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HomeMy WebLinkAbout10-5178u. ~ . . . t ~, ~ ,. ~ ~.. .. !. ~ . .._ ._ ~_ : Y 1 ; .. ~..... ao l c ~ uG ~ P nit 3 ~ ob ESTATE OF JESSIE E. JOHNSON IN THE COURT OF ~1V~~1!ION PLEASE i'~~ by James M. Johnson, Administrator of OF CUMBERLAND COI~JNT'~ PA ` ' the Estate of Jessie E. Johnson Petitioner V. CASE NO. lb - 51'18 ~iu~1.~~P.~'m Thomas Oyler : Respondent :CIVIL ACTION: LAW PETITION FOR THE COURT APPROVAL OF SETTLEMENTS FOR THE WRONGFUL DEATH AND SURVIVAL ACTION OF THE ESTATE OF JESSIE E. JOHNSON And now this ~ day of comes the petitioner, James M. Johnson, on behalf of the Estate of Jessie E. Johnson, through his attorney Marc G. Tarlow, Esquire of the law firm of Shumaker Williams, PC, and petitions the Court as follows: BACKGROUND INFORMATION 1. The Petitioner, James M. Johnson, is an adult individual residing at 476 Stonehouse Road, Carlisle, PA, 17015, and is the Administrator of the Estate of Jessie E. Johnson, his daughter. 2. On April 20, 2010, James M. Johnson was appointed the Administrator of the Estate of Jessie E. Johnson, by Register of Wills for Cumberland County, Pennsylvania (File No. 2010-00415). 3. Decedent Jessie E. Johnson was involved in a motor vehicle accident on Apri14, 2010, which resulted in a loss of her life. The Police Accident Report is marked Exhibit "A" and attached hereto. ~ ga.oo ~ ~T,ti1 ~~ ssr7 ~,~'ay~y40 4. Respondent Thomas Oyler, was an adult individual at the time of this accident, driving a vehicle owed by William C. Oyler, insured by Allstate Insurance Company, and has been represented throughout the pending claim by Allstate Insurance Company, Denise Pawling, claims adjuster. 5. Respondent Thomas Oyler lost control of his vehicle, causing it to spin and strike a utility pole on the passenger side, causing Decedent's injuries and death. 5. Respondent's insurance company has offered to compromise and settle the claim with payment of policy limits in the amount of $25,000.00 as set forth in the May 14, 2010 correspondence and proposed General Release, which is marked Exhibit "B" and attached hereto. 6. Decedent Jessie E. Johnson was covered by her parents' auto insurance policy through State Farm Insurance Company at the time of her accident and resulting death that afforded her $100,000.00 in underinsurance motorist benefits. 7. State Farm has offered to compromise and settle the claim with a payment of policy limits in the amount of $100,000.00 as set forth in the Apri130, 2010 correspondence, which is marked Exhibit "C" and attached hereto. 8. At the time of her death, Jessie E. Johnson was 17 years of age, survived by her parents as follows: a. James M. Johnson 476 Stonehouse Road Carlisle, PA 17015 b. Teresa E. Johnson 476 Stonehouse Road Carlisle, PA 17015 9. The wrongful death beneficiaries in this action aze her pazents named above. 10. Petitioner entered into a contingent fee agreement with Shumaker Williams, PC, in this matter providing for payment of 15% of any proceeds recovered or awazded, plus payment of costs. See Exhibit "D" which is attached hereto. 11. Petitioner's counsel has incurred $92.00 in advanced costs for the filing of the Petition with regazd to this claim. 12. Petitioner proposes allocation of the $125,000.00 settlement with 70% to the wrongful death component of this claim and 30% to the survival claim. 13. Proposed distribution of the $125,000.00 settlement is as set forth in the Final Accounting and Distribution of Settlement which is marked Exhibit "E" and attached hereto. 14. The Petitioner has agreed upon the settlement offer in the amount of $125,000.00 for the injuries and damages which resulted in the untimely death of the Decedent. 15. Petitioner, as Executor of the Estate of Jessie E. Johnson, believes and therefore avers that it would be in the best interest of the Estate to accept the aforementioned settlements. 16. The Commonwealth of Pennsylvania, Department of Revenue, Office of Chief Counsel has been put on notice of this settlement and has approved the allocation of the Survival Action and Wrongful Death Claim. See Exhibit "F" attached hereto. WHEREFORE, Petitioner prays Your Honorable Court to enter an order authorizing settlement in as outlined on the Final Accounting and Distribution of Settlement which is marked Exhibit "E," and that leave of court be granted to sign the General Release attached as Exhibit "A" to bring this matter to a conclusion. Respectfully submitted; " ~' .- Marc G. Tazlow, Esquire [ID 23474] Shumaker Williams, P.C. One East Mazket Street, Ste. 301 York, Pennsylvania 17401 Tele: [717] 848-5134 Fax: [717] 848-5125 :231772 EXHIBIT A 06/07/2010 10:10 7172492379 NELLWALNUTBOTTOM PAGE 02/06 AASOOTx . Incident Number:' woe-1929464 Commonwealth of Pl~nnsy~va~ia PAGE 1 cram Imrofves: Rollce Crash Report REPORTABLE cRas>i Q pUl Q Fly Q Nit and Run Q Commorolal Vehklo Q Stets Poiko Vahlels Q Local Pollee veniok Q fUA Q work Zone Q AN Q Snowmohite Q Commonwealth vehkle Q Local C;otr Vshkls !9 gency Name Casa Closed Patrot Zeno Inveetlgatlon pate o T PA STATE POLICE - CARLt3LE NO 23 0410414010 plapatch Time Artnlat Time Imrestlgator Ffadge Number ~ 19:43 n 19:46 ~ C~,OLDEN, ROBERT J 10787 ra. ~ Ppr~i Date Revlewer Reviewer Badge Number a 06/03/2090 OBERDORF, JERRY L 06025 Date of Crash me of Crash Day or the VYeelr Crash Desdiptbn 041041x010 19:47 hts, SUNDAY NIT FIXED OBJECT County Municipally CUiNBF..RLAND DICKINSON TYVP 9 r COndrtlorrs Ralagon t0 RoetlwAy o NO ADVERSE CONDmON$ OUTSIDE TRAFFICWAY ~ InumMadon Roetl Surface Contlitlono v DUSK pRY of Unlts of People of lnJured IGled EMS Agency MatliCel FAdlly 001 ooa 001 ooa CARLISLE EfNS cARLISI.E HOSPITAL School Bus Related Sohod Zone Related PennDOT NngBed of Inlersaction dal Location NO NO NO MIDBLOCK NOT APPLICABLE Zone Work Zone Type YVhar'E In tlVOrk Zone o NO x speed Lim tNOrkera Present OfM:er Presem rk Zonp Chataderistlcs Work on Shoulder Irttarrnittent or Flogger Q LAne Closur: ~ ~Petur ~ or Median ^ MovN~g work © Control ~ Other Route Signing Route Number Segment Number ravel Cartes Speed limit Orientation STATE HIGHWAY 0466 02 45 MPH V11EST .~ Wouse Number Street Name 5t. Ending ~ STATE FIWY 46s ROAfJ Route Slgntng Route Number Segment Number I Lance SpAetl omit Orientation a ~ Used in Intartedlon Crashes Strrxt Name St EndMg .Le 8 T Route Number Mile Poet Tenths Segment Marker Ramp uoa qny Feet ' ~ ~ ~ ~ Street Name euRNTHOUSE Street Ending Or Mlles enths ~ ~ ROAD o0 4 LL ~ a Route Number Or Mho Poet prdtrs r Sogrtror>t Marker Ramp U9e Ony m ~ '8 The above entry is ttte P distan f th C h ~ ' ~ ~ Street Name Street Entling ce rom e ras Scene to L { N 1 a ~ ADAMS ROAp anC ttta c D¢grees Minutes Seconds Dodmal Deflroos Mtnuteo Seconds Declmgr ~~~: 40 0$ M 39 u 997 Longitude: w 77 14 ~ 46 347 o R Tratflc Control 17evice 1YafflC Contra Funcdoning NOT APPLICABLE NO CONTROLS m ~ Carle Cktsed Lane Closure Dlrectton TrAffio Detoured Estimated Tlmo Closed FULLY EAST AND WEST YES 3-6 NRS Em-Ironnt6rrYal /Roadway Pvtsntlal Factors (FJR) FN~NE Fedor 2 Factor 8 `v First Harmful Ewsnt In the Crash Mget Hamtfuf Event In the Cn>ISh € Unit umbt>r tiam,FUl Everrt 007 HIT Ui1LITY POLE Unit Number l-ter~mful Event 041 NCf urrLITY POLE '~ I ndk~ted Prime Factor U it N C n umber Prints Factor Orlvor Actio DRIVER ACTION 001 OTHER IMPROPER n DRIVING ACTIONS Prime FBCtor Ernlromental/Roadway Prlm2 Fedor VehlGS Failure Prime Factor Petleatrlen Adbn Road Surface Type I Juriadictlon BLACKTOP 0 SPECIAL JURISDfC1'ION PtlnLed At: Pq State polMa - Carlisle 06NN2010 03:20 PIIA Page 1 Form B: NO2-1929464 06/07/2010 10:10 7172492379 NELLWALNUTBOTTOM PAGE 03/06 `~°-sooTx Commonwe~llth of Penns I aA~~ z IncidentiNumber:~ H02-1939464 ~/ 1l<"11'1)G crash InVOtva~s: Polpt:e Crash RBport REFORTABI.E CRASH O GUi ~ FatalNy O Nit end Run O Commarcl9l Voiticie O State Pollee Vohlda O Local FO11Ce Vehicle O NfA O IiVOrft 2ona Q ATV O Sn4wmobUC O CommomreatDt Vehcle O Lacal Ciiov Vohkle unit Number unrt Commardal VPJ11dp 001 Motor Vehlah3 In Transport No Fir9t NamO M1 Last N6Ma $ufihr GOB alaphol'te Number THOMAS W OLYER 01/27!7991 (717) 386-1045 Sereot Adtlre88 Cfly Zlp Code 11S N BALTIMORE AVE MT HOLLY SPRINGS PA 17t}66 Gentler License Number Liean92 State Class t3tpiretion Date OwneNDrlver ~ IaALE z978479t PA C 0112312013 PRNATE VEHICLE NOT OIIYNEDILEASED BY DRNER Driver Prosanoe Phyeleei Canditlon Ptlmary veMde Code Vblatlon Person Charged ~ DRNER OPERATED VEHICLE APPARENTLY NORMAL VC3809 NO ~ IoctlouDrugs Suspactee oehol Teat Type Alcohol Test Results ,°, NO BLOOD UNKNOWN RESULTS ~ Driver ~n OTH~t IMPROPER DRMNG ACTIONS m Pedestrian Aadon PadesMan 31gnais Padaatrien Clothing pedestrian Loation 1st flermful Event Loh or Right Side Moat Harmful Utllity Pole Number HIT UTILITY SOLE RIGHT YES 1403430 2nd Narmful Event Lett or Right Side Most Hamnur Utility Pete Number 3rd Hamrful Event Lsft or Right Sitle Moat Harmful Utllity Pole Number 4tlt Wgrmiul PveM Left or Right Skle Most Harntiul Utility Pde Number v~vi iei nryt ~vama WILLIAM trwnei MI C U4Yner Last Name Or 9USInas6 Name OYLER flbr Street Atltlresa City State Zip Code '113 N BALTIMORE AVE MT HOLLY SPRINGS PA 17065 Vohide Type Spedal usage Government Equipment AUTOMOBILE NOT APPLICABLE MOtlel Year Vahide Make snide M0de1 snide Color N 1999 FORD ESCORT RED 3FAKP11$9XR20102ti nsa Plate Reg, State Est, Sped ehkdo lowed Towed By RCS3L9 PA 05S YES JOHNS MOBILE nsurance insurance Compamr Poflry Number Expiratlon to YES ALLSTATE 07$7702200$!02 0210212D7D ~ Irectlon of Travel ehk:w Position snide Movement Initial Impact! Pc WasT RIGHT LANE "CURB" t30lNC~, STRAIGHT 3 O'CLOCK ~ Dama_ge Indkator Qratllem Roetl Atprlment Possible Vehicle Failuros ~ DISABLING LEVEL STRAIGHT UNKNOWN ft of UnRt+ Type unit 1 Tag Number ag Year Tag state ~ ~' 0 3 unit Make unit Owner R Yoe Urdt 2 ag Number ag Y~r eg State m cc Drh+or waimet e 's ~ assarfeer Hnl Printed At: FA State Police ~ CaAlsle t1610~1Rp70 b3:2o PIN Page R Fom- #: HO2-1928464 06/07/2010 10:10 7172492379 NELLWALNUTBOTTOM PAGE 04/06 IncidentNumber:' Hot-1929484 Commonwealth Of Pennsylvania PAGE 3 crass, Imrolver,: Police Crash Report REPORTABLE CRASH Q Dip ~/ Fatalky Q Hit end Run Q COngrlgrCtal Vohkla Q 9teta Police Vohlcle Q Local Pgtit:$ Vohklo Q NIA Q YVork Zone a ATV Q 3nowmgbllo Q Commonwgallh Vahlcia ~ Local Qov Vohlelo UnR # Driver ReetrJCllona Compliance DtPVar endorsement Compnanca Driver License Gompllanoe 01 NO RESTRICTIONSMOT APPLICABLE REQUIRED - COMPLIED t1111TF1 VALIA LICENSE FOR CLASS ~' Pnrrtxpel Impact Point voitlarbe Meneuver under Rice Indk~r 3 O'CLOCK STEERING AND BRAKING - EVIDENCE OR STATED NO UNDERRIDE OR OV>:RRIDE k Emergency Usa Dnu9 Test'type Drug Teat Results NOT IN EMERGENCY USE BLOOD Unit # Person . First Name 001 001 THOMAS et address = 113 N BALTIMORE AYE ~ Phone Number EMS Tranapor ~ (717) 385.1045 YES Seat PoslNgn m DRIVER -ALL VEtItCLE3 a a Safety Equipment 2 FRONT AIR BAG DEPLOYED (FOR'PHIS SEAT) ~~ NOT F_JECTED 001 ~ 002 ~ JESSIE street Atltlreas a7t3 STONEHOUSE RD rhgne Number '~ EMS Transpor (T17) 880-9775 NO ~eatlOat Pos10pn - ~.- FRONT SEAT RIGHT SIDE iafaty Equlpmem z FRONT AIR EIA,G DtPLOYED (FOR THL3 SEA'L') NOT EJECTED ~wnerg rasa name o° Street Adtlregs ~ 827 HAUMAN RD a Properly Description a UTILITY POLE: # 1408a-3013 UNKNOWN TEST RESUi_TS J W OLYER :rty ---- M'1'HOLLY SPRINGS vRlveR MALE Barely Equipment t LAP AND SHOUL,pER BELT USED >wxbtC2111gn NOT EXTRICATED :section Path NOT E.IECTEDMOT APPLICABLE MI Last Name E JOWNSON ,~ - ,,, CARLISLE PA95F~IGER FEMALE Safely Equipment t LAP AND SHOULDER BELT uSED Extrication FREED BY NON-INECHANICAL MEANS Jedlon Pam NOT FJECTI:DINOT APPLICABLE PPL ELETRIC UTILI77Es 01/22!1997 State Zlp Cotle PA 1T08S ~)ury seventy MINOR INJURY 01/OaM993 Stale Zip Code PA 17D15 Injury SEVe11fy KILLI=D (800)231-7288 aato zip cone PA 18104 Prlrlted At PA 9tata Pollca . CarDafe 06l04-2010 03:20 PM Pi1gp S Form !~; H02.79x9~/04 06/07/2010 10:10 ~.l~~ tX 7172492379 fncideni Number: HQ2-1929x64 Crash Invplves: 0 oui Q p~~y o h1lA o Work zone I~etAS MPH 31gn rr`~ 1- ~ l with; PBPCARS. olpgram o Conurlercial vehicle o ~~ Commonwealth of Pennsylvania Police Crash Report REPORta»I.ECRASH o Ht! and Run NELLWALNUTBOTTOM ~` a a w PAGE 05/06 ~adE: a o Sta~o Polka Vehicle o loll Pollee Vehicle o CanimonweaHh vehieia o I.ocei Gov Veltlcle u~t _ UnR!/Map ofFlnalRSe! _ This one vehicle fatal crash occun~ed on Q4144~1~l0 at approx.1947 hours on Walnut Bottom Road (SR 465), Dickinson 7~-p, Cumberland County. Unit 1 was traveling west on Walnut 13aKom Road at the time of this crash. Operator 1 then lost control of his unit, causing Unit 1 to travel across the east bound lane. At this tune the rear vd Ultlt 1 began to spin to acounter-clockwise manner. Unit 1 crossed the feg line of the asst bound lane. At this time Unit 7 impacted a utility pole on the passenger side, This cation caused Unit 1 to turn Nn clockwise manner before coming to fins! rest off of the roadway. A Copy of the News Release has placed in the crash attachment file. This one vehicle fatal crash occurred on 04/04/10 at approx.1941 hours on Walnut Bottom Rand (SR 46Sj, Dickinson Twp, Cumberland County. Unit 1 waS traveling west on Walnut 9ottam Road at the time of this crash. Operator 1 then last control of his unit, causing Unk 1 led travel across the east bound lane. At this time the rear of Unit 1 began to spin in acounter-clockwise manner, Unk 7 then crossed the fag line of the east bound fans. At this tim® Unit 1 impacted a utility pole on the passenger side. Thts action caused Unit 7 to tum In clock wise manner before coming to final rest off of the roadway. This was the position of Unit 1 upon my arrival. PArttod At: PA State Police - CraAla la 06/04!2090 0920 pM page 4 Form A: H02-7928484 o ATY 06/07/2010 10:10 717249: incident Number: x102»1828464 Crash Irn-olves: o DUI ©Fstelky o ~,~ o~wo~ one NELL4JALNUTBOTTOM ,PAGE ,06/06 !379 Commonwealth of PennSy~vani2l PAGE 5 Police Crssh R+aport ~FpoRTAeue cw-sH o Hk anb Run o Commercial Vehfcfa o stata} Ponce VeF-tcie o Local Police vehkla o A7V o SnpwmobNe o Co1111tlonMtA0lth Vehbie o taCAl Gov Vehkle Upon my arrival, their was one volunteer EMS personnel on scene. Passenger 1 showed no signs of life. Interview 1 (Oper 1) On 04!04110 at approx.1950 hours; i Interviewed Oper 1 at the scene. I observed Oper 1 walking around a field in the area of final rest. Upon seeing Oper 1, I asked ff he was a witness or was Involved in the crash? He related that he was the operator. He further related that "1 was taking my glrffr"iend horde" and "she squeezed my leg and I lost control", Operator 1 requested "a place to sit down". I then sat Oper 1 in the back of my marked patrol unit with the door open. Operator 1 was then an his cell phone and said #o the effect, "ok, mom I won't say anything to the police or anybody". On 04/04110 at approx. 2014 hours, Cumberland County Coroner Todd SGK~NRODE arrived an scene and pronounced Passenger 1 deceased. On 04104/10 at approx. 2142 hours, Trooper THII:RVYECHTER from FSP C,A.R.S arrived on sctane and conducted crash reconstruction. On 04104/10 at approx. 2150 hours, Trooper LEWIS from PSP 117 was on scene to fully photograph the crash scene. On 04/04/10 at approx. 2228 hours, .lohns Mobile Towing towed Unit 1 back to P3P-Carlisle secure Impound Lot. Unit 7 was erdered into evidence under Property Record # H2-13280 On 04104110, at approx. 2300 hours, Coroner ~CI~NRObt; and myself (Tpr. GOLDEN) an~ived at Passenger 1 residence and official death notiflcativn was given to the deceased father (.lames JOHNSON), The deceased parents had Passenger 1's IAA Photo Id only (PA 11~ 30319359) and it was not ca1Mc#ed lty the County Coroner. This Report will be Supplemen#ed pending C.A,R.S. report and further Crash investigation, A Copy of the News Release has placed In the crash attachment file. Page 8 Form #c Wok-~` Pi~teod 11~ PA Stal4 Ponce - CeAisle p61D41Z0'14 03~R0 P111 EXHIBIT B 05!1412010 09:20 2152938437 ~~"'`r . M 11 ~. Wi I3ow GxOVe 1NC0 li _ 309 LARES3~ NORS7~AM PA A90A 4 V6u4e In good harxfr, 'll'llllt~llrll~~~l~"'III'~~I1~1~~'~~'~~~~Irlrirlll~lllnlrl~rll DAVID LEDEI2MANN Esq. PO SOX 88 fp~,R,RISBIIRG PA 3.7108-0088 May t4, 2010 INSURED: WI>C,I,TAM OYLER DATE OF L035: April 04, 2010 C,LATM NUMBER: 0164607673 UpP Re; Estate of Jessie Johnson Aear AAVID LEDERM,ANN Esq., ALLSTATE PAGE 01!04 PHONE NUMBER: 800-776-4510 FAX NUMBER: 866-5245203 OFFICE HOURS: Mon - Tri 8:00 am - 5:30 pm, Sat 8:30. am - 3:00 pm Enclosed is the release to settle this case for our 525,000.00 policy limits. Please forward the completed release along with court approval for the survivors action and death: benefits. Upon receipt of same, we will send the draft to your offioe. SiA.cerely, 2~:~IS'~ ~~L~N,GI~C AENI;SE PAWLING 800-776-451.0 Ext. 8321 Allstate Insurance Company GBNI001 0 64607673 UDP 05/14/2010 09:20 2152935437 ALLSTATE RELEASE ~F ALL CLAIMS PAGE 02/04 GLA1M NO: oleos-o7s7~ uDP This Indenture WitrlesSeth that, in consideration of the sum of Twenty Five Thousand Dollars $2b,000.00 receipt whereof is hereby acknowledged, for myself and for my heirs, personal repn3sentstlves and assigns, I do hereby release and forever discharge William Oyler and Thomas Oyler and any other person, firm or corporation charged or chargeable with responsibility or liability, their heirs, representatives and assigns, from any and all daims. demands. damages, costs, expenses, loss of services, actions and causes of action, arising from any act or oxurrence up to the present time and particularly on account of all personal injury, disability, proper#y damages, loss or damages of any Idnd already sustained or that i may hereafter sustain in consequence of an accident that occurred on or about this 4th day of April, 2010, at or near Walnut Bottom Rd Dickenson, PA. To procurE payment of the said sum, I hereby dedare: that I am more than 18 years of age; that no representation about the nature and extent of said injuries, disabilities or damages made L»I a physician, attorney or agent of any party hereby released, nor any representation r+egardirrg the nature and extent of legal liability or finanaai responsibility of any of the parties hereby released, have induced me to make this settlement; that in detemnining said sum there has been taken into consideration not only the ascertained injuries, disabiHtles and damages, but also the possibility that the injuries sustained may be permanent and progressive and recovery there from uncertain and indefinite, so that k~rrsequences not now antidpated may result from the said accident. i hereby agree that, as a further oorrsideration and inducement for this compromise settlement, this settlement shalt apply to all unknown and unantidpated injuries and damages resulting from said accident, casualty or event. as well as to those now disclosed. I understand that the parties hereby released admit no liability of any sort by reason of said acddent and that said payment and settlement in compromise is made to terminate further controversy respectlng all claims for damages that 1 have heretofore asserted or that I or my personal representative might hereafter assert because of the said accident. I further understand that such liabil'rly as I may or shall have incurred, directly or indirectly. in connection with or for damages arising out of the accident to each person or organization released and discharged of ilability herein, and to any other person or organization, is expressly reserved to each of them, such liability not being waived, agreed upon, discharged not settled by this release. Uwe further understand and agree that this Release is inclusive of any and all present and future Ilene or claims for submgatlon against the payments to be made in accordance with this Release. I/we understand and agree that Nwe are nasponsitsle for the payment of any liens or charges against the payments to be made hereunder should any such Dens, subr+ogati~ claims, or claims for expenses and charges be asserted. This includes. but is not limited to. medkal expense liens, workers' compensation liens, ERISA Bens, Brms asserted by any federal, state, or local governmental entity or agency or any health care benefit daim. Should any person or entity make daim for payment of any liens or charges against Y„1111ham Oyler and Thomas Oyler. Uwe agree to indemnify and hold hamrless <Mlham Oyler and Thomas Oyjer from any such hens, charges, fees, claims, attorney fees, costs, interest and any other sum. "Any person who knowingly and with intent to injure or defraud any insurerfilQS an application or claim containing any false, incomplete or misleading infornation shall, upon convidlon, be subject to imprisonment for up to seven years and the payment of a fine of up to 515,000 " 05!14/2010 09:20 2152938437 ALLSTATE RELEASE OF ALL, CLAIMS PAGE 03!04 CLAIM NO: 01646-0767-3 UDP 'Any person who knowingly and with intent to defraud any insurance company or ether person filQS an application for insurance or statement of claim containing any materially false informatitffr or conceals for the purpose of misleading. irrfonnation concerning arty fact material thereto commits a fraudulent insurance act. which is a crime and subjects such person to criminal and civil penalties." Signed and sealed this day of (CAUTION -READ BEFORE SIGNING) Witnessed by: (SEAL) ~sEAL) SS 0n this day of _ ,before me personally Appeared ,tome known to be the person who e~aecuted the foregoing Instrument. and aclmowledged that executed the same as free act and deed. My commission expires Notary Public STATE OF 1 COUNTY•OF J 05f14f2010 09:20 2152938437 ~ ALLSTATE ~ PAGE 04f04. _ .' • • ( '. i I • i Coverage Information -1999,ESCRT,ESCRT,3~AKP1139XR201026 Road Coverage Limi! i , ~ r Bodily Injury Liability 25000150,000 Medical Payments ~ ~ 5,000 Underinsun~d MotoristcBodilylnjury a ~ Staekable 25,000 / 50,000 Un~sured Motorist Botilly Injury Staokable 25,000 /50,000 Comprehensive (Fuil~ .~ r 1 Funeral Expenses 2,500 !'-: Prt~cerq/ Damage Liability 26,000 I tteatl Coverage Deductible Type Deductlble ! I ! 50 Comoreher~~jv_e.(Fj~ Drivcrs Included: WILLIAM OYLER, LINDA OYLER, THOMAS OYLER Excluded: Norte j~d Polly Form ~3eve EXHIBIT C State Farm. Insurance Companies April 30, 2010 David Lederman, Attorney Shumaker Williams 3425 Simpson Ferry Rd Camp Hill, PA 17011 STATE FARM __.... INSYRANCE 8 State Farm Insurance Companies PO Box 142 Concordville, PA 1 9331-01 42 Fax: (888! 713-4693 _ RE: Claim Number: 38-L903-614 Date of Loss: April 4, 2010 Our Insured: James M Johnson Your Client: Estate of Jessie Johnson Dear Mr. Lederman: State Farm is offering the $100,000 non stacking underinsured policy limit for the Estate of Jessie Johnson. I am enclosing a certificate of coverage. Please forward the court approval once you obtain it. Sincerely, ~~n~ol ~ aren Kardos Claim Representative (724) 743-4972 State Farm Mutual Automobile Insurance Company Enclosure(s): certificate of coverage MAY 4 7 2010 HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 St-ate Farm Insura-nce -Compani-es-- CERTIFICATE OF COVERAGE Claim Number: 38-L903-614 Vehicle Number: 004 The undersigned is a Claim Team Manager for: State Farm County Mutual Insurance Company of Texas State Farm Lloyds, Inc. State Farm Indemnity Company State Farm Mutual Automobile Insurance Company State Farm Fire and Casualty Company fTATE FA E;M ~NSUewwce e State Farm Insurance Companies PO Box 142 Concordville, PA 19331-0142 Fax: (8881 713-4693 This certifies that policy number 7205-898-38T, covering a 2007 Chevrolet Cobalt, was issued to James M Johnson and was in effect on the accident date of April 4, 2010. The coverages and limits of liability for this policy on that date were: A 100/300/100,02 S,OOO,D,G500,H,U3 100/300,W3 100/300 F 2,500 This policy provides Limited Tort. ~~ eresa L. Wilson Claim Team Manager State of Pensylvania }ss. County of Washington Subscribed and sworn to before me this T~ day of ~ , ( ear v~ C.~ , ~~~~ Notary Public M Y 44 Notarial Seal Nlari~anre V. Harrison. Notary Pubic t-ny Carrnission E~ Hlov. ?2.201 t S obile Insurance Company HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 EXHIBIT D CONTINGENT FEE AGREEMENT FOR LEGAL SERVICES We, James M. Johnson and Teresa E. Johnson, and the Estate of Jessie E. Johnson, do hereby employ and retain SHtTMAI~ER WILLIAMS, P.C. ("Firm"), to represent us (i) in connection with the recovery from insurance carriers, and other potentially responsible parties, of damages arising from the accident of April 4, 2010, which resulted in the death of Jessie E. Johnson; and (ii) in the administration of the Estate of Jessie E. Johnson. We agree to pay the Firm on the following terms: (a) An amount equivalent to fifteen percent (15.0%) of the amount of the recovery from all insurance carriers and other potentially responsible parties, unreduced by any costs or expenses; provided, however, that the following percentages shall be substituted in place of fifteen percent (15.0%) in the event that the Firm expends time exceeding forty (40) hours to obtain a recovery from any responsible party: twenty-five percent (25.0%) of the settlement with such party if settlement is reached prior to filing suit; one-third (33.3%) if settlement is reached or a final judgment obtained after filing suit; and forty percent (40.0%} if settlement is reached or a final judgment obtained subsequent to the filing of an appeal from any judicial determination. (b) We understand and agree that all costs and expenses incurred by the Firm in connection with this representation will be reimbursed first to the Firm from any settlement or judgment. (c) The costs and expenses that may be incurred by the Firm and to which the Firm will be entitled to reimbursement, as described above, include, but are not limited to, filing fees, reproduction costs, telephone charges, travel expenses, court reporters' costs, investigation costs, witness fees, medical records, physicians' reports, expert witness expenses and any and all other expenses incurred in pursuing the claims. )n the event of no recovery on the claims, the Firm will make no charges for its time or services. However, any costs or expenses that the Firm may have advanced on our behalf will be paid by us if requested by the Firm. (d) In the event that we decide to change attorneys prior to resolution of our claims, and we retain substitute counsel, or if we decide to proceed without counsel, we agree to reimburse the Firm at such time all advanced costs then outstanding in addition to the amount described in (a), above. (e) We fiuther understand and agree that if, after conducting an investigation of our claims, the Firm decides, for whatever reason, that it does not wish to proceed with a formal action, or if a formal action has been filed, the Firm does not wish to proceed further with its prosecution, then after notifying me of same, the Firm sha11 have no further obligation to proceed in the matter. We acknowledge that we have read this Agreement prior to signing it and agree to be bound by its terms. ESTATE OF JESSIE E. 3OHNSON J es M. Johnso Administrator J es M. Johnso v eresa E. Johnson SHUMAKER WILLIAMS, P.C. By: avid J. rmann ca/~„~//p :230747 EXHIBIT E August 3, 2010 Estate of Jessie E. Johnson (#10-724) FINAL ACCOIINTING AND DI3TRiBUTION OF THIRD PARTY and ONDERIN30R~SD MOTORISTS 3BTTLB)1IBNTS Re: Bstate of Jessie B. Johnson, Accident of Aprll 4, 2010 ACCOONTING Costs Advanced: Cumberland County Prothonotary -filing fee 92.00 Cost Advanced Total: $ 92.00 Settlement Amount: Less: Shumaker Williams, PC fees (15%) 18,750.00 Shumaker Williams costs advanced 92.00 TOTAL FEES AND COSTS 18,842.00 Checks Written: James M. Johnson and Teresa E. Johnson $74,310.60 Estate of Jessie E. Johnson 31,847.40 Shumaker Williams, PC fees 18,750.00 Shumaker Williams, PC costs 92.00 TOTAL CHECKS WRITTEN $125,000.00 $125,000.00 Date: Approved: James M. Johnson Approved: Teresa E. Johnson •, ~~ . +, EXHIBIT F ~, ~ •~ 1 ~ /I • __ _ s --pen-~-~y va~a _ _ DEPARTMENT OF REVENUE July 14, 2010 Marc G. Tarlow, Esquire Shumaker Williams, PC 1 East Market Street, Suite 301 York, PA 17401 Dear Mr. Tarlow: Re: Estate of Jessie E. Johnson File Number 2110-0415 Court of Common Pleas Cumberland County The Department of Revenue has received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 17 year old decedent died as a result of a motor vehicle accident. Decedent is survived by her parents. Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $87,500.00 to the wrongful death claim and $ 37,500.00 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. §8302; 72 P.S. §9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. S' cerely, on E. Baker Trust Valuation Specialist Inheritance Tax Division Bureau of Individual Taxes Bureau of Individual Taxes ~ PO Box 280601 ~ Harrisburg, PA 17128 ~ 717.783.5824 ~ shabaker@state.pa.us RECEIPT FOR PAYMENT ------------------- ------------------- Cumberland County Prothonotary's Office Carlisle, Pa 17013 JOHNSON JESSIE E ESTATE OF Case Number 2010-05178 Received of PD ATTY TARLOW DKB Total Non-Cash..... Total Cash......... Change ............. Receipt total...... Receipt Date 8/09/201;0.';;;; Receipt Time 15:17:1,6.x... Receipt No. 246440-~ w ,.w.. _..«.,,, ( VS ) OYLER THOMAS , ..... + 92.00 + .00 - .00 _ $92.00 ~., Check# 5817 ~°~ ~. -- ~-r.. ~..«... .«~.~, ------------------------ Distribution Of Payment -------------------- -------~-.~~.. .,,... Transaction Description Payment Amount s.. PETITION 55.00 CUMBERLAND CO GENERAL FUND TAX ON PETITION .50 BUREAU OF RECEIPTS AND CONTROL,.W SETTLEMENT 8.00 CUMBERLAND CO GENERAL FUND AUTOMATION FEE 5.00 CUMBERLAND CO AUTOMATI ON FUND °" JCP FEE 23.50 BUREAU OF RECEIPTS AND CONTRO;L;:,. $92.00 AUG 10 2010 ESTATE OF JESSIE E. JOHNSON by James M. Johnson, Administrator of the Estate of Jessie E. Johnson Petitioner V. Thomas Oyler Respondent IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PA CASE NO. 10 - 51'18tvi (Term : CIVIL ACTION: LAW ORDER APPROVING SETTLEMENT AND NOW, this day of 2010, it is hereby ordered and decreed that James M. Johnson, Executor of the Estate of Jessie E. Johnson is authorized to execute the Release as set forth in Exhibit "A," and the settlement and distribution of the proceeds of the Plaintiff's claim shall be as follows: 1. $92.00 to the law offices of Shumaker Williams, P.C. for costs advanced in the suit. V 2. $18,750.00 to the law offices of Shumaker Williams, P.C. as o attorney's fees._ 3. Under the Wrongful Death Act: $74,310.60 to be paid in equal part to James M. Johnson and Teresa E. Johnson._ _ G 4. Under the Survival Act: $31,847.40 to be paid to the Estate of Jessie E. Johnson. 5. James M. Johnson, Executor of the Estate of Jessie E. Johnson is hereby authorized to execute the Release attached to the within Petition as Exhibit "A." BY THE COURT: ?--c? j? ES rn? t l., K. kcLa ,piss 02 .Jo ?(t8?io ESTATE OF JESSIE E. JOHNSON : IN THE COURT OF COMMON PLEAS by James M. Johnson, Administrator of OF CUMBERLAND COUNTY, PA the Estate of Jessie E. Johnson Petitioner V. CASE NO. 10-5178 CIVIL TERM n f C__ _.. -, Thomas Oyler ; Mr n ? -? ? rn E - Respondent CIVIL ACTION: LAW r?°.. rv * r n C -C a o PRAECIPE TO SETTLE, P. r.) SATISFY AND DISCONTINUE zco =r - =. o ._.C: 7trZ -4 TO THE PROTHONOTARY: - Please mark the above captioned action settled, satisfied and discontinued. submitted, 0.2 -,2S' -// BY: Mar G. T ow, squire [ID 23474] Sh aker, illiams, P.C. On E"arket Street, Ste. 301 Yor , Pennsylvania 17401 Tele: [717] 848-5134 Fax: [717] 848-5125 :237976