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02-1031
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of ~~~~~~~ l No. also known as To: Deceased. Social Security No. ~~ 3~- g~ .~~ 21-02-1031 Register of Wills or he County of v ~r in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Y~o~ petitioner(s), who is/are 18 years of age or older, appl t ~S for letters of administration . vl ~ on the estate of (d.b.n.; pendente lice; durante absentia; durante minoritate) the above decedent. Decendent was domiciled at death in e V Q County, Pennsylvania with last family or principal residence at s'~ ~ ` ~ ~ ~ (list street number an/d/ unicipality) ~ Decendent, then ~~ years of age, died / t/~~ G~_a~ V~ C 1, _ , -}9- ~~ Z, at Decendent at death owned property with estimated values as folllows: oc, (If domiciled in Pa.) All personal property $ ~~~` (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ situated as follows: ~oVi P~ Petitioner after a proper search ha,~ ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: Nam ~h d ~ J . - ~ ~ Ke ionship ~ Keside ce -~0~.~; N ~.~ ~P < <- a ~ ~ so 1 o ~ P ~ Gt S~C( i~o ~~ ~ ~°SG THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. c b ,-. ~~ xF ~o ~~ ~- ~a ~~ `a ~ ~~ ~C ce ~ K OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA 1 ss COUNTY OF CUMBERLAND J The petitioner(s) above-named swear(s) or affirm(s) that the staterrients in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal representative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before me this 19th dayy of NOVEMBER p~2002 Rester No. l 21-02-1031 Estate of CHARLES ROY BECHTEL ,Deceased GRANT OF LETTERS OF ADMINISTRATION y .. AND NOW NOVEMBER 19 ~~ 2002 in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that WENDY J BECHTEL is/are; entitled to Letters of Administration, and in accord with such finding, Letters of Administration are'hereby granted to WENDY J BECHTEL in the estate of Register of Wills ~2~c.[~j~ZX/ / FEES Letters of Administration .... . Short Certificates( ) ......... . Renunciation ................ JCP TOTAL Filed ....11-19- , , .. , ..... A $ lA_O~ $ 15.0 $ $ 10.00 $ 43.00 .D. >~?~. 3~y~`~ A ~ ORNEY (Sup. Ct. I. o.) ADDRESS /711 PHONE ~J ~~~C.°t-et~i ~ -020 ~- ~J lh ,_.. ,i,(, This is co cecity chat the irtormation here liven is correcr:~' C(i)itC{ is ,~i~ ,..,~ I_ .<_ _.~~ (, , . L,~cal Registrar. The original certiiicare will he Forwar~i~d ~o r~ ~ ~,; ~~':_ 'i ;:: T~_.I ~:~ ~.:.i:r.~ ti WARNING: It is illegal to duplicate this ~~~~~ a~~= pl~x~~e~;~~~~t s ; i;~e Eor cLis cc r+ jra(c, y.Ot __~ X777274__. r~,~ H705 144 Rev. 1191 II ~~~~~{ ~h~r. ,' ~C, ''~`~ " d r ^~~,. . ~ - 1~ 'et .At'~ ~ , \ = ~~A ~._-_ .~u~ ~~ ~~ /~pu ~2 131 ~~'-~' ~ COMMONWEALTH OP PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (Coroner) TYPE;PRINT IN PERMANENT BLACKINK W U sl t/r N 14 U 0 U z NAME OF DECEDENT (Flrsl. MiOdle, lest) Jr Bechtel R Ch l SEX Male ~'~ SECURRV NUMBER DATE OF DEATH (MOrllh. Day. Year) 206 38 8454 November 11 2002 . , . ar es ,, ~. 2. ,. , AGE (Last Birthday) UNDER 1 YEAR UNDER 1 DAY DATE OF BIRTH BIRTHPLACE (CUy and PLACE OF DEAfH (Check oMyone - cea ingrutlions on doer side) Monlhe Days Hours MinMee (MOnUr, Oey. Year) Stale or Fore,gn Camlryl HOSPITAL: OTHER: Jul 25, 1960 Harrisburg, Pa. 42 vre Inpali.nl ^ ERlOulpd.m ® ooA ^ ,",o"m;° ^ Residence ^ $~,ly) [~ . s. e. 7. e.. COUNTY OF BERTH CITY,BORO,TWPOF DEATH FACILITY NAME(Il not insleulion,gwe sheet and number) yWS CEDENT OF HISPANIC ORK3INT RACE~AmeriunlrWian, Black, Whea, elC. Bpecuyl No Vet ^ tl es eaty Cuban s y , , p hin Derry Twp. Hershey Medical Center M.aic•n.PuenoRicen..lc. White Dau p ab. •c. w. o. 10. DECEDENT'S USUAL OCCUPATION KIND OF BUSINESS/INDUSTRY WAS DECEDENT EVERIN DECEDENT'S EDUCATION MARITAL STATUS~Married SURVIVING SPOUSE ES? rf onl h Never MerrNd, Wfdowsd, Ilt wAe. give mmrten nerve) U.S. ARMED FOR C yy IG~ve kind of work done dw,rrrggg most I~-- of working I;do rot use eatlred Own Home Yee^ No L~ Elemanlery/Secondary Co•eg• DworpeQ lSpejdy) Wend J. Heinz 4 s Marred y ~ or ) (ot2) 1 n- I-lomemalK(e / . . . - 11 •. ltb. 12. 17. 1 DECEDENT'S MAILINGADDRESS (Steel. CityROwn. Stale, LpCode) DECEDENT'S ennsy vanta ~ Iver pang decedent lived In Iwp Dld 17c V . . , ACTUAL 17e. slate 526 Rittenhouse Square RESIDENCE e.c.anl Pennsylvania 1705 ~ e'"a"°"'°"~ kW fn. n nlhnr aide) Cumberland IowrYnip7 No, dsced.nl lived Mechanicsburg , ls. nb. Court ne.^ whom aauel limns or _ceyrooro. FATHER'S NAMEIFirsr. Middla.Lasl) Charles R. Bechtel Sr. MOTHER'S NAME(Fird. MldTe, Maiden Surname) Marie Zicarelli 16. 19. - ' ' - - " ~ i~aF:.Rr.,Af.T'S NAiviE,~ywrF,~„.i I Wendy J. Bechtel I u , lSueel, Cir own.Sm,e NFOFLikNT L ' t1EJ s ~L~`Ifi~en~iouse ~'quareYvlec~anicsburg, Pa. 17050 2a. DATE OF DISPOSITION METHOD OF DISPOSITION PUCE OF DISPOSITION-Name of Camelxy, Crematory LOCATION~CiIy/Wwn. Slate.Zp Code rr,, BurieL Cremation LJ Removal Iron Slate ^ (Month, Day. Y ) a Other PMu Resurrection Cemetery Harrisburg, Pa. 17112 opnatbnCl,,,elFrsAyl ^ Nov 15, 2002 21•. ~ 21b. 21c. 21 d. ~UNE SERyIC tLICEN EO SON ACTING AS 6UCH LICENSE NUMBER NAME AND ADDRESS OF FACILITY SIG/Ay! E Myers Funeral Home, Inc. 37 East Main Street Mechanicsburg, Pa 17055 !! ~ L .,.~ ~. FD-014318-L ` L 22c 22b nmplete hams 23a-c only wnenunitying To lha beat of my krw~Me death occurrW al the cline, tlel9 end place stated. LICENSE NUMBER DATE SIGNED (Mwsh. Dav, Yeail ysiaan is rwl avaiWDle ' u ~3i. canny cause o)de•dr 23b. 23c. Items 2428 mulltw completed by TIME OF DEATH DATE PRONOUNCED DEAD (Month Day. Year) WAS CASE REFER , RED TO MEDK:AL EXAMINER/CORONERT C~ ~ N pbrsonwhopronounces death. 1:07 p•m• November 11, 2002 2• L' o ~•• M :s 2•. 2T. PART 1: Emer the diseases, Injuries or compliulbM which cawed Ire tleath. Do not solar tM mode of dying, such as cardiac or resplrelory arrrNl, shock or hMn ladure. iApproaknale ilmervI baMesn PAf1T I1: Olha signnium CorWirion9 wnrribuling ro deaN, bW rrot resMlirp in Ire underlying cause given In PART I. List only one cause on each line. Ipneal end death IMMEDIATE CAUSE IF,nal I «,ndn,°n Multi le traumatic in'uries i e,mw~g~~~dnan,l-~ e. DUE TO (OR AS A CONSEQUENCE OF): I Sequemielly ksl mndilane b. it any, leading to immrldiale DUE TO (OR AS A CONSEQUENCE OFl: I se Enter UNDERLYING CAUSE (Oi:arasearnpny e. n~nlW nvn,es DUE TO IOR AS A CONSEQUENCE OF): 1 Uulliug in deem) LAST ~ d . WAS AN AUTOPSY WERE AU7ryPSV FlNDINOS MANNER OF DEATH DATE OF INJURY TIME OF INJURY INJURY Rf WORK? DESCRIBE MOW INJURY OCCURRED. PERFORMEDT AMAILABLE PRIOR IO (Month. Day. Vner) COMPLETION OF CAUSE vehicle ~•• ^ Ne ~1 vehicle vs '02 11:15 a m ^ N v 11 ~ . . . . , o ^ Homicide OF DERrH7 N.1prM yy~~qq •CS VM ^ No ^ AccM•M ~ Pending lnvesligatbn ^ 3M. ~ M. ~ ~' PLACE OF INJURY ~ At home.lum, arssl, laory, otliu LOCATION (SreM, CnYR wn. Sale) ^ N o Yn s0lcia ^ comerlaoeaaarmirrea ^ beikFn is °82"14 and Bent Creek Bl Silver S Cumber- °K'E . 2v 2~ 2f ,g•. SIGNRrUREANDTI IER an ty. CERTIFIER(Check«eyone) 'CERTIFYING PHYSICIAN (Physician cetleyup cause M deem when enomer physician has pronounced tleam and compered Vert, 23) t ^ / To 1M Beal of mY knowNep•, seem OC•rlrree eW b iM e•u•N•1 and rrlenrl•r Y •YW ..................................................... gt UCENS MBER DATE SIGN (M°nln Day, War) ~ November 11 2002 ' ~ 'PRONDUNCIND AND CERTtFVtIVO PHYSICIAN jPhysicWrbalh pronauncirp deem er,d certilying to cause of death) ^ 310. 31a. 7 w .......................... To1M b«t of my knarl.uw.a•.ln oeewr.dndw tMY.at•, she PMC•,•rw eu•am.o•uW).namemgr..•w NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH Q1 27) YPe or Pdnl _ Coroner ER Cir~ S. Hetrick O ' " , N MEDK;ALEXAYINERICOR ' On tM Danl. of •a.minStlon •ne/or MvNtlgSllon, In my ryplnbn, d••tb occurt•tl •t tM cline, date, •ne Place, end due to iM c•D••pl end ~ 1271 S PA 17111 Harrisburg 28th S t • • .. , . , . mentor u.biW ............................................................................................ 72. 318. DATE F 0 (Month. Day. Year) REGISTRAR' NATURE AND NUMBER ~ ~:. u- 7.. / 3 :~ d o ~ 77. - l CERTIFICATION OF NOTICE UNDER RULE 5 6(al CHARLES ROY BECHTEL Name of Decedent: NOVEMBER 11, 2002 Date of Death: 2002-01031 Will No. Admin. No. To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on NOVEMBER 2 6 , 2 0 0 2 Name Address WENDY J. BECHTEL 906 WOODLAND DRIVE, LEMOYNE, PA 17043 MICHAEL C. BECHTEL 906 WOODLAND DRIVE, LEMOYNE, PA 17043 TONI MARIE BECHTEL 906 WOODLAND DRIVE, LEMOYNE, PA 17043 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except NOT APPLICABLE Date: \"/ J / ~, ~Z ~ , % i l Name JOSEPH U. METZ Address DILWORTH PAXSON LLP, 112 MARKET STREET, $TH FLDOR, HARRISBURG, PA 1710 Telephone (71)7 2 3 6- 4 81 2 Capacity: Personal Representative X Counsel for personal representative COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES 5/20/2003 Joseph U Metz, Esquire Dilworth Paxson LLP 8th Floor 112 Market Street Harrisburg, PA 17101 '03 T"1~Y 28 ,~~ ~J+z...Cd ; -.... Telephone 717-783-0972 Re: Estate of Charles R Bechtel Jr. File Number: 2102-1031 Court: Cumberland-Orphans-2002-01031 Dear Mr. Metz: The Department of Revenue 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 was 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 42-year-old-decedent died as a result of motor vehicle accident. The sole heir to the decedent's estate is his spouse. Therefore, any proceeds paid to settle the survival action would pass to decedent's spouse and would be subject to a zero percent inheritance tax rate. 72 P.S. §9116(a)(l . l)(ii). Accordingly, regardless of the allocation of the subject proceeds, there would be no inheritance tax consequences. Please be advised that based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $ 135,000.00 to the wrongful death claim and $ 15,000.00 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and, although subject to the imposition of a zero percent inheritance tax rate in this instance, they must be reported on decedent's Pennsylvania inheritance tax return. 42 Pa.C.S.A. §8302; 72 P.S. §§9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending the hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a wrongful death /survival action. Sincerely, aul Dibert Business & Trust Valuation Manager Inheritance Tax Division Bureau of Individual Taxes DEPARTMENT 280601 HARRISBURG, PA 1`~°~2$-0601 ce: Cumberland County Clerk of Orphans Courts.~j IN RE: IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF CHARLES R. BECHTEL, JR. NO.2002-01031 ORPHANS' COURT DIVISION ORDER OF COURT AND NOW, this 6TH day of AUGUST, 2003, upon consideration of Petitioner's Petition to Approve Settlement and Compromise of Wrongful Death and Survival Actions, and of the attached letter dated July 31, 2003, from Brigid Q. Alford, Esquire, a hearing is scheduled for THURSDAY, AUGUST 28, 2003, at 9:00 a.m. in Courtroom #1 of the Cumberland County Courthouse, Carlisle Pa. .~ ~ v ~ '~ =~~1 ;tea ~ S Wendy J. Bechtel, Administrator of the Estate of • • Charles R. Bechtel, Jr., Deceased ~~ Joseph U. Metz, Esquire ~, ~j Tyeddie Desmarais, Claim Representative _~ ~ Progressive Insurance Company ,,~ 1J 1 Linda Koch, Claim Representative ~ ~ ~ ~ State Farm Insurance Company !~' _~ -~ ~ 1._.. ~_ ~ J Enclosures :sld By the Court, .3 fi ~ ~~..' f`a--' J: Wesley Oler, r., J. ~. BOSWELL, TINTNER, PICCOLA & WICKERSHAM COUNSELORS AT LAW 315 NORTH FRONT STREET P.O. Box 741 HARRISBURG, PA 17108-0741 LEONARD TINTNER WILLIAM D. BOSWELL JEFFREY E. PICCOLA 17171 236-9377 11943-19991 RICHARD B. WICKERSHAM FAX (7171 236-9316 JEFFREY R. BOSWELL btpw~att.net BRIGID O. ALFORD G. EDWARD SCHWEIKERT, IV July 31, 2003 The Honorable J. Wesley Oler Cumberland County Court of Common Pleas One Courthouse Square Carlisle, PA 17013 Re: Estate of Charles R. Bechtel, Jr., Deceased No. 2002-01031 Cumberland County Orphans Court Division Dear Judge Oler: Please be advised that I represent State Farm Insurance Company, insurer of the owner of a vehicle that struck a vehicle driven by Charles R. Bechtel, Jr., who died as a result of the accident. The driver of the vehicle was insured by Progressive Insurance Company. Both State Farm and Progressive have tendered their respective policy limits to Wendy J. Bechtel, Administrator of the Charles Bechtel Estate. On May 1, 2003, there was filed with the Court a Petition to Approve Settlement and Compromise of Wrongful Death and Survival Actions in this estate. At that time, Ms. Bechtel was being represented by Joseph U. Metz, Esquire, who signed the aforementioned Petition on behalf of Ms. Bechtel. Subsequently, this Court asked Mr. Metz to obtain and produce a clearance letter from the Department of Revenue addressing the proposed allocation of the gross proceeds of the settlement. I enclose that letter, signed by J. Paul Dibert, Business & Trust Valuation Manager, Inheritance Tax Division, with this letter to you. Earlier this week, Attorney Metz informed me that he is no longer representing Ms. Bechtel, and that she will henceforth be proceeding pro se. Ms. Bechtel also confirmed this fact to me in a subsequent telephone conversation, after which she sent me the Department of Revenue letter that I enclosed herein. I understand that, on July 11, 2003, Your Honor had approved the Estate's settlement of its underinsured motorist claim with Nationwide Insurance Company, upon presentation of a similar clearance letter. I now respectfully ask that Your Honor approve the pending settlement of the Estate's claims for benefits under the State Farm and Progressive policies, as it appears that the Petition is now ripe for approval. JUL 3 ~ ~ The Honorable J. Wesley Oler July 31, 2003 Page 2 Should you have any questions, please do not hesitate to contact me. Thank you for your consideration. Very truly yours, Brigid C2. Alford BQA:DEG CC: Wendy J. Bechtel, Administrator of the Estate of Charles R. Bechtel, Jr., Deceased (w/encl.) Joseph U. Metz, Esquire (w/encl.) Tyeddie Desmarais, Claim Representative (w/encl.) Progressive Insurance Company Linda Koch, Claim Representative (w/encl.) State Farm Insurance Company 5/20/2003 Joseph U Metz, Esquire Dilworth Paxson LLP 8th Floor 112 Market Street Harrisburg, PA 17101 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 ;._ i ~,` ~.~~:_ 717-783-0972 ~~ ~, ,~ v, 1C ti~ y 1 r ~~'`;~. Re: Estate of Charles R Bechtel Jr. File Number: 2102-1031 Court: Cumberland-Orphans-2002-01031 Dear Mr. Metz: The Department of Revenue 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 was 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 42-yearold-decedent died as a result of motor vehicle accident. The sole heir to the decedent's estate is his spouse. Therefore, any proceeds paid to settle the survival action would pass to decedent's spouse and would be subject to a zero percent inheritance tax rate. 72 P.S. §9116(a)(l .l)(ii). Accordingly, regardless of the allocation of the subject proceeds, there would be no inheritance tax consequences. Please be advised that based upon these facts and for inheritance tax purposes only, this Department'has no objection to the proposed allocation of the gross proceeds of this action, $ 135,000.00 to the wrongful death claim and $ 15,000.00 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and, although subject to the imposition of a zero percent inheritance tax rate in this instance, they must be reported on decedent's Pennsylvania inheritance tax return. 42 Pa.C.S.A. §8302; 72 P.S. §§9106, 9107. Costs and fees must he deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending the hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a wrongful death /survival action. / J,: f~ .5 J Paul Dibert Business & Trust Valuation Manager Inheritance Tax Division Bureau of Individual Taxes cc: Cumberland County Clerk of Orphans Courts IN RE: : IN THE COURT OF COMMON PLEAS :CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF CHARLES R. BECHTEL, JR., ORPHAN'S COURT DIVISION N0.2002-01031 ORDER AND NOW, this ~ day of , 2003, upon considcration of the attachcd Petition to Approve Settlement of Wrongful Death and Survival Actions, IT IS HEREBY ORDERED AND DECREED THAT: 1. The settlements described in the foregoing Petition are APPROVED. 2. The proposed apportionment of settlement proceeds are approved, as follows: Wrongful Death Action: $135,000.00 TO: Wendy J. Bechtel Survival Action: $15,000.00 TO: Wendy J. Bechtel, Administrator of the Estate of Charles R. Bechtel, Jr. '. ~' _ BY THE COURT: IN RE: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF CHARLES R. BECHTEL, JR. ORPHAN'S COURT DIVISION NO. 2002-01031 PETITION TO APPROVE SETTLEMENT AND COMPROMISE OF WRONGFUL DEATH AND SURVIVAL ACTIONS Pursuant to Pa.R.C.P. No. 2206(b)(1) and 20 Pa.C.S. Section 3323, Petitioner Wendy J. Bechtel, as surviving spouse of Charles R. Bechtel, Jr., and Administrator of the Estate of Charles R. Bechtel, Jr., by her attorneys, Joseph U. Metz, Esquire and Dilworth Paxson LLP, presents the following Petition to Approve Settlement of Wrongful Death and Survival Actions: 1. Petitioner, Wendy J. Bechtel, is an adult individual residing at 526 Rittenhouse Square, Mechanicsburg, Pennsylvania 17050. 2. Petitioner is the surviving spouse of the decedent, Charles R. Bechtel, Jr. 3. The decedent died intestate and the Cumberland County Court of Common Pleas, Orphans' Court Division granted his wife, Wendy J. Bechtel, Letters of Administration. A certified copy of the Letters of Administration is attached hereto as Exhibit A. 4. On November 11, 2002, the decedent was traveling on Bent Creek Boulevard, through the intersection of Route 114, in Silver Spring Township, Cumberland County, Pennsylvania. 5. At the same time and place, Mr. Howard Cosner, operating a vehicle owned by Edwin Watts, was traveling on Route 114 toward the intersection of Bent Creek Boulevard. 6. The intersection of Bent Creek Boulevard and Route 114 is controlled by a traffic signal light. 7. Mr. Cosner's traffic signal light was red as he approached the intersection. 8. Mr. Cosner traveled through the red light into the intersection, and his vehicle struck the decedent's vehicle. 9. The decedent was treated at the accident scene and then transported via Life Lion to Hershey Medical Center, where he succumbed to the injuries suffered in the accident. A true anal correct copy of the decedent's death certificate and medical records related to the accident are attached hereto as Exhibits B and C, respectively. 10. The decedent's wife, Wendy J.Bechtel, is the onlyperson entitled to receive benefits in this action. 11. Edwin Watts, owner of the vehicle that struck the decedent's car, was insured by a policy of motor vehicle insurance issued by State Farm Mutual Automobile Insurance Company, which policy was in effect at the time of the accident, and which provided coverage that included liability coverage in the amount of $50,000.00 per person. A Certificate of Coverage attesting to these limits is attached hereto, made part hereof, and identified as Exhibit D. 12. Howard Cosner, driver of the vehicle that struck the decedent's car, was insured by a policy of motor vehicle insurance issued by Progressive Insurance, which policy was in effect at the time of the accident, and which provided coverages that included liability coverage in the amount -2- of $100,000.00 per person. A copy of the Declaration Page for said policy attesting to these limits is attached hereto, made part hereof, and identified as Exhibit E. 13. State Farm Mutual Automobile Insurance Company has offered the sum of $50,000.00, which sum represents the policy limits, to settle the decedent's wrongful death and survival action claim against its insured, subject to this Court's approval of the settlement and Petitioner's execution of a Release relative to the same. A true and correct copy of a letter from State Farm Claim Representative Linda Koch to the Petitioner, confirming the offer of policy limits is attached hereto, made part hereof, and identified as Exhibit F. 14. Progressive Insurance has offered the sum of $100,000.00, which sum represents its policy limits, to settle the decedent's wrongful death and survival action claim against its insured, subj ect to this Court's approval of the settlement and Petitioner's execution of a Release relative to the same. A true and correct copy of a letter from Progressive Insurance Claim Representative Tyeddie L. Desmarais confirming the $100,000.00 settlement offer is attached hereto, made part hereof, and identified as Exhibit G. 15. The decedent was insured by Nationwide Mutual Insurance Company under a policy of motor vehicle insurance, which policy was in effect at the time of the accident. 16. Nationwide Mutual Insurance Company has consented to the within proposed settlement and has waived its subrogation rights. A true and correct copy of Nationwide's approval letter is attached hereto as Exhibit H. -3- 17. Petitioner proposes that the settlement be approved and the settlement funds be apportioned as follows: $135,000.00 allocated to Wrongful Death Action $ 15,000.00 allocated to Survival Action t 8. Petitioner is not aware of the existence of any liens or other impediments to the proposed settlement and distribution. 19. Petitioner believes and therefore avers that the proposed settlement is fair and just and should be approved by this Honorable Court. WHEREFORE, Petitioner respectfullyrequests that this Court approve the above-described proposed settlement. Date: '~ ~ ~~~ C/ ~, Respectfully submitted, DILWORTH PAXSON, LLP 0 __ , ~. - -, '1 ~; ~, J s~ph U. etz, squire ~ \.~ ~l~ARRl~BURG MAR 14 2003 RECEIVED STATE OF PENNSYLVANIA SHORT CERTIFICATE COUNTY OF CUMBERLAND 2002-01031 21-02-1031 11/11/2002 206-38-8454 estate of BECHTEL CHARLES ROY late of SIL in said county, deceased, to BECHTEL WENDY J and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 19th day of November A.D., Two Thousand and Two. File No. PA File No. Date of Death S.S. # I, MARY C. LEWIS Register for the Probate of Wills and Granting Letters of Administration &c. in and for said County of CUMBERLAND do hereby certify that on the 19th day of November A.D., Two Thousand and Two, Letters of ADMINISTRATION in common form were granted by the Register of said County, on the VER SPRING TOWNSHIP ~~ ~ ~o,~ ~~~ ~~, ~,~~~ ~ Register T NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL ,; ~,a ~ ;,, t . , 11 ~ ~:. 7',~is is to certit~~ t1~at T11e inter ultio' here ~ ~u~ is ~~~t,.,:(~ ~ „ t. , 1 ,will lle '~nv<Itt{c~ t ~ , , , _ ~.. •l.octl RL~gistrar. •i,he ori~inar ~c'Lihc: - WA~iNI1V~: It i:~ illegal to dupiica~e tt'hi~ ~ ,~~`~ ~~~° ~~ sa..: ~~ - . Pee 'tor > hts certittc ~l" SZ.(iO 1 ;, ~~~~ r _'r ;~~ ' \tC%~.~ .~ _ U ~~ 4 ~I'g - a,~~ ~ ~'1 : ~k;, ~ ~ , k :•, \ ~~i4 P 8 7 7.7 5 0 9 ---~~r~ r. ~-~~ ~~~ ~??_~~~ a. ~~,~ i ~.>. Inos taaNe". vs, COMMONWEALTH OF PE CERTIFICATE OF DEATHEALTH • VITAL RECORDS IYPErPF11NT (Coroner) STATE FILE NUMBER IN SOCIAL SECURITY NUMBER DATE OF DEATH (MOmh.Ib Y. Year) PERMANENT SEX Male B 206 38 8454 a. November 11, 2002 BL ACK INK NAME OF DECEDENT (Prat. MWtxe. Lest) x Charles R. Bechtel, Jr. 1' DATE OF BIRTH BIRTHPLACE (Clly antl PLACE OF DEATN(Checa only One-See insnucUOns,m dher sidel OTHER'. AGE (Last BuNday) UNDER, YEAR UNDER 1 DAV (Monln DaY, Year) Slute or Frxe;gn Couna Yl HOSPITAL: Nursing Other Monms DeYa Howe MInWN ERIOM tent ® DOA ^ Mome ^ Residence ^ ISpecnyl U Ju125, 1960 Harrisburg, Pa. Invatiarn^ wi I 42 Vrs. a. 7. °' YMSrp~E(CEDENT OF HISPANIC ORIGIN7 RACE-American lntlian, BAlack, Wnite, ,NC. 3. CITY, BORO,TWP OF DEATH fACILITV NAME(If nol;naa¢diwt, give street antl number) No l:7 Vss^If yea. 5p•ciry Cuban, (S~~Irl yyl llte COUNTY OF DEATH Hershey Medical Center Me.kan.Pwno Rlca"'°„ Derry `Iwtp• 'g _ Dauphin W. MARITAL STATUS Married SURVIVING SPOUSE b. WAS DECEDENT EVER IN DECEDENT'S EDlICA71ON Never Martial. Widowed. 111 wne. y~ve rna,dur,nwne) BC. KIND OF BUSINESS/INDUSTRY U.S.ARMED FORCES? S d oN hi esl r Divor (Spec,ry) DECEDENT'S USUAL OCCUPATION ElamenlarylSecontlery F'o"•g• IVtarned Wendy J. Helnz - IG;.eF,ndolw«ktl«wd,r,ngm°51 OWn HOme Yaa^ N°L~4 (o-t2) 1 (l.a«stl ls. of worxing I , do mtus~, etl /0. 1a. ~lomema `e~ llb ,x. ~-tr I ver pang ,wp - (la. DECEDENT'S ennsy vanla ~ „°,L_J Vae, aec,wem liwdb ~I DECEDENT'S MAILING ADDRESS (Slr,wl. OryROwn, Stare, Zlp Coda) ACTUAL 17a. State dx.dam - - -- _ - - - 526 Rittenhouse Square RESIDENCE live ina cnYrbn,o ,nsv°~"°n5 Cumberland mwnenlp7 Np,aac.d•"te"w ~ Mechanicsburg, Pennsylvania 1705 „wher5,de, - nd.^ wKlu^•°°e,am"°°' 1Tb. Coum 16 MOTHER'SNAME(PoSI,Ma1de.MaitlenSurnarne) Marie Zicarelli FATt1ER'S NAME U~~slM,tldla Lag) Charles R. Bechtel Sr. ,g. ;NFOnM,ANrs .....+^ P Es^cs~reac clt ^„::r Cla;d.' ^ ^,FOo,.^"T "^., ,... ," ., ~ ~~~Iffen~iouse Square ~171ec~ianicsburg, Pa. 1705 ta. .. _..._E..,;~..:.., Wendy J. BeCMeI LocATION cnYrt°wn.stala.z,vrAd. I DATE OF DISPOSITION PLACE OF DISPOSITION ~ Name of Cemetery. Crematory ~ xg, «OmerPlau Harrisburg, Pa. 17112 McTNOD of DlsrosmoN (MO°m, Dari vearl Resurrection Cemetery I Btrr~at Va° cremetan ^ RemoY,umm st.t.^ ^ Nov 15, 2002 xm. D«uuon ~._I ,.ether lS AY 21b. xle. LICENSE NUMBED rUME AND ADDRESS OF FACILRY xt•' ~J FD-014318-L Myers Funeral Home, Inc. 37 East Main Street Mechanicsburg, Pa 770 - SiGN~U E F~JNE SERyIC ~LICEN E SON ACTING AS SUCH ~` L ~ xxe. DATE SIGNED `~ 2xb. LICENSE NUMBER (MOnlh. Oay 1'eail 2 To (ne best or my krluwle death occurre0 al the tiro,date and place Slated. °mplale items 23at onN'w'h_en ~unityin9 23c. not availa~a Btlur»^'°°^••• •" x~' r'I yvc,an ~s ~ WAS CASE REFERRED TO MEDICAL EKAMINERICORONER? candy cause of deet(r xL. No ^ i TIME OF DEATH DIIIE PRONOUNCED DEAD (MO~t~. ;aY. 7~a•r^n~ Yea® 1 Items 2a~26 must be completed CY 1 • 07 NOVember 11 LW x!• person wno pro«+unce9 death. . p•m• M. 25. oslmale PART 11: Omer sipnlrlwnt contlitbns wn(nbubng to da PARM7 (t'. 2a. has cardiac or respiratory attest, shock Or been lallure. rAppr n«reauuingln the urNlerly,ng cause given in j inbrvel bWween 27. PART 1: Emar the diseases, inlurie9 or complicatbn9 wtiiCh tauaed the death. Do not BnIH the mode or dying, suc ,°rpet arM death ~~ List only one cause on eacn line. ICI IMNEOIATE CAUSE Ifinal Multi le traumatic in'uries ' .L~.uaw o, cc~ndmon a. i ,„ny u, neaay-~ DUE TO (OR ASACONSEOUENCE OF): i es rQl li b i - .t.l Sepuemially lis(Wnatwne DUE TO IOR ASACONSEOUENCE OF): -- deny. leadingbimmedlele 1 ' [) cause Enter UNDERLYING ° (J CAUSE ID,soaS°wurWrY DUE TO (OR ASACONSEOUENCE OF): I FC II~.,I ~~~e„Ind avUniS , a:~long m dean) UST TIME OF INJURY INJURY AT WORK7 DESCRIBE HOw tNJURV OCCUPPED. V tl. DATE OF INJURY (ll WAS AN AUTOPSY WERE AUTOPSY FlNINNOS MANNER OF DEATH (MOnm, OaY•Year) [~T ~ PERFORMEDT AWIIABLE PRIORro ^ Nov• 11 t02 11:15 a.m. ve. ^ Nog,., vehicle vs. vehicle ~ COMPLETKNl OF CAUSE Natural ^ Homkide + ro OF DEATH? M' ~ma"t ~ Pendnq lnveNigalbn ^ tea. LOCATIONISbaN, CUY/T~'n~5late) ~~t^r+ PUCE OF INJURY ~ At h,au, term. MrM, hclwY• aflke I RilVer S • an Ct Yw ^ N°~ YN ^ "° ^ sekie. ^ ceeld^°'o.d•'erml"ed ^ oat"°Et't:~p~i'lA and Bent Creek Bl. y• xW. 2°. SK3NRURE AND TR x°•' led Ittan 23) ^ I CERTIFIER (cnecF ordY «,el uusa d deaN when erwm« MYSinan naa pr«twncad death and compb ............................... ,b, DATE SIGN (M«M. Da Y. Vaar) •CERTIFYIND PHYSICIAN IPhYOCUn cendyap mmanrNrMMtlad..••~•""""" LICENS BER November 11, 2002 To the beat or mY ar,ovdadga, deatlt occ,urM Ow to Bla utu•lat • x1d. ........ ^ xlc. ,w ~ •PNONOUNCtNO AND CEATIFYNID I•IIV81GANlPnY~~anb°B'a°°O1AC'^g d••'n •^d CBfM~np to cauaeddeath) NpA,E AND ADDRESS OF PERSON WHO COMPLETEDCAUSE OF DEATH T° the beat of mY WroarMdga• WaBI aodurtW N dIa Ilrrla, dale, and plao•• and dal w the uu,rep) and manner u alatM .................. (Kam 27) TYpe o1 Pnnl w Gra7ham S. Hetrick, Coroner Inbn, death xdurrad at Ma Lima, data, and place, and due to the eeuae(q and ~ ~ 'MEDICAL EAAMINERICORDNER ~ 1271 S• 28th St. Harrisburg, PA 17111 LL ............ ~. ' On IM Calla of esamlMtlon artdlor InwMlpatbn, In Im op ............ . O ........................ .............................. manner as Mated........... DATE FI D (MOnln, DaY.'t•ar) i REGISTPAR' NATURE AND NUMBER ~ G~_ ~ Z. 33. rtlvlvJ IAI ~~ on S. Hersl edical Center ~ ~ _ ~ ~e of Nlediclne De rtment of Emer enc Medicine Record Date: Temp: oral Rectal Pulse i1 RR ~ CC: ~ /! L t ~ 0 HPI: a /~.ll .~--- . . -----~' T~ ~~ 3 6 5 2 2 .. _ .._ 0~~ 2 410 6 ~`~.'`'~/t~s MR 8181 EVER 00 00 00 BP 02 sat I } ~ dT j E i Room lime Physician T IPMH: r ~ ,. JA 2 2 ZG03 P i Allergies: 7 a n: Y Lo lion Quality Onset Radiation Quanti /10 r ~ Facto ROS: rs FHx: Cardiac Y N Diabetes Y N Unobtainable - Y N As noted, other systems negative Y N C onstitutional: Wt. Chan e N Y Fever N Y Chills E es: N Y Weakness N Y Fatigue Other: N Y y Blu vision N Y Diplopia N Y E e Pain ENT m th N Y Photophobia N Y Soc Hx: ETOH Y N Smoker Y N PPp , ou : Sore throat N Y Epistaxis N Y Ear Pain Cardiovas l N Y Rhinorrhea N Y cu ar: Chest pain N Y Pleuritic N Y Exertion ' Respiratory: Cough N Y Sputum N Y N Y Palpitations N Y Other: Laborato S GI: Dypnea N Y Orthopnea Wheezing tudies: N Y Abd. Pain N Y Nausea N Y Vomitin GU: N Y Constipation Diarrhea N Y Hematuria N Y D suria N Y Fr uenc Musculoskeletal: Ar i N N Y Va Inal D/C N g Y Incontinenece - - - - Neutropna N Y - rn n Y Le ain N Y Back ain Skin: Ra h N N Y Leg swelling N Y Arypicals s Y Lesion N Y N Y Neurolo ical Numbness N Y Tin lin N Y Seizure Psychiatric: N Y S nco e y p Dysphasia Ca N Y Suicidal N Y Anxiet N Y Y Ingestion N Y Depression N Y Hallucinations _ - . _ _ __ N Y Other: Mg Ph sical Exam: Rectal: Hemocult (+) (_) Troponin I: Myoglobin: , pT PTT: INR: T' Bi1i Alk Phos: ALT: Amylase: Lipase: ~~ Drug Screen: Cultures: Blood 1 2 Urine ' Radiolo check box if radiolo ist' to relation e See attached PROGRESS NOTE for additlonal information: Study #1: MOM/ Differer-tfalDiagnosis:l 3) ^Result: ~) ~~ ~ ~~ r q) Z) G i 5) 8) ~ Study #2: Procedure Note: i ^Result: EKG: Study #3: ED course: Treatment: O Result: GG l Response: Consult !Time Consult /Time Dtagnoses: (~~,,/~ yaac:~:.~~~c-,';, ~ ~ ~,J ~O O ` 'w-'~- +"" a~o (..~ ~p„~ p~~l In tientPathwa Initiated: Discharge Instructions: Please go directly to check out secretary at waiting room desk A. Fib ~ 23hr ^ a day ^ Chest Pain CI Dehydralinn OVT ^ 23hr ^ 5 day ^ 23hr trauma Follow up with within days. ^Com. Acq. Penumorna ^ Cellulitis Prescriptions !Medications: Retum to emergency department if ~ ) 21 ------ --- - ResidenVPA/NP/Student Si nat r 3) ------ u e Attendi i a ur Dictation Number Dischar a Admission Transfer ~~ i7 RBSOIved Serv~re Where L Irnl~rrwrrrl ~ Nn, h.u ~i p.~. Ln„' I ~ r: ~~~ ~dniln NEUROLOGIC EVALUATIO N VITAL SIGNS OUTE OF TEMP. Time Pupil Size Pupil React Motor Function Time Cardiac 02 ~ Warm Lites "Pain Scale R L ,L A R L 'L I S I Rhythm P BP RR Sat ~ T i B.H. Used Neonatal Pediatnc Ad Non- Communicative C nR~-oFCOnceaN -:NEUROVASCUL.AR ASSESSMENT - PuLSeassESSea TIME TEMPERATURE COLOR CAPILLARY REFILL SENSATION MOVEMENT PULSE i i t";' I 1 Y 4 ' I TOTALS - LABS ~~~~ TRAM-i F TRAM-2M TRAM-2F TRAM-3M TRAM-3F TRAM-P T8C ~ U T&S LEGAL URINE DRUG LEGAL BLOOD ETOH OTHER SITE CRITICAL VALUES CRITICAL VALUES PREPPED WITH POVIDONE-IODINE DRAWN BY '' ITOURIMARY FOLEY 0 HEME + SIZE FR BLOOD A MEATUS INSERTED BY TIME GASTRO At"` RECTAL HEME - TONE ^ GOOD DECREASED SENT PROSTATE ^ NORMAL ^ ABNORMAL DONE BY TIME N/G (ORAUNASAL) SIZE FR INSERTED BY TIME PERITONEAL LAVAGE DONE BY DR TIME RETURN ^ CLEAR ^ PINK ^ GROSS BLOOD AMOUNT INFUSED CC AMOUNT RETURNED CC FLUID TO LAB YES N0, OiOTHOR 1 C ' SIZE FR CVP R L CT SIZE FR R THORACOTOMY CUTDOWN JL THORACOTOMY BY: PERICARDIOCENTESIS TEE ECHO DONE BY 12 LEAD EKG YES NO NEUROLOGIC ICP BOLT INITIAL READING HALO DONE BY DR ......MEDICATIONS TIME DRUG DOSE ROUTE INIT. TET C ADULT Lore: X-RAY C-Spine Lateral A/P - Odontoid Swimmers CXR Pelvis Cystogram Extremities CT Cranial Abdomen Chest Other Angiogram VENT`: TIME RATE FLOW TIDAL VOL. PEEP RESRIRATORY _ SPONTANEOUS RATE _ 02 MASK UMIN 02 CANNULA UMIN _ ASSISTED RATE BVM RATE _ AAA~AY (ORAUNASAL) _/ETT (ORAUNASAL) SIZ~~O CRICO TRACH SIZE _ _1 1 .r ~.; JAiU 2 2 2G03 R~C>v:i~ii`a NEUROVASCULAR ASSESSMENT I TEMPERATURE COLOR CAPILLARY SENSATION MOVEMENT PULSE BRACELET LOCATION: ID ~ 2~1 REFILL BLOOD BAN f /r 7 9 6 6 7 W -Warm N -Normal R -Rapid N- Normal A -Active S -Strong C -Cool P-Pallor S-Sluggish T-Tingling W -Weak W -Weak T CD -Cold F -Flushed A -Absent NB-Numbness P -Paralysis A -Absent Documenting Nurse - RD If H -Hot C -Cyanotic P -Pain and A-Absent R-Regular Support Nurse: ~' I -Irregular Physician Signatu Pupil Size (MM) - ... ~ABBREIf#ATt41NS,.. > ~, ..~,~1t1~4~EU[1k~tt)N8 BVM =Bag Valve Mask LCT =Left Chest Tube NS =Normal Strength ~ ~ • • ~ • • • ET = Endotracheal Tube RCT =Right Chest Tube W =Weakness ABD =Abdomen PH =Pre-hospital FP =Flaccid Paralysis 2 3 4 5 6 7 8 9 RL =Right Leg LOC =Level of Consciousness R =Rigid iIVJURIES: LL =Left Leg PMH =Past Medical History DCB = Decerebrate Posture HEAD: RA =Right Arm BH = Bair Hugger DCT =Decorticate Posture LA =Left Arm PUPIL REACTIVITY: 9 =Brisk F =Fixed S =Sluggish D =Dilated N = Nonreactive ~ P i ~ CHEST: ADMITTED TO REPORT TO TIME OR NOTIFIED OR READY TO OR ABD: FAMILY NOTIFIED ® gY 1 RELATIONSHIP C-SPINE CLEARED: C YES C NO BY DR. EXTREM: C-COLLAR ON: C YES C NO ASPEN: C YES ^ NO VALUABLES:: ~' W/PATIENT _ SAFE C NONE C W/FAMILY~BELONGINGS FORM DONE C EXPIRED CORONER NOTIFIED ~ BURN: MATERIAL EVIDENCE TO POLICE: ~' YES C NO OFFICER BADGE # OTHER: TRANSFERRED TO _ VIA PENNSTATE The Milton S. Ham..,- .~ Medical Center The College of Medicine r i 3 -.7 TRAUMA HISTORY AND PHYSICAL EXAMINATION " c !3 ~ 1 3b52C0 ~. 001 YilOf ~ '` ~~>~fr~aeaao CR SAt~f SS i;301 Date: ~ ~ Time: `~=p Type of Trauma Briet History (Mechanism of Injury) MVC Belted? ^ Yes ^ No ^ Airbag ~S (~ r'Q~'~.:t ^ Pedestrian ^ MCC ^ Assault 30r.~.tVr . ^ Fall ^ Burn ^ Electrical ^ GSW ^ Stab ^ Other Fi'eid Resuscitation Airway: IV's: R.O.S. Field Vitals: P: ( BP: i'Y4~p RR: Immobilization ~~2. Fluid: ~ ~L Amnesia? ^ Yes ^ No Loss of Consciousness?~Yes ^ No Field Notes: ~a 1 ,• ~ ta:W Primary Survey Trauma Nis#ory Airway: ^ Patent ^ Obstructed Intubated: ^ OT ^ NT ^ Trach Allergies: Breathing• Breath Sounds• -~ Meds: ~, Circulation: P: ~ BP: RR: Sat: CD'Q{lt Disability: ^ Alert ^ Vocal ^ Painful ^ Unresponsive PMH: Exposure: ~~,L ~~~~~ Procedures: ^ NG-Tube ^ Urinary Catheter PSH: ^ A-line: ^ CVP(s): Chest tube: ^ right ^ left Last Meal: ^ DPL: Last Tetanus: Secondary Survey 2nd Vilals: Temp: P: BP: RR: 02 Sat: VNT , HEENT: Head: Eyes: ~~~ ;, C ~ Ears: TM's: Battle's: ~ ~ / Face: Maxilla: Mandible: ~-=~- -- ~ ~ ,~ ~ Nose: Dentitia: ! ~ ` Mouth: Dentures: II ~~ 1^ J y J Neck: Tenderness: Crepitus: Trachea ML: ~ _ ` Chest Wall: Tenderness: Crepitus: ~ ~ 1. ~ ,' Lungs: { ~.-~ i , Back: Tenderness: Crepitus: ~~`(yl, ~,. ~3~. 1 !~ ~ ~ Heart: - ~~ ~ Abdomen: Distention: BS: Tenderness: ~~, ~ ~ I '~ - Rectai: Tone: Heme: Prostate: ~ Pelvis: Stable: Tenderness: ( ~• t ' Vascular Exam: Radial RighULeft Femoral DP PT 1 LEGEND: { '~ i L -laceration ctx-dosed ~ ~ > fracture Resident Si nature g rnpvatruT ,.,.... ___. Title Date Tlme a.m./p.m. Ofx-open fracture - Ab -abrasion C -contusion Orig -Chart MR 611 Rev. 3/98 TRAUMA HISTORY AND PHYSICAL EXAMINATION Copy - Trauma Services TRAUMA HISTORY AND QHYSICAL EXAMINA ~..,N xtremity Exam i f ~N~{~fnv~L77'aJ JA N Z 2 2G03 ~~fl -~~\\ ~ - ~ LEGENO L -laceration C fx -closed ~\~ ~/ ~~-~ ~~~_ fracture .~, ~ r P~ Ofx-open fracture ~'- \_ __~ _ Ab -abrasion - :~ i ~ ~ C -contusion ir~ ) - ~ ~I i.~: I ;l !r , Neurological Exam SP^~ cord Injury: Glasgow Coma Scale/Peds ;ranial Nerves: ,~; ~ Eye Opening 1 -None Trauma Score VIOtOr: , ~ t_, ~ ;~ ~ 2 -Open to Pain 3 -Open to CommandNoice Resp. Rate SBP 0- 0 4-Spontaneous 0- 0 1- 1-9 1- 0-49 sensory: Pinprick T 1-12 Yerhal Response 1 -None 2 - >36 2 - 50-69 2 -Incomprehensible/Moans to Pain 3 - 25-35 3 -70-90 Proprioception crp, 3 -Inappropriate /Cries to Pain 4 -Confused /Consolable 4 - 10-24 4 - >90 QTR ~S ~~ ~ '_~ ~ 5 -Alert /Oriented /Interacts Motor Response GCS 0 - 3-4 _ ~~r= : L 1-5 ~' 1 -None 1 - 5-7 ~, ~'"' yr 2 - Decerebrate 3 -Decorticate 4 -Withdra 2 - 8-10 3 - 11-13 - ~ ws 5 -Localizes Pain 4 - 14-15 t~ t j ~ ~ 6 -Obeys - Total: Total: :aba/Stndles Evaluated ~ PT: Troponin: U/A: PTT: ~ Myoglobin: T:Bili: CPK: Drug Screen: ALT : Amylase: 46G: ALP : ICa: ETON: .CG: TEE: X-Ra CXR: Pelvis: CT Scans: Head: BHCG: Read: ' CSpine: Lat Extremities: Abdomen: AP Others: Odontoid Angio: T & L Spines: tt~. Problem List: Attending Note/Plan• .~ 0~ .-L_..,_._ ~_,_- ~-~- e .z..~-. .5~, u. ~ttending Orig -Chart MR 611 Rev. 3/98 Copy - Trauma Services TRAUMA HISTORY AND PHYSICAL EXAMINATION ED Trar~spor~t Note gECHTEL, CHARLES - 1278505 * Final Report F 9:,'r~~~~~'~~ JAN 2 2 2G03 LIFE LION ON SCENE TRANSPORT NOTE PATIENT NAME: BECHTEL, CHARLES ER: 0365220 DATE OF SERVICE: PATIENT NUMB DATE OF BIRTH: SEX: M Ri=CEiVED 11/11/2002 07/26/1960 FLIGHT NUMBER: 02-2166-A DISPATCH INFORMATION: Life Lion initially dispatched to standby for a vehicle crash in Silver Spring Township, Cumberland County, to assist Medic 81. Requested to respond STAT and Pennsylvania, lifted off at 1126 hours en route. REPORT FROM THE SCENE: We believed to be in his 30's d' al Center's Emergency will be transporting a male to the Penn State Milton S. Department. patient Hershey Me is ACS while responding, EMTP, Kelly Andress, SOURCE OF INFORMATION: and patient assessment. Weather was from Medic~86, West Shore ALS, This flight was not significant to patient care or transport. completed under VFR. rior to HISTORY OF PRESENT INCIDENT: Approximately 15-20 minutes p for unknown this vehicle, Life Lion's arrival to the remote LZ, ushed into a light reasons, was broadsided near aneanteEX~Ticationaatpthe time was e stand, and was severely entrapp greater than 20 minutes. Patient unresponsive in the vehic e. hest abdomen, and. pelvis area. While injuries reported to baththe~remote~LZ, it was requested that they Life Lion was landing roaching bring their equipment and crew down to the scenelacedconathe ground the scene, the patient had been extricated and p unit and then transfer was staatoWd theagroundeambulance, enteredtthe there, Life Lion team flagged roviders patient compartment to find neck assessmentaandBreport mrobefore our attending to the patient. 4 Kelly. The patient was given Versed, believed to be 5 g arrival, due to his combativeneTOVadedtforspatienterespirations. No intubation. BVM with 1000 02 p other HPI is noted at this time. Printed by: Duzick, Bonnie L Printed on: 1/15/2003 9:17 PM Page 1 of 3 (Continued) ED Transport Note PAST MEDICAL HISTORY: Unknown. ALLERGIES: Unknown drug allergies to medication. SA~ 2 2 2C03 Weight estimated to TMENTS PRIOR TO be approximately OUR ARRIVAL• As 90-100 kg. mentioned above 'F3~C~IV~ to include TREA - immobilization on a long board with C-collar, CID, and straps, one peripheral IV, airway management as above with supplemental 02. No other treatments are known at this time. PHYSICAL EXAM: Initial vital signs: BP is 124/86, pulse 146, respirations being assisted with bag-valve 100% 02 at 24-26 per minute, monitor showing sinus tach rate in the 140s, 02 saturations not tracking. Glasgow Coma Scale 3, 1-1-1. Other assessment showed patient had severe head injuries. Major bleeding is controlled. Also obvious was chest and abdominal area injuries, contusions and abrasions. Other neurological exam showed the patient's pupils to be 5-6, not reacting to light equally. Cardiovascular: S1-S2 heart sounds not audible, peripheral pulses not palpable; however, the patient did have a carotid pulse rate in the 140s, weak. The skin is cool, dry, pale, no capillary refill. IV is reported to be a 16 in the left AC with lactated Ringers flowing wide, bag #1. The second IV, 18 in the right AC with lactated Ringers attempting to flow wide, but having difficulty making it flow. Pulmonary: As above. Positive bilateral breath sounds, decreased on the left. On attempt by ground ALS for intubation, the jaw was clenched, he was unsuccessful. 9114 in the Life Lion successfully intubated patient with 8.0 ET tube, successful after RSI and Eshelman stylet. Palpated chest, some crepitus on the left, felt like possible fractured ribs. GI/GU: Abdomen is firm, slightly distended, possibly due to patient .~_... being assisted with bag-valve mask, and no cricoid pressure. No bowel sounds auscultated in four quadrants. LABORATORIES/X-RAYS/DIAGNOSTIC TESTS: Not applicable. TREATMENTS/PROGRESS NOTES: Vitals signs by Life Lion team, assisted ground ALS with intubation. Nurse Kennedy provided .3mg/kg of etomidate at 1145 via IV followed by 1.5mg/kg mg of succinylcholine for patient intubation. At 1146 hours at 9114, intubated patient successfully. Bag-valve through ET tube with 100% 02 provided. The patient re-evaluated,-could not auscultate heart sounds, trachea midline very, very weak carotid At that time, the crew discussed that the patient would benefit from increased IV fluid and 1 amp epinephrine. After quick re-evaluation of the patient, the trachea midline, bilateral breath sounds, end tidal C02 being produced, the patient then given 1 amp epi at 1153 via IV. The patient immediately re-evaluated. Very weak pulses. At this time, we were en route BECHTEL, ~;HARLES - 1278505 Printed by: Duzick, Bonnie L Page 2 of 3 Printed on: 1/15/2003 9:17 PM (Continued) ~ - ~ ED Transport Note BECHTEL, CHARLES - 1278505 towards aircraft. Patient hot loaded, all initiated treatment continuing, secured, re-evaluated, all appropriate on-board equipment applied. Life Lion departed to Penn State Milton S. Hershey Medical Center. While en route there, 9114 contacted medical command, updated and advised on incoming patient, short ETA. Medical command advised to push as much fluids as possible. The flight team complied. The transfer continued. The patient continuously evaluated. Ventilation provided via bag-valve with 1000 02. Third IV attempts were initiated but were unsuccessful. Vital signs en route, departing remote LZ at 1155 hours: BP not tracking, pulse isF~~~{~,~'~-~~s 140s, regular respirations being provided via bag-valve through ET tube at 24-26 per minute, 02 sats not tracking, end tidal C02 is now 28, cardiac monitor sinus tach, no ectopy. At 1202 hours, Life Lion arriving at Penn State Milton S. Hershey Medical Center helipad. BP is 124/86, pulse is 142, respirations 24 via bag-valve through ET tube with 100a 02, 02 Bats not tracking, end tidal C02 28, cardiac monitor sinus tach, no ectopy. IMPRESSION: Patient experienced multiple trauma with noted severe injury to head, chest, and abdominal area, and possible pelvic fracture also. DISPOSITION: The patient hot off loaded and taken to trauma room 1. There care transferred to awaiting trauma team and trauma doc. All questions answered. EMS equipment with patient: Plastic long board, straps, C-collar, CID. I & O: Approximately 1 liter of lactated infused, output estimated to be 10-15 cc bleeding from head wound. #397814 PRIMARY CREW MEMBER: Richard Schreffler, EMT-P SECONDARY CREW MEMBER: Ella M Kennedy, RN ATTENDING MD: Kym A. Salness, MD Professor & Director, Center for Emergency Medicine RS/jlh D: 11/11/2002 T: Printed by: Duzick, Bonnie L Printed on: 1/15!2003 9:17 PM 11/11/2002 15:20 JAN 2 2 ZCC R~CE~~I'~ Page 3 of 3 (End of Report) ED Summary EMERGENCY DEPARTMENT NOTE i SECHTEL, ~;HARLES - 1278505 * Final Report lJ:,~~~1~~~:!r~r, JAN 2 2 ZC03 R~'~~1Y~p PATIENT NAME: BECHTEL, CHARLES PATIENT NUMBER: 0365220 DATE OF SERVICE: 11/12/2002 SEX: M DATE OF BIRTH: 07/26/1960 CHIEF COMPLAINT: None stated by patient. HISTORY OF CHIEF COMPLAINT: Air medical personnel report that this patient reportedly was the driver of a car that struck a light standard, significant motor vehicle damage. He had head and chest injuries, was unresponsive on arrival of EMS. He had agonal respirations, rapidly sequence intubation. He was hypotensive, tachycardic in the field. Major damage to the vehicle and he was prolongedly entrapped in the vehicle, requiring extrication. He received etomidate, succinylcholine, and epinephrine, along with fluids in route to the trauma center. His past medical history is unknown. His medications are unknown. His allergies. are unknown. Patient was unresponsive, tachycardic with a weak thready pulse. No palpable blood pressure upon arrival at the trauma center. He has an oral tracheal tube in place and peripheral IV line and he was immobilized. Skin was pale and cool. HEENT was normocephalic. Oral tracheal tube. Pupils were dilated, nonreactive. Neck: Trachea was midline. Chest: Marked trauma and crepitus on the left side of the chest with diminished breath sounds on the left. Neck thoracostomy was performed on the left with no significant rush of air, no change in his condition. His endotracheal tube was also withdrawn and again no change in his condition. His abdomen was soft, no masses were felt. No bowel sounds. Pelvis was stable. Extremities: There are some wounds in deformity of his left fingers. His glossocoma scale was 3T. Patient had central lines placed. Volume resuscitation was initiated. Left chest tube thoracostomy was performed. We did restore a blood pressure for a period of time, however, we did lose Printed by: Duzick, Bonnie L Page 1 of 2 Printed on: 1/15/2003 9:16 PM (Continued) ~ ~ ED Summary BECHTEL, CHARLES - 1278505 his blood pressure and he required epinephrine and atzopine, along with the fluids and blood, and surgery performed open thoracotomy in the Emergency Department. During the resuscitation and emergently took the patient to the Operating suite for evaluation and treatment. IMPRESSION: 1. Multiple trauma. 2. Severe chest trauma. 3. Rule out intra-abdominal trauma and closed head injury. Pelvis x-ray revealed fractures in the Emergency Department. The chest x-ray revealed multiple left rib fractures with a hemothorax and tracheal deviation to the right. Trauma team evaluated and resuscitated the patient in the Emergency Department, performed a thoracotomy and was taken to the Operating room by Dr. Ku. #398208 DICTATING MD: ATTENDING MD: John A. Damiano, DO JAD/asw D: 11/11/2002 Printed by: Duzick, Bonnie L Printed on: 1/15/2003 9:16 PM JAN 2 2 2Q03 R~CEiVED T: 11/11/2002 17:45 Page 2 of 2 (End of Report) Spiritual Care Note SECHTEL, ~;HARLES - 1278505 * Final Report SPIRITUAL CARE NOTE DATE/TIME:1 l / 11/2002 17:18 PATIENT NAME:Bechtel, Charles PATIENT MRN:365220 PASTORAL SERVICES (place an * after those that apply): Routine Visit Referral Death* End of Life* Code Trauma* Pre Surgery Follow up Other (please enter service) SERVICES OFFERED (place an * after those that apply): Support* Guiding Sustaining Reconciling Griefs Prayer* Anointing Baptism Eucharist Advance Directive FAITH GROUP: If follow up is necessary refer to ~~,~ft~~~'~Rr ~a~u 2 z 2co3 R~~ ~#~ ~D COMMENTS (optional): Patient was brought to HMC. At mean time, we didn't have any info. I have called to Silver spring township 697-0607 and asked police, if they can find out, who is this man or if they can contact someone of this patient. They tried to do their best. So I have received call from his wife Wendy Bechtel 697-6677. At this time I got info about him from his wallet. People from OR gave it to me his belongings. When wife arrived I have notified doctor and nurse to talk with Wendy about her husband conditions. Wendy was with her father and daughter, + her nephew. I have stayed with them all the time. When doctor came, he told them sad news about Charles. He died. So I tried to support family, prayed with them and wait for person from decedant care. According his advise, wife and family decided not to see their husband and father. So they have left. Printed by: Duzick, Bonnie L Page 1 of 2 Printed on: 1/15/2003 9:17 PM (Continued) Spiritual Care Note ELECTRONICALLY SIGNED (type name):Ileninova Lydia SUPERVISOR (if required):Jim Winjum EMR 732-101 BECHTEL, CHARLES - 1278505 JA!u 2 2 2003 h~~:,ci'iED Printed by: Duzick, Bonnie L Page 2 of 2 Printed on: 1/15/2003 9:17 PM (End of Report) i ~ Spine XR (1-view) BECHTEL, ~;HARLES - 1278505 * Final Report * DX SPINE ANY LEVEL 1 VIEW - AP , PATIENT NAME: BECHTEL,CHARLES PATIENT MRN: 00365220 PATIENT DOB: 26-Jul-1960 EXAM NUMBER: 566B-111102 EXAM: DX SPINE ANY LEVEL 1 VIEW - AP , r~~si^~.~~~ ORDERING PHYSICIAN: KYM A SALNESS '~~~i„ vz•~- Exam: DX CHEST 1 VIEW - AP SUPINE, INSP, ~A~ 2 2 2003 Exam: DX SPINE ANY LEVEL 1 VIEW - AP , RE~~IVED Exam: DX PELVIS 1-2 VIEWS - AP , SUPINE, AP CHEST, AP PELVIS, AND AP C-SPINE HISTORY: Multi-trauma. DISCUSSION: There are no comparison exams available. Note this is a suboptimal trauma series as the patient was taken immediately to the operating room. CHEST: The overlying hardware and the trauma board obscure the bony and soft tissue details. There is marked medestinnalreatft to the right with a markedly widened mediastinum Bugg g g vessel injury. There is opacification of the left hemithorax and multiple left posterior rib fractures. PELVIS: There are bilateral inferior and superior pubic rami fractures and a fracture throu~h the left sacralrelresentcfreeed soft tissue density seen throu h the pelvis may p fluid or blood. C-SPINE: There is significant blurring of the AP C-spine. Noted is the endotracheal tube, the prior mentioned rib fractures, and road debris. The overlying trauma board obscures the fine details as does the motion artifact. IMPRESSION: 1. Suboptimal trauma series with probable great vessel injury noted on the AP chest x-ray. 2. Multiple rib fractures, left posterior. 3. Multiple pelvis fractures, as described above. 4. Suboptimal C-spine. Unable to interpret. Page 1 of 2 Printed by: Duzick, Bonnie L (Continued) Printed on: 1/15/2003 9:17 PM Spine ~R (1-view) EECHTEL, ~;HARLES - 1278505 Dr. Iyriboz reviewed the images and discussed the interpretation with Dr. Habakus. DICTATED: 18016 REVIEWED AND SIGNED: SCOTT J. HABAKUS, D.O./TUNC IYRIBOZ, M. D. 1/jlh J AN Z 2 2003 RAC EtV ~D Printed by: Duzick, Bonnie L Page 2 of 2 Printed on: 1/15/2003 9:17 PM (End of Report) Surg Op Note SECHTEL, CHARLES - 1278505 * Final Report OPERATIVE REPORT l~~~1 t- PATIENT NUMBBR:BE0365220CHARLES DATE OF BIRTH: 07/26/1960 ~ A N ~ ~ ZQ~3 LOCATION: 2328 DATE OF SERVICE: 11/12/2002 R~`i~~V GLJ SEX: M SIIRGEON(S): James Ku, MD ASSISTANT(S): Zandra Cheng, MD, Robert Strange, MD PREOPERATIVE DIAGNOSIS: Multiple trauma, cardiac arrest, hemorrhagic shock. POSTOPERATIVE DIAGNOSIS: Same, massive exsanguination, death. OPERATION PERFORMED: Emergency Department thoracotomy with open cardiac massage and thoracic aortic cross-clamping, placement of bilateral chest tubes, trauma laparotomy. ANESTHESIA: General. COMPLICATIONS: Death. Charles Bechtel is a 40-ish-year-old male who was involved in a motor vehicle crash. He presented to the Emergency Department with severe shock and hypotension. He was orally intubated, and had decreased breath sounds on the left chest. A left chest tube was placed, with return of SOOcc of fresh blood. Large bore intravenous access was achieved in both subclavian veins and agressive fluid resuscitation was initiated. The patient then lost his pulses, and a left anterolateral thoracotomy was performed in the trauma bay. There was a large amount of blood in his left hemithorax. His pericardium was incised, and no intrapericardial injury was noted. His aorta was identified, noted to be empty, and a crossclamp was applied. The patient's heart was empty and beating; open cardiac massage was initiated. The patient was also given medications for cardiac resuscitation per ACLS protocol. A blood pressure was achieved with placement of the aortic crossclamp. A diagnostic peritoneal lavage was performed which was grossly positive. The patient was taken emergently to the operating room. The patient's abdomen and chest were prepped and draped emergently. Attention was first directed at his thoracotomy site. The aortic crossclamp was confirmed to be in good position. The patient required additional resuscitation fluid and continuous open cardiac massage. The patient's abdomen was then opened through a generous midline inc$sion. There was gross blood in the abdomen in the upper quadrants, and a splenic laceration as well as a central hematoma were identified. Multiple packs were placed and hemostasis was achieved in the abdomen. The patient Printed by: Duzick, Bonnie L Page 1 of 2 Printed on: 1/15/2003 9:17 PM (Continued) Surg Op Note SECHTEL, VHARLES - 1278505 deteriorated to agonal fibrillation. Attempts were made to shock the patient out of this rhythm, but were unsuccessful. Decision was made then to cease the resuscitation and the patient was pronounced dead at 1:07 p.m. #398202 DICTATING NID: ATTENDING Nm: James Ku, NID Department of Surgery/General Surgery F~~~.7~:~~'t~ JK/dek D: 11/11/2002 T: 11/12/2002 07:45 JAN 2 2 2003 RECEiwED c: PCR Word Processing Clerk Surgical Fees Printed by: Duzick, Bonnie L Page 2 of 2 Printed on: 1/15/2003 9:17 PM (End of Report} Surg D/C Summary BECHTEL, c;HARLES - 1278505 * Final Report * DISCHARGE SIIMMARY PATIENT NAME: BECHTEL, CHARLES PATIENT NIIDffiER: 1278505 LOCATION: SEX: M ADMITTING PHYSICIAN: James Ku, M.D. OPERATIONS OR PROCEDURES PERFORMED: 1. Tube thoracostomy. 2. Deep peritoneal lavage. 3. ED resuscitative thoracotomy. 4. Open chest cardiac massage. DATE ADMITTED: 11/11/2002 DATE DISCHARGSD: 11/11/2002 DATE OF BIRTH: 07/26/1960 ~,~~~~y,'~~~~~ JAN 2 2 2003 RE~EiVED BRIEF HISTORY: The patient is a 42-year-old gentleman reported to be a driver in MVC involved in a high speed head-on collision with a significant entrapment of greater than 30 minutes, initially found to be unresponsive in the field. The patient was intubated, initially found to have heart rate in the 140s with a palpable blood pressure only. of 120s. The patient arrived to the Hershey Medical Center Trauma Bay for further evaluation and resuscitation. HOSPITAL COURSE: The patient was found to have lost his vital signs shortly after tube thoracostomy with significant drainage from the left chest. Simultaneous ED thoracotomy and deep peritoneal lavage were performed with return of gross blood on the DPL. Additional chest tube was placed on the patient's right side while the thoracotomy was being undertaken as well as a placed in the left chest. The aorta was cross-clamped. The patient was taken to the OR. Simultaneous exploratory laparotomy was performed while further exploration of the chest was performed. Shortly after exploration of the chest began, the patient's heart was noted to be in ventricular fibrillation, unable to be cardioverted despite attempts with direct defibrillation. The patient was therefore pronounced dead in the operating room at 1307 hours. Further exploration of the chest revealed a large defect in the isthmus of the aorta consistent with traumatic aortic rupture. #438472 DICTATING MD: Robert G Strange, Jr., MD ATTENDING MD: Printed by: Duzick, Bonnie L Page 1 of 2 Printed on: 1/15/2003 9:17 PM (Continued) Surg D/C Summary BECHTEL, CHARLES - 1278505 James Ku, MD Department of Surgery/General Surgery RGS/dts D: 12/23/2002 T: 12/24/2002 12:10 c: WP Clerk F~n~~~~n JAN 2 2 2603 RECEIVED Printed by: Duzick, Bonnie ~ Page 2 of 2 Printed on: 1/15/2003 9:17 PM (End of Report) Patient: BECHTEL, CHARLES Flowsheet Print Request Printed by: Duzick, Bonnie l MRN: 1278505 Last 120 Results Printed on: 1/15/2003 9:18 PM EVENTS 11/11/2002 1:10 PM 11/11/2002 1:00 PM 11/11!2002 12:22 PM 11/11/2002 12:20 PM 11/11/2002 12:00 AM U Na, wb 177 H LS K, wb 7.1 ' H J Cret 0.9 V Ion Ca, wb 1.09 L 'V WBC 4.4 L L1 Hgb 8.1 L ~ U Hct 25.5 L V RBC 2.56 L 't.! MCV 99.6 H ~ IJ MCHC 31.8 L L! MCH 31.6 '?_,t RDW 13.2 V Plts 101 L L} MPV :..~ 9.4 I iJ pH(a) 7.309 ' L iJ pC02(a} 113.8 H V p02(a) 34.7 L tJ HC03(a) 55.9 H iL1 Base XS(a) 25.1 , t~ Sa02(a) 68.1 L t.[ Temp(a) 36.0 !tJ FI02(a) 100 Hgb(a) 9.8 L !;~ ALT 30 't1 Amylase ... 68 U Troponin-1 ... 1.4 a1 EtOH med :. . <10 'ABO/Rh - ABO/Rh 'ABO Recheck ABO Rech... Antibody Scr NEGATIVE Spec Expires 11/14/2002 11/14/2002 ~ R Number R79667 R79667 j Component Type RED CELLS RED CELLS !~ # Units 12 12 BB Comments MASSIVE ... Head/Neck/Spine Spine XR (... Chest CXR (1-vie... Pelvis/GU Pelvis XR ... JAN 2 2 2003 R~~E~v~~ Page 1 Patient: BECHTEL, CHARLES Flowsheet Print Request Printed by: Duzick, Bonnie l MRN: 1278505 Last 120 Results Printed on: 1/15/2003 9:18 PM EVEI~F'S~= ,'titE1.112©02 11/1.1121)02 11/1<tf20t}Z ~''~1xtf~?M,, 1:Ot~~PRit ; 12:22 PM 11/11/2002 11/11t2002x_~- 12:20 PM 12:0QAFh_, ED Summary ' ""' y ED Summary .Sung D/C Summary; Surg D/C S... •. -. •- 'Surg Op Note ~ Surg Op Note -..- ED Note '',,"' ED Transp... ', Spirkual CareNote - ' JAN 2 2 2003 R~C~iV~CD Page 2 Insurance Companies State Far m CERTIFICATE OF COVERAGE Claim Number: 38-K061-150 The undersigned is a Claim Team Manager for: State Farm County Mutual Insurance Company of Texas St to Farm Lloyds, Inc. ~te Farm Indemnity Company State Farm Mutual Automobile Insurance Company State Farm Fire and Casualty Company STATE FAR M INSYRANC© State Farm Insurance 115 Limekiln Road PO Box 257 New Cumberland PA 17070-0257 This certifies that policy number 6632-278-38I 003, covering a 1994 Ford E350, was issued to Edwin D. Watts and was in effect on the accident date of November 11, 2002. The coverages and limits of liability for this policy on that date were: A 50/100/50,02 10,000,D100,G500,U-BI 15/30,F 2500, W 15/30,2. This policy provides full tort. / K~ e Bur Clam Team Manager State of PENNSYLVANIA ss . County of YORK Subscribed and sworn to before me this I day of , (Year) Notary Public My Commission Expires: ~a~TJ~~{t,~+~ ~~~'s~ .° -. ,.e ~„„~t~ a PL.i.t'y State Farm Mutual Automobile Insurance Company HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 led ttARRI$BUR~' Page : 1 Document Name : t _ MAR 13 03 - M~-Ri~ ~ 2003 CMSD0627 /CMSM0 627 P A C M A N OPID: TLD0009 AGY CLAIM POL COVERAGE TERMID: VT60~~~ 6033845 INSD: COSNER, C HRISTINA R POL: DOL NOV 11 02 PA-CASCPA-BRN- CLM: 029176842 OPEN REP: T DESMARAIS EFF DT: JVL 31 02 EXPR DT: JUL 31 03 CO* 05 3T* PA VEHICLE YR: 98 MARE* FORD MODEL: NINDSTAR NAE VIN: 2EMZA5146WBC68265 LN/COV/LIM COVERAGE DESC LIMITS / CpI~NTS 191908 RBI $100,000 EACH PERSON-$300,000 EACH ACCIDENT 198931 UM $100,000 EACH PERSON-$300,000 EACH ACCIDENT NON-STACKED 199031 UIM $100,000 EACH PERSON-$300,000 EACH ACCIDENT NON-STACKED 200105 PD $50,000 EACH ACCIDENT NO DEDUCTIBLE 210104 COMP ACV LESS $100 DEDUCTIBLE 210304 COLL ACV LESS $250 DEDUCTIBLE 211450 RENTAL $20 PER DAY $600 MAXIMUM DC912665 FIRST PAGE CObIIKAND : ATCHMT F10=CIMPOLI F11=PROD3EL F13~LM.SUM * Date: 3/13/03 Time: 7:15:02 AM State Farm December 24, 2002 Insurance Companies Wendy J. Bechtel 526 Rittenhouse Square Mechanicsburg, PA 17050 RE: Claim Number: Date of Loss: Our Insured: 38-K061-150 November 11, 2002 Edwin D. Watts Dear Mrs. Bechtel: STATE fAtM iNSUtwNC~ State Farm Insurance 1 15 Limekiln Road PO Box 257 New Cumberland PA 17070-0257 This letter is to confirm the telephone conversation Iclaam for your father regarding settlement of the bodily injury the estate of your husband. State Farm is willing to make an offer of $50,000 which is the policy limits for our insuend'of auto policy. As you recall, we have already issued paym $8,011.50 to the funeral home on your behent•issuedamolnt will need to be subtracted from the final paym roved before addition, this settlement will need to be court app payments can bereviewdthisloffercorlifeyouchaveuany questions opportunity to regarding this matter. Sincerely, Linda Koch Claim Representative (717) 774-9015 State Farm Mutual Automobile Insurance Company HOME OFFICES: BLOOMINGTON, ILLINOIS 61 7 1 0-0001 ~IARRISBUR6 MAR 14 2003 RECEIYi:O December 18, 2002 Wendy Bechtel 526 Rittenhouse Square Mechanicsburg, PA 1700 Insured Christina Cosner Claim No 029176842 Date of Loss 11/11/02 Claimant Charles Bechtel, deceased Please be advised that Progressive Companies is tendering our insured's policy limits of $100,000 in settlement of Charles Bechtel's bodily injury claim. Enclosed is a copy of the computer printout indicating that the amount of bodily injury limits available is $100,000 per person and $300,000 per accident under Progressive policy number 60338454-3. Please be advised that this settlement o$'er is contingent upon our receiving a full release of our insured, consent to settle and waiver of subrogation from your Underinsured Motorist Carrier, and a court approval, as discussed. Should you have any questions, please contact the undersigned at 717 791-5151. Progressive Northern Insurance, 7~eddie .C'. Deca Tyeddie L. Desmarais Casualty Representative enclosure N ~y ~u - FEe 2 6 20 03 RECEtV~ 1137A KENNEBEC DRIVE * CHAMBERSBURG, PA 17201 February 25, 2003 Wendy Bechtel 526 Rittenhouse Square Mechanicsburg, PA 17050 OUR INSURED : Bechtel OUR CLAIM NUMBER DATE OF ACCIDENT Dear Mrs. Bechtel: 58 37 D 499314 11112002 O1 11-11-2002 Based on the information that we have secured, Nationwide is electing to waive our subrogation rights. Please accept this letter as our consent to settle the bodily injury claim against Edwin Watts and Howard Cosner: Kindly forward a copy of the executed releases provided to State Farm and Progressive when that is resolved. Thank you for your attention to this matter. NATIONWIDE MUTUAL INSURANCE COMPANY Annette Long Claims Department (717)263-7965 cc: State Farm Insurance Company Attn: Linda Koch P O Box 257 New Cumberland, PA 17070 Progressive Insurance Company Attn: Tyeddie Desmarais 5053 Ritter Road, Suite 101 Mechanicsburg, PA 17055 Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or 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 a person to criminal and civil penalties. ouo -ooo~o=-oi VERIFICATION I, Wendy J. Bechtel, as surviving spouse of Charles R. Bechtel, and as Administrator of the Estate of Charles R. Bechtel, hereby verify that the facts contained in the foregoing Petition to Approve Settlement and Compromise of Wrongful Death and Survival Actions is true and correct to the best of my knowledge, information and belief. I understand that false statements herein are subject to the penalties of 18 Pa.C.S.A. §4904 relating to unsworn falsification to authorities. Wendy J. Bec tel a surviving spouse of Charles R. Bechtel, and a Administrator of the Estate of Charles R. Bechtel Date: y 2S 63 CERTIFICATE OF SERVICE I do hereby certify that I have served a true and correct copy of the foregoing Petition to Approve Settlement and Compromise of Wrongful Death and Survival Actions by placing the same in the United States Mail, first class, postage prepaid, at Harrisburg, Pennsylvania, addressed as follows: Brigid Q. Alford, Esquire Boswell, Tintner, Piccola & Wickersham 315 North Front Street Post Office Box 741 Harrisburg, PA 17108-0741 Attorney for Howard Cosner and Edwin Watts By: Date: ~ ~ SWARTZ CAMPBELL, LLC By: Andrew G. Cassidy, Esquire Attorney I.D.: 81259 One South Church Street, Suite 400 Attorneys for Petitioner West Chester PA 19382 Nationwide Mutual Ins. Co. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA ORPHAN'S COURT DIVISION IN RE: ESTATE OF CHARLES R. No: 2002-01031 BECHTEL, JR. JOINDER AND ACCEPTANCE OF SERVICE I, ~'~Iendy Bechtel, indiTJid;zally and as Ad~inistratri~ of the Estate of Charles R. Bechtel, do hereby join together in the SUPPLEMENTAL PETITION OF NATIONWIDE MUTUAL INSURANCE COMPANY TO APPROVE SETTLEMENT AND COMPROMISE OF AN UNDERINSURED MOTORIST CLAIM ARISING FROM THE WRONGFUL DEATH AND SURVIVAL ACTIONS OF CHARLES R. BECHTEL, DECEDENT ,and hereby accept and acknowledge service of said petition. Date: ~ , , `' ~~ `_" Wendy Becht~l _ ~, ~.~; ~,. ~~ ~~. SWARTZ CAMPBELL LLC ATTORNEYS AT LAW ONE SOUTH CHURCH STREET SUITE 400 WEST CHESTER, PA 19382 SWAR,TZ CAMPBELL, LLC By: Andrew G. Cassidy, Esquire Attorney I.D.: 81259 One South Church Street, Suite 400 Attorneys for Petitioner West Chester PA 19382 Nationwide Mutual Ins. Co. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA ORPHAN'S COURT DIVISION IN RE: ESTATE OF CHARLES R. No: 2002-01031 BECHTEL, JR. PETITION OF NATIONWIDE MUTUAL INSURANCE COMPANY TO APPROVE SETTLEMENT AND COMPROMISE OF AN UNDERINSURED MOTORIST CLAIM ARISING FROM THE WRONGFUL DEATH AND SURVIVAL ACTIONS OF CHARLES R. BECHTEL, DECEDENT COMES NOW, Nationwide Mutual Insurance Company, the underinsured motorist carrier for Brenda Lentz and Peter Lentz, hereby moves this Honorable Court for Order approving an underinsured motorist settlements reached in the above captioned matter on behalf of the Estate of Charles R. Becktel, and in support thereof avers as follows: 1. Petitioner Nationwide Insurance Company (hereinafter "Nationwide")is an Ohio corporation licensed to and doing business at 1137 A. Kennebec Drive, Chambersburg PA 17201. 2. Respondent Wendy J. Bechtel is an adult individual residing at 526 Rittenhouse Square, Mechanicsburg, PA 17050. 3. Nationwide hereby incorporates, by reference, the Petition To Approve Settlement And Compromise of Wrongful Death An Survival Actions previously filed on behalf of Wendy J. Bechtel as if same were fully set forth herein at length. 4. At the time of his death, Charles R. Bechtel (and his spouse Wendy J. Bechtel) had an automobile insurance policy issued by Nationwide under a policy numbered 58 37 D 499 314 444990. Attached hereto and marked as Exhibit "A" is a true and correct copy of the applicable Nationwide declarations page for the policy issued to Charles R. and Wendy J. Bechtel. SWARTZ CAMPBELL LLC ATTORN EVS AT LAW ONE SOUTH CHURCH STREET SUITE 400 WEST CHESTER, PA 19382 5. The Bechtel's policy insured two motor vehicles with stackable underinsured motorist coverage of $300,000.00 per vehicle. 6. Nationwide has offered Respondent Wendy Bechtel, individually and in her capacity as Adminstratrix of the Estate of Charles R. Bechtel, $350,000.00 to settle any and all underinsured motorist claims arising from the accident of November 11, 2002 and the death of Charles R. Bechtel. 7. The terms of the proposed settlement provide that Nationwide will pay Wendy Bechtel, individually and as Administratix of the Estate of Charles R. Bechtel $50,000.00 upon receipt of court approval of the settlement and execution of all necessary settlement documents. 8. In addition, the balance of the underinsured motorist settlement proceeds, $300,000.00, will be used to fund a structured settlement account which will pay Wendy Bechtel $1,494.00 per month, payable for life, guaranteed for 30 years, first payment being made on June 26, 2003 and the last guaranteed payment being made on May 26, 2003. Thereafter, continued monthly payments will be made for life. 9. The full terms of the underinsured motorist settlement are contained in the Release Agreement and Qualified Assignment, copies of which are attached hereto and marked as Exhibit "B". 10. It is further proposed that 100% of the settlement be allocated toward the Wrongful Death Action and a request from the Department of Revenue has been made to approve of this allocation. 11. Respondent Wendy Bechtel, individually and in her capacity as Administratrix of the Estate of Charles Bechtel, has agreed to the terms of the settlement offer made by Nationwide, pending court approval. SWARTZ CAMPBELL LLC ATTORNEYS AT LAW ONE SOUTH CHURCH STREET SUITE 400 WEST CHESTER, PA 19382 12. In addition, Respondent Wendy Bechtel, as the surviving spouse of Charles Bechtel, is entitled to the proceed so the wrongful death claim pursuant to 42 Pa. C.S. A. § 8301. WHEREFORE, Petitioner Nationwide Mutual Insurance Company respectfully requests that this Honorable Court approve the underinsured motorist settlement described above and the requested allocation between the wrongful death and survival actions. Respectfully sumbitted, SWARTZ CAMPBELL, LLC ~~~~ ~ ~ "LCLti-' ANDREW G. CASSIDY, ESQUIRE Attorney for Petitioner Nationwide Mutual Insurance Company SWARTZ CAMPBELL LLC ATTORNEYS AT LAW ONE SOUTH CHURCH STREET SUITE 400 WEST CHESTER, PA 19382 CERTIFICATE OF SERVICE I, Andrew G. Cassidy, Esquire, counsel for Petitioner, Nationwide Mutual Insurance Company, certify that I have caused true and correct copies of the foregoing Petition to be served by United States First Class Mail, postage prepaid, upon the following parties on the date below: Mrs. Wendy Bechtel 526 Rittenhouse Square Mechanicsburg, PA 17050 (Administratrix of the Estate of Charles R. Bechtel) Brigid Q. Alford, Esquire 315 North Front Street P.O. Box 741 Harrisburg, PA 17108-0741 Joseph Metz, Esquire 112 Market Street, 8th Floor Harrisburg, PA 17101 (Attorney for the Estate of Charles R. Bechtel) J1 ~ /`//~ ANDREW G. CASSIDY, ESQU E Attorney for Petitioner Nationwide Mutual Insurance Company Date: >a ~ ~- v~ SWARTZ CAMPBELL LLC ATTORNEYS AT LAW ONE SOUTH CHURCH STREET SUITE 400 WEST CHESTER, PA 19382 DEC 23 20P2 12 24 FR NAIIONWIDt h-,tu 1 ti~~ ~rz ~`°`' ~~ ~~'y'~"" "~ ~-- -- J. f. CENTURY it AUTO POLICY DECLARATIONS Pepe 1 of 3 These Declarations are a pan of the policy named abwo and Identified by policy number below. They supersede any Dedaratione Issued i~ elachYnsuredllvBhC le as IndlcetedBYoue poi cyll compiles with tha schedule of coverages. They apply barrage and Bodlty motortsta' financial reepon~fbllfty awa of your state only for vehicles for which Property Injury Liability coverages are provided. ppllCyh0lder: Policy Number: DB Account Number (Named Ineurad) 68 37 D 499314 444990 CHARLES R RAND WENDY J BECHpp~~TEL issued: 6tAN I~CSBURCiSEPAQ SEP 25, 2002 17060.1861 Policy Period From: SEP 09, 2002 to FEB 27, 2003 but only if the required premium for this pperiod has been paid and only (or stx month renewal ppeeriods ff renewal premiums have been paid as regt~lred. Thle policy Ie initiale~lodewlh chewer the time the application for Insurance Is completed, or (2) 12:01 a, m. on thq tlrst day o1 the poitcy p Is leedrhereln. This pollcygcancels apt 12 Otda.m at the address of the Harmed Insured stated herel~the named Insured sta I ~ IMPORTANT MESSAGES: I THE FOLLOWINt3 CHANGE(S) NAVE BEEN MADE TO YOUR POLICY: ~ EFFECTIVE SEP 09. 2002 .p~~lA qED RN~E AND/OR TADDRESS~ { = EFFECTIVE SEP 04, 2002 .CHANGED RESIDENTIAL TERRITORY i SEE ENCLOSED NOTICE FOR PREMII~I OETAIL p INSURED VEHICLE(S) & SCHEDULE OF COVERAGES 1. 18>i3 FORD T1F11P0 ID riFAPP38XOPK181760 S1x Month Coveraflea Llmlts Oi Llablltty Premium 100,000 EA~ OCCURRENCE S 75.60 PROPERTY DAMAGE LIABILITY 300,000 EA PERSON FlODILY INJURY LIABILITY 300,000 EACH OCCURRENCE $ 73.90 UNINSURED MOTORISTS-BODILY INJURY ENOOASEMENT 2367 300,000 EACH PERSON 300,000 EACH EN~DORSE~?AENT 2358 $ 6. SO UNDERINSURED MOTORISTS-BODILY INJURY ~ 300,000 EACH PERSON 300,000 EACH OCCURRENCE S 42.80 FIRST PARTY BENEFITS ~ $ 26.40 ri OPTION i-MEDICAL BENEFIT S 6,000 ~ LIMITED TORT TOTAL $ 225.50 r i~ ~_ tiii~ s !t s tt~ r .o ® '' t+q~ • E AUTO 71aaA FRAME: C 20 '• 4 I-'K f4HI IUIYWlLC ncu L vr-,v -,~~ v~~+.~ ~.. ~a~.,~•.. •••.••.. ~ --- -- DEC ~s ~~~~ 1~~~ Page 2 of 3 2 1884 MERC BABIE 138 ID afiMEUIE-QUOFU633010 Six Month Ccv~~Doo Llmita Ot Llablllty Pram(um COMPRE-LIENS I VE COLLISION A~UAL ~/~H VA(,UEi. ACTUAL CASH VALUE ESS S 600 41 .60 ~ 81.20 72 00 PROPERTY DAMALIE LIABILITY 3001LY INJURY LIABILITY 3100,000 A~ pRRENCE ~ 300;000 ~A(ai RRENCE . S $ 70.40 UNINSURED MOTORISTS-BODILY INJURY ~A~H RSEMENT 2367 11RRENCE 300, 000 EACH ~~~ S 6.80 UNDERINSURED MOTORISTS-(3001LY INJURY , ENDORSEMENT 2358 300,000 EA PERSON ~ $ 300, 000 E~+ E~jpORSD»IENT 2311 $ 41 .20 LOSS OF USE BROAD FORM 26 PER DAY ~ 800 PER ACCIDENT FIRST PARTY BENEFITS OPTION t•MEDICAL BENEFIT S 6,000 $ 19.70 LIMITED TORT TOTAL $ 345.70 INSURED DRIVERS: Drlver BIRh ~ D~t• Metltal Statu• LlCense Number ,v Namo 02 CHARLES BECHTEL 07%26/!30 AARRIE~D 8234866502660 APPLIED DISCOUNTS: i PASSIVE RESTRAINT SAFE DRIVER ACCIDENT FREE MULTI CAR Policy Form dr Endortemsrri~: AUTO 6000D 2248 2264A 2391 O-tlco UN: SEP 23. 2002 S 86.20- Is~uod ey: NATIOMMIDE MUTUAL INSURANCE CaMPANY 23787 CoumonlpnoCAt: HARRISBURQ, PA. 9y: JOHN T Home Ottlco - Columous, Ohlo MORITZ FRAME: N 2A D(_l.. ~~ L~U~ i ~' L~ 1 K 1 i~"'~ ~ 1 ~..~I~iW 1 :.~~ r:dU 1I'.I I~.G J (G C~J (~J 11..1 Jl f 1 f G~..J t (..J..i ~r i . c.-. c.... CENTURY 11 AUTO POLICY DECLARATIONS Pepe 3 of 3 Policy Nurnt»r: Pollo~h0ldsr: 58 37 D 49931 a (Named Insured) CHARLES R JR AND Issued: Policy Parlor! From: , SEP 26. 2002 3EP 09, 2002 to F® 27, 2003 Ld33 PAYABLE CLAUSE ENDOR8EMENT 0 A P Thle endorsement appiles to the t.:ompprenenen+e ana t:ansion caverdpes proviaea oy mis poncy. a protects mE~ lienholder Hamad In the pdicy Oeclaratlons. Peymeat for loss well tie made accordln to the Interest of the polcyholder and Ilenholder. Payment may be medo to both Jointly. or to ehhsr separately. Eger way, the company wpl protect the Interests of both. Tne Ilenhdder's Interest will tie protected, except from fraud or Omissions by the policyholder or the policyholder's representathro. II the comp ny cancels or retusee to renew the polCy, the Ilenhdder will receNe notice at least 10 days belora protection ohs Interest well end. The Ilenhdder shall no[tty tha company upon learnlnp d any change In awnerohip o1 the vehicle. To the extent of payment to the Ilenholder, thn company will be entftied to the Ilenholder'a rigMa of recovery. The endorsement Is Issued by the Nationwide Mutual Insurance Company or Nattonwlde Mutual Flre InsurancR Company, whichever het Issued the polcy to whfCh n Is attached. NATIONWIDE MUTUAL INSURANCE COMPANY 23787 HOME OFFICE: COLUMBU8, OHIO 43216.2220 Pr~~ld~n! ' - l~cnrr~ry ~ For OUESTIONB About Your Policy, Call Your NATIONWIDE AGENT : J. MORITZ 717-897-9489 For Heartnp Impaired: TTY t-eo0.8Z2-242t K.etlonwid• Replonal Otlice: 717-d67•dgo0 as~ so ones is ~^s tl• ti r..w n.w i tilt ti• tis a~ tttts t^^~ ... tttmt i li IMPORTANT PHONE NUMBERS Natlonwtd• T4-Hour Claims Number: 1-A4a-alt-9436 DEC 23 2002 12 ~ 24 FR NATIONWIDE Hbu 1 r~'d~ ~ ~ ~ ~" °-' ' ~ ~ l ' ` ` "'-' ' "", ~ ~ ~~ -- P _ e i acr-OY~IDi 1 tlJ. .- Policy Number= 58D499314 Named Insured: BECHTEL, CHARLES R A ent• JOHN T MORITZ County: CUMBERLAND g TART OpTZ4N6 PIOTICS TO ~NBVREDs NO`V'ICE TO NAMED YNSUR~DS A. "Limited Tort" Option - The Laws of the Commonwealth of Pennsylvania give you the right to choose a form of insurance that limits your right and the rights of members of your household to seek financial compensation for injuries caused by other drivers. Under this form of insurance, you and other household members covered under this policy may seek recovery for all medical and other out-of-pocket expenses, but not for pain and suffering ar other nonmonetary damages unless the injuries suffered fall within the definition of "serious injury" as set forth in the poesCy'The unless one of several other exceptions noted in the policy app annual premium for basic coverage as required by law this "limited tort's option is $ 784.20 Additional coverages under this option are available at additional cost. If you wish to choose the "limited tort" option described in paragraph A, you must sign this notice where indicated below and zeturn it. If you do not sign ar_d return this notice, you will be considered to have chosen the "full tort" coverage as described in paragraph B and you will be charged the "full tort" premium. I wish Co choose the "limited tort" option described in Paragraph A: _~C.r Date B. "Dull Tort" Option - The laws of the Commonwealth of Pennsylvania also give you the right to choose a form of insurance under which you maintain an unrestricted right for you and the members of your household to seek financial cor.~pensation fox injuries caused by other drivers. Under this form of insurance, you and other household membeze covered under this policy may seek recovery for all medical and other out-of-pocket expenses and may also seek Financial compensation for pain and suffering and other nonmonetary damages as a result of injuries caused by other drivers. The annual premium for basic coverage as required by law under this "full tort" option is $ 957.60 Additional coverages under this option are available at additional cost. If you wish to chose the "full tort" option described in paragraph B, you may sign this notice where indicated below and return it. However, if you do not sign and return this notice, you will be considered to have chosen the "full tort" coverage as described in paragraph B and you will be charged "full tort" premium. I wish to choose the "full tort" option described in paragraph ~: . Name Insured Date C. You may contact your insurance agent, broker or company to discuss the cost of other coveragee_ DEC 23 2x02 12 25 FK NH~1ur;wiLC ncu ~ ~~~ ~ ~ ~ ~.. •" -- - --- P.02 SEP-04-02 TUE 03:21 PM -•- policyholder Name HECHTEL, CHARLES R ~ Policy Number: 58D499314 Pennsylvania law reguill~ance9withginformation concerningpcertainlfirstrparty Applicant for auto ins fired informat~.on_ injury coveragesarefu11t1beforeHSigning.the officially reQu' Pleaea read it c Y IMPORTANT NOTICE INSURANCE COMpANZES OPERATING INCTH8EC~0 OL OWINGFBENEFITS S BAYOU, YOUROUR BY LAW TO MAR$ AVAILABLE FOR PUR HA SPOUSE OR OTfIBR RELATIVES OR MINERSLDN OC OP~~O~F YOUR MOTOR~VBHIOCLB OR ERSO 8 STRUCK BYNYpUR MOTOR yEHICLS:I UP TO AT LEAST $100.000. (1) bffiDICAL BgNEFIT3, (1'1) ~XTRAORDTNARY MEDIEALTOE OVIOR~YOUR RELATIVES REBIDINGOINOYOURTHOUgEHOLD) BSI~&FIT ONLY APPLI (2) INCOl~ L03S g$NEFITg~50p000,AT LEAST $2,500 PER MONTH UP TO A MAXIMUM BEN88IT OP AT LEAST $ , (31 ACCIDL'NTAL DEATH BENEFITS, VP TO AT LEAST $25,000. (q) FUNERAL BENEFITS, $2.500. (2) ~ (3) AND (~) , A COMBINATION (5 ) ~ AN p~i,TERNATIVg TO PARAGRAPHS (1) , BENEFIT UP TO AT L~AYEAR37FR~IO+~OTHE Dp~EFOFSTHE ACCIDENT~GWFIICHL'VE~CCURS PAYABLE IIP TO TIiRB FIRST, SUBTECON g~ti-g~LMBENEFITCOBDS~500DEATH aENEFIT OF UP TO $25, AND A LIMI (6) UNINSURED, ~,TpggINgVRED AND BODILY INJURY LIABILITY COVERAGE UP TO AT LEAST $100.000 BECAb3E OF INJURY TO ONS PERSON IN ANY ONE ACCIDENT AND UP TO AT LEAST $300,000 BECAQBT OF INJURY TO TAJO OR MORE PERSONS IN ANY ONE ACCIDENT OR, AT THE OPTION OF THE INSURER, UP TO AT LEAST $300,000 xN A 3INdLE LIMIT FOR THESE COVERAGES, TXCEPT BoR POLICIES UNDER THE ASSIGNED RISK PLAN. ALSO, AT LEAST $5000 FOR DAMAGE TO PROPERTY OF OTHERS IN ANY ONS ACCIDENT. ADDITIONALLY, II3SURER5 MAY OFFER HIGHER BENEFITS LEVELS THAN TH03S ENIIMERATBD ABOVE AS WELI, A5 ADDITIONAL BENEFITS. H04JEVER, AN INSURED MAY ELECT TO PURCHASE LOWER BENEFIT LEVELS THAN THOSE ENIIMERP-TED A$ovE. YOUR gIQNATURE ON TSIS NOTICE OR YOUR PAYMENT OF ANY RENEWAL PREMIUM EVIDENCES YOUR ACTUAL KN~LLD~ T8E B DNEFITg~ANDGLIbSIT8EY0U xAVEZ$ELECTSDTHEBE BgN$81Z'S AND LIMITS A3 IF YOU HAVE ANY QUESTIONS OR DO NOT UNDERSTAND ALL OF THE VARIOUS OPTIONS AYAILASLS TO YOU, CONTI~CT YOUR AGENT OR COMPANY. IF YOII DO NOT T,TNDER3TAND ANY OF TH8 PROVISIONS CONTAINED IN THIS NOTIC£, C02QTACT YOUR AGENT OR COMBANY BEFORE YOII 5YQ2t. Your aignatu ackn ledges you ve receivad and read this IM` RTANT 2dbTICE. .~ ~ • Signature o Po cyhol App icant Date we urge you to keep this notioe as part of your auto insurance records. You may want to refer to this information at same future time. SAMPLE RELEASE AGREEMENT This Release Agreement ("Agreement") is entered into among Wendy J. Bechtel, individually and as the Administratrix of the Estate of Charles R. Bechtel, Deceased; and Nationwide Mutual Insurance Company (hereinafter collectively referred to as "the Parties"). The "Insured" shall collectively mean Wendy J. Bechtel, individually and as the Administratrix of the Estate of Charles R. Bechtel, Deceased, their respective heirs, executors, administrators, personal representatives, successors and assigns; and the "Insurance Company" shall mean Nationwide Mutual Insurance Company, its successors and assigns. I. RECITALS A. On or about November 11, 2002, at or near the intersection of Route 114 and Bent Creek Road, Mechanicsburg, Pennsylvania, Charles R. Bechtel sustained personal injuries and died as a result of an automobile accident (hereinafter referred to as the "Occurrence"). In connection with the Occurrence, the Insured has asserted a claim against Nationwide Mutual Insurance Company. B. The parties desire to enter into this Agreement to provide, among other things, for certain payments in full settlement and discharge of all claims and actions of the Insured for damages arising out of or due to the Occurrence, on the terms and conditions set forth herein. NOW THEREFORE, it is hereby agreed as follows: II. UNDERINSURED MOTORIST RELEASE AGREEMENT Know all men by these presents: That, for sole consideration of the cash payment(s) referred to in Paragraph IV.A, the receipt of which is hereby acknowledged, and the promise to make the periodic payments referred to in Paragraphs IV.B.(1) and (2) from the Insurance Company, the Insured in his/her capacity as an insured does hereby forever release and discharge the Insurance Company of and from all claims of whatsoever kind and nature prior to and including the date hereof growing out of the Underinsured Motorist Coverage of an Automobile Insurance Policy number 5837 D 499314 issued by the Insurance Company to Charles R. Bechtel and Wendy J. Bechtel, and resulting from the Occurrence. III. INJURIES KNOWN AND UNKNOWN The Insured acknowledges that the consideration received under this Agreement is intended to and does release and discharge the Insurance Company for any claims for, or consequences arising from, such injuries and the Occurrence; and the Insured hereby waives any rights to assert in the future any claims not now known or suspected even though, if such claims were known, such knowledge would materially affect the terms of this Agreement. 2 IV. PAYMENTS TO INSURED A. Cash at Settlement (and Amounts Previously Paid). The Insurance Company has paid Fifty Thousand Dollars ($50,000) to the Insured, receipt of which is hereby acknowledged. This includes, but is not limited to, all out of pocket expenses, attorney fees, all medical liens, all rights of recovery, all medical subrogation claims, all worker compensation subrogation claims, known and unknown, and claims for general damages. B. Periodic Payments. The Insurance Company hereby agrees to pay, or cause to be paid, the following periodic payments to Wendy J. Bechtel: (1) The sum of One Thousand Four Hundred Ninety Four Dollars ($1,494) to be paid on or about the twenty-sixth (26~') day of each month beginning on or about June 26, 2003, and continuing for the life of Wendy J. Bechtel. The aforesaid payments are guaranteed to be paid for a period of three hundred sixty (360) months, with the last guaranteed payment to be made on or about May 26, 2033. (2) Should Wendy J. Bechtel die before May 26, 2033, then any remaining guaranteed payments set forth in Paragraph IV.B.(1) shall instead be paid, as they become due, equally to Michael Charles Bechtel and Toni Marie Bechtel, or the survivor, with the last guaranteed payment to be made on or about May 26, 2033. Should Michael Charles Bechtel and Toni Marie Bechtel both 3 die before the remaining guaranteed payments are made as set forth in Paragraph IV.B.(1), then all remaining guaranteed payments will be made, as they come due, to the estate of the last to die of Wendy J. Bechtel, Michael Charles Bechtel and Toni Marie Bechtel, with the last payment to be made on or about May 26, 2033. Should Wendy J. Bechtel die after May 26, 2033 then monthly payments as set forth in Paragraph IV.B.(1) shall cease. (3) Wendy J. Bechtel shall have the right to submit a request to change the Beneficiary by filing a written request with the owner of the annuity. This request will be reviewed by the owner of the annuity, and if approved by the owner of the annuity and the issuing annuity company it will become effective. Said request will be made in writing by Wendy J. Bechtel. C. Nature of Payments. All sums set forth in this Paragraph IV constitute damages on account of personal injuries or sickness, arising from the Occurrence, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. V. FINANCING OF PERIODIC PAYMENT OBLIGATION A. Assignment of Obli aq tion. It is understood and agreed by and between the parties hereto that the Insurance Company may, as a matter of right and in its sole discretion, assign its duties and obligations to make such future payments as set forth in 4 Paragraphs IV.B.(1) and (2) to Metropolitan Insurance and Annuity Company pursuant to a "Qualified Assignment and Release Agreement," within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as amended, in the form attached hereto as Exhibit A. Such assignment is hereby accepted by the Insured without right of rejection and in full discharge and release of the duties and obligations of the Insurance Company and all parties released by this Agreement with respect to such future payments. If the Insurance Company assigns the duties and obligations as provided herein, it is understood and agreed by and between the parties that Metropolitan Insurance and Annuity Company, as the assignee, shall make said future payments directly to the respective payees designated in Paragraphs IV.B.(1) and (2). THE PARTIES HERETO EXPRESSLY UNDERSTAND AND AGREE THAT WHEN AN ASSIGNMENT OF THE DUTIES AND OBLIGATIONS TO MAKE SAID FUTURE PAYMENTS IS MADE BY THE INSURANCE COMPANY TO METROPOLITAN INSURANCE AND ANNUITY COMPANY PURSUANT TO THIS AGREEMENT, ALL OF THE DUTIES AND RESPONSIBILITIES OTHERWISE IMPOSED UPON THE INSURANCE COMPANY BY THIS AGREEMENT WITH RESPECT TO SUCH FUTURE PAYMENTS SHALL CEASE, AND INSTEAD BE BINDING SOLELY UPON METROPOLITAN INSURANCE AND ANNUITY COMPANY IT IS FURTHER UNDERSTOOD AND AGREED THAT WHEN AN ASSIGNMENT IS MADE, THE INSURANCE COMPANY SHALL BE RELEASED FROM ALL OBLIGATIONS TO MAKE SUCH FUTURE PAYMENTS AND METROPOLITAN INSURANCE AND ANNUITY 5 COMPANY SHALL AT ALL TIMES REMAIN DIRECTLY AND SOLELY RESPONSIBLE FOR, AND SHALL RECEIVE CREDIT FOR, THE FUTURE PAYMENTS. IT IS FURTHER UNDERSTOOD AND AGREED THAT WHEN AN ASSIGNMENT IS MADE, METROPOLITAN INSURANCE AND ANNUITY COMPANY ASSUMES THE DUTIES AND RESPONSIBILITIES OF THE INSURANCE COMPANY WITH RESPECT TO SUCH FUTURE PAYMENTS. B. Third Party Payment. It is further understood and agreed by the parties that all future payments as set forth in Paragraphs IV.B.(1) and (2) may, solely at the option of the Insurance Company, or its assignee, Metropolitan Insurance And Annuity Company, be financed by the purchase of an Annuity Contract from Metropolitan Life Insurance Company (the "Annuity Contract"). When such an Annuity Contract is purchased, the assignee, Metropolitan Insurance And Annuity Company shall be the owner of the Annuity Contract and shall have and retain all rights of ownership in the Annuity Contract. For its own convenience, the assignee shall direct Metropolitan Life Insurance Company to make all periodic payments directly to the respective payees designated in Paragraphs IV.B.(1) and (2). Such payments will be applied against the obligation of the Insurance Company or its assignee and shall operate as a pro tanto discharge of the scheduled obligations set forth in this Agreement. C. Status of Insured. The Insured shall, at all times, remain a general creditor of the Insurance Company or its assignee and shall have no rights in the Annuity Contract 6 nor in any other assets of the assignee. The Insurance Company or its assignee shall not be required to set aside sufficient assets or secure its obligation to the Insured in any manner whatsoever. The Insured acknowledges that the Insured has no right to receive the present value of the payments due the Insured pursuant to Paragraphs IV.B.(1) and (2), or to control the investment of, or accelerate, defer, increase or decrease the amount of any payment required to be made to the Insured. The Insured shall only be entitled to receive the payments specified in Paragraphs IV.B.(1) and (2), as they are due. D. Date of Birth. Wendy J. Bechtel hereby warrants and represents that she was born on December 26, 1957. Notwithstanding anything to the contrary herein, if the actual date of birth is not as stated above, and if the Insurance Company or its assignee relies or has relied to its detriment on the accuracy of the above-stated date of birth, the Insurance Company or its assignee may adjust the amount and/or timing of the remaining periodic payments so that no additional cost than that necessary to purchase the Annuity Contract is incurred by the Insurance Company or its assignee. VI. NO CHANGES IN FUTURE PAYMENTS Neither the Insured, his/her estate, nor any subsequent beneficiary or recipient of any payments or any part of any payments under this Agreement, shall have the right to, and may otherwise be prohibited or restricted under applicable law to accelerate, commute, or otherwise reduce to present value or to a lump sum any of the payments or any part of any payments due under this Agreement. Neither the Insured, his/her estate, nor any subsequent beneficiary or recipient shall have the right to transfer, assign, anticipate, mortgage, or otherwise encumber in advance any payments or any part of any payments due under this Agreement. Any transfer of the periodic payments by the Insured may subject the Insured to serious adverse tax consequences. VII. ADEQUATE CONSIDERATION The Insured agrees and acknowledges that the Insured accepts payment of the sums that the Insured is to receive pursuant to this Agreement as a full, complete, final and binding compromise of matters involving disputed issues regardless of whether too much or too little may have been paid. VIII. ENTIRE AGREEMENT This Agreement contains the entire agreement between the Insured and the Insurance Company with regard to the matters set forth herein. There are no other understandings or agreements, verbal or otherwise, in relation thereto, between the parties except as herein expressly set forth. 8 IX. READING OF AGREEMENT In entering into this Agreement, the Insured represents that the Insured has completely read all terms hereof and that such terms are fully understood and voluntarily accepted by the Insured. X. FUTURE COOPERATION All parties agree to cooperate fully, to execute any and all supplementary documents and to take all additional actions that may be necessary or appropriate to give full force and effect to the terms and intent of this Agreement which are not inconsistent with its terms. XI. DRAFTING OF DOCUMENT AND RELIANCE BY INSURED This Agreement has been negotiated by the respective parties. The Insured warrants, represents and agrees that the Insured is not relying on the advice of the Insurance Company, or anyone associated with them as to the legal and income tax or other consequences of any kind arising out of this Agreement. Accordingly, the Insured hereby releases and holds harmless the Insurance Company, and any and all counsel or consultants for them from any claim, cause of action or other rights of any kind which Insured may assert because the legal, income tax or other consequences of this Agreement are other than those anticipated by the Insured. 9 The undersigned, and each of them, warrant and represent that no promise, inducement or agreement not herein expressed has been made to them and that this Agreement constitutes the entire agreement between the parties hereto and that the terms of this Agreement are contractual and not mere recitals. The undersigned, and each of them, have read the foregoing Agreement and fully understand it, and are aware of the propriety and legal effect of executing the same, and neither the Agreement nor the compromise and settlement recited herein were induced by fraud, coercion, compulsion or mistake, nor is this Agreement nor the compromise and settlement made by the undersigned in reliance upon any statement or representation of any of the parties hereby released, or their representatives, agents or attorneys. XII. COURT APPROVAL The Parties agree that the Insured will file petitions for all necessary court approvals, that all such petitions and orders shall be in a form satisfactory to all Parties, and that this Agreement will not be effective until such approvals have been obtained. io XIII. CONTROLLING LAW This Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. Dated: Dated: Wendy J. Bechtel, individually and as the Administratrix of the Estate of Charles R. Bechtel, Deceased, Insured Duly Authorized Representative for Nationwide Mutual Insurance Company APPLICABLE TO PENNSYLVANIA ONLY: For your protection, Pennsylvania requires the following to appear on this form: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or 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. 11 Exhibit A Uniform Qualified Assignment and Release "Claimant" Wendy J. Bechtel "Assignor" Nationwide Mutual Insurance Company "Assignee" Metropolitan Insurance and Annuity Company "Annuity Issuer" Metropolitan Life Insurance Company "Effective Date" This Agreement is made and entered into by and between the parties hereto as of the Effective Date with reference to the following facts: A. Claimant has executed a settlement agreement or release dated , 2003 (the "Settlement Agreement") that provides for the Assignor to make certain periodic payments to or for the benefit of the Claimant as stated in Addendum No.1 (the "Periodic Payments"); and B. The parties desire to effect a "qualified assignment" within the meaning and subject to the conditions of Section 130(c) of the Internal Revenue Code of 1986 (the "Code"). NOW, THEREFORE, in consideration of the foregoing and other good and valuable consideration, the parties agree as follows: The Assignor hereby assigns and the Assignee hereby assumes all of the Assignor's liability to make the Periodic Payments. The Assignee assumes no liability to make any payment not specified in Addendum No. 1. 2. The Periodic Payments constitute damages on account of personal injury or sickness in a case involving physical injury or physical sickness within the meaning of Sections 104(a)(2) and 130(c) of the Code. 3. The Assignee's liability to make the Periodic Payments is no greater than that of the Assignor immediately preceding this Agreement. Assignee is not required to set aside specific assets to secure the Periodic Payments. The Claimant has no rights against the Assignee greater than a general creditor. None of the Periodic Payments may be accelerated, deferred, increased or decreased and may not be anticipated, sold, assigned or encumbered. 4. The obligation assumed by Assignee with respect to any required payment shall be discharged upon the mailing on or before the due date of a valid check in the amount specified to the address of record. 5. This Agreement shall be governed by and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. 6. The Assignee may fund the Periodic Payments by purchasing a "qualified funding asset" within the meaning of Section 130(d) of the Code in the form of an annuity contract issued by the Annuity Issuer. All rights of ownership and control of such annuity contract shall be and remain vested in the Assignee exclusively. 7. The Assignee may have the Annuity Issuer send payments under any "qualified funding asset" purchased hereunder directly to the payee(s) specified in Addendum No. 1. Such direction of payments shall be solely for the Assignee's convenience and shall not provide the Claimant or any payee with any rights of ownership or control over the "qualified funding asset" or against the Annuity Issuer. 8. Assignee's liability to make the Periodic Payments shall continue without diminution regardless of any bankruptcy or insolvency of the Assignor. 9. In the event the Settlement Agreement is declared terminated by a court of law or in the event that Section 130(c) of the Code has not been satisfied, this Agreement shall terminate. The Assignee shall then assign ownership of any "qualified funding asset" purchased hereunder to Assignor, and Assignee's liability for the Periodic Payments shall terminate. 10. This Agreement shall be binding upon the 11. The Claimant hereby accepts Assignee's respective representatives, heirs, successors assumption of all liability for the Periodic and assigns of the Claimant, the Assignor and Payments and hereby releases the Assignor the Assignee and upon any person or entity that from all liability for the Periodic Payments. may assert any right hereunder or to any of the Periodic Payments. Assignor:Nationwide Mutual Insurance Company By: Authorized Representative Title Claimant: Wendy J. Bechtel Approved as to Form and Content: Assignee: Metropolitan Insurance and Annuity Company By: Authorized Representative Title By: n/a Claimant's Attorney Addendum No. 1 Description of Periodic Payments The following periodic payments to Wendy J. Bechtel: (1) The sum of One Thousand Four Hundred Ninety Four Dollars ($1,494) to be paid on or about the twenty-sixth (26th) day of each month beginning on or about June 26, 2003, and continuing for the life of Wendy J. Bechtel. The aforesaid payments are guaranteed to be paid for a period of three hundred sixty (360) months, with the last guaranteed payment to be made on or about May 26, 2033. (2) Should Wendy J. Bechtel die before May 26, 2033, then any remaining guaranteed payments set forth in paragraph (1) shall instead be paid, as they become due, equally to Michael Charles Bechtel and Toni Marie Bechtel, or the survivor, with the last guaranteed payment to be made on or about May 26, 2033. Should Michael Charles Bechtel and Toni Marie Bechtel both die before the remaining guaranteed payments are made as set forth in paragraph (1), then all remaining guaranteed payments will be made, as they come due, to the estate of the last to die of Wendy J. Bechtel, Michael Charles Bechtel and Toni Marie Bechtel, with the last payment to be made on or about May 26, 2033. Should Wendy J. Bechtel die after May 26, 2033 then monthly payments as set forth in paragraph (1) shall cease. (3) Wendy J. Bechtel shall have the right to submit a request to change the Beneficiary by filing a written request with the owner of the annuity. This request will be reviewed by the owner of the annuity, and if approved by the owner of the annuity and the issuing annuity company it will become effective. Said request will be made in writing by Wendy J. Bechtel. Initials Claimant: Wendy J. Bechtel Assignor: Nationwide Assignee: S vVARTZ CAMPBELL, LLC By: Andrew G. Cassidy, Esquire Attorney I.D.: 81259 One South Church Street, Suite 400 Attorneys for Petitioner West Chester PA 19382 Nationwide Mutual Ins. Co. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA ORPHAN'S COURT DIVISION IN RE: ESTATE OF CHARLES R. No: 2002-01031 BECHTEL, JR. SUPPLEMENTAL PETITION OF NATIONWIDE MUTUAL INSURANCE COMPANY TO APPROVE SETTLEMENT AND COMPROMISE OF AN UNDERINSURED MOTORIST CLAIM ARISING FROM THE WRONGFUL DEATH AND SURVIVAL ACTIONS OF CHARLES R. BECHTEL DECEDENT COMES NOW, Nationwide Mutual Insurance Company, the underinsured motorist carrier for decedent, Charles R. Bechtel, hereby moves this Honorable Court for Order approving an underinsured motorist settlement reached in the above captioned matter on behalf of the Estate of Charles R. Bechtel, and in support thereof avers as follows: 1. Petitioner Nationwide Insurance Company (hereinafter "Nationwide")hereby incorporates by reference its original Petition To Approve The Settlement And Compromise Of An Underinsured Motorist Claim Arising From The Wrongful Death And Survival Actions Of Charles R. Bechtel, Decedent, filed on or about May 16, 2003, as is same were fully set forth herein at length. 2. The terms of the original settlement between Nationwide and respondent Wendy Bechtel have been renegotiated and modified. 3. The terms of the new settlement, pending court approval, provide that Nationwide Mutual Insurance Company will pay the gross sum of $400,000.00 to settle any and all underinsured motorist claims arising from the accident of November 11, 2002 and the 1 SWARTZ CAMPBELL LLC ATTORNEYS AT LAW ONE SOUTH CHURCH STREET SUITE 400 WEST CHESTER, PA 19382 death of Charles R. Bechtel. 4. The settlement agreement provides that the settlement proceeds will be distributed as follows: a. $100,000.00 payable to Wendy Bechtel, individually and as Administratrix of the Estate of Charles R. Bechtel upon receipt of Court Approval and execution of all necessary settlement documents. b. The balance of the underinsured motorist settlement proceeds of $300,000.00 will be used to fund a structured settlement account which will pay Wendy Bechtel $1,494.00 per month, payable for life, guaranteed for 30 years, first payment being made on June 26, 2003 and the last guaranteed payment being made on May 26, 2033. Thereafter, continued monthly payments will be made for life. 5. The full terms of the updated underinsured motorist settlement are contained in the Release Agreement and Qualified Assignment, copies of which are attached hereto and marked as Exhibit "A". 6. It is, again, proposed that 100% of the settlement be allocated toward the Wrongful Death Action and a request from the Department of Revenue has been made to approve of this allocation. 7. Respondent Wendy Bechtel, individually and in her capacity as Administratrix of the Estate of Charles Bechtel, has agreed to the terms of the updated settlement offer made by Nationwide, pending court approval. 8. In addition, Respondent Wendy Bechtel, as the surviving spouse of Charles Bechtel, is entitled to the proceed of the wrongful death claim pursuant to 42 Pa. C.S. A. § 8301. WHEREFORE, Petitioner Nationwide Mutual Insurance Company respectfully requests that this Honorable Court approve the underinsured motorist settlement described above and the requested allocation between the wrongful death and survival actions. 2 SWARTZ CAMPBELL LLC ATTORNEYS AT LAW ONE SOUTH CHURCH STREET SUITE 400 WEST CHESTER, PA 19382 Respectfully submitted, SW Z CAMPB L, L c/ ANDREW G. CASSIDY, ES Attorney for Petitioner Nationwide Mutual Insurance Company SWARTZ CAMPBELL LLC ATTORNEYS AT LAW ONE SOUTH CHURCH STREET SUITE 400 WEST CHESTER, PA 19382 RELEASE AGREEMENT This Release Agreement ("Agreement") is entered into among Wendy J. Bechtel, individually and as the Administratrix of the Estate of Charles R. Bechtel, Deceased; and Nationwide Mutual Insurance Company (hereinafter collectively referred to as "the Parties"). The "Insured" shall collectively mean Wendy J. Bechtel, individually and as the Administratrix of the Estate of Charles R. Bechtel, Deceased, their respective heirs, executors, administrators, personal representatives, successors and assigns; and the "Insurance Company" shall mean Nationwide Mutual Insurance Company, its successors and assigns. I. RECITALS A. On or about November 11, 2002, at or near the intersection of Route 114 and Bent Creek Road, Mechanicsburg, Pennsylvania, Charles R. Bechtel sustained personal injuries and died as a result of an automobile accident (hereinafter referred to as the "Occurrence"). In connection with the Occurrence, the Insured has asserted a claim against Nationwide Mutual Insurance Company. B. The parties desire to enter into this Agreement to provide, among other things, for certain payments in full settlement and discharge of all claims and actions of the Insured for damages arising out of or due to the Occurrence, on the terms and conditions set forth herein. NOW THEREFORE, it is hereby agreed as follows: II. UNDERINSURED MOTORIST RELEASE AGREEMENT Know all men by these presents: That, for sole consideration of the cash payment(s) referred to in Paragraph IV.A, the receipt of which is hereby acknowledged, and the promise to make the periodic payments referred to in Paragraphs IV.B.(1) and (2) from the Insurance Company, the Insured in his/her capacity as an insured does hereby forever release and discharge the Insurance Company of and from all claims of whatsoever kind and nature prior to and including the date hereof growing out of the Underinsured Motorist Coverage of an Automobile Insurance Policy number 5837 D 499314 issued by the Insurance Company to Charles R. Bechtel and Wendy J. Bechtel, and resulting from the Occurrence. III. INJURIES KNOWN AND UNKNOWN The Insured acknowledges that the consideration received under this Agreement is intended to and does release and discharge the Insurance Company for any claims for, or consequences arising from, such injuries and the Occurrence; and the Insured hereby waives any rights to assert in the future any claims not now known or suspected even though, if such claims were known, such knowledge would materially affect the terms of this Agreement. 2 IV. PAYMENTS TO INSURED A. Cash at Settlement (and Amounts Previously Paid). The Insurance Company has paid One Hundred Thousand Dollars ($100,000) to the Insured, receipt of which is hereby acknowledged. This includes, but is not limited to, all out of pocket expenses, attorney fees, all medical liens, all rights of recovery, all medical subrogation claims, all worker compensation subrogation claims, known and unknown, and claims for general damages. B. Periodic Payments. The Insurance Company hereby agrees to pay, or cause to be paid, the following periodic payments to Wendy J. Bechtel: (1) The sum of One Thousand Four Hundred Ninety Four Dollars ($1,494) to be paid on or about the twenty-sixth (26th) day of each month beginning on or about June 26, 2003, and continuing for the life of Wendy J. Bechtel. The aforesaid payments are guaranteed to be paid for a period of three hundred sixty (360) months, with the last guaranteed payment to be made on or about May 26, 2033. (2) Should Wendy J. Bechtel die before May 26, 2033, then any remaining guaranteed payments set forth in Paragraph IV.B.(1) shall instead be paid, as they become due, equally to Michael Charles Bechtel and Toni Marie Bechtel, or the survivor, with the last guaranteed payment to be made on or about May 26, 2033. Should Michael Charles Bechtel and Toni Marie Bechtel both 3 die before the remaining guaranteed payments are made as set forth in Paragraph IV.B.(1), then all remaining guaranteed payments will be made, as they come due, to the estate of the last to die of Wendy J. Bechtel, Michael Charles Bechtel and Toni Marie Bechtel, with the last payment to be made on or about May 26, 2033. Should Wendy J. Bechtel die after May 26, 2033 then monthly payments as set forth in Paragraph IV.B.(1) shall cease. (3) Wendy J. Bechtel shall have the right to submit a request to change the Beneficiary by filing a written request with the owner of the annuity. This request will be reviewed by the owner of the annuity, and if approved by the owner of the annuity and the issuing annuity company it will become effective. Said request will be made in writing by Wendy J. Bechtel. C. Nature of Payments. All sums set forth in this Paragraph IV constitute damages on account of personal injuries or sickness, arising from the Occurrence, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. V. FINANCING OF PERIODIC PAYMENT OBLIGATION A. Assignment of Obligation. It is understood and agreed by and between the parties hereto that the Insurance Company may, as a matter of right and in its sole discretion, assign its duties and obligations to make such future payments as set forth in 4 Paragraphs IV.B.(1) and (2) to Metropolitan Insurance and Annuity Company pursuant to a "Qualified Assignment and Release Agreement," within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as amended, in the form attached hereto as Exhibit A. Such assignment is hereby accepted by the Insured without right of rejection and in full discharge and release of the duties and obligations of the Insurance Company and all parties released by this Agreement with respect to such future payments. If the Insurance Company assigns the duties and obligations as provided herein, it is understood and agreed by and between the parties that Metropolitan Insurance and Annuity Company, as the assignee, shall make said future payments directly to the respective payees designated in Paragraphs IV.B.(1) and (2). THE PARTIES HERETO EXPRESSLY UNDERSTAND AND AGREE THAT WHEN AN ASSIGNMENT OF THE DUTIES AND OBLIGATIONS TO MAKE SAID FUTURE PAYMENTS IS MADE BY THE INSURANCE COMPANY TO METROPOLITAN INSURANCE AND ANNUITY COMPANY PURSUANT TO THIS AGREEMENT, ALL OF THE DUTIES AND RESPONSIBILITIES OTHERWISE IMPOSED UPON THE INSURANCE COMPANY BY THIS AGREEMENT WITH RESPECT TO SUCH FUTURE PAYMENTS SHALL CEASE, AND INSTEAD BE BINDING SOLELY UPON METROPOLITAN INSURANCE AND ANNUITY COMPANY IT IS FURTHER UNDERSTOOD AND AGREED THAT WHEN AN ASSIGNMENT IS MADE, THE INSURANCE COMPANY SHALL BE RELEASED FROM ALL OBLIGATIONS TO MAKE SUCH FUTURE PAYMENTS AND METROPOLITAN INSURANCE AND ANNUITY 5 COMPANY SHALL AT ALL TIMES REMAIN DIRECTLY AND SOLELY RESPONSIBLE FOR, AND SHALL RECEIVE CREDIT FOR, THE FUTURE PAYMENTS. IT IS FURTHER UNDERSTOOD AND AGREED THAT WHEN AN ASSIGNMENT IS MADE, METROPOLITAN INSURANCE AND ANNUITY COMPANY ASSUMES THE DUTIES AND RESPONSIBILITIES OF THE INSURANCE COMPANY WITH RESPECT TO SUCH FUTURE PAYMENTS. B. Third Party Payment. It is further understood and agreed by the parties that all future payments as set forth in Paragraphs IV.B.(1) and (2) may, solely at the option of the Insurance Company, or its assignee, Metropolitan Insurance And Annuity Company, be financed by the purchase of an Annuity Contract from Metropolitan Life Insurance Company (the "Annuity Contract"). When such an Annuity Contract is purchased, the assignee, Metropolitan Insurance And Annuity Company shall be the owner of the Annuity Contract and shall have and retain all rights of ownership in the Annuity Contract. For its own convenience, the assignee shall direct Metropolitan Life Insurance Company to make all periodic payments directly to the respective payees designated in Paragraphs IV.B.(1) and (2). Such payments will be applied against the obligation of the Insurance Company or its assignee and shall operate as a ero tanto discharge of the scheduled obligations set forth in this Agreement. C. Status of Insured. The Insured shall, at all times, remain a general creditor of the Insurance Company or its assignee and shall have no rights in the Annuity Contract 6 The undersigned, and each of them, warrant and represent that no promise, inducement or agreement not herein expressed has been made to them and that this Agreement constitutes the entire agreement between the parties hereto and that the terms of this Agreement are contractual and not mere recitals. The undersigned, and each of them, have read the foregoing Agreement and fully understand it, and are aware of the propriety and legal effect of executing the same, and neither the Agreement nor the compromise and settlement recited herein were induced by fraud, coercion, compulsion or mistake, nor is this Agreement nor the compromise and settlement made by the undersigned in reliance upon any statement or representation of any of the parties hereby released, or their representatives, agents or attorneys. XII. COURT APPROVAL The Parties agree that the Insured will file petitions for all necessary court approvals, that all such petitions and orders shall be in a form satisfactory to all Parties, and that this Agreement will not be effective until such approvals have been obtained. 10 CERTIFICATE OF SERVICE I, Andrew G. Cassidy, Esquire, counsel for Petitioner, Nationwide Mutual Insurance Company, certify that I have caused true and correct copies of the foregoing Petition to be served by United States First Class Mail, postage prepaid, upon the following parties on the date below: Mrs. Wendy Bechtel 526 Rittenhouse Square Mechanicsburg, PA 17050 (Administratrix of the Estate of Charles R. Bechtel) Brigid Q. Alford, Esquire 315 North Front Street P.O. Box 741 Harrisburg, PA 17108-0741 Joseph Metz, Esquire 112 Market Street, 8th Floor Harrisburg, PA 17101 (Attorney for the Estate of Charles R. Bechtel) ~. '( ~~~ , ANDREW G. CASSIDY, ESQU~RE Attorney for Petitioner Nationwide Mutual Insurance Company Date: ~ ~ ~ ~~ SWARTZ CAMPBELL LLC ATTORNEYS AT LAW ONE SOUTH CHURCH STREET SUITE 400 WEST CHESTER, PA 19382 JUG 1 ~ 70n ~~ S ~i~ARTZ CAMPBELL, LLC By: Andrew G. Cassidy, Esquire ,~ ~ I1,1, j Attorney LD.: 81259 ;~' ~,~ Ilr One South Church Street, Suite 400 Attorneys for Petitioner West Chester. PA 19382 _ Nationwide Mutual Ins. Co IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA ORPHAN'S COURT DIVISION IN RE: ESTATE OF CHARLES R. BECHTEL, JR. ORDER da f ~ v 2003 u on consideration of AND NOW, this y p v~c~ ~~iG c ~~'~~s~9 ' 7 ~l 0 3 . the foregoing petition, it is hereby ORDERED and DECREED that the underinsured h settlement in compromise of this action for the gross sum of $400,000.00 is hereby APPROVED. It is further ORDERED that the settlement proceeds, pursuant to the terms of the settlement agreement and qualified assignment, copies of which are attached to the petition, are to be distributed and paid (or caused to be paid) as follows: a. $100,000.00 will be paid to Wendy J. Bechtel, individually and as Administratrix of the Estate of Charles R. Bechtel upon court approval and execution of necessary settlement documents; b. $300,000.00 will be used to fund a structured settlement account which will make monthly payments to Wendy J. Bechtel of $1,494.00, payable for life and guaranteed for 30 years starting on June 26, 2003 with the last guaranteed payment on May 26, 2033. Monthly payments will continue for life thereafter. The parties in this matter are hereby authorized to and shall fully execute said Release Agreement and Qualified Assignment. It is further ordered that the allocation of 100% ($400,000.00) of the settlement proceeds to the Wrongful Death Action and 0% ($0.00) of the settlement proceeds to the Survival Action is hereby APPROVED. rr~ r- ! SWARTZ CAMPBELL ATTO ~EYS AT LA1y ONE SOUTH CHURCH STREET SUI BY THE COURT i~ 400 WEST CHESTER, PA 19382 J. __ 07/11/2003 12:03 FAX 6106924936 07/11/?003 09:57 717-763-3467 SWARTZ CAMPBELL & DETWEI INHERITANCE TAX COMMONWEALTH OF PEivNSYLVrt1N1A pEPARTMEIVT OF REVENUE BUREAU OF lND1VIDUAL TAXES DEPARTMENT 280601 HARF~ISBURG, PA 1712&-Ofi01 _I~003 P 02/bY Telephone vl 1l2a03 Andrew Cx Cassidy, ]Esquixe SwartzlCaxtxpbe11/Detweiler Sane 404 1 S Clnrrch Street West Chester, PA 19382 717-783-0972 Re: Estate of Charles It l3echxel, Jr. File ]umber 2102103.1 Cwmtberland-CCp~2002-01Q31: Dear MT. Cassidy The Depaxttxaent of Ttevenue received the ]?etiiion for Approval of Settlen~iczit Claim to be filed on behalf of the above-refeeenced Estate in regard to a wrongRil death and survival action. It was faywarded t0 this Bureau for the Coxrumonwealth'sopproval of the allocation of the proceeds paid to settle the actions. Pursuant to the petition, tlxe 42-yegr-old~decedeiat died as e, result of a motor vehicle accident. The sole haeir to the decedent's estate is his spouse. Thcrelfoxe, any proceeds paid~to settle the survival action wvoald pass to decedent's spouse and would be subjeat to a zero percent inheritance tax rate. 72 h?.S. §9116(a}(1.1xii). Accordingly, regaz~dless of the allocation of the subject proceeds, there would be no inheritance tax consequences. Please be advised rhos based upozr these facts and for inheritance tax gurposes only, this Department hag no objection to the pro~5ed ah,loeatlon of the gross proceeds of foie action, $ 400,000.00 to the wrarigful death clams and $ 0.00 to~the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and, although subject to the imposition of x zem percent inheritance tax rate in this instance, they must be reported on decedent's Pennsylvania inheritane+~ tax return. 42 Pa.C.S.A. §$302; ?2 P.S. §§910b, 9107, Costs aad fees boast be deducted in the wame pea~oentages as the proceeds are allocated, In re Estate of Merrvman_ 669 A.Zd 1059 (l'a. Cmwlth. 1:995). The estate will receive a $ 100,000.00 outright distrihtxtion and an armuity for the life tune of the decedent's spouse with a thirty yeas ;uarautee payout. The Department wants to note that if Mrs. V-lend;~~ Bechtel dies before fire final guaranteed payout, that the annuity continues for the beneFit of Michael C ]3echtel and/or Tom Marie Bechtel. Xf amy of this annuity distn'butian passes to either Chaxles ox'I'ox<i~ Bechtel, the estate of Wendy Bechtel may lx responsible for a potential Pennsylvania inheritance tax. I trust that this letter is a sufficient representation of~the Departmen+t's positloz~ oxw this matter. As tlxe Dint leas r~o objections to the Petition, an attorney from the nepartrae=~t of Revenue will slot be attending the hearing regarding it. Please contact me if you ar the Court has any questions ar requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may tahse in any other proposcrl.distribution of proceeds of a wrongful death /survival action. ~_ Paul ' Business & Trust'Valua;tion 1Vlaz~ager Inheritance Tax Divisiwn But+eau of Individual Taaces Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 12/01/2004 METZ JOSEPH U ESQ 214 PINE STREET H3IRRISBURG, PA 17101 RE: Estate of BECHTEL CHARLES ROY File Number: 2002-01031 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES~ NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 11/11/2004 Your prompt attention to this matter will be appreciated. Thank You. Si~cerely~ GLEN-DA FARNER STRASBAUGH REGISTER OF WILLS cc: File Personal Representative(s) Judge Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 10/10/2005 BECHTEL WENDY J 526 RITTENHOUSE SQUARE MECHANICSBURG, PA 17050 RE: Estate of BECHTEL CHARLES ROY File Number: 2002-01031 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 11/11/2005 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, ~~,~~ GLENDA FARNER STR~SBAUGH REGISTER OF WILLS cc: File Counsel Judge LC:r Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 10/10/2005 METZ JOSEPH U ESQ 214 PINE STREET HARRISBURG, PA 17101 RE: Estate of BECHTEL CHARLES ROY File Number: 2002-01031 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after July I, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 11/11/2005 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, .~k~~ GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Personal Representative(s) Judge '-v Register of Wills of Cumberland County STATUS REPORT UNDER RULE 6.12 Name ofDecedent: 411(, /P ~ ~ rf!:e, ~ 'fer Date of Death: !/Ioveivt hev I!; '7- c'<:::Y-2 Estate No.: L-oor ~ 0/ 0 3- ! / Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes ~ No 0 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes 0 No ~ b. The separate Orphans' Court No. (if any) for the personal representative's account is: ~ c. Did the personal representative state an account informally to the parties in interest? Yes ~ No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be fiied with the Clerk of the Orphans' Court and may be attached to this report. \ ~ '\ \~<:-Q~ ~ 'bL~~ Signithn d 1 L~c ~ ~ ( Name G P-1, (;: Drj II /P ~c(V1 ic 4i.< Ii J f/ It Address . ' /7Qe 01';- ((;!; 7 7 C Telephone No. , c- Date: No\! ~;f. I D ~ C"'"-J Capacity: ~ Personal Representative o Counsel for personal representative ft