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HomeMy WebLinkAbout09-4960IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA GERMAN, GALLAGHER & MURTAGH BY: Robert P. Corbin, Esquire Audrey Ziadat, Esquire IDENTIFICATION NOS. 17897/87163 THE BELLEVUE, FIFTH FLOOR 200 S. BROAD STREET PHILADELPHIA, PA 19102 (215) 545-7700 Attorneys for Defendants American Motorcycle Association, Inc., and Dutchmen MX Park, LLC. HUNTER GRIMES, a minor, by and through his parent and natural guardian, JENNIFER ICKES V. AMERICAN MOTORCYCLE ASSOCIATION, INC. AND DUTCHMEN MX PARK, LLC. COURT OF COMMON PLEAS OF CUMBERLAND COUNTY NO. U4- yq 4a ("- PETITION FOR LEAVE TO SETTLE OR COMPROMISE A MINORS' ACTION TO THE HONORABLE, THE JUDGES OF THE SAID COURT: The Petitioner Hunter Grimes, a minor by and through his legal guardian, Jennifer Ickes, by and through attorney's German, Gallagher & Murtagh, respectfully submit the following petition for Leave to Settle or Compromise a Minor's Action: 1. Petitioner is Jennifer Ickes, on behalf of minor, Hunter Grimes. 2. The minor was born on September 7, 1998 and his Social Security Number is 177-78-1093. 3. The minor resides with his mother Jennifer Ickes at 285 Shed Road, Newville, Pennsylvania 17241. 4. The minor's father Joseph Grimes resides at 110 West Ridge Street, Carlisle, PA 17013. 580260_1 5. This matter arises from a motor vehicle accident which occurred on April 6, 2008 at the Dutchmen MX Park located in Pine Grove, Pennsylvania. 6. At the time of the accident, minor Hunter Grimes, was a spectator at an ATV (all- terrain) race when the driver of an ATV lost control of the vehicle and struck the minor on the left ankle and left lower leg. 7. Minor Hunter Grimes was treated with a long leg cast which he wore for approximately five (5) weeks. He was then placed in a short leg case for another three weeks at which time the cast was removed. 8. Attached hereto is an initial evaluation prepared by Kristine L. Fortuna, MD, dated May 11, 2008, setting forth the minor's injury. See copy of Initial Evaluation attached hereto as Exhibit "A". 9. A final report by Kristine L. Fortuna, MD, dated November 23, 2008, sets forth the present condition of the minor Hunter Grimes. The report states that the minor's injury has resolved and that the minor presents with no complaints of pain, the minor can toe walk and heel walk without difficulty and the minor can continue with full activity. See copy of Final Report attached hereto as Exhibit "B". 10. Attached hereto is an Affidavit of the minor's parent/guardian Jennifer Ickes verifying the present physical condition of the minor Hunter Grimes as well as setting forth the parent/guardian's approval of the proposed settlement and distribution. See copy of Affidavit of Jennifer Ickes attached hereto as Exhibit "C". 11. Litigation has not been initiated in this matter. 12. ACE American Insurance Company, on behalf of their insured American Motorcycle Association, Inc. and Dutchmen MX Park, LLC., have offered to resolve petitioner's claim in the amount of $33,378.55. 5802601 13. In addition, ACE American Insurance Company retained the services of Audrey Ziadat, Esquire of German, Gallagher & Murtagh to complete this settlement and obtain Court approval without any expense to petitioner. 14. It is the professional opinion of Ms. Ziadat of German, Gallagher & Murtagh that the proposed settlement of $33,378.55 is fair and reasonable. See Counsel's Affidavit attached hereto as Exhibit "D". 15. The proposed structured settlement is funded through the purchase of an annuity contract from Allstate Life Insurance Company. See copy of the Settlement Agreement and Release and Uniform Qualified Assignment and Release Agreement attached hereto as Exhibit «E„ 16. For the reasons set forth above, petitioner believes that the proposed settlement of $33,378.55 is fair and reasonable and approves the proposed settlement set forth within the proposed Order attached to this petition. See Exhibit "C". 17. Counsel Audrey Ziadat of German, Gallagher & Murtagh :has incurred expenses in preparing and prosecuting this minors' compromise. However said expenses and any attorney fees shall not be deducted from petitioner's gross structured settlement proceeds. 18. The petitioner does not have counsel nor has the petitioner ever retained counsel for this matter. Petitioner was made aware of her right to retain counsel and have representation on behalf of the minor child, Hunter Grimes; however, petitioner declined representation and elected to personally represent the interests of the minor in resolving this matter. Petitioner understands the need for Court approval of this settlement and both sides have decided and agreed that Audrey Ziadat of German, Gallagher & Murtagh would take the lead in preparing and filing said petition. See Exhibit "C". 19. The following settlement agreement has been proposed: 580260_1 GROSS STRUCTURED SETTLEMENT: TO: Hunter Grimes, a minor $25,000.00 Under the Structured Settlement Release Agreement, Hunter Grimes is guaranteed a $15,000.00 lump sum payable on September 7, 2016 (18 years of age) and a $22,810.00 lump sum payable on September 7, 2019 (21 years of age). Payment is to be made only after the execution of the Settlement Agreement and Release and 20 days from the date of filing the Order to Settle, Discontinue and End. TO: Joseph Grimes (father of minor Hunter Grimes) $8,378.55 Reimbursement for medical expenses paid by Mr. Grimes" health insurance provider. Payment is to be made only after the execution of the Settlement Agreement and Release and 20 days from the date of filing the Order to Settle, Discontinue and End. 20. Joseph Grimes, father of minor Hunter Grimes, seeks reimbursement for medical expenses paid by Mr. Grime's health insurance provider in the amount of $8,378.55. See copy of Explanation of Benefits attached hereto as Exhibit "F" 21. Attached hereto is a notice from the health carrier reflecting a lien amount to date of $3,762.13. See copy of Lien Documentation attached hereto as Exhibit "G". 22. The Department of Welfare has no cash assistance lien in this matter. WHEREFORE, petitioner respectfully request that the Court enter the proposed Order of Structured Settlement. Date: lu-M Respectfully submitted, GERMAN/ GALLAGHER & MURTAGH BY: Audrey Zi dat Robert P. Clbc? Attorneys for American Motorcycle Association, lnc. and Dutchmen MX Park, LLC. 580260_1 CERTIFICATE OF SERVICE I, Audrey Ziadat, hereby certify that a true and correct copy of the Petition for Leave to Settle or Compromise a Minors' Action was furnished to all parties/persons listed below by United States First Class Mail, postage pre-paid on , 2009 and addressed as follows: Jennifer Ickes 285 Shed Road Newville, Pennsylvania 17241 Minor's mother Joseph Grimes 110 West Ridge Street Carlisle, Pennsylvania 17013 Minor's father GERMAN GALLAGHER & MURTAGH BY: T drey Z Robert P. adatin Attorneys for American Motorcycle Association, Inc. and Dutchmen MX Park, LLC. 580260_1 EXHIBIT "A" 11 lton . Hershey Medical Center College of ill aane Patient Name: GRIMES, HUNTER D PSUHMC MRN: 1039781 O u t p a t i e n t N o t e D o c u m e n t Final Document Electronically Signed by: Fortuna, Kristine L 5/11/2008 2:45:47 PM OUTPATIENT NOTE Name: GRIMES, HUNTER D HMC Number: 1039781 DOB: 09/07/1998 Date of Service: 04/09/2008 Here for initial evaluation on 4/9/2008 for a left ankle injury. HISTORY OF PRESENT ILLNESS: He is a 9-year-old male who injured his left ankle. He was a bystander watching four wheelers and was actually run over by a four-wheeler. Due to all this deformity and pain in the lower extremity once in the emergency room where he underwent casting. He is allergic to peas, milk, corn, green beans, seafood, peanuts. MEDICATIONS: Prevacid. SOCIAL HISTORY: His family lives in Newville, PA. PHYSICAL EXAM: In general, he is well nourished. He is no acute distress. He is awake, alert, cooperative with exam. His splint overall is in good repair. The cast had been bivalved, so we reinforced the cast. Today I did x-rays. X-ray showed a distal tib-fib fracture with some lateral translation, approximately 0.5-cm shortening. On the lateral view, it seems to be well aligned. If anything, the distal fragment is a bit extended and is a bit anteriorly angulated. ASSESSMENT: Left distal tib-fib fracture. PLAN: We are going to treat this closed for now. We will see him back in one week. We will get new x-rays AP and lateral views of his left ankle prior to being seen. In the meantime, he is to remain nonweightbearing. Date Printed: 111312009 lime Printed: 6.55" EXHIBIT "B" t N01ton & fkm4pVVV Medical ? r College of Wl1ane Patient Name: GRIMES, HUNTER D PSUHMC MRN: 1039781 1 O u t p a t i e n t N o t e D o c u m e n t Final Document Electronically Signed by: Fortuna, Kristine L 11/23/2008 8:52:34 PM OUTPATIENT NOTE Name: GRIMES, HUNTER D HMC Number: 1039781 DOB: 09/07/1998 Date of Service: 11/12/2008 Here for followup evaluation for left distal tib-fib fracture. He is without complaints today. He has full plantar flexion, dorsiflexion, inversion, eversion. He can toe walk and heel walk without any difficulty. No tenderness with palpation. X-rays were reviewed and showed excellent beginning to remodeling. No signs of growth disturbances. Growth arrest line is nice and parallel to the growth plate. ASSESSMENT: Left distal fib-fib fracture. Plan is to see him back only on a p.r.n. basis. He can continue with full activity. 289108 Review/Sign: Fortuna, Kristine L, MD KLF /CO DD: 11/12/08 DT: 11/13/08 02:58 Date Printed: 111312009 7-um Printed: 6`41 AM EXHIBIT "C" 07/14/2009 01:18 FAX 7172457369 SYNTEC R&D DEPT AFFIDAVIT OF PETITIONER COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND I, Jennifer Ickes, being duly sworn according to law, deposes and says that I am the parent and natural guardian of Hunter Grimes, a minor, and that the minor is not presently suffering from any mental or physical condition as a result of the injury lie sustained from a motor vehicle accident involving an ATV arising on April 6, 2008. The minor is presently a healthy, active boy and appears to have made a complete recovery from the injury he sustained. Furthermore, I attest to the fact that I voluntarily choose not to obtain representation in this matter and the minor does not have counsel nor has the minor ever retained counsel for the Q001 subject incident. I am aware that Court approval is required to settle or compromise this action. I understand that Audrey Ziadat, Esquire of German, Gallagher & Murtagh represents American Motorcycle Association, Inc and Dutchmen MX Park, LLC and their interests in this action and that I have consented to Ms. Ziadat preparing and filing the within petition. I attest that I have reviewed the proposed distribution and request Court approval of same. I believe that the proposed distribution is fair, reasonable and adequate compensation for the injury and expenses incurred by my minor son, Hunter Grimes. I hereby verify that the statements made in the foregoing Petition to Settle or Compromise the Minors' Action are true and correct to the best of my knowledge, information and belief. I further understand that the statements in said Petition are made subject to the penalties of 18 § C.S.A. 4904 relating to unsworn falsification to the ho es. SWORN TO AND SUBCRIBED JE FER ICKES BEFORE ME" S DAY OF 21009. C 5802601 COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL DARCIE A. NEIL, Notary Public Boro of Carlisle, Cumberland Counti My Commission Expires Nov. 24, 2009 EXHIBIT "D" GERMAN, GALLAGHER & MURTAGH BY: Robert P. Corbin, Esquire Audrey Ziadat, Esquire IDENTIFICATION NOS. 17897/87163 THE BELLEVUE, FIFTH FLOOR 200 S. BROAD STREET PHILADELPHIA, PA 19102 (215) 545-7700 Attorneys for Defendants American Motorcycle Association, Inc., and Dutchmen MX Park, LLC. HUNTER GRIMES, a minor, by and through his parent and natural guardian, JENNIFER ICKES V. AMERICAN MOTORCYCLE ASSOCIATION, INC. AND DUTCHMEN MX PARK, LLC. : NO. VERIFICATION OF COUNSEL ATTESTING TO REASONABLENESS AND FAIRNESS OF SETTLEMENT BETWEEN THE PARTIES AND ALLOCATION OF SETTLEMENT PROCEEDS Audrey Ziadat, Esquire hereby verifies the following: 1. The parties reached a proposed settlement in the amount of $33,378.55. 2. The parties entered into their proposed settlement agreement prior to any involvement of counsel and any litigation. Counsel believes the proposed structured settlement is reasonable and fair. 4. Counsel on behalf of petitioner is not receiving any proceeds of the structured settlement proceeds. Rather counsel is receiving payment of its costs and fees from the defendants' insurance company. Therefore, counsel does not seek any fees from the proposed settlement proceeds associated with the filing of this petition. COURT OF COMMON PLEAS OF CUMBERLAND COUNTY 580260_1 I hereby verify that the facts in the foregoing petition are true and correct to the best of my information, knowledge and belief. I understand that this statement is made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unworn falsification to authorities. GALLAGHER & MURTAGH BY: Robert P. `Cabin Attorneys for American Motorcycle Association, Inc. and Dutchmen MX Park, LLC. Date: '- 6C? 5802601 EXHIBIT "E" SE'i ELEMENT AGREEMENT AND REjujEASE This Settlement Agreement and Release (the "Settlement Agreement") is made and entered into this day of , 2009, by and between: "Claimant" Hunter Grimes, a minor, by his mother and natural guardian, Jennifer Ickes "Defendants" American Motorcycle Association, Inc. and Dutchmen MX Park, LLC "Insurer" ACE American Insurance Company RECITALS A. Claimant made a claim against Defendants which arose out of certain alleged negligent acts or omissions by Defendants. Claimant sought to recover monetary damages as a result of that certain occurrence on or about April 6, 2008 which resulted in physical and personal injuries to Claimant. B. Insurer is the liability insurer of the Defendants, and as such, would be obligated to pay any claim made or judgement obtained against Defendants which is covered by its policy with Defendants. 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 are, or might have been, the subject matter of the claim, upon the terms and conditions set forth below. AGREEMENT The parties agree as follows: 1.0 Release and Discharge 1 In consideration of the payments set forth in Section 2, Claimant hereby completely releases and forever discharges Defendants and Insurer from any and all past, present and 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 Claimant now has, or which may hereafter accrue or otherwise be acquired, on account of, or may in any way grow out of, or which are the subject of the claim including, without limitation, any and all known or unknown claims for bodily and personal injuries to Claimant, or any future wrongful death claim of Claimant's representatives or heirs, which have resulted or may result from the alleged acts or omissions of the Defendants. 1.2 This release and discharge shall also apply to Defendants' and 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 Claimant shall be a fully binding and complete settlement among the Claimant, the Defendants and the Insurer, and their heirs, assigns and successors. 1.4 The Claimant acknowledges and agrees that the release and discharge set forth above is a general release. Claimant expressly waives and assumes the risk of any and all claims for damages which exist as of his date, but of which the Claimant does not know or suspect to exist, whether through ignorance, oversight, error, negligence, or otherwise, and which, if known, would materially affect Claimant's decision to enter into this Settlement Agreement. The Claimant further agrees that Claimant has accepted payment of the sums specified herein as a complete compromise of matters involving disputed issues of law and fact. Claimant assumes the risk that the facts or law may be other than Claimant believes. It is understood and agreed to by the parties that this settlement is a compromise of a doubtful and disputed claim, and the payments are not to be construed as an admission of liability on the part of the Defendants, by whom liability is expressly denied. 2.0 Payments In consideration of the release set forth above, the Insurer on behalf of the Defendants agrees to pay the sums outlined below: 2.1 Payments due at the time of settlement as follows: Cash at settlement is the amount of $ payable to 2.2 Periodic payments payable to Hunter Grimes (Payee) made according to the schedule as follows (the "Periodic Payments"): $15,000.00 guaranteed lump sum payable on September 7, 2016. $22,810.00 guaranteed lump sum payable on September 7, 2019. All sums set forth herein constitute damages on account of personal physical injuries or sickness, within the meaning of Section 104 (a) (2) of the Internal Revenue Code of 1986, as amended. 2 3.0 Claimant's Rights of Payments Claimant acknowledges that the Periodic Payments cannot be accelerated, deferred, increased or decreased by the Claimant or any Payee; nor shall the Claimant or Payee have the power to sell, mortgage, encumber, or anticipate the Periodic Payments, or any part thereof, by assignment or otherwise. 4.0 Claimant's Beneficiary Any payments to be made after the death of Hunter Grimes pursuant to the terms of this Settlement Agreement shall be made to the Estate of Hunter Grimes, unless otherwise Court ordered, until the age of majority. Upon reaching the age of majority, Hunter Grimes may designate any such person or entity as beneficiary in writing to the Insurer or the Insurer's Assignee. If no such person or entity is so designated by Payee, or if the person designated is not living at the time of the Payee's death, such payments shall be made to the Estate of the Payee. No such designation, nor any revocation thereof, shall be effective unless it is in writing 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 Claimant acknowledges and agrees that the Defendants andlor Insurer may make a "qualified assignment" ; within the meaning of Section 130 (c) of the Internal Revenue Code of 1986, as amended, of the Defendants' and/or Insurer's liability to make the Periodic Payments set forth in Section 2.2 to Allstate Assignment Company (the "Assignee"). The Assignee's obligation for payment of the Periodic Payments shall be no greater than that of Defendants and/or Insurer (whether by judgment or agreement) immediately preceding the assignment of the Periodic Payments obligation. 5.2 Any such assignment, if made, shall be accepted by the Claimant without right of rejection and shall completely release and discharge the Defendants and the Insurer from the Periodic Payments obligation assigned to the Assignee. The Claimant recognizes 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 pertain to the liability of the Defendants and the Insurer shall thereupon become final, irrevocable and absolute. 6.0 Right to Purchase an Annuity The Defendants and/or the Insurer, itself or through its Assignee reserves the right to fund the liability to make the Periodic Payments outlined in Section 2.2 through the purchase of an annuity policy from Allstate Life Insurance Company (the "Annuity Issuer"). The Defendants, the Insurer or the Assignee shall be the sole owner of the annuity policy and shall have all rights of ownership. The Defendants, the Insurer, or the Assignee may have Annuity Issuer mail payments directly to the Payee. The Claimant shall be responsible for maintaining a current mailing address for the Payee with the Assignee. 7.0 Discharge of Obligation The obligation of the Defendants, the Insurer and/or 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 named in Section 2.2 of this Settlement Agreement. 8.0 Representation of Comprehension of Document In entering into this Settlement Agreement, the Claimant represents that the terms of this Settlement Agreement have been completely read and explained to Claimant by his/her representatives; and the terms of the Settlement Agreement are fully understood and voluntarily accepted by Claimant. 9.0 Warranty of Capacity to Execute Agreement Claimant represents 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 Claimant has the sole right and exclusive authority to execute this Settlement Agreement and receive the sums specified in it; and that Claimant has 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 hereunder. 4 11.0 Governing Law This Settlement Agreement shall be construed and interpreted in accordance with the laws of the State 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, which may be necessary or appropriate to give full force and effect to the basic terms and intent of this Settlement Agreement. 13.0 Entire Agreement and Successors in Interest This Settlement Agreement contains the entire agreement between the Claimant, the Defendants 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. . Claimant By: Date: Insurer By: Date: 5 Uniform Qualified Assignment and Release "Claimant" "Assignor" "Assignee" "Annuity Issuer" "Effective Date" Hunter Grimes ACE American Insurance Company Allstate Assignment Company Allstate Life Insurance Company This Agreement is made and entered into by and between the 3. parties hereto as of the Effective Date with reference to the following facts: A. Claimant has executed a Settlement Agreement or Release dated , 2009 (the "Settlement Agreement") that provides for the Assignor to make certain periodic payments to or for the benefit of the Claimant as stated in Addendum No. 1 (the "Periodic Payments"); and The Assignee's liability to make the Periodic Payments is no greater than that of the Assignor immediately preceding this Agreement. Assignee is not required to set aside specific assets to secure the Periodic Payments. The Claimant has no rights against the Assignee greater than a general creditor. None of the Periodic Payments may be accelerated, deferred, increased or decreased and may not be anticipated, sold, assigned or encumbered. 4. The obligation assumed by Assignee with respect to B. The parties desire to effect a "qualified assignment" within any required payment shall be discharged upon the the meaning and subject to the conditions of Section mailing on or before the due date of a valid check in 130(c) of the Internal Revenue Code of 1986 (the "Code"). the amount specified to the address of record. NOW, THEREFORE, in consideration of the foregoing and other good and valuable consideration, the parties agree as follows: 1. The Assignor hereby assigns and the Assignee hereby assumes all of the Assignor's liability to make the Periodic Payments. The Assignee assumes no liability to make any payment not specified in Addendum No. 1. 2. The Periodic Payments constitute damages on account of personal injury or sickness in a case involving physical injury or physical sickness within the meaning of Section 104(a)(2) and 130(c) of the Code. 5. This Agreement shall be governed by and interpreted in accordance with the laws of the State of Nebraska. 6. The Assignee may fund the Periodic Payments by purchasing a "qualified funding asset" within the meaning of Section 130(d) of the Code in the form of an annuity contract issued by the Annuity Issuer. All rights of ownership and control of such annuity contract shall be and remain vested in the Assignee exclusively. The Assignee may have the Annuity Issuer send payments under any "qualified funding asset" purchased hereunder directly to the payee(s) specked in Addendum No. 1. Such direction of payments shall be solely for the Assignee's convenience and shall not provide the Claimant or any payee with any rights of ownership or control over the "qualified funding asset" or against the Annuity issuer. Printed in USA UQAR ED. 488 8. Assignee's liability to make the Periodic Payments shall 10 continue without diminution regardless of any bankruptcy or insolvency of the Assignor. 9. In the event the Settlement Agreement is declared terminated by a court of law or in the event that Section 130(c) of the Code has not been satisfied, this Agreement shall terminate. The Assignee shall then assign ownership of any "qualified funding asset" purchased hereunder to Assignor, and Assignee's liability for the Periodic Payments shall terminate. Assignor: ACE American Insurance Company By: Authorized Representative Title Claimant: Hunter Grimes On behalf of Claimant, a minor This Agreement shall be binding upon the respective representatives, heirs, successors and assigns of the Claimant, the Assignor and the Assignee and upon any person or entity that may assert any right hereunder or to any of the Periodic Payments. 11. The Claimant hereby accepts Assignee's assumption of all liability for the Periodic Payments and hereby releases the Assignor from all liability for the Periodic Payments. Assignee: Allstate Assignment Company By: Authorized Representative Title ]National Structured NS S 1.l A Settlements 'Trade Association Printed in USA UQAR ED. 488 Addendum No. 1 Description of Periodic Payments Periodic Payments Payable to Hunter Grimes: $15,000.00 guaranteed lump sum payable on September 7, 2016. $22,810.00 guaranteed lump sum payable on September 7, 2019. Beneficiary Designation: Any payments to be made after the death of Hunter Grimes pursuant to the terms of this Agreement shall be made to the Estate of Hunter Grimes, unless otherwise Court ordered, until the age of majority. Upon reaching the age of majority, Hunter Grimes may designate any such person or entity as beneficiary in writing to the Assignee. If no such person or entity is so designated by Payee, or if the person designated is not living at the time of the Payee's death, such payments shall be made to the Estate of the Payee. No such designation, nor any revocation thereof, shall be effective unless it is in writing and delivered to the Assignee. The designation must be in a form acceptable to the Assignee before such payments are made. Initials Claimant: Assignor: Assignee: On behalf of Hunter Grimes ACE American Insurance Company Allstate Assignment Company Printed in USA UQAR ED. 4-88 EXHIBIT "F" rage -i Ur z. I Ilk NealthAssurance Pennsylvania 3721 TecPort Dr P.O. Box 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insured: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RENT ID Number: 85140906104 Date: 04/06/2008 THIS IS NOT A BILL EXPLANATIQN OF I i f IT Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. made at the time services were rendered are not reflected on this statement.*" Claim Number: Plan Paid: Member Responsibility: 1811931788 $ 335.42 $ 0.00 Provider: MINNICH,KATHLEEN Provider Billing Address: 3632 HILL CHURCH RD LEBANON,PA 17046 from phvsical office location' Service Date From - To Procedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Remarks Amount Adjustment Amount Copav Coins Deduct Other Plan Paid 04/06/2008 - 04106/2008 $550.00 $411.14 $138.86 $0.00 $0.00 .$13.00 $0.00 $138.86 213 A0429 / AMBULANCE SERVICES 04/0612008 - 04106/2008 $780.00 $583.44 $196.56 $0.00 $0.00 $0.00 $0.00 $196.56 213 A0425 /AMBULANCE SERVICES Totals: $1,330.00 $994.58 $335.42 $0.00 $0.00 $0.00 $0.00 $335.42 Contractual Remarks: 213 -$ ABOVE CONTRACTUAL ALLOWANCE To ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. If you believe any of the services were incorrectly billed, contact a customer service representative using the toll free number listed on your insurance card. Complaint and Appeals Procedures: A covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to appeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit Plan Document for further details regarding your right to dispute a denied claim. Pagel of 2 HealthAssurance Pennsylvania 3721 TecPort Dr P.O. Box 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insur yd: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RE/T ID Number: 85140906104 Date: 04/06/2008 THIS IS NOT A BILL EXPLANATION OF, BENEFITS. Our organization processes and pays the claims submitted from your heatti i care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. "Payments made at the time services were rendered are not reflected on this statement.'" [aim Number: 2810511394 Provider: MILTON S HERSHEY MEDICAL CENTER PHYSICIANS Ian Paid: $ 0.00 Provider Billing Address: PO BOX 858 lember MCA410 esponsibility: $ 23.16 HERSHEY,PA 17033-0858 Provider billing address may differ from physical office location"* rvice Date From - To rocedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adiustment Amount Copay Coins Deduct Other Plan Paid Remarks (06/2008 - 04/06/2008 $62.00 $50.42 $11.58 $0.00 $0.00 $11.58 $0.00 $0.00 213/ 3610 / RADIOLOGY (06/2008 - 04/06/2008 $62.00 $50.42 $11.58 $0.00 $0.00 $11.58 $0.00 $0.00 213/ 3590 / RADIOLOGY ` Totals: $124.00 $100.84 $23.16 $0.00 $0.00 $23.16 $0.00 $0.00 :ontractual Remarks: A3 -$ ABOVE CONTRACTUAL ALLOWANCE to ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. f you believe any of the services were incorrectly billed, contact a customer service representative using the toll free lumber listed on your insurance card. :omplaint and Appeals Procedures: k covered Individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to appeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit 'Ian Document for further details regarding your right to dispute a denied claim. Page 2 of 2 THIS IS NOT A BILL. The amounts below include claims processed as of April 06, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars t `iliti ?hg c ?? ?, Out of Pocket Dollars Ye'Dateh, ait1 ax' Rniri IN NETWORK-individual $ 250.00 $ 250.00 $ 0.00 $ 0.0 $ 0.00 $ 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.00 $ 0.00 $ 0.00 OUT OF NETWORK-individual $ 0.00 $ 500.00 $ 500.00 $ 0.00 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.00 $ 10,500.00 $ 10,500.00 Page 1 of 2 HealthAssurance Pennsylvania 7- 3721 TecPort Dr P.O. Box 671 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insure4d: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RENT ID Number: 85140906104 Date: 04/06/2008 THIS IS NOT A BILL EXPLANATIO,IV_ O'KbtNEFITS Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining hove your claim(s), including payments or denials, are being processed. *"Payments made at the time services were rendered are not reflected on this statement." aim Number: 2810511396 Provider: MILTON S HERSHEY MEDICAL CENTER PHYSICIANS an Paid: $ 0.00 Provider Billing Address: PO BOX 858 amber MCA410 ssponsibility $ 11.58 HERSHEY,PA 17033-0858 Provider billing address may differ from physical office location" vice Date From - To )cedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adjustment Amount Copay Coins Deduct Other Plan Paid Remarks 16/2008 - 04/06/2008 $62.00 $50.42 $11.58 $0.00 $0.00 $11.58 $0.00 $0.00 _ 2131 i60 / RADIOLOGY Totals: $62.00 $50.42 $11.58 $0.00 $0.00 $11.58 $0.00 $0.00 >ntractual Remarks: 3 -$ ABOVE CONTRACTUAL ALLOWANCE D ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. you believe any of the services were incorrectly billed, contact a customer service representative using the toll free .Imber listed on your insurance card. )mplaint and Appeals Procedures: covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If yo, %Mish to jpeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Healti 1 Benefit an Document for further details regarding your right to dispute a denied claim. THIS IS NOT A BILL The amounts below include claims processed as of April 06, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars ?. a (ear T atet IUIIa Win 'a?nirg: t Yea`s 0" Ma m Ften?ainln .a;.Satisfied_. .. .00 NlNETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0.0 0.00$ 0 $ N NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.0 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.0 $ 3,500.00 $ 3,500.OC OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.00 $ 10,500.00 $ 10,500.0( Page 1 of 2 Payments made on behalf of: HEALTHASSURANCE HASPA Insurild: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & REfT ID Number: 85140906104 Date: 04/06/2008 HealthAssurance Pennsylvania 3721 TecPort Dr P.O. Box 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 THIS IS NOT A BILL EXPLANATION OF BENEFITcl Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. "Payments made at the time services were rendered are not reflected on this statement.*" Nairn Number: 2810511399 Provider: MILTON S HERSHEY MEDICAL CENTER PHYSICIANS 31an Paid: $ 0.00 Provider Billing Address: PO BOX 858 Aember MCA410 tesponsibility: $ 91,58 HERSHEY,PA 17033-0858 mvice Date From - To differ from 'rocedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adiustment Amount Copay Coins Deduct Other Plan Paid Remarks 1/06/2008 - 04/06/2008 $62.00 $50.42 $11.58 $0.00 $0.00 $11.58 $0.00 $0.00 m 2131 3610/RADIOLOGY Totals: $62.00 $50.42 $11.58 $0.00 $0.00 $11.58 $0.00 $0.00 Contractual Remarks: 213 -$ ABOVE CONTRACTUAL ALLOWANCE To ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. If you believe any of the services were incorrectly billed, contact a customer service representative using the toll free number listed on your insurance card. Complaint and Appeals Procedures: A covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If yoij wish to appeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit Plan Document for further details regarding your right to dispute a denied claim. Page 2 of 2 THIS IS NOT A BILL The amounts below include claims processed as of April 06, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars > `? ry ie y6ar To Dater Satisfld, Alfa Iiiu ii ? m „ $_ R6rimainin ; Yeah -To-Da fe -Satisfied ximum Re! nainin9 IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0.0 $ 0.00 $ 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.0 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.00 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.0 $ 10,500.00 $ 10,500.00 Page 1 of 2 HealthAssurance Pennsylvania 3721 TecPort Dr P.O. Box ox 671 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insurld: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RE/T ID Number: 85140906104 Date: 04/06/2008 THIS IS NOT A BILL EXOLANATION OF' BENEFITS Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. **Payments made at the time services were rendered are not reflected on this statement" :laim Number: 2810710708 Provider: MILTON S HERSHEY MEDICAL CENTER PHYSICIANS Ilan Paid: $ 154.76 Provider Billing Address: PO BOX 858 MCA410 lember HERSHEY,PA 17033-0858 'esponsibility: $ 0.00 ** Provider billing address may differ from physical office location" !rvice Date From - To rocedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adiustment Amount Copay Coins Deduct Other Plan Paid Remarks 106/2008 - 04106/2008 $269.00 $114.24 $154.76 $0.00 $0.00 $0.00 $0.00 $154.76 213/ )284 / MEDICAL Totals: $269.00 $114.24 $154.76 $0.00 $0.00 $0.00 $0.00 $154.76 :ontractual Remarks: ` '.13 -$ ABOVE CONTRACTUAL ALLOWANCE To ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. If you believe any of the services were incorrectly billed, contact a customer service representative using the toll free number listed on your insurance card. 'omplaint and Appeals Procedures: `? covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to tppeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit 'lan Document for further details regarding your right to dispute a denied claim. Page 2 of 2 THIS IS NOT A BILL The amounts below include claims processed as of April 06, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars x- ype 3 Year-To-Date' Satisfied imurt r :? xW f2iiiri?rig $ Year l? Datb Satisti, Mast lnum $ IZ, maining $.. IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0.0 $ 0.00 $ 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.00 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.00 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.00 $ 10,500.00 $ 10,500.00 Page 1 of ? HealthAssurance Pennsylvania 3721 TecPort Dr P.O. Box 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insured: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RE/T ID Number: 85140906104 Date: 04/06/2008 THIS IS NOT A BILL, EXPLANATIft OI, Bb4tFIT a Our organization processes and pays the claims submitted from your healLli care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining ho,,-.j your claim(s), including payments or denials, are being processed. "Payments made at the time services were rendered are not reflected on this statement." Nalm Number: 2810712318 Provider: MILTON S HERSHEY MEDICAL CENTER PHYSICIANS Ilan Paid: $ 11.58 Provider Billing Address: PO BOX 858 MCA410 //ember HERSHEY,PA 17033-0858 2esponsibility: $0.00 Provider billing address may differ from physical office location" nrvice Date From - To Irocedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adjustment Amount Copay Coins Deduct Other Plan Paid Remarks 1/06/2008 - 04/06/2008 $62.00 $50.42 $11.58 $0.00 $0.00 $0.00 $0.00 $11.58 2131 3590 / RADIOLOGY Totals: $62.00 $50.42 $11.58 $0.00 $0.00 $0.00 $0.00 $11.58 'ontractual Remarks: 213 -$ ABOVE CONTRACTUAL ALLOWANCE To ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. If you believe any of the services were incorrectly billed, contact a customer service representative using the toll free number listed on your insurance card. Complaint and Appeals Procedures: 4 covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to appeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit Plan Document for further details regarding your right to dispute a denied claim Page 2 of 2 THIS IS NOT A BILL. The amounts below include claims processed as of April 06, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars i e fear'I°c1b ie Maxiinurri: - I2eina???irg; ^ ?(eaf-Td-Date ?` a I m Remaining f mSatisfled SAiffac IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0.0 $ 0.00 $ 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.0 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.0 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.0 $ 10,500.00 $ 10,500.00 Page 1 of 3 Payments made on behalf of: HEALTHASSURANCE HASPA Insurgd: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RENT ID Number: 85140906104 Date: 04/06/2008 HealthAssurance Pennsylvania 3721 TecPort Dr P.O. Box 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE-PA 17013 THIS IS NOT A BILL EXPLANATION OF BENEFITS Our organization processes and pays the claims submitted from your heallli care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. "Payments made at the time services were rendered are not reflected on this statement.*" [aim Number: 2810720351 Provider: MS HERSHEY MEDICAL CENTER Ian Paid: $ 2,333.69 Provider Billing Address: PO BOX 856 lember HERSHEY,PA 17033-0856 esponsibility: $ 100.00 Provider billing address may differ from physical office location" rvice Date From - To ° .?.? •ocedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adjustment Amount Copay Coins Deduct Other Plan Paid_ Remarks '06/2008 - 04/06/2008 $50.20 $18.83 $31.37 $31.37 $0.00 $0.00 $0.00 $0.00 2041 250 / PRESCRIPTIONS '07/2008 - 04/07/2008 $3.00 $1.13 $1.87 $1.87 $0.00 $0.00 $0.00 $0.00 204/ 250 / PRESCRIPTIONS ` '06/2008 - 04/06/2008 $6.00 $2.25 $3.75 $3.75 $0.00 $0.00 $0.00 $0.00 2041 258 / INJECT-THERAPUT/DIAG '07/2008 - 04/0712008 $6.00 $2.25 $3.75 $3.75 $0.00 $0.00 $0.00 $0.00 2041 258 / INJECT-THERAPUT/DIAG '06/2008 - 04/06/2008 $61.00 $22.88 $38.12 $38.12 $0.00 $0.00 $0.00 $0.00 2041 260 / INJECT-THERAPUT/DIAG '06/2008 - 04/06/2008 $55.00 $20.63 $34.37 $21.14 $0.00 $0.00 $0.00 $13.23. 2041 270 / HOSPITAL OUTPATIENT '07/2008 - 04/0712008 $36.00 $13.50 $22.50 $0.00 $0.00 $0.00 $0.00 $22.50~ 204/ 270 / HOSPITAL OUTPATIENT fO6/2008 - 04/06/2008 $19.00 $14.35 $4.65 $0.00 $0.00 $0.00 $0.00 $4.65 2131 A15 / LAB/PATHOLOGY 106/2008 - 04/06/2008 $154.00 $57.75 $96.25 $0.00 $0.00 $0.00 $0.00 $96.25 _ 204/ 1560 / RADIOLOGY '06/2008 - 04/06/2008 $151.00 $56.63 $94.37 $0.00 $0.00 $0.00 $0.00 $94.37 2041 Page 2 of 3 THIS IS NOT A BILL 590 F RADIOLOGY 06/2008 - 04/06/2008 $151.00 $56.63 $94.37 $0.00 $0.00 $0.00 $0.00 $94.37 2041 590 / RADIOLOGY 06/2008 - 04/06/2008 $141.00 $52.88 $88.12 $0.00 $0.00 $0.00 $0.00 $88.12 2041 610/RADIOLOGY 06/2008 - 04/06/2008 $141.00 $52.88 $88.12 $0.00 $0.00 $0.00 $0.00 $88.12 2041 610 / RADIOLOGY 06/2008 - 0410612008 $110.00 $41.25 $68.75 $0.00 $0.00 $0.00 $0.00 $68.75 2041 170/ANESTHESIA 06/2008 - 04106/2008 $782.00 $293.25 $488.75 $0.00 $0.00 $0.00 $0.00 $488.75 2041 150 / HOSPITAL OUTPATIENT 06/2008 - 04/06/2008 $647.00 $242.63 $404.37 $0.00 $0.00 $0.00 $0.00 $404.3 7 2041 150 / HOSPITAL OUTPATIENT 0612008 - 4/06/2008 $5.35 $2.01 $3.34 $0.00 $0.00 $0.00 $0.00 $3.34 2041 250 / INJECT-THERAPUT/DIAG 06/2008 - 04/06/2008 $6.00 $2.25 $3.75 $0.00 $0.00 $0.00 $0.00 $3.75 2041 270 / PRESCRIPTIONS 07/2008 - 04/07/2008 $3.00 $1.13 $1.87 $0.00 $0.00 $0.00 $0.00 $1.117 2041 270 / PRESCRIPTIONS 0712008 - 04/07/2008 $1,378.00 $516.75 $861.25 $0.00 $0.00 $0.00 $0.00 $861-`5 2041 '621 HOSPITAL OUTPATIENT Totals: $3,905.55 $1,471.86 $2,433.69 $100.00 $0.00 $0.00 $0.00 $2,333.5=? ontractual Remarks: 04 -$ ABOVE DISCOUNT% 13 -$ ABOVE CONTRACTUAL ALLOWANCE -o ensure that your health plan was prope rly billed, pl ease review the services listed on your explanation of beneiil:,. f you believe any of the services were incorrectly billed, contact a customer service representative using the toll fi cle lumber listed on your insurance card. :omplaint and Appeals Procedures: covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to ppeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit 'Ian Document for further details regarding your right to dispute a denied claim. Page 3 of 3 THIS IS NOT A BILL The amounts below include claims processed as of April 06, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars `?'? z:7ype ? d i '?ea a? f ? Rema?hing Year=??a ' E?1 8ximurri ??°ntaini a, wf, id,? S ?$_' Satisfi Y S IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0.0 $ 0.00 $ 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.0 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.00 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.0 $ 10,500.00 $ 10,500.00 Page 1 of 2 HealthAssurance Pennsylvania 3721 TecPort P.O. Box ox 671 67103 3 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insurgd: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RENT ID Number: 85140906104 Date: 11/12/2008 THIS IS NOT A BILE. EXPL WATT "WOF ElEkt IT a Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. made at the time services were rendered are not reflected on this statement.** [aim Number: 8832427847 Provider: MS HERSHEY MEDICAL CENTER an Paid: $ 82.66 Provider Billing Address: PO BOX 856 ember HERSHEY,PA 17033-0856 zsponsibility: $ 0.00 ** Provider billing address may differ from ahysical office location** mice Date From - To ocedure CodeMescription Billed Contractual Approved Member's Resnonsibility to Provider Amount Adjustment Amount Copay Coins Deduct Other Plan Pais! Remarks 12/2008 - 11/12/2008 $131.00 $48.34 $82.66 $0.00 $0.00 $0.00 $0.00 $82.66 2041 600 / RADIOLOGY Totals: $131.00 $48.34 $82.66 $0.00 $0.00 $0.00 $0.00 $82.66 ontractual Remarks: 04 -$ ABOVE DISCOUNT% -o ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. f you believe any of the services were incorrectly billed, contact a customer service representative using the toll free lumber listed on your insurance card. :omplaint and Appeals Procedures: , covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to ppeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit 'Ian Document for further details regarding your right to dispute a denied claim. Page 2 of 2 THIS IS NOT A BILL. The amounts below include claims processed as of November 12, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars iDut of Pocket Dollars u pb rM? lam ate f `a?o=D a fiximum r. ts ?.?, ??: a pjng Yeaho-©a?e g 4 aka Miur } ?: x Refna?ni?n- ,.. S#ie_d? s?_ .Sai5fi d.r?4 ?.O.r. kR $ IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0.0 $ 0.00 $ 0.00 IN NETWORK-Family $ 343.02 $ 750.00 $ 406.98 $ 0. $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.0 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.00 $ 10,500.00 $ '10,500.00 Page 1 of 2 HealthAssurance Pennsylvania 3721 TecPorl Dr P.O. Box 671 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA InsurV& GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RENT ID Number: 85140906104 Date: 11/12/2008 THIS IS NOT A BILL EXPLANATION & BENEFIT? Our organization processes and pays the claims submitted from your heaiLh care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. **Payments made at the time services were rendered are not reflected on this statement.** 1aim Number: 8832644528 Provider: MILTON S HERSHEY MEDICAL CENTER PHYSICIANS Ian Paid: $ 11.56 Provider Billing Address: PO BOX 858 lember MCA410 :esponsibility: $0.00 HERSHEY,PA 17033-0858 ** Provider billing address may differ from physical office location** rvice Date From - To rocedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adjustment Amount Copay Coins Deduct Other Plan Paid Remarks /12/2008 - 11/12/2008 $61.00 $49.44 $11.56 $0.00 $0.00 $0.00 $0.00 $11.56T 2131 3600/RADIOLOGY Totals: $61.00 $49.44 $11.56 $0.00 $0.00 $0.00 $0.00 $11.56 :ontractual Remarks: !13 -$ ABOVE CONTRACTUAL ALLOWANCE To ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. If you believe any of the services were incorrectly billed, contact a customer service representative using the toll free lumber listed on your insurance card. :omplaint and Appeals Procedures: % covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to ippeal a denial decision, contact the Customer Service Otganization number on the back of your Card Review your Health Benefit )[an Document for further details regarding your right to dispute a denied claim Page 2 of 2 THIS IS NOT A BILL The amounts below include claims processed as of November 12, 2008. The information does not reflect any claims received or adjusted after the above: mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars r ,ts 3 ?sr :ef ate ?ilai `4am Remaning y Year Td$a,? rrl R nainhg ' . r. < < x- sd. _ ?" h * Sati6fiacj°, 0 IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0.0 $ 0.00 $ 0.00 IN NETWORK-Family $ 343.02 $ 750.00 $ 406.98 $ 0.0 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.00 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family' $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.0 $ 10,500.00 $ 10,500.00 Page 1 of HealthAssurance Pennsylvania 3721 TecPort Dr P.O. Box 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insured: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE 8, RENT ID Number: 85140906104 Date: 11/12/2008 THIS IS NOT A BILL EXPI-AN ATION'OF BENEPi7S Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining hour your claim(s), including payments or denials, are being processed. "Payments made at the time services were rendered are not reflected on this statement." Min Number: 8833142804 Provider: MILTON S HERSHEY MEDICAL CENTER PHYSICIANS in Paid: $ 0.00 Provider Billing Address: PO BOX 858 MCA410 amber HERSHEY PA 17033-0858 sponsibility: $ 29.46 , Provider billing address may differ from physical office location" vice Date From - To )cedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adjustment Amount Copay Coins Deduct Other Plan Paid Remarks 2/2008 - 11/12/2008 $77.00 $47.54 $29.46 $29.46 $0.00 $0.00 $0.00 $0.00 2131 11 / OFFICE VISIT - F/U Totals: $77.00 $47.54 $29.46 $29.46 $0.00 $0.00 $0.00 $0.00 )ntractual Remarks: %, ?3 -$ ABOVE CONTRACTUAL ALLOWANCE o ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. you believe any of the services were incorrectly billed, contact a customer service representative using the toll free umber listed on your insurance card. :)mplaint and Appeals Procedures: covered Individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to )peal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit an Document for further details regarding your right to dispute a denied claim. Page 2 of 2 THIS IS NOT A BILE. The amounts below include claims processed as of November 12, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars Year o-Date ?SaSfled ~` Maximums ?'? .5? Rerliaining $ Year-To-DA ett Satisf)ey Maximum y Roi>>aining $ ?? IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0. $ 0.00 $ 0.00 IN NETWORK-Family $ 343.02 $ 750.00 $ 406.98 $ 0.0 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.0 0 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family 1 $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.00 $ 10,500.00 $ 10,500.00 Page 1 of Payments made on behalf of: HEALTHASSURANCE HASPA Insuied: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D ' Group Name: CUMBERLAND GOODWILL FIRE & RENT ID Number: 85140906104 Date: 08/12/2008 HealthAssurance Pennsylvania 3721 TecPort Dr P.O. Box 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 THIS IS NOT A BILK, EXPLANATION OF BENEFITS Our organization processes and pay:., the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining ho-..,v your claim(s), including payments or denials, are being processed. made at the time services were rendered are not reflected on this statement." ;;aim Number: 2822810236 Provider: MEDICAL ARTS ALLERGY PC elan Paid: $ 164.67 Provider Billing Address: 220 WILSON STREET STE 213 Member CARLISLE,PA 17013 2esponsibility: $ 30.00 Provider billing address may differ from physical office location" ervice Date From - To 'rocedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adiustment Amount Copay Coins Deduct Other Plan Paid Remarks 3/12/2008 - 08/12/2008 $104.00 $9.07 $94.93 $30.00 $0.00 $0.00 $0.00 $64.93 2131 19214 / OFFICE VISIT - F/U 3112/2008 - 08/1212008 $90.00 $55.35 $34.65 $0.00 $0.00 $0.00 $0.00 $34.65 _ 2131 140110/MEDICAL 3/12/2008 - 08/12/2008 $200.00 $134.91 $65.09 $0.00 $0.00 $0.00 $0.00 $65.09 213/ 15075 / MEDICAL Totals: $394.00 $199.33 $194.67 $30.00 $0.00 $0.00 $0.00 $164.67 Contractual Remarks: 213 -$ ABOVE CONTRACTUAL ALLOWANCE To ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. If you believe any of the services were incorrectly billed, contact a customer service representative using the toll free number listed on your insurance card. Complaint and Appeals Procedures: A covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to appeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit Plan Document for further details regarding your right to dispute a denied claim. Page 2 of 2 THIS IS NOT A BILL The amounts below include claims processed as of August 12, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars T Type , 1?ear,To-[3ate Ix?mdm Rearg , Yea??To-Date "Mai RArn ++r?j IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0. $ 0.00 $ 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.0 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.0 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family 4 $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.00 $ 10,500.00 $ 10,500.00 Page 1 of 2 HealthAssurance Pennsylvania 3721 Ter-Port Dr P.O. Box 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLiSLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insurld: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RENT ID Number: 85140906104 Date: 12/09/2008 THIS IS NOT A BILL EXPL,i1NATliON dF'''13?NEFITS Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. ents made at the time services were rendered are not reflected on this statement.** laim Number: 8834749421 Provider: MEDICAL ARTS ALLERGY PC an Paid: $ 644.93 Provider Billing Address: 220 WILSON STREET STE 213 ember 3sponsibility: $ 30.00 CARLISLE PA 17013 ** Provider billing address may differ from Dhvsicai office location** vice Date From - To ocedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adjustment Amount Copay Coins Deduct Other Plan Paiti _Remarks 0912008 - 12/0912008 $104.00 $9.07 $94.93 $30.00 $0.00 $0.00 $0.00 $64.93 2131 214 / OFFICE VISIT - F/U Totals: $104.00 $9.07 $94.93 $30.00 $0.00 $0.00 $0.00 $64.93 ontractual Remarks: 13 -$ ABOVE CONTRACTUAL ALLOWANCE -o ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. f you believe any of the services were incorrectly billed, contact a customer service representative using the toll free lumber listed on your insurance card. :omplaint and Appeals Procedures: , covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If yott wish to ppeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit 'Ian Document for further details regarding your right to dispute a denied claim. Page 2 of 2 THIS IS NOT A BILL The amounts below include claims processed as of December 09, 20011 The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars ' y g Y =daa; d?I atel Maxiintlm etnaining' Yean ba a fie tAA ruin 4u . Remain??g ` IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0. $ 0.00 0.00 $ IN NETWORK-Family $ 343.02 $ 750.00 $ 406.98 $ 0. $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.00 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.00 $ 10,500.00 $ 10,500.00 Pagel of 2 j? HealthAssurance Pennsylvania 3721 TecPort Dr P.O. Box 671 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insured: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & REJT ID Number: 85140906104 Date: 07/29/2008 THIS IS NOT A BILL.. EXPLANATION Cit. BENEFt Our organization processes and prays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. **Payments made at the time services were rendered are not reflected on this statement ** iim Number: 2821407756 Provider: MEDICAL ARTS ALLERGY PC in Paid: $ 97.83 Provider Billing Address: 220 WILSON STREET STE 213 !mber CARLISLE,PA 17013 sponsibility• $ 30.00 ** Provider billing address may differ from physical office location** ,rice Date From - To wedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adjustment Amount Copay Coins Deduct Other Plan Paid Remarks :9/2008 - 07/29/2008 $104.00 $9.42 $94.58 $30.00 $0.00 $0.00 $0.00 $64.58 2131 '.14 / OFFICE VISIT - F/U 19/2008 - 07/29/2008 $90.00 $56.75 $33.25 $0.00 $0.00 $0.00 $0.00 $33.25 213l )10/MEDICAL Totals: $194.00 $66.17 $127.83 $30.00 $0.00 $0.00 $0.00 $97.83 )ntractual Remarks: 13 -$ ABOVE CONTRACTUAL ALLOWANCE o ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. you believe any of the services were incorrectly billed, contact a customer service representative using the toll free umber listed on your insurance card. omplaint and Appeals Procedures: covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to )peal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit an Document for further details regarding your right to dispute a denied claim. Page 2 of 2 THIS IS NOT A HILL The amounts below include claims processed as of July 29, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars ,Ty?1e ¢ ear TIate Mxmum r Remaining `. l(eal-Tb Date ; yaximum tnalnng 1 ?.. ;?'SatiSfld ? T?.Sn. y .. S Sat?sfieda IN NETWORK-individual $ 250.00 $ 250.00 $ 0.00 $ 0.0 $ 0.00 $ 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.00 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.0 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.0 $ 10,500.00 $ 10,500.00 Page 1 of 2 Payments made on behalf of: HEALTHASSURANCE HASPA Insurgd: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RENT ID Number: 85140906104 Date: 07/29/2008 HealthAssurance Pennsylvania 4?4e 3721 TecPort Dr P.O. Box 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 THIS IS NOT A BILE. EXPLANATONrOF BENEI=iTS Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. ents made at the time services were rendered are not reflected on this statement ** aim Number: 2821810799 Provider: CARLISLE HMA INC an Paid: $ 71.74 Provider Billing Address: 45 SPRINT DR amber CARLISLE,PA 17015 isponsibility: $ 0.00 ** Provider billinq address may differ from physical office location** vice Date From - To Dcedure Code/Description Billed Contractual Approved Member's Resoonsibility to Provider Amount Adjustment Amount Copay Coins Deduct other Plan Paid_ Remarks 29/2008 - 07/29/2008 $9.00 $4.14 $4.86 $0.00 $0.00 $0.00 $0.00 $4.86 213/ 415 / LABIPATHOLOGY 29/2008 - 07/29/2008 $78.75 $60.77 $17.98 $0.00 $0.00 $0.00 $0.00 $17.98 2131 0481 LAB/PATHOLOGY 29/2008 - 07129/2008 $38.54 $27.86 $10.68 $0.00 $0.00 $0.00 $0.00 $10.68 _ 213/ 040 / LAB/PATHOLOGY 29/2008 - 07/2912008 $86.22 $72.17 $14.05 $0.00 $0.00 $0.00 $0.00 $14.05 213/ 735 / LAB/PATHOLOGY 29/2008 - 07129/2008 $45.86 $37.99 $7.87 $0.00 $0.00 $0.00 $0.00 $7.87 2131 155 / LAB/PATHOLOGY I 29/2008 - 07/29/2008 $60.54 $44.24 $16.30 $0.00 $0.00 $0.00 $0.00 $16.30 2131 025 / LAB/PATHOLOGY Totals: $318.91 $247.17 $71.74 $0.00 $0.00 $0.00 $0.00 $71.74 ontractual Remarks: 13 -$ ABOVE CONTRACTUAL ALLOWANCE 'o ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. : you believe any of the services were incorrectly billed, contact a customer service representative using the toll free umber listed on your insurance card. Page 2 of 2 THIS IS NOT A BILL. mplaint and`Appeals Procedures: :overed individual has the right to dispute a denied claim through the Complaint and. Grievance Review Process. If you 4vish to Seal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Henefit n Document for further details regarding your right to dispute a denied claim. The amounts below include claims processed as of July 29, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars } ` Ir To=ltep' stied` xl?iil?iri - (2emaining ?:_ Year To-D 1 Satisfied `Mc?um' a % Remainitfi $' IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 -? IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.00 $ 0.00 0.00 $ 'OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.0 $ 3,500.00 $ 3,!;00.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.0 $ 10,500.00 $ 10,500.00 Page 1 of 2 tlealthAssurance Pennsylvania 3721 TecPort P.O. Box ox 67 67103 3 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insurgd: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name. CUMBERLAND GOODWILL FIRE & RENT ID Number: 85140906104 Date: 06111/2008 THIS IS NOT A BILL. EXPLAIVATfOh - BENEFITS Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. ments made at the time services were rendered are not reflected on this statement.** laim Number: 2816962604 Provider: MS HERSHEY MEDICAL CENTER Ian Paid: $ 76.25 Provider Billing Address: PO BOX 856 ember HERSHEY,PA 17033-0856 esponsibility: $ 0.00 ** Provider billing address may differ from physical office location- rvice Date From - To •ocedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adjustment Amount Copay Coins Deduct Other Plan Paid Remarks 11/2008 - 06111/2008 $122.00 $45.75 $76.25 $0.00 $0.00 $0.00 $0.00 $76.25 2041 ,600 / RADIOLOGY Totals: $122.00 $45.75 $76.25 $0.00 $0.00 $0.00 $0.00 $76.25 ontractual Remarks: 04 -$ ABOVE DISCOUNT% ,o ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. f you believe any of the services were incorrectly billed, contact a customer service representative using the toll free lumber listed on your insurance card. :omplaint and Appeals Procedures: k covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to ppeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit 'Ian Document for further details regarding your right to dispute a denied claim. Page 2 of 2. THIS IS NOT A BILL The amounts below include claims processed as of June 11, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars ` pe z ;A " Pa'To Date ` , Y r M ax um Y "a??t Yeas- DA e"t Ma lm?[ri r ? Reniainl lg ' ~ Sans Ad .?'a t _ . IN NETWORK-Individual $ 250..00 $ 250.00 $ 0.00 $ 0. $ 0.00 $ 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.00 $ 0.00 $ 0.00 OUT OF NETWORK-individual $ 0.00 $ 500.00 $ 500.00 $ 0.0 $ 3,500.00 $ :3,500.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.00 $ 10,500.00 $ 10,500.00 Page 1 of 2 HealthAssurance Pennsylvania 3721 TecPort Dr P.O. Box 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insured: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RElr ID Number: 85140906104 Date: 06/11/2008 THIS IS NOT A BILL EXPLANATION OV`BENEFITS Our organization processes and pays the claims submitted from your heall.h care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining ho,Yv your claim(s), including payments or denials, are being processed. **Payments made at the time services were rendered are not reflected on this statement.** aim Number: 2817005387 Provider: MILTON S HERSHEY MEDICAL CENTER PHYSICIANS an Paid: $ 10.54 Provider Billing Address: PO BOX 858 MCA410 ember HERSHEY PA 17033-0858 !sponsibility: $0.00 , ** Provider billing address may differ from physical office location** vice Date From - To - )cedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adjustment Amount Copay Coins Deduct Other Plan Paid Remarks 11/2008 - 06/1112008 $57.00 $46.46 $10.54 $0.00 $0.00 $0.00 $0.00 $10.54 2131 300 / RADIOLOGY Totals: $57.00 $46.46 $10.54 $0.00 $0.00 $0000 $0.00 $10.54 3ntractual Remarks: 13 -$ ABOVE CONTRACTUAL ALLOWANCE . o ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. you believe any of the services were incorrectly billed, contact a customer service representative using the toll free umber listed on your insurance card. omplaint and Appeals Procedures: covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to 3peal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit Ian Document for further details regarding your right to dispute a denied claim. Page 2 of THIS IS NOT A BILL.. The amounts below include claims processed as of June 11, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars :Type .Year-?Tb-date Maximum Remaining Yeah To-Da a Maxi um Reinai'hi " Satisflecj?` r IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0.0 $ 0.00 $ 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.00 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.0 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.0 $ 10,500.00 $ 10,500.00 Page 1 of ) HealthAssurance Pennsylvania 3721 TecPort Dr P.O. Box 671 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insur%d: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RE/T ID Number: 85140906104 Date: 05/14/2008 made at the time services Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. rendered are not reflected on this statement." iim Number: 2814144857 Provider: MS HERSHEY MEDICAL CENTER in Paid: $ 88.12 Provider Billing Address: 'PO BOX 856 mber sponsibility: $ 0.00 HERSHEY,PA 17033-0856 THIS IS NOT A BILL EXPLANATION OF BENEOIT5 "" Provider billina address may differ from Owsical office location" rice Date From - To cedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adiustment Amount Copay Coins Deduct Other Plan Paid Remarks 4/2008 - 05/14/2008 $141.00 $52.88 $88.12 $0.00 $0.00 $0.00 $0.00 $88.12 204/ ,10 / RADIOLOGY Totals: $141.00 $52.88 $88.12 $0.00 $0.00 $0.00 $0.00 $88.12 ,ntractual Remarks: 4 -$ ABOVE DISCOUNT% :) ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. you believe any of the services were incorrectly billed, contact a customer service representative using the toll free ember listed on your insurance card. )mplaint and Appeals Procedures: covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to ipeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit an Document for further details regarding your right to dispute a denied claim. Page 2 of 2 THIS IS NOT A BILL The amounts below include claims processed as of May 14, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars rik s ; rty ;Year To Uate'i ?:- AiAM R tti nin0 Year'-T"&DAW, tJ?axlmGm Remaintri y Satisfied _S. S? Satisfied,+ ' b S IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0.0 $ 0.00 $ 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.0 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.00 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.00 $ 10,500.00 $ 10,500.00 Page 1 of 2 HealthAssurance Pennsylvania 3721 TecPort Dr P.O. Box 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insured: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RENT ID Number: 85140906104 Date: 05114/2008 "Payments made at the time services were rendered are not reflected on this statement.** THIS IS NOT A BILL EXPLA14ATIOW( r,13ENEFITS Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. aim Number: 2814206824 Provider: MILTON S HERSHEY MEDICAL CENTER PHYSICIANS an Paid: $ 11.58 Provider Billing Address: PO BOX 858 MCA410 amber -sponsibility: $0.00 HERSHEY,PA 17033-0858 ** Provider differ ** vice Date From - To )cedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adiustment Amount Copay Coins Deduct Other Plan Paid Remarks 14/2008 - 05/14/2008 $62.00 $50.42 $11.58 $0.00 $0.00 $0.00 $0.00 $11.58 2131 910 / RADIOLOGY Totals: $62.00 $50.42 $11.58 $0.00 $0.00 $0.00 $0.00 $11.58 )ntractual Remarks: 13 -$ ABOVE CONTRACTUAL ALLOWANCE o ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. you believe any of the services were incorrectly billed, contact a customer service representative using t1ie toll free umber listed on your insurance card. omplaint and Appeals Procedures: covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to 3peal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit Ian Document for further details regarding your right to dispute a denied claim. Page 2 of 2 THIS IS NOT A BILL, The amounts below include claims processed as of May 14, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars - Type r? Year-To-Date Satisfied Maximum $ a,< Remaining >?. ,1?. YearyTo-Date x Satisfied k 3 Maximum x. r$'.. Reitiain ng ?e. .4rj IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.0 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.0 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family t $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.0 $ 10,500.00 $ 10,500.00 Page 1 0 ' liealthAssurance Pennsylvania 372 1. TecPort Dr P.O. Box 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insured: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RENT ID Number: 85140906104 Date: 04/22/2008 THIS IS NOT A BILL EXOLANATIUN OF BtNtFIt 3, Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) a? our notification to you explaining how your claim(s), including payments or denials, are being processed. "Payments made at the time services were rendered are not reflected on this statement.** :laim Number: 2812046065 Provider: MS HERSHEY MEDICAL CENTER "Ian Paid: $ 94.37 Provider Billing Address: PO BOX 856 Member tesponsibility: $ 0.00 HERSHEY,PA 17033 0856 ** Provider billina address may differ from ohvsic:al office location" 3rvice Date From - To 'rocedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adiustment Amount Copay Coins Deduct Other Plan Paid Remarks 1/22/2008 - 04/2212008 $151.00 $56.63 $94.37 $0.00 $0.00 $0.00 $0.00 $94.37 2041 3590 / RADIOLOGY Totals: $151.00 $56.63 $94.37 $0.00 $0.00 $0.00 $0.00 $94.37 Contractual Remarks: 204 -$ ABOVE DISCOUNT% To ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. If you believe any of the services were incorrectly billed, contact a customer service representative using the toll free number listed on your insurance card. Complaint and Appeals Procedures: A covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If y13u wish to appeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit Plan Document for further details regarding your right to dispute a denied claim. Page 2 of 2 THIS IS NOT A BILL The amounts below include claims processed as of April 22, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars y""} ?? '?fpe"' a ear 76-Uate `Fti?s; R" it(fig ??k Year To-Date- Satisficl ,'• f AIax3muin ° S _ FFeuf11Jinj6g' 3 ?yX: IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0. $ 0.00 $ 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.0 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.0 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.0 $ 10,500.00 $ 101500.00 Page 1 of 2 Payments made on behalf of: HEALTHASSURANCE HASPA Insurgd: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RElf ID Number: 85140906104 Date: 04/22/2008 4? fiealthAssurance Pennsylvania 3721 TecPort Dr P.O. Box 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 THIS IS NOT A BILL EXPLANATION OF-BtNEFITS' Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. "*Payments made at the time services were rendered are not reflected on this statement." :laim Number: 2812066902 Provider: MILTON S HERSHEY MEDICAL CENTER PHYSICIANS 'Ian Paid: $ 11.58 Provider Billing Address: PO BOX 858 Member MCA410 tesponsibility: $ 0.00 HERSHEY,PA 17033-0858 ervice Date From - To rocedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adjustment Amount Copay Coins Deduct Other Plan Paid remarks /22/2008 - 04/22/2008 $62.00 $50.42 $11.58 $0.00 $0.00 $0.00 $0.00 $11.58 2131 3590 / RADIOLOGY Totals: $62.00 $50.42 $11.58 $0.00 $0.00 $0.00 $0.00 $11.58 :ontractual Remarks: ?13 -$ ABOVE CONTRACTUAL ALLOWANCE To ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. If you believe any of the services were incorrectly billed, contact a customer service representative using the tall free number listed on your insurance card. ;omplaint and Appeals Procedures: % covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to appeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit Nan Document for further details regarding your right to dispute a denied claim. Page 2 of 2 THIS IS NOT A BIM. 1 0, .0 The amounts below include claims processed as of April 22, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars Type s C :' (ea To=D?je , Ma j r* wft Rey aln g Year Tc?Da e t xlni' hi Ft?ma+ning r $sc?h ?i IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.00 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.0 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.0 $ 10,500.00 $ 10,500.00 f Page 1 of 2 HealthAssurance Pennsylvania 3721 TecPort Dr P.O. Box 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insurgd: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & REIT ID Number: 85140906104 Date: 04/16/2008 THIS IS NOT A BILL EXP4Al4A710N OF ' BENEFITS Our organization processes and pad the claims submitted from your heali; care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. **Payments made at the time services were rendered are not reflected on this statement.** :lahn Number: 2811343920 Provider: MS HERSHEY MEDICAL CENTER plan Paid: $ 88.12 Provider Billing Address: PO BOX 856 Aember HERSHEY,PA 17033 0856 tesponsibility $ 0.00 ** Provider billing address may differ from physical office location`* arvice Date From - To rocedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adiustment Amount Copay Coins Deduct Other Plan Paic% 416/2008 - 04/16/2008 $141.00 $52.88 $88.12 $0.00 $0.00 $0.00 $0.00 $88. 3610 / RADIOLOGY Totals: $141.00 $52.88 $88.12 $0.00 $0.00 $0.00 $0.00 $88.•11 ,ontractual Remarks: 204 -$ ABOVE DISCOUNT% To ensure that your health plan was properly billed, please review the services listed on your explanation of benefits If you believe any of the services were incorrectly b illed, contact a customer service representative using the toll free: number listed on your insurance card. Remarks 2041 3omplaint and Appeals Procedures: 4 covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If yc„ .wish to appeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your He:? `h Benefit Plan Document for further details regarding your right to dispute a denied claim Page 2 J 2 THIS IS NOT A BU i. , k, 0 The amounts below include claims processed as of April 16, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars rt ,l , TY 1 *w } + f>r r Yea Too=bate * Sa s ed Max iurhy r .. _., . Re ain ng ? 5 _ . ,...? Ye.4 fd=Date 5atis e ;*, it m m ; , _ w, ., mafri? g ?," __ IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0. $ 0.00 $ 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.0 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.0 $ 3,500.00 $ _ 3,500.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.00 $ 10,500.00 $ 10,500.00 Page 'I of 2 HealthAssurance Pennsylvania 3721 Tec;Porl Dr P.O. Box ox 671 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insurld: GRIMES,JOSEPH D Patient: GRIMES,HUNTER D Group Name: CUMBERLAND GOODWILL FIRE & RE/T ID Number: 85140906104 Date: 04/1612008 THIS IS NOT A BILL. EXPLANATION OF BENEH rS Our organization processes and pays the claims submitted from your health care provider(s). You have rec(3ivc::d this Explanation of Benefits (E013" as our notification to you explaining !,-.-)w your claim(s), including payments or denials, are being processed. *"Payments made at the time services were rendered are not reflected on this statement." Ulm Number: 2811408538 Provider: MILTON S HERSHEY MEDICAL CENTER PHYSIC. IS 'fan Paid: $ 11.58 Provider Billing Address: PO BOX 858 lember MCA410 :esponsibility: $ 0.00 HERSHEY,PA 17033-0858 Provider billing address may differ from physical office location- ,rvice Date From - To rocedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adjustment Amount Copay Coins Deduct Other Plan Pai, !'emarks 116/2008 - 04/16/2008 $62.00 $50.42 $11.58 $0.00 $0.00 $0.00 $0.00 $11.5t; 2131 3610/RADIOLOGY Totals: $62.00 $50.42 $11.58 $0.00 $0.00 $0.00 $0.00 $11.5,1; :ontractual Remarks: !13 -$ ABOVE CONTRACTUAL ALLOWANCE ro ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. 'f you believe any of the services were incorrectly billed, contact a customer service representative using the toll free lumber listed on your insurance card. :omplaint and Appeals Procedures: 1 covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to ippeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit elan Document for further details regarding your right to dispute a denied claim. Page 2 of 2 THIS IS NOT A BILL The amounts below include claims processed as of April 16, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollar '" Type 7 Year 6ate ?`a M?aiftium,' x x Ftefiainirg Year T o-Dat K Ill?iml;m ?mainirig Satisfied 4aUsfied °y IN NETWORK-Individual $ 250.00 $ 250.00 $ 0.00 $ 0.0 $ 0.0o l : 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.0 $ 0.00 `F 0.00 OUT OF NETWORK-Individual 0.00 $ 500.00 $ 500.00 $ 0.0 $ 3,500.00 3,500.00 OUT OF NETWORK-Family r 0.00 $ 1,500.00 $ 1,500.00 $ 0.0 $ 10,500.00 10,500.0! ? i Page 1 of 2 HealthAssurance Pennsylvania 3721 TeoPort Dr P.O. Box ox 671 67103 Harrisburg, PA 17106 GRIMES,HUNTER D 110 W Ridge Street CARLISLE,PA 17013 Payments made on behalf of: HEALTHASSURANCE HASPA Insurgd: GRIMES,JOSEPH D Patient: GRIMES,HUN-rER D Group Name: CUMBERLAND GOODWILL FIRE & RENT ID Number: 85140906104 Date: 04/09/2008 THIS IS NOT A BILL EX0L#f4A ldt4-6 BENEFITS Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your clairn(s), including payments or denials, ai+: being processed. **Payments made at the time services were rendered are not reflected on this :statement." laim Number: 2810641911 Provider: MS HERSHEY MEDICAL CEN TER Ian Paid: $ 15.65 Provider Billing Address: PO BOX 856 iember HERSHEY,PA 17033-0856; esponsibility: $ 72.47 ** Provider billinq address may differ from phvsical office location" rvice Date From - To •ocedure Code/Description Billed Contractual Approved Member's Responsibility to Provider Amount Adjustment Amount Copay Coins Deduct Other Plan Paid Remarks '09/2008 - 04109/2008 $141.00 $52.88 $88.12 $0.00 $0.00 $72.47 $0.00 $15.65 2041 1610/RADIOLOGY Totals: $141.00 $52.88 $88.12 $0.00 $0.00 $72.47 $0.00 $15.65 :ontractual Remarks: 04 -$ ABOVE DISCOUNT% fo ensure that your health plan was properly billed, please review the services listed on your expkination of benefits . f you believe any of the services were incorrectly billed, contact a customer service representative using the toll free lumber listed on your insurance card. :omplaint and Appeals Procedures: i covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If yo-1 wish to ppeal a denial decision, contact the Customer Service Organization number on the back of your Card Review your Health Benefit 'Ian Document for further details regarding your right to dispute a denied claim. THIS IS NOT A BILL , r( The amounts below include claims processed as of April 09, 2008. The information does not reflect any claims received or adjusted after the above mentioned date. Member medical Benefit Usage for Dates of Service January 01, 2008 - December 31, 2008 Deductible Dollars Out of Pocket Dollars Type ` 1( of Tti gate Satisfied ' lalxl?iiurri .5.._ .. Re inhig ' f rN.. `Year To-Date`' Satisfied _ ' Maftlrndfn airing IN NETWORK-individual $ 250.00 $ 250.00 $ 0.00 $. 0.0 $ 0.00 $ 0.00 IN NETWORK-Family $ 250.00 $ 750.00 $ 500.00 $ 0.0 $ 0.00 $ 0.00 OUT OF NETWORK-Individual $ 0.00 $ 500.00 $ 500.00 $ 0.0 $ 3,500.00 $ 3,500.00 OUT OF NETWORK-Family $ 0.00 $ 1,500.00 $ 1,500.00 $ 0.00 $ 10,500.00 $ 10,500.00 MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 02/02/09 at 08:36 AM 3uarantor: GRIMES JENNIFER L 285 SHED ROAD NEWVILLE, PA 17241-0000 Patient: GRIMES HUNTER D Visit #: 12315115 ------------------------ Date Svc Code -- ----------------------- Description ---------------------- Units) Debits I ------------ Credits I - ---------- 11/12/08 ----------- 184221 ----------------------- ANKLE 1-2 VIEWS LEFT --------------------- 1 131.00 ------------- 11/28/08 910011 HMO PAYMENT HOSP -1 82.66- 11/28/08 ------------- 920083 ---------- HEALTHASSURANCE/HPS A ------- -1 48.34- - * - Not posted ----------------- ----------•---------- Balance: -------------- -- ---------- 0.00 ------------- MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 02/02/09 at 08:36 AM Guarantor: GRIMES JENNIFER L 285 SHED ROAD NEWVILLE, PA 17241-0000 Patient: GRIMES HUNTER D Visit #: :922060 ----------------------- I Date I Svc Code ------------- -- ------------------------ I Description --------------------- Units Debits ------------- Credits 06/11/08 - ------- 184221 ------------------------ ANKLE 1-2 VIEWS LEFT --------------------- 1 122.00 ------------- 06/26/08 910011 HMO PAYMENT HOSP -1 76.25- 06/26/08 ------------- 920083 ---------- HEALTHASSURANCE/HPS A --- ------ - -1 45.75- * - Not posted - - ------------ --------------------- Balance: -------------- ------------- 0.00 ------------- , R MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 02/02/09 at 08:35 AM 3uarantor: GRIMES JENNIFER L 285 SHED ROAD NEWVILLE, PA 17241-0000 Patient: GRIMES HUNTER D Visit #: 9823465 --------- Date --------- --------------- Svc Code 1 --------------- ----------------------- Description - -----------•--------- Units Debits I ------------- Credits 05/14/08 184222 ---------------------- ANKLE 3 OR MORE VIEWS --------------------- 1 141.00 ------------- 05/30/08 910011 HMO PAYMENT HOSP -1 88.12- 05/30/08 --------- ---- 920083 ----------- HEALTHASSURANCE/HPS A ---------- -1 52.88- * - Not posted ------------- --------------------- Balance: -------------- ------------- 0.00 ------------- MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 02/02/09 at 08:35 AM Suarantor: GRIMES JENNIFER L 285 SHED ROAD NEWVILLE, PA 17241-0000 Patient: GRIMES HUNTER D Visit #: 9742366 ---------- ----Date------Svc-Code-- ----------------------- Descri tion --------------------- Units) Debits ------------- Credits 04/22/08 184219 -------- p -- -- TIBIA & FIBULA AP&LAT ---------------------- 1 151.00 ------------ 05/08/08 910011 HMO PAYMENT HOSP -1 94.37- 05/08/08 920083 HEALTHASSURANCE/HPS A -1 56.63- * - Not posted ---- ---------------------- I Balance: --------------- ------------ 0.00 ------------ k MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 02/02/09 at 08:35 AM 3uarantor: GRIMES JENNIFER L 285 SHED ROAD NEWVILLE, PA 17241-0000 Patient: GRIMES HUNTER D Visit #: 9721719 --------- 1 Date --------------- 1 Svc Code 1 ----------------------- Description 1 --------------------- Unitsl Debits 1 ------------ Credits 1 --------- 04/16/08 ---- ---------- 184222 ------------------------ ANKLE 3 OR MORE VIEWS ------- 1 ------------- 141.00 - ------------ 05/01/08 910011 HMO PAYMENT HOSP -1 88.12- 05/01/08 920083 HEALTHASSURANCE/HPS A -1 52.88- -- --------- * - Not -------------- posted ------------------------ --------------------- Balance: 1 -------------- ----------- 0.00 ------------- t MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 02/02/09 at 08:35 AM 3uarantor: GRIMES JENNIFER L 285 SHED ROAD NEWVILLE, PA 17241-0000 Patient: GRIMES HUNTER D Visit #: 9694028 --------- Date --------- --------------- Svc Code --- ----------------------- Description ---------------------- Units Debits ------------ Credits 04/09/08 - ----------- 184222 ----------------------- ANKLE 3 OR MORE VIEWS --------------------- 1 141.00 ------------- 04/24/08 910011 HMO PAYMENT HOSP -1 15.65- 04/24/08 920083 HEALTHASSURANCE/HPS A -1 52.88- 05/08/08 --------- --- 935056 ---------- GATEWAY CONT ADJ IAR -1 72.47- * - Not -- posted ----------------------- --------------------- 1 Balance: -------------- ------------- 0.00 ------------- MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 02/02/09 at 08:35 AM Guarantor: GRIMES JENNIFER L 285 SHED ROAD NEWVILLE, PA 17241-0000 Patient: GRIMES HUNTER D Visit #: 9680816 ------------------------------------------------------------------- I -Date------Svc-Code----------Description Units ]Debits Credits I -------------------------------------- 04/06/08 04/06/08 04/06/08 04/06/08 04/06/08 04/06/08 04/06/08 04/06/08 04/06/08 04/06/08 04/06/08 04/06/08 04/06/08 04/06/08 04/06/08 04/06/08 04/07/08 04/07/08 04/07/08 04/07/08 04/07/08 04/07/08 04/24/08 04/24/08 05/08/08 46472 46620 46699 46806 46939 245694 246706 249241 307310 307315 307319 600511 621043 621055 621106 627070 70211 246706 251175 600510 600511 621054 910011 920083 935056 EMERGENCY VISIT, LEVE ROUTINE VENIPUNCTURE THERA/DIAG INJECTION TX FX DISTAL TIBIA MOD SEDATION >SYRS 1S KETAMINE HCI 10 MG/ML MORPHINE SULFATE 2 MG MIDAZOLAM 10MG/2ML KNEE 1-2 VIEWS LEFT TIBIA & FIBULA AP&LAT ANKLE 3 OR MORE VIEWS PULSE OXIMETER SNSR P I V SODIUM CHLORIDE 0 KIT ER IV START YANKAUER SUCT TB W/O IV EXT SET 90" W/FLAS XD OBS EMERGENCY DEPT MORPHINE SULFATE 2 MG ACETAMINOPHEN/CODEINE PULSE OXIMETER SNSR A PULSE OXIMETER SNSR P IV LACTATED RINGERS 1 HMO PAYMENT HOSP HEALTHASSURANCE/HPS A GATEWAY CONT ADJ IAR 1 1 1 1 1 1 2 10 1 2 2 1 1 1 1 1 13 1 1 1 1 1 -1 -1 -1 647.00 19.00 61.00 782.00 110.00 50.20 6.00 5.35 154.00 302.00 282.00 18.00 6.00 10.00 5.00 22.00' 1378.00- 3.00 3.00 18.00 18.00 6.00 2333.69- 1471.86- 100.00- * - Not posted Balance: .0.00 --------------------------- k . 10 EXHIBIT "G" r ` ACS Recovery Services P.O. Box 4003 Schaumburg, IL 60168-4003 A C S' May 22, 2009 Ace Insurance Attn: Mary Schulze P.O. Box 983 Houston, TX 77001 Claimant: Your Insured: Our Case ID: Date of Loss: Our Client: Your Claim Number: Hunter Grimes Wells Fargo Motorsports 10108430 04/06/2008 HealthAmerica and HealthAssurance 2381005642 Please be advised that the lien amount to date is $3,762.13. Please call prior to settlement or judgment to determine the total amount of benefits paid by our client. Also, would you kindly provide us with a list of the medical specials that you have received from the attorney for the claimant. Very truly yours, o? Saira Pasha ACS Recovery Services - (847) 755-7486 ACS Recovery Services Insured: Joseph Grimes Our Case ID: 10108430 Date of Accident: 04/06/2008 Our Client: HealthAmerica and HeafthAssurance Claimant: Hunter Grimes Patient Claim Number Misc Provider Dates of Service Claim Amount Benefit Amount Hunter 1811931788 959.7 CENTRAL MEDICAL SE 04/06/2008 - 04/0612008 $1,330.00 $335.42 Hunter 2810712318 824.8 DIV OF DIAG RADIOL 04/06(2008 - 04/0612008 $62.00 $11.58 Hunter 2810720351 823.82 MS HERSHEY MEDICAL 04/06/2008 - 04107/2008 $3,905.55 $2,333.69 Hunter 2810710708 823.82 OLYMPIA MD ROBERT 04106/2008 - 04/05/2008 $269.00 $154.76 Hunter 2610712462 824.8 DIV OF DIAG RADIOL 04109/2008 - 04/09/2008 $62.00 $11,58 Hunter 2812066531 823.22 FORTUNA MD KRISTIN 04/0912008 - 04/09/2008 $1,294.00 $413.09 Hunter 2810641911 824.8 MS HERSHEY MEDICAL 04/09/2008 - 04/09/2008 $141.00 $15.65 Hunter 2811408538 V64.89 DIV OF DIAG RADIOL 04/16/2008 - 04/1612008 $62.00 $11.58 Hunter 2811343920 V64.89 MS HERSHEY MEDICAL 04/16/2008 - 04/16/2008 $141.00 $88.12 Hunter 2812066902 V54.16 DIV OF DIAG RADIOL 04/22/2008 - 04/22/2008 $62.00 $11.58 Hunter 2812046065 V54.16 MS HERSHEY MEDICAL 04/2212008 - 04/2212008 $151.00 $94.37 Hunter 2814206824 V54.19 DIV OF DIAG RADIOL 05114/2008 - 05/14/2008 $62.00 $11.58 Hunter 2814144857 V54.19 MS HERSHEY MEDICAL 05/14/2008 - 05/14/2008 $141.00 $88.12 Hunter 2817005387 V54.19 DIV OF DIAG RAD10L 06/11/2008 - 06/1112008 $57.00 $10.54 Hunter 2816962604 V54.19 MS HERSHEY MEDICAL 06111/2008 - 06111/2008 $122.00 $76.25 Hunter 8832644528 V54.16 DIV OF DIAG RADIOL 11/12/2008 -11/12/2008 $61.00 $11.56 Hunter 8832427847 V54.16 MS HERSHEY MEDICAL 11/12/2008 -11/12/2008 $131.00 $82.66 Totals: 8,053.55 $3,762.13 Itemized Benefits Paid Page 1 0512212009 r r7 M FI?.?L-?;_rl'vL OE THE „r !Ct, TAF?Y 2009 jUL 22 FFi 131 78.50 Po AT7'1 CV *5a4at/ 6a40(o eaags Iq JUL 2 3 20094 .. , IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA HUNTER GRIMES, a minor, by and through his parent and natural guardian, JENNIFER ICKES V. COURT OF COMMON PLEAS OF CUMBERLAND COUNTY NO. 09 - ygloo C iv i t Ism AMERICAN MOTORCYCLE ASSOCIATION, INC. AND DUTCHMEN MX PARK, LLC. : PRELIMINARY DECREE AND NOW, this a ? day of 2009 upon consideration of the attached Petition it is hereby ORDERED and DECREED that a hearing hereon is to be held in Courtroom 5?' , Cumberland County Courthouse, 1 Courthouse Square, Carlisle, Pennsylvania, 17013 on oZS , 2009 at 11"16- o'clock 74 . M. BY THE COURT 5902601 FILED-- )i"t',uE OF PROTC'NMARY 2009 JUL 27 Phi 1: 02 PE.4lva'.lV i 7/.-k7/O9 ,.'k'?LLS=L 4 7 0 . '21 bjz?- HUNTER GRIMES, a minor, by IN THE COURT OF COMMON PLEAS OF and through his parent and natural CUMBERLAND COUNTY, PENNSYLVANIA guardian, JENNIFER ICKES, Plaintiff CIVIL ACTION - LAW NO. 09-4960 CIVIL vs. AMERICAN MOTORCYCLE ASSOCIATION, INC. AND DUTCHMEN MX PARK, LLC, Defendants IN RE: PETITION FOR LEAVE TO SETTLE OR COMPROMISE A MINOR'S ACTION ORDER AND NOW, this 9` day of August, 2009, at the request of counsel for the plaintiff, hearing in the above-captioned matter set for August 26, 2009, is continued to Thursday, September 17, 2009, at 9:30 a.m. in Courtroom Number 4, Cumberland County Courthouse, Carlisle, PA. BY THE COURT, Bert P. Corbin, Esquire Audrey Ziadat, Esquire For the Plaintiff rlm (20 t-ES' Mz L l_C4v 18 TA.4 1 oq i 2 uu9 J'-uiG -.{: E?. I. 213 vii ? .. rte R ?" HUNTER GRIMES, a minor, by and through his parent and natural guardian, JENNIFER ICKES V. AMERICAN MOTORCYCLE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY NO. 09-4960 Civil Term ASSOCIATION, INC. AND DUTCHMEN MX PARK, LLC. ORDER AND NOW, this .,3 ` day of 0&s-# loci , 2009, upon consideration of the Petition for Leave to Settle or Compromise a Minor's Action, it is hereby ORDERED and DECREED that Petitioner is authorized to enter into a settlement with defendant's and their insurance company in the gross sum of Thirty-Three Thousand Three Hundred and Seventy- Eight Dollars and Fifty-Five Cents ($33,378.55). It is further ORDERED and DECREED that the settlement proceeds be distributed as follows: TO: Hunter Grimes, a minor $29,616.42 Under the Structured Settlement Release Agreement, Hunter Grimes is guaranteed a $20,547.66 lump sum payable on September 7, 2016 (18 years of age) and a $22,810.00 lump sum payable on September 7, 2019 (21 years of age). Payment is to be made only after the execution of the Settlement Agreement and Release and Uniform Qualified Assignment and Release and 20 days from the date of filing the Order to Settle, Discontinue and End. TO: Joseph Grimes (father of minor Hunter Grimes) $3,762.13 Reimbursement for medical expenses paid by Mr. Grime's health insurance provider. Payment is to be made only after the execution of the Settlement Agreement and Release and Uniform Qualified Assignment and Release and 20 days from the date of filing the Order to Settle, Discontinue and End. BY THE COURT: 4-- J. 580260_1 Ft L RY ? ?? _?T Phi gas On 1 3 lOll3 f Oar - ? m?c?L 444, R. z? ? GERMAN, GALLAGHER & MURTAGH BY: AUDREY ZIADAT, ESQUIRE Attorney I.D. No. 87163 The Bellevue - Fifth Floor 200 S. Broad Street Philadelphia, PA 19102 (215) 875-4025 ziadata@ggmfirm.com HUNTER GRIMES, a minor, by and through his parent and natural guardian, JENNIFER ICKES COURT OF COMMON PLEAS OF CUMBERLAND COUNTY V. NO. 09-4960 Civil Term AMERICAN MOTORCYCLE ASSOCIATION, INC. AND DUTCHMEN MX PARK, LLC. ORDER TO SETTLE, DISCONTINUE AND END TO THE PROTHONOTARY: Kindly mark the above-captioned matter Settled, adat, ?(_ 11 Dated: and Ended. 644115_1 FILED-OiFlOE OF THE PROTHO MARY 2009 NOV 19 PM 2.41