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HomeMy WebLinkAbout09-4812 THOMAS, THOMAS & HAFER, LLP Stephanie L. Hersperger, Esquire I.D. No. 78735 P.O. Box 999 Harrisburg, PA 17108-0999 (717) 255-7617 Attorney for the Petitioner IN RE: JOSHUA COOK AND COLLIN COOK, minors CHRISTOPHER COOK, as parent and natural guardian of JOSHUA COOK AND COLLIN COOK, minors, PETITIONER IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA CIVIL ACTION - LAW NO. Oq- y?Ia. ac, 4j L? PETITION FOR APPROVAL OF MINORS' SETTLEMENT 1. Petitioner Christopher Cook ("Petitioner") is the parent and natural guardian of Joshua Cook and Collin Cook, minors ("Minor-Petitioners"). 2. 17055. 3. years of age. 4. years of age. 5. Petitioner and Minor-Petitioners reside at 424 Pawnee Drive, Mechanicsburg, PA Minor-Petitioner, Joshua Cook, was born on July 22, 1999, and is currently 9 Minor-Petitioner, Collin Cook, was born on October 18, 1993, and is currently 15 This Petition is filed as a result of an accident that occurred on July 2, 2007, when the vehicle being driven by Minor-Petitioners' mother, Delanie Cook, collided with another vehicle at the intersection of Centerville Road and Walnut Street Bottom Road near Newville, f Cumberland County, PA; as a result of the collision, the vehicle in which Minor-Petitioners were passengers, rolled off of the roadway into a gulley. Injuries of Minor-Petitioner, Joshua Cook 1 6. As a result of the accident, Minor-Petitioner, Joshua Cook, was taken to the Emergency Room of Carlisle Regional Medical Center where he was diagnosed with chest pain from a small abrasion to his chest area, apparently caused by the seatbelt. A true and correct copy of relevant portions of Joshua Cook's medical records from Carlisle Regional Medical Center are attached hereto and marked as Exhibit "A". 7. A chest-x-ray was negative and the Emergency Room physician's clinical impression was (1) motor vehicle accident; (2) chest pain; and (3) musculoskeletal pain. See Exhibit "A". 8. Minor-Petitioner, Joshua Cook, did not need any stitches or further treatment and was released from the E.R. after being there for approximately 1 to 1 % hours. See Exhibit "A". 9. Minor-Petitioner, Joshua Cook, recovered from his injuries. Injuries of Minor-Petitioner, Collin Cook 10. As a result of the accident, Minor-Petitioner, Collin Cook, was taken to the Emergency Room of Carlisle Regional Medical Center for treatment; he had complaints of right and left ankle pain and left shoulder pain. A true and correct copy of relevant portions of Collin Cook's medical records from Carlisle Regional Medical Center are attached hereto and marked as Exhibit "B". 11. X-rays were performed and as a result of same, Minor-Petitioner, Collin Cook, was diagnosed as having a bimalleolar fracture of the right ankle and soft tissue swelling over the lateral aspect of the left ankle. See Exhibit "B". T t 12. On July 2, 2007, Minor-Petitioner, Collin Cook, underwent open reduction internal fixation of the right ankle (right ankle surgery) while under general anesthesia. The procedure was uneventful and Collin Cook was discharged from the hospital on July 4, 2007. See Exhibit "B". 13. One week following the accident, at a follow-up appointment, it was noted that there was considerable swelling of the right ankle, which was to be expected, but no signs of infection; Collin was instructed to keep the right ankle elevated, have limited activity and not to bear any weight on the ankle. See Exhibit "B". 14. On July 18, 2007, x-rays showed the internal fixation to be in satisfactory position and Collin was instructed that he could engage in activities based on symptoms, and motion and strengthening exercises. See Exhibit "B". 15. On August 13, 2007, it was recorded that Collin Cook had a smooth course post open reduction internal fixation of the right ankle; there was little difficulty, and he was able to walk without pain and had been in the ocean. The x-rays showed optimal alignment and Collin was instructed he could engage in advanced activity and motion and strengthening exercises. See Exhibit "B". 16. Minor-Petitioner, Collin Cook has recovered from his injuries. 17. At the time of the automobile accident, Petitioner, Christopher Cook, and his wife, Delanie Cook, had automobile liability insurance through West American Insurance Company. Proposed Settlement of Claims of Minor-Petitioner, Joshua Cook I 18. On behalf of Minor-Petitioner, Joshua Cook, West American Insurance Company offered $1,000.00 to settle his claims, and same was accepted by Petitioner, Christopher Cook, who is the natural parent and guardian of Joshua Cook. 19. Petitioner, Christopher Cook, executed a Release settling the claims of Minor- Plaintiff, Joshua Cook, for $1,000.00. A true and correct copy of the executed Release as to Joshua Cook is attached hereto and marked as Exhibit "C". 20. The aforesaid insurance also provided first-party medical benefits in the amount of $5,000.00; West American Insurance Company paid $647.94 for Joshua Cook's medical expenses, which were the result of the injuries he sustained in the automobile accident at issue. 21. There is no Medicare or Medicaid or any other recoverable subrogation liens as to the settlement for the claims by Minor-Petitioner, Joshua Cook. 22. Petitioner, Christopher Cook, believes the offer as to Joshua Cook, and the proposed distribution of settlement funds thereof is fair and in the best interest of said Minor-Petitioner. Proposed Settlement of Claims of Minor-Petitioner, Collin Cook 23. On behalf of Minor-Petitioner, Collin Cook, West American Insurance Company offered $42,500.00 to settle his claims, with $7,500.00 to be made payable to Christopher Cook, Individually and as Parent and Natural Guardian of Collin Cook, a minor, upon approval of the agreement by the Court. A true and correct copy of the executed Settlement Agreement and Release as to Collin Cook, prepared by Ringer Associates, is attached hereto and marked as Exhibit "D". 24. The remaining portion of the settlement, specifically, $35,000.00, is to be placed into a structured settlement. See Exhibit "D". 25. The Structured Settlement Agreement and Release provides that $4,345.28 is to be paid to Minor-Petitioner, Collin Cook, semi-annually, for a period of 8 years, beginning on October 8, 2015. The last guaranteed payment is due on April 8, 2023. See Exhibit "D". 26. The total guaranteed amount payable under the structured settlement portion of the proposed settlement is $69,524.48. 27. Petitioner, Christopher Cook, executed the Settlement Agreement and Release settling the claims of Minor-Petitioner, Collin Cook. See Exhibit "D". 28. The aforesaid insurance also provided first-party medical benefits in the amount of $5,000.00; West American Insurance Company paid $5,000.00 for Collin Cook's medical expenses, which were the result of the injuries he sustained in the automobile accident at issue. 29. There is no Medicare or Medicaid or any other recoverable subrogation liens as to the settlement for the claims by Minor-Petitioner, Collin Cook. 30. Petitioner, Christopher Cook, believes the offer as to Collin Cook, and the proposed distribution thereof is fair and in the best interest of said Minor-Petitioner. 31. West American Insurance Company shall be responsible to pay all court costs and legal fees charged by the undersigned in preparing and filing the within Petition and in representing the Petitioner in any proceedings required to obtain court approval of the within minor's settlement. Consequently, the full amount of the settlement proceed shall be paid to the Petitioner undiminished by attorneys' or legal fees or court costs. 32. Petitioner, Christopher Cook, presents the instant Petition in order to obtain court approval of the proposed settlements as described above. WHEREFORE, Petitioner respectfully requests that this Honorable Court enter an Order approving of the proposed settlement as to Minor-Petitioner, Joshua Cook, and Minor-Petitioner, Collin Cook. Respectfully submitted, THOMAS, THOMAS & HAFER, LLP Stephanie L. Hersperger, Esquire I.D. Number: 78735 305 North Front Street, P.O. Box 999 Harrisburg, PA 17101 (717) 255-7239 Attorney for Petitioners Date: 7/17/09 c ADMISSION RECORD MEDICAL CENTER ACCOUNT NO. - -MEDICAL RECORDS NO 361 Alexander Spring Road a Carlisle, PA 17015-9129 .1717) 249.1212 - 9 3 7 3 6 3 5 . 0001062740 P ADMIT DATE I TIME ROOM NO. PT FC AGE DATE OF BIRTH SEX RA MS LOCATION PROGRAM A 07/02/2007 10:15 0000 E1 F 7 07/22/1999 M 1 S T PATIENT NAME ADDRESS COOK, JOSHUA E NU 777-77-7777 PATIENT El CHILD MPLOYER PHONE NO.. E 424 PAWNEE DR N MECHANICSBURG PA 17050 PHONE NUMBER COUNTY T US (717)763-1294 CUMB B N I COOK, CHRISTOPHER D NESTLE EMPLOYER ? 424 PAWNEE DR 181-52-9902 (717)795-5454 A MECHANICSBURG PA R MECHANICSBURG PA 17050 PHONE NUMBER 17055 RELATIONSHIP TPATIENT US (717)763-1294 FATHER RESP EMERGENCY CONTACT NAME EMERGENCY CONTACT PHONE EMERGENCY CONTACT RELATIONSHIP TO PATIENT COMMENTS MSP M ED. KEY IVACY NPP ADMIT. BY ?v ON ?v MN Y CLC PRIVACY 950 ATO FPW35003283 09/1OJ1967 RG?ORDIA NORTHEAST INC NS OOKECHRISTOPHER 4900 RITTER RD N MECHANICSBURG PA 17055 UROUP NUMBER GROUP NAM (866)235-6076 NONE S AU I 1 N 2 PAYER PLAN - U Y U E DATE OF BIRTH V INSURANCE R GROUP NUMBER GROUP NAME A AUTHORIZATION N 3 PAY LAN L1CY ER __ TE F BIRTH INSURANCE C GROUP NUM UP N E E AUTHORIZATION M OR. ATTENDING / A MI ING DR. FAMILY / PRIMARY ARE GATRELL, CLOYD B NONSTAFF, OUT OF TOWN S DIAGNOSIS C MVA--MINOR INJURY NO FAULT 07/02/2007 PRINCIPAL DIAGNOSIS (Tile condition established after study to be chiefly responsible for occasioning the admission of the patient to the HOSPITAL for carol. I COMPLICATIONS COMORSIDITYIIESI 111INCIPAL PROCEDURE 0?0 ?Ga -90 3 $,a VPIF 10 `..- 9373835 11IIIIIIINIII?I?IIIIlI1?{gIIIIIINIIII MEDICAL RECORDS COPY IINIII?INIIIIINII??IIIII?IIIIIIIi Pennsylvania EMS Deport LX r\ --I Service Name Unit No. PCR No. PSAP Incid. No. Date Friendship Hose Co. Ambulance 2100502 0700603 84584 07/02/2007 Incident Location MCD Receiving Agency Centerville Road & Walnut Bottom Road Newville, Pa 21922 Carlisle Hospital Patient Name Phone No. Age Date of Birth Social Sec No Sex ID Josh Cook (717) 763-1294 07 Years 07/22/1999 , . 777-77-7777 Malc Street Address Crew Times On* 424 Pawnee Drive A#1 Bear, Teresea E 118559 911 08 57 i•+ r City State "Lip A #2 Bitner, Mike A Dispatch : 09:06 i Mechanicsburg PA 17055 A #3 Gurganious, Lona J. E 164190 Enroute 09 06 Patient Number Merntw p A #4 Arrive Scene : 09:13 No Contact 09:14 ^ I+I Private Physician / Out On-Scene Dest. In Depart Scene 09:29 51431 51 437 51446 51457 Arrive Facility 09:38 Transporting Assist Units 1 OS Time Medical Command Physician 1 MCC Available 10:05 In Quarters 10:15 Chief Complaint: M chest hurts n t here. PP: Possible from seat belt. - Current Meds: Nonc Allergies meds : None Narrative PMHx: None. Bls was dispatched along with several other ambulances and Medic units to Ritner Hwy. and Centerville Road for an auto accident with entrapment with fire. While enroute to the scene, we were informed that the accident was at Centerville Road and Walnut Bottom Road. Bls arrived on the scene, to find Ambulance 147 with a patient and several other patient's was being cared for by firefighters. Ambulance 247 found a 7 year old male sitting on the grass by the road shaking and rocking back and forth. Patient was crying. Bls asked the patient if he was hurt anywhere. Patient pointed to the center of his chest. Bls found a small abrasion to the patient's chest where his seat belt.was. Patient's c-spine was held. Bls palpated the patient's neck and back for tenderness and deformity and none was noted. Patient was placed onto a long back board with CID's put into place. Patient was picked up off the ground and placed into the back of the ambulance on the bench seat, due to Bls transporting 2 patients. Patient's vitals were taken. Patient was awake, alert and oriented x4. Patient's skin was pink, warm and dry. Pupils were equal and reactive to light in the mid-position. Trachea was mid- line. Negative JVD. Lung sounds were present and clear in all fields. Abdomen was soft and non-tender with no palpable masses. Negative edema to hands, legs, ankles and feet. Pulse ox o2 sat was at 100% on room air. Patient was able to move all extremities before and after being backboarded. Patient also had good pedal pulses before and after being backboarded. There was no fluid coming out of his ears, nose, eyes or mouth. Patient was transported to the Carlisle Hospital. When we arrived at the Carlisle Hospital, patient care was given over to E.R. nurse Carol in Trauma Room 3 with a full patient report being given by Bls. The patient's mother signed the HIPAA see tripsheet 0700604. P..: >: ? :;;Q? qx..;' L11as Cam' _ ... htn .T#?atment,::' .. Ptuvidet . ies risvComtttettts`?" 09:15 C-S ine Stabilize Al AO - 09:17 Cervical Collar Al AO 09:21 C-S ine Imm. Dev. AO 0930 105 22 120/070 100 4/516 Took t. vitals. Al 0935 104 22 120/070 100 4/5/6 Took t. vitals. Al Provider JL,?F 0 W N W .gyp. J O f CARLISLE REGIONAL MEDICAL CENTER 361 ALEXANDER SPRINGS ROAD CARLISLE PA 17015 (717) 960-1683 RADIOLOGICAL INTERPRETATION PATIENT NAME: COOK JOSHUA E X-RAY#: 1062740 EXAM DATE: 7/02/2007 ORDERING: CLOYD B GATRELL, MD- ATTENDING: CONSULTING: OUT OF TOWN NON-STAFF MD- HISTORY: MVA--MINOR INJURY MVA--MINOR INJURY TWO VIEW CHEST - 7/2/07: INDICATION: Trauma. COMPARISON: None. MED REC #: 1062740 ACCOUNT #: 9373635 D.O.B.: 07/22/1999 ROOM: ER FINDINGS: The lungs are adequately inflated. A consolidation is not seen. A pneumothorax is not visualized. The visualized bony structures are intact, the cardiomediastinal silhouette is also intact. IMPRESSION: Negative chest. REVIEWED AND SIGNED SCOTT WRIGHT INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED: DATE SIGNED: TRANSCRIPTIONIST: 4347785 RADI CHEST PA & LATERAL 7/02/2007 7/02/2007 12:59 7/03/2007 9:54:02 JXS OLOGIST AUDIT PAGE 1 OF 1 APPALACHIAN ORTHOPEDIC CENTER, LTD Thomas J. Green, MD Daniel P. Hely, MD Michael J. Oplinger, MD James A. Oliverio, MD RADIOLOGICAL REPORT PATIENT: XRAY DATE: DATE OF INTERPRETATION: OFFICE VISIT DATE: ORDERING PHYSICIAN: X-RAY PERFORMED: Collin Cook 08/13/2007 08/13/2007 08/13/2007 DANIEL P HELY, M.D. Right ankle - 2 views 1 Dunwoody Dr Carlisle, PA 17015 (717)249-6112 Tax ID: 25-1829749 INTERPRETATION: X-ray of the right ankle, AP and lateral, shows optimal alignment of the internal fixation without untoward signs. DICTATED AND READ BY: DANIEL P HELY, M.D. DPH/jmn cc: Auto AvPALACHIAN ORTHOPEDIC CENTER, LTD Thomas J. Green, M.D. Daniel P. Hely, M.D. Michael J. Oplinger, M.D. James A. Oliverio, M.D. 1 Dunwoody Dr Phone: (717) 249-6112 Carlisle, PA 17015 Fax: (717) 249-6235 OFFICE RECORDS Cook, Collin DOB:10/08/1993 08/13/07 OFFICE VISIT: Smooth course post open reduction internal fixation of the right ankle. Very little difficulty. Tom has been walking without pain and has been in the ocean. X-RAYS: X-ray of the right ankle, AP and lateral, shows optimal alignment of the internal fixation without untoward signs. PLAN: Advance activity. Motion and strengthening exercises. Follow up one month, re-exam, progress check. Daniel P. Hely, M.D./jmn cc: Dr. Guillermo Garcia Auto APPALACHIAN ORTHOPEDIC CENTER, LTD Thomas J. Green, M.D. Daniel P. Hely, M.D. Michael J. Oplinger, M.D. James A. Oliverio, M.D. 1 Dunwoody Dr. Phone: (717) 249-6112 Carlisle, PA 17015 Fax: (717) 249-6235 OFFICE RECORDS Cook, Collin DOB:10/0811993 07/18/07 CHIEF COMPLAINT: Follow up bimalleolar fracture, right ankle. Other past medical history, surgical history, family history, social history, review of systems have been reviewed and updated from the new patient intake form, copy is signed, dated, and in the chart. PHYSICAL EXAMINATION: Collin's wound is clean. No sign of infection X-RAYS: X-ray of the right ankle does not show any evidence of displacement. The internal fixation appears to be in satisfactory position. PLAN: Activity based on symptoms. Motion and strengthening exercises. Follow up three weeks re-exam and x-ray. Toe-touch bearing only until then. 44191a4<1-0 Daniel P. Hely, M.D. DPH/DS-amh cc: Guillermo Garcia, M.D. AUTO Carlisle Regional Medical Center Laboratory, 45 Sprint Dr Duckkyu Chang, M.D., Medical Direct Carlisle, PA 17013 Sun Y. Kim, M.D., Pathologist NEW AFTER DISCHARGE COOK, COLLIN MRN:0001062735 Location:MS3-0310-W Admitted: 07/02/07 DOB:10/08/1993 Sex:M Discharged: DIS.CH.: 07/04/07 Physician: HELY MD, DANIEL P P O I N T O F CIA R E T E S T I N G GLUCOSE -----------------------+------------------ Test Name i Glucose . 7112707-SK Reference Ranges 170-100 mg/dl -----------------------+------------------ 79040197 07/04/07 12:55 98 * Key for. Abnormal Column (L-Low H-High AS-Abnormal C-Critical T-Toxic COOK, COLLIN MS3-0310-W continued P 0 1 N T O F C A R E T E S T I N G 3 of 4, 54 of 80 PRINTED 07/05/2007 03:25 Page : 1 of 1 1 Fax Server 7/2: 107 7:17:30 PM PAGE 1/00 Fax Server COOK, COLLIN HOP 07/02/2007 1062735 DATE OF OPERATION: SURGEON: ASSISTANT SURGEON: 07/02/2007 Daniel P. Holy, M.D. PREOPERATIVE DIAGNOSIS: Bimalleolar fracture, right ankle. POSTOPERATIVE DIAGNOSIS: Bimalleolar fracture, right ankle. PROCEDURE PERFORMED: Open reduction internal fixation. DESCRIPTION OF PROCEDURE: After satisfactory general anesthesia was achieved, the patient's right lower extremity was prepped and draped. The pneumatic tourniquet was inflated to 325 mm. An incision was made over the fibular fracture and extended through the skin and SUbcutanPOUS tissue using sharp dissection. A hernatoma was encountered through the fascia. The fracture site was visualized. There was minimal displacement. A semiWbular plate was placed over the fracture and hcid in place with a Verbruggc clamp. The x-ray was used to visualize the position of the plate. It appeared to be quite s3tlRf3ctOry. The, plate was secured to the, bone Using cortical Screws, sequenbally drilled, measured, and placed without difficulty getting b1cortcal fixation. Attention was turned to the medial side. An indsion was made over the medial malleolus and extended through the skin and subcutanPOUS tissue using sharp dissection, Hemostasis was assured after the hematoma was encountered. The periosteum was taken out of the fracture and elevated back up over the rnetaphysis. The fracture was reclueed using a drill hole in then metaphysis and a bone tcnaGUILJm to hold the fracture in a reduced position. Two K-wires were placed across the, fracture. site, checked with the. Image, intensifier and the, tracks were, drilled, me.3SUrocl, and cannUlated screws were, placed over the. K-WrP,s to 3SSUrP, fixation. These, appeared to be. some opening anteriorly and a third screw was added to compress this area down. The guidPwire was placed followed by the drill and a third eannulatcd screw was placed into position, Having achieved optimal reduction of the fracture and fixation in the AP and lateral views, the wounds were irrigated and dosed Using 2-0 Vieryl to close the subultaneous tissue and staples to close the skin. A sterile dressing and soft wrap and splint were added. The patient was awake without mishap and returned to the recovery room in satisfactory condition. TOUrnigLlP.t timP. was 50 minLltPc;. DPH/sap D: 07/02/2007 1 ^0:40:51 T: 07/02/2007 19:11:05 C: Daniel P. Holy, M.D. Daniel P. Holy, M.D. 7712348 COOK, COLLIN HOP 1062735 07/02/2007 10/08/1993 HELY, DANIEL P Pagel of1 DICTATING PHYSICIAN COPY CARLISLE REGIONAL MEDICAL CENTER OPERATIVE REPORT reiiii?yivaiilla r.ivl? nCY? ce Name Unit No PCR No. Date plshippens bur Area EMS 2-73 - 2100302 0701066 07/02/2007 F t Name Date of Birth Social Security Number PSAP Cook 10/08/1993 070084584 [:WINo Complaint Nausea Vomiting Diarrhea Constipated Area(s) Effected LUQ RUQ LLQ RLQ omen Q? Soft Firm Guarding Bowel Sounds Absent Distended - No O Yes O Tender- No O Yes O Pain E) Constant Intermittent EJ Burning Sharp Dull Radiating - No O Yes O GU p? No Complaint Urgency Frequency Pain Burning Incontinent Retention Foley Total Output _ Extremities No Comp laints LA RA LL RL Paralysis ? 1:1 1:1 El Paresthesia ? E] El 0 Pulse El El El El LA RA LL RL Pain ?0 Q Pallor Edema E] 11 E] El Reproductive Q? No Complaints Female Vaginal Bleeding Discharge Pregnant - No O Yes O Gravida _ Para _ Week _ Fetal Movements Fetal Heart Tones _ Male E] Penile Discharge E] Testicular Pain 0 J 0 F+ 0 01 CN Narrative th Ul On July 2 2007 amb 2073 was dispatched to Centerville Rd and Walnut Bottom Rd in Penn O Twp Cumberland co. for a auto accident with 4 pt one critical. When responding to the scene There was not much info for what pt we would have do so many pt. When we were about 2 miles from the Oo scene Cumberland med ask for are location. I told them about two miles from the scene. At this time they said are pt would be a class three with a ankle injury. That the pt was already on a back board and cid that we could just pull up to the scene and the pt is ready to by loaded into your amb. When on the scene the fire fighters had the pt on a back board with the cid blocks around the pt head with his right ankle rapped with a long board under the pt right leg. The emt on the scene said that there was deformity to the ankle. And that the pt was walking round after the accident. I could not see it do to the cling wrap around the leg. When in the amb I talked to the pt. He was conscious oriented and alert and said he was 13 yr old. I palped the pt body and the only pain was in his ankles. There was swelling to his left ankle all so. I placed a ice pack on both ankles and got a set of vitals. Pulse 78 resp32 by 170/72 o2 sat 98% on room air both lungs were equal and both purples were reactive and equal. When at the hospital the pt was placed in exam room 2 and the nurse was give the pt info and the pt care was turned over at this time.) did not get any representative signature because there was no parent around to sign and he was only 13. T $rtc P R B P. °o Qx O _ F1 -C027- Glasgow` Rh - tlunt }. - t eatment r Pravi de Re nts 14 „ ? ? aa . 09:30 78 I 32 170/72 4/5/6 Initial VS; Resp. Effort: Tachypnea I and Non-labored 09:40 70 26 160/68 99 4!5/6 Printed On: 07/03/2007 07:56 EMStat Reporting(c) 1998-2007, Med-Media, Inc. All Rights Reserved 170 A;;?" r Page: 2 of 2 CARLISLE REGIONAL MEDICAL CENTER 361 ALEXANDER SPRINGS ROAD CARLISLE PA 17015 (717) 960-1683 RADIOLOGICAL INTERPRETATION PATIENT NAME: COOK COLLIN MED REC #: 1062735 X-RAY#: 1062735 ACCOUNT #: 9373630 EXAM DATE: 7/02/2007 D.O.B.: 10/08/1993 ORDERING: CLOYD B GATRELL, MD- ROOM: ER ATTENDING: CONSULTING: OUT OF TOWN NON-STAFF MD- HISTORY: MVA MVA BILATERAL ANKLES - 1/2/07: INDICATION: Trauma. FINDINGS: RIGHT ANKLE: An oblique fracture is demonstrated in the distal fibula, just proximal to the ankle mortise. Additionally, a fracture through the medial malleolus is demonstrated. There is increased distance between the medial aspect of the talus and medial malleolus suggesting disruption of the ankle mortise. Marked soft tissue swelling is also demonstrated. LEFT ANKLE: The visualized bony structures are intact. There is soft tissue swelling over the lateral aspect of the ankle. IMPRESSION: 1. Right sided medial malleolar fracture and distal fibular fracture, with disruption of the ankle mortise. Orthopedic consultation is advised. 2. Soft tissue swelling over the lateral aspect of the left ankle. Findings were relayed to the Emergency Department at the time of dictation. REVIEWED AND SIGNED SCOTT WRIGHT INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED: DATE SIGNED: TRANSCRIPTIONIST: 4347726 RADI ANKLE MIN 3V BI 7/02/2007 7/02/2007 12:59 7/03/2007 14:05:42 JXS OLOGIST AUDIT PAGE 1 OF 1 'VO'd 99TZ Z99 LIL SEIVI OSSV NVISIHIL LZ:CT 800Z-06-NVC' • 0 CARLISLE REGIONAL MEDICAL CENTER 361 ALEXANDER SPRINGS ROAD CARLISLE PA 17015 (717) 960-1683 RADIOLOGICAL INTERPRETATION PATIENT NAME: COOK COLLIN X-RAY#: 1062735 EXAM DATE: 7/02/2007 ORDERING: DANIEL P HELY,MD 249-6112 ATTENDING: CONSULTING: HISTORY: RIGHT ANKLE FRACTURE OR, ANKLE; ORI F RIGHT ANKLE TWO VIEWS - 7/2/07: CLINICAL HISTORY: Ankle fracture. MED REC #: 1062735 ACCOUNT #: 7712348 D.O.B.; 10/08/1993 ROOM: 0310 COMMENT- Digital intra-operative spot film radiographs were obtained which demonstrate screw fixation of the medial malleolar fracture seen earlier the same day. A dynamic compression plate and screws is seen about the distal fibular shaft fracture. Alignment is anatomic on the intra-operative radiographs obtained. REVIEWED AND SIGNED CHRISTOPHER LADD,MD INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED: DATE SIGNED: TRANSCRIPTIONIST: 4346212 RADI ANKLE AP & LAT 7/03/2007 7/03/2007 10:22 7/03/2007 13:04:19 JXS OLOGIST AUDIT PAGE 1 OF 1 90'd 99T3 399 LTL SSZtlI 0SSV NHZSIHI L-:ET 800'-0E;-NNP ?aw -+.1 COOK, COLLIN MS3 0310 W 1062735 DATE DISCHARGED: 07/04/2007 DISCHARGE DIAGNOSIS: Bimalleolar fracture, right ankle. OPERATION: Open reduction and internal fixation. CLINICAL SUMMARY: This is a 13-year-old boy with a bimalleolar fracture of the ankle. He underwent open reduction and internal fixation on the day of admission. Postoperative course was uneventful. He was discharged with the recommendations to continue limited activity at home, Percocet as needed for pain, follow-up appointment in my office in 5 to 7 days following discharge, and call in the interim if problems arise. DPH/am D: 07/04/2007 09:26:09 T: 07/05/200711:23:22 C: Daniel P. Hely, M.D. Daniel P. Hely, M.D. 4 7712348 COOK, COLLIN MS3 0310 W 1062735 07/02/2007 10108/1993 Daniel P Hely Page 1 of 1 THIS DOCUMENT IS NOT A LEGAL COPY UNLESS SIGNED. CARLISLE REGIONAL MEDICAL CENTER DISCHARGE SUMMARY F COOK, COLLIN DATE OF OPERATION: SURGEON: ASSISTANT SURGEON: MS3 0310 W 07/02/2007 Daniel P. Hely, M.D. PREOPERATIVE DIAGNOSIS: Bimalleolar fracture, right ankle. POSTOPERATIVE DIAGNOSIS: Bimalleolar fracture, right ankle, PROCEDURE PERFORMED: Open reduction internal fixation. 07/04/2007 1062735 DESCRIPTION OF PROCEDURE: After satisfactory general anesthesia was achieved, the patient's right lower extremity was prepped and draped. The pneumatic tourniquet was inflated to 325 mm. An incision was made over the fibular fracture and extended through the skin and subcutaneous tissue using sharp dissection. A hematoma was encountered through the fascia. The fracture site was visualized. There was minimal displacement. A semitubular plate was placed over the fracture and held in place with a Verbrugge clamp. The x-ray was used to visualize the position of the plate, It appeared to be quite satisfactory. The plate was secured to the bone using cortical screws, sequentially drilled, measured, and placed without difficulty getting bicortical fixation. Attention was turned to the medial side. An incision was made over the medial malleolus and extended through the skin and subcutaneous tissue using sharp dissection. Hemostasis was assured after the hematoma was encountered. The periosteum was taken out of the fracture and elevated back up over the metaphysis. The fracture was reduced using a drill hole in then metaphysis and a bone tenaculum to hold the fracture in a reduced position. Two K-wires were placed across the fracture site, checked with the image intensifier and the tracks were drilled, measured, and cannulated screws were placed over the K-wires to assure fixation. There appeared to be some opening anteriorly and a third screw was added to compress this area down. The guidewire was placed followed by the drill and a third cannulated screw was placed into position. Having achieved optimal reduction of the fracture and fixation in the AP and lateral views, the wounds were irrigated and closed using 2-0 Vicryl to close the subcutaneous tissue and staples to close the skin. A sterile dressing and soft wrap and splint were added. The patient was awake without mishap and returned to the recovery room in satisfactory condition. Toumiquet time was 50 minutes. DPH/sap D: 07/02/2007 18:40:51 T: 07/02/2007 19:11:05 C: Daniel P, Hely, M.D. Daniel P. Hely, M.D. 7712348 COOK, COLLIN MS3 0310 W 1062735 07/02/2007 10/0811993 HELY, DANIEL P Page 1 of 1 THIS DOCUMENT IS NOT A LEGAL COPY UNLESS SIGNED CARLISLE REGIONAL MEDICAL CENTER OPERATIVE REPORT SLE REGION' MEDICAL CEF " 361 AL ER SPRINGAw&D CARLISLL`?17015 (717) 960-1683 RADIOLOGICAL INTERPRETATION PATIENT NAME: COOK COLLIN X-RAY#: 1062735 EXAM DATE: 7/02/2007 ORDERING: DANIEL P HELY,MD 249-6112 ATTENDING: CONSULTING: HISTORY: RIGHT ANKLE FRACTURE OR. ANKLE ORIF RIGHT ANKLE TWO VIEWS - 7/2/07: CLINICAL HISTORY: Ankle fracture. MED REC #: 1062735 ACCOUNT #: 7712348 D.O.B.: 10/08/1993 ROOM: 0310 COHNENT : Digital intra-operative spot film radiographs were obtained which demonstrate screw fixation of the medial malleolar fracture seen earlier the same day. A dynamic compression plate and screws is seen about the distal fibular shaft fracture. Alignment is anatomic on the intra-operative radiographs obtained. REVIEWED AND SIGNED CHRISTOPHER LADD,MD INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED: DATE SIGNED: TRANSCRIPTIONIST: 4346212 ANKLE AP & LAT 7/03/2007 7/03/2007 10:22 7/03/2007 13:04:19 JXS FLOOR PAGE 1 OF 1 RAD ANKLE BILATERAL CARLISLE REGIONAL MEDICAL CTR Adm Dt: 7/02/07 Coid: 858 Pat Nbr: 9373630 COOK, COLLIN COMPLETE Result: 07/03/2007 14:05 MVA MVA Procedure Acknowledge Date: 07/02/2007 10:44:56 BILATERAL ANKLES - 7/2/07: INDICATION: Trauma. FINDINGS: RIGHT ANKLE: An oblique fracture is demonstrated in the distal fibula, just proximal to the ankle mortise. Additionally, a fracture through the medial malleolus is demonstrated. There is increased distance between the medial aspect of the talus and medial malleolus suggesting disruption of the ankle mortise. Marked soft tissue swelling is also demonstrated. LEFT ANKLE: The visualized bony structures are intact. There is soft tissue swelling over the lateral aspect of the ankle. F8=Next Page F18=Prior Report F5=Patient F2=Print F12=Return-PriorMScreen F7=Prior Page F17=Next Report F6=Census F1=Help F11=Demo F3=Exit-Menu Record(s) Displayed. SROSE r RAD ANKLE BILATERAL CARLISLE REGIONAL MEDICAL CTR Adm. Dt: 7/02/07 Coid: 858 Pat Nbr: 9373630 COOK, COLLIN COMPLETE Result: 07/03/2007 14:05 IMPRESSION: 1. Right sided medial malleolar fracture and distal fibular fracture, with disruption of the ankle mortise. Orthopedic consultation is advised. 2. Soft tissue swelling over the lateral aspect of the left ankle. Findings were relayed to the Emergency Department at the time of dictation. WRIGHT SCOTT Dictated By WRIGHT SCOTT Reviewed & Signed Bottom F8=Next Page F18=Prior Report FS=Patient F2=Print F12=Return-Prior Screen F7=Prior Page F17=Next Report F6=Census F1=Help Fll=Demo F3=Exit-Menu Bottom of List. SROSE Fax Server 7/2/2007 7:17:30 PM PAGE 1/001 Fax Server COOK, COLLIN HOP 07/02/2007 1062735 DATE OF OPERATION: SURGEON: ASSISTANT SURGEON: 07/02/2007 Daniel P. Holy, M.D. PREOPERATIVE DIAGNOSIS: Simalleolar fracture, right ankle. POSTOPERATIVE DIAGNOSIS: Simalleolar fracture, right ankle. PROCEDURE PERFORMED: Open reduction internal fixation, DESCRIPTION OF PROCEDURE: After satisfactory general anesthesia was achieved, the patient's riot lower extremity was prepped and draped. The pneumatic tourniquet was inflated to 325 mm. An incision was made over the fibular fracture and extended through the skin and subcutaneous tissue using sharp dissection. A hematoma was encountered through the fascia. The fracture -it- was visualized. There was minimal displacement. A Semitubular plate was placed over the fracture and held in place with a Vcrbruggc clamp. The x-ray was used to visualize the position of the plate. It appeared to be gL.litc satisfactory. The plate, was sP.CUred to the, bone using cortical screw, sequentially drilled, measured, and placed Without difficulty getting I1cortical fixation. Attention Was turned to the, medial side. An incision was made, over the, medial mallP.OILIS and extended through the, skin and subUltaneous tiSSUP. U%ing sharp dissection. Hemostasi was assured after the hematoma was encountered. The pchostaum was taken out of the fracture and elevated back UP over the metaphytiis, The fracture was reduced wing a drill hole in then metaphysis and a bone tenaeulum to hold the fracture in a reduced position. Two K-wires were placed across the fracture Sit(-, checked with the image intensifier and the tracks were thrilled, mPasured, and cannulated screws were placed over the K-wires to assure fixation. There appeared to he some q:)ening anteriorly and a third screw was added to compress this area down. The guidewire was placed followed by the drill and a third cannulated screw was placed into position. Having achieved optimal reduction of the fracture and fixation in the AP and lateral views, the wounds were irrigated and closed Lasing 2-0 Vicryl to close the subcutaneous tissue and staples to close the skin. A sterile dressing and soft wrap and splint were added. The patient was awake without mishap and returned to the recovery room in sfactory condition. Toumiqu(-t time was 50 minutPS. sati DPH/sap D: 07/0212007 18:40:51 T: 07/02/2007 19:11:05 C: Daniel P. HPIy, M.D. Daniel P. HPIy, M.D. 7712.348 COOK, COLLIN HOP 1062735 07/02/2007 10/08/1993 HELY, DANIEL P Page 1 of 1 DICTATING PHYSICIAN COPY CARLISLE REGIONAL MEDICAL CENTER OPERATIVE REPORT GENERAL RELEASE For and in consideration of the above payment to Christopher Cook, individually and as parent and natural guardian of Joshua Cook of the sum of ($1000.00), One Thousand Dollars and 00/100, 1, Christopher Cook, parent and natural guardian of Joshua Cook do hereby release and forever discharge Christopher Cook and Delanie Cook and West American Insurance Company, their insurers, reinsurers, employees, related entities, agents, and any and all other persons and fines, of and from any and al l actions, causes of action, claims, demands, damages, costs, loss of services, expenses, compensation, consequential damage, or any other thing whatsoever, including any claim for bad faith, on account of or in any way growing out of, any and all known and unknown personal injuries, debts, and property damage resulting or to result from an incident that occurred on or about 07/02/2007 at or near Newville, PA. I hereby acknowledge and assume all risk, chance, or hazard that the said injuries or damages may be or become permanent, progressive, greater, or more extensive than is now known, anticipated, or expected. No promise or inducement which is not herein expressed has been made to me and in executing this Release, I do not rely upon any statement or representation made by any person, f?ru:, or corporation, hereby released or any agent, physician, doctor, o?- other person representing them or any of them concerning the nature, extent, or duration of said damages or losses, or the legal liability therefore. I understand that this settlement is the compromise of a disputed claim and that the payment is not to be construed as an admission of liability on the part of the persons, firms, and/or corporations hereby released by whom liability is expressly denied. I further certify, state, acknowledge, warrant, and declare that each and every person, attorney, carrier, entity or association which claims to have a lien on the proceeds of this settlement arising out of this incident, lawsuit, or litigation, is aware of this Release and its terms and i understand that said released parties hereunder are relying expressly upon this unconditional express warranty in making payment hereunder. The Releasor(s) accept responsibility for satisfying any liens that have been asserted against this recovery by any worker's compensation carrier, health care provider or insurer, or anyone else asserting a lien, and hereby discharge Releasee(s) from any such responsibility. In further consideration of the above payment, I, Christopher Cook as parent and natural guardian of Joshua Cook, for my heirs, next of kin, executors, administrators, successors, or assigns, covenant and agree to indemnify and hold harmless Christopher Cook and Delanie Cook AND West American Insurance Company, their insurers, reinsurers, employees, related entities, agents, and attorneys, from all claims, demands, and suits for damages, costs, loss of services, expenses, or compensation which I or my heirs, insurers, next of kin, executors, administrators, successors or assigns have or may have in the future on account of or in any way growing out of the injuries or damages I sustained in this incident. I certify that I am over eighteen (18) years of age and am acting as individuals and parent/natural guardian of Joshua Cook and I further state that 1 have carefully read the foregoing Release and I know the contents thereof and I have signed the same as my free act and intending to be legally bound thereby. EZ: I N ?O 0 Li y rLl? U ; Cam( 552 1 This Release contains the entire agreement between the parties hereto and the terms of this Release are contractual and not a mere recital. The undersigned acknowledge that he has had this Release reviewed by counsel of their choosing, or that he understands that lie had the right to do so. Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete, or misleading information shall upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000. th IN WITNESS WHEREOF, I/WE have hereunto set my/our hand(s) and seal(s) this ( 2 day of AMEN , 2009. WITNESSETH: Cl A i m No. o-l o-45 50 2- x ' 'rl! C fl COMMONWEALTH OF A COUNTY OF Co?NkA?IJ?i On this Upt day of V%AAe(4 , 2009, before me personally appeared , COOS (Wo< known to me to be the person(s) whose name(s) is/are subscribed to the within Release, and acknowledged that he/she/they executed the same for the purposes therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. PAAA N RY PUBLIC My C ommit sion Expires: I h of Pennsvi NOTARIAL SEAL TERRI BROWN, Notary Public Hampden Twp., County of Cumberland My Commission Expires March 18, 2010 SETTLEMENT AGREEMENT AND RELEASE This Settlement Agreement and Release is made and entered into this 3 ?" day of '-Ti M L , 2009, by and between: "CLAIMANTS" CHRISTOPHER COOK, Individually and as Parent and Natural Guardian of COLLIN COOK, a minor "INSURER" WEST AMERICAN INSURANCE COMPANY RECITALS A. On or about July 2, 2007, minor Claimant, Collin Cook, was injured in an accident occurring in Newville, Pennsylvania. B. Insurer provided UNINSURED/UNDERINSURED MOTORIST COVERAGE under Policy Number FPW35003283 with effective dates 3/8/07 - 8/28/07 under which Claimants have presented a claim for damages. C. The parties desire to enter into this Settlement Agreement in order to provide for certain payments in full settlement and discharge of all claims which have, or might be made, by reason of the incident described in Recital A above, upon the terms and conditions set forth below. AGREEMENT The parties agree as follows: 1.0 RELEASE AND DISCHARGE 1.1 In consideration of the payments set forth in Section 3, Claimants hereby completely release and discharge Insurer from any and all past, present or future claims, demands, obligations, actions, causes of action, wrongful death claims, rights, damages, costs, losses of services, expenses and compensation of any nature whatsoever, whether based on a tort, contract or other theory of recovery, which the 1 s Claimants now have, or which may hereafter accrue or otherwise be acquired, on account of, or may in any way grow out of the incident described in Recital A above, including, without limitation, any and all known or unknown claims for bodily and personal injuries to the Claimants, or any future wrongful death claim of Claimants' representatives or heirs. 1.2 This release and discharge shall also apply to Insurer's past, present and future officers, directors, stockholders, attorneys, agents, servants, representatives, employees, subsidiaries, affiliates, partners, predecessors and successors in interest, and assigns and all other persons, firms or corporations with whom any of the former have been, are now, or may hereafter be affiliated. 1.3 This release, on the part of the Claimants, shall be a fully binding and complete settlement between the Claimants and the Insurer, and their heirs, assigns and successors. 1.4 The Claimants acknowledge and agree that the release and discharge set forth above is a general release. Claimants expressly waive and assume the risk of any and all claims for damages which exist as of this date, but of which the Claimants do not know or suspect to exist, whether through ignorance, oversight, error, negligence, or otherwise, and which, if known, would materially affect Claimants' decision to enter into this Settlement Agreement. The Claimants further agree that Claimants have accepted payment of the sums specified herein as a complete compromise of matters involving disputed issues of law and fact. Claimants assume the risk that the facts or law may be other than Claimants believe. 1.5 It is understood and agreed that the Claimants warrant that no Insurer, attorney, employer, judgment creditor or other person has any type of lien or prospective lien upon the cause of action described in Recital A above or upon the proceeds of this settlement; the Claimants further agree to defend, indemnify and hold harmless the parties released herein from any such claims or actions or from any other claims or actions brought against them by virtue of any inaccuracies or omissions in any representations made herein by the undersigned. 1.6 The undersigned further represents that there are no past or future liens or rights of reimbursement by any hospital, ambulance service, or other medical provider, Medicare, Medicaid, insurance company, workers' compensation provider, or attorney enforceable against the proceeds of this settlement or against the parties released, or the persons, firms or corporations making the payment herein. If such a 2 lien or right is asserted, against the proceeds herein or against the parties released or against any person, firm, or corporation making payment herein, then, in consideration of the payment made to the undersigned, the undersigned covenants to pay and satisfy such asserted lien or right, or to satisfy the same on a compromise basis, and to obtain in any event, a release and discharge of such lien or right, and, in any event, to indemnify and hold harmless the parties released and the persons, firms or corporations making the payment herein, from any costs, expenses, attorney fees, claims, actions, judgments, or settlements resulting from the assertion or enforcement of such lien by any entity having such lien or right. 1.7 It is understood and agreed further that at the time of the incident described in Recital A above, the undersigned Claimants were on their own business and not on business for any employer, and that no employer or workers compensation carrier, therefore, is interested in any claim arising out of said incident. Any and all liens or claims arising out of the incident will be the responsibility of and will be paid and discharged out of the settlement proceeds by Claimants or their representatives, assigns, successors in interest and executors. 2.0 PAYMENTS In consideration of the release set forth above, the Insurer agrees to pay to the individual(s) named below ("Payee(s)") the sums outlined in this Section 3 below: 3.1 Payments due at the time of Settlement as follows: Seven Thousand Five Hundred Dollars and No Cents ($7,500.00) payable to Christopher Cook, Individually and as Parent and Natural Guardian of Collin Cook, a minor, upon execution of this agreement by the parties and upon approval by a court having proper jurisdiction. 2.2 Periodic Payments will be made according to the schedule as follows (the "Periodic Payments"): Payee: Collin Cook Four Thousand Three Hundred Forty-Five Dollars and Twenty-Eight Cents ($4,345.28), payable semi-annually for a period certain of eight (8) years, beginning October 8, 2015. The last guaranteed payment is due on April 8, 2023. 3 All sums set forth herein constitute damages on account of physical injuries and sickness, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. 3.0 CLAIMANTS' RIGHTS TO PAYMENTS Claimant acknowledges that the Periodic Payments cannot be accelerated, deferred, increased or decreased by the Claimant; nor shall the Payee have the power to sell, mortgage, encumber, or anticipate the Periodic Payments, or any part thereof, by assignment or otherwise, except as authorized in advance in a qualified order as defined in Section 5891(b)(2) of the Code (a "Qualified Order") and otherwise complying with applicable state law, including without limitation any applicable state structured settlement protection statute. 4.0 BENEFICIARY DESIGNATION Any payments to be made after death of Collin Cook, pursuant to the terms of this Settlement Agreement, shall be made to the Estate of Collin Cook. Upon reaching the age of majority, Collin Cook shall have the right to submit a request to change the Beneficiary designation. No such designation, nor any revocation thereof, shall be effective unless it is in writing, signed by Collin Cook, and delivered to the Insurer or the Insurer's Assignee. The designation must be in a form acceptable to the Insurer or the Insurer's Assignee before such payments are made. 5.0 CONSENT TO QUALIFIED ASSIGNMENT 5.1 Claimants acknowledge and agrees that the Insurer may make a "qualified assignment", within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as amended, of the Insurer's liability to make the Periodic Payments set forth in Section 2.2 to Liberty Assignment Corporation ("the Assignee"). The Assignee's obligation for payment of the Periodic Payments shall be no greater than that of the Insurer (whether by judgment or agreement) immediately preceding the assignment of the Periodic Payments obligation. 4 5.2 Any such assignment, if made, shall be accepted by the Claimants without right of rejection and shall completely release and discharge the Insurer from the Periodic Payments obligation assigned to the Assignee. The Claimants recognize that, in the event of such an assignment, the Assignee shall be the sole obligor with respect to the Periodic Payments obligation, and that all other releases with respect to the Periodic Payments obligation that pertains to the liability of the Insurer shall thereupon become final, irrevocable and absolute. 5.3 Liberty Mutual provides a Certificate of Guarantee on all cases, which guarantees the performance of Liberty Life Assurance Company of Boston, the annuity issuer. 6.0 RIGHT TO PURCHASE AN ANNUITY The Insurer, through its Assignee, reserves the right to fund the liability to make the Periodic Payments through the purchase of an annuity policy from Liberty Life Assurance Company of Boston. The Assignee shall be the sole owner of the annuity policy and shall have all rights of ownership. The Assignee may have Liberty Life Assurance Company of Boston mail payments directly to the Payee(s). The Claimants shall be responsible for maintaining a current mailing address for Payee(s) with Liberty Life Assurance Company of Boston. 7.0 DISCHARGE OF OBLIGATION The obligation of the Assignee to make each Periodic Payment shall be discharged upon the mailing of a valid check in the amount of such payment to the designated address of the Payee(s) named in Section 2.2 of this Settlement Agreement. 8.0 REPRESENTATION OF COMPREHENSION OF DOCUMENT In entering into this Settlement Agreement, the Claimants represent that the terms of this Settlement Agreement have been completely read by Claimants; and 5 that the terms of this Settlement Agreement are fully understood and voluntarily accepted by Claimants. 9.0 WARRANTY OF CAPACITY TO EXECUTE AGREEMENT Claimants represent and warrant that no other person or entity has, or has had, any interest in the claims, demands, obligations, or causes of action referred to in this Settlement Agreement, except as otherwise set forth herein; that Claimants have the sole right and exclusive authority to execute this Settlement Agreement and receive the sums specified in it; and that Claimants have not sold, assigned, transferred, conveyed or otherwise disposed of any of the claims, demands, obligations or causes of action referred to in this Settlement Agreement. 10.0 CONFIDENTIALITY The parties agree that neither they, nor their attorneys, nor representatives shall reveal to anyone, other than as may be mutually agreed to in writing, any of the terms of this Settlement Agreement or any of the amounts, numbers or terms and conditions of any sums payable to Payee(s) hereunder. 11.0 GOVERNING LAW This Settlement Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. 12.0 ADDITIONAL DOCUMENTS All parties agree to cooperate fully and execute any and all supplementary documents and to take all additional actions that may be necessary or appropriate to give full force and effect to the basic terms and intent of this Settlement Agreement. 7 13.0 ENTIRE AGREEMENT AND SUCCESSORS IN INTEREST This Settlement Agreement contains the entire agreement between the Claimants and the Insurer with regard to the matters set forth in it and shall be binding upon and inure to the benefit of the executors, administrators, personal representatives, heirs, successors and assigns of each. 14.0 EFFECTIVENESS This Settlement Agreement shall become effective immediately following execution by each of the parties below and upon approval by a court having proper jurisdiction. CLAIMANTS By: Christopher Cook, Individually and as Parent and Natural Guardian of Collin Cook, a minor INSURER West American Insurance Company By: Title: Date: 6 -/ 3 - 2l o q Date: D?1\ S\M(I f?d '0(?t \3 day ?vo?? :"?f?Mf7f'dVi1?:6-?,z} !? F_;NNSYLVANIA -, i 1' i V ? uDI1G :7IIY'rf J.•'?tlil;a j'?I•J `., ^t:r " nd County JM, 2f3, 2Q ;2 g 14 VERIFICATION I, Christopher Cook, as Parent and Natural Guardian of Joshua Cook, a minor, and Collin Cook, a minor, do hereby verify that I am the Petitioner in the above-captioned action and further verify that I have read the foregoing document and that it is true and correct to the best of our knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities. Date: ?p - 2ln - 2 00 9 f Christopher ook, as Parent and Natural Guardian of Joshua Cook, a Minor and Collin Cook, a Minor e. 4 r Certificate of Service I, Stephanie L. Hersperger, Esquire, hereby verify that on the 17th day of July 2009, I served the following with a true and correct copy of the Petition for Approval of Minors' Settlement, with service being made by the United States Postal Service, first class mail, postage pre-paid, and by certified, return receipt requested: Mr. Christopher Cook 424 Pawnee Drive Mechanicsburg, PA 17055 Ms. Lisa Tusveld Ringler Associates 110 Gilsum Mine Road Alstead, NH 03602 I verify that the statements made in this Certificate are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities. THOMAS, THOMAS & HAFER, LLP Stephanie L. Hersperger OF THE I- o' -:7tc worn 2009 JUL 20 PM G 0 u J= '4,SYC AKi $'j8. So PQ AT -f l4q (f 38 ET#.12 8193 THOMAS, THOMAS & HAFER, LLP Stephanie L. Hersperger, Esquire I.D. No. 78735 P.O. Box 999 Harrisburg, PA 17108-0999 (717) 255-7617 Attorney for the Petitioner IN RE: JOSHUA COOK AND COLLIN COOK, minors CHRISTOPHER COOK, as parent and natural guardian of JOSHUA COOK AND COLLIN COOK, minors, PETITIONER IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA CIVIL ACTION - LAW NO. 2009-04812 AMENDED PETITION FOR APPROVAL OF MINORS' SETTLEMENT 1. Petitioner Christopher Cook ("Petitioner") is the parent and natural guardian of Joshua Cook and Collin Cook, minors ("Minor-Petitioners"). 2. 17055. 3. years of age. 4. years of age. 5. Petitioner and Minor-Petitioners reside at 424 Pawnee Drive, Mechanicsburg, PA Minor-Petitioner, Joshua Cook, was born on July 22, 1999, and is currently 9 Minor-Petitioner, Collin Cook, was born on October 18, 1993, and is currently 15 This Petition is filed as a result of an accident that occurred on July 2, 2007, when the vehicle being driven by Minor-Petitioners' mother, Delanie Cook, collided with another vehicle at the intersection of Centerville Road and Walnut Street Bottom Road near Newville, Cumberland County, PA; as a result of the collision, the vehicle in which Minor-Petitioners were passengers, rolled off of the roadway into a gulley. Injuries of Minor-Petitioner, Joshua Cook 6. As a result of the accident, Minor-Petitioner, Joshua Cook, was taken to the Emergency Room of Carlisle Regional Medical Center where he was diagnosed with chest pain from a small abrasion to his chest area, apparently caused by the seatbelt. A true and correct copy of relevant portions of Joshua Cook's medical records from Carlisle Regional Medical Center are attached hereto and marked as Exhibit "A". 7. A chest-x-ray was negative and the Emergency Room physician's clinical impression was (1) motor vehicle accident; (2) chest pain; and (3) musculoskeletal pain. See Exhibit "A". 8. Minor-Petitioner, Joshua Cook, did not need any stitches or further treatment and was released from the E.R. after being there for approximately 1 to 1 '/2 hours. See Exhibit "A". 9. Minor-Petitioner, Joshua Cook, recovered from his injuries. Injuries of Minor-Petitioner, Collin Cook 10. As a result of the accident, Minor-Petitioner, Collin Cook, was taken to the Emergency Room of Carlisle Regional Medical Center for treatment; he had complaints of right and left ankle pain and left shoulder pain. A true and correct copy of relevant portions of Collin Cook's medical records from Carlisle Regional Medical Center are attached hereto and marked as Exhibit "B". 11. X-rays were performed and as a result of same, Minor-Petitioner, Collin Cook, was diagnosed as having a bimalleolar fracture of the right ankle and soft tissue swelling over the lateral aspect of the left ankle. See Exhibit "B". 12. On July 2, 2007, Minor-Petitioner, Collin Cook, underwent open reduction internal fixation of the right ankle (right ankle surgery) while under general anesthesia. The procedure was uneventful and Collin Cook was discharged from the hospital on July 4, 2007. See Exhibit "B". 13. One week following the accident, at a follow-up appointment, it was noted that there was considerable swelling of the right ankle, which was to be expected, but no signs of infection; Collin was instructed to keep the right ankle elevated, have limited activity and not to bear any weight on the ankle. See Exhibit "B". 14. On July 18, 2007, x-rays showed the internal fixation to be in satisfactory position and Collin was instructed that he could engage in activities based on symptoms, and motion and strengthening exercises. See Exhibit "B". 15. On August 13, 2007, it was recorded that Collin Cook had a smooth course post open reduction internal fixation of the right ankle; there was little difficulty, and he was able to walk without pain and had been in the ocean. The x-rays showed optimal alignment and Collin was instructed he could engage in advanced activity and motion and strengthening exercises. See Exhibit "B". 16. Minor-Petitioner, Collin Cook has recovered from his injuries. 17. At the time of the automobile accident, Petitioner, Christopher Cook, and his wife, Delanie Cook, had automobile liability insurance through West American Insurance Company. Proposed Settlement of Claims of Minor-Petitioner Joshua Cook 18. On behalf of Minor-Petitioner, Joshua Cook, West American Insurance Company offered $1,000.00 to settle his claims, and same was accepted by Petitioner, Christopher Cook, who is the natural parent and guardian of Joshua Cook. 19. Petitioner, Christopher Cook, executed a Release settling the claims of Minor- Plaintiff, Joshua Cook, for $1,000.00. A true and correct copy of the executed Release as to Joshua Cook is attached hereto and marked as Exhibit "C". 20. The aforesaid insurance also provided first-party medical benefits in the amount of $5,000.00; West American Insurance Company paid $647.94 for Joshua Cook's medical expenses, which were the result of the injuries he sustained in the automobile accident at issue. 21. There is no Medicare or Medicaid or any other recoverable subrogation liens as to the settlement for the claims by Minor-Petitioner, Joshua Cook. 22. Petitioner, Christopher Cook, believes the offer as to Joshua Cook, and the proposed distribution of settlement funds thereof is fair and in the best interest of said Minor-Petitioner. Proposed Settlement of Claims of Minor-Petitioner Collin Cook 23. On behalf of Minor-Petitioner, Collin Cook, West American Insurance Company offered $49,000.00 to settle his claims, with $7,500.00 to be made payable to Christopher Cook, Individually and as Parent and Natural Guardian of Collin Cook, a minor, upon approval of the agreement by the Court. A true and correct copy of the executed Settlement Agreement and Release as to Collin Cook, prepared by Ringer Associates, is attached hereto and marked as Exhibit "13". 24. The remaining portion of the settlement, specifically, $41,500.00, is to be placed into a structured settlement. See Exhibit "D". 25. The Structured Settlement Agreement and Release provides that $4,345.28 is to be paid to Minor-Petitioner, Collin Cook, semi-annually, for a period of 8 years, beginning on October 8, 2015. The last guaranteed payment is due on April 8, 2023. See Exhibit "D". 26. The total guaranteed amount payable under the structured settlement portion of the proposed settlement is $69,524.48. 27. Petitioner, Christopher Cook, executed the Settlement Agreement and Release settling the claims of Minor-Petitioner, Collin Cook. See Exhibit "D". 28. The aforesaid insurance also provided first-party medical benefits in the amount of $5,000.00; West American Insurance Company paid $5,000.00 for Collin Cook's medical expenses, which were the result of the injuries he sustained in the automobile accident at issue. 29. There is no Medicare or Medicaid or any other recoverable subrogation liens as to the settlement for the claims by Minor-Petitioner, Collin Cook. 30. Petitioner, Christopher Cook, believes the offer as to Collin Cook, and the proposed distribution thereof is fair and in the best interest of said Minor-Petitioner. 31. West American Insurance Company shall be responsible to pay all court costs and legal fees charged by the undersigned in preparing and filing the within Petition and in representing the Petitioner in any proceedings required to obtain court approval of the within minor's settlement. Consequently, the full amount of the settlement proceed shall be paid to the Petitioner undiminished by attorneys' or legal fees or court costs. 32. Petitioner, Christopher Cook, presents the instant Petition in order to obtain court approval of the proposed settlements as described above. WHEREFORE, Petitioner respectfully requests that this Honorable Court enter an Order approving of the proposed settlement as to Minor-Petitioner, Joshua Cook, and Minor-Petitioner, Collin Cook. Respectfully submitted, THOMAS, THOMAS & HAFER, LLP Stepha ie L. Hersperger, Esquire I.D. Number: 78735 305 North Front Street, P.O. Box 999 Harrisburg, PA 17101 (717) 255-7239 Attorney for Petitioners Date: 7/21/09 CT&W ADMISSION RECnRn 361 Alexander Spring Road . Carlisle, PA 17015-9129 . 1717) 249.1212 ACCOUNT NO, 9 3 7 3 6 3 5 0001062740 P ADMIT DATE 'TIME ROOM NO. PT FC AGE DATE OF BIRTH SEX RA MS LOCATION PROGRAM A 07/02/2007 10:15 0000 El F 7 07/22/1999 M 1 S T I PATIENT NAME 6 ADDRESS COOK, JOSHUA E SS NUMBER 777-77-7777 PATIENT EMPL R CHILD EMPLOYER PH NEN . E 424 PAWNEE DR N MECHANICSBURG PA 17050 PHONE NUMBER COUNTY T US (717)763-1294 CUMB RESPONSIBLE PARTY ADDRESS U G COOK, CHRISTOPHER D NESTLE L U 424 PAWNEE DR 181-52-9902 (717)795-5454 A MECHANICSBURG PA 17050 PHONENUMBER MECHANICSBURG PA 17055 REL T R US A IONSHIPT PATIENT (717)763-1294 FATHER RESP EMERGENCY CONTACT NAME EMERGENCY CONTACT PHONE EMERGENCY CONTACT RELATIONSHIP TO PATIENT COMMENTS MSP MED. KEY IVACY NPP ADMIT. BY ?Y MN Ely MN Y CLC PRIVACY PAYER 950 ATO FPW35003283 09/10/1967 INSURANCE C NAME & ADDRESS ACORDIA NORTHEAST INC INSURED' NAME COOK, CHRISTOPHER 4900 RITTER RD N MECHANICSBURG PA 17055 GROUP NUMBER (866)235-6076 NONE S AUTHORIZATION 2 PAYER PLAR - POLICY NUMBER DATE I U INSURANCE NAME & A / I DDRESS INSURED'S A R GROUP NUMBE CROUP NAME A A TH RIZATION S PAY PLAN POLICY NUMBER GATE OF F BIRTH I AN N ' C SUREU NAM E S GROUP NUMBER GROUP NAME E AUTH I ATION M OR. ATT ENOIN / ADMITTING R. AMILY / PRIMARY ARE GATRELL, CLOYD B NONSTAFF, OUT OF TOWN S DIAGNOSIS SIGNS v C MVA--MINOR. INJURY NO FAULT 07/02/2007 PRINCIPAL DIAGNOSIS (The condition established after study to be chiefly tesponside for occasioning the admission of me patient to the HOSPITAL for caret. I AFIGE 1 COMPLICATIONS COMORBIDITYIIES) PRINCIPAL PROCEDURE (HI MEDICAL RECORDS COPY ?Ga g,a 9373636 111111NIII1IN1111NI1Illl)IIIII111III zl? Pennsylvania EMS Deport Service Name Friendship Hose Co. Ambulance Unit No. 2100502 PCR No. 0700603 I'SAP Incid. No. 84594 Date 0710212007 Incident Location Cenlerville Road & Walnut bottom Road Newville, Pa MCI) 21922 Receiving Agency Carlisle Hospital Patient Name Josh Cook Phonc No. (717) 763-1294 Age 07 Years Uate of Birth 07/2211999 Social Sec. No. 777-77-7777 Sex Male = Strect Address Crew Times H 424 Pawnce Drive A #1 Bear, "I eresea I 118559 911 08:57 i.. (5t State Lip Mechanicsburg PA 17055 A 42 A #3 13itner, Mike A Gurgamous, Lona J. I: 164190 Dispatch Enroute 09:06 09:06 Patient Nornlwr Mt-rnhe p A #4 Arrive Scene 09:13 No Contact 09:14 Private Physician Out On-Scene Dest. In Depart Scene 09:29 Frl 51431 51437 51446 51457 Arrive Facility 09:38 'I ransporting Assist Units OS Time Medical Command Physician MCC Available In Quarters 10:05 10:15 Chief Complaint: M chest hurts right here. PI': Possible frorn seat belt. Current Meds: None Allergies (meds): None Narrative PMHx: None. Bls was dispatched along with several other ambulances and Medic units to Ritner Hwy. and Centerville Road for an auto accident with entrapment with fire. While enroute to the scene, we were informed that the accident was at Centerville Road and Walnut Bottom Road. Bls arrived on the scene, to find Ambulance 147 with a patient and several other patient's was being cared for by firefighters. Ambulance 247 found a 7 year old male sitting on the grass by the road shaking and rocking back and forth. Patient was crying. Bls asked the patient if he was hurt anywhere. Patient pointed to the center of his chest. Bls found a small abrasion to the patient's chest where his seat belt,was. Patient's c-spine was held. Bls palpated the patient's neck and back for tenderness and deformity and none was noted. Patient was placed onto a long back board with CID's put into place. Patient was picked up off the ground and placed into the back of the ambulance on the bench seat, due to Bls transporting 2 patients. Patient's vitals were taken. Patient was awake, alert and oriented x4. Patient's skin was pink, - warm and dry. Pupils were equal and reactive to light in the mid-position. Trachea was mid- line. Negative JVD. Lung sounds were present and clear in all fields. Abdomen was soft and non-tender with no palpable masses. Negative edema to hands, legs, ankles and feet. Pulse ox o2 sat was at 100% on room air. Patient was able to move all extremities before and after being backboarded. Patient also had good pedal pulses before and after being backboarded. There was no fluid coming out of his ears, nose, eyes or mouth. Patient was transported to the Carlisle Hospital. When we arrived at the Carlisle Hospital, patient care was given over to E.R. nurse Carol in Trauma Room 3 with a full patient report being given by Bls. The patient's mother signed the HIPAA see tripsheet 0700604. Tttn _ y R $; P, o (7k { Issggw t41tn1 Ticatmccit ;_ - _ _ r Ptavidci ( 'Itrs ins lCnn?tztcttt<; - --- 09:15 _ .. _ . .-- _ ._ C-S ine Stabilize Al AO 09:17 Cervical Collar Al AO 09:21 C-S ine Imm. Dev. AO 09:30 105 22 1201070 100 4/5/6 Took t. vitals. Al 0935 104 22 120/070 100 4/5/6 Took t. vitals. Al O O O O tir) J N W O O n D r Prov;d?r CARLISLE REGIONAL MEDICAL CENTER 361 ALEXANDER SPRINGS ROAD CARLISLE PA 17015 (717) 960-1683 RADIOLOGICAL INTERPRETATION PATIENT NAME: COOK JOSHUA E X-RAY#: 1062740 EXAM DATE: 7/02/2007 ORDERING: LLOYD B GATRELL, MD- ATTENDING: CONSULTING: OUT OF TOWN NON-STAFF MD- HISTORY: MVA--MINOR INJURY MVA--MINOR INJURY TWO VIEW CHEST - 7/2/07: INDICATION: Trauma. COMPARISON: None. MED REC 1062740 ACCOUNT 9373635 D.O.B.: 07/22/1999 ROOM: ER FINDINGS: The lungs are adequately inflated. A consolidation is not seen. A pneumothorax is not visualized. The visualized bony structures are intact, the cardiomediastinal silhouette is also intact. IMPRESSION: Negative chest. REVIEWED AND SIGNED SCOTT WRIGHT INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED: DATE SIGNED: TRANSCRIPTIONIST: 4347785 RADI CHEST PA & LATERAL 7/02/2007 7/02/2007 12:59 7/03/2007 9:54:02 JXS OLOGIST AUDIT PAGE 1 OF 1 APPALACHIAN ORTHOPEDIC CENTER, LTD Thomas J. Green, MD Daniel P. Hely, MD Michael J. Oplinger, MD James A. Oliverio, MD RADIOLOGICAL REPORT PATIENT: XRAY DATE: DATE OF INTERPRETATION: OFFICE VISIT DATE: ORDERING PHYSICIAN: X-RAY PERFORMED: Collin Cook 08/13/2007 08/13/2007 08/13/2007 DANIEL P HELY, M.D. Right ankle - 2 views 1 Dunwoody Dr Carlisle, PA 17015 (717)249-6112 Tax ID: 25-1829749 INTERPRETATION: X-ray of the right ankle, AP and lateral, shows optimal alignment of the internal fixation without untoward signs. DICTATED AND READ BY: DANIEL P HELY, M.D. DPH/jmn cc: Auto AvPALACHIAN ORTHOPEDIC CENTER, LTD Thomas J. Green, M.D. Daniel P. Hely, M.D. Michael J. Oplinger, M.D. James A. Oliverio, M.D. 1 Dunwoody Dr Phone: (717) 249-6112 Carlisle, PA 17015 Fax: (717) 249-6235 OFFICE RECORDS Cook, Collin DOB:10/08/1993 08/13/07 OFFICE VISIT: Smooth course post open reduction internal fixation of the right ankle. Very little difficulty. Tom has been walking without pain and has been in the ocean. X-RAYS: X-ray of the right ankle, AP and lateral, shows optimal alignment of the internal fixation without untoward signs. PLAN: Advance activity. Motion and strengthening exercises. Follow up one month, re-exam, progress check. Daniel P. Hely, M.D./jmn cc: Dr. Guillermo Garcia Auto APPALACHIAN ORTHOPEDIC CENTER, LTD Thomas J. Green, M.D. Daniel P. Hely, M.D. Michael J. Oplinger, M.D. James A. Oliverio, M.D. 1 Dunwoody Dr. Carlisle, PA 17015 OFFICE RECORDS Cook, Collin DOB:10/08/1993 07/18/07 CHIEF COMPLAINT: Follow up bimalleolar fracture, right ankle. Phone: (717) 249-6112 Fax: (717) 249-6235 Other past medical history, surgical history, family history, social history, review of systems have been reviewed and updated from the new patient intake form, copy is signed, dated, and in the chart. PHYSICAL EXAMINATION: Collin's wound is clean. No sign of infection X-RAYS: X-ray of the right ankle does not show any evidence of displacement. The internal fixation appears to be in satisfactory position. PLAN: Activity based on symptoms. Motion and strengthening exercises. Follow up three weeks re-exam and x-ray. Toe-touch bearing only until then. 4ut/_244?? Daniel P. Hely, M.D. DPH/DS-amh cc: Guillermo Garcia, M.D. AUTO Carlisle Regional Medical Center Laboratory, 45 Sprint Dr Duckkyu Chang, M.D., Medical Direct Carlisle, PA 17013 Sun Y. Kim, M.D., Pathologist NEW AFTER DISCHARGE COOK, COLLIN MRN:0001062735 Location:MS3-0310-W Admitted: 07/02/07 DOB:10/08/1993 Sex:M Discharged: DISCH.: 07/04/07 Physician; RELY MDF DANIEL P P O I N T O F C A R E T E S T I GLUCOSE N G -----------------------+-------------- Test Name l Glucose - 712107-SK Reference Ranges 170-100 mg/dl -----------------------+-------------- 79040197 07/04/07 12:55 98 * Key for Abnormal Column M-Low H-High AB-Abnormal C-Critical T -Toxic) COOK, COLLIN MS3-0310-W continued P O I N T O F C A R E T E S T I N G 3 of 4, 54 of 80 PRINTED 07/05/2007 03:25 Page: 1 of 1 Fax Server 7/2, 107 7:17:30 PM PAGE 1/00 Fax Server COOK, COLLIN HOP 07/02/2007 1062735 DATE OF OPERATION: SURGEON: ASSISTANT SURGEON: 07/02/2007 Daniel P. Hely, M.D. PREOPERATIVE DIAGNOSIS: BimallPolar friCtUre, right ankle. POSTOPERATIVE DIAGNOSIS: Bimallcolar fracturc, right ankle. PROCEDURE PERFORMED: Open reduction internal fixation. DESCRIPTION OF PROCEDURE: Aftpr satisfactory general anesthPsla was achieved, the. patient's right lower extremity was prepped and draped. Thp pnPUmaft tourniyuPt was inflated to 325 mm. An incision was made. over the fibular fracture and Pxtended through the skin and SUl-)CUtaneouS tissUP using sharp dissection. A hematoma was cncountcrcd through the fascia. The fracture site was visualized, There wa minimal displacement, A scmitubular plate was placed over the fracturc and held in pia cc with a Verbrugge clamp. The x-ray was used to visualize the position of the plate, It appeared to be quite Satisfactory. The, plate, was sPUlred to the, Done using cortiml screws, sP.gUentially drlllPd, measured, and placed without dlfflCUlty gPtting Ucortical fixation. Attention Was turned to the, medial side,. An Incision was made over the, medial malleolUS and Pxtendecl through the, skin and SubCLltaneous tISSLIP. LlSing sharp dissection. Hcmostasis was assured after the hcmatoma was cncountcrcd. The PChO-Stcum was taken out of the fracturc and elevated back up over tic mc0physis, The fracture was reduced Lasing a drill hole in then metaphysis and a bone tenaeulum to hold the fraetLirc in a reduced position. Two K-wire were plaCPd across the, fliaCturP Sb, checked with the, Image. IntP.nslfiP,r and the, tracks were drlllpd, MeasLll-P.d, and Cannulated screws wP.re placed over the, K-WrP,s to aSSUrp fixation. These, appeared to bp scmP. oppning antP,rlorly and a third -,crew was added to compress this area down. The, gUldewlre was placed followed by the drill and a third cannulatad screw was placed into position. Having achieved optimal reduction of the fracturc and fixation in the AP and lateral views, the wounds were irrigated and closed U.Sing 2-0 Vicryl to close the subcut<aneoL.ls tissue and staples to close the skin. A sterile dressing and soft wrap and splint were added. Thp patient was awake without mishap and returned to the. recovery room in satisfactory condition. ToUrnigUPt timP was 50 minutes. DPH/sap D; 07/02/200718;40,51 T. 07/02/2007 19:11:05 C. Daniel P. HPIy, M.D. Pa gc1 oft DICTATING PHYSICIAN COPY CARLISLE REGIONAL MEDICAL CENTER OPERATIVE REPORT Daniel P. HPIy, M.D. 7712348 COOK, COLLIN HOP 1062735 07/02/2007 10/08/1993 HELY, DANIEL P cc Name Unit No YCR No. Date hi ensbur Area EMS '-%3 - 2100302 0701066 07/02/2007 Patient Name Date of Birth Social Security Number PSAP Collin Cook 10/08/1993 070084584 Gastrointestinal []No Complaint ? Nausea Vomiting ? Diarrhea ? Constipated Abdomen Z Soft ? Firm F-1 Guarding l ? B Pain ? Constant ? Intermittent ? Burning ? Sharp GU 0 No Complaint ? Urgency F-1 Frequency ? Pain ? Burning Area(s) Effected ? LUQ ? RUQ ? LLQ ? RLQ owe Sounds Absent Distended- No O Yes O Tender- No O Yes O ? Dull Radiating - No O Yes O ? Incontinent ? Retention ? Foley Total Output _ Extremities Reproductive ?? No Complaints ? No Complaints Female Male LA RA LL RL LA RA LL RL []Vaginal Bleeding []Discharge ? Penile Discharge Paralysis ? ? ? ? Pain ? ? []? []? Pregnant - No O Yes O ? Testicular Pain Paresthesia ? [] ? ? Pallor ? ? ? ? Gravida _ Para _ Week _ Pulse ? ? ? ? Edema ? ? ? ? []Fetal Movements Fetal Heart To nes Narrative On July 2 2007 amb 2073 was dispatched to Centerville Rd and Walnut Bottom Rd in Penn Twp Cumberland co. for a auto accident with 4 pt one critical. When responding to the scene There was not much info for what pt we would have do so many pt. When we were about 2 miles from the scene Cumberland med ask for are location. I told them about two miles from the scene. At this time they said are pt would be a class three with a ankle injury, That the pt was already on a back board and cid that we could just pull up to the scene and the pt is ready to by loaded into your amb. When on the scene the fire fighters had the pt on a back board with the cid blocks around the pt head with his right ankle rapped with a long board under the pt right leg. The emt on the scene said that there was deformity to the ankle. And that the pt was walking round after the accident. I could not see it do to the cling wrap around the leg. When in the amb I talked to the pt. He was conscious oriented and alert and said he was 13 yr old. I palped the pt body and the only pain was in his ankles. There was swelling to his left ankle all so. I placed a ice pack on both ankles and got a set of vitals. Pulse 78 resp32 by 170/72 o2 sat 98% on room air both lungs were equal and both purples vvere reactive and equal. Wlhen at the hospital the pt was placed in exam room 2 and the nurse was give the pt info and the pt care was turned over at this time.1 did not get any representative signature because there was no parent around to sign and he was only 13. Tfine P R BT, % Ox ET 0024 ?r u Glasggw t R _vthm Treatment Provider Re nt5 d! # 1 ? 4 i . r . akp . ?dR ; ????h r, lt, ?I 09:30 78 32 170/72 4/5/6 Initial VS; Resp. Effort: Tachypnea and Non-labored 09:40 70 26 160/68 99 4/5/6 Printed On: 07/03/2007 07:56 EMStat Reporting(c) 1998-2007, Med-Media, Inc. All Rights Reserved O U'll .p. O O? 00 - 2 0/?P! P'0'1 r Page: 2 of 2 CARLISLE REGIONAL MEDICAL CENTER PATIENT NAME: X-RAY#: EXAM DATE: ORDERING: ATTENDING: CONSULTING: HISTORY: MVA MVA 361 ALEXANDER SPRINGS ROAD CARLISLE PA 17015 (717) 960-1683 RADIOLOGICAL INTERPRETATION COOK COLLIN MED REC #: 1062735 1062735 ACCOUNT #: 9373630 7/02/2007 D.O.B.: 10/08/1993 CLOYD B GATRELL, MD- ROOM: ER OUT OF TOWN NON-STAFF MD BILATERAL ANKLES - 7/2/07: INDICATION: Trauma. FINDINGS: RIGHT ANKLE: An oblique fracture is demonstrated in the distal fibula, just proximal to the ankle mortise. Additionally, a fracture through the medial malleolus is demonstrated. There is increased distance between the medial aspect of the talus and medial malleolus suggesting disruption of the ankle mortise. Marked soft tissue swelling is also demonstrated. LEFT ANKLE: The visualized bony structures are intact. There is soft tissue swelling over the lateral aspect of the ankle. IMPRESSION: 1. Right sided medial malleolur fracture and distal fibular fracture, with disruption of the ankle mortise. Orthopedic consultation is advised. 2. Soft tissue swelling over the lateral aspect of the left ankle. Findings were relayed to the Emergency Department at the time of dictation. REVIEWED AND SIGNED SCOTT WRIGHT INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED: DATE SIGNED: TRANSCRIPTIONIST: 4347726 RADI ANKLE MLN 3V III IV 0'd 09TZ -,99 _)TL 7/02/2007 7/02/2007 12:59 7/03/2007 14:05:42 JXS OLOGIST AUDIT PAGE 1 OF 1 SEIVI IY) ;d-V 11)111; I?11 L" : s:T 800Z-f?F;-NVf' CARLISLE REGIONAL MEDICAL CENTER 351 ALEXANDER SPRINGS ROAD CARLISLE PA 17015 {717) 960-1683 RADIOLOGICAL INTERPRETATION PATIENT NAME: COOK COLLIN X-RAY#: 1062735 EXAM DATE: 7/02/2007 ORDERING: DANIEL P HELY,MD 249-6112 ATTENDING: CONSULTING: HISTORY: RIGHT ANKLE FRACTURE OR. ANKLE ORIF RIGHT ANKLE TWO VIEWS - 7/2/07: CLINICAL HISTORY: Ankle fracture. MED REC #: 1062735 ACCOUNT V: 7712348 D.O.B.: 10/08/1993 ROOM: 0310 CoyffAENT : Digital intra-operative spot film radiographs were obtained which demonstrate screw fixation of the medial malleclar fracture seen earlier the same day. A dynamic compression plate and screws is seen about the distal fibular shaft fracture. Alignment is anatomic on the intra-operative radiographs obtained. REVIEWED AND SIGNED CHRISTOPHER LADD,MD INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED: DATE SIGNED: TRANSCRIPTIONIST: 4346212 RADI ANKLE AP & LAT 7/03/2007 7/03/2007 10:22 7/03/2007 13:04:19 SIX S OLOGIST AUDIT PAGE 1 OF 1 Sir) 'd 'i9T? -99 -)TL S*3,LVI;1,-_,2:;'d NHZSI8Z ?_:8T £i(ifi^-OF:-PIIfL' ..I.d COOK, COLLIN MS3 0310 W 1062735 DATE DISCHARGED: 07104/2007 DISCHARGE DIAGNOSIS: Bimalleolar fracture, right ankle. OPERATION: Open reduction and internal fixation. CLINICAL SUMMARY: This is a 13-year-old boy with a bimalleolar fracture of the ankle. He underwent open reduction and internal fixation on the day of admission. Postoperative course was uneventful. He was discharged with the recommendations to continue limited activity at home, Percocet as needed for pain, follow-up appointment in my office in 5 to 7 days following discharge, and call in the interim if problems arise. DPH/am D: 07/04/2007 09:26:09 T : 07/05/2007 11:23:22 C: Daniel P. Hely, M.D. Daniel P. Hely, M.D. L 7712348 COOK, COLLIN MS3 0310 W 1062735 07/02/2007 10/08/1993 Daniel P Hely Page 1 of 1 THIS DOCUMENT IS NOT A LEGAL COPY UNLESS SIGNED. CARLISLE REGIONAL MEDICAL CENTER DISCHARGE SUMMARY k COOK, COLLIN DATE OF OPERATION: SURGEON: ASSISTANT SURGEON: MS3 0310 W 07/02/2007 Daniel P. Hely, M.D. PREOPERATIVE DIAGNOSIS: Bimalleolar fracture, right ankle, POSTOPERATIVE DIAGNOSIS: Bimalleolar fracture, right ankle. PROCEDURE PERFORMED: Open reduction internal fixation. 07/04/2007 1062735 DESCRIPTION OF PROCEDURE: After satisfactory general anesthesia was achieved, the patient's right lower extremity was prepped and draped. The pneumatic tourniquet was inflated to 325 mm. An incision was made over the fibular fracture and extended through the skin and subcutaneous tissue using sharp dissection. A hematoma was encountered through the fascia. The fracture site was visualized. There was minimal displacement. A semitubular plate was placed over the fracture and held in place with a Verbrugge clamp. The x-ray was used to visualize the position of the plate, It appeared to be quite satisfactory. The plate was secured to the bone using cortical screws, sequentially drilled, measured, and placed without difficulty getting bicorticat fixation. Attention was turned to the medial side. An incision was made over the medial malleolus and extended through the skin and subcutaneous tissue using sharp dissection, Hemostasis was assured after the hematoma was encountered. The periosteum was taken out of the fracture and elevated back up over the metaphysis. The fracture was reduced using a drill hole in then metaphysis and a bone tenaculum to hold the fracture in a reduced position. Two K-wires were placed across the fracture site, checked with the image intensifier and the tracks were drilled, measured, and cannulated screws were placed over the K-wires to assure fixation. There appeared to be some opening anteriorly and a third screw was added to compress this area down. The guidewire was placed followed by the drill and a third cannulated screw was placed into position. Having achieved optimal reduction of the fracture and fixation in the AP and lateral views, the wounds were irrigated and closed using 2-0 Vicryl to close the subcutaneous tissue and staples to close the skin. A sterile dressing and soft wrap and splint were added. The patient was awake without mishap and returned to the recovery room in satisfactory condition. Tourniquet time was 50 minutes. DPH/sap D: 07/02/2007 18:40:51 T : 07/02/2007 19:11:05 C: Daniel P, Hely, M.D. Daniel P. Hely, M.D. 7712348 COOK, COLLIN MS3 0310 W 1062735 07/02/2007 10/0811993 HELY, DANIEL P Page 1 of 1 THIS DOCUMENT IS NOT A LEGAL COPY UNLESS SIGNED CARLISLE REGIONAL MEDICAL CENTER OPERATIVE REPORT ..0? SLE 361 ALER REGION' MEDICAL CEN SPRINGS'*w?AD CARLISLL? 17015 4ad (717) 960-1683 RADIOLOGICAL INTERPRETATION PATIENT NAME: COOK COLLIN X-RAY#: 1062735 EXAM DATE: 7/02/2007 ORDERING: DANIEL P HELY,MD 249-6112 ATTENDING: CONSULTING: HISTORY: RIGHT ANKLE FRACTURE OR. ANKLE ORIF RIGHT ANKLE TWO VIEWS - 7/2/07: CLLNICAL HISTORY: Ankle fracture. MED REC #: 1062735 ACCOUNT #: 7712348 D.O.B.: 10/08/1993 ROOM: 0310 Coffl4ENT : Digital intra-operative spot film radiographs were obtained which demonstrate screw fixation of the medial malleolar fracture seen earlier the same day. A dynamic compression plate and screws is seen about the distal fibular shaft fracture. Alignment is anatomic on the intra-operative radiographs obtained. REVIEWED AND SIGNED CHRISTOPHER LADD,MD INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED DATE SIGNED: TRANSCRIPTIONIST 4346212 ANKLE AP & LAT 7/03/2007 7/03/2007 10:22 7/03/2007 13:04:19 JXS FLOOR PAGE 1 OF 1 RAD ANKLE BILATERAL CARLISLE REGIONAL MEDICAL CTR Adm Dt: 7/02/07 Coid: 858 Pat Nbr: 9373630 COOK, COLLIN COMPLETE Result: 07/03/2007 14:05 MVA MVA Procedure Acknowledge Date: 07/02/2007 10:99:56 BILATERAL ANKLES - 7/2/07: INDICATION: Trauma. FINDINGS: RIGHT ANKLE: An oblique fracture is demonstrated in the distal fibula, just proximal to the ankle mortise. Additionally, a fracture through the medial malleolus is demonstrated. There is increased distance between the medial aspect of the talus and medial malleolus suggesting disruption of the ankle mortise. Marked soft tissue swelling is also demonstrated. LEFT ANKLE: The visualized bony structures are intact. There is soft tissue swelling over the lateral aspect of the ankle. More... F8=Next Page F18=Prior Report F5=Patient F2=Print F12=Return-Prior Screen F7=Prior Page F17=Next Report F6=Census F1=Help F11=Demo F3=Exit-Menu Record(s) Displayed. SROSE RAD ANKLE BILATERAL CARLISLE REGIONAL MEDICAL CTR Adm Dt: 7/02/07 Coid: 858 Pat Nbr: 9373630 COOK, COLLIN COMPLETE Result: 07/03/2007 14:05 IMPRESSION: 1. Right sided medial malleolar fracture and distal fibular fracture, with disruption of the ankle mortise. Orthopedic consultation is advised. 2. Soft tissue swelling over the lateral aspect of the left ankle. Findings were relayed to the Emergency Department at the time of dictation. WRIGHT SCOTT Dictated By WRIGHT SCOTT Reviewed & Signed Bottom F8=Next Page F18=Prior Report FS=Patient F2=Print F12=Return-Prior Screen F7=Prior Page F17=Next Report F6=Census F1=Help Fll=Demo F3=Exit-Menu Bottom of List. SROSE Fax Server 7/2/2007 7:17:30 PM PAGE 1/001 Fax Server COOK, COLLIN HOP 07/02/2007 1062735 DATE OF OPERATION: SURGEON: ASSISTANT SURGEON: 07/02/2007 Daniel P. Hely, M.D. PREOPERATIVE DIAGNOSIS: Rimalleolar fracture, right ankle. POSTOPERATIVE DIAGNOSIS: Simallcolarfracturc, right ankle. PROCEDURE PERFORMED: Open rcCluction internal fixation, DESCRIPTION OF PROCEDURE: After Satisfactory general anesthe%ia was achieved, the patient's right lower extremity was prepped and drained. The PnPUmatic tourniquet was inflated to 325 mm. An incision was made over the fibular fracture and extended through the skin and SLII3cutaneou5 tiSSUP, using sharp ctisscction. A hcmatoma was encountered through the fascia, The fracture site was visualized. There was minimal displacement. A 5emitubular plate was placed over the fracturc and held in place with a Verbrugge clamp, The x-ray was used to visualize the position of the plate, It appeared to be quite Satisfactory. The, plate was Secured to the bone Using cort cal Screws, sequentially drlllpd, mP.aSUred, and P13CP,CI Without difficulty getting bicortlcal fixation. AttentJon was turned to the, medial SKIP.. An incision was made over the, medial malleOIUS and extended through the. Skin and SUIDCLItaneOLIS bsSUP, Using Sharp clissection, Hemostasis was assured after the hematoma was encountered, The pchostCum was taken out of the fracturc and elevated back up over the mc0physis. The fracture was redUCCd wing a drill hole in then metaphysis and a bone tonaeLILlm tohold the fracturc in a rcCJueed position. Two K-wires were placed across the fracture Site, checked with the image intensifier and the tracks were drilled, measured, and cannulated Screw-, were placed over the K-wirP-, t0 3SSUre fixation. There appParPd to be scmp opPninganteriorly and a third screwwas added to comprP-,s this area down. The guidewlrP was placed followed by the drill and a third eannulated screw was placed into position. Having achieved optimal reduction of the fracturc and fixation in the AP and lateral views, the wouncis were irrigated and closed L.ising 2-0 Vicryl to close the subeutz--jneous tissue and staples to close the skin. A stCrile dressing and soft wrap and splint were added. The patient was awake without mishap and returned to the recovery room in satisfactory condition. TourniquPt time was 50 minutes. DPH/sap D: 07/0212007 10:40:51 T: 07/02/2007 19:11:05 C: Daniel P. HPIy, M.D. Daniel P. HPIy, M.D. 7712342 COOK, COLLIN HOP 1062735 07/02/2007 10/08/1993 HELY, DANIEL P Page 1 of 1 DICTATING PHYSICIAN COPY CARLISLE REGIONAL MEDICAL CENTER OPERATIVE REPORT GENERAL RELEASE For and in consideration of the above payment to Christopher Cook, individually and as parent and natural guardian Of.loshua Cook ofthe sum of ($1000.00), One Thousand Dollars and 00/100, 1, Christopher Cook, parent and natural guardian of Joshua Cool: do hereby release and forever discharge Christopher Cook and Delauie Cook and West American Insurance Company, their insurers, reinsurers, employees, related entities, agents, and any and all other persons and firms, of and from any and all actions, causes of action, claims, demands, damages, costs, loss of services, expenses, compensation, consequential damage, or any other thing whatsoever, including any claim for bad faith, on account of or in any way growing out o{', any and all known and unknown personal injuries, debts, and property damage resulting or to result from an incident that occurred on or about 07/02/2007 at or near Newville, PA. I hereby acknowledge and assume all risk, chance, or hazard that the said injuries or damages may be or become permanent, progressive, greater, or more extensive than is now known, anticipated, or expected. No promise or inducement which is not herein expressed has been made to me and in executing this Release, I do not rely upon any statement or representation ii-lade by any person, firin, o :;oi* Oration, hereby r' le'u _-d oi' any agent, physic -in, doctor, Or other person representing them or any of them concerning the nature, extent, or duration of said damages or losses, or the legal liability therefore. I understand that this settlement is the compromise of a disputed claim and that the payment is not to be construed as an admission of liability on the part of the persons, firms, and/or corporations hereby released by whom liability is expressly denied. I further certify, state, acknowledge, warrant, and declare that each and every person, attorney, carrier, entity or association which claims to have alien on the proceeds of this settlement arising out of this incident, lawsuit, or litigation, is aware of this Release and its terms and I understand that said released parties hereunder are relying expressly upon this unconditional express warranty in making payment hereunder. The Releasor(s) accept responsibility for satisfying any liens that have been asserted against this recovery by any worker's compensation carrier, health care provider or insurer, or anyone else asserting a lien, and hereby discharge Releasee(s) from any such responsibility. In further- consideration of the above payment, I, Christopher Cook as parent and natural guardian of Joshua Cook, for my heirs, next of kin, executors, administrators, successors, or assigns, covenant and agree to indemnify and hold harmless Christopher- Cool< and Delanie Cook AND West American Insurance Company, their insurers, reinsurers, employees, related entities, agents, and attorneys, from all claims, demands, and suits for damages, costs, loss of services, expenses, or compensation which I or my heirs, insurers, next of kin, executors, administrators, successors or assigns have or may have in the future on account of or in any way growing out of the injuries or damages I sustained in this incident. 1 certify that I am over eighteen (18) years of age and am acting as individuals and parent/natural guardian of Joshua Cook and I further state that 1 have carefully read the foregoing Release and I know the contents thereof and I have signed the same as my free act and intending to be legally bound thereby. EXHIBIT O A! >r? 'J ? v 7 vG(5 5? 2 This Release contains the entire agreement between the parties hereto and the terms of this Release are contractual and not a mere recital. The undersigned acknowledge that lie has had this Release reviewed by counsel of their choosing, or that he understands that he had the right to do so. Any person who knowingly and with intent to injure of defraud any insurer files an application or claim containing any false. incomplete, or misleading information shall upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to %15,000. +t-, IN WITNESS WHEREOF, 1/WE have hereunto set my/our hand(s) and seal(s) this 2 day of Ari(6,4 2009. WITNESSETH: CLAIAI W,, D-Ib/45502- x ?X COMMONWEALTH OF R1)4111V VANth COUNTY OF Fa On this to day of 1kAAi? --,2009, before me personally appeared , CWJS COCK known to me to be the person(s) whose name(s) Ware subscribed to the within Release, and acknov,,ledged that he/she/they executed the same for the ptu-poses therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. N RY PUBLIC My C o.rr,t.i ion Expires: nw ih f n i NOTARIAL SEAL TERRI BRO!/still, ivotery Public Hampden Twp., C ii„nty of Cumberland MY Commission E=.xpi°es March 18, 2010 SETTLEMENT AGREEMENT AND RELEASE This Settlement Agreement and Release is made and entered into this J N day of s? ' , 2009, by and between: "CLAIMANTS" CHRISTOPHER COOK, Individually and as Parent and Natural Guardian of COLLIN COOK, a minor "INSURER" WEST AMERICAN INSURANCE COMPANY RECITALS A. On or about July 2, 2007, minor Claimant, Collin Cook, was injured in an accident occurring in Newville, Pennsylvania. B. Insurer provided UNINSURED/UNDERINSURED MOTORIST COVERAGE under Policy Number FPW35003283 with effective dates 3/8/07 - 8/28/07 under which Claimants have presented a claim for damages. C. The parties desire to enter into this Settlement Agreement in order to provide for certain payments in full settlement and discharge of all claims which have, or might be made, by reason of the incident described in Recital A above, upon the terms and conditions set forth below. AGREEMENT The parties agree as follows: 1.0 RELEASE AND DISCHARGE 1.1 In consideration of the payments set forth in Section 3, Claimants hereby completely release and discharge Insurer from any and all past, present or future claims, demands, obligations, actions, causes of action, wrongful death claims, rights, damages, costs, losses of services, expenses and compensation of any nature whatsoever, whether based on a tort, contract or other theory of recovery, which the Claimants now have, or which may hereafter accrue or otherwise be acquired, on account of, or may in any way grow out of the incident described in Recital A above, including, without limitation, any and all known or unknown claims for bodily and personal injuries to the Claimants, or any future wrongful death claim of Claimants' representatives or heirs. 1.2 This release and discharge shall also apply to Insurer's past, present and future officers, directors, stockholders, attorneys, agents, servants, representatives, employees, subsidiaries, affiliates, partners, predecessors and successors in interest, and assigns and all other persons, films or corporations with whom any of the former have been, are now, or may hereafter be affiliated. 1.3 This release, on the part of the Claimants, shall be a fully binding and complete settlement between the Claimants and the Insurer, and their heirs, assigns and successors. 1.4 The Claimants acknowledge and agree that the release and discharge set forth above is a general release. Claimants expressly waive and assume the risk of any and all claims for damages which exist as of this date, but of which the Claimants do not know or suspect to exist, whether through ignorance, oversight, error, negligence, or otherwise, and which, if known, would materially affect Claimants' decision to enter into this Settlement Agreement. The Claimants further agree that Claimants have accepted payment of the sums specified herein as a complete compromise of matters involving disputed issues of law and fact. Claimants assume the risk that the facts or law may be other than Claimants believe. 1.5 It is understood and agreed that the Claimants warrant that no Insurer, attorney, employer, judgment creditor or other person has any type of lien or prospective lien upon the cause of action described in Recital A above or upon the proceeds of this settlement; the Claimants further agree to defend, indemnify and hold harmless the parties released herein from any such claims or actions or from any other claims or actions brought against them by virtue of any inaccuracies or omissions in any representations made herein by the undersigned. 1.6 The undersigned further represents that there are no past or future liens or rights of reimbursement by any hospital, ambulance service, or other medical provider, Medicare, Medicaid, insurance company, workers' compensation provider, or attorney enforceable against the proceeds of this settlement or against the parties released, or the persons, firms or corporations making the payment herein. If such a 2 lien or right is asserted, against the proceeds herein or against the parties released or against any person, firm, or corporation making payment herein, then, in consideration of the payment made to the undersigned, the undersigned covenants to pay and satisfy such asserted lien or right, or to satisfy the same on a compromise basis, and to obtain in any event, a release and discharge of such lien or right, and, in any event, to indemnify and hold harmless the parties released and the persons, firms or corporations making the payment herein, from any costs, expenses, attorney fees, claims, actions, judgments, or settlements resulting from the assertion or enforcement of such lien by any entity having such lien or right. 1.7 It is understood and agreed further that at the time of the incident described in Recital A above, the undersigned Claimants were on their own business and not on business for any employer, and that no employer or workers compensation carrier, therefore, is interested in any claim arising out of said incident. Any and all liens or claims arising out of the incident will be the responsibility of and will be paid and discharged out of the settlement proceeds by Claimants or their representatives, assigns, successors in interest and executors. 2.0 PAYMENTS In consideration of the release set forth above, the Insurer agrees to pay to the individual(s) named below ("Payee(s)") the sums outlined in this Section 3 below: 3.1 Payments due at the time of Settlement as follows: Seven Thousand Five Hundred Dollars and No Cents ($7,500.00) payable to Christopher Cook, Individually and as Parent and Natural Guardian of Collin Cook, a minor, upon execution of this agreement by the parties and upon approval by a court having proper jurisdiction. 2.2 Periodic Payments will be made according to the schedule as follows (the "Periodic Payments"): Payee: Collin Cook Four Thousand Three Hundred Forty-Five Dollars and Twenty-Eight Cents ($4,345.28), payable semi-annually for a period certain of eight (8) years, beginning October 8, 2015. The last guaranteed payment is due on April 8, 2023. 3 All sums set forth herein constitute damages on account of physical injuries and sickness, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. 3.0 CLAIMANTS' RIGHTS TO PAYMENTS Claimant acknowledges that the Periodic Payments cannot be accelerated, deferred, increased or decreased by the Claimant; nor shall the Payee have the power to sell, mortgage, encumber, or anticipate the Periodic Payments, or any part thereof, by assignment or otherwise, except as authorized in advance in a qualified order as defined in Section 5891(b)(2) of the Code (a "Qualified Order") and otherwise complying with applicable state law, including without limitation any applicable state structured settlement protection statute. 4.0 BENEFICIARY DESIGNATION Any payments to be made after death of Collin Cook, pursuant to the terns of this Settlement Agreement, shall be made to the Estate of Collin Cook. Upon reaching the age of majority, Collin Cook shall have the right to submit a request to change the Beneficiary designation. No such designation, nor any revocation thereof, shall be effective unless it is in writing, signed by Collin Cook, and delivered to the Insurer or the Insurer's Assignee. The designation must be in a form acceptable to the Insurer or the Insurer's Assignee before such payments are made. 5.0 CONSENT TO QUALIFIED ASSIGNMENT 5.1 Claimants acknowledge and agrees that the Insurer may make a "qualified assignment", within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as amended, of the Insurer's liability to make the Periodic Payments set forth in Section 2.2 to Liberty Assignment Corporation ("the Assignee"). The Assignee's obligation for payment of the Periodic Payments shall be no greater than that of the Insurer (whether by judgment or agreement) immediately preceding the assignment of the Periodic Payments obligation. 4 5.2 Any such assignment, if made, shall be accepted by the Claimants without right of rejection and shall completely release and discharge the Insurer from the Periodic Payments obligation assigned to the Assignee. The Claimants recognize that in the event of such an assignment, the Assignee shall be the sole obligor with respect to the Periodic Payments obligation, and that all other releases with respect to the Periodic Payments obligation that pertains to the liability of the Insurer shall thereupon become final, irrevocable and absolute. 5.3 Liberty Mutual provides a Certificate of Guarantee on all cases, which guarantees the performance of Liberty Life Assurance Company of Boston, the annuity issuer. 6.0 RIGHT TO PURCHASE AN ANNUITY The Insurer, through its Assignee, reserves the right to fund the liability to make the Periodic Payments through the purchase of an annuity policy from Liberty Life Assurance Company of Boston. The Assignee shall be the sole owner of the annuity policy and shall have all rights of ownership. The Assignee may have Liberty Life Assurance Company of Boston snail payments directly to the Payee(s). The Claimants shall be responsible for maintaining a current mailing address for Payee(s) with Liberty Life Assurance Company of Boston. 7.0 DISCHARGE OF OBLIGATION The obligation of the Assignee to make each Periodic Payment shall be discharged upon the mailing of a valid check in the amount of such payment to the designated address of the Payee(s) named in Section 2.2 of this Settlement Agreement. 8.0 REPRESENTATION OF COMPREHENSION OF DOCUMENT In entering into this Settlement Agreement, the Claimants represent that the terns of this Settlement Agreement have been completely read by Claimants; and 5 that the terms of this Settlement Agreement are fully understood and voluntarily accepted by Claimants. 6 9.0 WARRANTY OF CAPACITY TO EXECUTE AGREEMENT Claimants represent and warrant that no other person or entity has, or has had, any interest in the claims, demands, obligations, or causes of action referred to in this Settlement Agreement, except as otherwise set forth herein; that Claimants have the sole right and exclusive authority to execute this Settlement Agreement and receive the sums specified in it; and that Claimants have not sold, assigned, transferred, conveyed or otherwise disposed of any of the claims, demands, obligations or causes of action referred to in this Settlement Agreement. 10.0 CONFIDENTIALITY The parties agree that neither they, nor their attorneys, nor representatives shall reveal to anyone, other than as may be mutually agreed to in writing, any of the terms of this Settlement Agreement or any of the amounts, numbers or terms and conditions of any sums payable to Payee(s) hereunder. 11.0 GOVERNING LAW This Settlement Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. 12.0 ADDITIONAL DOCUMENTS All parties agree to cooperate fully and execute any and all supplementary documents and to take all additional actions that may be necessary or appropriate to give full force and effect to the basic terms and intent of this Settlement Agreement. 7 13.0 ENTIRE AGREEMENT AND SUCCESSORS IN INTEREST This Settlement Agreement contains the entire agreement between the Claimants and the Insurer with regard to the matters set forth in it and shall be binding upon and inure to the benefit of the executors, administrators, personal representatives, heirs, successors and assigns of each. 14.0 EFFECTIVENESS This Settlement Agreement shall become effective immediately following execution by each of the parties below and upon approval by a court having proper jurisdiction. CLAIMANTS INSURER West American Insurance Company By: By: j7 Christopher Cook, Individually and as Parent and Natural Guardian of Collin Cook, a minor Title: Date: 6 Date: CA ?? . ?r_,unty i ?A ? , Z 8 VERIFICATION I, Christopher Cook, as Parent and Natural Guardian of Joshua Cook, a minor, and Collin Cook, a minor, do hereby verify that t am the Petitioner in the above-captioned action and further verify that I have read the foregoing document and that it is true and correct to the best of our knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities. Date: Christopher ook, as Parent and Natural Guardian of Joshua Cook, a Minor and Collin Cook, a Minor Certificate of Service I, Stephanie L. Hersperger, Esquire, hereby verify that on the 21 st day of July 2009, I served the following with a true and correct copy of the Petition for Approval of Minors' Settlement, with service being made by the United States Postal Service, first class mail, postage pre-paid, and by certified, return receipt requested: Mr. Christopher Cook 424 Pawnee Drive Mechanicsburg, PA 17055 Ms. Lisa Tusveld Ringler Associates 110 Gilsum Mine Road Alstead, NH 03602 I verify that the statements made in this Certificate are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities. THOMAS, THOMAS & HAFER, LLP tenSt??IA hame L. Hersperger FiEQ -0, OF THE 200 JUL 22 PH 1: q- i PrI THOMAS, THOMAS & HAFER, LLP Stephanie L. Hersperger, Esquire I.D. No. 78735 P.O. Box 999 Harrisburg, PA 17108-0999 (717) 255-7617 Attorney for the Petitioner IN RE: JOSHUA COOK AND COLLIN COOK, minors IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA CHRISTOPHER COOK, as parent and natural guardian of JOSHUA COOK AND COLLIN COOK, minors, PETITIONER CIVIL ACTION - LAW NO. 2009-04812 AMENDMENT TO AMENDED PETITION FOR APPROVAL OF MINORS' SETTLEMENT No Judge has ever ruled upon this case or any other issue in the same or related matter. WHEREFORE, Petitioner respectfully requests that this Honorable Court enter an Order approving of the proposed settlement as to Minor-Petitioner, Joshua Cook, and Minor-Petitioner, Collin Cook. Respectfully submitted, THOMAS, THOMAS & HAFER, LLP A?i.' lez , - Steph ie L. Hersperger, Esquire I.D. Number: 78735 305 North Front Street, P.O. Box 999 Harrisburg, PA 17101 (717) 255-7239 Attorney for Petitioners Date: 7/28/09 A Certificate of Service I, Stephanie L. Hersperger, Esquire, hereby verify that on the 28th day of July 2009, 1 served the following with a true and correct copy of the foregoing, with service being made by the United States Postal Service, first class mail, postage pre-paid, and by certified, return receipt requested: Mr. Christopher Cook 424 Pawnee Drive Mechanicsburg, PA 17055 Ms. Lisa Tusveld Ringler Associates 110 Gilsum Mine Road Alstead, NH 03602 I verify that the statements made in this Certificate are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities. THOMAS, THOMAS & HAFER, LLP `L Step- L. Hersperger Fit L- MJ4. OF -M- 2 6 0 9 JUL 30 i'= !: 3 1 s t t , x_ •?( IN RE: JOSHUA COOK AND COLLIN COOK, minors CHRISTOPHER COOK, as parent and natural guardian of JOSHUA COOK AND COLLIN COOK, minors, PETITIONER JUL 2 3 2009 4 C? IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA CIVIL ACTION - LAW NO. 2009-04812 ORDER AND NOW, this 3 d day of emu,. 1-11 , 2009, upon consideration of the within Petition for Approval of the Settlements of Minors, Joshua Cook and Collin Cook, it is hereby ORDERED and DECREED that said Petition is GRANTED and settlement between Petitioner, Christopher Cook, Individually and as Parent and Natural Guardian of Minor, Joshua Cook, and Minor, Collin Cook, and the insurance company, is APPROVED as follows: (1) $1,000.00 will be paid directly to Christopher Cook, Individually, and as Parent and Natural Guardian of Minor, Joshua Cook; (2) $7,500.00 will be paid directly to Christopher Cook, Individually, and as Parent and Natural Guardian of Minor, Collin Cook; (3) West American Insurance Company, the insurer, is hereby directed to purchase an annuity through Liberty Life Assurance Company of Boston (the Annuity Issuer) in the amount of $41,500.00 [which includes any annuity fees], which will be payable to Collin Cook, beginning on October 8, 2015, in the amount of $4,345.28, semi-annually, for a period of 8 years, with the last guaranteed payment being due on April 8, 2023; and (4) The Petitioner is hereby directed to discontinue with prejudice the above- captioned matter. BY THE COURT: t ii_ - tyy? } 10 }} .F? -( sm?ctS c4a S1. H