HomeMy WebLinkAbout13-7293 IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY,PENNSYLVANIA
In re: ALYSSA DEAL, PETITION FOR COURT APPRO`5§9
a Minor OF MINOR'S SETTLEMENT
NO. 13 ,
�
PETITION FOR APPROVAL OF MINOR'S SETTLEMENT
AND NOW COMES the Petitioner,Michelle Deal, as parent and natural guardian of
Alyssa Deal, a minor child,by and through George J. Costopoulos,Esquire, and represents:
1. Petitioner is Michelle Deal, who resides at 5145 North Susquehanna Trail
Lot 19, York,PA 17406. She is the parent.and natural guardian of Alyssa Deal, age 9. Alyssa's
date of birth is 08/29/04; her social security number is 408-99-1473.
2. On May 4, 2012,Alyssa was injured in a motor vehicle collision while a
front seat passenger in an automobile driven by her mother,Michelle Deal. The collision
occurred when Michelle Deal, attempting to make a left turn into the parking lot of Alyssa's
elementary school, was struck by an oncoming vehicle driven by Mitchell Hopple. A copy of the
police crash report is attached as Exhibit"A."
3. The collision, which occurred in West Pennsboro Township, Cumberland
County,Pennsylvania, caused multiple cuts and lacerations to the right side of Alyssa's face.
Alyssa's injuries were treated conservatively at the emergency room and through follow-up visits
with her doctors. A plastic surgeon was consulted who opined that Alyssa had residual facial
scarring which may be permanent.
4. On June 21, 2012,the undersigned counsel was retained to negotiate a
settlement and/or to institute legal proceedings for Alyssa's damages resulting from the
collision. A co of the fee agreement is attached as Exhibit"B." � /6,3' r
copy eta
gS 3
R #•" 9gz87
5. In September, 2013, the undersigned counsel negotiated a proposed third party
settlement on Alyssa's behalf with Nationwide Mutual Insurance Company, the insurer of the
vehicle driven by Mitchell Hopple, for the full amount of its bodily injury liability limits of
$50,000.00. Copies of Nationwide's Settlement Letter and Certification of Coverage are
attached as Exhibits "C" &"D."
6. Around this time, the undersigned counsel also negotiated proposed settlements
on Alyssa's behalf with State Farm Fire and Casualty Company,the insurer of the vehicle driven
by Michelle Deal, for the full amount of its underinsured motorist benefits of$25,000.00, and
for the full amount of its bodily injury liability limits of$25,000.00, for an additional proposed
settlement of$50,000.00. Copies of State Farm's Offer Letters and Certification of Coverage
are attached as Exhibits `B," "F," &"G."
7. The undersigned counsel is of the professional opinion that these proposed
settlements, totaling$100,000.00, are reasonable given the exhaustion of the policy limits frorn
all sources of insurance coverage through both Nationwide and State Farm, and based on
previous settlements in comparable matters.
8. There are no unpaid creditors or liens against the proposed settlements, and
approval thereof will not prejudice any rights belonging to Alyssa.
9. From the total combined proposed settlement of$100,000.00,Petitioner consents
to a distribution to the undersigned counsel consistent with their contingent fee agreement,
which provides for counsel fees in the amount of 25% ($25,000.00). The undersigned counsel
has agreed to waive reimbursement of case related costs for the benefit of Alyssa.
10. Petitioner agrees that the proposed settlement, along with the distribution to the
undersigned counsel, is fair and reasonable, and therefore requests that this Honorable Court
enter an Order:
a) approving the settlements for: (i) $50,000.00 in bodily injury liability
benefits with Nationwide Mutual Insurance Company; (ii) $25,000.00 in
bodily injury liability benefits with State Farm Fire and Casualty
Company; and (iii) $25,000.00 in underinsured motorist benefits with
State Farm Fire and Casualty Company, with the net proceeds of
$75,000.00 to be deposited in one or more savings accounts in the name
of Alyssa Deal in banks,building and loan associations, savings and loan
associations or credit unions, deposits in which are insured by a federal
government agency or in one or more accounts in the name of Alyssa Deal.
investing only in securities guaranteed by the United States government or
a Federal Governmental agency managed by responsible financial
institutions. Said accounts shall contain a provision that no withdrawal
can be made from any such account until the minor attains majority,
except as authorized by a prior order of court. Proof of the deposit shall
be promptly filed of record; and '
b) approving the payment of counsel fees of$25,000.00 to the Law Offices
of George J. Costopoulos.
11. Petitioner requests that the Court enter the aforementioned Order without the
need for a hearing. However, should the Court deem it necessary to schedule a hearing,Alyssa
and Petitioner together with the undersigned counsel will be present at the hearing.
WHEREFORE,Petitioner respectfully requests that this Honorable Court issue an Order
approving the aforementioned proposed settlements on behalf of Alyssa Deal, a minor, and the
distribution and payment of counsel fees.
RESPECTFULLY SUBMITTED:
George Costopoulos,Esquire
I.D. No. 8423
153 North Hanover Street
Carlisle,Pennsylvania 17013
Phone: (717) 243-0407
Attorney for Alyssa Deal, a minor
Date: iz iv 113
VERIFICATION
I, George I Costopoulos, counsel for Ashly Strahosky, a minor child, do hereby verify
that the statements made in the foregoing Affidavit are true and correct. I understand that any
false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to
unsworn falsification to authorities.
GEORON4. COSTOPOULOS
Date: /2 �� 3
Print CRS NV0277400 Page ] of 7
fc0AN14lQNWEALTH GFIEMNSY.LVAMIA:
POLICE CRASH REKM7i d6 MM � Gash Number ,
, _..__._. •Castif]osed -. It@poitsblsGafh•-•_. � '- - _ ._ ..._-_ ;a. -
fy4 540;1
7' I)♦.,.Yes-..O No; ref p : ' 1 , .-: . .. 1N0277400'. _•
No• , r
Msddert'.flunrber"' Police Agency 1:atnol Lone
•12-0515 21408 :. 002
A Nang rwaft Invest • Date{fLWMYYYY)
Newvi]le Borough OS -[04 • 2012
t DI Yxne(nM� Arrival Twe 04 Investigator Bad Nuaft
S 0721 0724 PTLM.•J01IN.5ZCZYPTA 29-3
Rlatewer Nui@bu oval Date (aiMOO-YYYY)
TUD1)A KOSER 29-4 T OS _16 _ 2012
Co° (ou Name "kW Mrnidpap Name
`2l • umbedand 1219 JWesi Pennsboro Towaship �� U sun O Thu
_ CfUh 1we(Mif+FOU rY errash nme� No of units Peo M ed Killed, ■N>go O Mon a Fa
OS - 04 - 2012 0721 2 6 4 0 aw F t° O wed p LM
W""MU, C=Ley)O Yes 0 fro R �"O Yes No R ya one Yes O No OrQ•Yes No
s 162WdbP bM O 4 Way lnterseojon O 'Y'intersection O M .O Oil Ramp O No ad-crosting '
*Midpioct O.'T'Intaseai@n O Traffic Girtk O Oa ia"9 'O Cr° ovO.r CteRound Aout 00
lout@ Numhii _ ._
.S melt(Optional!•-••Tr@vcl isles°Seeed IImR•;...:-_ .._ .-.: '• Houcri Number Of appitebk)
02 ... 1 S- _.... ......_.: ..----._.. � O south'' 45
• Streel Ending i Q Ersl, For 'vaults or]tr UsF
MOIJNTiCOCK l OYVest_•.- fwsw N:n:k«e@�maasun
�knROdwr Nimei
C] u onm 1f
filed v,
` `° :kkerstate Trrntpike Tu"*e• SUIe; i•: County -'tusat Road O Private Otto-
Ptoc T )'::O-(fs:uWest} O Spur or strew Road O Unknown
�:=-lbufefRertbe► _.• ,: .. ._ ( -Tnvei'lanei_'Sp@edUMt•.- . -;:�. :.. ._-_-;. /'�.._..... :-, ' -. :. _ Y.
.� `,5:� .r ••�. IHale@ Strut Ending 0 East
f _. . _..... (�'� C)west•
O b,lealale Cj Tomryke O T« °O slas �r O 4 o°sires O Rwd b--
°un"kr I
(Nol Tumprkc) tEastAhksU Spur Hi
a r . tlnra se Rt N Or Mgt Post .❑ Or So em Usher
h
Fe O North
utMtenecdn
Or rneeM N Street Nme nil O Easl ]r Miles hkmntla O wet
for POTH
Ell]
tali R311 s tnt@rswdng Rt Num Or folk Post Or begm@nt Marker
E r ° Distance Fran trash
' tlhis Opfion Zr O North
• : 'Scene to landmark 1 •
o.wh. srr«t Name d O.s«rlh
Std.—J'O East landmark tIaand�
J
O west Landmark 2)
De tees Minutes Sewnds - Deareef Mlnum Seconds
' Latltuda 40 !0 26 .� t@ngRude:— 77 22 ;F55--1. 000
d Yeld'Sign O• ce 0flicer o• '
a ad Not Applicable O TraiGc Signal O
Active R Crossing . O e,TWC.TCO 0 Na eaumis O inQ' b k�rWncy
fiuAi119 Traffic Signs'
O Sgrol - O Stop Sign-._.C7 Cosa g Controls O Unknown Q_Q,:i ar ,fl' u; Furtctiotrng.,Q•,�known
N _
latteled Ol'kof^ppFxalfe',skit'rtsta/the lane Closure rrcfian) One l�uuis O Nonh O East O North and South O AI
Na Applicable O.pani*.. O Fully • O L!*wvn -OikitLEkM O South O---Il/rrt-- b:East and west 1N•S•E,IN)
Eid Mar n �Loasd SV^k ):O.f'_ ii Y dries O 3-6 ks .Ob g'hii• •O 3;9.hours O Unknown
Porw,Mtaspaaxl EXHIBIT =-_`"_'=•-'_ --
a
A
-
Print CRS W0277400 Page 2 of 7
IM CIM IMMOTM FUM d Paga: VIII I�III�I � Cruh Number
AA-5W 2 W0277400
a Motor M
Transport 0 WA Nn V#W O Ilgy Paked O LegaNy Parked Q Non-Motorized Commerde!Veide
Up►t Q 0 Pedtstian m Skates.O Disabled from 0 Train O PI►antom 1+etrick 0 Yes ®N°
n 1Mneeld a'r,etc PrtwlOrs trash (if Yer,Complete form U
(It'hdes"n'or'Pedestrian on States in Wheekhairr etc',Com lete Form At,Section le
Unit No Ant Wme MI Data of NNh(MM-WYYYY)
01 1 MICHELLE O8 25 1973
We? List N" Tole sa Butntser
O 1 DEAL 1 3049808235 l
Address l Citv I Stale
20 TIPTOP CIRCLE CARLISLE PA 11015
DriverLirewNumber State Class
E698200 ��
AlbahohaaasSumetled A_Vlweva/rasemianlA�lplWn�Hon
11
600 O two Drugs O Medication 8 rPma
boWeO Og J Fati
9ve Q W6caton
O Akdd O Akno and M gs 0 Unknown O Had Ban
Drudr O Sick O Asleep p Urdenvwn
Akvhal test lbw
e Test Not Given 0 Breath O Other hhrWn tlefride cede ViolathM Clwyed7
O slow 0 Urine 0 Urkooym if VEHICL>;'fURMN,LEFT 11111% ONO
f Test Grw
3
Alcohol Ted 11 wis 0 Test Refused O R� tM�4-4�'r�Me 1*Oriver Operated 3=Ddwt Fled Scene
0 C st Given. N�ewlrs 11 I V�k "it and"Hun I
' L.—i bNo Driver 9-Unkttrtwn �••8•�
W cHot Applicable 02.Private Vehicle Nil OeStale lbliice W ide OUMudupal Malice Vah O9=Federal Gnv Veh
F Ol 01_pimte VeNde-Ownedr• OwnedWsed by 0riyer OS=/iNWDOT Vehicle '08--Other Muv+dpal gempdrzr
Leased by Driver 03dtented Vehicle 064ther State Gov veh Govemment Vehicle 99dlnkmm
Seise u Owner Fist Naete Owner last me"of Berdnass Name(if And Wwk Alp this Section)
°rte O MICHELLE DEAL
nss/ /Stole I zip Vahlde Mako •Make Cade
1510 RADER 5T SUMMERSVILLE WV 26651
1qN FAWel Tear vehkle MOM (w OveWy1
IB3XA46KXNI 14897 1998 SUNFIRE
License Hare Beg_state at Steed Y&U ►owed TO*"a
2KH606 r�� r 1 a Yes 0 No HIPPENSTEEL
berancr Inturulce Company MoOcy No
eyes Q trio Q kn- n STATE FARM 10722 1S3B05-48C-001
to T N4 I=Tavring Truck S=Caaw r q.. TnNer Tag No 7 Tag St
Di urg l�--^---~I
�. ,..,,.,3404ng Utility Tracer CnfvN T.aNNer 9.IAraugvvn
Medfon of (U"I -While laskbn 01 •Rt venre+tt 12 ;yeclad Usarfe ,
1
NrAWe Potion Vehicle Tie OS�.atge Trudr 20-Urigde.liclMe. 00 12=Cmawtrcal
OibeYeraw 01-Womobte 064W Tdcyde 00=Not Ap kWle
07-Wet O1 02=l4lotorcycre 07-Van 21=Odwpedakyrk 01=FreVeh 13=Tau
O3Aus 10=Snowmobile 22.Horse a 0 sggy
01=014 09-1rown Oe=Small truck 1146M(quly 23=Norse 9 Rida 01"A°k4a"a 21=Tractor Trader
024ed 1�Or ((!b2;Complete Form WoCu strtAion 24=Trio 03�blie 22-Twin Trailer
0--mite 1 T=Pt At Section 26) I ATV 2S=Trolley 00arw Emergency 23=Triot Twrkr
04-teen 12=0the Of•2O•ar'21-.Complete 18�ther Type Spec VA 98=Other Vehicle 31=Madiihed Veh
4SaBfack 99=tMtno" form M,Section 271 194Mk.Type Spec Veh 99=Unkrtourrt 11=pupil Transport 99atlfdcnpMm
ii"11"Aw Nint Wetter krdlcator 6rar♦lertt 3-pown114 Rai Alanment
—d —
03 00--watalikin 11--Uedercarriage ❑"One 24=ioeal ❑ 4=Nollom Of Hot 1=Straight
01 12=Cbc2 Pointy 1 S=Towed Unit 3 t=tumor 3Disabli+g 4 loltve) S-Top of Ml 1 2drased
13-TOP 99--tk*rwyn 9=tl b*wq 2QUphrl 94N"060 9atlnknown
emu a v.vp WWM oauursnT erwv
Vll IVUI U1U'G
Print URN V0177400 Page 3 ot'7
FOLICE Gild§REMI M MAC u�lln�lu�lli�ll111 Page: Gish Number '
AA 500 2 rr6rc inr oM, M W0277400
. Motor Vile in � Nil 3 Run Vehicle Q Parked all Piked
e Fie T:anspat 0b9�T1 Y Nrts-1Ao1 xited Commercial Vehicle
t1 t Unit "Sl an OP Win. Dubltd Pom Q Yes S No
? O Pedessian O n Vvheetti m,etc O Frevious C:asl� O Train O M'•antom Vehrck
(N'PeWes!rian'nr'Pedestrian on Skates,in Wheekhair,etc',Cem lele FormµSection 2$ A/Yes,Complete form Q
Unit Tlo first Name Ul Date of Blrih M1M-DD•YYYY)
MITCHELL a 66 22 1993
Welt? Last hame Tele hone&lumber
C3 HOPPLE 7177137443
Adores /C' 1 sate 2
12 HILLTOP LN NEWVILLE PA 17241
Driver License Number State Class
30093853 PA Q
r
Afeoll s Suseechd Darer a ledcshlan MrIcal Cormplen ;
r t Ti
a kp Q Ilegal Drugs Q Medicafion 6 FDrinki ndy 0/
al 0re9 O Faigue O MedcM.
O W*d O Akotd and Drugs O Uirknam Q Haadken Q Skk
0 asleep V (hskrsossys
p" Alraho/Felt Tyke
0 Test Not Give` Q Breath O other Vehicle Code Vidati0n ChugW2
Vent' Vn•1 PERIOD FOR RL UIRING LIGFI aYes ONO
gp �itp4d �U:ine 1] Q
5 e0 ven
Ahohot Test Results Q Test ftiy� O Unknown Drier Pier 1-BdMgs nperaltd I=Oriwf Fled Scene �
Results
'►,1 a O Test Given, a VeNcle 44 it and Ilun
Contaminated Results 2=Nj Driver 9=Vnkrpvn
OwrserMtiver 00=Not Applicable 02=Kovate Vehclee Nos 04=Slate Poke Vehicle 01=Municipal Poke Veh 09=Federal Gov veh
02 01=hivate Velkle Owned] Owned/sased by Dsn-er OS-eENWOT Vehicle Op=Othes Municipal 9a=0dter
leased by Duvet 03=Rcnled Vel ide 06--0(her Stale Gov Vey Gavetnmenl Vehicle 99=lMskmvn
r2l Owner wst Nara! Owner last Na me a IvIlness Name R/Ankstrien,skip thin 3econ)ROSI DA S HOPPLE
/Stale/i Vehicle Make *make Code
TOP LN NEWVILLE PA 17241 Ford Model Year Vehicle Model isee 0vetlay)
IFMDU35PX1LB0W71 1996 �XPLOREK
Ucetse Platt Neg.State Est.Speed Vehicle towed Towed By
HVP2055 PA 0?5 O Yes a No
hrsrvarre Inst-rance company Policy No
o WYN ONO pkj,,, NATIONWIDE 5837D11465
ri q Tram Tie 1=TOwing PaN.Veh 4="leM)duer Hccrt 7=5err•ET•ailet Tag No Tag Year Tag St
b IraiT g D '"r 2=Towing Truck S=Carrper. BvOJ a ❑
Y Urks: 3=Tmvipg Llifly Trades 6"]Laiec ¢Unknown►
Q •Vehiclk Position I • vement 0) _ 'See cal
Travel
Overlay
Vek Color Vehicle nDe OS arge fact 20:01tcy ie,Bicycle, 0D 124onnerdal
07=Sik Ow 01=Automobile tricycle 00=No1 Applicable CAI*
t14 07=5t1xr p2-llranrcyrle 07=Ven 21=di}tc?edalcrdc 01=fire VCh 13=Gatti
Oa-Gold 03--Sus I:Snona 4hik l7-Horsed Y 02=Amisularsce 21=Tractor Tra?a
01=31ue 0--grown 04=5nsal Truck I lefarm(coif- 23--Hasse S fide O2=Amb 12-11FaM her
0),=Red le-Orange pl 02,Complete Form I2=Conswex)n Esprit: 24wrain OB=Other Emayc+xy I3-= n railer
03--WNm 1 IrPorple M,Section 26) l3=ATV 25=Trofe
04sateeq 12.001et (1►'2t7-or?i',Complete II=Other TypeSpe;Vels 90=Cthei Vehicle 31=7Uod0ed Veh
OS4btk g9■UrlWsown form Sectkm 271 19=Unk.Tspe Spec Ve, gg=Unknam 1 i=PuOB lcanspott A Unknown
1_111N,t!omit Aolnr Dareaae Mdleafor bra n Road Atlanmrnl
9ANnnc 2dun tiorul d 3=rk wnyil
01 00=Nan-Cdlision 1r=Uudcrcauiaye 4,Bouom of KII ��{'''�� 1�SVaighs
L 01--I=CWkP&IIS 14=TastedUnit I■lei so 3.Dishung l evel S=Tap 01 Hit k_J 2=Currd
.3'•100 9:=UnLnmvn 3-Jaknovn 2=Upf4l s=UnknOmn 9=hknowi
tan'a na Soo p2Mi PENNDOT C4*Y
Print CRS W0277400 Page 4 of 7
COMMONWEALTH Of POUCE CRASH REPORTIPIG WIAIdIA h9e "�I,�I�+ 1�q Clrsh pra6er
AA 500 3 tr 1N0277400
A 1�D�dter ieat�ite�' SafeYfOiiigamlQae-
[D 00=Nat A lasengerAO�tuprru E 00=None used!Not AaplltaNe G ONO1�AppGuble
2--Passertgcr ot=0riret•Al vehicles ot=5houldn Iklt used t=Not Elected
7><Pedman 01=Front Seri Middle Position 02=tap Be.Used 1=7otaay Eject
B�dcer 03-Front Seat Right Side 03=lap•And Shoulder kit used 3=par6aAy EE
9-Unknoum 04-Second Raw-left Side Or 04=(Md Seery Seat Used 9=Unknown
Motorcycle tasien9v 05=motorcyde Helmet tlstd
OS=Second Row-Middle Poston 06.11.yde VeW Used
05-wend Now-Righ1 Side 10=Safety Idt used Impiopetiy H 0 lot End I Not bk
F=Fenke 07=Third Pow Or Greater• 11=Chid$defy Seat Used Improperby
B M=leak Left Side 11=Helmet Used lmproperif I-Through Side Door aing
U-utnown 06=third Row Or Greater- %=Resin!used.Tra Unknown 2=Through Side Window
3=Throb Wrtdshlerd
Mrdde Position 99.tlntrww, gh
"Through 09•ihird Row Of Greater- 9h Door
1*t side Nhrough Bak Door Teik�ate O/em4
lrhSleeper Sectiat of TnckcA F 00=None Use !Not 6=111mugh Roof Open'' 15rnroo/t
umd 11=lei Atirer Eedoud 01-front Ali flap IFa.lhis ksU Convertible T�Dowg
C t2kd 1imggeCargo Area 02-Sid eAT a Ar (For This Seat) 9- R00I ing(CoAte�2--m4N Ini y?! ��Wr 3=tuderate PitkEtcJ 0r_Mdto Ar Bags Woo
YY�rppnrryy 3.TraNrV udt OS=MatoW.le Eye Frolettion r
4.Mincr krjury 1e=Aidinng On Vehicle Ei<teriar 06=1i_*W ftia u7 ERrCuvlKnedPads
11-Iniury,UFrJIcr 15■Buc Pass tiger 10=Air lag Not Deplortd Switch On itabk
Seventy 98�Iher IImAir Rag lint Deployed Switch Aft 1�1ot Eat led
9=ti1da10vvn H 94--ftrimn 11=Air ilag Na OePWIVA� 2=Eztricmd By Methrnicai Meam
trjury unk Swhilr SEW 3-Freed By Non-Me(hankal Means
11-M Rag Rtnr He=ron 7o Cmh) &other
s9=lktt;nc6,It Air Bag Depbyed 9 lkrlurown
99=Unknom
r EMS Agengr: FRIENDSHIP HOSE OF N Medical fecntty: CARLISLE REGIONAL
Unit• O l yo hewn No DO i7 gr of Binh (M M•OD•YYYY)73 I� F�0� O 10 03 E l O F 0 0 0
o�c�da�
Name I Address 1 ph*4
❑ ;am'� BAL,MICHELLE 20 TIPTOP CIRCLE CARLISLE PA 17015 304880 EiNS Transport
tt�r� Oyes tli No
Unit no hewn No Drse of Binh IMM-OD YM A B C D E F G H 1
Ol 02 p1 08 -[25 - 1973 fl F�4� 06 03 00 0��a
Rime/Ilddross/!hone
Opera DEAL 20 TIPTOP CIRCLE CARLISLE PA 17015 304880823 Tr
tkrh NO rason No 11161 4e7 WNe of/firth M -yrm A F
Ol 03 1 p 08 - 25 - 1973 2 F1 F1 04 03 � 0�o 0�
Marne I AM ms I drone Tansprrt
C=r A1tIANNE DEAL 20 TIPTOP CIRCLE CARLISLE PA 17015 30488082 eves ON.
Ikril No remn No Oats al NMh tmm4x)-VYY10 A B C 0 F F G N ( I
02 01 F Delete? Q- 22 _ 1993 la M�0� 01 03 IU EIIE
sense as HOPPLE,MITCHELL B 12 HILLTOP LN NEWVILLE PA 1724171771 EMS Trenspon
overatoe O Yes ON.
IInN NO reason 1116 Gate of Nrth.(ru*myYYY) A I C 0 E F G H [
02 t-�_ 1 p T t;- t- 22 _ 1993 2a M� 4❑ 03 03 10 EjE1L_J
Marge I Address I Phone fNS Transport
Q Opmtor CAMERON HOP
PLE 12 HILLTOP EN NEWVILLE PA 17241717713744 Q va O No
Unh No femn No beet of kilns, RNJ4*-wm A B C D E G
02 F03 --j DO 2�RF 4� 01
km*I Address I Phone
sne as I I.YDIA HOPPLE 12 HILLTOP LN NEWVILLI;PA 17241717713 7443 EMs Transport
operator Over oft
iaRM I M�00 ttM7r «.•........�`.�:.ww
Print CRS W0277400 Page 5 of 7
POUCE CRASH REPORTING FORMAPl4A CIO X11dwr
fl9=
AA 500 4 .iway
L" W0277400
Cmb an OaNan•Gdlsion 24W On 4=Arpla 6=Sldeswlpe tkF1q Padeeklert
€ u 1,aear Ew �r a r , je a l�pa��a•oF.abn►
Deng) (6eme 6011=n} 7 Find 044d 9wDAW nknmrn
Aepeton ro IMadrar tin Travel lsrNS 3�iedlan 5 OuGide TreRawy 7�oro LRemp htaenegan)
2-Shoulder 4=Raadsld0 6*Paddng Lena 9=iWNwwn
I+DaylQitt 3-0�Stan Sawn
NM+ekratiart l�OYw .
44W L
1 eoedlbor� a 1� 3•sleet tHatq WOO S w0_ I=U* M
MIA 4=Seotv 6-.P.*a Fog 6=OBrm
Refitlteaet Rdac4�Carsdlll�orts Q li=Ory z.Ssna.Wrd.Oak 425w 6=1ce PikuwS 8#er
1=WeR M"M Covmad 5=1CA 7.1V SlandrnQ
Marmlal fererm!Heron!EverrFE 30--Hit face Qi WTI
1 12 ❑ 0 02=RR Unit 1 7 31=ltit[�
�y 02dtit lket 32_!61
0{ s a ❑ 03atd Ural 3 33=t k Pwap rirr d AWrdnerrt
B4�t tlnh 4 34=Hi rat[End
05-Hit Ilnt 5 IS-MBridge,Rai
B6altu ork4r irafre Unit 36-M Sodder Or Ohsade
ftue Pal 07.4 it Deer On Rwdwaayy
fvRMr i�3 ❑ Q ~�� OB-Hit Other Atr nal 37-rd
krgacl Allenuaax
yppNyl 09=CoBsim YWh Other Han 36=Md Fire Hydra;
O Food Byaf 39�ftBoldhvltTqupmdtt
11=Stock Wit 1 40=Fil MaB bon
1)-urw Iv Unit 2 41�f1italfiChtMd
=4 13=Soock By Unit) 42-Hit%w-bnk
Flamer Evart[IR (Rost? Ulpty hle Huwdw 14--Struck krk iy�5 43= empwary Cant oket kfdu
i 0I 16=Slnrd�By Ober Traffic 0* 40-WR Other Faced Obkdd
Unit 1% 11404 Tree 0r Wubhery 49-Fk!Unknown Feud
�2 O 2I4ti1 Embankment 504 ttu(k 4Th Over n9
23161 Utilittyy Pole 5t=Struck Thepnn 0(Fifi
24--f4 TraO•c Lln 06jec1
2s.4i A'Ard Rod 52-rot 11o1rs Or Oder
Pkate Put 3 Q El h Hal Guard Rail End rave"m kregulmlies
Fvenh In Q 2)=Hit Curb 53=1adde
seqquential 28-M[owiew Or 54-fire h VAide
Okrke LongiturGnal Buflt( SB=Other Nen•Co 4ioo
4 0 29•H:I rAr 99-Unkra nt Hansful Event
am Uah so Naen Evaat Unit No Hann Evartt Qrlver Action M) tT-Carelga Or illegal
'i a joi a{ 12 ven Ad 02 0{ 00=No Cantriburing Action Backing On Wway
0144wer Was NfAcled 18.OiMrg On The Wrong
OI-Orivkrg thing Fiord FteM Phone Side O(Road
o.uteservrwtrnrrn...aikr�R pg3•p�"��9 t."Haruh Ff"Rift t9dlAakng ingtooppeerr
fnvkorrnentatlAoarfivaV -4AQ"- 'I_w- UTum EnVanaToTMg�P
r�lil Fallon{f/R) OQ 054pw?edCarelas Tv � 2tkMakia hgroper Ewe
1 2 3 06.fteniig From Wmng� From l ghway
OD Hare �SG ROad fOnddbn!OctfSrnw) 07=10= ng W/O ;Idarr]rss h
01 [evb Bans
1121= Clearance After Slop 72=OvevlUrder '
02= den Wtalav Cadiilorrs a3=Pothtt e$ Oo AoadwYy OOgB+Rantn6nn9g Itta liBhn ComAI+W fion Al[are
03.01kr Weather C"ions 14-Broken Or Cracked Pavement IOeFaBue to Reri.'d To 23=Spewing
04�Den In Rogdv4yt t i=TCO Obmucted O1hec TWk Gonad Device 7;=0r14°Q too Fan Fa Corw1mv
8%amude On dewy t o-Soh pwulder Or*wjw Omp OH I 1=tailga 254atrPe TO MAntaln Mrya Speed
06.OUr,e Anitnal�h pv dta ray ze-O ha Ibadway factor I2=strdrdett 27 rating e
p 07.{aare 29�dtar Emnarwe00 Facto 1l=�egaly On 2B.Faiute T�SpedaFmM Eg1nY
08>rAak T=oe ki" 99=Unteaum H C Wag Or Lane 92dU►=gtd h Physical eadilmg
+e tbnthM NeA(de rallwes M 12--fYipd; t3=lassing in No Passing .tone 9999 Zoper Wo;wq Actions
OO�tortt 06.EehauA 13.060 Sea W'gl�Conad *--DrrAng Ire Wrong Way On
01 Tres 074 lets 14�odv.0o�r6l1ood.tic 1•WaySareel
D2,erdkt Syriem Oki- lets 1ST Iordr hu r------ Q
a.Sra rropn xnr 10-If" is '�0-1.,.Jf t OS : 3 4
a GS=f bvmr Train 11.4d pea I=Tpier Ovetbaded
Al it Ol T 00 u Q 1B c Moit 02 t 98 2 = 3= 4E]
20-k=rynperT
Nom 02 t 00 Z 299dlnknarnt Ao*aop(/) DkP Vel+cle
t.-.,—_.J 014atemg Or Crossing Ai 0-...AAppppmadwg Or Leming lhttlde
me Factor Unit No Factor Code Spiked I"ioa 06=Wgrk q On Vehicle
— 02=Walk%Riming.jogging. 07=Staadmg
b.a nrea Nc srrauwbn a Dr Playing 9B-0Ukv
F/A» �Pger.
lei 05 99�Unknarvn t--^—y
0 Y 0 P Unit No O{ 1 i tUN1 No Q2 I I
Q Q 6 Q fl E/A h Me Arime Feeror
Type,k4vc flat No!!laid
roaataeaooptArB PEtD4t3O'TCOt►V
Print CRS W0277400 Page 6 of 7
COMONWEALTH OF PE
POLICE CRASS{REPO TING FORMANIA �9e MINOR cm1h Number
AA 500 5 �traie;n�o� ----� r---3
It I � W0277400
3
__'--f_�.i..._'....��_..i...._.i.......;..-....j._._...;.-___I._..-i - -. __. .._.t....:.._Y.......T_.:.I......_�....--:.....rte_„�......,; 0 r i
• i t '.. i i i i i 1 r t I � l
___+ ��..... � ...j.... t „.i..�..,{......F.....�..«..,�,.._^' I __ _..:....-.'�•'.--•. y........1.......1......_x....,. �._....-,....-._....._-....'
- I
i
CL ,
G
"!" 3 i 3 _.r.• 1 i.�.. . I_.�..r.......�
A.
r
1 3
what Name Addr Mona
t PAMELA HOSLER 691 MT.ROCK RD NEWVILLE PA 17241 17177766361
Z
Nartatm and additional w1b"N", Acddmt kweftatioq"hats Imed7 0 Property Damage Q
Unit was traveling south on Mt.Rock Rd and attempted to make a left turn Into Mt.Rock Elementary School.
Deal slated that she never saw the other vehicle coming because it did not have any headlights on"
Unit 2 was tweling ttprth on ML Rode Rd when unit 1 turned into his path.Unit 2 struck unit 1 on the passenger
aide just behind the door.Unit 1 came to rest about 55 feet from the impaul point.
Alyssa Deal a rear seat passenger on the passenW tide of unit was Uransported to the hospital for lacerations
on the right side of her face.Unit t was towed from the scene by Hippensteels Towing,
There was a fight tain mid heavy log that reduced visibility to 25 yards.
Pamela Hosier witnessed the aocident.Hosier stated that the Ford Explorer did not have any lights on and it
appeared to be traveling last.
Print CRS W0277400 Page 7 of 7
Crash Number.M277400
Incident Number: 12-0515
I
,I
S
1 0
h A W O I, I; 1 C I; S O I, G L O R G 1: J
CO S T 0 P 0 U L WC,
153 NORT]I IIAN(ATR STRI171' CARLISLF, ITNNS)ANANIA 17013 O
(717)243-0407 ol, 1:,,.(717)243-0450 /( 0 py
Contingent Fee Agreement
1, Michelle Deal,as Parent and Natural Guardian of Alyssa Deal, a minor, do hereby
retain the Law Offices of George J. Costopoulos, 153 North Hanover Street, Carlisle,
Pennsylvania 17013 (hereinafter"attorneys"), to negotiate for Alyssa Deal a settlement or to
institute for her any legal proceedings that in their judgment are necessary to pursue any claim for
damages and/or injuries sustained by Alyssa Deal due to a motor vehicle accident on or about
May 4, 2012 against any person, firm, corporation or entity who may be responsible for said
claim, and/or to obtain an amicable settlement
As parent and natural guardian, I hereby give to Alyssa Deal's attorneys a Power of
Attorney to execute all documents connected with the claim for the prosecution of which the
attorneys are retained, including pleadings, contracts, commercial papers, settlement agreements,
compromises and releases, verifications, dismissals, orders, settlement checks and all other
documents that I, as her parent and natural guardian, could properly execute in connection with
this matter.
As parent and natural guardian, I agree to fully cooperate with Alyssa Deal's attorneys in
the prosecution of the claim that comprises the subject matter of this Agreement. This includes,
but is not limited to, making Alyssa Deal available for legal proceedings and consultations with
Alyssa Deal's attorneys; keeping her attorneys informed as to Alyssa Deal's current mailing
address, phone numbef and the current status of Alyssa Deal's medical condition.
In consideration of the services performed and to be performed by Alyssa Deal's
attorneys, I agree to attorneys' fees from the total amount recovered from any source in the
amount of a 25% contingent fee. In the event that no recovery is obtained on this claim, Alyssa
Deal's attorneys will make no charges for their time or services.
Costs: It is understood that attorneys may advance out-of-pocket costs in the
investigation, prosecution,preparation and trial of this case. Such costs are to be paid from
Alyssa Deal's share of the total amount recovered and include, but may not be limited to:
photocopies; notaries; investigation charges; photographs; court costs; medical records costs; fee
for police report; deposition costs; expert witness fees; stenographer costs; and,video deposition
fees.
As one possible settlement option,I authorize Alyssa Deal's attorneys to explore the
possibility of a structured settlement through the use of deferred periodic payments. I agree that
if any claim is settled through such structure,the attorneys' fees may be paid directly to said
attorneys from the insurance company, either in one lump sum payment at settlement, or, at the
sole option of said attorneys and/or insurance company, deferred into future payments. However,
in any event, said attorneys' fees shall be calculated in the percentage as set forth above based
upon the cost of the structured settlement or present value thereof in accordance with applicable
law.
EXHIBIT
13
I agree that, in the event the investigation and discovery performed by attorneys shall in
the judgment of attorneys reveal no meritorious claims exist on behalf of Alyssa Deal, then
attorneys may withdraw from the further representation of Alyssa Deal in this matter. It is
further agreed that Alyssa Deal, or her parent and natural guardian, shall be permitted to
discharge attorneys from their employment in this matter. However, in the event that attorneys
are discharged,attorneys shall be entitled to receive payment of fees from any recovery which is
ultimately made on these claims. The fees payable to attorneys shall be in an amount which
would reasonably and equitably compensate attorneys for their efforts on behalf of Alyssa Deal
in the prosecution of the claims. If a dispute to the amount exists at the time of discharge,then
the matter shall be submitted to arbitration.
This Contingent Fee Agreement applies to all proceedings up to and including verdict or
decision at trial or arbitration. If, in the discretion of the attorneys, post-trial proceedings,
including appeals, are warranted, they will not be covered by this Contingent Fee Agreement and
a new fee agreement will be required by said attorneys.
And Now, on the day and year written below, the above Contingent Fee Agreement and
Power of.Attorney has been read, approved, and understood by all parties and the receipt of a
copy thereof acknowledged. The terms set forth are agreeable.
� �✓ u �y y
George,G— stopoulos,.Esquire Michelle Deal, Parent and Natural
Guardian of Alyssa Deal
Date:
•^ +���++�•• �.vi vi vv.a_.. 1L 12 vv rra rAVL. G/VVG
Nationwide Insurance
Allied Insurance
Natiomvide Agribusiness
Titan Insurance
On Your Side" Victoria Insurance
George Costopoulos, Esq.
Date prepared October 8,2013
George Costopoulos, Esq. Claim number 58 37 D 111465
153 N. Hanover St. 05042012 01
Carlisle, PA 17103
Questions? Contact Claims Associate
Maria Amanto
amantom @nationwide.com
Phone (610)2342795
Claim details
Insurer Nationwide Mutual Insurance Company
Policyholder Rosinda&Timothy Hopple
Claimant: Alyssa Deal
Claim number. 58 37 D 111465 05042012 01
Loss date: 05-04-2012
Dear Mr.Costopoulos,
Please allow this letter to serve as written confirmation that the above claim has been settled for$50,000.
This sum shall be paid in as one lump sum.
For more information
If you have any questions or concerns, please contact me at(610)234-2795 or amantom @nationwide.com.
Sincerely,
Maria Amanto
Nationwide Mutual Insurance Company
One Nationwide Gateway,Dept 5867
NESRO
DES MOINES,IA 50391-5868
Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement terially false Information or conceals for the
purpose of misleading, information co m. EXHIBIT ereto commits a fraudulent insurance act,
which is a crime and subjects such a nalties.
io
Z
Nationwide Insurance
Allied Insurance
Nationwide Agribusiness
Titan Insurance
On Your Side' Victoria Insurance
George Costopoulos, Esq.
Date prepared August 2, 2012
George Costopoulos, Esq. Claim number 58 37 D 111465 05042012 01
153 N. Hanover St.
Carlisle, PA 17103 Questions? Contact Claims Associate
Maria Amanto
amantom @nationwide.com
Phone (610)234-2795
Claim details
Insurer: Nationwide Mutual Insurance Company
Policyholder: Rosinda &Timothy Hopple
Claimant: Alyssa Deal
Claim number: 58 37 D 111465 05042012 01
Loss date: 05-04-2012
Dear Mr. Costopoulos, Esq.,
Please review your file and send me copies of any up to date specials, medical reports and
related information.
If your client is no longer treating, please forward the demand package.
Also,please be advised that our insured carries bodily injury liablity limits of$50,000 per
person and $100,000 per accident.
If you have any questions,please call me. Thank you for your cooperation.
For more information
If you have any questions or concerns, please contact me at(610)234-27V—
Sincerely,
Maria Amanto
Nationwide Mutual Insurance Company
One Nationwide Gateway, Dept 5867
NESRO
DES MOINES, IA 50391-5868
Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim con m EXHIBIT a information or conceals for the purpose of
misleading, information concerning an mits a fraudulent insurance act, which is a crime
and subjects such a person to criminal 2
0
a
Prepared on March 23,2012 Page 2 of 4
Nationwide® Your Policy Declarations
On Your Side
Nationwide Auto Policy
Policy Period: Apr 17,2012-Oct 17,2012
For coverage definitions and descriptions, Policy Number: 5837D111465
visit Nationwide.com
Insured Vehicle(s)and Schedule of Coverages
2000 Ford Expdtn
VIN 1FMFU16LXYLC37557
Coverages Limits of Liability Premium
Comprehensive and$1,500 Actual Cash Value Less$ 250 $ 39.40
IN Customization
Including Car Key
Replacement Coverage
Collision and$1,500 Actual Cash Value Less$ 500 $ 120.10
IN Customization
Including Pet Injury
Collision Coverage
Property Damage Liability $ 100,000 Each Occurrence $ 131.90
Bodily Injury Liability $ 50,000 Each Person
$ 100,000 Each Occurrence $ 71.30
Uninsured Motorists-Bodily Injury (Non-Stacked)
$ 25,000 Each Person
$ 50,000 Each Occurrence $ 3.30
Underinsured Motorists-Bodily Injury (Non-Stacked)
$ 25,000 Each Person
First Party Benefits $ 50,000 Each Occurrence $ 10.80
Option 1-Medical Benefit $ 5,000
Option 2-Income Loss Benefit $ 5,000 Total $ 24.40
$ 1,000 Monthly $ 4.70
Option 3-Accidental Death Benefit $ 10,000
Option 4-Funeral Benefit $ 2,500 $ 1.30
Limited Tort $ 20
Vehicle Endorsements 3455A 3475
Lienholder-Credit Acceptance Lien Expires On Jul 21,2013
Total for this Vehicle $ 407.40
Continued on the next page
Prepared on March 23,2012 Page 3 of 4
Nationwide® Your Policy Declarations
On Your Side
Nationwide Auto Policy
Policy Period: Apr 17,2012-Oct 17,2012
Policy Number: 5837D111465
Insured Vehicle(s)and Schedule of Coverages(continued)
1997 Pontiac Gr Am Se
VIN 1G2NE12T5VC825594
Coverages Limits of Liability Premium
Property Damage Liability $ 100,000 Each Occurrence $ 110.40
Bodily Injury Liability $ 50,Q00 Each Person
$ 100,000 Each Occurrence $ 68.90
Uninsured Motorists-Bodily Injury (Non-Stacked)
$ 25,000 Each Person
$ 50,000 Each Occurrence $ 3.30
CD Underinsured Motorists-Bodily Injury (Non-Stacked)
CD $ 25,000 Each Person
LA $ 50,000 Each Occurrence $ 10.80
C) First Party Benefits
CD Option 1-Medical Benefit $ 5,000 $ 26.70
o Option 2-Income Loss Benefit $ 5,000 Total
N $ 1,000 Monthly $ 5.50
C) Option 3-Accidental Death Benefit $ 10,000 $ 1.50
Option 4-Funeral Benefit $ 2,500 $ .30
Limited Tort
Total for this Vehicle $ 227.40
1996 Ford Explrera
VIN 1FMDU35PXTZB00471
Coverages Limits of Liability Premium
Property Damage Liability $ 100,000 Each Occurrence $ 120.60
Bodily Injury Liability $ 50,000 Each Person
$ 100,000 Each Occurrence $ 71.40
Uninsured Motorists-Bodily Injury (Non-Stacked)
$ 25,000 Each Person
$ 50,000 Each Occurrence $ 3.30
Underinsured Motorists-Bodily Injury (Non-Stacked)
$ 25,000 Each Person
$ 50,000 Each Occurrence $ 10.80
First Party Benefits
Option 1-Medical Benefit $ 5,000 $ 25.00
Option 2-Income Loss Benefit $ 5,000 Total
$ 1,000 Monthly $ 5.30
Option 3-Accidental Death Benefit $ 10,000 $ 1.40
Option 4-Funeral Benefit $ 2,500 $ .30
Limited Tort
Total for this Vehicle $ 238.10
Continued on the next page
' Prepared on March 23,2012 Page q of 4
On Your Side
Nationwide® Your Policy Declarations
Nationwide Auto Policy
Policy Period: Apr 17,2012-Oct 17,2012
Policy Number: 5837D 111465
Policy Level Schedule of Coverages
Coverages Limits of Liability Premium
Roadside Assistance Plus-Covers Disablement $ 20.00
Up To 100 Miles/$100 Lockout/
$ 500 Trip Interruption
Endorsement 3436
Accident Forgiveness Feature incl
-Accident Currently Forgiven
Total for Policy Coverages $ 20.00
Policy Form and Endorsements
V-0378 Nationwide Auto Policy
V-3272 Limited Tort Option Election(Pennsylvania)
V-3329 Amendatory Endorsement
V-3393 Guaranteed Automobile Insurance Coverage(Pennsylvania)
V-3457 Amendatory Endorsement(Pennsylvania)
V-3453 Amendatory Endorsement
V-3436 Roadside Assistance Coverage
V-3535 Amendatory Endorsement
V-3455A Car Key Replacement Coverage
V-3475 Pet Injury Collision Coverage
For Office Use Only: H0815024
03/15/12 $ 0.00
Issued By: Nationwide Mutual Insurance Company
Countersigned At: Harrisburg,PA.
By: R Sue Dangello Nalu
How to Contact Us
Your Nationwide Agent R.Sue Dangello 717.532.8478
Customer Service 1.877.669.6877
Internet Nationwide.com
24-Hour Claims Reporting 1.800.421.3535
Hearing Impaired(TTY) 1.800.622.2421
Providing Insurance and Financial Services
Home Office, Bloomington. IL Rau..1rin'
August 26, 2013
George J. Costopoulos, Esq. State Farm Claims
153 N Hanover St PO Box 106114
Carlisle PA 17013-2409 Atlanta GA 30348-6114
RE: Claim Number: 48-126T-279
Date of Loss: May 04, 2012
Our Insured: Michelle Deal
Policy Number: 072215348C
Your Client: Alyssa Deal
Dear Mr. Costopoulos:
Per our discussion, we completed our evaluation of Ms. Deal's UIM claim.
We are tendering our limit of underinsured motor vehicle coverage or$25,000.00. At your
earliest convenience, please forward Alyssa's minor's compromise. Once received, we will
forward our draft immediately to you.
Your cooperation is appreciated.
Sincerely,
Robert W Heck
Claim Representative
(610) 361-4817
Fax: (888) 713-4693
State Farm Fire and Casualty Company
EXHIBIT
Z
w
a
Providing Insurance and Financial Services '
Home Office,Bloomington,IL O* far Cr,
September 06, 2013
George J. Costopoulos State Farm Claims
153 N Hanover St PO Box 106114
Carlisle PA 17013-2409 Atlanta GA 30348-6114
RE: Claim Number. 48-126T-279
Date of Loss: May 04, 2012
Our Insured: Michelle Deal
To Whom It May Concern:
Enclosed is the Release confirming our settlement agreement in the amount of$*25,000.00**.
After the Release is properly signed, dated, and retumed to this office,we will forward payment.
To ensure we can identify and match all documents to the claim file, please include the claim
number on all correspondence.
If you have any questions, please contact us
Sincerely,
Kimberly Sokol
Claim Represer)tative
(888)713-4694 F-4t. 7247430119
"Ft A
State Farm Fire ON Car;.ualty Company
{
Enclosures: Release
k
PS: We will need court ap rriraXaI fqr minor's settlement,
h
EXHIBIT
6
a
0
0
Z
Release
For the Sole Consideration of
48-126T-279
**Twenty five thousand and 00/100 ("$25,000.00`*)dollars the receipt and sufficiency whereof is hereby acknowledged,
the undersigned hereby releases and forever discharges Michelle Deal her heirs, executors, administrators, agents and
assigns, and all other persons,firms or corporations liable or,who might be claimed to be liable, none of whom admit any
liability to the undersigned but all expressly deny any liability,from any and all claims, demands,damages, actions,
causes of action or suits of any kind or nature whatsoever, and particularly on account of all injuries, known and unknown,
both to person and property, which have resulted or may in the future develop from an accident which occurred on or
about May 04, 2012, at or near Mount Rock Elementary School, Newville, PA.
This release expressly reserves all rights of the parties released to pursue their legal remedies, if any, against the
undersigned, their heirs,executors, agents and assigns.
Undersigned hereby declares that the terms of this settlement have been completely read and are fully understood and
voluntarily accepted for the purpose of making a full and final compromise adjustment and settlement of any and all
claims, disputed or otherwise, on account of the injuries and damages above mentioned, and for the express purpose of
precluding forever any further or additional claims arising out of the aforesaid accident.
Undersigned hereby accepts draft or drafts as final payment of the consideration set forth above.
Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or a statement of claim containing any materially false information or conceals for
the purpose of misleading, information concerning any fact material hereto commits a fraudulent insurance
act,which is a crime and subjects such person to criminal and civil penalties.
In Witness Whereof,
I/We have hereunto set 111y/qur:hand(s)anal peal(s)this _day of (year)
r
In presence of:
Signed X:
Witness Sipnat re
Name:
Witness yams'( nt)
Signed X:
Address
Name:
Aw State Farm-
Certified Policy Record
I, the undersigned, do hereby certify that I am custodian of the records pertaining to the issuance of
policies by State Farm Fire and Casualty Company.
I certify that the attached documents represent a true and accurate record of the terms and conditions
of Policy Number 072 2153-1305-48C including any endorsements and/or inserts, if applicable, for the
policy term(s) 02/05/2012 - 08/05/2012 and insuring Michelle Deal of 1510 Rader St, Summersville
WV 26651-1582 based on available records.
It is State Farm's business practice to print a new Declarations Page only when a policy issuance
transaction such as a change of coverage occurs. Therefore, the included Declarations Page which
was in effect at the time of loss will indicate the policy period of the last policy issuance transaction.
The policy was in effect on the loss date of 05/04/2012.
Jean Hassler
Auto Operations Team Manager
State of Virginia
County of Albemarle
Subscribed and sworn to before me this�_day of 1 0 oil 20 I c�..
Notary Public
My Commission Expires: 3 �b((�
Karen S Hasenius
NOTARY PUBLIC
REG,#101962
COMMONWEALTH OF VIRGINIA
MY COMMISSION EXPIRES JAN.31,2016
1004516 EXHIBIT 2000 143551 200 03-21-2012
Z
W
d
State Farm Fire and Casualty Company 59644-4-Q FIRE OVL
1500 State Farm Blvd DECLARATIONS PAGE
Charlottesville VA 22909
NAMED INSURED
AT1 48-1336-4 Q A POLICY NUMBER 072 2153-1305-48C
000283 0058
DEAL, MICHELLE POLICY PERIOD OCT 18 2011 to FEB 05 2012
1510 RADER ST 12:01 A.M.Standard Time
Mw SUMMERSVILLE WV 26651-1582
STATE FARM PAYMENT PLAN NUMBER
0408441221
AGENT
ROD WIGHTMAN a
ARBUCKLE ROAD AND LAYNE DRIVE
SUMMERSVILLE,WV 26651
NO
l
PHONE:(304)872-4400 or (304)872-3060
DO NOT PAY PREMIUMS SHOWN ON THIS PAGE.
IF AN AMOUNT IS DUE,THEN A SEPARATE STATEMENT IS ENCLOSED.
YOUR CAR
1998 PONTIAC SUNFIRE 2DR 1 G2JB1240W7504167 1 BOO171200
B OVFA ilsr
a�llity,'�GY1RGaQ.,
Bodil In'u Limits o
$25,000 $50 00x10
Mr M
Each Accident
C Medical Pa ments Covers e
$109.66
r x � x
$25000
U Uninsured Motor Vehicle Covers a $18.32
Each Person Each Accident
i Mmm
Pro a Dama a Limit �-
$25,000 FIN
Bodil In'u Limits §
$25000 50 000
Each Accident
S Death,Dismemberment and Loss of Si ht Covera e
$2.79
DEAL MITCHELL
, _., `FEBl15' OT2K
F-
Replaced policy number 0722153-48B.
Your total renewal premium for AUG 05 2011 to FEB 05 2012 Is$696.27.
Location used to determine rate charged-1510 RADER ST,SUMMERSVILLE WV 26651.
YOUR POLICY CONSISTS OF THIS DECLARATIONS PAGE THE POLICY BOOKLET -
FORM 9848A AND ANY ENDORSEMENTS THAT APPLY, IACLUDING THOSE ISSUED TO YOU
4�ITH ANY SOBSEQUENT RENEWAL NOTICE.
bCOVBU-BASICA$12.05OEXC ENDORSEMENT.. .
,'Agent: ROD WIGHTMAN
Telephone:(304)872-4400
0 06 06/01 979 See Reverse Side Prepared OCT 27 2011 1336-661
155-0866.2 04-2005((.1a025M) (.7.0254.)
14SMN (ote025te)
d 1
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY,PENNSYLVANIA
In re: ALYSSA DEAL, PETITION FOR COURT APPROVAL
a Minor OF MINOR'S SETTLEMENT
NO. 13 - 3 C r L
ORDER
AND NOW,this day of '2013, upon consideration of
the herein Petition for Approval of Minor's Settlement, it is hereby ORDERED and DECREED
that Petitioner, Michelle Deal, as parent and natural guardian of Alyssa Deal, a minor child, and
George J. Costopoulos, Esquire, are authorized to enter into settlements for: (1) $50,000.00 in
bodily injury liability benefits with Nationwide Mutual Insurance Company; (ii) $25,000.00 in
bodily injury liability benefits with State Farm Fire and Casualty Company; and(iii) $25,000.00
in underinsured motorist benefits with State Farm Fire and Casualty Company, for a total
combined sum of$100,000.00:
It is further ORDERED and DECREED that all settlement drafts or checks shall be
forwarded to the Law Offices of George J. Costopoulos for proper distribution of the aggregate
gross proceeds as follows:
a. Alyssa Deal, a minor: $75,000.00
b. Law Offices of George J. Costopoulos: $25,000.00
(Counsel fee at 25%)
Total Settlement: $100,000.00
it is further ORDERED and DECREED that the net proceeds of the settlement for Alyssa
Deal, a minor, in the amount of$75,000.00, is to be deposited in one or more savings accounts
in the name of Alyssa Deal in banks, building and loan associations, savings and loan
r
w rt
associations or credit unions, deposits in which are insured by a federal government agency or in
one or more accounts in the name of Alyssa Deal investing only in securities guaranteed by the
United States government or a federal governmental agency managed by responsible financial
institutions. Said accounts shall contain a provision that no withdrawal can be made from any
such account until the minor attains majority, except as authorized by a prior order of court.
Proof of the deposit shall be promptly filed of record.
BY THE COURT:
I
J.
Distribution:
Xaw Offices of George J. Costopoulos
153 N. Hanover Street
Carlisle,PA 17413
g c7 70
uo
X-C,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY,PENNSYLVANIA
c:
71 a
In re: ALYSSA DEAL, : PETITION FOR APPOINTMENT;
a Minor : GUARDIAN AD LITEM FOR e
-T`
: NO. 13-7293 Civil Term
i>c
N.)
PETITION FOR APPOINTMENT OF GUARDIAN AD LITEMFOR MINOR
AND NOW COMES the Petitioner, George J. Costopoulos,Esquire, and respectfully
represents:
1. Petitioner is George J. Costopoulos,Esquire, an attorney who is licensed to
practice law in the Commonwealth of Pennsylvania(I.D. No. 78423), maintaining an office
address at 153 North Hanover Street, Carlisle,Pennsylvania 17013.
2. The minor,Alyssa Deal, was born on 08/29/04, and currently resides with her
mother and natural guardian,Michelle Deal, at 41 Robinson Street, Summersville, West
Virginia, 26651.
3. Petitioner was retained by Michelle Deal to represent Alyssa for the injuries she
sustained in a motor vehicle collision on May 4, 2012.
4. Petitioner negotiated a settlement on behalf of Alyssa, and on December 18,
2013, this Honorable Court issued an Order approving said settlement and granting distribution
of the proceeds in accordance with a petition presented by Michelle Deal. See Order of
December 18, 2013, attached hereto as Exhibit "A"; see also Petition for Approval of Minor's
Settlement(exhibits omitted), attached hereto as Exhibit "B. "
5. This Honorable Court's Order specified that the net proceeds of$75,000.00 are
"to be deposited in one or more savings accounts in the name of Alyssa Deal in banks,building
and loan associations, savings and loan associations or credit unions, deposits in which are
insured by a federal government agency or in one or more accounts in the name of Alyssa Deal
investing only in securities guaranteed by the United States government or a Federal
Governmental agency managed by responsible financial institutions. Said accounts shall contain
a provision that no withdrawal can be made from any such account until the minor attains
majority, except as authorized by a prior order of court." See Exhibit A.
6. Following the entry of this Order,Petitioner received the total settlement
proceeds from the appropriate insurance carriers, and deposited said proceeds in his client
escrow account to effectuate the settlement distribution. In the weeks that followed, however,
Petitioner experienced considerable difficulty making contact with Michelle Deal to arrange for
the opening of an account in which to deposit Alyssa's settlement proceeds pursuant to the
Court's Order of December 18, 2013.
7. After repeated attempts, in late February, 2014, Petitioner was finally able to
reach Michelle Deal, who attributed her unavailability to ongoing serious health problems which
resulted in a recent hospitalization. She added that her family had moved from Pennsylvania to
West Virginia, further contributing to her unavailability.
8. Due to these circumstances, and following a lengthy discussion,Michelle Deal
requested and authorized Petitioner to establish a bank account for Alyssa and to deposit her
settlement proceeds therein.
9. In order to accomplish this objective,Petitioner believes it is necessary he be
appointed Guardian Ad Litem of Alyssa for the limited purpose of establishing an account in her
name and depositing the balance of the settlement proceeds therein, as specified in this Court's
2
Order of December 18, 2013.
10. Michelle Deal executed an authorization requesting the appointment of Petitioner
as Guardian Ad Litem of Alyssa for this limited purpose. See Authorization for Appointment of
Guardian Ad Litem, attached hereto as Exhibit "C. "
11. Petitioner believes said appointment would be in the best interests of Alyssa, and
will result in the deposit of her settlement proceeds into a federally insured interest bearing
account without further delay. Following the opening of this account,Petitioner, as Guardian Ad
Litem, will promptly file proof of deposit with the Court.
WHEREFORE,Petitioner respectfully requests that this Honorable Court issue an Order
appointment him Guardian Ad Litem for the limited purpose of establishing an account in the
name of Alyssa Deal, a minor, and depositing the aforementioned settlement proceeds therein,
pursuant to this Honorable Court's Order of December 18, 2013.
RESPECTFULLY SUBMITTED:
r �
Geor.,1410 stopoulos,Esquire
I.D. No. 78423
153 North Hanover Street
Carlisle,Pennsylvania 17013
Phone: (717)243-0407
Attorney for Alyssa Deal, a minor
Date: 2 /19--//y
3
VERIFICATION
I, George J. Costopoulos,Esquire, do hereby verify that the statements made in the
foregoing Petition are true and correct. I understand that any false statements herein are made
subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.
GE/A,E J. COSTOPOULOS
Date: z/2'-//r
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY,PENNSYLVANIA
In re: ALYSSA DEAL, : PETITION FOR COURT APPROVAL
a Minor : OF MINOR'S SETTLEMENT
NO. /3 793
fur
1�
AND NOW,this 134\ day of I)en(1 ,2013,upon consideration of
the herein Petition for Approval of Minor's Settlement,it is hereby ORDERED and DECREED
that Petitioner,Michelle Deal, as parent and natural guardian of Alyssa Deal, a minor child, and
George J. Costopoulos, Esquire, are authorized to enter into settlements for: (i)$50,000.00 in
bodily injury liability benefits with Nationwide Mutual Insurance Company; (ii)$25,000.00 in
bodily injury liability benefits with State Farm Fire and Casualty Company; and(iii)$25,000.00
in underinsured motorist benefits with State Farm Fire and Casualty Company, for a total
combined sum of$100,000.00.
It is further ORDERED and DECREED that all settlement drafts or checks shall be
forwarded to the Law Offices of George J. Costopoulos for proper distribution of the aggregate
gross proceeds as follows:
a. Alyssa Deal, a minor: $75,000.00
b. Law Offices of George J. Costopoulos: $25,000.00
(Counsel fee at 25%)
Total Settlement: $100,000.00
It is further ORDERED and DECREED that the net proceeds of the settlement for Alyssa
Deal, a minor, in the amount of$75,000.00, is to be deposited in one or more savings accounts
in the name of Alyssa Deal in banks,building and loan associations, savings and loan
ILl
associations or credit unions, deposits in which are insured by a federal government agency or in
one or more accounts in the name of Alyssa Deal investing only in securities guaranteed by the
United States government or a federal governmental agency managed by responsible financial
institutions. Said accounts shall contain a provision that no withdrawal can be made from any
such account until the minor attains majority, except as authorized by a prior order of court.
Proof of the deposit shall be promptly filed of record.
BY THE COURT:
)5P 491
Distribution:
Law Offices of George J. Costopoulos
153 N. Hanover Street
Carlisle, PA 17013
r�
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY,PENNSYLVANIA c 7
In re: ALYSSA DEAL, : PETITION FOR COURT APPRO r ,=
a Minor : OF MINOR'S SETTLEMENT �.
-< a
< -- C:1-.1
• 3
: NO. r?= .%
PETITION FOR APPROVAL OF MINOR'S SETTLEMENT -° r•
AND NOW COMES the Petitioner,Michelle Deal, as parent and natural guardian of
Alyssa Deal, a minor child,by and through George J. Costopoulos,Esquire,and represents:
1. Petitioner is Michelle Deal,who resides at 5145 North Susquehanna Trail
Lot 19, York,PA 17406. She is the parent and natural guardian of Alyssa Deal, age 9. Alyssa's
date of birth is 08/29/04; her social security number is 408-99-1473.
2. On May 4, 2012, Alyssa was injured in a motor vehicle collision while a
front seat passenger in an automobile driven by her mother,Michelle Deal. The collision
occurred when Michelle Deal, attempting to make a left turn into the parking lot of Alyssa's
elementary school, was struck by an oncoming vehicle driven by Mitchell Hopple. A copy of the
police crash report is attached as Exhibit"A."
3. The collision, which occurred in West Pennsboro Township, Cumberland
County, Pennsylvania, caused multiple cuts and lacerations to the right side of Alyssa's face.
Alyssa's injuries were treated conservatively at the emergency room and through follow-up visits
with her doctors. A plastic surgeon was consulted who opined that Alyssa had residual facial
scarring which may be permanent.
4. On June 21, 2012, the undersigned counsel was retained to negotiate a
settlement and/or to institute legal proceedings for Alyssa's damages resulting from the
collision. A copy of the fee agree • - •ibit`B."
EXHIBIT
1
5. In September, 2013, the undersigned counsel negotiated a proposed third party
settlement on Alyssa's behalf with Nationwide Mutual Insurance Company, the insurer of the
vehicle driven by Mitchell Hopple, for the full amount of its bodily injury liability limits of
$50,000.00. Copies of Nationwide's Settlement Letter and Certification of Coverage are
attached as Exhibits"C"& "D."
6. Around this time,the undersigned counsel also negotiated proposed settlements
on Alyssa's behalf with State Farm Fire and Casualty Company, the insurer of the vehicle driven
by Michelle Deal, for the full amount of its underinsured motorist benefits of$25,000.00, and
for the full amount of its bodily injury liability limits of$25,000.00, for an additional proposed
settlement of$50,000.00. Copies of State Farm's Offer Letters and Certification of Coverage
are attached as Exhibits "E," "F,"& "G."
7. The undersigned counsel is of the professional opinion that these proposed
settlements, totaling$100,000.00, are reasonable given the exhaustion of the policy limits from
all sources of insurance coverage through both Nationwide and State Farm, and based on
previous settlements in comparable matters.
8. There are no unpaid creditors or liens against the proposed settlements, and
approval thereof will not prejudice any rights belonging to Alyssa.
9. From the total combined proposed settlement of$100,000.00, Petitioner consents
to a distribution to the undersigned counsel consistent with their contingent fee agreement,
which provides for counsel fees in the amount of 25%($25,000.00). The undersigned counsel
has agreed to waive reimbursement of case related costs for the benefit of Alyssa.
10. Petitioner agrees that the proposed settlement, along with the distribution to the
undersigned counsel, is fair and reasonable, and therefore requests that this Honorable Court
enter an Order:
a) approving the settlements for: (i)$50,000.00 in bodily injury liability
benefits with Nationwide Mutual Insurance Company; (ii)$25,000.00 in
bodily injury liability benefits with State Farm Fire and Casualty
Company; and(iii) $25,000.00 in underinsured motorist benefits with
State Farm Fire and Casualty Company, with the net proceeds of
$75,000.00 to be deposited in one or more savings accounts in the name
of Alyssa Deal in banks,building and loan associations, savings and loan
associations or credit unions, deposits in which are insured by a federal
government agency or in one or more accounts in the name of Alyssa Deal
investing only in securities guaranteed by the United States government or
a Federal Governmental agency managed by responsible financial
institutions. Said accounts shall contain a provision that no withdrawal
can be made from any such account until the minor attains majority,
except as authorized by a prior order of court. Proof of the deposit shall
be promptly filed of record; and
b) approving the payment of counsel fees of$25,000.00 to the Law Offices
of George J. Costopoulos.
11. Petitioner requests that the Court enter the aforementioned Order without the
need for a hearing. However, should the Court deem it necessary to schedule a hearing, Alyssa
and Petitioner together with the undersigned counsel will be present at the hearing.
WHEREFORE,Petitioner respectfully requests that this Honorable Court issue an Order
approving the aforementioned proposed settlements on behalf of Alyssa Deal, a minor, and the
distribution and payment of counsel fees.
RESPECTFULLY SUBMITTED:
4&---
George Costopoulos,Esquire
I.D.No. 8423
153 North Hanover Street
Carlisle,Pennsylvania 17013
Phone: (717)243-0407
Attorney for Alyssa Deal, a minor
Date: i1- I/o 1/3
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY,PENNSYLVANIA
In re: ALYSSA DEAL, : PETITION FOR APPOINTMENT OF
a Minor • GUARDIAN AD LITEM
: NO.
AUTHORIZATION FOR APPOINTMENT OF GUARDIAN AD LITEM
I,Michelle Deal, an adult individual residing at 41 Robinson Street, Summersville, West
Virginia, 26651,hereby authorize and request that the Court appoint George J. Costopoulos,
Esquire, Guardian Ad Litem of my minor daughter,Alyssa Deal (date of birth 08/29/04; social
security number 408-99-1473), for the limited purpose of establishing an account in her name
and depositing therein the balance of the settlement proceeds in accordance with in the attached
Order,dated December 18, 2013,docketed at No. 13-7293 Civil Term.
I sign this authorization of my own free will, for the limited purposes expressed herein,
fully understanding my actions.
Sworn or affirmed to and acknowledged before me by Michelle Deal,this 21st day of
February, 2014.
Notary Public
A\\ c
Michelle eal
JENNIFER SEAL jD3 QY\
JENNIFER SLEAR ,���
Notary Public �-�
CARLISLE BORO.,CUMBERLAND COUNTY Social Security Number
My Commission Expires May 9,2016
EXHIBIT
w
a
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
In re: ALYSSA DEAL, : PETITION FOR APPOINTMENT OF
a Minor : GUARDIAN AD LITEM FOR MINOR
: NO. 13-7293 Civil Term
ORDER
AND NOW, this fit day of /fidAe-A-/ , 2014, upon consideration of
the herein Petition for Appointment of Guardian Ad Litem, it is hereby ORDERED and
DECREED that George J. Costopoulos, Esquire is appointed Guardian Ad Litem of minor,
Alyssa Deal, for the limited purpose of establishing an account in the name of Alyssa Deal, a
minor, and depositing the balance of settlement proceeds therein. It is further ORDERED and
DECREED that said account shall be established, and the settlement proceeds deposited, in
accordance with the Order of this Court, dated December 18, 2013, docketed at No. 13-7293
Civil Term.
BY THE COURT:
Distribution:
George J. Costopoulos, Esquire
153 N. Hanover Street
Carlisle, PA 17013
Christylee L. Peck, J.
-
-c-
=.
';•=3.
••••••..
IN TBE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
In re: ALYSSA DEAL,
a Minor
AFFIDAVIT OF DEPOSIT OF
MINOR'S SETTLEMENT FUND C:1
c -s
: NO. 13-7293 Civil Term
AFFIDAVIT OF DEPOSIT OF MINOR'S FUNDS
I, George J. Costopoulos, Esquire, counsel and guardian ad litem for Alyssa Deal, a
minor, in the above -captioned matter, hereby state and affirm as follows:
1. On May 19, 2014, the sum of $75,000.00 was deposited into a federally
insured savings account (Account No.: 15004229460776), with M&T Bank, pursuant to the
Court Orders entered on December 18, 2013 and March 5, 2014.
2. A copy of the above -referenced Court Orders were provided to M&T Bank at
the time the account was opened.
3. The account is in the name of the minor, Alyssa Deal, born August 29, 2004, and
the express prohibition of withdrawals of income or principal before the minor attains majority,
except by order of Court, has been noted on the depository's records. A copy of M&T Bank's
Record is attached hereto as Exhibit "A."
BY:
Date:l/Z ®// /
J. Costopoulos, Esquire
# 78423
153 North Hanover Street
Carlisle, PA 17013
Phone: (717) 243-0407
Attorney/Guardian ad litem for Alyssa Deal
�.7•-; . .�v...uu�iiivcuuc. W..11L1L Lcu
RSHO 2 FSS RST HARD HOLD INQ/MAINT 14/05/19 14.35.35
RSMU CO 96 OP EBRN MS ACTION SUCCESSFUL
ACTION ADD COID
PROD CODE DDA ACCT 15004229460776 SHORT NAME DEAL ALYSSA
CLASS: 1 (1,2,3) TYPE: 13 SEQ CURRENCY
TYPE CODE
REASON CODE
SPECIAL COMMENTS LINE 1
LINE 2
RESTRAINT REASON LINE 1
LINE 2
STATUS CODE VALUES :
1 = ACTIVE
A = ACTIVE PAID
DATE PLACED 114/05/19
DATE EXPIRES 999/99/99
STATUS CODE 1
NO WITHDRAWALS TO BE MADE FROM
THIS ACCOUNT UNTIL MINOR ATTAI
NS MAJORITY,(18)EXCEPT BY AUTH
ORTIY OF A COURT ORDER.
2 = DELETE
B = DELETE PAID
PF: 2 -CONT 4-CHG 5 -FAD 6-INQ 9-NXT -DEL -ADD
Date: 5/19/2014 Time: 2:38:06 PM