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Home My WebLink About12-2037 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNS YLVAN1LK CIVIL DIVISION - T;+ ., Plaintiff(s) & Address(es) - -± Blase & Christina Salomone as parents ` ?y , and natural guardians of their minor children, Anthony & Vincent Salomone = c? 221 Mountain Road, Dillsburg,PA 17019 Case No. Civil Term VS. Civil Action - LAW Defendant(s) & Address(es) Erie Insurance Exchange 4901 Louise Drive , Mechanicsburg, PA 17055 PRAECIPE FOR WRIT OF SUMMONS TO THE PROTHONOTARY/CLERK OF SAID COURT: Issue summons in the above case Writ of Summons shall be issued and forwarded to,At?torne / rift Please Circl , 'ce) Date : March 29, 2012 ature of Attorney Print Name: George J. Costopoulos Address: 153 N. Hanover Street Carlisle, PA 17013 TO: Erie Insurance Exchange _ 4* Q,N,? ?to3.?Spd ath,l 3103 1 • • • • • WRIT OF SUMMONS Telephone #: (717) 243-0407 Supreme Court ID Number: 78423 YOU ARE NOTIFIED THAT THE ABOVE-NAMED PLAINTIFF(S) HASMAVE MMENCED AN ACTION AGAINST YOU. Prothonotary/Clerk, Civil Division Date: (a by Deputy BLASE AND CHRISTINA SALOMONE, as parents and natural guardians of their minor children, ANTHONY AND VINCENT SALOMONE, Plaintiffs : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA Case No. 12-2037 Civil Term J rTJLQ f" V. ERIE INSURANCE EXCHANGE, Defendant : CIVIL ACTION -LAW PETITION FOR APPROVAL OF MINOR'S SETTLEMENT IF t, AND NOW COME the Petitioners, Blase and Christina Salomone, parents and natural guardians of Anthony Salomone, a minor child, by and through their counsel, George J. Costopoulos, Esquire, and represent: 1. Petitioners are Plaintiffs, Blase and Christina Salomone, who reside at 221 Mountain Road, Dillsburg, PA 17019. Petitioners are the parents and natural guardians of Anthony Salomone, age 17 (date of birth: 3/29/95; social security number: 167-76-6409). 2. On November 21, 2010, Anthony was injured in a motor vehicle collision while a front seat passenger in an automobile driven by his mother, Christina Salomone. The collision was caused when Michael Posten, an uninsured driver of an uninsured vehicle, failed to yield at a stop sign and t-boned the Salomone's vehicle. A copy of the police crash report is attached as Exhibit "A." 3. The collision, which occurred in South Middleton Township, Cumberland County, Pennsylvania, caused cuts and lacerations to Anthony's face, and a suspected nasal fracture. Anthony's injuries were treated conservatively at the emergency room and through follow-up visits with his doctors. 4. On December 17, 2010, Petitioners retained the undersigned counsel to negotiate AA-500 TX IncidE nt Nts,mber: H02-1987354 Crash Involves: 0 DUI 0 Fatality Q NIA 0 work Zone Commonwealth of Pennsylvania PAGE 1 Police Crash Report REPORTABLE CRASH 0 Hit and Run 0 Commercial Vehicle 0 State Police Vehicle C) Local Police Vehicle 0 ATV 0 Snowmobile 0 Commonwealth Vehicle 0 Local Gov Vehicle A c Agency Name Case Closed Patrol Zone Invesfigation Date PA STATE POLICE - CARLISLE YES 24 1112112010 a Dispatch Time rrival Time Investigator Badge Number 13:05 hrs. 13:07 hrs. SUMMITS, JEFFREY M 11101 Approval Date Reviewer Reviewer Badge Number a° 1112512010 AMMONS, DAWN R 08496 Date of Crash ime of Crash Day of the Week Crash Description 1112112010 13:00 hrs. SUNDAY ANGLE County Municipality CUMBERLAND SOUTH MIDDLETON TWP a Weather Conditions Relation to Roadway O t NO ADVERSE CONDITIONS ON TRAVEL LANES L^, Illumination Road Surface Conditions U DAYLIGHT DRY # of Units # of People # of Injured # Kitled EM$ Agency Medical Facility 002 004 003 000 CARLISLE CARLISLE REGIONAL Scholl Bus Related School Zone Related PennDOT Noflffed Typecifintersection Spe l Location NO NO I NO 4 WAY INTERSECTION NOT APPLICABLE u Zone Wok Zone Type here in Work Zone C T N 0 N 7 d Limit Workers Present Officer Present Work Zone Characteristics 0 ? Lane Closure Road Closed Work on Shoulder Intermittent or Flagger ? [] with Detour ? or Median ? Moving Work El Control ? Other ,o c Route Signing Route Number Segment Number Travel lanes Speed Limit Orientation x STATE HIGHWAY 0174 02 35 MPH EAST a House Number Street Name St. Ending a WALNUT BOTTOM ROAD x Route Signing Route Number Segment Number Travel Lanes Speed Limit Orientation m Used in LOCAL ROAD OR STREET 0000 01 Intersection 25 MPH SOUTH Crashes Street Name St. Ending ROCKLEDGE c DRIVE m r Route Number Or Mile Post Tenths Or Segment Marker Ramp Use Only Feet o E W m a Street Name Street Ending Or Miles Tenths E 0 2 '6 N Rouse Number Or We Post Tenths Or Segment Marker Ramp Use Only The above entr is the c -?S E y c Street Name Street Ending distance from the Crash o Scene to Landmark 1 rn o. Degrees Minutes Seconds Decimal Degrees Minutes Seconds Decimal Latitude: 40 ' 08 32 Longitude: . 442 r 77 12 03 848 I Traffic Control Device Traffic Control Functioning F STOP SIGN DEVICE FUNCTIONING PROPERLY 0 Lane closed Lane Closure Direction Traffic Detoured Estimated Time Closed FULLY J EAST AND WEST YES 30 - 60 MIN. Environmental I Roadway Potential Factors (EIR) Factor 1 Factor 2 Factor 3 NONE o First Harmful Event in the Crash Most Harmful Event in the Crash v Unit Number Harmful Event U b it N b E n um er um er HIT Event 001 HIT UNIT 2 c I ndicated Prime Factor Unit Number Prime Factor Driver Action DRIVER ACTION 001 RUNNING STOP SIGN W Prime Factor EnviromentallRoadway Prime Fact Prime Factor Pedestrian Action R oad Surface Tvr,e r-vurnrr Printed At: PA State Police - Carlisle 12/lor2ol 9m zz w a Form #: H02-1987354 AA-300 Tx incidentN4mber: ,H02-1987354 Commonwealth of Pennsylvania PAGE 2 :rash Involves: Police Crash Report REPORTABLE CRASH Q DUI O Fatality O Hit and Run. O Commercial Vehicle O State Police Vehicle 0 Local Police Vehicle 0 NIA O Work Zone O ATV O Snowmobile 0 Commonwealth Vehicle 0 Local Gov Vehicle Unit Number ype Unit Commercial Vehicle 001 Motor Vehicle in Transport No First Name MI Last Name Suffix DOB Telephone Number MICHAEL A POSTEN 0812011988 Street Address City State Zip Code 812 HOLLY PIKE MT HOLLY SPRINGS (USA) PA 17065 Gender License Number License State Class Expiration Date OwnerlDriver MALE 29429170 PA C 0812112011 PRIVATE VEHICLE OWNEDILEASED BY DRIVER 0 A Driver Presence Physical Condition Primary Vehicle Code Violation Person Charged o DRIVER OPERATED VEHICLE APPARENTLY NORMAL PA VC 3323 YES c AlcoholfDrugs Suspected rJ?Dhol Test Type Alcohol Test Results a NO TEST NOT GIVEN z Driver Action RUNNING STOP SIGN v u a Pedestrian Action Pedestrian Signals Pedestrian Clothing Pedestrian Location r roc 1st Harmful Event Left or Right Side Most Harmful Utility Pole Number HIT UNIT 2 YES 2nd Harmful Event Left or Right Side Most Harmful Utility Pole Number 3rd Harmful Event Left or Right Side Most Harmful Utility Pole Number 4th Harmful Event Left or Right Side Most Harmful Utility Pole Number Owner First Name Owner MI Owner Last Name or Business Name Suffix TIMOTHY E TREGO Street Address Ciry State Zip Code 7 N LOCUST ST CAMP HILL (USA) PA 17011 Vehicle Type Special Usage Government Equipment Number AUTOMOBILE NOT APPLICABLE Model Year et?cle Make Vehicle Model Vehicle Color \nN- 1998 PLYMOUTH Neon GOLD T 1P3ES47C9WD687875 rise Plate Reg. State Est. Speed Vehicle Towed Towed By 999999 PA 099 YES SELF nsurance Insurance Company Policy Number Expiration Date NO o rcection of Travel Vehicle Position Vehicle Movement Initial Impact Point a SOUTH RIGHT LANE "CURB" GOING STRAIGHT 12 O'CLOCK Damage Indiealor Gradient Road Alignment Possible Vehicle Failures 8 DISABLING DOWNHILL STRAIGHT UNKNOWN K of Units Type Unit 1 Tag Number Tag Year Tag State t 0 m c Unit Make Unit Owner m ---- c Type Unit 2 ] Tag Number - Tag Year Tag State Unit Make Unit Owner Engin! Passenger? Saddle BaglTrunk? Trailer? Driver Education? m mi Driver Type Hel t Helmet Stayed On? DOT/Snell Designation? Eye Protection.) Long Sleeves? Long Pants? Over Ankle Boots? 0 0 assenger Helme! Type Helmet Stayed On? DOT/Snell Designation? Eye Protection? Long Sleeves? Long Pants? Over Ankle Boots? d v a U Passenger? Helmet? v Head Lights? Rear Reflectors? a Printed At: PA State Police - Carlisle 1211012010 10:05 AM Page 2 Form #: H02-1987354 AA-5oo TX IncidentNuinber: H02-1987354 Commonwealth of Pennsylvania PAGE 3 Crash Involves: Police Crash Report REPORTABLE CRASH O DUI O Fatality O Hit and Run Q Commercial Vehicle O State Police Vehicle O Local Police Vehicle OO NIA 0 Work Zone O ATV 0 Snowmobile O Commonwealth Vehicle Q Local Gov Vehicle Unit Number ype Unil Commercial Vehicle 002 Motor Vehicle in Transport No First Name MI Last Name Suffix DOB Telephone Number CHRISTINA T SALOMONE 1 .071311111967 (717) 4864032 Street Address City Stale Zip Code 6 TRIPLETT CT DILLSBURG PA 17019 Gender License Number License State Class Expiration Date Owner/Driver FEMALE 21325367 PA C 0810112013 PRIVATE VEHICLE OWN EDILEASED BY DRIVER 0 Driver Presence Physical Condition Primary Vehicle Code Violation Person Charged DRIVER OPERATED VEHICLE APPARENTLY NORMAL NONE NO Alcohol/Drugs Suspected Eohol Test Type Alootlol Test Results ro NO TEST NOT GIVEN Driver Action NO CONTRIB UTING ACTION o Pedestrian Action Pedestrian Signals Pedestrian Clothing Pedestrian Location z n 1st Harmful Event Left or Right Side Most Harmful Utility Pole Number STRUCK BY UNIT 1 NO 2nd Harmful Event Left or Right Side Most Harmful Utility Pole Number HIT UTILITY POLE RIGHT YES 153337 3rd Harmful Event Left or Right Side Most Harmful Utility Pole Number 4th Harmful Event Left or Right Side Most Harmful U6ky Pole Number Owner First Name Owner MI Owner Last Name or Business Name uffrx BLASE P SALOMONE Street Address City State Zip Code 12 N THUSH DRIVE CARLISLE PA 17015 Vehicle Type Special Usage Government Equipment Number SUV NOT APPLICABLE Model Year Vehicle Make ehide Model Vehicle Color IN 1999 ISUZU RODEO GREEN 4S2CM58WTX4318101 License Plate Reg. State Est. Speed ehiccle Towed Tdrived By HNE0278 PA 099 YES ROYER'S GULF TOWING Insurance Insurance Company Policy Number Expiration Date YES ERIE INS Q042505767H 0412512011 Direction of Travel ehEIe Position Vehicle Movement Initial Impact Point 0 EAST RIGHT LANE "CURB" GOING STRAIGHT 10 O'CLOCK Damage Indicator Gradient Road Alignment Possible Vehicle Failures DISABLING LEVEL STRAIGHT NONE 3 r >w of Units Type Unit 1 Tag Number Tag Year Tag State 0 'c Unit Make Unit Owner c Type unit 2 Tag Number Tag Year a g Stale 1_ I r r- Unit Make Unit Owner Engine Size Passenger? Saddle Bag/Trunk? Trailer? Driver Education? m cc 0 Driver Helmet Type Helmet Stayed On? DOT/Snell Designation? Eye Protection? Long Sleeves? Long Pants') Over Ankle Boots? a 2 Passenger Helmet Type Helmet Stayed On? DOT/Snell Designation? Eye Protect*0 Long Sleeves? Long Pants? Over Ankle Boots? 2 Passenger? Helmet? L' Z Head Lights? a Rear Reflectors? a PnntW At: PA State Police - Carlisle 1211012010 10:05 AM Page 3 form #: H02-1987354 AA-500 TX Incident Number: H02-1987354 Commonwealth of Pennsylvania PAGE 4 Crash Involves: Police Crash Report REPORTABLE CRASH O DUI O Fatality 0 Hit and Run Q Commercial Vehicle Q State Police Vehicle Q Local Police Vehicle Q WA Q Work Zone Q ATV Q Snowmobile Q Commonwealth Vehicle Q Local Gov Vehicle Unit # Person ,No. First Name MI Last Name Suffix DOB 001 7 001 CHAEL A POSTEN 0812011988 tfeet Address Ciry State Zip Code C 812 HOLLY PIKE MT HOLLY SPRINGS (USA) PA 17065 w Phone Number EMS Transport Person Type Gender injury Seventy E NO DRIVER MALE NOT INJURED 0 c Seat Position Safety Equipment 1 o DRIVER ALL VEHICLES LAP AND SHOULDER BELT USED a a Safety Equipment 2 E icaton AIR BAG NOT DEPLOYED - SWITCH ON NOT APPLICABLE Ejection Ejection Path NOT EJECTED NOT EJECTEDINOT APPLICABLE Unit # Person No. First Name MI Last Name Suffix DOB 002 002 CHRISTINA T SALOMONE 07131/1967 Street Address City State Zip Code 6 TRIPLETT CT DILLSBURG PA 17019 -?°? Phone Number EMS Transport Person Type Gender Injury Severity E 0 (717) 486-4032 NO DRIVER FEMALE MINOR INJURY c Seat Position Safety Equipment 1 m 0 DRIVER - ALL VEHICLES LAP AND SHOULDER BELT USED a Safety Equipment 2 Extrication MULTIPLE AIRBAGS DEPLOYED NOT APPLICABLE Ejection Ejection Path NOT EJECTED NOT EJECTEDINOT APPLICABLE Unit # Person N irst me MI Last Name Suffix DOB 002 ? 003 F ONY C SALOM ONE 0312911995 Street Address Ciry State Zip Code 6 TRIPLETT CT DILLSBURG PA 17019 Phone Number EMS Transport Person Type Gender Injury Severity o (717)486 4032 YES PASSENGER MALE MODERATE INJURY c Seat Position Safety Equipment 1 m FRONT SEAT RIGHT SLOE LAP AND SHOULDER BELT USED n I°o Safety Equipment 2 Extrication FRONT AIR BAG DEPLOYED (FOR THIS SEAT) NOT APPLICABLE Elecuon Ejection Path NOT EJECTED NOT EJECTEDINOT APPLICABLE Unit # Person No. First Name MI last Name Suffix DOB 002 004 VINCENT B SALMONE 0210211999 Street Address city state Zip Code 6 TRIPLETT CT DILLSBURG PA 17019 a Phone Number EMS Transport Gender Injury Severity E (717) 486-4032 YES MALE MODERATE INJURY PASSENGER 0 Seat Position ty Equipment 1 m n # SECOND ROW - RIGHT SIDE P AND SHOULDER BELT USED 0 Safety Equipment 2 cation NONE USED I NOT APPLICABLE T APPLICABLE Ejection Ejection Path NOT EJECTED NOT EJECTEDINOT APPLICABLE PersonV3usiness Notified Phone Number Date Notified Time Notified MET ED (800) 545-7741 11121/2010 15:30 hrs o . Reason for Notification z POLE STRUCK Printed At: PA State Police - Carlisle 12[1012010 10:05 AM Page 4 Form #: HOZ-1987354 AA-500 TX lAcidentNumber: H02-1987354 Commonwealth of Pennsylvania PAG Crash Involves: ' Police Crash Report REPORTABLE CRASH O DUI O Fatality O Hit and Run Q NIA Q Work Zone O AN 0 Commercial Vehicle O snow 16; 117 H 0 State Police Vehicle O Local Police Vehk O Commonwealth Vehicle Q Local Gov Vehicle Rockledge Drive 35 MPH ! I N ' oint of Initial Impac inal Rest Unit 1 U it 1 final Rest Unit N N, N N Unit 2t II tility Pole 1532-2951 Walnut Bottom Road 40 MPH I p r 127 Sri E I Carlisle Boro 1 mile This crash occured as unit 1 traveled south on Rockledge Drive and unit 2 traveled east on Walnut Bottom Road, South Middleton Township, Cumberland County. As unit 2 approached the intersection of Walnut Bottom and Rockledge Drive, unit 1 failed to stop at the stop sign and struck the driver side door of unit 2. After initial impact, unit 2 struck utility pole #15353-29514. Unit 1 came to final rest facing south east on SR 174. Unit 2 came to final rest facing southeat on Sr 174. Operator 2 and her passengers all sustained injuries. Operator 1 and his passenger did not sustain injuries. Both vehicles sustained disabling damage. This crash occured as unit 1 traveled south on Rockledge Drive and unit 2 traveled east on Walnut Bottom Road, South Middleton Township, Cumberland County. As unit 2 approached the intersection of Walnut Bottom and Rockledge Drive, unit 1 failed to stop at the stop sign and struck the driver side door of unit 2. After Initial impact, unit 2 struck utility pole #15353-29514. Unit 1 came to final rest facing south east on SR 174. Unit 2 came to final rest facing southeat on Sr 174. Operator 2 and her passengers all sustained injuries. Operator 1 and his passenger did not sustain injuries. Both vehicles sustained disabling damage. The physical evidence observed on scene was consistent with the crash described. Unit 1 sustained heavy front end damage. Unit 2 sustained damage to its driver Printed At: PA State Police - Carlisle 7211012010 10:05 AM Page 5 Form M H02-1987354 AA-500 TX Incident Number: H02-1987364 commonwealth of Pennsylvania PAGE 6 Crash16volves: ' Police Crash Report REPORTABLE CRASH Q DUI Q Fatality Q HR and Run Q Commercial Vehicle 0 State Police Vehicle Q Local Police Vehicle Q NIA Q Work Zone Q ATV Q Snowmobile Q Commonwealth Vehicle Local Gov Vehicle 1 side and heavy damage to the passenger side where it struck the utility pole. I observed approximately 5 feet of skid marks left from unit 1. Minimal damage was done to the utility pole. On 11121110, at approximately 1310 hours, I interviewed operator 2 on scene. She related that she was traveling east on SR 174 when she observed unit 1 approaching the intersection and not stopped. She further related that she did not have enough time to come to a complete stop and unit 1 struck into the drive side, causing her vehicle to collide with the utility pole. On 11121110, at approximately 1320 hours, I interviewed operator 1 on scene. He related he was traveling south on Rockledge Drive when he realized his brakes were not working. He further related that when he realized that he was not going to stop, he put on his emergency brake and collided into the side of unit 2. He further related that he jsut purchased the car from a friend. Both passengers in unit 2 were transported to Carlisle EMS to Carlisle Regional for moderate facial injuries. Fire and Rescue, as well as Fire Police, responded to the scene. Operator was was cited for Pa VC 1543, 1301, 1786, 3323, and 4703. A News Release was completed. Met Ed was contacted by CDC in regards to the utility pole struck. Printed At: PA State Police - Carlisle 12/012010 10:05 AM Page 6 Form 1/: H02-1997354 SP 7-0501TX-Driver Exchange SP 7-0099TX-Non Reportable f INCIDENT NUMBER ommonwealth of Pennsylvania uriver Notice and Exchange Report H02-1987354 I PA STATE POLICE - CARLISLE (717) 249-2121 DATE OF CRASH TIME OF CRASH DAY OF WEEK COUNTY MUNICIPALITY 11/21/2010 13:00 hrs. SUNDAY CUMBERLAND SOUTH MIDDLETON TWP ROUTE # SEGMENT # STREET STREET ENDING 0174 WALNUT BOTTOM ROAD PATROL ZON INVESTIGATOR \ INVESTIGATOR SIGNATURE BADGE NUMBER 24 SUMMITS, JEFFREY M 11101 REVIEWER REVIEWER BADGE NUMBER APPROVAL DATE Latitude: Degrees 4 Minutes 08 Seconds 32 Decimal 442 Longitud rees Minutes Seconds Decimal 12 03 848 ON STATE HWY 174 AT ITS INTERSECTION WITH ROCKLEDGE DR vml i e UKIVtK"J LN51 NAME FIRST NAME MI SUFFIX DOB GENDER PHONE NUMBER 1 001 POSTEN - - - MICHAEL A 08/2011988 MALE STREET ADDRESS CITY STATE ZIPCODE 812 HOLLY PIKE MT HOLLY SPRINGS (USA) PA 17065 LICENSE NUMBER LICENSE STATE CLASS EXPIRATION DATE 29429170 PA C 08/2112011 INSURANCE COMPANY POLICY NUMBER POLICY EXPIRATION DATE z m i OWNER'S LAST NAME OR BUSINESS NAME FIRST NAME MI SUFFIX TREGO TIMOTHY E C STREET ADDRESS CITY STATE ZIP CODE 7 N LOCUST ST CAMP HILL (USA) PA 17011 VEHICLE YEAR MAKE MODEL 1998 PLYMOUTH NEON VIN LICENSE PLATE # STATE VIOLATIONS (INCLUDING SECTION NUMBERS): DRIVER CHARGED? 1P3ES47C9WD687875 999999 PA PA VC 3323 YES UNIT # D ' RIVER S LAST NAME FIRST NAME MI SUFFIX DOB GENDER PHONE NUMBER 002 SALOMONE CHRISTINA T 07/31/1967 FEMALE (717) 486-4032 STREETADDRESS CITY STATE ZIP CODE 6 TRIPLETT CT DILLSBURG PA 17019 LICENSE NUMBER LICENSE STATE CLASS EXPIRATION DATE 21325367 PA C 08/01/2013 INSURANCE COMPANY E POLICY NUMBER ERIE INS POLICY EXPIRATION DATE Q042505767H 04/2512011 ` OWNER'S LAST NAME OR BUSINESS NAME FIRST NAME MI SUFFIX _SALOMONE - BLASE P o STREETADDRESS CITY 12 N THUSH DRIVE CARLISLE STATE ZIP CODE PA 17015 VEHICLE YEAR MAKE MODEL 1999 ISUZU RODEO VIN LICENSE PLATE # STATE VIOLATIONS (INCLUDING SECTION NUMBERS): DRIVER CHARGED? 4S2CM58W7X4318101 HNE0278 PA NONE NO 2emarks\Notes This crash occured as unit 1 traveled south on Rockledge Drive and unit 2 traveled east on Walnut Bottom Road, South Middleton Township, Cumberland County. As unit 2 approached the intersection of Walnut Bottom and Rockledge Drive, unit 1 failed to stop at the stop sign and struck the driver side door of unit 2. After initial impact, unit 2 struck utility pole #15353-29514. Unit 1 came to final rest facing south east on SR 174. Unit 2 came to final rest facing southeat on Sr 174. Operator 2 and her passengers all sustained injuries. Operator 1 and his passenger did not sustain injuries. Both vehicles sustained disabling damage. I,A0 FFIC1?S U1? C, 1 Ok..l--- ) (-' 0 ST0P0UL0 ?,; N O R RIII II.INO VI R c1RII I ?? C\R11SI.G, PIfNNS1LVAN1:1 17013 17 1 7 1 24 3-040 7 I,1\(7171243-0950 Contingent Fee Agreement We, Blase and Christina Salomone, as Parents and Natural Guardians of Anthony Salomone, a minor (hereinafter "clients"), do hereby retain the Law Offices of George J. Costopoulos, 153 North Hanover Street, Carlisle, Pennsylvania 17013 (hereinafter "attorneys"), to negotiate for us a settlement or to institute for us any legal proceedings that in their judgment are necessary to pursue any claim for damages and/or injuries sustained by Anthony Salomone due to a motor vehicle accident on or about November 21, 2010 against any person, firm, corporation or entity who may be responsible for said claim, and/or to obtain an amicable settlement We hereby give to our attorneys a Power of Attorney to execute all documents connected with the claim for the prosecution of which the attorneys are retained, including pleadings, contracts, commercial papers, settlement agreements, compromises and releases, verifications, dismissals, orders, settlement checks and all other documents that we could properly execute in connection with this matter. We agree to fully cooperate with our attorneys in the prosecution of the claim that comprises the subject matter of this Agreement. This includes, but is not limited to, making ourselves available for legal proceedings and consultations with our attorneys; keeping our attorneys informed as to our current mailing address, phone number and the current status of Anthony Salomone's medical condition. In consideration of the services performed and to be performed by our attorneys, we agree to pay attorneys' fees from the total amount recovered from any source a contingent fee of 25% . In the event that no recovery is obtained on this claim, our attorneys will make no charges for their time or services. Costs: It is understood that attorneys may advance out-of-pocket costs in the investigation, prosecution, preparation and trial of this case. Such costs are to be paid from our (clients') share of the total amount recovered and include, but may not be limited to: photocopies; notaries; investigation charges; photographs; court costs; medical records costs; fee for police report; deposition costs; expert witness fees; stenographer costs; and, video deposition fees. As one possible settlement option, we authorize our attorneys to explore the possibility of a structured settlement through the use of deferred periodic payments. We agree that if any claim is settled through such structure, the attorneys' fees may be paid directly to said attorneys from the insurance company, either in one lump sum payment at settlement, or, at the sole option of said attorneys and/or insurance company, deferred into future payments. However, in any event, said attorneys' fees shall be calculated in the percentage as set forth above based upon the cost of the structured settlement or present value thereof in accordance with applicable law. EXHIBIT Z Z W a Clients agree that, in the event the investigation and discovery performed by attorneys shall in the judgment of attorneys reveal no meritorious claims exist on behalf of clients, then attorneys may withdraw from the further representation of the clients in this matter. Clients and attorneys further agree that, in the event that clients shall become dissatisfied with the services of attorneys, clients shall be permitted to discharge attorneys from their employment in this matter. However, in the event that clients elect to discharge attorneys, attorneys shall be entitled to receive payment of fees from any recovery which clients ultimately makes on these claims. The fees payable; to attorneys shall be in an amount which would reasonably and equitably compensate attorneys for their efforts on behalf of clients in the prosecution of the claims. If clients and attorneys are not able to reach an agreement as to the amount of those fees at the time of discharge, then the matter shall be submitted to arbitration. This Contingent Fee Agreement applies to all proceedings up to and including verdict or decision at trial or arbitration. If, in the discretion of the attorneys, post-trial proceedings, including appeals, are warranted, they will not be covered by this Contingent Fee Agreement and a new fee agreement will be required by said attorneys. And Now, on the day and year written below, the above Contingent Fee Agreement and Power of Attorney has been read, approved, and understood by us and the receipt of a copy thereof acknowledged. The terms set forth are agreeable. r Georg 'J. Costopoulos, Esquire Blase Salomone, Parent and Natural Guardian of Anthony Salomone (l Christina Salomone, Parent and Natural Guardian of Anthony Salomone Date: /2 /11-io Page 2 of 2 CLAIM #: 010171128128 RELEASE AND AGREEMENT Under policy # Q042505767 issued by ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY, l/We, claiming coverage for myself/ourselves or on behalf of Anthony Salamone in consideration of Fifteen Thousand Dollars ($15,000.00) dollars, which I/We have received, RELEASE AND DISCHARGE ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY from any and all claims, causes of action or other rights which I/We have, have had or could have under the Uninsured Motorists coverage as set forth in said policy, which claims, causes of action or other rights arose or could have arisen as a result of a loss or accident which happened on the 21" day of November, 2010 at or near Route 174 in the county of Cumberland in the State of Pennsylvania. In consideration of such payment, I/We agree as follows: 1) to assign Erie Insurance Exchange/Erie Insurance Company to my/our rights of recovery against any person(s) or party(ies) legally liable to me/us, to the amount of and for the purpose of the payment noted above; 2) that I/We have not and will not make any separate settlement with nor give any separate release to any person(s) or party(ies) who caused or are alleged to have caused the above mentioned loss or accident; 3) that suit may be instituted by Erie Insurance Exchange/Erie Insurance Company in my/our name; 4) to execute all papers required to commence such suit; and 5) to cooperate in prosecuting any or all actions which Erie Insurance Exchange/Erie Insurance Company may bring to recover from any person(s) or party(ies) for the claims or causes of action which I/We have growing out of said loss or accident. It is expressly understood and agreed that, out of any amount recovered, costs of collection, including by not limited to counsel fees, shall be first paid to ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY. Except in states which apply comparative negligence in determining legal liability, any recovery in excess of collection costs shall be paid to me/us, up to the full extent of my/our loss. In states which apply comparative negligence, any recovery of my/our loss, in excess of collection costs, shall be reduced by a factor equal to the percentage of my/our negligence which contributed to cause the above mentioned accident, before it is paid to me/us. I/We further understand and agree that this RELEASE AND AGREEMENT is inclusive of any and all present and future liens or claims for subrogation against the payments to be made in accordance with this RELEASE AND AGREEMENT. 1/We understand and agree that I/we are responsible for the payment of any liens or charges against the payments to be made hereunder should any such liens, subrogation. claims or claims for expenses and charges be asserted. This includes, but is not limited to, medical expense liens, worker's compensation liens, ERISA liens, liens asserted by any federal, state or local governmental entity or agency or any medical expense claim. Should any person or entity make claim for payment of any liens or charges against ERIE, INSURANCE: EXCHANGE/ERIE INSURANCE COMPANY or their counsel, I/we agree to indemnify and hold harmless ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY and their counsel from any and all such liens, charges, fees, claims, attorney fees, costs, interests and any other sum. I/We understand that this settlement is the compromise of a disputed claim, and that the payment is not to be construed as an admission of liability on the part of the persons, firms and corporations hereby released by whom liability is expressly denied. (CAUTION: READ BEFORE SIGNING) Intending to be legally bound thereby, WITNESS my/our hand(s) and seal(s) this _day of Witnessed by: STATE OF COUNTY OF On this day of to me known to be the person executed the same as My commission expires (SEAL) (Blase Salomone as parent & natural guardian) (SEAL) SS (Christina Salomone as parent & natural guardian) before me personally appeared who executed the foregoing instrument, and acknowledged that free act and deed. Notary Public NOTICE: Any person who knowingly and with intent to deFZEXHIBIT other person files an application for insurance or statement of claim containing any materially false information or conce g, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the p i, s. a? v? m a N r O M M O a N r O N O N t N ?- O J ? ? t O m CL O ? r N r O ° V r 0 N N T- ti W O N r ? O d Oehm l!i a LL 0 0213 co E W 2 U LL LL O O m 3 a J C ED as r a. 0 U. _w 0 F- o a a `' N N C I w N N w F - cq M OD 00 tG V Q NIp cn IA C w to C L H rcnen V N{cgV0 N N N N Z, 0 U ,a m G N C F- .a 0 d lR F- D O 7 a C N N .0 ? ,v U U rni" CU cu dd E oc (D v a) m 'c 2Uaa aLD (D 4) N c 0 o o E 0 0 U N N CD (n 5,0 C". N N r r r e- ? ? 0) I,- N N M 0) N O N N fl- N M O O O C) N C T 0 E o O fn Q ?a y O H C O t w C Q d EXHIBIT E I R N z O E- W a BLASE AND CHRISTINA SALOMONE, as parents and natural guardians of their minor children, ANTHONY AND VINCENT SALOMONE, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA : Case No. 12-2037 Civil Term V. ERIE INSURANCE EXCHANGE, Defendant : CIVIL ACTION -LAW AFFIDAVIT We, Blase and Christina Salomone, parents and natural guardians of Anthony Salomon, a minor child, hereby state and affirm that: a) We authorize and request that our attorney, George J. Costopoulos, Esquire, finalize a settlement for uninsured motorist benefits with Erie Insurance Exchange for the amount of $15,000.00 arising from the personal injuries sustained by our minor son, Anthony Salomone, in an automobile collision caused by an uninsured motorist on November 21, 2010; b) We consent that out of this settlement of $15,000.00 may be deducted attorney's fees of 25% equaling $3,750.00, plus costs amounting to $136.70, for a total of $3,886.70. We agree that this amount is fair and reasonable, and is consistent with our contingent fee agreement; C) We agree that the remaining net proceeds of $11,113.30 will be deposited in one or more savings accounts in the name of Anthony Salomone in banks, building and loan associations, savings and loan associations or credit unions, deposits in which are insured by a federal government agency or in one or more accounts in the name of Anthony Salomone investing only in securities guaranteed by the United States government or a Federal Governmental agency managed by responsible financial institutions. Said accounts shall contain a provision that no withdrawal can be made from any such account until the minor attains 1W:71 majority, except as authorized by a prior order of court; d) We agree to promptly provide and file with the Court proof of this deposit on behalf of Anthony Salomone; e) We understand and acknowledge that Court approval of this proposed settlement and distribution is necessary, and have submitted along with my attorney the attached Petition and proposed Order; f) We ask that the Court approve the proposed settlement and distribution, and enter the attached Order, without the need for a hearing. However, should the Court deem it necessary to schedule a hearing, we will present with Anthony Salomone and our attorney; and g) We sign this Affidavit of our own free will, and verify that the statements made herein are true and correct. We understand that any false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. Blase Salomon Christina Salomone Page 2 of 2 V VERIFICATION I, George J. Costopoulos, counsel for Petitioners, Blase and Christina Salomone, as parents and natural guardians of Anthony Salomone, a minor child, do hereby verify that the statements made in the foregoing document are true and correct. I understand that any false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. GEMOC J.COSTOPOULOS Date: _? l? BLASE AND CHRISTINA SALOMONE, as parents and natural guardians of their minor children, ANTHONY AND VINCENT SALOMONE, Plaintiffs V. ERIE INSURANCE EXCHANGE, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA., ,- )-- Case No. 12-2037 Civil Term CIVIL ACTION - LAW PETITION FOR APPROVAL OF MINOR'S SETTLEMENT AND NOW COME the Petitioners, Blase and Christina Salomone, parents and natural guardians of Vincent Salomone, a minor child, by and through their counsel, George J. Costopoulos, Esquire, and represent: 1. Petitioners are Plaintiffs, Blase and Christina Salomone, who reside at 221 Mountain Road, Dillsburg, PA 17019. Petitioners are the parents and natural guardians of Vincent Salomone, age 13 (date of birth: 2/2/99; social security number: 184-78-3277). 2. On November 21, 2010, Vincent was injured in a motor vehicle collision while a rear seat passenger in an automobile driven by his mother, Christina Salomone. The collision was caused when Michael Posten, an uninsured driver of an uninsured vehicle, failed to yield at a stop sign and t-boned the Salomone's vehicle. A copy of the police crash report is attached as Exhibit "A." 3. The collision, which occurred in South Middleton Township, Cumberland County, Pennsylvania, caused a laceration to Vincent's forehead, a pelvic fracture, a low back contusion and emotional unrest. Vincent's forehead laceration required stitches, and his other injuries were treated conservatively at the emergency room and through follow-up visits with his doctors. 4. On December 17, 2010, Petitioners retained the undersigned counsel to negotiate a settlement and/or to institute legal proceedings for Vincent's damages resulting from the collision. A copy of the fee agreement is attached as Exhibit "B." 5. In March, 2012, the undersigned counsel negotiated a proposed settlement on Vincent's behalf for the uninsured motorist benefits provided by his parents' automobile insurance policy with Erie Insurance Exchange in the amount of $62,500.00. A copy of Erie's proposed settlement agreement and release is attached as Exhibit "C." 6. The undersigned counsel is of the professional opinion that the proposed settlement for uninsured motorist benefits is reasonable based on previous settlements in comparable matters, and given that there are no unpaid creditors or liens. 7. From the proposed settlement of $62,500.00, Petitioners consent to a distribution to the undersigned counsel consistent with their contingent fee agreement, which provides for counsel fees in the amount of 25% ($15,625.00), plus costs in the amount of $163.25. A summary of counsel's disbursements is attached as Exhibit "D." Petitioners agree that the proposed settlement, along with the distribution to the undersigned counsel, is fair and reasonable, and therefore request that this Honorable Court enter an Order: a) approving the settlement for $62,500.00 with Erie Insurance Exchange, with the net proceeds of $46,711.75 to be deposited in one or more savings accounts in the name of Vincent Salomon in banks, building and loan associations, savings and loan associations or credit unions, deposits in which are insured by a federal government agency or in one or more accounts in the name of Vincent Salomone investing only in securities guaranteed by the United States government or a Federal Governmental agency managed by responsible financial AA-500 Tx • IncidentNupber: _H02-1987354 Commonwealth of Pennsylvania PAGE 1 Crash Involves: Police Crash Report ?IREPORTABLE CRASH O DUI O Fatality O Hit and Run O Commercial Vehicle O State Police Vehicle O Local Police Vehicle Q NIA O Work Zone O ATV O Snowmobile 0 Commonwealth Vehicle 0 Local Gov Vehicle Agency Name Case Closed Patrol lone Investigation Date ro o PA STATE POLICE - CARLISLE YES 24 11/2112010 Dispatch Time rival Time Investigator Badge Number Q 13:05 hrs 13:07 h SUMMITS JEFFREY M 11101 rs , rmi Approval Date Reviewer Reviewer Badge Number a 1112512010 AMMONS, DAWN R 08496 Dale of Crash rme of Crash Day of the Week Crash Description 1112112010 13:00 hrs SUNDAY ANGLE County Municipality CUMBERLAND SOUTH MIDDLETON TWP Weather Conditions Relation to Roadway o t NO ADVERSE CONDITIONS ON TRAVEL LANES A Illumination Road Surface Conditions DAYLIGHT DRY # of Units # of People #oflnlured # Killed EMS Agency Medical Facility 002 004 E 000 CARLISLE CARLISLE REGIONAL School Bus Related Sce Related PennDOT Notified Type of Intersection Special Location NO N NO 4 WAY INTERSECTION NOT APPLICABLE Work Zone Work Zone Type Where in Work Zone c NO 0 N Speed Limit Workers Present Officer Present Work Zone Characterist cs Road Closed Work on Shoulder Intermittent or Flogger ? Lane Closure ? with Detour ? or Median ? Moving Work ? Control ? Other m ? Route Signing Route Number Segment Number Travel Lanes Seed Limit p Orientation ¢ STATE HIGHWAY 0174 02 35 MPH EAST U House Number Street Name St. Ending WALNUT BOTTOM ROAD a Route Signing Route Number Segment Number Travel Lanes Speed Limit Orientation a z Used in LOCAL ROAD OR STREET 0000 01 25 MPH SOUTH Intersection o v Crashes Street Name St. Ending m c ROCKLEDGE DRIVE ` m z Route Number Or Mile Post Tenths Or Segment Marker Ramp Use Only Feet N E m f A E j J Street Name Street Endin 9 Or Miles Tenths E U o m j LL D N Route Number Or Mile Post Tenths r Segment Marker Ramp use only 41 U M ] o The above entry is the di f Street Name Street Ending stance rom the Crash Scene to Landmark 1 o J m a. Latitude: Degrees Minutes Seconds Decimal Degrees Minutes Seconds Decimal 40 08 32 442 Longitude: ,. 77 12 03 848 o Traffic Control Device Traffic Control Functioning u STOP SIGN DEVICE FUNCTIONING PROPERLY „ Lane Closed Lane Closure Direction Traffic Detoured Estimated Time Closed n FULLY EAST AND WEST YES 30 - 60 MIN. Environmental 1 Roadway Potential Factors (E/R) Factor 1 Factor 2 Factor 3 NONE o nrsc narmrul went in the crash Most Harmful Event in the Crash 4 Unit Number Harmful Event Unit Number Harmful Event E 0 001 HIT UNIT 2 001 HIT UNIT 2 `c Indicated Prime Factor me Factor Driver Action DRIVER ACTION RUNNING STOP SIGN actor Vehicle Failure Prime Factor Pedestrian Action w Prime Factor Enviromea7rh Road Su face Type - _ E EXHIBIT Printed 010 1 g 4 1 Form #: H02-1987354 z W a AA-500 Tx incident Number: H02-1987354 Commonwealth of Pennsylvania PAGE 1 ii. ;rash Involves: Police Crash Report REPORTABLE CRASH O DUI O Fatality Q Hit and Run 0 Commercial Vehicle Q State Police Vehicle 0 Local Police Vehicle * NIA O Work Zone 0 ATV O Snowmobile 0 Commonwealth Vehicle 0 Local Gov Vehicle Unit Number Type Unit Commercial Vehicle 001 Motor Vehicle in Transport No First Name MI Last Name Suffix DOB Telephone Number MICHAEL A POSTEN 08/20/1988 Street Address City State ip Code 812 HOLLY PIKE MT HOLLY SPRINGS (USA) PA 17065 Gender License Number License State Class Expiration Dale Owner/Driver MALE 29429170 PA C 0812112011 PRIVATE VEHICLE OWNED/LEASED BY DRIVER 0 A Driver Presence Physical Condition Primary Vehicle Code Violation Person Charged E DRIVER OPERATED VEHICLE APPARENTLY NORMAL PA VC 3323 YES 0 c Alcohot/Drugs Suspecled Icohol Test Type Alcohol Test Results `m z NO TEST NOT GIVEN w d a Driver Action RUNNING STOP SIGN d a _ d Pedestrian Action Pedestrian Signals Pedestrian Clothing Pedestrian Location 1st Harmful Event Left or Right Side Most Harmful Utility Pole Number HIT UNIT 2 YES 2nd Harmful Event Left or Right Side Most Harmful Utility Pole Number 3rd Harmful Event Left or Right Side Most Harmful Utility Pole Number 4th Harmful Event left or Right Side Most Harmful Utility Pole Number Owner First Name Owner MI Owner Lasl Name or Business Name uflx TIMOTHY E TREGO Street Address City State Zip Code 7 N LOCUST ST CAMP HILL (USA) PA 17011 Vehicle Type Special Usage Government Equipment Number AUTOMOBILE NOT APPLICABLE Model Year Vehicle Make Vehicle Model Vehicle Color VIN 1998 PLYMOUTH Neon GOLD 1P3ES47C9WD687875 icense Plate Reg. State Est. Speed Vehicle Towed Towed By 999999 PA 099 YES SELF nsurance Insurance Company Policy Number Expiration Date NO Direction of Travel Vehicle Position Vehicle Movement Initial Impact Point o_ SOUTH RIGHT LANE "CURB" GOING STRAIGHT 12 O'CLOCK p E Damage Indicator Gradient Road Alignment Possible Vehicle Failures DISABLING DOWNHILL STRAIGHT UNKNOWN 2 # of Units Type Unit 1 Tag Number Tag Year Tag State t 0 d > ^ c Unit Make -- Unit Owner D S Type Unit 2 Tag Number Tag Year Tag Slate Unit Make Unit Owner Engine Size Passenger? Saddle BagfTrunk? Trailer? Driver Education? cc 0 Driver Helmet Type Helmet Slaved On? DOT/Snell Designation? Eye Protection? Long Sleeves? Long Pants? Over Ankle Boots? 0 assenger Helmet Type helmet Stayed On? DOT1Snell Designation? Eye Protection? Long Sleeves? Long Pants? Over Ankle Boots? d U a U Passenger? Helmet c Head Lights? Rear Reflectors? J. Printed At: PA State Police • Carlisle 1211012010 10:05 AM Page 2 Form #: 1-1024987354 AA-500 TX IncidentNlynber: H02-1987354 %ommonwealth of Pennsylvania PAGE 3 Crash Involves: Police Crash Report REPORTABLE CRASH O DUI Q Fatality Q Hit and Run Q Commercial Vehicle O State Police Vehicle Local Police Vehicle Q NIA O Work Zone O ATV Q Snowmobile Q Commonwealth Vehicle O Local Gov Vehicle Unit Number Type Unit Commercial Vehicle 002 Motor Vehicle in Transport No First Name MI Last Name Suttix QOB Telephone Number CHRISTINA T SALOMONE 0713111967 (717) 486-4032 SUeel Address City Stale Zip Code 6 TRIPLETT CT DILLSBURG PA 17019 Gender License Number License State Class Expiration Date OwnerlDriver FEMALE 21325367 PA C 0810112013 PRIVATE VEHICLE OWN EDILEASED BY DRIVER 0 Driver Presence Physical Condition Primary Vehicle Code Violation Person Charged E DRIVER OPERATED VEHICLE APPARENTLY NORMAL NONE NO 0 • Alcohol/Drugs Suspected Icohol Test Type Alcohol Test Results ro NO TEST NOT GIVEN .c m Driver Action NO CONTRIBUTING ACTION V m a Pedestrian Action Pedestrian Signals Pedestrian Cloth ing Pedestrian Location t n 1sl Harmful Event Left or Right Side Most Harmful Utility Pole Number STRUCK BY UNIT' 1 NO 2nd Harmful Event Left or Right Side Most Harmful Utility Pole Number HIT UTILITY POLE RIGHT YES 153337 3(d Harmful Event Left or Right Side Most Harmful Utility Pole Number 4th Harmful Event left or Right Side Most Harmful U61ity Pole Number Owner First Name Owner MI Owner Last Name or Business Name uffur BLASE P SALOMONE Street Address City State Zip Code 12 N THUSH DRIVE CARLISLE PA 17016 Vehicle Type Special usage Government Equipment Number SUV NOT APPLICABLE Model Year Vehide Make Vehicle Model Vehicle Color VIN 1999 ISUZU RODEO GREEN 4S2CM58W7X4318101 License Plate Reg. State Est. Speed ehicle Towed Towed By HNE0278 PA 099 YES ROYER'S GULF TOWING Insurance Insurance Company Policy Number Expiration Date YES ERIE INS 0042505767H 0 U2512011 Direction of Travel Vehicle Position Vehicle Movement tial Impact Pant 1 c n EAST RIGHT LANE "CURB" GOING STRAIGHT 7 0 O' CLOCK 1 E Damage Indicator Gradient Road Alignment Possible Vehicle Failures 2 DISABLING LEVEL STRAIGHT NONE m p o ?TypeUng Tag Number Tag State a _ " c Unit Make Unit Owner a c _ Type Unil 2 Tag Number Tag Year Tag Stale N Unit Make Unil Owner Engine Size Passen er? 9 Saddle Bag/Trunk? Trailer? Driver Education? cc U ` Driver Helmet Type Helmet Stayed On? DOTISneA Designation? Eye Protection? Long Sleeves? Long Pants Over Ankle Boots? o 0 Passenger Helmet Type Helmet Stayed on? DOTISnell Designation? Eye Protection? Long Sleeves? Long Pants? Over Ankle Boots? m u u Passenger) Helmet? c m Head Lights? Rear Reflectors? o- Printed At, PA State Police - Carlisle 1211012010 10:05 AM Page 3 Form ff: H02-19BT354 f AA-500 TX Incident Number: H02-1987354 Commonwealth of Pennsylvania PAGE 4 Crash Involves: Police Crash Report REPORTABLE CRASH O DUI O Fatality 0 Hit and Run 0 Commercial Vehicle 0 State Police Vehicle 0 Local Police Vehicle Q NIA 0 Work Zone Q ATV Q Snowmobile 0 Commonwealth Vehicle Q Local Gov Vehicle Unit # Person No. First Name MI last Name Suffix DOB 001 001 MICHAEL A POSTEN 08120/1988 treet Address City State Zip Code C 812 HOLLY PIKE - J MT HOLLY SPRINGS (USA) PA 17065 ro Phone Number EMS Transport Person Type Gender Injury Severity E NO DRIVER MALE NOT INJURED 0 i Seat Position Safety Equipment 1 m DRIVER - ALL VEHICLES LAP AND SHOULDER BELT USED a0 Safety Equipment 2 Extrication AIR BAG NOT DEPLOYED - SWITCH ON NOT APPLICABLE Ejection Ejection Path NOT EJECTED NOT EJECTED/NOT APPLICABLE Unit # Person No First Name MI Last Name suffix DOB 002 002 CHRISTINA T SALOMONE 0713111967 Street Address City State Zip Code 6 TRIPLETT CT DILLSHURG PA 17019 n Phone Number EMS Transport Person Type Gender Injury Severity E ` (717) 486.4032 NO DRIVER FEMALE MINOR INJURY o c Seat Position Safety Equipment 1 m DRIVER - ALL VEHICLES LAP AND SHOULDER BELT USED a i a, Safety Equipment 2 Extrication MULTIPLE AIRBAGS DEPLOYED NOT APPLICABLE L Ejection Ejection Path NOT EJECTED NOT EJECTEDINOT APPLICABLE Unit # Person No. First Name MI Last Name Suffix DOB 002 003 ANTHONY C SALOMONE 0312911995 Street Address City State Zip Code o 6 TRIPLETT CT -- DILLSBURG PA 17019 Phone Number EMS Transport Person Type Gender Injury Severity E 0 (717) 486-4032 YES PASSENGER MALE MODERATE INJURY c Seat Position Safely Equipment 1 m FRONT SEAT RIGHT SIDE LAP AND SHOULDER BELT USED CL a Safety Equipment 2 Extrication FRONT AIR BAG DEPLOYED (FOR THIS SEAT) NOT APPLICABLE Ejection Ejection Path NOT EJECTED NOT EJECTED/NOT APPLICABLE Unit # Person No. First Name MI Last Name Suffix DOB 002 004 VINCENT B S 0210211999 Street Address City State Zip Code 6 TRIPLETT CT DILLSBURG PA 17019 M Phone Number EMS Transport Person Type Gender Injury Severity E (717) 4864032 YES PASSENGER MALE MODERATE INJURY 0 c Seat Position Safety Equipment t d SECOND ROW -RIGHT SIDE LAP AND SHOULDER BELT USED a a Safety Equipment 2 Extrication NONE USED 1 NOT APPLICABLE NOT APPLICABLE Ejection Ejection Path NOT EJECTED NOT EJECTEDINOT APPLICABLE PersonlBusiness Noticed hone Number Date Notified Time Notified d : MET ED r1 800) 545 7741 1112112010 15:30 hrs. a _ Reason for Notification ? - - - Z POLE STRUCK Printed At: PA State Police - Carlisle 1211012010 10:05 AM Page 4 Form rye H02-1987354 AA-5D0 TX Incident Number: H02-1987354 Crash Involves: O DUI O Fatality Q NIA O Work Zone Commonwealth of Pennsylvania PAG Police Crash Report REPORTABLE CRASH 0 Hit and Run O Commercial Vehicle 0 State Police Vehicle Local Police Vehk Q AN 0 Snowr- -"" Q Commonwealth Vehicle O Local Gov Vehicle 16' 1 -411-110- Rockledge Drive 35 MPH Point of Initial ImDad ? inal Rest Unit U itI 1 final Rest Unit N N _ N - - -E - Walnut Bottom Road 40 MPH Unit 2-J? - II tility Pole 1532-2951 Carlisle Boro - 1-mile -ash Synopsis -- - - This crash occured as unit 1 traveled south on Rockledge Drive and unit 2 traveled east on Walnut Bottom Road, South Middleton Township, Cumberland County. As unit 2 approached the intersection of Walnut Bottom and Rockledge Drive, unit 1 failed to stop at the stop sign and struck the driver side door of unit 2. After initial impact, unit 2 struck utility pole #15353-29514. Unit 1 came to final rest facing south east on SR 174. Unit 2 came to final rest facing southeat on Sr 174. Operator 2 and her passengers all sustained injuries. Operator 1 and his passenger did not sustain injuries. Both vehicles sustained disabling damage. This crash occured as unit 1 traveled south on Rockledge Drive and unit 2 traveled east on Walnut Bottom Road, South Middleton Township, Cumberland County. As unit 2 approached the intersection of Walnut Bottom and Rockledge Drive, unit 1 failed to stop at the stop sign and struck the driver side door of unit 2. After initial impact, unit 2 struck utility pole #15353-29514. Unit 1 came to final rest facing south east on SR 174. Unit 2 came to final rest facing southeat on Sr 174. Operator 2 and her passengers all sustained injuries. Operator 1 and his passenger did not sustain injuries. Both vehicles sustained disabling damage. The physical evidence observed on scene was consistent with the crash described. Unit 1 sustained heavy front end damage. Unit 2 sustained damage to its driver Printed At: PA State Police • Carlisle 12/1012010 10:05 AM Page 5 Form #: H02-1987354 AA 500 TX Incident Number: H02-1987354 commonwealth of Pennsylvania PAGE 6 Crash i6volves: ' Police Crash Report REPORTABLE CRASH 0 Bbl 0 Fatality 0 Hit and Run 0 Commercial Vehicle 0 State Police Vehicle 0 Local Police Vehicle Q NIA 0 Work Zone 0 ATV 0 Snowmobile 0 Commonwealth Vehicle 0 Local Gov Vehicle side and heavy damage to the passenger side where it struck the utility pole. I observed approximately 5 feet of skid marks left from unit 1. Minimal damage was done to the utility pole. On 11121/10, at approximately 1310 hours, I interviewed operator 2 on scene. She related that she was traveling east on SR 174 when she observed unit 1 approaching the intersection and not stopped. She further related that she did not have enough time to come to a complete stop and unit 1 struck into the drive side, causing her vehicle to collide with the utility pole. On 11/21110, at approximately 1320 hours, I interviewed operator 1 on scene. He related he was traveling south on Rockledge Drive when he realized his brakes were not working. He further related that when he realized that he was not going to stop, he put on his emergency brake and collided into the side of unit 2. He further related that he jsut purchased the car from a friend. Both passengers in unit 2 were transported to Carlisle EMS to Carlisle Regional for moderate facial injuries Fire and Rescue, as well as Fire Police, responded to the scene. Operator was was cited for Pa VC 1543, 1301, 1786, 3323, and 4703. A News Release was completed. Met Ed was contacted by CDC in regards to the utility pole struck Printed At: PA State Police • Carlisle 12/012010 10:05 AM Page 6 Form #: H02-1997354 SP 7-0501TX-Driver Exchange SP 7-0099CX-Non Reportable mmonwealth of Pennsylvania INCIDENT NUMBER cover Notice and Exchange Report H02-1987354 PA STATE POLICE - CARLISLE (717) 249-2121 DATE OF CRASH TIME OF CRASH DAY OF WEEK COUNTY MUNICIPALITY 11/21/2010 13:00 hrs. SUNDAY CUMBERLAND SOUTH MIDDLETON TWP ROUTE # SEGMENT # STREET STREET ENDING 0174 WALNUT BOTTOM ROAD PATROL ZON INVESTIGATOR \ INVESTIGATOR SIGNATURE BADGE NUMBER 24 SUMMITS, JEFFREY M 11101 REVIEWER REVIEWER BADGE NUMBER APPROVAL DATE Latitude: Degrees 1 Minutes Seconds Decimal L it d De rees ? 1 Minutes Seconds Decima l 40 08 32 442 ong e:- u 7 12 03 848 LVl. t-1. ON STATE HWY 174 AT ITS INTERSECTION WITH ROCKLEDGE DR (UNIT # DRIVER'S LAST NAME FIRST NAME MI SUFFIX DOB GENDER PHONE NUMBER 001 POSTEN MICHAEL A 08/20/1988 MALE STREET ADDRESS CITY STATE ZIP CODE 812 HOLLY PIKE MT HOLLY SPRINGS (USA) PA 17065 LICENSE NUMBER LICENSE STATE CLASS EXPIRATION DATE 29429170 PA C 08/2112011 Z L INSURANCE COMPANY POLICY NUMBER POLICY EXPIRATION DATE d 7 - OWNER'S LAST NAME OR BUSINESS NAME FIRST NAME MI SUFFIX TREGO TIMOTHY E STREET ADDRESS CITY STATE ZIP CODE 7 N LOCUST ST CAMP HILL (USA) PA 17011 VEHICLE YEAR MAKE MODEL 1998 PLYMOUTH NEON VIN LICENSE PLATE # STATE VIOLATIONS (INCLUDING SECTION NUMBERS): DRIVER CHARGED? 1 P3ES47C9WD687875 999999 PA PA VC 3323 YES UNIT # DRIVER'S LAST NAME FIRST NAME MI SUFFIX DOB GENDER PHONE NUMBER 002 SALOMONE CHRISTINA T 07131!1967 FEMALE (717) 486-4032 STREET ADDRESS CITY STATE ZIP CODE 6 TRIPLETT CT DILLSBURG PA 17019 LICENSE NUMBER LICENSE STATE CLASS EXPIRATION DATE 21325367 PA C 08/01/2013 INSURANCE COMPANY POLICY NUMBER POLICY EXPIRATION DATE w ERIE INS 0042505767H 04/2512011 OWNER'S LAST NAME OR BUSINESS NAME FIRST NAME MI SUFFIX SALOMONE BLASE P STREET ADDRESS CITY STATE ZIP CODE 12 N THUSH DRIVE CARLISLE PA 17015 VEHICLE YEAR MAKE MODEL 1999 ISUZU RODEO VIN LICENSE PLATE # STATE VIOLATIONS (INCLUDING SECTION NUMBERS). DRIVER CHARGED? 4S2CM58W7X4318101 HNE0278 PA NONE NO This crash occured as unit 1 traveled south on Rockledge Drive and unit 2 traveled east on Walnut Bottom Road, South Middleton Township, Cumberland County. As unit 2 approached the intersection of Walnut Bottom and Rockledge Drive, unit 1 failed to stop at the stop sign and struck the driver side door of unit 2. After initial impact, unit 2 struck utility pole #15353-29514. Unit 1 came to final rest facing south east on SR 174. Unit 2 came to final rest facing southeat on Sr 174. Operator 2 and her passengers all sustained injuries. Operator 1 and his passenger did not sustain injuries. Both vehicles sustained disabling damage. LAXX 0 FIIICLS 01= 61U0 1k, L-' ? CO S T 0 P 0 U L O S 153 NOR] 111 1ANOYI'Rc1RiH CkRIISIII,PI?\N IINAMAI M13 1717) )43-0.407 V I-AX (I1-0 241-1950 Contingent Fee Agreement We, Blase and Christina Salomone, as Parents and Natural Guardians of Vincent Salomone, a minor (hereinafter "clients"), do hereby retain the Law Offices of George J. Costopoulos, 153 North Hanover Street, Carlisle, Pennsylvania 17013 (hereinafter "attorneys"), to negotiate for us a settlement or to institute for us any legal proceedings that in their judgment are necessary to pursue any claim for damages and/or injuries sustained by Vincent Salomone due to a motor vehicle accident on or about November 21, 2010 against any person, firm, corporation or entity who may be responsible for said claim, and/or to obtain an amicable settlement We hereby give to our attorneys a Power of Attorney to execute all documents connected with the claim for the prosecution of which the attorneys are retained, including pleadings, contracts, commercial papers, settlement agreements, compromises and releases, verifications, dismissals, orders, settlement checks and all other documents that we could properly execute in connection with this matter. We agree to fully cooperate with our attorneys in the prosecution of the claim that comprises the subject matter of this Agreement. This includes, but is not limited to, making ourselves available for legal proceedings and consultations with our attorneys; keeping our attorneys informed as to our current mailing address, phone number and the current status of Vincent Salomone's medical condition. In consideration of the services performed and to be performed by our attorneys, we agree to pay attorneys' fees from the total amount recovered from any source a contingent fee of 25%. In the evens: that no recovery is obtained on this claim, our attorneys will make no charges for their time or services. Costs: It is understood that attorneys may advance out-of-pocket costs in the investigation, prosecution, preparation and trial of this case. Such costs are to be paid from our (clients') share of the total amount recovered and include, but may not be limited to: photocopies; notaries; investigation charges; photographs; court costs; medical records costs; fee for police report; deposition costs; expert witness fees; stenographer costs; and, video deposition fees. As one possible settlement option, we authorize our attorneys to explore the possibility of a structured settlement through the use of deferred periodic payments. We agree that if any claim is settled through such structure, the attorneys' fees may be paid directly to said attorneys from the insurance company, either in one lump sum payment at settlement, or, at the sole option of said attorneys and/or insurance company, deferred into future payments. However, in any event, said attorneys' fees shall be calculated in the percentage as set forth above based upon the cost of the structured settlement or present value thereof in accordance with applicable law. EXHIBIT m Z w d Clients agree that, in the event the investigation and discovery performed by attorneys shall in the judgment of attorneys reveal no meritorious claims exist on behalf of clients, then attorneys may withdraw from the further representation of the clients in this matter. Clients and attorneys further agree that, in the event that clients shall become dissatisfied with the services of attorneys, clients shall be permitted to discharge attorneys from their employment in this matter. However, in the event that clients elect to discharge attorneys, attorneys shall be entitled to receive payment of fees from any recovery which clients ultimately makes on these claims. The fees payable to attorneys shall be in an amount which would reasonably and equitably compensate attorneys for their efforts on behalf of clients in the prosecution of the claims. If clients and attorneys are not able to reach an agreement as to the amount of those fees at the time of discharge, then the matter shall be submitted to arbitration. This Contingent Fee Agreement applies to all proceedings up to and including verdict or decision at trial or arbitration. If, in the discretion of the attorneys, post-trial proceedings, including appeals, are warranted, they will not be covered by this Contingent Fee Agreement and a new fee agreement will be required by said attorneys. And Now, on the day and year written below, the above Contingent Fee Agreement and Power of Attorney has been read, approved, and understood by us and the receipt of a copy thereof acknowledged. The terms set forth are agreeable. Georg J. Costopoulos, Esquire Blase Salomone, Parent and Natural Guardian of Vincent Salomone Christina Salomon, Parent and Natural Guardian of Vincent Salomone Date: 10-/1-10 Page 2 of 2 CLAIM #: 010171128128 RELEASE AND AGREEMENT Under policy # Q042505767 issued by ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY, I/We, claiming coverage for myself/ourselves or on behalf of Vincent Salamone in consideration of Sixty-Two Thousand Five Hundred Dollars ($62,500.00) dollars, which I/We have received, RELEASE AND DISCHARGE ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY from any and all claims, causes of action or other rights which I/We have, have had or could have under the Uninsured Motorists coverage as set forth in said policy, which claims, causes of action or other rights arose or could have arisen as a result of a loss or accident which happened on the 21" day of November, 2010 at or near Route 174 in the county of Cumberland in the State of Pennsylvania. In consideration of such payment, I/We agree as follows: 1) to assign Erie Insurance Exchange/Erie Insurance Company to my/our rights of recovery against any person(s) or party(ies) legally liable to me/us, to the amount of and for the purpose of the payment noted above; 2) that I/We have not and will not make any separate settlement with nor give any separate release to any person(s) or party(ies) who caused or are alleged to have caused the above mentioned loss or accident; 3) that suit may be instituted by Erie Insurance Exchange/Erie Insurance Company in my/our name; 4) to execute all papers required to commence such suit; and 5) to cooperate in prosecuting any or all actions which Erie Insurance Exchange/Erie Insurance Company may bring to recover from any person(s) or party(ies) for the claims or causes of action which 1/We have growing out of said loss or accident. It is expressly understood and agreed that, out of any amount recovered, costs of collection, including by not limited to counsel fees, shall be first paid to ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY. Except in states which apply comparative negligence in determining legal liability, any recovery in excess of collection costs shall be paid to me/us, up to the full extent of my/our loss. In states which apply comparative negligence, any recovery of my/our loss, in excess of collection costs, shall be reduced by a factor equal to the percentage of my/our negligence which contributed to cause the above mentioned accident, before it is paid to me/us. I/We further understand and agree that this RELEASE AND AGREEMENT is inclusive of any and all present and future liens or claims for subrogation against the payments to be made in accordance with this RELEASE AND AGREEMENT. I/We understand and agree that Uwe are responsible for the payment of any liens or charges against the payments to be made hereunder should any such liens, subrogation, claims or claims for expenses and charges be asserted. This includes, but is not limited to, medical expense rnin -liens, worker's compensation liens; ERISA liens,-liens-asserted by-any federal, state or local gove. ental entity or agency or any medical expense claim. Should any person or entity make claim for payment of any liens or charges against ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY or their counsel, Uwe agree to indemnify and hold harmless ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY and their counsel from any and all such liens, charges, fees, claims, attorney fees, costs, interests and any other sum. I/We understand that this settlement is the compromise of a disputed claim, and that the payment is not to be construed as an admission of liability on the part of the persons, firms and corporations hereby released by whom liability is expressly denied. (CAUTION: READ BEFORE SIGNING) Intending to be legally bound thereby, WITNESS my/our hand(s) and seal(s) this Witnessed by: of (SEAL) (Blast Salomone as parent & natural guardian) (SEAL) STATE OF COUNTY OF On this day of to me known to be the person executed the same as My commission expires Notary Public EXHIBIT NOTICE: Any person who knowingly and with intent to defra n r person files an application for insurance or statement of claim containing any materially false information or conceals o l.? information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the pe z W d SS (Christina Salomon as parent & natural guardian) before me personally appeared who executed the foregoing instrument, and acknowledged that free act and deed. T a N O M M O CO) O J O CL O H CO) O ' L) N T W N I ? O OM. W t L 021 N W LL ` LL O I Q J w Lo r w w as c 0040 m 1- m M M co co Q r1-!fr• of NNN N eip= O C L wNcovv = Ne'»d'9) N N N N N L c 7 0 U c ca N ? O 0 U U V Q lZ' CC M O (U 0 (D m p d n O p Lma?a0 c-'T"n CU C c O L o m m L L I- 2UUaCL m Ni CD C N N N c 0 w 0 a -2-2 v o E m a0i a0i a U p o a?a?m0? N r ?NCN(V f- ? C4 M 0 p f- N N M M N O O N N r ? N N M F- O O O O O a) C p 0 c O 0 i ?> 0 N M <O r iA U) N Cl) co R r 0 F C d V C d EXHIBIT c o W d BLASE AND CHRISTINA SALOMONE, : IN THE COURT OF COMMON PLEAS as parents and natural guardians of their CUMBERLAND COUNTY, PENNSYLVANIA minor children, ANTHONY AND VINCENT SALOMONE, Plaintiffs : Case No. 12-2037 Civil Term V. ERIE INSURANCE EXCHANGE, Defendant CIVIL ACTION -LAW AFFIDAVIT We, Blase and Christina Salomone, parents and natural guardians of Vincent Salomone, a minor child, hereby state and affirm that: a) We authorize and request that our attorney, George J. Costopoulos, Esquire, finalize a settlement for uninsured motorist benefits with Erie Insurance Exchange for the amount of $62,500.00 arising from the personal injuries sustained by our minor son, Vincent Salomone, in an automobile collision caused by an uninsured motorist on November 21, 2010; b) We consent that out of this settlement of $62,500.00 may be deducted attorney's fees of 25% equaling $15,625.00, plus costs amounting to $163.25, for a total of $15,788.25. We agree that this amount is fair and reasonable, and is consistent with our contingent fee agreement; C) We agree that the remaining net proceeds of $46,711.75 will be deposited in one or more savings accounts in the name of Vincent Salomone in banks, building and loan associations, savings and loan associations or credit unions, deposits in which are insured by a federal government agency or in one or more accounts in the name of Vincent Salomone investing only in securities guaranteed by the United States government or a Federal Governmental agency managed by responsible financial institutions. Said accounts shall contain Z EXHIBIT m 0 Z W d I a provision that no withdrawal can be made from any such account until the minor attains majority, except as authorized by a prior order of court; d) We agree to promptly provide and file with the Court proof of this deposit on behalf of Vincent Salomone; e) We understand and acknowledge that Court approval of this proposed settlement and distribution is necessary, and have submitted along with my attorney the attached Petition and proposed Order; f) We ask that the Court approve the proposed settlement and distribution, and enter the attached Order, without the need for a hearing. However, should the Court deem it necessary to schedule a hearing, we will present with Vincent Salomone and our attorney; and g) We sign this Affidavit of our own free will, and verify that the statements made herein are true and correct. We understand that any false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. Blase Salomone al'z ?-- - - Z Christina Salomone Page 2 of 2 J A VERIFICATION I, George J. Costopoulos, counsel for Petitioners, Blase and Christina Salomon, as parents and natural guardians of Vincent Salomone, a minor child, do hereby verify that the statements made in the foregoing document are true and correct. I understand that any false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. Date: q - /I - fz- BLASE AND CHRISTINA O MONE, as parents and natural guardians of their minor children, ANTHONY AND VINCENT SALOMONE, Plaintiffs v. ERIE INSURANCE EXCHANGE, Defendant IN THE COURT OF PENNSYLVANIA . CUMBERLAND Case No. 12-2037 Civil Term : CIVIL ACTION -LAW O ER , k 1 , 2012, upon consideration of AND NOW, this day of herein Petition for Approval of Minor's Settlement Xit is hereby ORDERED and DECREED the that Petitioners, Blase and Christina Salomone, as parents and natural guardians of Anthony a minor child, are authorized to enter into a settlement for uninsured motor" benefits Salomone, with Erie Insurance Exchange in the gross amount of $15,000.00. It is further ORDERED and DECREED that all settlement drafts or checks shall be forwarded to petitioners' counsel, the Law Offices of George J. Costopoulos, for proper distribution of the gross proceeds as follows: $11,113.30 a. Anthony Salomone, a minor: $ 3,750.00 b. Law Offices of George J. Costopoulos (Counsel fee at 25%) 136._70 C. Law Offices of George J. Costopoulos (Costs Advanced) $15,000.00 Total Settlement: It is further ORDERED and DECREED that the net proceeds of the settlement for Anthony Salomone, a minor, in the amount of $11,113.30, is to be deposited in one or more savin s accounts in the name of Anthony Salomon in banks, building and loan associations, g .. vin s and loan associations or credit unions, deposits in which are insured by a federal sa g rernrnf It agency or in one or more accounts in the name of Anthony Salomone investing only securities guaranteed by the United States government or a Federal Governmental agency managed oy responsible financial institutions. Said accounts shall contain a provision that no withdray i1 can be made from any such account until the minor attains majority, except as authoriz( d by a prior order of court. Proof of the deposit shall be promptly filed of record. BY THE CO 11 Thom s A. PlaceY J. Common Pleas 3ud9e Distribi tion: ? i.ieorge J. Costopoulos, Esquire Attorney for Petitioners 153 N. Hanover Street Carlisle, PA 17013 ? Donald Bottini Erie insurance 4901 Louise Drive P.O. Box 2013 Mechanicsburg, PA 17055-0710 .,, 5 ,w; ,{d q Isla ?r (. p-g BLASE AND CHRISTINA SALOMONE, IN THE COURT OF COMMON PLEAS as parents and natural guardians of their CUMBERLAND COUNTY, PENNSYLVANIA minor children, ANTHONY AND VINCENT SALOMONE, ; Plaintiffs V. ERIE INSURANCE EXCHANGE, Defendant Case No. 12-2037 Civil Term : CIVIL ACTION -LAW O ER AND NOW, this day of , 2012, upon consideration of the herein Petition for Approval of Minor's Settlement, it is hereby ORDERED and DECREED that Petitioners, Blase and Christina Salomone, as parents and natural guardians of Vincent Salomone, a minor child, are authorized to enter into a settlement for uninsured motorist benefits with Erie Insurance Exchange in the gross amount of $62,500.00. It is further ORDERED and DECREED that all settlement drafts or checks shall be forwarded to Petitioners' counsel, the Law Offices of George J. Costopoulos, for proper distribution of the gross proceeds as follows: a. Vincent Salomone, a minor: $46,711.75 b. Law Offices of George J. Costopoulos $15,625.00 (Counsel fee at 25%) C. Law Offices of George J. Costopoulos 163.25 (Costs Advanced) Total Settlement: $62,500.00 It is further ORDERED and DECREED that the net proceeds of the settlement for Vincent Salomone, a minor, in the amount of $46,711.75, is to be deposited in one or more savings accounts in the name of Vincent Salomone in banks, building and loan associations, savings and loan associations or credit unions, deposits in which are insured by a federal 1 V Tr., vernment agency or in one or more accounts in the name of Vincent Salomon investing only rs, R1 rnor c tce E. Ok "ners, ,SS Pi Salc ces o ''fee a, sof4 nrcec 'ent. D ft the a vine '""edit securities guaranteed by the United States government or a Federal Governmental agency managed by responsible financial institutions. Said accounts shall contain a provision that no withdrawal can be made from any such account until the minor attains majority, except as authorized by a prior order of court. Proof of the deposit shall be promptly filed of record. BY THE COURT: 11 ThomaW . Placey J. Common PI as Judge Distribution: ? George J. Costopoulos, Esquire Attorney for Petitioners 153 N. Hanover Street Carlisle, PA 17013 ? Donald Bottini Erie Insurance 4901 Louise Drive P.O. Box 2013 Mechanicsburg, PA 17055-0710 a)p-- e S mQ )'Ci-4 4/s//j- 01 =' co BLASE AND CHRISTINA SALOMONE, as parents and natural guardians of their minor children, ANTHONY AND VINCENT SALOMONE, Plaintiffs V. ERIE INSURANCE EXCHANGE, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Case No. 12-2037 Civil Term ?C> caa c.?° a _o CIVIL ACTION -LAW b Qr'? -4 o PRAECIPE TO MARK CASE SETTLED, DISCONTINUED AND ENDED TO THE PROTHONOTARY: Kindly mark the above-captioned action settled, discontinued and ended. Thank you. BY: _ 4-4 G J. Costopoulos, Esquire D. # 78423 153 N. Hanover Street Carlisle, PA 17013 Phone: (717) 243-0407 Attorney for Plaintiffs Date: ?// / Xz BLASE AND CHRISTINA SALOMONE, as parents and natural guardians of their minor children, ANTHONY AND VINCENT SALOMONE, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Case No. 12-2037 Civil Term c7 4 -C 3< C.7 3p ".J C'^= w -v V. ERIE INSURANCE EXCHANGE, Defendant : CIVIL ACTION -LAW AFFIDAVIT OF DEPOSIT OF MINOR'S FUNDS 00 3 C) M M-rj trn I, George J. Costopoulos, Esquire, counsel for Anthony Salomone, a minor, in the above- captioned matter, hereby state and affirm as follows: 1. On April 17, 2012, the sum of $11,113.30 was deposited into a federally insured interest-bearing Certificate of Deposit (Account No.: 31003920485389), with M&T Bank, pursuant to the Court Order entered on April 4, 2012. 2. A copy of the above-referenced Court Order was provided to M&T Bank at the time the Certificate was opened. 3. The Certificate of Deposit is in the name of the minor, Anthony Salomone, born March 29, 1995, and the express prohibition of withdrawals of income or principal before the minor attains majority, except by order of Court, has been noted on the depository's records. A copy of M&T Bank's Record is attached hereto as Exhibit "A." BY: eorge J. Costopoulos, Esquire I.D. # 78423 153 North Hanover Street Carlisle, PA 17013 Phone: (717) 243-0407 Attorney for Plaintiff Date: ?j//j Ir // Z New Account 04/17/12 MANUFACTURERS AND TRADERS TRUST COMPANY CONSUMER DEPOSIT ACCOUNT OPENING REQUEST ACCOUNT TITLE AND STATEMENT ADDRESS OFFICE OF ACCOUNT ANTHONY C SALOMONE 4344 Spring Garden Office BLASE P SALOMONE, GUARDIAN ACCOUNT NUMBER NO WITHDRAWALS UNTIL AGE 18 31003920485389 COURT ORDERED ACCOUNT TYPE 221 MOUNTAIN RD 12 - 13 Month CD DILLSBURG PA 17019 CUST 1 PHONE # (717)502-6006 COST 1 SSN: 167766409 BIRTHDATE 03/29/1995 COST 2 SSN: 218948202 BIRTHDATE 04/16/1966 By signing below, I (we) (1) request that M&T Bank open in my (our) names the deposit account requested below with the features requested, and (2) acknowledge receipt of, and agree to all provisions of, the General Deposit Account Agreement, Availability Disclosure for Consumer Deposit Accounts, the Specific Features and Tenns containing information about the account, the applicable fee schedule and, if the account is a Jumbo Certificate of Deposit, the Agreement for Telephone Instructions. By signing below, I (we) acknowledge and agree that if the account is opened in the names of two or more individuals, the account will be a Joint Account with Right of Survivorship unless it is a fiduciary or custodial account. Certification: Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number (or 1 am waiting for a number to be issued to roe), and (2) 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) 1 have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that 1 am no longer subject to backup withholding, and (3) 1 am a U.S. citizen or other U.S. person. Certification Instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. (Also, see Part II - Certification under Specific Instructions on the separate W-9 form). The IRS does not require your consent to an rovision of this document other than the certifications required to avoid backup withholding. &?g ? SIGNATURE CUST I DATE SIGNATURE CUST 2 ?? f121/!G q / G^r? DATE SIGNATURF CUST 3 DATE SIGNATURE CUST 4 DATE IDENTIFICATION CUST 1 BCSS COMMON OF PA 0298850 PA BOSS 6409 COMMON OF PA CUST 2 DL 04/ 14 20983438 PA CUST 3 CUST 4 ID A n'oval OPENING AMOUNT $11,113.30 DATE 04/17/12 ACCOUNT SPECIFICS CHECKING: Relationship Package Interest Rate Transfer Interest to Account PR Safecheck? OD Funding Account SAVINGS: Interest Rate Transfer Interest to Account PR CLUB: Transfer to Account Interest Rate TIME DEPOSIT: Initial Tenn 12 Months Initial Maturity Date 04/17/13 Automatically Renewable? YES Final Maturity Date Interest Rate 0.10 Transfer Interest to Account Interest Check? Interest Cycle 00 Basis Points PR Promotional Code Service Charge Waive Code EMPLOYMENT: CUST 1 Student NORTHERN HIGH SCHOOL CUST 2 Self Employed ADS PUBLIC ADJUS CUST 3 CUST 4 DEPOSIT SOURCE DEPOSIT AMOUNT 1) M&TChecking I) $11,113.30 2) 2) 3) 3) SOURCE OF CASH FUNDS OVER $10,000: NO EXHIBIT SOURCE: s ;n 14 m Original - Account Services WPA001 (03/12) 9 1 ` 6VF cw3 a MANUFACTURERS AND TRADERS TRUST COMPANY AUTHORITY OF FIDUCIARY TO OPEN DEPOSIT ACCOUNT (For use for trusts, estates, by escrow agents, landlords, etc.) ACCOUNT NUMBER: 31003920485389 DEPOSITOR: ANTHONY C SALOMONE, BLASE P SALOMONE, GUARDIAN NO WITHDRAWALS UNTIL AGE 18, COURT ORDERED (Title of estate, trust, escrow fund, etc.) Fiduciary BLASE P SALOMONE Title Address 221 MOUNTAIN RD DILLSBURG PA 17019 Telephone 717 502-6006 SSN 2189 02 4 Signature r `Ct l xi? - Signer Title Address Telephone SSN Signer Title Address Telephone SSN Signature Signer Title Address Telephone SSN Signature Signature 1. I certify that Depositor named above is a(n) (trust under will, revocable trust, escrow fund, security deposit, deposit in lieu of bond, etc.) validly created or existing under the laws of the State of and I am authorized to act on Depositor's behalf by statute or by: ? An agreement with entitled dated appointing the undersigned as (escrow agent, trustee, executor, landlord, etc.); or ? The last will and testament of and letters testamentary issued naming me as ; or ? A trust agreement of grantors named naming me as trustee; or P1 Court order dated 1--/-/ . ?_ naming me as (--Z L" guardian, custodian, trustee, etc.) 2. 1 certify that only one signature is required to authorize banking transactions for Depositor, and acknowledge that dual signature requirements or restrictions impose no duty of enforcement on M&T Bank. 3. 1 further certify that each signature appearing above or on a Rider hereto is a true specimen of the signature of the person whose signature it purports to be. ti ?lLa L_ 1?, ?Gt1U10(G)4 Print Name of first Fid iarynamed above Print Name of second Fiduciary named above (if applicable) I a Y 5r'rh Lam... ?f Signature of first Fiduciary named above Title Signature of second Fiduciary named above (if applicable) Title Print Name of third Fiduciary named above Signature of third Fiduciary named above Title Print Name of fourth Fiduciary named above (if applicable) Signature of fourth Fiduciary named above (if applicable) Title Original - Account Services; Copy - Branch PA047(01/11) 6VF VERIFICATION I, George J. Costopoulos, counsel for Anthony Salomone, a minor child, do hereby verify that the statements made in the foregoing Affidavit are true and correct. I understand that any false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. GEO .COSTOPOULOS Date: 7 ?,Y 2 BLASE AND CHRISTINA SALOMONE, as parents and natural guardians of their minor children, ANTHONY AND VINCENT SALOMONE, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA : Case No. 12-2037 Civil Term V. ERIE INSURANCE EXCHANGE, Defendant : CIVIL ACTION -LAW AFFIDAVIT OF DEPOSIT OF MINOR'S FUNDS c? za x. -n 2z a K3 r t;? r= c:7 -ra 3' ..f I, George J. Costopoulos, Esquire, counsel for Vincent Salomone, a minor, in the above- captioned matter, hereby state and affirm as follows: 1. On April 17, 2012, the sum of $46,711.75 was deposited into a federally insured interest-bearing Certificate of Deposit (Account No.: 31003920485397), with M&T Bank, pursuant to the Court Order entered on April 4, 2012. 2. A copy of the above-referenced Court Order was provided to M&T Bank at the time the Certificate was opened. 3. The Certificate of Deposit is in the name of the minor, Vincent Salomone, born February 2, 1999, and the express prohibition of withdrawals of income or principal before the minor attains majority, except by order of Court, has been noted on the depository's records. A copy of M&T Bank's Record is attached hereto as Exhibit "A." BY: Geor J. Costopoulos, Esquire I.D. # 78423 153 North Hanover Street Carlisle, PA 17013 Phone: (717) 243-0407 Attorney for Plaintiff Date: t/// r//2 New ACC InI VV/ l 1114 MANUFACTURERS AND TRADERS TRUST COMPANY CONSUMER DEPOSIT ACCOUNT OPENING REQUEST ACCOUNT TITLE AND STATEMENT ADDRESS OFFICE OF ACCOUNT VINCENT I3 SALOMONE 4344 Spring Garden Office BLASE P SALOMONE, GUARDIAN ACCOUNT NUMBER NO WITHDRAWALS UNTIL AGE 18 31003920485397 COURT ORDERED ACCOUNT TYPE 221 MOUNTAIN RD 60 - 72 Month CD DILLSBURG PA 17019 CUST 1 PHONE # (717)502-6006 CUST I SSN: 184783277 BIRTHDATE 02/02/1999 CUST 2 SSN: 218948202 BIRTHDATE 04/16/1966 By signing below, I (we) (1) request that M&T Bank open in my (our) names the deposit account requested below with the features requested, and (2) acknowledge and agree to all provisions of, the General Deposit Account Agreement, Availability Disclosure for Consumer Deposit Accounts, the Specific Features and receipt of , Terms containing information about the account, the applicable fee schedule and, if the account is a Jumbo Certificate of Deposit, the Agreement for Telephone Instructions. By signing below, I (we) acknowledge and agree that if the account is opened in the names of two or more individuals, the account will be a Joint Account with Right of Survivo ship unless it is a fiduciary or custodial account. Certification: Under penalties of perjury, 1 certify that: (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and (2) 1 am not subject to backup withholding because: (a) 1 am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and (3) 1 am a U.S. citizen or other U.S. person. Certification Instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. (Also, see Part II - Certification under Specific Instructions on the separate W-9 form). The IRS does not require our consent to 1 provision of this document other than the certifications required to avoid backup withholding. SIGNATURE GUST I 4) L all 42,4 - •39it DATE G f f / DATE SIGNATURE CUSP 2 SIGNATURE CUST 3 DATE SIGNATURE Ct1S"1'4 DATE IDENTIFICATION CUST I BOSS COMMON OF PA 3078810 PA BCSS 3277 COMMON OF PA CUST 2 DL 04/ 14 20983438 PA CUST 3 CUST4 ID Approval OPENING AMOUNT $46,711.75 DATE 04/17/12 ACCOUNT SPECIFICS CHECKING: Relationship Package Interest Rate Transfer Interest to Account PR Safecheck? OD Funding Account SAVINGS: Interest Rate Transfer Interest to Account PR CLUB: Transfer to Account Interest Rate TIME DEPOSIT: Initial Tenn 60 Months Initial Maturity Date 04/17/17 Automatically Renewable? YES Final Maturity Date Interest Rate 0.55 Transfer Interest to Account Interest Check" Interest Cycle 00 Basis Points PR 1.10 Promotional Code Service Charge Waive Code EMPLOYMENT: CUST I Student NORTHERN MIDDLE SCHOOL CUST 2 Self Employed ADS PUBLIC ADJUS CUST 3 C't1Sf 4 DEPOSIT SOURCE I ) M&T Checking 2) 3) SOURCE OF CASH FUNDS OVER $10,000: NO SOURCE: DEPOSIT AMOUNT 1) $46,711.75 2) 3) A?? Original - Account Services WPA001 (03/12) EXH BIT Z Z a 6VF MANUFACTURERS AND TRADERS TRUST COMPANY AUTHORITY OF FIDUCIARY TO OPEN DEPOSIT ACCOUNT (For use for trusts, estates, by escrow agents, landlords, etc.) ACCOUNT NUMBER DEPOSITOR Signer Title Address Telephone SSN Signature _ Signer Title Address Telephone SSN Signature _ Fiduciary BLASE P SALOMONE Title Address 221 MOUNTAIN RD DILLSBURG PA 17019 Telephone 717 502-6006 SSN 218948202 Signature Signer Title Address Telephone SSN Signature 1. I certify that Depositor named above is a(n) (trust under will, revocable trust, escrow fund, security deposit, deposit in lieu of bond, etc.) validly created or existing under the laws of the State of and I am authorized to act on Depositor's behalf by statute or by: 31003920485397 VINCENT B SALOMONE, BLASE P SALOMONE, GUARDIAN NO WITHDRAWALS UNTIL AGE 18, COURT ORDERED (Title of estate, trust, escrow fund, etc.) entitled dated appointing the undersigned as (escrow agent, trustee, executor, landlord, etc.); or The last will and testament of and letters testamentary issued naming me as or ? A trust agreement of grantors named naming me as trustee; or Yf Court order dated lr /? " ( naming me as _ > y ' r cti t guardian, custodian, trustee, etc.) 2. 1 certify that only one signature is required to authorize banking transactions for Depositor, and acknowledge that dual signature requirements or restrictions impose no duty of enforcement on MST Bank. 3. 1 further certify that each signature appearing above or on a Rider hereto is a true specimen of the signature of the person whose signature it purports to be. Print Na a of first Fiduci am,led above Print Name of second Fiduciary named above (if applicable) 1. Ck1 "?L1:.J ?)?`C- E?-N??,-- C?GC ..,r ?t 1..lih _ Signature of first Fiduciary named above Title Signature of second Fiduciary named above (if applicable) Title Print Name of third Fiduciary named above Signature of third Fiduciary named above Title Print Name of fourth Fiduciary named above (if applicable) Signature of fourth Fiduciary named above (if applicable) Title Original - Account Services; Copy - Branch PA047(01/11) 6VF VERIFICATION I, George J. Costopoulos, counsel for Vincent Salomone, a minor child, do hereby verify that the statements made in the foregoing Affidavit are true and correct. I understand that any false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. GE E J. COSTOPOULOS Date: h' lZ