlement Petition. BILLING SUMMARY Total expenses incurred $186.08 ...................................... Total of new charges for this invoice $186.08 ....................................... Total balance now due $186.08 Page 2 0.70 5.00 78.50 ......... -------------- $186.08 PLEASE MAKE CHECKS PAYABLE TO METZGER WICKERSHAM RLED-%-TrE aF THE PRO HOWTARY 2004 APR -3 PM 4: 17 COUNTY 8ifA -) fir, 5-0 p d, a. jq7 M cty e d ?1 c e- t " /-/b3 6 3 A APR 0 6 2009y Metzger, Wickersham, Knat By: Andrew W. Norfleet, E Attorney I.D. No. 83894 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 IN RE: JONATHAN a Minor AND NOW, this Petition for Approval of & Erb, P.C. Attorneys for Petitioners IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 65 cav. DECREE " day of A'i, oli 2009, upon consideration of the Sinor Settlement, it is hereby ORDERED and DECREED that the Petitioner is authorized to enter into the following settlement for third party liability in the amount of $1,700.00. Petitioner is authorized to sign releases for this settlement. The gross settlemeint amount of $1,700.00 shall be distributed as follows: (1) TO: Met ger, Wickersham, P.C., $300.00 for counsel fees; (2) TO: Met ger, Wickersham, PC., $186.08 for reimbursement of costs; (3) TO: Dav d Ritz and Jennifer Ritz, as Parents and Natural Guardians of Jonathan Ritz, a Minor, $1,213.92 to be deposited into a restricted, federally insured account or certificate of deposit mark4d "No withdrawals prior to age 18 without prior court approval." 412596-1 NV'1 S IN3d L I %Zi Wd £ i NJV 600Z MVi HiC8d 3HI JO TOTAL ANIOUNT OF DISTRIBUTION: $1,700.00 Counsel shall of the settlement funds, cc: ?zidrew W. Norfleet, -'Patricia Wise - State l:op t'G-S eh 1/13/of txll-n to the Court, within sixty (60) days from the date of the distribution of such deposit. uire - couns n Insurance .LPL 412596-1 BY THE COURT: