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HomeMy WebLinkAbout12-5187_s i! :i E t r '- t 6. !?tEli 6 aj s{ I STAMBAUGH LAW, P.C. 2121 S. QUEEN ST. YORK, PA V. Marie Tamney 7 Perennial Drive Fairless Hills, PA 19030 and William Hammill 427 Welsford Road Fairless Hills, PA 19030 Defendants. PRAECIPE FOR SUMMONSES TO THE PROTHONOTARY/CLERK OF SAID COURT: X Issue summonses on Civil Action - Law in the above case. Writ of Summons shall be issued and forwarded toA IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Beverly Thomas, Administratrix of the No. ?9 Estate of Dustin C. Stevens, 1 5 Ewell Drive East Berlin, PA 17316, Plaintiff, Civil Action - Law Date: W hz squire 110. N 64331/ 21 South Queen Street York, PA 17403 (717) 846-1400 5'103. 25-?d 4#7 (-k, 17 $d- V5. SUMMONS IN CIVIL ACTION TO: Marie Tamney, 7 Perennial Drive, Fairless Hills, PA 19030 William Hamill, 427 Welsford Road, Fairless Hills, PA 19030 YOU ARE NOTIFIED THAT THE ABOVE-NAMED PLAINTIFF(S) HAS/HAVE COMMENCED AN ACTION AGAINST YOU. Date: 6 I oIDI , -I d 43. -Do Prothonotary/Clerk, Civil Division B / . y Deputy bay) I STAMBAUGH LAW, P.C. 2121 S. QUEEN ST. YORK, PA c-~ C c r: -~ , '0 3 ~`' ~ -:- -n z~ ° ~~'= ~~ ~ ~~ ~ ~ ~ -~c z - ~Dp ~ n x ~~ I'' ~ - r-1 '~ „ -. ~3 -C _"' IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY THOMAS, Administratrix of the CIVIL DIVISION Estate of Dustin C. Stevens, Plaintiff, NO. 12-5187 v. PRAECIPE FOR APPEARANCE MARIE TAMNEY and WILLIAM HAMMILL, (Jury Trial Demanded) Defendants. Filed on Behalf of the Defendants Counsel of Record for This Party: Kevin D. Rauch, Esquire Pa. I.D. #83058 SUMMERS, McDONNELL, HUDOCK, GUTHRIE and SKEEL, P.C. Firm #911 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 (717) 901-5916 #19576 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY THOMAS, Administratrix of the CIVIL DIVISION Estate of Dustin C. Stevens, Plaintiff, NO. 12-5187 v. (Jury Trial Demanded) MARIE TAMNEY and WILLIAM HAMMILL, Defendants. PRAECIPE FOR APPEARANCE TO: THE PROTHONOTARY Kindly enter the Appearance of the undersigned, Kevin D. Rauch, Esquire, of the law firm of Summers, McDonnell, Hudock, Guthrie & Skeel, P.C., on behalf of the Defendants, Marie Tamney and William Hammill, in the above case. JURY TRIAL DEMANDED Respectfully submitted, SUMMERS, McDONNELL, HUDOCK, GUTHRIE ~ SKEEL, P.C. By: \~~ Kevin D. Rauch, Esquire Counsel for Defendants CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing PRAECIPE FOR APPEARANCE has been mailed by U.S. Mail to counsel of record via first class mail, postage pre-paid, this 8th day of November, 2012. Steven D. Stambaugh, Esquire Stamblaugh Law, P.C. 2121 S. Queen Street York, PA 17403 (Attorney for Plaintiff) SUMMERS, McDONNELL, HUDOCK, GUTHRIE ~ SKEEL, P.C. r ,~ j Kevin D. Rauch, Esquire Counsel for Defendants ' ~ ~~.EU-OPFiC~ ' ; i= THE PR0~1=0~~GTA '~ ZCti2 NOY 13 PM 2~ ~ i ~~ pENNSYL~VAN R ~~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY THOMAS, Administratrix of the CIVIL DIVISION Estate of Dustin C. Stevens, Plaintiff, NO. 12-5187 v. PRAECIPE FOR RULE TO FILE COMPLAINT MARIE TAMNEY and WILLIAM HAMMILL, Defendants. (Jury Trial Demanded) Filed on Behalf of the Defendants Counsel of Record for This Party: Kevin D. Rauch, Esquire Pa. I.D. #83058 SUMMERS, McDONNELL, HUDOCK, GUTHRIE and SKEEL, P.C. Firm #911 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 (717) 901-5916 #19576 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY THOMAS, Administratrix of the CIVIL DIVISION Estate of Dustin C. Stevens, Plaintiff, NO. 12-5187 v. (Jury Trial Demanded) MARIE TAMNEY and WILLIAM HAMMILL, Defendants. PRAECIPE FOR RULE TO FILE COMPLAINT TO: The Prothonotary Kindly rule the Plaintiff, Beverly Thomas, Administratrix of the Estate of Dustin C. Stevens, to file a Complaint in Civil Action within twenty (20) days. Respectfully submitted, SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, P.C. /~ B : `~ Y Kevin D. Rauch, Esquire Counsel for Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY THOMAS, Administratrix of the CIVIL DIVISION Estate of Dustin C. Stevens, Plaintiff, NO. 12-5187 v. (Jury Trial Demanded) MARIE TAMNEY and WILLIAM HAMMILL, Defendants. RULE AND NOW, this /.3~ day of NOV 2012, upon consideration of Defendants' Praecipe for Rule to File a Complaint, a Rule is hereby granted upon Plaintiff to file a Complaint within twenty (20) days of service, or suffer judgment Non Pros. Rule issued this /3~' day of IVby , 2012. Prothonotary CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that a true and correct copy of the foregoing PRAECIPE FOR RULE TO FILE COMPLAINT has been mailed by U.S. Mail to counsel of record via first class mail, postage pre-paid, this 8th day of November, 2012. Steven D. Stambaugh, Esquire Stamblaugh Law, P.C. 2121 S. Queen Street York, PA 17403 (Attorney for Plaintiff) SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, P.C. By: Kevin D. Rauch, Esquire Counsel for Defendants 'I r, r f 9 F ` t i IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA I Beverly Thomas, Administratrix of the No. 12-05187 Estate of Dustin C. Stevens, 5 Ewell Drive : East Berlin, PA 17316, Plaintiff, V. Marie Tamney, Civil Action- Law 7 Perennial Drive Fairless Hills, PA 19030, and William Hammill, 427 Welsford Road ; Fairless Hills, PA 19030, Defendants. For Plaintiff: Steven D. Stambaugh, Esquire 2121 S. Queen Street York, PA 17403 (717) 846-1400 Fax: (717) 846-1071 sttambaugh @stambaugh-law.com For Defendants Kevin D. Rauch, Esquire Summers, McDonnell, Hudock Guthrie& Skeel, P.C. 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 Main: (717) 901-5916 Fax: (717) 920-9129 STAMBAUGH LAW,P.C. 2121 S.QUEEN ST YORK,PA PLAINTIFF'S PETITION FOR APPROVAL OF THIRD PARTY AND UNDERINSURED MOTORIST INSURANCE SETTLEMENTS AND PAYMENTS PURSUANT TO TITLE 20 §3323 I Ii 1T I I IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Beverly Thomas, Administratrix of the No. 12-05187 Estate of Dustin C. Stevens, 5 Ewell Drive East Berlin, PA 17316, : Plaintiff, V. Marie Tamney, Civil Action - Law 7 Perennial Drive Fairless Hills, PA 19030, and William Hammill, 427 Welsford Road Fairless Hills, PA 19030, Defendants. PETITION FOR APPROVAL OF THIRD PARTY AND UNDERINSURED MOTORIST INSURANCE SETTLEMENTS AND PAYMENTS PURSUANT TO TITLE 20 §3323 TO THE HONORABLE JUDGES OF SAID COURT: i And now comes Beverly Thomas, the duly appointed Adminstratrix of the Estate of Dustin C. Stevens, by her attorneys, Steven D. Stambaugh, Esquire and Stambaugh Law, j P.C., and brings this Petition for Approval of Third Party and Underinsured Motorist Insurance Settlements and Payments Pursuant to Title 20 §3323 and, in support thereof, STAMBAUGH LAW,P.C. 2121 S.QUEEN ST. says as follows: YORK,PA I. Dustin Stevens, died on August 21, 2010, in Upper Allen Township, Cumberland County, Pennsylvania,lvania a s a result of motorcycle accident described below. I i 2. The subject accident occurred on August 21, 2010 at 12:40 p.m. Dustin Stevens was driving a 2003 Honda motorcycle northbound on US Route 15. At the same time, a vehicle driven by William Hamill and owned by Marie McTamney was likewise traveling northbound on US Route 15, ahead of Mr. Stevens, and which vehicle was hauling a piece I of furniture. As the McTamney vehicle proceeded northbound,the furniture came loose from the vehicle with the result that the furniture fell onto and in the middle of the northbound travel lanes of US Route 15. The vehicles following behind the McTamney vehicle began to evade to the right and to the left. As Mr. Stevens came upon the scene, he I did not see the furniture in the roadway and began to overtake a vehicle that, due to the furniture, evaded to that driver's left. As that driver evaded to her left, Mr. Stevens struck her vehicle, which, upon impact, ejected Mr. Stevens from his motorcycle. He was pronounced dead at the scene. A true and correct copy fo the subject Police Accident Report is served and filed herewith as Exhibit "A". I 3. i On August 31, 2010, Petitioner, Decedent's mother, was appointed Administratrix of the Estate of Dustin Stevens, deceased, by the York County Register of Wills, under Docket# 6710-1268. Letters of Testamentary were issued to Petitioner and ever since that time she has been and now is the duly appointed, qualified and acting Administratrix of the Estate of Dustin C. Stevens, deceased. A true and correct copy of the Letters of sTnMaAUCH yaw,P.C. Administration and the Short Certificate are collectively served and filed herewith as 2127 S.QUEEN ST. Exhibit"D". YORK.PA I 4. Summons was timely filed under the subject docket number and both Defendants were properly served. Defendant Hammill was insured by Progressive Insurance i � I Company. Defendant McTamney was insured by State Farm Insurance Company. Defendant Hammill/Progressive were represented by Progressive's assigned claims adjustor, Michael Rains. Defendant McTamney/ State Farm were represented by Kevin D. Rauch, Esquire. 5. Progressive Insurance Company, carrier for the tortfeasor, William Hammill, has offered its full policy limits of$15,000.00 in settlement of the Estate's claims. State Farm I, Insurance Company, carrier for the tortfeasor, Marie McTamney, has offered its full policy limits of$25,000.00 in settlement of the Estate's claims. A copy of the proposed Global Release of Third Parry Claims is served and filed herewith as Exhibit"C". Both Defendants concur in this Petition and the proposed Order. 6. Dairyland Cycle/Sentry Insurance Group, Mr. Stevens' underinsured motorist carrier, has offered its full policy limits of$15,000.00 in settlement of the Estate's I underinsured motorist claims. A copy of the proposed Underinsured Motorist Release is served and filed herewith as Exhibit"D". Dairyland concurs in this Petition and proposed Order. 7. Plaintiff s intestate left the following next of kin beneficiaries: his son, Dustin C. Stevens, Jr.; and his son, Griffen Gene Stevens. Plaintiff is also survived by his mother, STAMBAUGH LAW,P.C. Beverly Thomas, and his brother, Jason M. Stevens. 7_121 S.QUEEN ST. p YORK.PA 8. The decedent Dustin C. Steven's date of birth was January 8, 1982. He was twenty eight years of age at the time of his death. Dustin C. Stevens was in good health prior to the injuries which culminated nated in his death. I I i 9 The Administratrix engaged Steven D. Stambaugh, Esquire, under contingent fee agreement. A copy of the Contingent Fee Agreement is served and filed herewith as Exhibit"E". The law firm is to be paid a 33 1/3 % fee in the amount of$18,333.33 from i the Settlement proceeds. In addition, the law firm is entitled to be reimbursed for costs advanced in the amount of$691.20. 10. The settlement is not subject to Pa.R.C.P. Rules 2206 and 2037. i 11. The proposed distribution of the settlement proceeds is as follows: i A). Progressive Insurance Company - $15,000.00 payment, State Farm Insurance Company- $25,000.00 payment, and Dairyland Cycle/Sentry Insurance Group - $15,000.00 payment, in settlement of the Estate's p Ym claims; B). Attorney ees and costs under the contingent fee Y agreement totaling $18,333.33 in attorney's fees and $691.20 in costs; g C.) Reimbursement to the Administratrix for funeral expenses totaling $8,500.00; D.) Net settlement proceeds to the Estate of Dustin Stevens in the amount of $27,475.47. 12. The Pennsylvania Inheritance Tax Bureau has agreed to allocate the net settlement proceeds from the tort settlement, 50%to wrongful death and 50%to survival, as to the Estate of Dustin C. Stevens. A copy of the PA Department of Revenue Bureau of STAMBAUGH LAW,P.C. Individual Taxes' letter dated March 13, 2013 confirming the aforesaid allocation is served 2;21 S.QUEEN ST. YORK,PA j and filed herewith as Exhibit"F". 13. The Administratrix has reviewed this Petition and the proposed Order, and hereby confirms her consent to and approval of the same as evidenced by the attached Affidavit of i Administratrix/Petitioner Beverly Thomas in Support of the Approval of Third Party and Underinsured Motorist Insurance Settlements and Payments Pursuant to Title 20 §3323 for the Estate of Dustin Stevens,the original of which is served and filed herewith as Exhibit «G" i Wherefore,the Petitioner requests that this Honorable Court enter an Order granting the following relief: A) Approve the settlement of Progressive Insurance Company's $15,000.00 payment, State Farm Insurance Company's $25,000.00 payment, and Dairyland Cycle/Sentry Insurance Group's $15,000.00 payment for and to the Estate of Dustin Stevens; B) Authorize Petitioner to execute the attached Releases in full and final settlement of the subject case and claims, and to dismiss the third party case upon distribution of the settlement proceeds; C) Authorize the Estate to fulfill its contractual obligation for payment of attorney fees and costs under the contingent fee agreement totaling $18,333.33 in attorney's fees and $691.20 in costs; I' D) Authorize the Estate to reimburse the Administratrix for funeral expenses totaling $8,500.00; and E) Authorize that the net settlement proceeds totaling $27,475.47 to be proportioned fifty percent (50%) for wrongful death, and fifty percent (50%) for the survival action for the Estate of Dustin Stevens, and paid to the Estate accordingly. Respectfully Submitted, STAMBAUGH I Date: March Z6, 2013 STAMBAUGH LAW,P.C. Stet/ gh, Esquire 2121 S.QUEEN ST. I.D. 643 YORK,PA Att rney rorPetitioner 2121 South Queen Street York, PA 17403 (717) 846-1400 i v0709 Tnt C Page I of 13 PPO Ofliit E RASH REPORTING FORMANIA Crash Number page Case Closed Reportable Gash 1 W4172009 AA 500 1 Q Yes 0 No 0 Yes Q No incident Plumber _ Pofke Agency �Patrol zone� UAT2Gloo810581 21104 envy Flame Precinct Investigation Date(MM-DD-YYYY) Upper Allen Township i i G8 e 21 -12010 y Dispatch Time(mil) Arrival Time(mil) In eta Badge Number 3 1242 1249 OFFICER DORY HARLAN 2318 L LJ Reviewer Number � royal Date�(.M"M- 1 2010 ANDREW D PARSONS 2309 08 26 -12010 County CountV Name Municipality Municipe ter Name Day of INaek 21 Cumberland 104 Jpper Alien Township Q sun Q Thu ® Crash Date(MM-DD-YYYY) Gash Time(mil) No of Unfits Injured Killed* *If>00 Q Mon Q Fri s 2010 1242 3 5 0 1 C7 Tue sat Focofe Q Wed Q Unk LilWarksons llf Yes Complete Q Yes 0 No School Bus Q Yes !No School Zane Q Y NotNy PENNDOTQ Yes i No Norm M,Section 29) Related Related PYIainXenmce /�tlrsection Tvoe _ Multi-Ley 9 Q 4 Way Intersection Q "Y"Intersection Q Q Off Ramp Q Railroad Crossing GG Intersection Miciblock Q "T"intersection Q Round Traffic Ckcw Q on Ramp Q Crossover Q Ctther ___ See Overla Route Number Segment(Optional) Travel Lanes S Limn House Number (if applicable) North 0015 38.1 55 `o Q South ���----w4 � Street Name Street Ending 0 East For Mid-block crashes only.Use 4 US ROUTE 15 HW ° 0 west pasta!Hone Number and make sure frindpai Roadway Street Name a Q Unknown filled in 4 using this option Interstate Turnpike Turnpike State County Local Road Private Other/ Q (Not Turnpike) 0 (Ease/4kreso Q Spur way 0 Road Q or Street Q Road Q Unknown Route Number _i Segment(O tionaQ Travel es Speed h Q Q North C Q South s Street Name Street Ending Q East (� 0 Q West S �J Q Unknown $ Q Interstate Q Turnpike Q Turnpike Q State Q County Q Local Road Q Private Q Other/ (Not Turnpike) (East/West) Spur Highway Road or Street Road Unknown Intersecting Rt Num Or Mile Post Or t Marker � .❑ Segment North feet 0 South s Please i Or Intersecting Street Name St Endi Q East J Or Miles Enter Information Q West s for BOI U b Landmarks Intersecting Rt Num Or Mile Post Or Segment Marker `gd using N Distance from Crash This Option a .❑ O Q North Q South Scene to Landmark t x v Or Intersecting Street Name St Endin (For Crash between a e Q East Landmark t and EE Q West Landmark 2) E- Degrees Minutes Seconds Degrees Minutes Seconds ' Latitude 40 11 03 . 000 Longitude: — 76 58 , 59 000 Traffic Control Device Q Yield Sign Q Police Officer or IM _ Not Applicable Q Traffic Signet Active RR Crossing � i No Controls Q Device Functioning Q Free • Q Q Other Type TCD improperly e` Flashing Traffic Controls Signal Q Signal Q Stop Sign Q Passive RR Q Unknown Q Device Not Q Device Functioning Q Unknown Crossing Controls Functioning Properly Larm Qa d(d'Not Applicable',skip rest of the lane Closure"nj law Una* Q North Q East Q North and South Q All $ 0 Not Applicable Q Partially Q Fully Q Unknown RhAft Q south Q West Q East and West (N,S,E,W) e rmfG� Yes Q No Q C C Unknown Q 0<30 Min, Q 30.60 Min. Q 1-3 hrs Q 3-6 hrs Q 6.9 hrs Q>9 hours Q Unknown FORM 0 AA-W tilt a PLAINTIFF'S Ul EXHIBIT j http://www.dot6.state.pa.us/ersapp/Prin � 08061220100907160220220.... 9/7!2010 Print CRS W0172009 Page 2 of 13 COMMONWEALTH OF POLICE CRASH REPOWI G FORS PENNSYLVANIA Page: Crash Number AA 500 2 1 Police use Only W0172009 Type Motor ransportthicle in O Hit&Run Vehide Q Illegally Parked O Legally Parked Q Non•Motorized Commercial Vehicle tea Unit Pedestrian on Skates, Disabled From O Yes 0 No O Pedestrian O in Wheelchair,etc Previous Crash O Train O Phantom Vehicle (If'Pedestrian'or"Pedestrian on Skates,in Wheelchair,etc',Complete Form M,Section 18) (if Yes, Complete Form C) Unit No First Name MI Date of Birth(MM-DD-YYYY) [017 1 DUSTIN C� 01 08 1.1982 Delete? last Name Tele hone Number O STEVENS 7172599386 Address/City 1 State ZIP ° 4959 EAST BERLIN ROAD THOMASVILLE PA 17364 Driver License Number State Gass 25879531 pA = e Akoho0ruas Suspected Driver or Pedestrian Physical Condition tt Dru s Q No Q Illegal 9 9 O Medication O NoPmalntiy O Illegal Drug O Fatigue Q Medication O Alcohol Q Alcohol and Drugs 0 Unknown Had Been ` O Drinking"' Sick Q Asleep a Unknown >e Akahol Test Type s Primary Vehide Code Violation Char ed? p Test Not Given Q Breath O Other 9 O Blood Q urine O Unknown if FOLLOWING TOO CLOSELY O Yes •No a Test Given y` Akoho/Test Results O Test Refused O Unknown Driver Presence 1=Driver Operated 3=Driver Fled Scene Resuhs O O Test Given, 1 Vehicle 4--Hit and Run ❑ �• Contaminated Results 2=No Driver 9=Unknown Owner/Drfver 00--Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh 99 01=Private Vehide Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98--Other Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown Same as Owner First Name Owner Last Name or Business Name(If Pedestrian,ski this Section) Driver p VELLONS AUTO SALES Address/City/State/Zip Vehicle Make _ *Make Code 412 NORWAY STREET YORK PA 17403 Honda 37 VIN Model Year Vehide Model (see overlay) JH2SC50083M103779 2003 CBR900 -� License Plate Reg.State Est.Speed Vehide Towed Towed B YDP95 PA 999 •Yes O No HESS'GARAGE Arsuranoe Insurance Company Policy No SQ Yes Q No known t2 Tre T 1=Tong Pass.Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No Tag Year Tag St n No.of I/ a wi 2=Towing Truck S=Camper B=Other �� a Trailing 0 oil 3=Towing Utility Trailer 6=Full Trailer 9=Unknown Travel y •Vehide Position 03 *Movement 08 *See Speda/Usage Overlay Vehide Color Vehide TA" 05--Large Truck 20=Unicycle,Bicycle, 00 12=Commercial 06=Yellow 2 01=Automobile 06-SUV Tricycle Passenger �2 07=Silver 02 02=Motorcycle 07=Van 21=Other Pedalcycle 00-Not Applicable Carrier 08=Gold 01=Fire Veh 13=Taxi 03=Bus 10--Snowmobile 22=Horse&Buggy 01=81ue 09=Brown 04=Small Truck 11=Farm Equip 23=Horse&Rider 02=Ambulance 21=Tractor Trailer 02=Red 10=Orange (ff'01',Complete Form 12=Construction Equip 24=Train 03=Police 22=Twin Trailer 03=White 11=Purple M,Section 26) 13=ATV 25=Trolley 08--Other Emergency 23=Triple Trailer 04=Green 12=other 18=Other T Set Veh 98=Other Vehicle 31=Modified Veh 05=91ack 99=Unknown (If'20'or'21",Complete 1g=Unk.Type Spec Veh 99=Unknown 11=Pupil Transport 99=Unknown Form M,Section 27) /nitfa/Impact Point Damage Indicator Gradient 3=Downhill Road Alignment i2 I 00-Non-Collision 14=Undercarriage O=None 2=Functional 4--Bottom of Hill t=Straight 01-12-Ckxk Points 15=Towed Unit a 1=Minor 3=Disabling a t=Level 5-To of Hill 2=Curved 13-Top 99=Unknown 9=Unknown 2-Uphill 9=Unknown 9=Unknown Foa"9 AA-5W(1202) PENNDOT COPY http://www.dot6.state.pa.us/crsapp/Printlmages/XmIFiles./201008061220100907160220220.... 9/7/2010 Print CRS WO 172009 Page 3 of 13 J POLICE CRASH COMMONWFALTH FORM Page: IIIIAI���I� � Gash Number Page: AA 500 2 1 Pdice Use Only W0172009 Motor Vehicle in Hit&Run Vehicle Tie Transport 0 O Illegally Parked O Legally Parked 0 Non-Motorized Commercial Vehicle to C unit Pedestrian on Skates, Disabled From 0 Yes a No `e — Q Pedestrian 0 in Wheelchair,etc 0 Previous Crash 0 Train O Phantom Vehicle (If'Pedestrian'or"Pedestrian on Skates,in wheelchair,etc',Complete form M,Section 28) (If Yes, Complete form C) Unit No First Name MI Date of Birth(MM-DD-YYYY) r 02 I KELLY E❑ 03 1990 Delete? Last Name Tele hone Number Q SPRAGUE 9044036445 Address/City/State Zi ° 4551 ORTEGA ISLAND DR N JACKSONVILLE FL 32210 Driver License Number State Class 8 S162505906000 FL e Alcoho4Drugs Suspected Driver or Pedestrian Phvska/Condition 11 Illegal Drugs A rent) Il al Drug No Q 9 9 O Medication Normal Y Q U�9 g Q Fatigue Q Medication m O Alcohol O Alcohol and Drugs 0 Unknown Had Been 0 Drinking O Sick Q Asleep Q Unknown = Akoho/Test Type $ a Test Not Given Q Breath O Other Primary Vehicle Code Violation Charged? v O Blood Q Urine Q Unknown H N/A 0 Yes 0 No Test Given Alcohol Test Results Q Test Refused 0 Unknown Driver Presence 1=Driver Operated 3=Driver Fled Scene Results Q Test Given, � Vehicle 4--Hit and Run Contaminated Results 2=No Driver 9=Unknown OwnedDdver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh 02 01=Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98=Other Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99-Unknown Same as Owner First Name Owner Last Name or Business Name(if Pedestrian,skip this Section) Driver O RICHARD SPRAGUE Address/City/State/Zip Vehicle Make *Make Code 14551 ORTEGA ISLAND DR N JACKSONVILLE FL 32210 Ford 12 VIN Model Year Vehicle Model (see overlay) 1FMEU73E57UB68306 2007 EXPLORER License Plate Reg.State Est Speed Vehide Towed Towed By U122ZS JFL 1 030 Q Yes a No Insurance Insurance Company Policy No 5 a Yes Q No O known PROGRESSIVE � 21768704-7 a 17 T 1=Towing Pass,Veh 4=MobiletModular Home 7=Semi-Trailer Tag No Tag Year Tag St M Trail ng a unit 2=Tovving Truck S=Camper B=Other �� Units: 3=Towing Utility Trailer 6=Full Trailer 9=Unknown D of a *Vehicle Position 17 •ANovemeni 08 Y Trevcq Overla Spedal Usaoe Vehicle Color Vehicle Type 12=Commercial g y , y , F Passenger er O6=Yellow 01=Automobile 06=SUV Tricycle 07=Silver 06 02=Motorcycle 07=Van 21=Other Pedakcle 00=Not A pp licable Carrier O y01=Are Veh 13=Taxi = o 03=Bus 10=Snowmobile 22=Horse&Buggy 01=Blue 09=Brown 04=Small Truck 11=Farm Equip 23=Horse&Rider 02=Ambulance 21=Tractor Trailer 03=Police 22=Twin Trailer 02=Red 10=0range (if"02",Complete Form 12=Construction Equip 24=Train 03=White 11=Purple M,Section 26) 13=AN 25=Trolley 08--Other Emergency 23=Triple Trailer 04=Green 12=Other Of 20"or"21 ,Complete 18=Other Type Spec Veh 98=Other Vehicle 31=Modified Veh 05=81ack 99=Unknown p 19=Unk.Type 11=Pupil Transport 99=Unknown Form M,Section 27) YP Spec Veh 99=Unknown Initial impact Point Damaae Indicator Gradient 3=Downhill Road Af mnent 07 00=Non-Collision 14=Undercarriage O=None 2=Functional 4=Bottom of Hill 1=Straight 01-12=Clock Points 15-Towed Unit o 1=Minor 3=Disabling E12--Uphill 1Level 5=Top of Hill 2=Curved 13=Top 99=Unknown 9-Unknown ° 9--Unknown 9=Unknown FORM+'AA-5W(IM) PENNDOT COPY http://www.dot6.state.pa.us/crsapp/Printlmages/XmIFiles/201008061220100907160220220.... 9/7/2010 Print CRS W0172009 Page 4 of 13 COMMONVEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page: Crash Number M 5500 2 Pdke Use Only L±__j. W0172009 1;11 70Pedestrian otor Vehicle in Tyoe ansport O Hit&Run Vehicle Q Illegally Parked O Legally Parked QNon-Motorized Commercial Vehide to Unit Pedestrian on Skates, Disabled From O Yes 0 No — O in Wheelchair,etc Previous Crash O Train O Phantom Vehicle edestrian'or'Pedestrian on Skates,in Wheelchair,etc',Complete form M,Section 18) (If Yes,Complete Form C) Unit No First Name MI Date of Birth(MM-DD-YYYY) 03 WILLIAM i I 09 29 1988 Delete? Last Name Tele hone Number Q 1 HAMILL 2157154685 ——� Address/C /State Zi K 427 WELSFORD RD FAIRLESS HILLS PA 19030 Driver License Number State Class 28334046 PA C AkohoW ugs Suspected Driver or Pedestrian Phvsidaf Condition 11 No O Illegal Drugs Q Medication N9 mrn e nt) y a O Illegal Drug 0 Fatigue O Medication O Alcohol O Alcohol and Drugs Q Unknown Use DHraidnk8iegen O Sick O Asleep O Unknown Akohol Test Tvce p Test Not Given O Breath O Other Primary Vehicle Code Violation Charged? O Blood O Urine O TUnknown if SOURING LOAD IN VEHICLE •Yes O No a y Alcohol Test Results O Test Refused O Unknown Driver Pmence 1-Driver Operated 3=Driver Fled Scene Resu O Test Given, a Vehicle 4--Hit and Run Contaminated Results 2=No Driver 9=Unknown OwnerMriver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh 02 01=Private Vehicle Owned/ OwnedlLeased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98=0ther Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown Same as Owner First Name Owner Last Name or Business Name(If Pedestrian,skip this Section) Driver O MARIE MCTAMNEY Address/City/State/Zip Vehicle Make 'Make Code 7 PERENNIAL DR FAIRLESS HLS PA 19030 Toyota 49 VIN Model Year Vehicle Model (see overlay) 5TELU42N48Z517332 12008 License Plate Reg.State Est,Speed Vehide Towed Towed By YTR4673 PA 999 O Yes S No Insurance Insurance Company Policy No Yes O No O Un- known STATE FARM 385 9615 A 18387 12 Trani 1=Towing Pass.Veh 4--Mobile/Modular Home 7=Semi-Trailer Tag No Tag Year Tag St nU it No.of � Unrt ❑2=Towing Truck S=Camper 8=Other (� a Unit"g 3=Towing Utility Trailer 6=full Trailer 9=Unknown L—_J Direction of � Wehide PoslVan 01 -Movement 01 *See Special Usage ram Overlay Veh Color VeMde Tvice 05=Large Truck 20-Unicycle,Bicycle, �� 12=Commercial 06=Yellow 01=Automobile 06=SUV Tricycle Passenger 07 07=Silver 04 00=Not Applicable Carrier 02=Motorcycle 10=Van 21=Other&Buggy 01=Fire Veh 13=Taxi 08=Gold 03=Bus 10=Snowmobile Z2=Horse&Buggy 01=81ue 09=Brown 04--Small Truck 1I=Farm Equip 23=Horse&Rider 02-Ambulance 21=Tractor Trailer 02=Red 10=Orange (if"01',Complete form 12=Construction Equip 24--Train 03=Police 22=Twin Trailer 03=White 1 purple M,Section 26) 13=ATV 25=Trolley 08=Other Emergency 23=Triple Trailer 04=Green 12=Other 18=Other T Spec Veh 98=Other Vehicle 31=Modified Veh 05=81ack 99=Unknown (lm M or 1,)plate 19=Unk.Type Spec Veh 99=Unknown I 1=Pupil Transport 99=Unknown Initial Impact Poin I Damage Indicator Gradient 3=Downhill Road Alignment 00 00 -Collision 14=Undercarriage O=None 2=Functional 4=Bottom of Hill 1=Straight 01-12=Clock Points 15=Towed Unit i=Minor 3=Disabling 1=Level 5=Top of Hill 2=Curved 13-Top 99=Unknown 9-Unknown 2=Uphill 9=Unknown 9=Unknown FORM a nn-50o(1=) PENNDOT COPY http://www.dot6.state.pa.us/crsapp/Pri ntlmages/XmIFiles/201008061220100907160220220.... 9/7/2010 Print C'?S vd0172009 Page 5 of 13 POLICEOCR CRASH REPORTING FORM LI PENNSYLVANIA 1111111111al Gash Number Pa 1 ' 9e AA 500 3 (-P-0"use ony I W0172009 Person Tvrx: 5eaY.El2i'Won: Safety Qui0�141! Vie: A 1=Driver D OD-Not A Passenger/Occupant E �=None Used J hit Applicable G 0--Not Applicable 2=Passenger 01--Driver-All Vehicles 01=Shoulder Belt Used 1=Not Ejected 7=Pedestrian 02=Front Seat Middle Position 02=Lap Belt Used 2=Totally Ejected 8=Other 03=Fronk Seat Right Side 03=Lap And Shoulder Belt Used 3=Partially Ejected 9=Unknown 04--Second Raw-Left Site Or 04--Child Safety Seat Used 9=Unkr"wn Motorcycle Passenger 05=Motorcycle Helmet Used 05=Second Row-Middle Position 064cycle Helmet Used 06=Second Row-Right Side 10--Safety Belt Used Improperly O=NoEjected/Not Applicable F =Female 47=Third Row Or Greater• 11=Child Safety Seat Used Improperly p B M=Male Left Side 12=Helmet Used Impropedy 1=Through Side Door Opening U=Unknown 08=Third Row Or Greater- 90=Restraint Used,Type Unknown 2=Through Side Window 3=Through Windshield Middle Position 99=Unknown 09--Third Row Or Greater- 4=Through Back Door Right Side Safe(y�gyirxnerrt Two: 5=Through Back Door Tailgate Opening 5 lniury 5everiry 1 o=Sleeper Section of Truckcab 00=NOne Used/Not Applicable 6=Through Roof Openingg(Sunroof) r O=Not Injured 11=in Other Enclosed 01=Front Air Bag Deployed(For This Seat) Convertible Tap Down) 1=Killed Passenger Or Cargo Area 02=Side Air Bag Deployed(For This Seat) 7=Through Roof Opening(Convertible 2=Major Injury 12=1n Open Area 03=Other Type Air Bag Deployed Top Up) 3=Moderate (Back Of Pickup,Etc.) 04=Multiple Air Bags Deployed 9=Unknown Injury 13=Trailing Unit 05=Motorcyde Eye Protection ' 4=Minor Injury 14--Riding On Vehicle Exterior 06-Bicydist Wearing Elbow/Knee/Pads Extrka 8=Injury,Unk 15=Bus Passenger 10=Air Bag Not Deployed,Switch On 00-Not Applicable Severity, 98--Other 11=Air Bag Not Deployed,Switch Off 1=Not Extricated 9=Unknown if 99--Unknown 12--Air Bag Not Deployed, 2=Extricated By Mechanical Means Injury 13=A Unk r Bag itch Se ti (Prior To Crash) 3=Freed By Non-Mechanical Means 19--unknown if Air Bag Deployed 8=Other 99--Unknown 4=Unknown 13 EMS Agency:I WEST SHORE EMS Medical Facility:I HOLY SPIRIT HOSPITAL Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I 01 OI (� OI - 08 - 1982 la7-1 O1 00 00 L_J Oa Name/Address/Phone EMS Transport ❑Oppwa or STEVENS,DUSTIN C 4959 EAST BERLIN ROAD THOMASVILLE PA 1 Q Yes •No Unit No Person No Delete? Date of Birth (MM-DD.YYYY) A B C D E F G H I OZ Ol O 03 - 09 - 1990 1" F110 O1 03 Name/Address/Phone Sarin EMS Transport as Operator SPRAGUE,KELLY E 4551 ORTEGA ISLAND DR N JACKSONVILLE FL Q Yes +♦Na Unit No Person No Delete? Date of Birth (MM-DD-YYYY) i A B C - D E F G H I 02 02 p 03 - 23 - 1995 2][T]10 103 103 1 00 U a Name/Address/Phone EMS Transport ❑Same EMILY K SPRAGUE 4551 ORTEGA ISLAND DR N JACKSONVILLE FL Operatt e 0 Yes ON. Unit No Person No Delete? Date of Birth (MM.DD-YYYY) A B C D E F G H I 03 Oi 0 �- 29 - 1988 0 01 03 00 [�]F][�] Name/Address/Phone Same EMS Transport El HAMILL,WILLIAM J 427 WELSFORD RD FAIRLESS HILLS PA 1903 Q Yes 0 No Unit No Person No Date of Birth (MM-DD-YYYY) A $ C-- D E F G H I 03 02 p 11 - 07 - 1957 2 [F IF 03 03 00 F1 F1 Name/Address/Phone EMS Transport E]oOperra� PATRICIA R HAMILL 427 WELSFORD RD FAIRLESS HILLS PA 1903 p Yes 0 No Unit No Person Na Date of Birth (MM-DD-YYYY) A B C D E F G H I ! Name/Address/Phone Same as EMS Transport Operator 0 Yes 0 No row r AA-W(1202) PENNDOT COPY ` http.//Avww.dot6.st ate.pa.us/ersapp/PrintlnTages/`XmIF .,,s/2010080611-1-0100907160220220.... 91712010 'I r, r f 9 F ` t i IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA I Beverly Thomas, Administratrix of the No. 12-05187 Estate of Dustin C. Stevens, 5 Ewell Drive : East Berlin, PA 17316, Plaintiff, V. Marie Tamney, Civil Action- Law 7 Perennial Drive Fairless Hills, PA 19030, and William Hammill, 427 Welsford Road ; Fairless Hills, PA 19030, Defendants. For Plaintiff: Steven D. Stambaugh, Esquire 2121 S. Queen Street York, PA 17403 (717) 846-1400 Fax: (717) 846-1071 sttambaugh @stambaugh-law.com For Defendants Kevin D. Rauch, Esquire Summers, McDonnell, Hudock Guthrie& Skeel, P.C. 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 Main: (717) 901-5916 Fax: (717) 920-9129 STAMBAUGH LAW,P.C. 2121 S.QUEEN ST YORK,PA PLAINTIFF'S PETITION FOR APPROVAL OF THIRD PARTY AND UNDERINSURED MOTORIST INSURANCE SETTLEMENTS AND PAYMENTS PURSUANT TO TITLE 20 §3323 I Ii 1T I I IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Beverly Thomas, Administratrix of the No. 12-05187 Estate of Dustin C. Stevens, 5 Ewell Drive East Berlin, PA 17316, : Plaintiff, V. Marie Tamney, Civil Action - Law 7 Perennial Drive Fairless Hills, PA 19030, and William Hammill, 427 Welsford Road Fairless Hills, PA 19030, Defendants. PETITION FOR APPROVAL OF THIRD PARTY AND UNDERINSURED MOTORIST INSURANCE SETTLEMENTS AND PAYMENTS PURSUANT TO TITLE 20 §3323 TO THE HONORABLE JUDGES OF SAID COURT: i And now comes Beverly Thomas, the duly appointed Adminstratrix of the Estate of Dustin C. Stevens, by her attorneys, Steven D. Stambaugh, Esquire and Stambaugh Law, j P.C., and brings this Petition for Approval of Third Party and Underinsured Motorist Insurance Settlements and Payments Pursuant to Title 20 §3323 and, in support thereof, STAMBAUGH LAW,P.C. 2121 S.QUEEN ST. says as follows: YORK,PA I. Dustin Stevens, died on August 21, 2010, in Upper Allen Township, Cumberland County, Pennsylvania,lvania a s a result of motorcycle accident described below. I i 2. The subject accident occurred on August 21, 2010 at 12:40 p.m. Dustin Stevens was driving a 2003 Honda motorcycle northbound on US Route 15. At the same time, a vehicle driven by William Hamill and owned by Marie McTamney was likewise traveling northbound on US Route 15, ahead of Mr. Stevens, and which vehicle was hauling a piece I of furniture. As the McTamney vehicle proceeded northbound,the furniture came loose from the vehicle with the result that the furniture fell onto and in the middle of the northbound travel lanes of US Route 15. The vehicles following behind the McTamney vehicle began to evade to the right and to the left. As Mr. Stevens came upon the scene, he I did not see the furniture in the roadway and began to overtake a vehicle that, due to the furniture, evaded to that driver's left. As that driver evaded to her left, Mr. Stevens struck her vehicle, which, upon impact, ejected Mr. Stevens from his motorcycle. He was pronounced dead at the scene. A true and correct copy fo the subject Police Accident Report is served and filed herewith as Exhibit "A". I 3. i On August 31, 2010, Petitioner, Decedent's mother, was appointed Administratrix of the Estate of Dustin Stevens, deceased, by the York County Register of Wills, under Docket# 6710-1268. Letters of Testamentary were issued to Petitioner and ever since that time she has been and now is the duly appointed, qualified and acting Administratrix of the Estate of Dustin C. Stevens, deceased. A true and correct copy of the Letters of sTnMaAUCH yaw,P.C. Administration and the Short Certificate are collectively served and filed herewith as 2127 S.QUEEN ST. Exhibit"D". YORK.PA I 4. Summons was timely filed under the subject docket number and both Defendants were properly served. Defendant Hammill was insured by Progressive Insurance i � I Company. Defendant McTamney was insured by State Farm Insurance Company. Defendant Hammill/Progressive were represented by Progressive's assigned claims adjustor, Michael Rains. Defendant McTamney/ State Farm were represented by Kevin D. Rauch, Esquire. 5. Progressive Insurance Company, carrier for the tortfeasor, William Hammill, has offered its full policy limits of$15,000.00 in settlement of the Estate's claims. State Farm I, Insurance Company, carrier for the tortfeasor, Marie McTamney, has offered its full policy limits of$25,000.00 in settlement of the Estate's claims. A copy of the proposed Global Release of Third Parry Claims is served and filed herewith as Exhibit"C". Both Defendants concur in this Petition and the proposed Order. 6. Dairyland Cycle/Sentry Insurance Group, Mr. Stevens' underinsured motorist carrier, has offered its full policy limits of$15,000.00 in settlement of the Estate's I underinsured motorist claims. A copy of the proposed Underinsured Motorist Release is served and filed herewith as Exhibit"D". Dairyland concurs in this Petition and proposed Order. 7. Plaintiff s intestate left the following next of kin beneficiaries: his son, Dustin C. Stevens, Jr.; and his son, Griffen Gene Stevens. Plaintiff is also survived by his mother, STAMBAUGH LAW,P.C. Beverly Thomas, and his brother, Jason M. Stevens. 7_121 S.QUEEN ST. p YORK.PA 8. The decedent Dustin C. Steven's date of birth was January 8, 1982. He was twenty eight years of age at the time of his death. Dustin C. Stevens was in good health prior to the injuries which culminated nated in his death. I I i 9 The Administratrix engaged Steven D. Stambaugh, Esquire, under contingent fee agreement. A copy of the Contingent Fee Agreement is served and filed herewith as Exhibit"E". The law firm is to be paid a 33 1/3 % fee in the amount of$18,333.33 from i the Settlement proceeds. In addition, the law firm is entitled to be reimbursed for costs advanced in the amount of$691.20. 10. The settlement is not subject to Pa.R.C.P. Rules 2206 and 2037. i 11. The proposed distribution of the settlement proceeds is as follows: i A). Progressive Insurance Company - $15,000.00 payment, State Farm Insurance Company- $25,000.00 payment, and Dairyland Cycle/Sentry Insurance Group - $15,000.00 payment, in settlement of the Estate's p Ym claims; B). Attorney ees and costs under the contingent fee Y agreement totaling $18,333.33 in attorney's fees and $691.20 in costs; g C.) Reimbursement to the Administratrix for funeral expenses totaling $8,500.00; D.) Net settlement proceeds to the Estate of Dustin Stevens in the amount of $27,475.47. 12. The Pennsylvania Inheritance Tax Bureau has agreed to allocate the net settlement proceeds from the tort settlement, 50%to wrongful death and 50%to survival, as to the Estate of Dustin C. Stevens. A copy of the PA Department of Revenue Bureau of STAMBAUGH LAW,P.C. Individual Taxes' letter dated March 13, 2013 confirming the aforesaid allocation is served 2;21 S.QUEEN ST. YORK,PA j and filed herewith as Exhibit"F". 13. The Administratrix has reviewed this Petition and the proposed Order, and hereby confirms her consent to and approval of the same as evidenced by the attached Affidavit of i Administratrix/Petitioner Beverly Thomas in Support of the Approval of Third Party and Underinsured Motorist Insurance Settlements and Payments Pursuant to Title 20 §3323 for the Estate of Dustin Stevens,the original of which is served and filed herewith as Exhibit «G" i Wherefore,the Petitioner requests that this Honorable Court enter an Order granting the following relief: A) Approve the settlement of Progressive Insurance Company's $15,000.00 payment, State Farm Insurance Company's $25,000.00 payment, and Dairyland Cycle/Sentry Insurance Group's $15,000.00 payment for and to the Estate of Dustin Stevens; B) Authorize Petitioner to execute the attached Releases in full and final settlement of the subject case and claims, and to dismiss the third party case upon distribution of the settlement proceeds; C) Authorize the Estate to fulfill its contractual obligation for payment of attorney fees and costs under the contingent fee agreement totaling $18,333.33 in attorney's fees and $691.20 in costs; I' D) Authorize the Estate to reimburse the Administratrix for funeral expenses totaling $8,500.00; and E) Authorize that the net settlement proceeds totaling $27,475.47 to be proportioned fifty percent (50%) for wrongful death, and fifty percent (50%) for the survival action for the Estate of Dustin Stevens, and paid to the Estate accordingly. Respectfully Submitted, STAMBAUGH I Date: March Z6, 2013 STAMBAUGH LAW,P.C. Stet/ gh, Esquire 2121 S.QUEEN ST. I.D. 643 YORK,PA Att rney rorPetitioner 2121 South Queen Street York, PA 17403 (717) 846-1400 i v0709 Tnt C Page I of 13 PPO Ofliit E RASH REPORTING FORMANIA Crash Number page Case Closed Reportable Gash 1 W4172009 AA 500 1 Q Yes 0 No 0 Yes Q No incident Plumber _ Pofke Agency �Patrol zone� UAT2Gloo810581 21104 envy Flame Precinct Investigation Date(MM-DD-YYYY) Upper Allen Township i i G8 e 21 -12010 y Dispatch Time(mil) Arrival Time(mil) In eta Badge Number 3 1242 1249 OFFICER DORY HARLAN 2318 L LJ Reviewer Number � royal Date�(.M"M- 1 2010 ANDREW D PARSONS 2309 08 26 -12010 County CountV Name Municipality Municipe ter Name Day of INaek 21 Cumberland 104 Jpper Alien Township Q sun Q Thu ® Crash Date(MM-DD-YYYY) Gash Time(mil) No of Unfits Injured Killed* *If>00 Q Mon Q Fri s 2010 1242 3 5 0 1 C7 Tue sat Focofe Q Wed Q Unk LilWarksons llf Yes Complete Q Yes 0 No School Bus Q Yes !No School Zane Q Y NotNy PENNDOTQ Yes i No Norm M,Section 29) Related Related PYIainXenmce /�tlrsection Tvoe _ Multi-Ley 9 Q 4 Way Intersection Q "Y"Intersection Q Q Off Ramp Q Railroad Crossing GG Intersection Miciblock Q "T"intersection Q Round Traffic Ckcw Q on Ramp Q Crossover Q Ctther ___ See Overla Route Number Segment(Optional) Travel Lanes S Limn House Number (if applicable) North 0015 38.1 55 `o Q South ���----w4 � Street Name Street Ending 0 East For Mid-block crashes only.Use 4 US ROUTE 15 HW ° 0 west pasta!Hone Number and make sure frindpai Roadway Street Name a Q Unknown filled in 4 using this option Interstate Turnpike Turnpike State County Local Road Private Other/ Q (Not Turnpike) 0 (Ease/4kreso Q Spur way 0 Road Q or Street Q Road Q Unknown Route Number _i Segment(O tionaQ Travel es Speed h Q Q North C Q South s Street Name Street Ending Q East (� 0 Q West S �J Q Unknown $ Q Interstate Q Turnpike Q Turnpike Q State Q County Q Local Road Q Private Q Other/ (Not Turnpike) (East/West) Spur Highway Road or Street Road Unknown Intersecting Rt Num Or Mile Post Or t Marker � .❑ Segment North feet 0 South s Please i Or Intersecting Street Name St Endi Q East J Or Miles Enter Information Q West s for BOI U b Landmarks Intersecting Rt Num Or Mile Post Or Segment Marker `gd using N Distance from Crash This Option a .❑ O Q North Q South Scene to Landmark t x v Or Intersecting Street Name St Endin (For Crash between a e Q East Landmark t and EE Q West Landmark 2) E- Degrees Minutes Seconds Degrees Minutes Seconds ' Latitude 40 11 03 . 000 Longitude: — 76 58 , 59 000 Traffic Control Device Q Yield Sign Q Police Officer or IM _ Not Applicable Q Traffic Signet Active RR Crossing � i No Controls Q Device Functioning Q Free • Q Q Other Type TCD improperly e` Flashing Traffic Controls Signal Q Signal Q Stop Sign Q Passive RR Q Unknown Q Device Not Q Device Functioning Q Unknown Crossing Controls Functioning Properly Larm Qa d(d'Not Applicable',skip rest of the lane Closure"nj law Una* Q North Q East Q North and South Q All $ 0 Not Applicable Q Partially Q Fully Q Unknown RhAft Q south Q West Q East and West (N,S,E,W) e rmfG� Yes Q No Q C C Unknown Q 0<30 Min, Q 30.60 Min. Q 1-3 hrs Q 3-6 hrs Q 6.9 hrs Q>9 hours Q Unknown FORM 0 AA-W tilt a PLAINTIFF'S Ul EXHIBIT j http://www.dot6.state.pa.us/ersapp/Prin � 08061220100907160220220.... 9/7!2010 Print CRS W0172009 Page 2 of 13 COMMONWEALTH OF POLICE CRASH REPOWI G FORS PENNSYLVANIA Page: Crash Number AA 500 2 1 Police use Only W0172009 Type Motor ransportthicle in O Hit&Run Vehide Q Illegally Parked O Legally Parked Q Non•Motorized Commercial Vehicle tea Unit Pedestrian on Skates, Disabled From O Yes 0 No O Pedestrian O in Wheelchair,etc Previous Crash O Train O Phantom Vehicle (If'Pedestrian'or"Pedestrian on Skates,in Wheelchair,etc',Complete Form M,Section 18) (if Yes, Complete Form C) Unit No First Name MI Date of Birth(MM-DD-YYYY) [017 1 DUSTIN C� 01 08 1.1982 Delete? last Name Tele hone Number O STEVENS 7172599386 Address/City 1 State ZIP ° 4959 EAST BERLIN ROAD THOMASVILLE PA 17364 Driver License Number State Gass 25879531 pA = e Akoho0ruas Suspected Driver or Pedestrian Physical Condition tt Dru s Q No Q Illegal 9 9 O Medication O NoPmalntiy O Illegal Drug O Fatigue Q Medication O Alcohol Q Alcohol and Drugs 0 Unknown Had Been ` O Drinking"' Sick Q Asleep a Unknown >e Akahol Test Type s Primary Vehide Code Violation Char ed? p Test Not Given Q Breath O Other 9 O Blood Q urine O Unknown if FOLLOWING TOO CLOSELY O Yes •No a Test Given y` Akoho/Test Results O Test Refused O Unknown Driver Presence 1=Driver Operated 3=Driver Fled Scene Resuhs O O Test Given, 1 Vehicle 4--Hit and Run ❑ �• Contaminated Results 2=No Driver 9=Unknown Owner/Drfver 00--Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh 99 01=Private Vehide Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98--Other Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown Same as Owner First Name Owner Last Name or Business Name(If Pedestrian,ski this Section) Driver p VELLONS AUTO SALES Address/City/State/Zip Vehicle Make _ *Make Code 412 NORWAY STREET YORK PA 17403 Honda 37 VIN Model Year Vehide Model (see overlay) JH2SC50083M103779 2003 CBR900 -� License Plate Reg.State Est.Speed Vehide Towed Towed B YDP95 PA 999 •Yes O No HESS'GARAGE Arsuranoe Insurance Company Policy No SQ Yes Q No known t2 Tre T 1=Tong Pass.Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No Tag Year Tag St n No.of I/ a wi 2=Towing Truck S=Camper B=Other �� a Trailing 0 oil 3=Towing Utility Trailer 6=Full Trailer 9=Unknown Travel y •Vehide Position 03 *Movement 08 *See Speda/Usage Overlay Vehide Color Vehide TA" 05--Large Truck 20=Unicycle,Bicycle, 00 12=Commercial 06=Yellow 2 01=Automobile 06-SUV Tricycle Passenger �2 07=Silver 02 02=Motorcycle 07=Van 21=Other Pedalcycle 00-Not Applicable Carrier 08=Gold 01=Fire Veh 13=Taxi 03=Bus 10--Snowmobile 22=Horse&Buggy 01=81ue 09=Brown 04=Small Truck 11=Farm Equip 23=Horse&Rider 02=Ambulance 21=Tractor Trailer 02=Red 10=Orange (ff'01',Complete Form 12=Construction Equip 24=Train 03=Police 22=Twin Trailer 03=White 11=Purple M,Section 26) 13=ATV 25=Trolley 08--Other Emergency 23=Triple Trailer 04=Green 12=other 18=Other T Set Veh 98=Other Vehicle 31=Modified Veh 05=91ack 99=Unknown (If'20'or'21",Complete 1g=Unk.Type Spec Veh 99=Unknown 11=Pupil Transport 99=Unknown Form M,Section 27) /nitfa/Impact Point Damage Indicator Gradient 3=Downhill Road Alignment i2 I 00-Non-Collision 14=Undercarriage O=None 2=Functional 4--Bottom of Hill t=Straight 01-12-Ckxk Points 15=Towed Unit a 1=Minor 3=Disabling a t=Level 5-To of Hill 2=Curved 13-Top 99=Unknown 9=Unknown 2-Uphill 9=Unknown 9=Unknown Foa"9 AA-5W(1202) PENNDOT COPY http://www.dot6.state.pa.us/crsapp/Printlmages/XmIFiles./201008061220100907160220220.... 9/7/2010 Print CRS WO 172009 Page 3 of 13 J POLICE CRASH COMMONWFALTH FORM Page: IIIIAI���I� � Gash Number Page: AA 500 2 1 Pdice Use Only W0172009 Motor Vehicle in Hit&Run Vehicle Tie Transport 0 O Illegally Parked O Legally Parked 0 Non-Motorized Commercial Vehicle to C unit Pedestrian on Skates, Disabled From 0 Yes a No `e — Q Pedestrian 0 in Wheelchair,etc 0 Previous Crash 0 Train O Phantom Vehicle (If'Pedestrian'or"Pedestrian on Skates,in wheelchair,etc',Complete form M,Section 28) (If Yes, Complete form C) Unit No First Name MI Date of Birth(MM-DD-YYYY) r 02 I KELLY E❑ 03 1990 Delete? Last Name Tele hone Number Q SPRAGUE 9044036445 Address/City/State Zi ° 4551 ORTEGA ISLAND DR N JACKSONVILLE FL 32210 Driver License Number State Class 8 S162505906000 FL e Alcoho4Drugs Suspected Driver or Pedestrian Phvska/Condition 11 Illegal Drugs A rent) Il al Drug No Q 9 9 O Medication Normal Y Q U�9 g Q Fatigue Q Medication m O Alcohol O Alcohol and Drugs 0 Unknown Had Been 0 Drinking O Sick Q Asleep Q Unknown = Akoho/Test Type $ a Test Not Given Q Breath O Other Primary Vehicle Code Violation Charged? v O Blood Q Urine Q Unknown H N/A 0 Yes 0 No Test Given Alcohol Test Results Q Test Refused 0 Unknown Driver Presence 1=Driver Operated 3=Driver Fled Scene Results Q Test Given, � Vehicle 4--Hit and Run Contaminated Results 2=No Driver 9=Unknown OwnedDdver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh 02 01=Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98=Other Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99-Unknown Same as Owner First Name Owner Last Name or Business Name(if Pedestrian,skip this Section) Driver O RICHARD SPRAGUE Address/City/State/Zip Vehicle Make *Make Code 14551 ORTEGA ISLAND DR N JACKSONVILLE FL 32210 Ford 12 VIN Model Year Vehicle Model (see overlay) 1FMEU73E57UB68306 2007 EXPLORER License Plate Reg.State Est Speed Vehide Towed Towed By U122ZS JFL 1 030 Q Yes a No Insurance Insurance Company Policy No 5 a Yes Q No O known PROGRESSIVE � 21768704-7 a 17 T 1=Towing Pass,Veh 4=MobiletModular Home 7=Semi-Trailer Tag No Tag Year Tag St M Trail ng a unit 2=Tovving Truck S=Camper B=Other �� Units: 3=Towing Utility Trailer 6=Full Trailer 9=Unknown D of a *Vehicle Position 17 •ANovemeni 08 Y Trevcq Overla Spedal Usaoe Vehicle Color Vehicle Type 12=Commercial g y , y , F Passenger er O6=Yellow 01=Automobile 06=SUV Tricycle 07=Silver 06 02=Motorcycle 07=Van 21=Other Pedakcle 00=Not A pp licable Carrier O y01=Are Veh 13=Taxi = o 03=Bus 10=Snowmobile 22=Horse&Buggy 01=Blue 09=Brown 04=Small Truck 11=Farm Equip 23=Horse&Rider 02=Ambulance 21=Tractor Trailer 03=Police 22=Twin Trailer 02=Red 10=0range (if"02",Complete Form 12=Construction Equip 24=Train 03=White 11=Purple M,Section 26) 13=AN 25=Trolley 08--Other Emergency 23=Triple Trailer 04=Green 12=Other Of 20"or"21 ,Complete 18=Other Type Spec Veh 98=Other Vehicle 31=Modified Veh 05=81ack 99=Unknown p 19=Unk.Type 11=Pupil Transport 99=Unknown Form M,Section 27) YP Spec Veh 99=Unknown Initial impact Point Damaae Indicator Gradient 3=Downhill Road Af mnent 07 00=Non-Collision 14=Undercarriage O=None 2=Functional 4=Bottom of Hill 1=Straight 01-12=Clock Points 15-Towed Unit o 1=Minor 3=Disabling E12--Uphill 1Level 5=Top of Hill 2=Curved 13=Top 99=Unknown 9-Unknown ° 9--Unknown 9=Unknown FORM+'AA-5W(IM) PENNDOT COPY http://www.dot6.state.pa.us/crsapp/Printlmages/XmIFiles/201008061220100907160220220.... 9/7/2010 Print CRS W0172009 Page 4 of 13 COMMONVEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page: Crash Number M 5500 2 Pdke Use Only L±__j. W0172009 1;11 70Pedestrian otor Vehicle in Tyoe ansport O Hit&Run Vehicle Q Illegally Parked O Legally Parked QNon-Motorized Commercial Vehide to Unit Pedestrian on Skates, Disabled From O Yes 0 No — O in Wheelchair,etc Previous Crash O Train O Phantom Vehicle edestrian'or'Pedestrian on Skates,in Wheelchair,etc',Complete form M,Section 18) (If Yes,Complete Form C) Unit No First Name MI Date of Birth(MM-DD-YYYY) 03 WILLIAM i I 09 29 1988 Delete? Last Name Tele hone Number Q 1 HAMILL 2157154685 ——� Address/C /State Zi K 427 WELSFORD RD FAIRLESS HILLS PA 19030 Driver License Number State Class 28334046 PA C AkohoW ugs Suspected Driver or Pedestrian Phvsidaf Condition 11 No O Illegal Drugs Q Medication N9 mrn e nt) y a O Illegal Drug 0 Fatigue O Medication O Alcohol O Alcohol and Drugs Q Unknown Use DHraidnk8iegen O Sick O Asleep O Unknown Akohol Test Tvce p Test Not Given O Breath O Other Primary Vehicle Code Violation Charged? O Blood O Urine O TUnknown if SOURING LOAD IN VEHICLE •Yes O No a y Alcohol Test Results O Test Refused O Unknown Driver Pmence 1-Driver Operated 3=Driver Fled Scene Resu O Test Given, a Vehicle 4--Hit and Run Contaminated Results 2=No Driver 9=Unknown OwnerMriver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh 02 01=Private Vehicle Owned/ OwnedlLeased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98=0ther Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown Same as Owner First Name Owner Last Name or Business Name(If Pedestrian,skip this Section) Driver O MARIE MCTAMNEY Address/City/State/Zip Vehicle Make 'Make Code 7 PERENNIAL DR FAIRLESS HLS PA 19030 Toyota 49 VIN Model Year Vehicle Model (see overlay) 5TELU42N48Z517332 12008 License Plate Reg.State Est,Speed Vehide Towed Towed By YTR4673 PA 999 O Yes S No Insurance Insurance Company Policy No Yes O No O Un- known STATE FARM 385 9615 A 18387 12 Trani 1=Towing Pass.Veh 4--Mobile/Modular Home 7=Semi-Trailer Tag No Tag Year Tag St nU it No.of � Unrt ❑2=Towing Truck S=Camper 8=Other (� a Unit"g 3=Towing Utility Trailer 6=full Trailer 9=Unknown L—_J Direction of � Wehide PoslVan 01 -Movement 01 *See Special Usage ram Overlay Veh Color VeMde Tvice 05=Large Truck 20-Unicycle,Bicycle, �� 12=Commercial 06=Yellow 01=Automobile 06=SUV Tricycle Passenger 07 07=Silver 04 00=Not Applicable Carrier 02=Motorcycle 10=Van 21=Other&Buggy 01=Fire Veh 13=Taxi 08=Gold 03=Bus 10=Snowmobile Z2=Horse&Buggy 01=81ue 09=Brown 04--Small Truck 1I=Farm Equip 23=Horse&Rider 02-Ambulance 21=Tractor Trailer 02=Red 10=Orange (if"01',Complete form 12=Construction Equip 24--Train 03=Police 22=Twin Trailer 03=White 1 purple M,Section 26) 13=ATV 25=Trolley 08=Other Emergency 23=Triple Trailer 04=Green 12=Other 18=Other T Spec Veh 98=Other Vehicle 31=Modified Veh 05=81ack 99=Unknown (lm M or 1,)plate 19=Unk.Type Spec Veh 99=Unknown I 1=Pupil Transport 99=Unknown Initial Impact Poin I Damage Indicator Gradient 3=Downhill Road Alignment 00 00 -Collision 14=Undercarriage O=None 2=Functional 4=Bottom of Hill 1=Straight 01-12=Clock Points 15=Towed Unit i=Minor 3=Disabling 1=Level 5=Top of Hill 2=Curved 13-Top 99=Unknown 9-Unknown 2=Uphill 9=Unknown 9=Unknown FORM a nn-50o(1=) PENNDOT COPY http://www.dot6.state.pa.us/crsapp/Pri ntlmages/XmIFiles/201008061220100907160220220.... 9/7/2010 Print C'?S vd0172009 Page 5 of 13 POLICEOCR CRASH REPORTING FORM LI PENNSYLVANIA 1111111111al Gash Number Pa 1 ' 9e AA 500 3 (-P-0"use ony I W0172009 Person Tvrx: 5eaY.El2i'Won: Safety Qui0�141! Vie: A 1=Driver D OD-Not A Passenger/Occupant E �=None Used J hit Applicable G 0--Not Applicable 2=Passenger 01--Driver-All Vehicles 01=Shoulder Belt Used 1=Not Ejected 7=Pedestrian 02=Front Seat Middle Position 02=Lap Belt Used 2=Totally Ejected 8=Other 03=Fronk Seat Right Side 03=Lap And Shoulder Belt Used 3=Partially Ejected 9=Unknown 04--Second Raw-Left Site Or 04--Child Safety Seat Used 9=Unkr"wn Motorcycle Passenger 05=Motorcycle Helmet Used 05=Second Row-Middle Position 064cycle Helmet Used 06=Second Row-Right Side 10--Safety Belt Used Improperly O=NoEjected/Not Applicable F =Female 47=Third Row Or Greater• 11=Child Safety Seat Used Improperly p B M=Male Left Side 12=Helmet Used Impropedy 1=Through Side Door Opening U=Unknown 08=Third Row Or Greater- 90=Restraint Used,Type Unknown 2=Through Side Window 3=Through Windshield Middle Position 99=Unknown 09--Third Row Or Greater- 4=Through Back Door Right Side Safe(y�gyirxnerrt Two: 5=Through Back Door Tailgate Opening 5 lniury 5everiry 1 o=Sleeper Section of Truckcab 00=NOne Used/Not Applicable 6=Through Roof Openingg(Sunroof) r O=Not Injured 11=in Other Enclosed 01=Front Air Bag Deployed(For This Seat) Convertible Tap Down) 1=Killed Passenger Or Cargo Area 02=Side Air Bag Deployed(For This Seat) 7=Through Roof Opening(Convertible 2=Major Injury 12=1n Open Area 03=Other Type Air Bag Deployed Top Up) 3=Moderate (Back Of Pickup,Etc.) 04=Multiple Air Bags Deployed 9=Unknown Injury 13=Trailing Unit 05=Motorcyde Eye Protection ' 4=Minor Injury 14--Riding On Vehicle Exterior 06-Bicydist Wearing Elbow/Knee/Pads Extrka 8=Injury,Unk 15=Bus Passenger 10=Air Bag Not Deployed,Switch On 00-Not Applicable Severity, 98--Other 11=Air Bag Not Deployed,Switch Off 1=Not Extricated 9=Unknown if 99--Unknown 12--Air Bag Not Deployed, 2=Extricated By Mechanical Means Injury 13=A Unk r Bag itch Se ti (Prior To Crash) 3=Freed By Non-Mechanical Means 19--unknown if Air Bag Deployed 8=Other 99--Unknown 4=Unknown 13 EMS Agency:I WEST SHORE EMS Medical Facility:I HOLY SPIRIT HOSPITAL Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I 01 OI (� OI - 08 - 1982 la7-1 O1 00 00 L_J Oa Name/Address/Phone EMS Transport ❑Oppwa or STEVENS,DUSTIN C 4959 EAST BERLIN ROAD THOMASVILLE PA 1 Q Yes •No Unit No Person No Delete? Date of Birth (MM-DD.YYYY) A B C D E F G H I OZ Ol O 03 - 09 - 1990 1" F110 O1 03 Name/Address/Phone Sarin EMS Transport as Operator SPRAGUE,KELLY E 4551 ORTEGA ISLAND DR N JACKSONVILLE FL Q Yes +♦Na Unit No Person No Delete? Date of Birth (MM-DD-YYYY) i A B C - D E F G H I 02 02 p 03 - 23 - 1995 2][T]10 103 103 1 00 U a Name/Address/Phone EMS Transport ❑Same EMILY K SPRAGUE 4551 ORTEGA ISLAND DR N JACKSONVILLE FL Operatt e 0 Yes ON. Unit No Person No Delete? Date of Birth (MM.DD-YYYY) A B C D E F G H I 03 Oi 0 �- 29 - 1988 0 01 03 00 [�]F][�] Name/Address/Phone Same EMS Transport El HAMILL,WILLIAM J 427 WELSFORD RD FAIRLESS HILLS PA 1903 Q Yes 0 No Unit No Person No Date of Birth (MM-DD-YYYY) A $ C-- D E F G H I 03 02 p 11 - 07 - 1957 2 [F IF 03 03 00 F1 F1 Name/Address/Phone EMS Transport E]oOperra� PATRICIA R HAMILL 427 WELSFORD RD FAIRLESS HILLS PA 1903 p Yes 0 No Unit No Person Na Date of Birth (MM-DD-YYYY) A B C D E F G H I ! Name/Address/Phone Same as EMS Transport Operator 0 Yes 0 No row r AA-W(1202) PENNDOT COPY ` http.//Avww.dot6.st ate.pa.us/ersapp/PrintlnTages/`XmIF .,,s/2010080611-1-0100907160220220.... 91712010 Print CRS W0172009 Page 6 of 13 JCOMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page Crash Number AA 500 4 1 Police use Only W0172009 Crash Description a O=Non-Cogision 2=Head On 4=Angle 6 Sideaw'pe 8=Hit Pedestrian 1--Rear End 3=Rear to Rear pa� (Opposite Direction) e (Backing) �Direcllon) 7 Hit Fixed Object 9--Other/Unknown 0 0 __ c Relation to Roadway a 1=0n Travel lanes 3--Median 5=Outside Trafficway 7--Gore(Ramp Intersection) 2=Shoulder 4=Roadside 6=ln Parking Lane 9--Unknown +s € INumination 1Daylight 3--0ark-Street S=pawn 8=Other v 1D 2= -No u9� t>-- •Unknown Street Lights 4=Dusk Roadway L gMing _ ? Weather Conditions a 1=NCoondriwnse 3=Sleet(Hall) 5-F09 7=Sleet&Fog 9=Unknown 2=Rain 4--Snow 6--Rain&Fog 8--Other 2- Mud,Dirt, 6=Ice Patches Road Surface Conditions Wei 3--Snow Covered 5=lce� 7 Dior Mev Standing B=Ckher-� Ing Harm Event L/R Mi-w? Uti ity Pole Number Harmlu/Events(Harm Event) 3D--Hit Fence Or Wall 1 25 L❑ 01=Hit Unit 1 31=Hit Building Unit No 02=Hit Unit 2 32=Hit Culvert O 17 2 ❑ Q 03=Hit Unit 3 33=Hit Bridge Pier Or Abutment 04--Hit Unit 4 34=Hit Parapet End 05=Hit Unit 5 35=Hit Bridge Rail 06=Hit Other Traffic Unit 36=Hit Boulder Or Obstacle Please Put 07=Hit Deer On Roadway Events in 3 Q 08--Hit Other Animal 37=Hit Impact Attenuator Sequential 09=Collision With Other Non 38=Nit Fire Hydrant Order ❑ Fixed Object 39=Hit Roadway Equipment 4 CD 11 Struck By Unit 1 40-Hit Mail Box 12=Struck By Unit 2 41=Hit Traffic Island 16 13=Stnlck By Unit 3 42=Hit Snow Bank Harm Event L/R Most? Utility Pole Number 14=Struck By Unit 4 43=Hit Temporary Construction 5 15=Struck By Unit 5 Barrier Unit No 1 09 �� 16=5tn1ck By Other Traffic Unit 48--Hit Other Fixed Object 21=Hit Tree Or Shrubbery 49=Hit Unknown Fixed Object 22=Hit Embankment 50--Overturn/Roll Over 23=Hit Utility Pole 51=Struck By Thrown Or Falling 02 2 F Q 24=Hil Traffic Sign Object C 25=Hi1 Guard Rail 52=Pot Holes Or Other Please Put 26=Hit Guard Bait End Pavement Irregularities Events in 3 ❑ Q 27=Hi1 Curb 53=Jazknite Sequential 28--Hit Concrete Or 54=Fire In Vehicle Order 4 ❑ O Longitudinal Barrier 58=Other wn Harmful 29=Hit Ditch 99=Unknown Harmful Event first Unit No Harm Event Alm Unit No Hann Event Driver Action(D) 17--Careless Or Illegal n )To—ri nt in �fin 00=No Contributing Action Backing On Roadway � O1 25 12:�in O1 25 01=Driver Was Distracted 18--Driving On The Wrong tV rash vie f ssh 02=Driving Using Hand Held Phone Side Of Road Do not repeat M information w mLO60 pa¢s 03=Driving Using Hands Free Phone 19=Making Improper fnvkonmental/Roadway 04=Making Illegal U•Turn Entrance To Highway OSolmproper/Careless Turning 20--Making Improper Exrt Poter1041 FaAors(EAR) 1 OS 2 3 06=Tummg From Wrong Lane From Highway 00=None 11=Slippery Road Conditions(ICe/Snow) 07=Proceeding W/O 21=Careless ParkmgtUnparking Clearance After Stop 21=0verA)nder Oi=Windy Conditions 12=Substance On Roadway 08=Runrung St Sign Compensation 02=Sudden Weather Conditions 13=Potholes g �lion At Curve 09=Running Lght 23=5 in 03=Od1er Weather Conditions 14--Broken Or Cracked Pavement 10=Failure To Respond To 24-Driving Too Fast For Conditions 04=Deer In Roadway 15=TCD Obstructed Other Traffic Control Device 25=Failure To Maintain Proper Speed 05=Obstacle On Roadway 16--Soft Shoulder Or Shoulder Drop Off 11=Ta' ng 26--Driver Fleeing Police(PoI Chase) 06=Other Animal In Roadway 28=01her Roadway Factor 12=Su n SlowinySto%ing 27=Dritrer Inexperienced 1e 07 =Glare 29=Other Environmental Factor 13=Illegally Stopped On Road 28=Failure To Use C 08=Work Zone Related 99=Unknown 14=Careless Passing Or Lane Specialized Equip �° Change 92=Affected By Physical Condition A PpsslWe Vehicle Failures M 2=Wipers 15=Passing In No Passing Zone 98=Other Improper Driving Actions $ 00=None 06=Exhaust 13=Driver Seating/Control 16=Driving The Wrong Way On 99-Unknown 01=Tires 07=Headlights 14=Body,Doors,Hood,Etc 1-Way Street 02=Brake System OS=Srgpal Lights 15=Trailer Hitch 03=Steering System 09=Other Lights 16=Wheek No O1 1 11 2 3 .4 04=Suspension 10=Hom 17=Airbags 05-Power Train 11=Mirrors 18=Trader Overloaded 19=Uniler Load Unft c Unit Trailer Load 02 9 00 2 3 4 No O i 1 01 2 03 20=Improper Towing N0—Pedeshillan 21�-U-Obstnxted Windshield Ado 03=Working Unit 02 1 00 2 = 00--None 04=Pushing Vehicle NO 01=Entering Or Crossing At 05=Approaching Or Leaving Vehicle Specified Location 06=Working On Vehicle Indicated Prime Factor Unft No Factor Code 02=Walking,Running,Jogging, 07=Standing Do ml repeat this infw tion on Or Playing 98=Other 19 m itiple Paget. 01 11 99--Unknown E/R V D P Unit No O1 = Unit No 02 Q 00 Q if f/R is the Prime Factor Type,leave Unit No blank FORM I AA•SW(12M) pENINDO ,COPY -_--�— http://www.dot6.state.pa.us/crsapp/PrintImages/XmIFiles/2010080612201009071602?0220.... 9/17/2010 Print CRS W0172009 Page 7 of 13 JCOMMONWEALTH OF PENNSYLVANIA Crash Number POLICE CRASH REPORTING FORAM Page AA 500 4 1"i"t use Only W0172009 i Crash r9esaiDtion Non-Collision 2=Head On 4--Angle 6-Si B=HII Pedestrian 1=Rear End 3=Rearto Rear 5= �e (=Direction) u a __❑ (Backing) J=Direction) 7=Hh Fixed Object 9--Other/Unknown Relation to RoaEs!M 1=0n Travel Lanes 3--Median 6--Outside Traflicway 7--Gore(Ramp Intersection) o 2=Shoulder 4--Roadside 6=in Parking Lane 9=Unknown _J is p 1=Daylight 3 DLfaRlum(nation 9hStreet 5--Dawn B--Oer 2�ark-No ---! IET_ 6--Dark•Unknown Street Lights 4=Dusk Roadway_Lighting _ ---------- Y s" Weather Conditions 1 0 p 3--Sleet(Hell)— 5--Fog --7=Sloe►&Fog - 9--Unknown -� Ft 2=Rain 4=Snow 6=Rain&Fog 8=0ther E Road Surface Conditions O=Dry 2=Sand,Mud,Dut, 4=Slush 6=Ice Patches 8=01her-� OA 7=Water-Starrding 1=Wet 3=Snow Covered 5=Ice _ or Mowng __ Harm Event L1R Most? Upe Plumber Harmful Events(Harm Event) 30--Hit Fence Or Wall 1 58 r] 01=Hit Unit 1 31=Hit Building Unit No 02=Hit Unit 2 32=Hit Culvert 03 ❑ 03=Hit Unit 3 33=Hit Bridge Pier Or Abutment ll 04=Hit Unit 4 34=Hit Parapet End 2 O 05=Hit Unit 5 35=Hit Bridge Rail 06-Hit Other Traffic Unit 36--Hit Boulder Or Obstacle Please Put 07=Hit Deer On Roadway Events in 3 O 08=Hit Other Animal 37=Hit Impact Attenuator ❑ Sequential 09=Collision With Other Non 38=Hit Fire Hydrant Order Fixed Object 39--Hit Roadway Equipment oc 4 O 11=Struck By Unit 1 40=Hit Mail Box is 12=5tnxk By Unit 2 41--Hit Traffic Island se 13=Struck By Unit 3 42=Hit Snow Bank Ham Event L1R Most? Utility Pole Number 14=Struck By Unit 4 43=Hit Temporary Construction c 15=Struck By Unit 5 Barrier 16=Struck By Other Traffic Unit 48--Hit Other Fixed Object c 1 O 21=Hit Tree Or Shrubbery 49-Hit Unknown Fixed Object v Unit No W 21=Hit Embankment 50=OverturrvUl Over N 2 ❑ O 23=Hit Utility Pole 51=51ruck By Thrown Or Falling 24--Hit Traffic Sign Object C ZS=Nit Guard Rail 52=Pot Holes Or Other Please Put 26=Hit Guard Rail End Pavement Irregularities Events in 3 O 27=Hit Curb 53=Jacknife Sequential 28=Hit Concrete Or 54-Fire In Vehicle Order 4 ❑ O Longitudinal Barrier 58=Other wn Harmful 29--Hit Ditch 99=Unknown Harmful Event First Unit No Harm Event A4ast Unit No Harm Event Driver Action(D) 17--Careless Or Illegal it Parmfu! 70-mful � 0146 Contributing Action Backing On Roadway O1 25 1'�in O 1 25 Ot=Driver Was Distracted 18=Driving On The Wrong t rTe Trashh ­­­9 Using Hand Held Phone Side Of Road Do not repeat this information on multiple pages 03=Driving Using Hands Free Phone 19=Making Improper EnvMrnnrevabl/Roadway 4--Making illegal U-Turn Entrance To Highway OSAmproper/Careless Turning 20=Making Improper Exit Potential Factors(E/R) 1 05 2 3 06=Tumkng From Wrong Cane From Highwa DO=None 11=Sli Road Conditions(Ice/Snow) 07=Clarance W!0 21=Careless ParkmgflJnparking IPPctf' Clearance After Stop 22=OverNnder 01=Windy Conditions 12=Substance On Roadway 08=11unning Stop Sin Compensation At Curve 02=Sudden Weather Conditions 13=Potholes 09=Running Red Light 23=5 eedkrg 03=Other Weather Conditions 14--Broken Or Cracked Pavement 10=Failure To Respond To 24=Drriviny Too Fast For Conditions 04=Deer In Roadway 15=TCD Obstructed Other Traffic Control Device 25=Failure To Maintain Proper Speed 05=Obstacle On Roadway 16--Soft Shoulder Or Shoulder Drop Off 11=Tailgatingg 26=-Diver Fleeing Police(Pol Chase) 06=Other Animal in Roadway 28-Other Roadway Factor 12=Sudden Slowinq/Stoping 27-Driver tmpenenced ss 07=Glare 290ther Environmental Factor 13=I1legally Stoppei3 On Road 28=Failure To Use Specialized Equip 08=Work Zone Related 99=Unknown 14=Careless Passing Or Lane 92=Affected By Physical Condition W Possible Vehicle Failures M 12=Wipers 15=Passir Change In No Passing Zone 98=Qther Improper Driving Actions 00--None 06--Exhaust 13=Driver SeatinVControl 16=Driving The Wrong Way On 99-Unknown .° 01=Tires 07=Headlights 14=Body,Doors,Hood,Etc 1-Way Street 02=8take System 08--Signal Lights 15=Trailer Hitch Unit 03=Steering System 09--,Other lights »_A IS No 03 9 28 2 3 4 04=Suspension 10=Noon 9 a we ' 05=Por Train 11=Mirrors 18=Trailer Overloaded t 19=Unsecure/Shifted e Unit Trailer Load No 1 2 3 4 URI4 = vo No 03 1 00 2 2D Improper Towing 21=Obstructed Windshield Pedestrian Alton(P) 03=Working Unit 99--Unknown 00=None 04--Pushing Vehicle No 1 2 05= roachin Or:eavin Vehicle 01=Entering Or Crossing At +APP 9 9 Specified Location 06=Working On Vehicle lndiated Prime Factor Unit No Factor Code OZ=Walking,Running,logging, 07=Standing tg Doi�e tt this information on Q 1 11 Or Playing 98---Other 99=Unknown f/R V D P 03 O O a O if E/R is the Prime Factor Unit No Unit No Type,leave Unit No blank L_ FORM I AA-SW(12M) PENWDOT COPY http://www.dot6.state.pa.us/ersapp/Printlmages/XmIFiles/201008061220100907160220220.... 9/7/2010 Print CRS W01 72009 Page 8 of 13" POLICE COMMONWEALTH PENNSYLVANIA CRASH REPORTING FORM Page Crash Number M J 500 a Police Use 0* J�1V W0172009 .........:...........l._........i......................................................5.....,.....;..... ... ........... ... ... ._ _ .. ....i.... ....i .... ....i.... ..........__i-_.._i........ ._ ... ... .... .. ._ .. _ -.4 i .. A ° ... .. .. ... _. .. .. i... A -................................:...........:......_._:.......................:. ..................... ... ... .- -•- - -.. ......................... ... ... ... ... ..... ... ... ... ... ... ... ... ... ... ... _ ._ ._. ._ ... _. ... ... ... ._ ...— ---- ... ... ... ... ... ... ._ ... ._ .......�......._............ ......_..j._...................i..............................................' E .... ... ... ... ... _.. ...................................... ........ ....i.... ....i.... ...... ._ ... ... ... ... ... ... ... ... .. Witness Name Address Phone it t JESICA M GUTH 40 FOREST ROAD ANDOVER NJ 07821 9082466774 2 DEBRA G JACKSON 407 LITTLE JOHN DRIVE DILLSBURG PA 1 7174320914 Narrative and additional witnesses: Accident Investigation Notification Issued]0 Property Damage O On Saturday,August 21,2010 at 1240 hours,the Upper Allen Police were dispatched to US Route 15 northbound in the area of mile marker 38.1 for a piece of furniture in the roadway. The caller, Patricia Hamill, also the passenger in Unit 3, stated that a piece of furniture had fallen off of the pickup truck she was riding in. She requested police assistance in moving it from the roadway. Two minutes after the dispatch of that call,Cumberland County Communications(CCC)dispatched emergency units to the same location for a motorcycle accident. CCC advised that there was an EMT on the scene advising that the operator of the motorcycle appeared to be dead. zFollowing the preliminary on scene investigation, it appears that Unit 3 was travelling north on US Route 15 in V the area of mile marker 38.1 when a piece of furniture fell off the bed of the pickup truck,operated by William a Hamill. Hamill pulled off of the roadway within several hundred yards and exited his vehicle. As he was walking N down the shoulder of the roadway to retrieve the lost load,Patricia Hamill made the first 911 call. Unit 1 was reported by witness Debra Jackson to have been following Unit 2 too closely. Jackson also reported that Unit 1 had previously been weaving in and out of traffic,switching between lanes and passing cars in both lanes. Unit 2 started to brake and steer to the left to avoid the piece of fumiture. Several FORM s r"W nnMZl PENNDOT COPY http://w«,w.dot6.state.pa.us/crsapp/Printlmages/XmlFiles/201008061220100907160220220.... 9/7/2010 O ,N Page 9 of COMIXAMMALIN OF MPdSnVMIt Crash Number PCLICE MAN VAMMM FORM PW 0 New W0172009 AA 500 IN ffe t?w 0* ED o2owntItuation Narrative and additional wines m 22 other cars in the right and left lane had successfully avoided the object and continued north. Unit 2s operator, Kelly Sprague stated that she heard the squeal of brakes,and then felt a bump on her vehicle. She then observed that the motorcycle had crashed to the rear of her. She pulled to the left side of the roadway and stopped. Unit I had driven off the roadway onto the shoulder of the left side of the road. There were tire marks on the roadway which indicated that the motorcycles brakes locked and the motorcycle began to skid. The motorcycle impacted the center guard rail at the 12 Oclock position and the operator, Dustin Stevens,was ejected. Stevens body was propelled forward and up into the air,then landed on the center guard rail. Stevens body then continued forward and impacted the 7 Oclock position of Unit 2. At some point during the impacts of Stevens body,his head sustained a massive injury which caused brain matter to be spread across the left lane of US Route 15 North as well as brain matter residually left on the drivers side body of Unit 2. Stevens body came to rest in the left shoulder of the northbound lanes. Unit I continued for an unknown distance up the left shoulder of the northbound lanes. Unit 2 stopped just north of the final resting place of Unit 1, Unit I sustained severe damage to the engine components as well as various exterior pieces such as lights,mirrors and plastic body pieces. Unit 2 sustained minor damage in the form of a cracked left brake lens and displaced rear bumper cover. Unit 3 sustained no damage. Unit I was towed from the scene by Hess Garage. Unit 2 was driven from the scene. Unit 3 was driven from the scene. No other operators or a passengers sustained any injuries that were reported to authorities. This accident is still under investigation pending the Cumberland County Accident Reconstruction Team and the Cumberland County Coroners Office reports. FORM#AA4=fUM PENNDOT COPY http://www.dot6.state.pa.us/ersapp/'Printlmages/XmIFilesi'201008061220100907160220220.... 9/7/2010 ?rint C3,S WO i 72005 Page 10 of 13 4 O N.w�UMRVWG 0� cnshMunitw AA 500 F °0 ke use Only 10 O � W0172009 Road Surfaos TvDa p Brick or Block p Dirt SDwW Jwfsdkdon Q Military Q Other Federal Sites u O Concrete O SkGravelor O Other a� O Indian Reservation O Other O ^'v rh Q Unkno wn wn W Blacktop Q Unknown O National Park �p Please complete Unit Information for each unit involved in a fatal crash.Do not repeat the information in the fields above on multiple pages. Unit No PhWdj a krwa Point O 1 0 Non-Coliision 011 12 010 Dvnarr IeKSri<tiore O Restrictions O Not a Pennsylvania 0 Top 010*., . 2 0 Complied With Driver 009 030 O Restrictions Not 0 Unknown p Undercarriage No Restrictionsi Not AppRoblejpllance Compliance 0 0 40 0 U� Wn 0 Towed Unit 06 5 0 Required- Not a Pennsylvania O Unknown O O 0 Complied With O Driver rA VMS O Required-Non 0 Unknown AvoManae INaeeuver _ None Required Compliance Compliance No Avoidance red- 0 Maneuver 0 Braking-Other O Other Avoidance 25 0 0 Compliance Unknown Evidence Maneuver Braking-Skid Steering-Evidence Inconclusive Drhw{1ayKe 0 Not Required for 0 Unk if CDL or 0 Marks Evident 0 or Driver Stated 0 Vehicle Class CDL Required 0 M rSkid .Steering and Braking O Unknown No Valid License 0 Not a Pennsylvania for Class Driver O Not Licensed 0 Valid License for Stated Evidence or Stated O Unknown Class undorRrde Underide,No Drug Test Dpe -Blood 0 Other No Underide or 0 Compartment O Override,Other O None O Urine O Unknown if Test 0 Override Intrusion Vehicle Given Underside, Underside, Unknown if Drug Test ResuRs-ft to Four Resells) p Compartment O Compartment 0 Underside or 0=No Test Given 5=Amphetamines � F1 Intrusion intrusion Unknown Override 1=No Drug Reported 6=PCP Both Lights and 2-Marihuana 8=Other Emwwacr Ilse 0 Lights Flashing O Siren 3=Cocaine 9=Unknown Test ❑ ❑ - Not in Emergency 4=Opiates Results Use 0 Siren Sounding O Unknown Unit No PAnable koma Pobrt 0 02 O Non-Collision 1 12 olp Restrictions Not a Penns lvania O 1 02 0 anoe — p ComD�With Driver y O Top Q 09 03 p Restrkdons/ 0 Comg lied Not 0 Unknown Compliance O Undercarriage O Not sable Complrcd With Compliance O 08 �. ., 4 O °j compliance a O Unknown O Towed Unit p7 6 Endwsenmt so 0 Required Not a Pennsylvania 0 Unknown 0 0 Complied With Driver 0 Required-Non O Unknown Avoldano Wneuver _ p None Required 0 Compliance Compliance 0 Marewer Avoidance O Braking-Other O Other Avoidance Compliance Unknown Evidence Maneuver Braking Skid Steering-Evidence Inconclusive Ddvw OEM O Vehicle Class Class for O Unk if CDL or O h4arks Evident 0 or Driver Stated O CDL Required No Valid License Braking-No Skid 0 for Class -Not a Pennsylvania a Narks,Driver 0 Steering and Braking Q Unknown Q Not Licensed V� Driver Stated Evidence or Stated O 0 License for Unknown lfidar Ride k►e5otor Drug Test True Other No Underride or Underide,No Override,Other p Blood O O Compartment 0 Vehicle (♦ None Urine O Unknown if Test Override Intrusion O Given UnderrW– Underide, Unknown if Oruo Test Results-"to Four Resales) O Compartment O Compartment O Underride or ❑ F] Intrusion Intrusion Unknown Override 0=No Test Given 5=Amphetamines 1=No Drug Reported 6=PCP D Emergency Use Lights Flashing Both Lights and 2==uana 8=Other ❑ 0 9 9 0 Siren 3=Come 9=Unknown Test Not in Emergency 4=Opiates Results Use O Siren Sounding O Unknown P OPM a AA-MFeraaw PEiN1DOT COPY http://www.dot6.state.pa.us/crsapp/Printlmages/XmiFiles/201008061220100907160220220.... 9/7/2010 Print C.<_S W,'�'7 2CQ9 7 age 0' C�©G �C4in1 GR7R!155Y7�F9nIU� �I���"I�IIIN�IIN� O New erast►niumbav Page [�itDC�L�4� fR21cf�W4U�l� l�RA AA 500 F W0172009 r w��uY°^y 11 awe l continuation _ Road Surface Typo Spedal babiliction 0 Military O Other Federal Sites Q Bride o Block Q Dirt , O Concrete Slag Gravel or Q Other a No Special Q Indian Reservation O Other O Jurisdiction • Blacktop Stone Q Unknown O National Park Q Campus CaIegeAJniersiry O Unknown Please complete Unit Information for each unit involved in a fetal crash.Do not repeat the information in the fields above on multiple pages. Unit No Prindpk Imtpad Point O 03 0 0 Non-Collision X11 12 01 010 020 Restrictions Not a Pennsylvania O Top Ddver O Complied With O Driver 009 03 0 Restrictions Not Unknown Q Undercarriage No Restrictions/ complied with O Compliance Q o o40 ri Not Applicable liance'' y w 0 j*#ed Unit .- O Unknown F 07 06 050 Required- Not a Pennsylvania O Unknown O 0 O compiled with O Drier C °e O Required-Non O Unknown a✓��M�� j Compliance Compliance No Avoidance None Required raking•Other Other Avoidance Required Maneuver Q 0 ss — O Complia a.U.nknown Evidence Maneuver Driver Braking-Skidj� Steering-Evidence O Inconclusive O Not Required for 0 Unk f CDL or O Marks Evident O or Driver Stated Vehicle Class CDL Required No Valid license Not a Pennsylvania Braking-No Skid Steering and Braking O Unknown Q for Class O Driver O Marks,Driver O Evidence or Stated O Nat Licensed -Valid License for 0 Unknown Stated Class Undo Ride lndkatcr Underride,No Override,Other Ora Test 7Ype O Blood O Other O No Underride or O Compartment O S None Override intrusion Vehicle Unknown if Test O Urine O Given Unknown if Underride, U ide, Underride, Drug Test Box&-(Up to Four Results) a ❑ O Compartment em O Compartment Underride o Intrusion intrusion Unknown Override 0=No Test Given S=Amphetamines 1=No Drug Reported 6=PCP D Both Lights and 2=Man uana 8=Other Erneroertcy O lights Flashing O Siren 3=C.ne 9=Unknown Test F1 El Not in Emergency 4=Opiates Results a Use O Siren Sounding O Unknown Unit No Pr/ndde impact Point 0 O Non-Collision 11 12 010 coons Restrictions Not a Pennsylvania O To O 1 02 O O Complied With O Driver p 009 030 Restrictions Not Unknown O Undercarriage No RestrictimW O Complied With O Compliance 0 08 040 Not Applicable 050 mce O Towed Unit O 07 06 0 Orar na snnt O Compiled With Driver O Required-Non 0 Unknown Avoidance Ma►reus'e► $ 0 None Required Compliance Compliance No Avoidance eq Q Braking-Other Other Avoidance 75 O Required- Maneuver O Evidence Q Maneuver Compliance Unknown � Braking Skid Steering-Evidence Inconclusive Driver Ltuetrsa O Not Required for O Unk if CDL or O Marks Evident 0 or Driver Stated 0 compffmce Vehicle Class CDL Required No Valid License Marks, -No Skid O for pass 0 Not a Pennsylvania 0 Marks Driver O Steering and Braking Q Unknown Q Not Licensed O Valid License for 0 Unknown Stated Evidence or Stated Class Under Ride Mdfotor Dna Test Tree Other No Underride or Underride'No Override,Other Override 0 Compartment O O Blood 0 O Intrusion Vehicle Q None Urine O Unknown if Test O Given Underride, Underide, Unknown H Ong Test Results-(tM to FortyRewksl F1 ❑ Intrusion intrusion Unknown Over ide O Compartment O Compartment O Underride or 0=No Tat Given 5=Amphetamines 1=No Ong Reported 6=PCP D Emergency Use Both Lights and 2=Marijuana 8=Other O Lights Flashing O Siren 3=Coca�ne 9=Unknown Test ❑ ❑ 0 Not in Emergency O Siren Sounding O Unknown 4=Opiates Results Use POW°AA4KDstreae PENNOOT COPY I http://w—,A,.dot6.state.pa.us/crsapp/Printlmages./XmlFiles/201008061220100907160220220.... 9/71-2010 age ,1 2 of 1 CORMCHURVALTH OF P® AS BENIN FORM �9 I� M 1� Page O New pI�II � CrnehNumber AA 500 M I'"`"'0^ 12 O � 6. W0172009 Unit No L For Answers to the below(except for Engine Size and Helmet Type)use the following Codes:Y=Yes N=No U=Unknown 01 Engine Size 0900 CC Driver Protection? Helmet Type Passenar Protection? Helmet Tvoe 0-No Helmet 0= No Helmet Ifttorgde Has?The Driver Has? 1,T Eye Protection 1 =Full Helmet ❑ Eye Protection ❑ 1= Full Helmet I* J' f9 Passenger a MC Education 2=3/4 Style 1= 3/4 Style 3=Half Helmet 3= Half Helmet Saddle a Long Sleeves Style ❑ Long Sleeves Style g ❑ Bag and/ 9=Unknown 9= Unknown or Trunk N Lon Pants N Helmet Stay On1 Long y Long Pants Helmet Stay On? Trailer Helmet has Helmet has Over Ankle Boots DOT or Snell Over Ankle Boots a DOT or Snell Designation Designation Unit No Unit No Use Codes � Passenger? Helmet? Passenger? Helmet? Y= Yes Y= Yes F1 ❑ 17 N=No F N. No U= Unknown Lights? ❑ Rear U= Unknown ❑ Lets? Refle-dors? Unit [ {grpo � Un� Pltdes6fin Lootlon 01= Marked Crosswalks at Intersection 01= Marked Crosswalks at Intersection 01= At Intersection-No Crosswalks 02= At Intersection-No Crosswalks Pedeshbn 03= Non-Intersection Crosswalks p0clestdan Si9nlLt 03= Non-Intersection Crosswalks 04= Driveway Access 04= Driveway Access C O Yes 05= In Roadway O Yes 05= In Roadway O No 06= Not in Roadway O No 06= Not in Roadway b Q Not at Intersection 07= Median O Not at Intersection 07- Median 08= Island 08= Island 09= Shoulder Pedestrian Oothino 09= Shoulder O Light 10= Sidewalk O Light 10= Sidewalk 11= <10 Feet Off Road 11= <10 Feet Off Road O Dark 12= >10 Feet Off Road Dark 11= >10 Feet Off Road O Reflearve 13= Outside Trafficway O Reflective 13= Outside Trafficway O Unknown 14= Shared Paths/rrails Q Unknown 14= Shared Paths!rraiis 99= Unknown 99= Unknown Work zone Tvoe J IMIN In Work Zone 1 ftd Lane Closure? O Construction 0 Before 1st Work Zone orA lknit aal Work lane Road Closed with (Long Term) Warning Sign LaW En 0mraderktics ❑ Detour? • Maintenance O Advance Warning Area Offiff (Mark all that ❑ff Work on Shoulder (Short Term) O Yes appN. not or Median? O Transition Area Workers Amen t involved or ❑ Inter ktent or O Activity Area O Yes O No O Utility Company Work? O Other O Termination Area O blank)unknow,leave Moving No O Unknown Flagger Control? O Other O Unknown ❑ Other List an Wmnw sm in Alerrative Additional M-ftp 10ftmodon fi FORM•aa40mttnrar4 PENNDOT COPY http://www.dot6.state.pa.us/crsapp/Printlmages/XmIFiles/201008061220100907160220220.... 9/7/2010 Print CRS W0172009 Page 13 of 13 Crash Number: W0172009 Incident Number: UAT20100800581 vp� WVNJM lY k>r td:r I.11: 4 i. _ ti it http://www.dot6.state.pa.us/crsapp/PrintImages/Xrn IFiles/201008061220100907160220220.... 9/7/2010 CLERK OF WWH diNS';COURT Y61 Cou4Jttdieial Center ` 4 feore St. yo> c,fix 17401 Bradley C. Jacobs Certificate of Grant of Letters REGISTER OF WILLS Administration York County, Pennsylvania Estate No. 67i0-1268 Estate of DUSTIN CHARLES STEVENS SR Deceased Late of PARADISE TOWNSHIP YORK COUNTY Soc Sec No. 176-62-7778 WHEREAS,DUSTIN CHARLES STEVENS SR,late of PARADISE TOWNSHIP,York County, who died on August 21, 2010 and; WHEREAS,the Grant of LETTERS OF ADMINISTRATION is required for the administration of the estate. THEREFORE,I,Bradley C.Jacobs,Register of Wills in and for the County of York,in the Commonwealth of Pennsylvania,hereby certify that I have this day granted LETTERS OF ADMINISTRATION to BEVERLY J.THOMAS who has duly qualified as ADMINISTRATOR(RIX)and has agreed to administer the estate according to law,all of which fully appears on record in my Office at York County Judicial Center in York,Pennsylvania. IN TESTIMONY WHEREOF, I have here unto set my hand and affixed the seal of my Office on August 31, 2010. { e ister of 6 Ls BRADLEY C. JACOBS Register of Wills&Clerk of Orphans'Court My Commission Expires First Monday,January,2012 PLAINTIFF'S EXHIBIT a Commonwealth of Pennsylvania - Short Certificate County of York I,Bradley C. Jacobs,Register for the Probate of Wills and Granting Letters of Administration in and for YORK County, do hereby certify that on August 31, 2010, LETTERS OF ADMINISTRATION in common form were granted by the Register of said County, on the estate of DUSTIN CHARLES STEVENS SR, late of PARADISE TOWNSHIP in said county,deceased,to BEVERLY J. THOMAS and that same has not since been revoked. I7V TESTIMONY WIiEREOF,I have here unto set my hand and affixed the seal of said office at YORK,PENNSYLVANIA,on August '11, 2010. File No: 6710-1268 Date of Death : August 21, 2010 S.S. #: 176-62-7778 Register Wills BRADLEY C JACOBS Register of Wills&Clerk of Orphans'Court My Commission Expires First Monday,January,2012 NOT VALID WITHOUT OFFICIAL SIGNATURE AND SEAL OF OFFICE - 01/31/2 50 1717/9-209129 RELEASE For the Sole Consideration of Forty Thousand ($40,000.00) Dollars the receipt and sufficiency whereof is hereby acknowledged, the undersigned, BEVERLY THOMAS, Administratrix of the Estate of Dustin C. Stevens, hereby releases and forever discharges MARIE TAMNEY and WILLIAM HAMMILL, their executors, administrators, agents and assigns, and all other persons, firms or corporations liable or, who might be claimed to be liable, none of whom admit any liability to the undersigned but all expressly deny any liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, and particularly on account of all injuries, known and unknown, both to person and property, which have resulted or may in the future develop from an accident which occurred on or about the 215t day of August, 2010, on Route 15 northbound at or around mile marker 38.1, Upper Allen Township, Cumberland County, Pennsylvania, This includes, but is not limited to, any and all claims filed in the Court of Common Pleas of Cumberland County at No. 12-5187. This release expressly reserves all rights of the parties released to pursue their legal remedies, if any, against the undersigned, their heirs, executors, agents and assigns. The undersigned agrees to be responsible for the satisfaction of any and all liens for medical expenses or wage loss which may be asserted by any party or entity as a result of any injuries alleged to have been sustained as a result of the accident of August 21, 2010. Satisfaction of any and all liens includes, but is not limited to, any liens of the Commonwealth of Pennsylvania, Department of Public Welfare, Medicare or other entity or subdivision of the United States of America, any worker's compensation liens or any liens from any government sponsored programs providing payment for medical care or wage loss benefits to the undersigned as a result of any injuries alleged to have been sustained in this motor vehicle accident. The undersigned agrees to indemnify, defend and hold harmless Marie Tamney, William Hammill, Progressive Insurance Company and State Farm Mutual Automobile Insurance Company from any claims asserted by any third party, including but not limited to, DPW, Medicare or any government related entities, any worker's compensation insurer or any third party for medical expenses or wage loss payments. Said agreement to defend, indemnify and hold harmless includes, but is not limited to, any and all liens from any first party insurer, health insurer, worker's compensation carrier, DPW, Medicare or any other government entity asserting a lien. This release does not act as a waiver of any claims, causes of action, or suits, made or to be made in the future, for bad faith, medical negligence, uninsured or underinsured motorist coverage, first party medical or wage loss coverage, health insurance coverage, disability coverage, or workers' compensation coverage related to the August 21, 2010, motor vehicle accident. In the event that Beverly Thomas, Administratrix of the Estate of Dustin C. Stevens makes any claims for medical negligence against any provider rendering services for injuries sustained by Dustin C. Stevens in the August 21, 2010, motor vehicle accident, the undersigned agrees to indemnify and hold harmless Marie Tamney, William Hammill, Progressive Insurance Company and State Farm Mutual Automobile Insurance Company, for any such claims, cross-claims, or counter-claims. Said defense and indemnification includes attorney's fees connected with the defense of Marie Tamney, William Hammill ind Aftnatip Fn Mutual Automobile Insurance Company, in any such action. PLAINTIFF'S EXHIBIT a 1_ 1792091.29 Aa- Undersigned hereby declares that the terms of this :settlement have been completely read and are fully understood and voluntarily accepted for the purpose of making a full and final compromise adjustment and settlement of any and all claims, disputed or otherwise, on account of the injuries and damages above mentioned, and for the express purpose of precluding forever any further or additional claims arising out of the aforesaid accident. Undersigned hereby accepts draft or drafts as final payment of the consideration set forth above. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim 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 Whereof, I have hereunto set my hand and seal this day of . 2013. In presence of: Signed x Witness BEVERY THOMAS, Administratrix of the Estate of Dustin C. Stevens File No. 19576 Page 2 of 2 Sentry Insurance P.O.Box 8042 Stevens Point,WI 54481 SENTRY INSURANCE RELEASE AND TRUST AGREEMENT UNINSURED MOTORIST COVERAGE KNOWN BY ALL MEN BY THESE PRESENTS: that 1, the undersigned,the estate of Dustin Stevens, as an individual for and in consideration of the payment to me of the sum of Fifteen Thousand Dollars ($15,000) receipt of which is hereby acknowledged, do release, acquit and discharge Sentry Insurance (herein called company), from any and all liability under Policy Number 364050844PA issued in the name of Dustin Stevens on account of bodily injury to or death caused by an underinsured motorist motorcycle accident occurring on or about the Twenty-first day of August, 2010, in or near Upper Allentown, Pennsylvania. It is understood and agreed that is full and final settlement of any claims for death or injuries both known and unknown which I (we) may now or hereafter have, and also all claims or rights of action for damages which I (we) have or may have hereafter have under the Protection Against Uninsured Motorist Coverage of the aforementioned policy. The undersigned agrees to indemnify and hold harmless the company from all claims of liens of any nature but not limited to medical services. As a further consideration of this payment to the undersigned, I(we) agree to bind myself (ourselves), my (our heirs) administrator, executor and assigns to fully indemnify and hold harmless the company against and from any loss or expense on account of any claim by me (us) arising out of or in any way growing out of said accident. Specifically 1 (we) will satisfy all liens, specifically but not limited to Medicare. It is expressly warranted and agreed that no promise or agreement not herein expressed has been made to me (us), and in executing this release, I (we) am(are) not relying upon any statement or representation made to me (us) by anyone who has acted for the company or on its behalf, but I (we) am (are) relying solely upon my(our) own judgment. I (we), will take, through the representative designed by the company, such action in my (our) name, as is requested by the company to recover damages from the owner, operator, or other person or organization legally responsible for the use of the uninsured automobile or motorcycle. Expenses and costs incident to the taking of any action REQUESTED by the company will be paid by the company. Any moneys recovered as a result of judgment, settlement, or otherwise,whether obtained as a result of action requested by the company or not,will be paid by the company provided, however, any net recovery in excess of Fifteen thousand dollars ($15,000.00) shall be retained by me (us). PLAINTIFF'S EXHIBIT a In witness whereof, I (we), further state that I (we) have carefully read the following release and know the contents thereof and I (we) hereunto set my (our) hand and seal this day of CAUTION: READ BEFORE SIGNING Witness The Estate of Dustin Stevens C"NTINGENT FEE AGRF"7MENT The Client employs Steven D. Stambaugh, Esquire ana the law firm of Stambaugh Law, P.C. as my attorney with full power and authority to appear on my behalf in the repre�Sentation, arbitration, trial and/or settlement of any claim regarding: ,J �,- j ;.` /r+.�/-} � � �°� rte. � ..� �• For all services performed, the client agrees that the att&n'y shall receive the following stated percentages of any recovery, including without limitation all liability, i underinsurance, uninsurance, and/or any other claims and/or payments, as full payment of and for the professional services: z As to liability recovery- 0(4_ y r ;' ,�° ;' through to and including the Pre-Trial Conference, and e,1L 4-- thereafter. In the ev rat hat the parties gre to resol a liability case via Afbitration, the I / )-/_,41Trial fee shall apply to the Arbitration. As tau derinsured /uninsured motorist recovery-c'1 J�' ����F, �/J/I�through to either the Pre-Trial Conf ,e ce or two rpo sMr to the Arbitration tion Hearing, whichever applies, and thereafter. The employment is on a contingent basis and if no recovery is received, no attorneys' fees are due. The contingent fee shall be calculated from the gross recovery and before any j expenses are deducted. The fees are valid through the conclusion of Trial and/or Arbitration and do not include an appeal nor do they include claims for bad faith and/or breach of contract. Any fees for proceedings to a higher court and/or for bad faith and/or breach of contract must be negotiated separately. I In the event that this contract is terminated by either party, the attorney shall be paid the same percentage as stated above of any oral and/or written settlement offer and/or award from any recovery and/or source, plus all costs. In the event that this contract is terminated and no offer, award and/or recovery has been made, entered and/or j received, the attorney shall be paid a quantum meruit fee for the reasonable value of the j services rendered by the attorney. I The client is and shall be responsible to pay for all costs incurred regardless of whether or not there is a recovery. Client's costs include but are not limited to medical reports, copying costs, postage, stenographic services, office expenses, computer VS research fees, filing fees, Sheriffs costs, investigation costs, medical-paralegal costs, and (c• expert costs. These costs shall be paid in advance unless other arrangements are made. '� here will be a charge of$30.00 for each returned check. In the event that the client requests the return of his/her file, the client will be responsible for payment of staff time in preparing the copies at a rate of$75.00 per hour plus $.10 per page for the copies. The attorney will retain the original file and the client will agree to accept a duplicate copy. I The client agrees that the attorney may withdraw his representation at any time, for any reason, in attorney's sole discretion. / sTAnneAUGH LAW,P.C. This agreement has been signed on 2010. 2121 S.QUEEN ST. YORK,PA The Client acknowledges receipt of a copy of this Contingent Fee Agreement. � U U WITNESS: IientC-t N,s,27 �rx.• A�E✓i., aoiltiLJ PLAINTIFF'S EXHIBIT Client pennsylvania 8 ?0:3 DEPARTMENT OF REVENUE March 13,2013 Steven Stambaugh, Esquire Stambaugh Law, PC 2121 South Queen Street York,PA 17403 Re: Estate of Dustin C. Stevens File Number 6710-1268 Court of Common Pleas 176-62-7778 County Dear Mr. Stambaugh: The Department of Revenue has received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition,the 28 year old decedent died as a result of a motor vehicle accident. Decedent is survived by his sons. Please be advised that,based upon these facts and for inheritance tax purposes only,this Department has no objection to the proposed allocation of the net proceeds of this action, $13,737.74 to the wrongful death claim and$13,737.73 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. §8302; 72 P.S. §9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). 1 trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Sincerely, j Shannon E.Baker Trust Valuation Specialist Inheritance Tax Division PLAINTIFF'S EXHIBIT a � Bureau of Individual Taxes I PO Box 280601 1 Harrisburg, PA 17128 1 717.783.5824 1 shabaker @pa.gov �I i i I AFFIDAVIT OF ADMINISTRATRIX/ PETITIONER BEVERLY THOMAS IN SUPPORT OF THE APPROVAL OF THIRD PARTY AND UNDERINSURED MOTORIST INSURANCE SETTLEMENTS AND PAYMENTS PURSUANT TO !f TITLE 20 §3323 FOR THE ESTATE OF DUSTIN C STEVENS i I, Beverly Stevens, of 5 Ewell Drive, East Berlin, PA 17316, Pennsylvania, do hereby make this Affidavit in Support of the Estate of Dustin C. Steven's Petition for I Approval of Third Party and Underinsured Motorist Insurance Settlements and Payments, and in support thereof, do hereby swear and affirm, as follows: 1. I verify that the statement made herein are true and correct to the best of my knowledge, information, and belief. 2. I verify that I am the duly appointed Administratrix of the Estate of Dustin C. Stevens, and am the Petitioner herein. 'j 3. I verify that I have read the Petition for Approval of Third Party and Underinsurance Motorist Insurance Settlements and Payments Pursuant to Title 20 §3323, and the Proposed Order, as to the Estate of Dustin C. Stevens, as well as all of the exhibits thereto. To the extent that the contents are based upon information which I have given to STAMBAUGH LAW,P.C. ,2, S.QUEEN ST counsel, it is true and correct to the best of my knowledge, information and belief. To the YORK,PA extent that the contents are that of counsel, I have relied upon my counsel in making this Affidavit and the Estate Settlement Petition. PLAINTIFF'S EXHIBIT i i 4. I hereby request that this Honorable Court enter an Order approving the I Estate Settlement Petition, and granting the following relief: A) Progressive Insurance Company- $15,000.00 payment, State Farm Insurance Company - $25,000.00 payment, and Dairyland Cycle/Sentry Insurance Group - $15,000.00 payment, in settlement of the Estate's claims; I B) Authorize the execution of the global Release against Progressive Insurance Company, State Farm Insurance Company, Dairyland Cycle/Sentry Insurance Group for the release of the tortfeasors' funds and the underinsurance motorist funds; C) Authorize the Estate to fulfill its contractual obligation for payment of attorney fees and costs under the contingent fee agreement totaling 18,333.33 in attorney's fees and $691.20 in costs; respectively; and i D) Authorize that the net settlement proceeds totaling of$27,475.47, after legal fees and expenses, shall be proportioned fifty percent(50%) for wrongful death, and fifty percent(50%) for survival action for the Estate of Dustin C. Stevens. I understand that false statements herein are made subject to penalties of 18 PA C.S. §4904, relating to unsworn falsification to authorities. ks Date Beverly even, Administratrix of i the Estate of Dustin C. Stevens Ij STAMBAUGH LAW, P.C. 2121 S.QUEEN ST. YORK.PA ii r s BEVERLY THOMAS, IN THE COURT OF COMMON PLEAS OF Administratrix of the Estate of CUMBERLAND COUNTY,PENNSYLVANIA DUSTIN C. STEVENS, Plaintiff 'i V. : MARIE TAMNEY, AND NO. 2012—5187 CIVIL TERM WILLIAM HAMMILL, Defendants ORDER OF COURT AND NOW,this 5TH day of APRIL, 2013, a hearing on the Petition for Approval of Settlement is scheduled for THURSDAY APRIL 25 2013 at 1:00 p.m. in Courtroom# 3. By Edward E. Guido, J. Steven D. Stambaugh, Esquire { ✓ Kevin D. Rauch, Esquire :sld ( x`C s h4a. Cn -ti r _ W -o rr' 7? Ln r 1 BEVERLY THOMAS, IN THE COURT OF COMMON PLEAS OF Administratrix of the CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF DUSTIN C. STEVENS, Plaintiff MM V. r-O � k k MARIE TAMNEY, and 2012—5187 CIVIL TERM WILLIAM HAMMIL, ; Defendants CIVIL ACTION- LAW ^ C PLAINTIFF'S PETITION FOR APPROVAL OF THIRD PARTY AND UNDERINSURED MOTORIST INSURANCE SETTLEMENTS AND PAYMENTS PURSUANT TO TITLE 20 43323 ORDER OF COURT AND NOW,this 28TH day of MAY, 2013, upon consideration of the Petition for approval of Third Party and Underinsured Motorist Insurance Settlements and Payments Pursuant to Title 20 §3323, and following the hearing held on Thursday, April 25, 2013; IT IS HEREBY ORDERED: A) The ESTATE OF DUSTIN STEVENS, by its Administratrix, is authorized to accept Progressive Insurance Company's $15,000.00 payment, State Farm Insurance Company's $25,000.00 payment, and Dairyland Cycle/Sentry Insurance Group's $15,000.00 in settlement of Petitioner the ESTATE OF DUSTIN STEVEN'S third party liability and underinsured motorist claims; B) The ESTATE OF DUSTIN STEVENS, by its Administratrix, is authorized to execute the Releases attached as Exhibits "C" and"D"to the subject Petition in full and final settlement of the subject third party and underinsured motorist claims, and to dismiss the third party case upon distribution of the settlement proceeds; C) The ESTATE OF DUSTIN STEVENS, by its Administratrix, is authorized to fulfill the Estate's obligation for payment of attorney fees and costs under the contingent fee agreement in the amount of$18,333.33 in attorney's fees and $691.20 in costs, which leaves a sub-total net balance of$35,975.47; D) Petitioner's counsel shall allocate fifty percent (50%) of said proceeds ($17,987.73)to the survival claim. v E) The ESTATE OF DUSTIN STEVENS, by its Administratrix, is authorized to reimburse the Administratrix for funeral expenses totaling $8,500.00, which shall be deducted from the survival claim of$17,987.73, which leaves a net balance of $9,487.73. The ESTATE OF DUSTIN STEVENS, by its Administratrix, shall distribute said proceeds to decedent's heirs in conformity with the law. F) Decedent's heirs are his sons, Dustin C. Stevens, Jr. and Griffen Gene Stevens, both of whom are minors. The Administratrix is hereby authorized and specifically directed to execute all documentation necessary to deposit the funds belonging to the minors whether from the wrongful death or survival claim in an interest bearing savings account or savings certificate in a federally insured financial institution in the name of the minor only. The savings account or certificate shall be titled and restricted as follows: DUSTIN C. STEVENS, JR., a minor, not to be redeemed except for renewal in its entirety, nor to be withdrawn, assigned, negotiated, or otherwise alienated before the minor attains majority, except upon prior Order of Court. GRIFFEN GENE STEVENS, a minor, not to be redeemed except for renewal in its entirety, nor to be withdrawn, assigned, negotiated, or otherwise alienated before the minor attains majority, except upon prior Order of Court. If no withdrawals are made from the investments authorized by this Order,the depository may pay over the balance on deposit when the minor attains majority, as defined with reference to 20 Pa. C.S.A. §102, upon the order of the late minor, without further Order of this Court. Counsel shall file with the Prothonotary within sixty (60) days from the date of entry of this final Order proof of the establishment of the accounts as required herein, by Affidavit from counsel certifying compliance with this Order. Counsel shall attach to the Affidavit a copy of this Order as well as a copy of the Certificate of Deposit or bank accounts showing the amount deposited and containing the required restrictions. The Prothonotary shall provide copies of this Order to Steven D. Stambaugh, Esquire, attorney for the Petitioner. By the Court, Date Edward E. Guido, J. y r L