HomeMy WebLinkAbout11-0641E.
ANNABELLE DONOVAN,
Defendant
PETITION FOR APPROVAL OF MINOR'S SETTLEMENT
AND NOW come Plaintiffs, Emily Huffer, a minor, by her natural mother and
guardian, Kristen Gold and Kristen Gold, in her own right, by their attorneys Freeburn
8v Hamilton, PC, and Petition this Court for approval of minor's settlement:
1. PARTIES
1. Plaintiff, Emily Huffer, is a minor born on May 25, 1994, who resides
with her natural mother and guardian, Kristen Gold, at 534 Salmon Road,
Mechanicsburg, Cumberland County, Pennsylvania.
2. Plaintiff, Kristen Gold, is Emily Huffer's natural mother and guardian,
who resides at 534 Salmon Road, Mechanicsburg, Cumberland County, Pennsylvania.
3. At all times relevant hereto, Kristen Gold has had and continues to have
primary physical custody of Emily Huffer and is authorized to bring this litigation
pursuant to Pa. R.C.P. No. 2228(b).
4. Kristen Gold and Emily Huffer are represented in this matter by
Freeburn & Hamilton, PC based upon a contingent fee agreement of 25% oche gross
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Christina L. Bradley, Esquire
FREEBURN & HAMILTON
ID No. 89107
4415 North Front Street
Harrisburg, PA 17110
(717) 671-1955
F11 ?D-CFFI , CE
CF THE.
CU?j ?Ft=i,;drJY D- ?A?i ?TY
Attorney for Plaintiffs
EMILY HUFFER, a minor, by KRISTEN IN THE COURT OF COMMON PLEAS
GOLD, her natural mother and CUMBERLAND COUNTY, PENNSYLVANIA
Guardian, and KRISTEN GOLD in her
own right,
Plaintiffs : C(?ITerm
NO V. oC
settlement proceeds, plus expenses. A true and correct copy of the Attorney's
Agreement is attached hereto as Exhibit "A".
5. Defendant, Annabelle Donovan, is an adult individual who resides at 104
Hillcrest Road, Camp Hill, Cumberland County, Pennsylvania.
II. FACTS
6. The facts and occurrences hereinafter related took place on or about
November 28, 2009, at or near the intersection of Market Street and Hillcrest Road,
Hampden Township, Cumberland County, Pennsylvania.
7. At or about that time and place, Plaintiff, Emily Huffer, was a front seat
passenger in a vehicle being driven by her step-father, Aaron Gold, which was
traveling westbound on Market Street, approaching the intersection of Market Street
and Hillcrest Road.
8. At or about that time and place, Defendant, Annabelle Donovan, was
operating her motor vehicle traveling southbound on Hillcrest Road.
9. At or about that time and place, Defendant, Annabelle Donovan, failed to
stop at a legally posted stop sign on Hillcrest Road at the intersection with Market
Street, and struck the vehicle in which Plaintiff, Emily Huffer was a passenger.
10. The impact caused the vehicle in which Plaintiff, Emily Huffer, was a
passenger to spin into the eastbound lane of Market Street, where it was struck by
another vehicle, the result of this impact causing the vehicle to roll onto the driver's
side, where it came to rest.
11. The Pennsylvania State Police conducted an investigation of the collision,
and the Commonwealth of Pennsylvania Police Crash Reporting Form is attached
hereto as Exhibit "B".
2
that no transfers or withdrawals can be made from the account until May 25, 2012,
when Emily Huffer reaches the age of 18.
25. Plaintiffs believe that this settlement is in the best interest of Emily
Huffer because it avoids the risk of obtaining a lesser recovery or no recovery at all.
WHEREFORE, Petitioner Kristen Gold hereby requests that this Honorable
Court enter an Order:
a. Approving the full and final settlement of this action;
Kristen Gold to sign all documents necessary to accomplish
y and
b. Authorizing
the settlement, including but not limite to the
of milyHuffer, Release, land all checks;
as parent and natural guardian
and expense proceeds as set forth herein,
c. Approving the distribution of the
including the payment of counsel fees
d. Directing payment of the net funds be made to a custodial savings
account be opened in the name of Emily Huffer with Metro Bank.
e, Directing Petitioner to file a Praecipe with the
ter settled and discontinued once
matter
Cumberland County marking this
the $14,000.00 payment has been received and the savings account
opened and funds disbursed; and
f. Staying all proceedings meanwhile.
Respectfully Submitted,
FREEBURN & HAMELTON, PC
By.
Christina L. Bradley,
I.D. No. 89107
4415 North Front Street
Harrisburg PA 17110
(717) 671-1955
Date: 1 /2 d Ilt Counsel for Plaintiffs
5
VERIFICATION
1, Kristen Gold, individually and as mother and natural guardian
of Emily Huffer, hereby verify that we are Plaintiffs in the foregoing
matter and that the statements in the PETITION FOR APPROVAL OF
MINOR'S SETTLEMENT are true and correct. We understand that false
statements herein are made subject to the penalties of 18 Pa.C.S. Section
4904, relating to unsworn falsification to authorities.
Dated:
Kristen Gold, individually and as
parent and natural guardian of Emily
Huffer
???$?
FREEBURN & HAMILTON, PC
ATTORNEY'S AGREEMENT
da of December, 2009, by and
THIS AGREEMENT entered into thi C? ys at-Law (hereinafter referred to as
between FREEBURN & HAMILTON, P ,
"Attorney") and KRISTEN GOLD, INDIVIDUALLY AND O eBEHALeferred MIL "Client,') FER,
HER MINOR DAUGHTER, her successors and ass g
WITNESSETH: That Attorney, for the consideration ? as leaal counsel indnegotiating settlement
and if the
does hereby undertake and agree with Client(s) to ac 9
of third party claims andlor claims for ctinsuand prosecuting ac ons t inlclud ng but not limited
same- is not effected, in bringing, condu g
to, actions for uninsured and Underinsured motof the be so'nal anju es wlhichaoccurred on or
determine may be liable for damages as a resu P
about 11/28/2009
ATTORNEY FEES:
In consideration for services so rendered b ensated as followsereby agreed by and
between the parties hereto that Attorney shall be comp
TWENTY-FIVE PERCENT (25%) oss re overy° shall mean the full amoeuntof sett ement
are filed with the court to list it for trial. G re- ud ment interest, without reduction for
proceeds or the full amount of verdict, including any p j 9
expenses or costs advanced or incurred.
THIRTY-THREE AND ONE-THIRD PERCENT (33 1/3%) of grosseree proceed ngpapers
are filed with the ith he court to? strit forltrial, hen codmmencement f trial is when the hearing
papers are filed with t
begins.
If Client(s) receive, via settlement °atio'n1g of Attorneyslashalll be t based ' onludhe
reimbursement for Attorneys' fees, compens
percentages as set forth above. Any award of attoenb led atsTwot Hundred and Fifty ($250 00)
Court to be computed on an hourly basis shall b er hour for law clerks and paralegals.
Dollars per hour for Attorneys and Ninety Five ($95.00) p
If you enter into a structured settlement edgo the sum of any ash paid n settlement
applicable percentage determined as above, app
plus the present cash value of the structured portion of the settlement, and payable in full from
the cash portion of the settlement.
If any additional work is required by uated for sucht'work at outer Segulah hourly ratestaand
witnesses or otherwise, we will be compens
for costs incurred.
ATTORNEY'S LIEN:
Attorney shall have a lie Veoed whether by settlement ar judgment ced and expenses
incurred on any sum or sums reco ,
Should this agreement be breached or otherwise terminated by Client prior to the
for any costs advanced by Attorney up to
resolution of the claim, Client shall reimburse Attorney
the any time of the breach or termination, and Attorney shall have a/tie n of a y settlement ?o i alin
recovered in the amount of TWENTY-FIVE PERCENT ment of the said
existence at the time of Client's
sum tor Attorneytout of the proceeds fi allya recovered.
fee, Client hereby assigns s the he said
Client shall
Should Attorney discharge Client or withdraw on the grounds sethef time olf discharge or
reimburse Attorney for any costs advanced by Attorney up to
he timount
withdrawal, and Attorney shall have a lien on any sum seor sums ttlement finally recd eyed in the
of TWENTY-FIVE PERCENT (25%) of any offer
ment of the said fee, Client hereby assigns the
discharge or withdrawal. In order to secure pay
said sum to Attorney out of the proceeds finally recovered.
EXPENSES:
d reasonable costs advanced by Attorney in the preparation and
from
reim
Any necessary an shall
the proceeds resentation of any Client's recovery. claim, and all expenses atteed Vath thereto,espect termi ation obth's agreeme t
p Except as set forth abov
prior to resolution of the case, Client shall have no obligation to reimburse Attorney for such
is obtained.
expenses if no recovery LEGAL REPRESENTATION
It is understood that FREEBURN & HAMILTON repress is Cliendwith rFREEBURNespect to
party claims and/or underinsured or uninsured motorist claims only, that & but
not HAMILTON does not represent Client with respect to any ti benef is such asl'so'c al
to property damage claims, insurance claims, claims for governmental
BURN unless
security benefits, or workers' compensation claims,
HAMILTONand eby F eeburnte&
understands
agreement is signed by both Client and FREE
FREEBURN and
Hamilton agrees to represent Client on such other matter. In earesear, Client
agrees that discussion of other legal matters with any p staff or attorneys &
HAMILTON, including it's attorneys d or stff or statements a legal m tters do notd constitute an agreement by
FREEBURN & HAMILTON regarding othe matter o that
FREEBURN & HAMILTON to represent Client co `otect Client's tights wi9h (respect torsuch
FREEBURN & HAMILTON will take any action to p tements
conduct
or by
the other legal matters. This provision cannot be modified thataother legal matters have t me
part of FREEBURN & HAMILTON. Client also understands file suit or ake
limits within which suit must be brought or actions thtsn, Cl and ent thaunderstandst the failure
agrees tthat
such actions will result in the loss of Clients rights. s rights on any
FREEBURN & HAMILTON will not file suittagreementpsosgnedllbytboth Client and
other legal matter unless and until a separate written
FREEBURN & HAMILTON, whereby FREEBURN & HAMILTON agrees to represent Client on
such other legal matter.
We will try to keep you currently informed of the status and progress of the case, but if at
any time you have questions or concerns about the case, please feel free to contact us. We will ly timely furnish you with copies of pertinent documents meand d as rtosyoua condition andsanybpert Went
manner. You agree to keep us currently informed
developments that come to your attention.
The decision to file suit and to list for trial shall be made by you in consultation with us.
2
We will make a reasonable effort to retain significant papers in the file for a reasonable
ll of
period after the conclusion of the matter. A our work touus by you will be will be owned and retained by
us. Original documents and other tangible things furnished sums due us, unless such
of our and upon payment of any
at your request at the erne d course our
items are consumed in work.
Legal representation contemplated herein does not include appeals or post trial motions, the but is limited to work up to a verdict or award. We all haveth that righwt utour sole obligation
etiono
prosecute or defend any appeals or post trial motions
deem expedient, economical or advisable, or to decline to do so in which event the
representation provided for herein shall be ended.
SETTLEMENT PROVISIONS:
Client(s) will not settle, adjust or compromise the above claim, or any proceedings in Attorney. connection therewith, without the advice andfor settlement of
made by furth
anderno9r to
to consider seriously any recommendation
unreasonably withhold consent to such settlement.
DISCHARGE OR WITHDRAWAL:
In the event that Attorney subsequently determines that the claim or suit lacks merit, or
fide settlement recommendation made by
Client(s) unreasonably withhold consent to any bona conceal Attorney, or Client(s) refuse or fail to cooperat with Attorney, this Agreeme t,
misrepresent facts regarding the above claim, o Client(s) commit reasonable notice to Client(s).
Attorney shall have the right to terminate his services upon giving
MISCELLANEOUS:
Client(s) understand, acknowledge and agree that Attorney does not guarantee the
outcome or eventual result of the above claim. t relates to Client agrees to promptly notify attorney
medical treatment or information
mp oymenthachanges in
Clients' claim such as changes in Client's
physical condition, and any witnesses, documents or other things that might be relevant to
Clients' claim.
-/ filed for
In addition, Client has advised Attorney that Client has __ has not
bankruptcy and agrees to immediately notify attorney if Client should file for bankruptcy.
-'*" received SSI
In addition, Client has advised Attorney that Client has has not
or public assistance benefits, and agrees to immediately notify attorney if Client should receive
SSI or public assistance benefits.
In addition, Client has advised Attorney of any potential liens that could be asserted
immediately notify Attorney if
including those listed below, and agrees to
against any recovery,
this information should change or if Client becomes aware of the possibility of any liens:
1. Child or spousal support obligations?
2. Medicare benefits?
3. Veterans benefits?
4. Public Assistance benefits of any kind?
5. Private health insurance?
6. HMO, PPO or other health benefits?
7. Disability benefits?
g, Workers' Compensation benefits?
9. Unpaid medical bills?
10. Other possible claims against recovery?
YES NO
-77-
-77
Client Initials
dical coverage in addition to
automobile
Client has --'does nq# nave me
insurance. If so, client has _ as not provided attorney with medical coverage
information including a copy of card. Client agrees to provide information about all medical
coverage to his/her medical providers at the time of medical service.
List each and every motor vehicle (including motorcycles) owned by or furnished for the
use of anyone who lived in your household at the time of the accident.
FREEBURN & HAMILTON, PC
By:
LRRiUchard E. Freeburn, Es ' e
4415 North Front Street
Harrisburg, PA 17110
(717) 671-1955
W it
Kristen Gold
4
IN WITNESS WHEREOF, the parties hereto, intending to be legally bound, have
hereunto set their hands and seals of this Agreement, in execution thereof, the day and year
first above written.
I ',?
0
Page 1 of 9
Print CRS W0134381
COMMONWEALTH OF PENNSYLVANIA I IIIIIII IIII VIII IIII IUI Crash Number
POLICE CRASH REPORTING FORM Page W0134381
Case Closed Reportable Crash
- patrol 500 1 0 Yes 0 No 0 Yes O No lice A ency - Patrol Zone
Inddent Poumber 21103 SE
HAM20091100946 Precinct nInvesO tonDate (M-DD YYYY)
A Name - 2$ - 2009
Hampden Township Badge Number
Di atch rime (mil) Arrival Time (miq Investi ato? 19-9
1100 1102 PTLM RICHARD NULTY Bade Number Approval Date (MM DD YYYY)
Reviewer 19-1 j 12 02 - 2009
JEFFREY A SNYDER oav °f week
County P?Crash e Municipality municipal . Name 0 Sun Q Thu
103 Hampde den Township 0 Mon O Fri
nd
Time (mil) No of Units Peo le Injured Killed' complete Q Tue O Sat
Crash Date (MM-DD-YYYY) 3 5 ?4 ?'i = form F Q Wed O Unk
s 11 - 28 - 2009 1100
11 School Zone , Notify PENNOOTO Yes 0 No
School Bus 0 Yes O No Related 0 les 0 NO Maintenance
WorkzoneYes Complete 0 yes O No Related
m M Section 29) ?Spgia(
M e4 Q Off Ramp Q Railroad Crossing job 00
f fta 0 4 Way Intersection O 'Y" Intersection O IntersectUOr
Traffic Circle/ 0 On Ramp
0 Midblock 0 'T" Intersection O Round About
Route Number Segment (Optional) Travel Lanes Speed Limit
e 1010 03 40
Street Name
MARKET
Turnpike Turnpike O State
Interstate Hi hw
iDnfDQ 0 (Not Turnpike) 0 (East/West) 0 Spur 9
signing
Q Crossover O Other . See Overia
Hous e Number (if applicable)
O North
c O South
!
Street Ending •
.A. (D East
For Mid-block crashes only. Use
ostal House Number and make sure
ST (? West p
Principal Roadway Street Name is
(? Unknown }filled in if using this option
County
O Local Road
O O Private O Other!
Road Unknown
Road or Street
Q North
O South
3
t Ending
S
O East
tree ?
Q West.
RD O 0 Unknown
County O Local Road
Road or Street
Route N? Se ment 1uPooneq • -- 25 -
in r 02
u =Street Name
HILLCREST
8
Route Interstate 0 Turnpike Turnpike 0 State
Highwa)
P
s SigniW 0 (Not Turnpike) (East/West)
Private O Other/
0 Road Unknown
intersecting Fit Hum Or Mile Post ? Or Segment Marker
O
Q North
Q South Feet
v " S
ui
P
o Please e
E Or intersecting Street Name
( q
t 0 East
Q West Or Miles
?
Enter °C •
16 Information
° for BOTH
Landmarks
if Using
Intersecting Rt Num Or Mile Post
x ??
Or Segment Marker
? Q North
? N Q South
Distance From Crash
Scene to Landmark t
(for Crash between
option
This t . St Ending O East Landmark 1 and
e E Or Intersecting Street Name
E
E Q West
Landmark 2)
®
l J Degrees?
D reel Minutes Seconds
1 6 Latitude: ?•?-? Lon gitude: -
URMfic ceam l Dev ice Q Yield Sign Q Police Officer or
Flagman
® Q Not Applicable O Traffic Signal Active RR Crossing
Controls 0 Other Type TCD
e oV- O Flashing Traffic
Signal 0 Stop Sign O Passive RR
Crossing Controls_ Q Unknown
_
L,lag_12Md (If Not Applicable`, skip rest of the Lane closure section)
Q Not Applicable 0 Partially O Fully O Unknown
Minutes Seconds
ILU-MUHRRUM Emergency
Device Functioning 0 Preemptive
0 No Controls O Improperly Signal
Device Not 0 Device Functioning 0 Unknown
0 Functioning Properly
LA cl.+= Q North O East O North and South Q NIIS,E,W)
Qirio 0 South Q West O East and West
Ij > 9 hours lJ unKnow11 ,
SO No CD ?-r- Q < 30 Min. 0 30-60 Min. Q 1-3 hrs O 3 Ei hrs O 6 9 hrs ' J
Unknown O cow _
FOmr r AA-M (tarox) F ENNDOT COPY 1
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Page 2 of 9
Print CRS W0134381
CORflMORRf81F.t LTN OIF PENNSYLVANIA IIIIIIII?I?III I ? Crash Number
POLICE CRASH REPORTING FORM Page:
V-1- A 500 2 PoUse Use Only W0134381
Motor Vehicle in ille ali Parked O Legally Parked O Non - Motorized Commercial Vehicle
Q Hit & Run Vehicle O 9 Y O Yes O No
O Trnsrt Disabled From Q Train Phantom Vehicle
O Pedestrian on Skates, O Previous Crash !f yes, Complete Form C)
Q Pedestrian in Wheelchair, etc
(If 'Pedestrian" or "Pedestrian on Skates, in Wheelchair, etc", Complete ForMro M, Date of Birth (MM-DD-YYYY)
3
e
6
r
unit No First Name [M_? 08 l 3p 1923
Ol ANNABELLE Tele hone Number
fast Name 7177379791
DeleQte? DONOVAN
Zi
LAdo dr ess Ci / state 4 HILLCREST RD CAMP HILL PA smote Class
Driver license Number PA
Alcohol/Drugs sus ed Medication
O No O Illegal Drugs O
Q Alcohol O Alcohol and Drugs O Unknown
Alcohol Test Tree
Q Test Not Given
O Breath Q Other
Unknown if
O Blood O Urine O Test Given
Alcohol Test Results
O Test Refused Unknown
O Results
Fo? " Test Given,
O Contaminated Results
Owner/Driver 00=Not Applicable
01=Private Vehicle Owned/
01 Leased by Driver
Vehide True
01=Automobile
O l 02=Motorcycle
K03=Bus
04=Small Truck
(If "02", Complete Form
M. Section 26)
(if '20' or "2.1, Complete
O Illegal Drug O Fatigue O Medication
Apparently O Use Normal
O Had Been O Sick O Asleep O Unknown
n.1..L?nn --
Primary Vehide Code Violation Charged?
----- O Yes O No
STOP SIGNS & YIELD SIGNS
Driver Presence 1=Driver operated 3=Driver Fled Scene
Vehicle 4=Hit and Run
?
1 2=No Driver 9=Unknown
04=State Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh
05=PENNDOT Vehicle 08=01her Municipal 98=Other
06=Other State Gov Veh Government Vehicle 99=Unknown
owner Last Name or Business (74destrian, skip this Section)
DONOVAN
•lylovement 01 *See
Overlay
05=Large Truck 20=Unicycle, Bicycle,
06=SUV Tricycle
21=Other Pedalycie
07=Van
10=Snowmobile 22=Horse & Buggy
11 =Farm Equip 23=Horse & Rider
12=Construction Equip 24
13=ATV =Trolley
18=Other Type Spec Veh 98=0ther
19=Unk. Type Spec Veh 99=Unknown _
2nn /?ndkator
initial impact int ? O=None 2=Functional
12 00=Non-Collision 14=Undercarriage 3 1=Minor 3=Disabling
1-12=Clock Points 15=Towed Unit 9=Unknown
0
13=Top 99=Unknown
Vehid a Col"
____ 06=Yellow
07 07=Silver
08=Gold
Ot=Blue 09=Brown
02=Red 10=Orange
03=White 11 =Purple
04=Green 12=0ther
05=Black 99=Unknown
1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No Tag rear V
2=Towing Truck 5=Camper 8=Other
Unit 9=Unknown
3=Towing Utility Trailer 6=Full Trailer
Direction of [S 'Vehide position
01
rave
ailin
Tr
U E
nit No. of a
Trailing
r Units:
V
Drier O FRANCIS J & ANN -Make Code
Vehicle Make
Address / City / State f Zip Cadillac 19
104 HILLCREST RD CAMP HILL PA 17011
Model Year Vehicle Modell (see overlay)
v1N 1998 CATERA
W06VR52R8WR204152
Reg. State Est. Speed Vehicle Towed Towed By
License Plate PA 999 O Yes O No ROADSIDE AUTO R
PS00845
Policy No
Insurance insurance Company
O Yes O No O known LIBERTY MUTUAL A0228107057580
4
T. St
02=Private Vehicle Not
OwnecIA-eased by Driver
03=Rented vehicle
Same as Owner First Name
FORM 0 M-500 (12/02)
PENNDOT COPY
Special l/sa4e
00 12=Commercial
Passenger
00=Not Applicable Carrier
01=Fire Veh
02=Ambulance 13=Taxi
21 =Tractor Trailer
03=Police 22=Twin Trailer
08=0ther Emergency 23=Triple Trailer
31 =Modified Veh
Vehicle
11 =Pupil Transport 99=Unknown
-Gradient 3=Downhill
4=Bottom of Hill
1=Level 5=Top of Hill
32=Uphill l 9=Unknown
Road A!lanment
1=Straight
2=Curved
9=Unknown
es/20091194892009120215595959... 12/2/2009
Page 3 of 9
Print CRS W0134381
?IN II I?I ?
Crash Number
O6bWEALVQ9 OF PI:NNSVLVANIA IIII?II?
OORRRfl
('POLICIE CRASH REPORVIIdCs F®R6Vli page:
AA 500 2 Poke Use Only ? WO,134381
Parked O Non Motorized Commercial Vehicle
Hit & Run Vehicle O Illegally Parked Legally
O O Yes O No
Q Train O (If Yes, Complete Form Q
V:7777 Disabled From Phantom Vehicle
Pedestrian on Skates, O Previous Crash
in Wheelchair, etc M, Section destrian on Skates, in Wheelchair, etc",
,
NAi Date of Birth(MM-DD-YYYY)
d?
Y
Unit No First Name a [11
j l g 1976
02
K AARON ___
Tele hone Number
Last Name 7175541516
Deleette? GOLD
zi
Address / Ci / State 17050
534 SALMON RD MECHANICSBURG PA Class
t
S
Driver license Number e
ta
1=:D Em=
Alcoh S-?clegd Medication
Q No Q Illegal Drugs O
Q Alcohol O Alcohol and Drugs O Unknown
Alcohol Test e
n
Gi
Q Breath Q Other
ve
Q Test Not Unknown if
O
Q Blood Q Urine Test Given
Alcohol Test Results
O Test Refused Unknown
O Results
MI" = Test Given,
O Contaminated Results
OwnerlDriyer 00=Not Applicable
01 =Private Vehicle Owned/
0 1 Leased by Driver
Sam as owner First Name
e
Driver Q
/ State /
Lailin' of
`t Unrt Trai No.linngEl
e Units:
RMMon of M
rave
WWI v,
Apparently Q illegal Drug O Fatigue Q Medication
O Normal
O Had Been O Sick Q Asleep Q Unknown
n.inwnn
primary?Code ViolationCharged?
Q Yes O No
NONE
Driverc? 1=Driver Operated 3=Driver Fled Scene
? Vehicle 4=Hit and Run
1 2=No Driver 9=Unknown
04=State Police Vehicle 07 =Municipal Police Veh 09=Federal Gov Veh
05=PENNDOT Vehicle 08=0ther Municipal 98=Other
06=Other State Gov Veh Government Vehicle 99=Unknown
rVAULTRUST ner Last Name or Business Name (If Pedestrian, skip this Section)
Make Code
Vehicle Make
Cadillac 19
SS CENTER DR HORSHAM PA 19044 l (see overlay)
d
555 BUSINE Model Year e
Vehicle Mo
VIN 2006 CTS
1G6DP577X60190396
Reg. State Est. Speed Vehicle Towed
Towed By
License Plate
PA
999
Q Yes O No
ROADSIDE AUTO R
FP12010
Policy No
insurance
n Insurance Company
NCE Q052507753H
` O Yes O No O k ERIE INSURA _
o own Y Tag St
1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer lag No lag ear
e 2=Towing Truck 5=Camper B=Other
Unrt 9=Unknown
3=Towing utility Trailer 6=Full Trailer
wehicle Position E:1
Vehicle Color
06=Yellow
03 07=Silver
08=Gold
01=81ue 09=Brown
02=Red 10=Orange
03=White 11=Purple
04=Green 12=Other
05=Black 99=Unknown
Vehicle Tvae
01=Automobile
O 1 02=Motorcycle
K03=Bus
04=Small Truck
(if -02m
on 26) fete Form
M. Sect
(If "20" or '21", Complete
initial impact Point
03 00=Non-Collision 14=Undercarriage
01-12=Clock Points JovorwedUnit
13=Top 99
p
Fonts 1 AA-5W t12W)
02=Private Vehicle Not
OwnedA-eased by Driver
03=Rented Vehicle
•pgovement E1 *See
overlay
05=Large Truck 20=Unicycle, Bicycle,
06=SUV Tricycle
21 =Other Pedalcycle
07=van
10=Snowmobile 22=Horse & Buggy
11 =Farm Equip 23=Horse & Rider
12=Construction Equip
Trolley
25
13=AN
18=0ther Type Spec Veh 98=0ther
19=Unk. Type Spec Veh 99=Unknown
Damaa?fidic?to!
? O=None 2=Functional
3 1=Minor 3=Disabling
9=Unknown
PENNDOT COPY
Special Usa 1
00 12=Commercial
Passenger
00=Not Applicable Carrier
01 =Fire Veh 13=Taxi
21 =Tractor Trailer
02=Ambulance
03=Police 22=Twin Trailer
08=Other Emergency 23=Triple Trailer
31 =Modified Veh
Vehicle
11=Pupil Transport 99=Unknown
Gradient 3=Downhill
4=Bottom of Hill
1E 1=Level 5=Top of Hill
2=Uphill 9=Unknown
Road Alignment
1=Straight
2=Curved
9=Unknown
Files/20091194892009120215595959... 12/2/2009
Page 4 of 9
Print CRS W0134381
IIII?I? III I?I? ?
flI I®61'I?i9(EALQI41 Off PENNSYLVANIA I II I Crash Number
_.J COR
POLICE CRASH REPORTING FORM Page:
AA 500 2 PoiKeuseo?y W0134381
Motor Vehicle in Q Hit& Run Vehicle O Illegally Parked O Legally Parked Q Non - Motorized Commercial Vehicle
Q Yes Q No
T e O Transport
Pedestrian on Skates, Q Disabled From
Previous Crash
it
U
O Phantom Vehicle
Q Train O (if Yes, Complete Form C)
o n
Q Pedestrian
in Wheelchair, etc
M,
m
destrian on Skates, in Wheelchair, etc', Complete For
"P
'
e
or
(If 'Pedestrian
First Name M
l
Date of Birth (MM DD YYYY)
1 1956
Unit No 02 O
K] I BRIAN Tele hone Number
Last Name
7177661481
Delete?
Q
DIBERT -'-
ZI
Address 'C* I state 17050
6179 HAYMARKET WAY MECHANICSBURG PA Class
Driver License Number State
PA
e 22141922
Driver or Pedestrian Physical Condition
t ed
AlcohoVDruas Sus ct
Medication
Q Illegal Drugs O illegal Drug O Fatigue Q Medication
Apparently
Q O Use
Normal
Q No
Q Alcohol Q Alcohol and Drugs O Unknown
Unknown
Drnkin
O Had Been Q Sick Q Asleep O
a
Primary Vehide Code Violation Charged?
Alcohol Test Type ?- Q Yes Q No
O Other
s Q Test Not Given Q Breath
Unknown if
O
NONE
Test Given
Q Blood O Urine
Unknown
Driver Ce 1=Driver Operated 3=Driver Fled Scene
y Alcohol Test Results Q Test Refused O Results
Test Given Vehicle 4=Hit and Run
No Driver 9=Unknown
a 2
Fol ,
O Contaminated Results =
.
_ownerlDriVer 00=Not Applicable 02=Private Vehicle Not
i 04=State Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh
Municipal
O
D
ver
0 1=Private vehicle Owned/ Owned/Leased by Dr
01 Leased by Driver 03=Rented Vehicle Vehicle 99 =Unknown
tate Gov Veh
S
06=Other
st Name or Business Name (If Pedestrian, skip this Section)
L
Owner first Name
Same as a
Owner
LEASE TRUST
HONDA
Driver Q 1 __j
Address / Ci /state !Zip -
Vehicle Make "Make Code
Honda 37
SUIT NEWARK PA 19713
INENTAL DR l (see overlay)
d
,
121 CONT Model Year e
Vehicle Mo
VIN 2008 ACCORD
1HGCP26398AO12242
Reg. State Est. Speed Vehicle Towed Towed By
License Plate
PA Q Yes O No ROADSIDE AUTO R
999
ETB2033 Policy No
fnsurance Insurance company
RM
6638566E17-380
e Q Yes ONO O kn
n STATE FA
ow Y Ta St
a
Trails
Unit No. of a
Trailing
I Units:
.Y
1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No ag ear
T 5=Camper 8=Other
2=Towing Truck ?
U
3=Towing Utility Trailer 6=Full Trailer 9=Unknown
> Direr of a "Vehid °-n O l
rave
Vehide Color
06=Yellow
07
K 07=Silver
06=Gold
01=81ue 09=Brown
02=Red 10=Orange
03=White 11 =Purple
04=Green 12=0ther
05=81ack 99=Unknown
*movement 01 *see
Overlay
Vehicle TVae 05=Large Truck 20=Unicycle, Bicycle.
Tricycle
01=Automobile 06=SUV
07=Van
21 =Other Pecialcycle
O1 02=Motorcycle 10=Snowmobile 22=Horse & Buggy
03=Bus
04=Small Truck 11=Farm Equip
i 23=Horse & Rider
24=Train
{If "02Complete Form p
12=Construction Equ 25=Troiley
m, Section 26) 13=ATV
18=Other Type Spec Veh 98=Other
(if "20" or '21", Complete 19=Unk. Type Spec Veh 99=Unknown
Form m, section 27)
Initial Impact Point
12 00=Non-Collision
01-12=Clock Points
13=Top
FORM # M-500 (12102)
Damaoe Indicat°? Gradient
14=Undercarriage O=None 2=Functional 1 1=Level
15=Towed Unit 3 1=Minor 3=Disabling 2=Uphill
9=Unknown
99=Unknown ==
PENNDOT COPY
Special Usaae
00 12=Commercial
Passenger
00=Not Applicable Carrier
01=Fire Veh
02=Ambulance 13=Taxi
21=Tractor Trailer
03=Police 22=Twin Trailer
08=Other Emergency 23=Triple Trailer
31=Modified Veh
vehicle
i t=Pupil Transport 99=Unknown
3=Downhill Road Alirlnment
4=Bottom of Hill a 1=Straight
2=Curved
5=Top of Hill
9=Unknown 9=Unknown
]Files/20091194892009120215595959... 12/2/2009
Page 5 of 9
Print CRS W0134381
` COMMOV41WEALTH OF PENNSYLVANIA ?IINII?IIIII?II?III
J POLICE CRASH REPORTING FORM Page
AA 500 3 Police use Only W0134381
Gi?iM
A 1=Driver D 00=Not APassenger/Occupant
i
l
2=Passenger es
c
01=Driver - All Veh
02=Front Seat Middle Position
7=Pedestnan
8=Other 03=front Seat Right Side
9=Unknown Row
ft Side Or
04=Second
L
e
yc a Pa
ition
P
dl
os
e
05=Second Row - Mid
06=Second Row - Right Side
&x_: 07=Third Row Or Greater -
B F =Female Left Side
M=Male 08=Third Row Or Greater -
U =Unknown Middle Position
09=Third Row Or Greater -
S
ity:
)
n
e Right Side
10=Sleeper Section of Truckcab
,rv
r
n
ev
O=Not Injured 11 =in other Enclosed
Passenger Or Cargo Area
1=Killed
2=Major Injury 12=ln open Area
(Back Of Pickup, Etc.)
3=Moderate
1M 13 =Trailing Unit
14=Riding On Vehicle Exterior
4=
nor Injury
B=Injury, Unk 15=Bus Passenger
Seventy
9=Unknown if 98=Other
99=Unknown
injury
E 00=None Used / Not Applicable
01=Shoulder Belt Used
02=Lap Belt Used
03=Lap And Shoulder Belt Used
04=Child Safety Seat Used
05=Motorcycle Helmet used
06=Bicycle Helmet Used
10=Safety Belt Used Improperly
i t=Child Safety Seat Used improperly
12=Helmet Used Improperly
90=Restraint Used, Type Unknown
99=Unknown
Kai n. C.viinmeni TWO:
F 00=None Used / Not Applicable
01=Front Air Bag Deployed (For This Seat)
02=Side Air Bag Depployed (For This Seat)
03=Other Type Air Ba Deployed
04=Multiple Air Bags Deployed
05=Motorcycle Eye Protection
06=Bicyclist wearing Elbow/Knee/Pads
10=Air Bag Not Deployed, Switch On
11 =Air Bag Not Deployed, Switch Off
12=Air Bag Not Deployed,
Unk Switch Settingg((
I 3=Air Bag 9=UnknownelmAirr BagrDeployedsh)
1
99=Unknown
(3 3=-Not Applicable
1=Not Ejected
2=Totally Elected
3=Partially Ejected
9=Unknown
Crash Number 7
OO=Not Ejjec ed / Not Applicable
1=Through Side Door Opening
2=Through Side Window
3=Through Windshield
4=Through Back Door
5=Through Back Door Tailgate opening
6=Through Roof opening (Sunroof/
Convertible Top Down)
7=Through Roof Opening (Convertible
Top Up)
9=Unknown
Extra anon: .
O=Not Applicable
1=Not Extrcated
2=Extricated By Mechanical Means
3=Freed By Non - Mechanical Means
8=Other
9=Unknown
ll ___ ----
Ems Agency: HAMPDEN, SILVER SPRI Medical Facility: HOLLY SPIRIT HOSPITAL, HERSHEY M II
0?2?
Unit No Person No Delete? Date of Birth (MM-DD YYY A B C D E F
0 ] 103 04 ?
08 30 - 1923
0]
O1 O
sp No
Name / Address / Phone ERRS Transport
Same as DONOVAN, ANNABELLE M 104 HILLCREST RD CAMP HILL PA 17011 EM Yes _
Operator G H I
Unit No Person No Date of Birth (MM DD YYYY) E F
04 a
Delete? _ 18 - 1976 ? E] a 01 V 03 15-1 El
02 O1 O 11 EMS Transport
Name / Address / Phone
El same as GOLD, AARON J 534 SALMON RD MECHANICSBURG PA 17050 71755 Q Yes O No
Operator E F G H I
04
Unit No Person No Delete? 1994 2 F 4 03 0o 3 Date of Birt h 5 uv . ro F E? c] o 0 0 0
02 02 O OS - 25 EMS Transport
Name / Address / Phone O No
c Same as EMILY HUFFER 534 SALMON RD MECHANICSBURG PA 17050 717554 EM Yes
Operator _ H I
O Birth (MM DD YYYY) a Ll D E
_J 04 F 1 0 1
Unit No Person No Delete? fff]
] 956 EI M 4 O l 1I 03
03 O1 - O1 -?
EMS Transport
Name / Address / Phone O No
C1 Same as DIBERT, BRIAN R 6179 HAYMARKET WAY MECHANICSBURG PA 1705 EM Yes
Operator F G H I
Unit No Person Na Delete? Date of Birth (MM-DD-YYYY) ? B C 070 03E 04 E] a a
6
03 02 O 06 - 0? - 1995 EMS Transport
Name /Address /Phone
same as JENNIFER DIBERT 6179 HAYMARKEY WAY MECHANICSBURG OA 1705 Q Yes O No Operator ---
Date of Birth (MM DD-YYYY) "D E F G H I
Unit No Person No Detete7 - = ? ? ? C I = EXT]
?
a O EMS Transport
Name I Address I Phone - -J Q Yes O No
E) Same as I
Operator
FORM a AA-5W (12J=) PENNDOT COPY
aaP,;/XmlFiles/20091194892009120215595959... 12/2/2009
Wage 6 of 4
Print CRS W0134381
COMMONWEALTH OF PENNSYLVANIA
POLICE CRASH REPORTING FORM Page
AA 500 4 rrorce Use Only
O=Non Co illisonGsn 2=Head On 4=AM el
Ell =Rear End 3=Rear to Rear 5 ?m
(Baddng)
C
1=0n Travel Lanes 3=Median
Relation. _ to y 2=Shoulder 4=Roadside
3=0a? rk - Sireet-
c 1=Daylight Lights
M § IRuminatfon 2=Dark - No
Street Lights 4=Dusk
n
O 1=No Af)yerse 3=Sleet (Hall)
fNeather_ Conditions Condlhons
2=Rain 4=Snow^__
1.2 Dry v 2=S la
Road Sun`a a nd, Mud, Dirt,
V Conditions O=
a 1=Wet 3=Snow Covered -
Harm EYen? ?/R Most7 U41 rty Pole Plumber
t 02 ? O
Unit No
01
a El 0
Please Put 3 ? O
1 E:::==
Events in
SqO?erial ?
0 4 O
n
is E
Horn Event L/R Most? Utility Pole Number
-` t 11 F1 O
Unit No
02 2? ? O
Please Put 3 O
c
Events in
sequential
order 4 0
Unit No Harm Event
First Unit No Harm Event Iwost
rarful armful 02
17 vent m O1 02 vent rn O]
h t e rash
Do not repeat this informatan w multiple Paw
Environmental / Roadwa 1 00 2 3
potential Factors (E/R)
00=None 11=Slippery Road Conditions (ice/Snow)
of=Windy Conditions 12=Substance On Roadway
02=Sudden Weather Conditions 13=Potholes
03=0ther Weather Conditions 15 7CD Obstructed ed Pavement
04=peer Roadway 16=Soft Shoulder Or Shoulder Drop Off
05=Obstacle cle Roadway 28=Other Roadway Factor
O6=Other Animal in Roadway 29=other Environmental Factor
18 07=Glare
c 08=Work Zone Related 99=Unknown
0 12=Wipers
E Possible Vehicle Failures N) 13=Driver Seating/ Control
06=Exhaust
14=8 ody, Doors, Hood, Etc
w 00-T?e 07=Headlights 15=Trailer Hitch
5 02=8rake System 08=S' nal Lights 16=Wheels
rn 03=Steering System 09=0ther Lights 17=Airbags
a 04=Suspension 10=Horn 18=Trailer overloaded
05=Power Train 11 =Mirrors 19=Unsecure/Shifted
Trailer Load
e unit 1 00 2 20=Improper Towing
$ No O1 ? 21=Obstructed Windshield
99=Unknown
unit 02 t 00 2
No _J
Indicated Prime Factor Unit No Factor Code
Do not repeal this inramation on 01 08
19 multiple pages.
E/R V D P
if E/R is the Prime Factor
O O O O Type, leave unit No blank _
I?
?III?I?INII? Crash Number
M
W0134381
6=Sideswipe 8=Hit Pedestrian
(opposite Direction)
7=Hit Fixed Object
9=0therlUnknown
- _J
5=Outside TrafRCway
6=1n parking Lane
5=Fog
6=Rain &
4=Slush
5=ice
7=Gore (Ramp Intersection)
l)=Unknown
7=Sleet & Fog 9=Unknown
8=Other
6--ice Patches 8=0ther
Harmful Events (Harm Eventl
01=Hit Unit 1
02=Hit Unit 2
03=Hit Unit 3
04=Hit Unit 4
05=Hit Unit 5
06=Hit other Traffic Unit
07=Hit Deer
08=Hit Other Animal
09=Collision with other Non
Fixed Object
11 =Struck By Unit 1
12=Struck By Unit 2
13=Struck By Unit 3
14=Struck By Unit 4
15=Struck By Unit 5
16=Struck By Other Traffic Unit
21=Hit Tree Or Shrubbery
22=Hit Embankment
23=Hit Utility Pole
24=Hit Traffic Sign
25=Hit Guard Rail
26=Hit Guard Rail End
27=Hit Curb
28=Hit Concrete Or
Longitudinal Barrier
29=Hit Ditch
30-Hit Fence Or Wall
31 =Hit Building
32=Hit Culvert
33=Nit Bridge Pier Or Abutment
34=Hit Parapet End
35=Hit Bridge Rail
36=Hit Boulder Or Obstacle
On Roadway
37=Hit impact Attenuator
38=Hit Fire Hydrant
39=Hit Roadway Equipment
40=Hit Mail Box
41 =Hit Traffic island
42=Hit snow Bank
43=Hit Temporary Construction
Barrier
48=Hit other Fixed Ob1ect
49=Hit unknown Fixed Object
50=OvertufrVR011 Over
51=Struck By Thrown Or Falling
Object
52=Pot Holes Or Other
Pavement Irregularities
53=Jacknife
54=Fire In Vehicle
58=Other Non-Collision
99=Unknown Harmful Event
00=No Contributing Action
01 =Driver Was Distracted
02=Driving Using Hand Held Phone
03=Driving Using Hands Free Phone
04=Making illegal U-Turn
05=Improper/Careless Turning
06=Turning From Wrong Lane
07 Pr=oceeding a After Stop
lo Respond To
Traffic Control Device
Stopped On Road
i Passing Or Lane
In No Passing Zone
The Wrong Way On
Street
Backing On Roadway
18=Driving On The Wrong
Side Of Road
19=Making improper
Entrance To Highway
20=Making improper Exit
From Highway
21 =Careless Parking/Unparking
22=Over/Under
Compensation At Curve
23=Speeding
24=Driving Too Fast For Conditions
25=Failure To Maintain Proper Speed
26=Driver Fleeing Police (Pol Chase)
27=Driver inexperienced
28=Failure To Use Specialized Equip
92=Affected By Physical Condition
98=Other improper Driving Actions
99=Unknown
UUnit 01 r It E8:] 2 3 41 1
rUni
t 0? 2 3 4
I_
n' <03=Working
04=Pushing Vehicle
roaching Or Leaving Vehicle
05=App
ing Or Crossing At 06=Working On Vehicle
fied Location 07=Standing
ing, Running, Jogging, 9B=Other
aying 99=Unknown
o O1 Unit No 02
FORM 9 A A-600 COPY
mages/XmlFiles/20091194892009120215 595 959... 12/2/2009
Page 7 of 9
Print CRS W0134381
J COMMONWEALTH OF PENNSYLVANIA
j? PONCE CRASH REPORTING FORM Page
AA 500 4 Police use only . J
O=Non-Collision 2s Head On
Crash Description 1=Rear End 3=Rear to Rear-
(Backing)
Rotation to Roadwav
1=0n Travel Lanes 3=Median
2=Shoulder 4=Roadside
F1
N KR nation
v«
herCo !d_itions
c
y Surface Conditions
i =uayny, .
1 2=Dark - No
_ Street Light
? 1=No ditto se
] Conditions
2=Rain
0Dry
=
I =Wet
4=Dusk
III II?I?IWIIII?IN?? Crash Number
W0134381
4=Angle 6=Sideswipe B--Hit Pedestrian
5= ideswipa (Opposite Direction)
Same oiradion) 7=HR Fixed Object 9=OtherlUnknown
-
I
5=0utside Trafficway 7'=Gore (Ramp Intersection)
6=1n Parking Lane 9=Unknown
--- -- 9=Unknown
3=Sleet (Hail) 5=Fog 7=Sleet Fog
6=Rain r£ Fog B=Other
4=Snow --- ---._ _ -__ -- - =----- --
2=Sand, Mud, Dirt, 4=Slush 6=Ice Patches 8=Other
01 5=Ice 7=W t r -. Standing
3=Snow Covered orovmg -_
Harmful Events (Harm Eventl
1 12 ?
Unit No El O
K:]2 F] O
Please Put 3 []o E:::==
Events in
Sequential
order 4 ? 0
0
E
Harm Event L/R Most? Utility Pole Number
1 El o
Unit No
El 0
Please Put 3
Events in F? o E::::=
c
Sequential
order 4 ? ? 0
First Unit No Harm Event Most unit mo namr ?.or
}7armful armful
vent m O1 02 vent rn O1 02
o rash e rash
Do not repeat this information on multipk pages
Environmental / Road a 1 00 3
Potential Factors (E/R)
00=None 11 =Slippery Road Conditions (Ice/Snow)
01--Windy Conditions 12=Substance On Roadway
02=Sudden Weather Conditions 13=Potholes
03=01her Weather Conditions 14=Broken Or Cracked Pavement
o4=Deer in Roadway 15=TCD Obstructed
05=Obstacle On Roadway 16=Soft Shoulder Or Shoulder Drop Off
06=0ther Animal in Roadway 28=0ther Roadway Factor
07=Glare 29=Other Environmental Factor
08=Work Zone Related 99=Unknown
0
12=wipers
a Possible Vehicle Failures M 13=Driver Seating/Control
E 00=None 06=Exhaust 14=Body, Doors, Hood, Etc
.° 01=Tires 07=Headlights 15=Trailer Hitch
02=Brake System 08=Signal Lights 16=wheels
03=Steering System 09=Other Lights 17=Airbags
T1 04=Suspension 10=Horn 18=Trailer Overloaded
05=Power Train 11 =Mirrors 19=Unsecure/Shifted
v Unit 03 Trailer Load
No 1 00 2 20=Improper Towing
21=Obstructed Windshield
99=Unknown
No Unit = 1 2 _
Indicated Prime Factor -Unit No Factor Code
Do not repeal this infwma[ron on O 1 OS
multiple pages.
E/R V D P ff
O O (P E/R is the Prime Factor
Type, leave Unit No blank
FORM a M-500 (sue)
01=Hit Unit 1
02=Hit Unit 2
03=Hit Unit 3
04=Hit Unit 4
05=Hit Unit 5
06=Hit Other Traffic Unit
07=Hit Deer
08=Hit other Animal
09=Collision with other Non
Fixed Object
11=Struck By Unit 1
12=Struck By Unit 2
13=Struck By Unit 3
14=Struck By Unit 4
15=Struck By Unit 5
16=Struck By Other Traffic Unit
21=Hit Tree Or Shrubbery
22=Hit Embankment
23=Hit Utility Pole
24=Hit Traffic Sign
25=Hit Guard Rail
26=Hit Guard Rail End
27=Hit curb
28=Hit Concrete Or
Longitudinal Barrier
29=Hit Ditch
00=No Contributing Action
01=Driver Was Distracted
02=Driving Using Hand Held Phone
03=Driving Using Hands Free Phone
04=Making illegal U-Turn
05=Improper/Careless Turning
06=Turning From Wrong Lane
07=Proceeding W/O
Clearance After Stop
To
oI Device
Stopped On Road
s Passing Or lane
in No Passing Zone
The Wrong Way On
Street
30=Hit Fence Or Wall
31 =Hit Building
32=Hit Culvert
33=Hit Bridge Pier Or Abutment
34=Hit Parapet End
35=Hit Bridge Rail
36=Hit Boulder Or Obstacle
On Roadway
37=Hit impact Attenuator
38=Hit Fire Hydrant
39=Hit Roadway Equipment
40=Hit Mail Box
41 =Hit Traffic Island
42=Hit Snow Bank
43=Hit Temporary Construction
Barrier
48=Hit Other Fixed Object
49=Hit Unknown Fixed Object
50=Overturn/Roll Over
51=Struck By Thrown Or Falling
Object
52=Pot Holes Or Other
Pavement irregularities
53=Jacknife
54=Fire in Vehicle
58=Other Non-Collision
99=Unknown Harmful Event
Backing On Roadway
18=Driving On The Wrong
Side Oi Road
19=Making improper
Entrance To Highway
20=Making improper Exit
From Highway
21=Careless Parking/Unparking
22=OverlUnder
compensation At Curve
23=Speeding
24--Driving Too Fast For Conditions
25=Failure To Maintain Proper Speed
26=Driver Fleeing Police (Pol Chase)
27=Driver Inexperienced
28=Failure To Use Specialized Equip
92=Affected By Physical Condition
98=Other improper Driving Actions
99=Unknown
-..uy
Noit 03 1 001 Z 3 4
4
Unit t C? 2 3
No
Pedestrian Action (P)
00=None
01=Entering Or Crossing At
Specified Location
02=Walking, Running, Jogging,
Or Playing
Unit No 03 ??
03=Working
04=Pushing Vehicle
05=Approaching Or Leaving Vehicle
06=Working on Vehicle
07=Standing
98=Other
99=Unknown
Unit No
PENNDOT COPY
1PR/20091194892009120215595959... 12/2/2009
Page 8 of 9
Print CRS W0134381
COMMONWEALTH OF PENNSYLVANIA Crash Number
POLICE CRASH REPORTING FORM Page
AA 500 5 PotKe use ony W0134381
:...
......... ........._........._...... o
Witness Name Address - 7172213990
YVETTE KANE 228 WALNUT ST HARRISBURG PA 17101
HANNA MARIE WENK 5138 JENNIFER CIR MECHANICSBURG PA 1 7177373838
17737 Damage O
Narrative and additional witnesses: Accident Investigation Notification Issued? 0 Property
Cadillac Ca 10-45 RPT, 44303 Carlisle Pk- V1 Donovan
CTS ( P12010) , (V3 Dbert (2211418922)/2008 Honda Acccord (ETB2033). V1 was
(26494737) 737)!2006 Cadillac crest d when, according to several heading south on Halnd Carl isle Pk V1 struck V2 which wasthead heading west on the Carlisle Pk. Based upone
sign scene
by V3.
was st
rest Rd ane where
The evidence, tire marks and vehicle roll over onto the spun into the eastbound
side of the vehicle. V3lthen cont nued eastron the Carl isle
resulting impact caused and
suffered Pk where it struck which she was unableto the
provide any details of he acc dent. V 1takentooHe shey Med Ct via
from several lacerations;
West Shore EMS. V2 had multiple airbag deployment. The occupants of V2 were able to exit out of the sunroof
a airbag
n
deployment. the vehicle; they rt transported
y a Silver Spirit via Hampden EMS. V3 had Spring EMS after complaining o chest) pai . Roadside Rescue The
z driver of V3 was taken Y
c towed all vehicles from the scene. Weather and lighting did not appear to be factors in this
M accident.
M
C
M
FOR Y M•5o0 (1M) PENNDOT COPY
P?,/20091194892009120215595959... 12/2/2009
Page 9 of 9
Print CRS W0134381
Crash Number: W0134381
Incident Number: HAM20091100946
Carlisle Pk 6
M 1?
Z
ri I 1
H
UN I I
FE
V
r
c
i
1194892009120215595959... 12/2/2009
c
z
/.00
Z/
FV7,
Pennsylvania EMS Report
- ----
Service Name "._-.-? - - lJnit Name, No. &"Type ?Date
Stution ----- 9%2 1 --- -11%28%2009
2-71 / 2100702 /BLS _
Ilampden Township EMS _
County, Municipality & Incideut'Lip YS AP Incid. No.
Incident
Location CUMBERLAND, Hampden "iownship, 17011 155162
4300 block Carlisle Nike, Camp Hill, NA 17011
Street or Highway Receiving Agency
University Hospital -Hershey
Crew s O
Patient Name
Emily Huffer
_ C1: Stare, Mike
EM'I' 164595
O
Street Address C2: Swade, Kevin EMT-P 886027 N
, 534 Salmon Rd. C3:
i
'
City /.
p
st?tc
1'N 17050 C4: Ir
Mechanicsburg
L"
DOB Phon No. Primary Caregiver: CI
Driver: C2
Sex Age
Female IS Years 05/25/1994 (717) 12 0633 1Vlileag
Patient Number Social Sec. No. Pt. Weight
Out On-Scene
Uest. In
Q.t 204-74-7050
32797 32799 32815 32834
Private Physician
Driver's License
Times
Transporting Assist Units Assist OS
Response 'l'ime: 1
911:
Medic 83 1123
ER "Cimc: 2 Dis atch: 11:01
P
Response Outcome Nature of Incident
ALS OS Time: 26 En route: 11:02
Treated, Transp. by EMS Transport Mode ERH Time: 19 Arrive Scene: 11:04
Response Mode
Lights and Sirens Lights and Sirens, Destination Time: 70 Contact 11:04
'rotal''ime:: 118 Depart Scene: 11:30
Patient Condition on Scene Patient Condition at Facility
'rime out or 0
Arrive: 11:49 Q?
Moderate
Mod Unchanged
Quarters:
Available: 12:59
In Quarters: W
CluetComplaint: Auto accident.
Current Meds: Stralara.
Allergies (mods): None.
PMtlx: I ADD.
(Narrative
D/D: Amb. 71, Medic 86 to the area of hlillcrest Rd. and Carlisle Pike for an auto accident vehicle
overturned, class 1.
CCC: Informed en-route. Elderly female that is to be still in the veh., and also a male having chest pains.
Prior to arrival amb. 2-71 requested to have another BLS sent.
Amb. 2-71 AOS in the 4300 block of Carlisle Pike to find the roadway blocked by three vehs. One of
which was on its side with sever damage to the rear of the car. There was a young female that was sitting
on the curb with her neck being held by a by-stander, and elderly female still inside on another veh.
Attendant 1 went to check on the young female on the curb while attendant 2 went to check on other
Printed On: 11/28/2009 14:33 Provider
R' 1998-2009 Med Media !nc All Rights.Reserved. Page: 1 of 3
F.MStat eportm6(c)
Pennsylvania EMS Report
`---- _---- IJnit No PCIt No.
Service Name 2-71 / 2100702 / 131,S 0902241
Hampdcn'1'ownship EMS
Patient Name Date of Birth Social Security Number YSAY
ISSlG2
Emily 1lufler 05/25/1994 204-74-7050
injuries.
Young female had no visible trauma, but was crying and very upset.
CC:"I'm seared."
PMH: See above.
1vMEDS: See above.
Date
11/28/2009
ALL: None.
HPI: Pt. just recalls being struck by another veh., and thinks that she made have blacked out during the
wreck.
PE/ TX: Pt. c-spine was continued to be held by a by-stander with instruction from attendant 1.
Attendant 1 then placed a c-collar around the pt. neck to secured her c-spine. C-spine continued to be
held while with assistance by another by-stander a LSB was placed behind the pt.
Pt. was lowered back onto the LSB, and then C-spine was txd. from the bystander to attendant 1.
With assistance from by-standers, the pt. wag slid into position on the LSB, and secured in the supine
position. CID's were placed around the pt. head. Pt. was then list onto the amb. stretcher via a two
person lift/ carry, and secured.
Pt. was placed in the back of amb. 2-71 to have a proper PE done. Pt. father was the driver of the veh.
that the pt. was in, and initially stated that he was fine and just wanted to focus care on the pt.
DECAP-BTLS was done, and found that the pt. was having neck and lower back pain. Pt. also stated
that the top of her head was hurting her. No visible bleeding was noted from the pt. Pt. had equal rise
and fall of the chest, and no kreptus noted during deep inhalation. "There was some left sided tenderness
to palpation with a shall amount of bruising in the area of the left upper abdominal quadrant. Pelvis was
all intact as well as all lower extremities with associated movement throughout all extremities. Lungs
were clear and equal bi-lat. Pt. was restrained passenger in the veh. on, its side, and as well as self
extricated by her father. Pt. was hypertensive, as well as tachycardiac. Resp. were normal and non-
labored. No complaints of chest pains or shortness of breath were noted. Pt. did state that she was
feeling tired and dizzy upon completion of the exam.
ALS was requested for the pt.
When Medic 83 AOS, pt. care report was given, and pt. care was then txd.
Amb. 2-71 then went en-route to University hosp. with Medic 83 on-board, class 2.
Pt. was monitored throughout the transport.
Pt. was placed on 41pm of 02 via a NC.
11t. condition remained stable, and more relaxed throughout the transport with no new complaints.
Pt. care report was given to the receiving facility by Medic 83.
Pt. condition remained stable and unchanged upon arrival at the hosp.
Pt. was txd. to a hosp. bed in trauma room 1 via a three person lilt/ carry with all immobilization
equipment in place.
Pt. care report was given to the nurse by Medic 83, and pt. care was then txd.
HIPAA signature was obtained.
Amb. 2-71 then returned to serv.
Printed On: 11/28/2009 14:33 Provider
EMStat Repor ing(c) 1998-2009, Mcd Media, Inc. All Rights Reserved. Page: 2 of 3
I
Pennsylvania EMS Report
-----------------------
Service Name Unit No `--- -- 1'CRNo.
N
1lampden Township EMS 2-71 ! 2100702 /BLS )902241
Patient Name Date of Birth Social Security Number PSAP
05/2511994 204-74-7050 155162
Emily Huffer
Date
11/28/2009
Time
Events Provider Comments
i
11:06 Immob: Spinal Immobilization ke
Stare, M
1114 Vitals: Pulse: 100; Resp: 24; Oximetry: 99%; B.Y.: 142/92; GCS: 4/5/6 Stare, Mike
11:26 Vitals: Pulse: 100; Resp: 24; B.Y.: 142/84; GCS: 4/5/6 1 Stare, Mike
11:30 Med: Oxygen, Dose: 4 I..PM; City: 4; Route: Nasal prongs Stare, Mike
11:36 Vitals: Pulse: 112-, Resp: 24; Oximetry: 100%; B.P.: 130/; GCS: 4/5/6 Stare, Mike
Printed On: 11/28/2009 14:33
EMStat Reporting(c) 1998-2009, Med Media, Inc. All Rights Reserved.
<7i v
Pro Vt er
Page: 3 of 3
???i?
PENN-STATE HERSHEY
ti miton S. Hershey
medical Center
Penn State Hershey Tel: (717) 531-8055
Millon S. Hershey Medical Center
Health Information Services, HU24
500 University Drive
P.O. Box 850
Hershey, PA 17033-0850
Patient Name: HUFFER, EMILY Visit Number: 13849093
Clinic
MRN: 1358149;7506527 Visit Type:
Patient Location: EORT; ;
Date of Birth: 512511994
Patient Gender: Female ....................... .......... ........
:
. .........................
............................................... .........
Outpatient Letter
Final
RESULT STATUS:
DOCUMENT SUBJECT: Bramley, Harry P (1/4/2010 11:04 EST)
ELECTRONICALLY SIGNED BY:
December 29, 2009
Name: HUFFER, EMILY
HMC Number: 1358149
DOB: 05/25/1994
Date of Service: 12/2312009
Richard Davis, M.D.
4470 Valley Rd.
Enola, PA 17025
Dear Dr. Davis:
I had the opportunity to see one of your patients by the name Emily Huffer in the Penn State Concussion Program on
December 23rd, 2009. She presents to the clinic with her mother. nt on o the
Emily is a 15-year-old who was involved in a motor observed veea n?the hospital un iI t>lrovembe930theShwas e ws dischtarged
Pediatric Trauma Service and was monitored and
home with the diagnosis of a concussion. hes
, but
the Since that time, she indicates that she certainly has still has some very mPd fight sensitiv'1y to nocl ght Sens tivity.
are much better. She denies any fatigue or dizz ness>
Her sleep is back to her baseline as is her mood and she also feels that her cognitive iunctioning appears to be back to
baseline as well.
Past medical history is significant for concussion one year ago while cheer leading and she had symptoms for about 1
week.
Page 1 of 3
Date/Time Printed: 1/15/2010 06:43 EST
Printed By: Tice, Cindy L
PENNSTATE HEKSHEY
Milton S. Hershey
Medical Center MRN 1358149; 7506527
Patient Name: HUFFER, EMILY
--------
Outpatient Letter
.....
Medications are Strattera.
Socially, she is in the 10th grade in Cumberland Valley. She enjoys dance and likes to get back to dance. She wants to
go to college and lives with mom and step dad.
REVIEW OF SYSTEMS: As per the HPI, the remainder is negative. , she
is in ress,
. She
PHYSICAL EXAM: Blood pressure is 120!70, weighe4unremarkable. 5 l Heart isregular! Lungs are d ar. Her abdiomen
very pleasant, and appropriate. HEENT exams we is 5/5
with is soft. She is well-pertused with brisk capillary refill. examicis exam was grossly intact. app opriate. Deep tendonrreflexes are 214. She has
and lower extremities. Sensation is intact. Finger-to-nose
negative Romberg and steady heel-to-toe gait.
Emily is a 15-year-old status post concussion approximately 1 month prior to my visit, who appears to be clearing her
symptoms nicely.
RECOMMENDATIONS: A long talk with mom and milt' about concussion, and I do suspect that over the next few
weeks to a month she should be back to her baseline problems.
I did suggest that she pay attention to her symptoms and if headache certainly becomes a problem, then she should rest. symptoms
are
ance In regards to return to dance, I do think that it's probably oha?y aCd dthwoukll?probab,Y be a good test to ?seeDhow she suld
not pose an increased risk for head injury and increasing Y
doing. I did indicate that if her symptoms start to get worse while she is dancing, she should slop this activity and rest. , but did
o ahead
and I stated, I am hopeful that in the next few weeks her week I did tell that sheecould callgme to d s? prior?tolthe
idlowup appointment to see her back in about 3 to
visit to see if we need to keep the appointment, but certainly if she still continues to have symptoms, I should see her to
discuss options for additional treatment.
I stated to mom to contact me prior to the next appointment with any questions that she may have.
Thank you for allowing me to participate in the care of one of your patients. Please contact me with questions.
Page 2 of 3
Date/Time Printed: 1/15/2010 06:43 EST
Printed By: Tice, Cindy L
PENN-STATE HERSHEY
Nfilton S. Hershey
Medical Center
Patient Name: HUFFER, EMILY
Outpatient Letter.
269846
Electronic Signature on Fite
CC: Forward to Addressee:
CC: Kerry M Fagelman, MD
Penn State Milton S. Hershey Medical Center
PO Sox 850
Hershey PA 17033
Sincerely,
Harry P Bramley, DO Author Signature Dt/Tm: 04.01.2010 11:04 AM
HPS /CO DD: 12129109 DT: 12130109 05:00 AM
Dale/Time Printed: 1/15/2010 06:43 EST
Printed By Tice, Cindy L
MRN 1358149; 7506527
Page 3 of 3
u?'
??' ?
?fi
22/16/2009
11:01
SG4
CMRP051R
CLAIMS MANAGEMENT SYSTEM PAGE: 1
GENERAL COVERAGE INFO
AUTO
««««««««««««««* * <«NOTE»>> *»»»»»»»»»»»»»»
This is a replication of the cragfoinformation tcontainedain
CMS. It does NOT contain all the
declarations page. For complete information., refer to the
original declarations page.
ERIE INSURANCE EXCHANGE EFFECTIVE: 11/06/2009 TO 05/25/2010
POLICY NUMBER: Q05 2507753 --________._-------------------
----------------------------
NT: Ap,7034 JAMES B. MURDOCH INS. GRP. INC AGENT PHONE: (717)737-9900
AGE
LOB: APV TORT OPTION: F
INSURED: KRISTEN J GOLD &
AARON J GOLD
534 SALMON RD
MECHANICSBURG PA
UNIT YEAR MFG MAKE MODEL VIN
17050 2548
E
PER PERSON PER OCCUR DEDUCT C
COVERAGE
---------------------------
POL LVL POLICY LEVEL
NO POL LVL COVERAGE INFO AVAILABLE
1G6DP577X60190396
001 2006 CADI CTS/CTS SP
INJURY SPLIT LIMITS $
100,000
$ $ 300,000
100,000
BODILY
PROPERTY DAMAGE
J
D
T 100,000
00 $
$ 300,000
300,000
INJURY $
BODILY
UNDERUNINS NSURED
MOTORISTT 100,0
ROAD SERVICE
COMPREHENSIVE
$
COLLISION 500
2!,
FPB - FUNERAL
$ 10
,000
FPB - MEDICAL $ 15,000
FPB - INCOME $ 25,000
FPB - ACCIDENTAL DEATH
TRANSPORTATION-LOSS OF USE-COMPREHE $
$ 1,350
1,350
'TRANSPORTATION-LOSS OF USE-COLLISIO
1GNDT13S462136468
002 2006 CHEV TRAILBLAZE
Y INJURY SPLIT LIMITS $
100,000
$ $ 300,000
100,000
BODIL
PROPERTY DAMAGE
ST BODILY
UN
T 100,000
000
1C0 $
$ 300,000
300,000
RIST BODILY INJURY $
MOTO
DERINSURED
UN
,
Y
Y
$ 50
$ 500
Y
Y
Y
Y
Y
Y
12/16/2009
11:01
SG4
CLAIMS MANAGEMENT SYSTEM CMRP051R
PAGE: 2
GENERAL COVERAGE INFO
AUTO
««««««««««««««<«»> * *»»»»»»»»»»»»»»
** NOTE
This is a replication of the ctheragformationtonnthenorigidnaln
CMS. It does NOT contain a refer to the
declarations page. For complete information,
original declarations page.
<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
ERIE INSURANCE EXCHANGE
OLICY NUMBER: Q05 2507753 --------EFFECTIVE_-11/'06/2009 TO 05/25/2010
ROAD SERVICE
COMPREHENSIVE
COLLISION $ 2,500
FPB - FUNERAL $ 100,000
FPB - MEDICAL $ 15,000
FPB - INCOME $ 25,000
FPB - ACCIDENTAL DEATH
OF USE-COMPREHE $ 1,350
TRANSPORTATION-LOSS $ 1,350
TRANSPORTATION-LOSS OF USE-COLLISIO
003 1999 FORD MUSTANG GT 1FAFP45XX
$ XF189580
100,000
$ 300,000
BODILY INJURY SPLIT LIMITS $ 100,000
PROPERTY DAMAGE
UN
J
D
T 100,000
000
100 $
$ 300,000
300,000
INJURY $
BODILY
MOTORISTT
DERINSURED
UN ,.
ROAD SERVICE
COMPREHENSIVE
COLLISION $ 2,500
FPB - FUNERAL $ 100,000
FPB - MEDICAL $ 15,000
FPB - INCOME $ 25,000
FPB - ACCIDENTAL DEATH
OF USE-COMPREHE $ 1,350
TRANSPORTATION-LOSS $ 1,350
TRANSPORTATION-LOSS OF USE-COLLISIO
1G6DP567 850155761
004 2005 CADI CTS
BODILY INJURY SPLIT LIMITS $
100,000
$ $ 300,000
100,000
PROPERTY DAMAGE
UNINSURED MOTORIST BODILY INJURY $ 100,000
000
100 $
$ 300,000
300,000
UNDERINSURED MOTORIST BODILY INJURY $ ,
ROAD SERVICE
COMPREHENSIVE
COLLISION $ ;2,500
FPB - FUNERAL $ 100,000
FPB - MEDICAL
50
500
Y
Y
Y
Y
Y
Y
$ 50
$ 500
Y
Y
Y
Y
Y
Y
$ 50
$ 500
Y
12/16/2009
11:01
SG4
CLAIMS MANAGEMENT SYSTEM
GENERAL COVERAGE INFO
AUTO
CMRP051R
PAGE: 3
««««««««««««««* < < «NOTE» > > *»»»»»»»»»»»»»»
This is a replication of thil ctheragformationtonnthenorigidnaln
CMS. It does NOT contain a refer to the
declarations page. For complete information,
original declarations page.
<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
ERIE INSURANCE EXCHANGE EFFECTIVE: 11/'06/2009 TO 05/25/2010
POLICY NUMBER: Q05 2507753 -
------------
--- ------------
FPB - INCOME $ 15,000
$ 25,000
FPB - ACCIDENTAL DEATH $ 1,350
TRANSPORTATION-LOSS OF USE-COMPREHE $ 1,350
TRANSPORTATION-LOSS OF USE-COLLISIO
-----------------
___ --- ENDORSEMENT FORMS ------
--------------------
FORM NUMBER EDITION DATE DESCRIPTION
POLICY LEVEL
FAP
AFPF01
AFPA03
UNIT: 001
AFAL01
AFPU01
UNIT: 002
AFAL01
AFPU01
UNIT: 003
AFPU01
UNIT: 004
AFPU01
UNIT DETAIL
001 GMAC
ISAOA
PO BOX 674 MINNEAPOLIS MN 055440 0674
03/07 DESCRIPTION NOT IN SYSTEM
03/07 DESCRIPTION NOT IN SYSTEM
10/08 DESCRIPTION NOT IN SYSTEM
03/03 DESCRIPTION NOT IN SYSTEM
UNINSURED/UNDERINSURED MOTORISTS COVE
03/03 PA-
03/03 DESCRIPTION NOT IN SYSTEM
03/03 PA-UNINSURED/UNDERINSURED MOTORISTS COVE
03/03 PA-UNINSURED/UNDERINSURED MOTORISTS COVE
03/03 PA-UNINSURED/UNDERINSURED MOTORISTS COVE
---------- LIENHOLDER/MORTGAGEE INFORMATION
002 GMAC
ISAOA
PO BOX 674 MINNEAPOLIS MN 055440 0674
------------------ ------ ADDITIONAL INSURED
UNIT DETAIL
Y
Y
Y
12/16/2009
11:01
SG4
CLAIMS MANAGEMENT SYSTEM
GENERAL COVERAGE INFO
AUTO
CMRP051R
PAGE: 4
«««««««««««««« <<«»>> *»»»»»»»»»»»»»»
* NOTE
This is a replication of tctherinformationtonnthenoriginaln
CMS. It does NOT contain all
declarations page. For complete information, refer to the
original declarations page.
<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
ERIE INSURANCE EXCHANGE EFFECTIVE: 11%06/2009 TO 05/25/2010
POLICY NUMBER: Q05 2507753 ------------
001 GMAC
ISAOA
PO BOX 618 MINNEAPOLIS MN 055440 0618
002 GMAC
ISAOA
PO BOX 618 MINNEAPOLIS MN 055440
0618
____
______________ DRIVER INFORMATION ----- - -
SE # -----
- - - - - - - - - - -BIRTHDAY
STATE LICEN 03/19/67
ID NAME
01 KRISTEN J GOLD PA 21486710
26494737 11/18/76
02 AARON J PA
GOLD
EXCLUDED DRIVER INFORMATION ----------
NO EXCL'D DRIVERS ON POLL
-------------
END OF CMS COVERAGE PRINT --------
k????
???
Z003
03/26/,2010 17: 32 FAX 7177952
ERIE INS
315
Claims Management System CSPP191B
Page: 2
03/26/2010 Medical Management Print
Req: S
KUHNS ,
17:00 Medical payments
Claim: 0101 71065717 Ins: KRISTEN J GOLD &
Claimant: 002 EMILY J HUFFER
100000.00 Paid:
Limit:
:27929.68
CK
Amount Payee Service Date
20091128 to 20091128
JM90887 550.00
00
65 HAMPDEN TOWNSHIP
MILTON S HERSHEY ED
C
8
2 to 20091128
to 20091128
JP30933
JP30942 .
1
1968.00 MEDICAL
F ER
MILTON S HER
MEDICAL CENTER 009112
20091128
to 20091128
JP30944 97.09
340.00 MILTON S HERSHEY
MILTON S HERSHEY MEDICAL
E
220091129
0092130
to 20091129
to 20091130
JP31559
JP31571 191.00 R
MEDICAL CENT
MILTON S HERSHEY 20091128 to 20091129
JP33035
6 4381.00
25
18833 DIV PEDIATRIC SURGERY
MS HERSHEY MEDICAL CENTER 20091128
20091128 to 20091130
to 20091128
JP3367
JQ01903 .
934.34 WEST SHORE EMS
S HERSHEY MEDICAL CENTER
20091128
to 20091128
J040857 470.00 MILTON
el<zl
LMG, 12/7/2010 3:19:45 PM PAGE 3/005 Fax Server
CLAIM NUMBER LA82 413083502 Q? DATE OIi GO5 1_1r2R12009
RELEASE AND SETTLEMENT OF CLAIM FORM
(PLEASE READ CAREFULLY BEFORE SIGNING) _
For the sole consideration of Fourteen Thousand Dollars ($14000.00), paid by Liberty Mutual Fire Insurance
Cumpany (hereiuaf tCr referred to as LIBERTY), 1, Kristen Gold, the PARENTlLEGAL GUARDL,*.N of
EMILY HUFFER, a minor, for ourselves, our heirs, executives, administrators, successors, trustees,
creditors, agents, representatives and assigns, hereby release(s), acquit(s), and forever discharge(s)
ANNABELLE M DONOVAN, Any and All Parties Known and Unknown.. LIBERTY, its assigns, directors,
officers, employees, a ents, attorneys, insurers, subsidiaries, successors, predecessors, parents,
representatives and a iliates (hereinafter "RELEASEES") from any and all claims and demands, rights,
damages, causes of action. costs, losses or expenses, whether known or unknown, whether foreseen or
unforeseen, whether accrued or not yet accrued, and the consequences thereof (hereinafter referred to as
"CLAIMS"), in any way arising out of the incident that took place on 1112812009, at UNK CAMP HILL, PA.
The undersigned agrees, individually and on behalf of EMILY WFFER, not to sue RELEASEES for any of
the CLAIMS released herein. The undersigned agrees that the above-referenced settlement amount includes
any right, claim or demand for pre-settlement or post-settlement interest.
It is understood and agreed that this settlement is a compromise of disputed CLAIMS and represents an
unliquidated amount of damages that may be permanent, progressive and/or ongoing, and the payment is not
to be construed as an admission of liability, fault or wrongdoing on the part ofRELEASEES. RELFASEES
expressly deny liability. It is further agreed that this release shall not be offered as evidence in any judicial
or administrative proceeding for the purpose of proving any such liability or otherwise. except that this
re!rase may be introduced in any proceeding for the sole purpose of enforcing its terms. It is understood and
agreed to by Kristen Gold that this settlement money is to be used solely for the benefit of
EMILY DUFFER.
I, as the PARENl'ILEGAL GUARDIAN of EMILY HUFFER. represent that I am at least eighteen (18)
years of age; that I have never been declared incompetent by a court or agency of government; that no
representations have induced me to enter into this agreement other than the matters set forth herein; that I
relieA solely upon my own judgment, belief and knowledge (after consultation with my attorney, if
applicable) regarding the extent, nature and duration of the injuries, disabilities and damages sustained,
including possible unknown or unanticipated injuries, results, death, disabilities, losses and damages. I
expressly waive all CLAIMS of which I know or suspect to. exist. I represent that no promise, inducctnent or
agreement not expressed herein has been made to me and that this is the entire agreement between the
parties. I enter this agreement under no duress or coercion.
The terms of this agreement are contractual and not a mere recital. Should any provision or term of this
agreement be deemed unenforceable as a matter of law or public policy by t court of competent jurisdiction,
then the balance of the agreement shall remain in full force and effect.
(over)
ASC251C
LMG. 12/7/2010 3:19:45 PM PAGE 4/005 Fax Server
All parties to this release shall be responsible for their own attorney's fees and expenses related in any way
to this incident, except that, if a breach of this release occurs, the non-breaching xparty pen = shall be entitled to
recover, from the breaching party, its reasonable attorney's fees and costs incurred to enforcing this release.
The undersigned further represents that there are no past or future liens or rights of reimbursement by any
hospital, ambulance service. or other medical provider, Medicare. Medicaid. insurance company, workers'
compensation provider, Governmental entity, non-governmental entity, attorney, or person enforceable
against the proceeds of this settlement or against the parties released, or the persons, firms, or corporations
making the payment herein. If such lien or right is asserted against the proceeds herein or against the parties
released or any person, firm or corporation making payment herein, then, in consideration of the payment
nt
made to the undersigned, the undersigned covenants to pay and satisfy such asserted lien o
right. The undersigned promises to obtain a release and discharge such lien or reimbursement right, and to
defend, indemnify and hold harmless the parties released and the persons, firms or corporations making the lements ting
payment herein, fi-om ?ycement expenses. lien ore reimfees. claims. bursements ght by any person or entity ha ing succh
from the assertion n or or enfor
lien or right.
Notwithstanding anything herein to the contrary, this release shall not release claims that EMILY HUFFER
may have, past and future, against medical care providers. The undersigned reserve their right to pursue and
recover all future medical expenses from any person, firm or organization who may be responsible for
payment of such expenses, including any first-party health or auto insurance coverage, but such reservation
does not include the RELEASEES, their agents or employees.
I represent and warrant that no other person or entity, other than EMILY HUFFER has or has had any
interest in the CLAIMS referred to in this release and that I have the sole right and exclusive authority to
execute this release and receive the sum specified in it for the benefit of EMILY HUFFER for all claims. I
have not sold, assigned. transferred, conveyed or otherwise disposed of any of the CLAIMS referred to in
this release.
The parties agree that the consideration and promises contained herein are mutual, adequate and accepted as
full and binding consideration. This release agreement contains all of the terms and agreements between the
parties and supersedes all, or cancels each and every other prior conflicting agreement, promise and/or
negotiation between the parties. This release agreement may not be altered, amended or modified except in
writing by all parties to the release agreement.
rlti4'25 1 C
LMG. 12/7/2010 3:19:45 PM PAGE 5/005 Fax Server
CLAIM NUMBER: LA930-0I3083502-05 DATE OR LOSS: 11/28/2009
By sign in below, I afain? eneral released, understand and voluntarily accept the terms of the final
settl omen agreement 8
Any person who knowingly and with intent to defraud any
insurance company or other person files an application for
insurance or statement of clam containing any materially
false information or conceals for the purpose of misleading,
information concerning any fact,material thereto commits a
fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
IN WITNESS THEREOF, we have hereunto set my hand and seal this _day of
. 2
SIGNATURE
As father and next friend
SIGNATURE
As mother and next friend
I CERTIFY THAT THIS RELEASE was signed in my presence by the above who acknowledged that they
understood it fully.
Witness name
Witness :address
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EMILY HUFFER, a minor, by KRISTEN
GOLD, her natural mother and
Guardian, and KRISTEN GOLD in her
own right,
Plaintiffs
V.
ANNABELLE DONOVAN,
Defendant
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYhVAAHA
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NO. 2011-641 -<A w
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EMILY HUFFER ACCOUNT AGREEMENT
By, Metro Bank, Mechanicsburg, Pennsylvania:
WHEREAS, a copy of a Order Approving Minor's Settlement has been provided
to Metro Bank, Mechanicsburg, Pennsylvania; and,
WHEREAS, the net settlement proceeds in the sum of $10,167.51 has been
deposited in a bank account in the name of Emily Huffer with Metro Bank,
Mechanicsburg, Pennsylvania (hereinafter referred to as the "Emily Huffer Account");
and,
WHEREAS, Metro Bank, Mechanicsburg, Pennsylvania is insured by the FDIC.
AGREEMENT
Metro Bank, Mechanicsburg, Pennsylvania, agrees that a hold will be placed on
the Emily Huffer Account so that no transfers or withdrawals can be made from the
account until Emily Huffer attains her majority, except as authorized by a prior Order
of Court.
ATTEST:
(o By;
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Prin a and Position with Bank
Christina L. Bradley, Esquire
FREEBURN & HAMILTON
ID No. 89107
4415 North Front Street
Harrisburg PA 17110
(717) 671-1955
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*ntiffs
EMILY HUFFER, a minor, by KRISTEN
GOLD, her natural mother and
Guardian, and KRISTEN GOLD in her
own right,
Plaintiffs
V.
ANNABELLE DONOVAN,
Defendant
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
: NO. 2011-641
PRAECIPE TO DISCONTINUE
TO: Prothonotary
Kindly mark the above-captioned matter settled and discontinued.
Respectfully Submitted,
FREEBURN & HAMILTON, PC
By: ) aD?.i
Christina L. Bradley, Esq ire
I.D. No. 89107
4415 North Front Street
Harrisburg PA 17110
(717) 671-1955
Date: 02/18/11 Counsel for Plaintiffs