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Home My WebLink About02-25-05 SWARTZ CAMPBELL LLC By: Christina L. Bradley, Esquire I.D. No. 89107 1631 North Front Street, 2"d Floor Harrisburg, PA 17102 (717) 233-3515 Attorney for Petitioners, Michael Diller, James Sadler, Jordan Sadler and Nationwide Mutual Fire Ins. Co. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION IN RE: SETTLEMENT OF PERSONAL INJURY CLAIM OF KYLE STIMELING A MINOR No. ;;}t - 0 '5 - .101 "~,, ~ PETITION FOR LEAVE TO COMPROMISE MINOR'S CLAIM ..-,,: Pursuant to PaRC.P. 2039, Michael Diller, James Sadler, Catherine Sadler, Jordan Sadler, -' Lori Schweitzer, Alex Schweitzer and Nationwide Mutual Fire Insurance Company, by and through their attorneys, Swartz Campbell, LLC, hereby petition this Honorable Court to enter an Order permitting settlement in compromise of this action, and in support thereof, aver the following: 1. Petitioner, Michael Diller is an adult individual residing at 6875 Wertzville Road, Enola Pennsylvania, 17025-1035. 2. Lori Schweitzer is an adult individual and the parent and natural guardian of Alex Schweitzer, a minor, both of whom also reside at 6875 Wertzville Road, Enola Pennsylvania, 17025- 1035 with petitioner Michael Diller. 3. Petitioners James Sadler and Catherine Sadler are an adult individuals and James Sadler is the parent and natural guardian of Jordan Sadler a minor, both of whom reside at 5 Lodge Road, Mechanicsburg, PA 17055. 4. Petitioner Nationwide Mutual Fire Insurance Company (hereinafter "Nationwide"), is a corporation organized and existing under the laws of the State of Ohio and having its principal place of business in Columbus, Ohio, being duly authorized to conduct business in the Commonwealth of Pennsylvania at 1137 A Kennebec Drive, Chambersburg, P A 17201. 5. Respondents Mark and Tammy Stimeling are adult individuals residing at 6 Red Fox Lane, Mechanicsburg, Pennsylvania, 17050, and are the natural parents and guardians of respondent Kyle Stimeling, a minor, who was born on February 25, 1991. 6. Petitioner Nationwide, has agreed to incur the expense of preparing the instant Petition. 7. On or about December 31, 2003, while on the property of petitioner Michael Diller, petitioner Jordan Sadler, a minor, and respondent Kyle Stimeling, a minor, along with Alex Schweitzer and several other friends, all minors, were playing with pellet guns and shooting target practice. 8. At the time ofthe occurrence, Kyle Stimeling had placed the pellet gun he was using in the "fort" which was on the Diller's property. The other boys did the same. Kyle proceeded to cross the field, and Jordan Sadler was using the pellet gun of Alex Schweitzer at the time. The truck was in close proximity to Kyle and to his left. Jordan Sadler was the only boy shooting at the time, and evidently, one of the pellets that he shot at the truck accidently ricocheted offthe truck and struck respondent Kyle Stimeling in the left eye. Attached and marked as Exhibit "A" is a photocopy ofa photograph of the scene ofthe incident which identifies the location ofthe truck and the approximate locations of Kyle Stimeling and Jordan Sadler at the time ofthe incident. 9. Kyle was immediately taken to the emergency room at Holy Spirit Hospital in Camp Hill, Pennsylvania, where he was diagnosed with sustaining an obvious anterior chamber hyphema and obvious globe penetration of his left eye. Attached hereto and marked as Exhibit "B" are true and correct copies of Kyle Stimeling's medical records following the incident in question. 10. While at the hospital, Kyle underwent surgical repair of his ruptured globe and removal of the foreign body from his left eye. See Exhibit "8" 11. Following his treatment at the hospital, Kyle Stimeling has seen a number of specialists concerning his eye, but despite his treatment, Kyle currently has no light perception or vision in his \eft eye, and no additional improvement is anticipated. See Exhibit "8" 12. In addition, it is anticipated that at some point in the future, Kyle will need to undergo enucleation or evisceration of the left eye with placement of an orbital implant and prosthesis. The orbital implant and prosthesis will obviously require routine ongoing care and maintenance. See Exhibit "B". 13. Kyle's parents, respondents Mark and Tammy Stimeling had insurance coverage at the time of the accident through Capital Blue Cross, subject to various deductibles and required co- pays. To date, Capital Blue Cross has paid approximately $4977.08 and are asserting a lien against any recovery made on behalf of Kyle Stimeling. Attached hereto and marked as Exhibit "c" is evidence of the lien being asserted on behalf of Blue Cross. 14. The Stimelings, because of their applicable co-pays and deductibles, have been required and will be continued to be required to pay all applicable co-payments and deductibles out of their own pocket. 15. In addition, it is believed that Kyle Stimeling will be required to undergo future medical treatment prior to his eighteenth (18th) birthday, and incur additional medical expenses, including but not limited to the cost for placement of the orbital implant and prosthesis. 16. At the time of the incident, property owner, Michael Diller, had liability insurance coverage through a homeowner policy issued by petitioner, Nationwide Mutual Fire Insurance Company with $300,000.00 in liability coverage. Attached hereto and marked as Exhibit D is a true and correct copy of Michael Diller's declaration's page from Nationwide. 17. In addition, petitioner Jordan Sadler, a minor, had liability coverage through a homeowner policy issued to his father, petitioner James Sadler, by petitioner Nationwide Mutual Fire Insurance Company with $100,000.00 in liability coverage. Attached hereto and marked as Exhibit E is a true and correct copy of James Sadler's declarations page from Nationwide. 18. Nationwide, on behalf of petitioner Michael Diller, the property owner, has already paid Mr. and Mrs. Stimeling $3,000.00 to reimburse them for their out of pocket expenses incurred to date. 19. In addition, a settlement, pending court approval, has been reached between the parties and Nationwide has agreed to pay Kyle Stimeling, $100,000.00 from the insurance policy issued to petitioner James Sadler, and an additional $240,000.00 from the insurance policy issued to petitioner Michael Diller. (The settlement totals $340,000.00 plus the $3,000 previously advanced). The terms of the settlement release Michael Diller, James Sadler, Catherine Sadler, Jordan Sadler, Lori Schweitzer and Alex Schweitzer from any and all liability, including but not limited to past and future medical expenses. 20. It is further agreed between the parties and proposed that the settlement proceeds be distributed as follows: a. $40,000 to be paid to Mark and Tammy Stimeling to be held in trust for minor Kyle Stimeling and to be used only to pay the existing $4,977.08 lien being asserted on behalf of Blue Cross and any future medical expenses necessary for the treatment of the injuries sustained by Kyle Stimeling in loss of December 31, 2003. Any balance remaining of this $40,000.00 must be immediately paid to Kyle Stimeling upon his eighteenth (I8!h) birthday. b. $300,000.00 will be placed in guaranteed structured settlement account for Kyle Stimeling which will make the following periodic payments: I. $950.00 per month to Kyle Stimeling, increasing 3% compounding on an annual basis for LIFE with 30 years guaranteed. First payment will be on February 25, 2009 and the last guaranteed payment will be made on January 25,2039. Payments will continue thereafter for life. 2. $ 20,000.00 to Kyle Stimeling on February 25, 2016 3. $ 65,606.00 to Kyle Stimeling on February 25, 2026 4. $100,000.00 to Kyle Stimeling on February 25, 2036 5. $135,000.00 to Kyle Stimeling on February 25, 2046 21. The full terms of settlement are contained in the Settlement Agreement and Qualified Assignment, copies of which are attached hereto and marked as Exhibit "F". 22. Respondents Mark and Tammy Stimeling are aware that the release, is a general release of all claims and it releases Petitioners from any further liability for this incident, including any responsibility for past and future medical expenses, whether foreseen or unforseen. An affidavit signed by respondents is attached hereto and marked as Exhibit "G". 23. Respondents are also aware of their right to obtain legal representation in this matter and have decided to proceed without legal representation. Id. 24. Respondents approve of the proposed settlement because they believe, under the circumstances, that it is fair and adequate compensation for the injuries sustained by their son, and because they believe the settlement is in Kyle's best interest. Id 25. Respondents understand that once the Court approves of the settlement and once the settlement documents are executed, no further claim can be made against Michael Diller, James Sadler, Catherine Sadler, Jordan Sadler, Lori Schweitzer, Alex Schweitzer and/or their liability insurance companies for any of the injuries sustained by minor, Kyle Stimeling, in the incident of December 31, 2003, whether now known or unknown, including any and all claims for past and/or future medical expenses(foreseen and unforseen). Id WHEREFORE, Petitioners Michael Diller, James Sadler, Catherine Sadler, Jordan Sadler, Lori Schweitzer and Alex Schweitzer and Nationwide Mutual Fire Insurance Company respectfully request this Honorable Court to approve ofthe compromise or settlement ofthe personal injury claim made on behalf of Kyle Stimeling, by his parents, Mark and Tammy Stimeling. Respectfully submitted, SWARTZ CAMPBELL, LLC C1-u ~ L.13.-\C . CHRISTINA L. BRADLEY ~ Attorney for Petitioners j~.~ TammylStimeling Mother of Kyle Stimeling /~/c(#~ Mark Stimeling '-' Father of Kyle Stimeling SWARTZ CAMPBELL LLC By: Christina L. Bradley, Esquire I.D. No. 89107 1631 North Front Street, 2nd Floor Harrisburg, PA 17102 (717) 233-3515 Attorney for Petitioners, Michael Diller, James Sadler, Jordan Sadler and Nationwide Mutual Fire Ins.Co. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION IN RE: SETTLEMENT OF PERSONAL INJURY CLAIM OF KYLE STIMELING A MINOR No. ACCEPTANCE OF SERVICE TO THE CLERK OF THE ORPHAN'S COURT: We, Mark and Tammy Stimeling, parents and guardians of Kyle Stimeling, a minor, do hereby accept service ofthe petition of Michael Diller, James Sadler, Catherine Sadler, Jordan Sadler , Lori Schweitzer, Alex Schweitzer, and Nationwide Mutual Fire Insurance Company for Court Approval of Minor's Settlement/Compromise. j~ ~i 0 Tammy St\meling ~ \ Mother of Kyle Stimeling Date: cJ. - 7~ ().r /1/,v(' r.~ Mark Stimeling Father of Kyle Stimeling SWARTZ CAMPBELL LLC By: Christina L. Bradley, Esquire I.D. No. 89107 1631 North Front Street, 2"d Floor Harrisburg, PA 17102 (717) 233-3515 Attorney for Petitioners, Michael Diller, James Sadler, Jordan Sadler and Nationwide Mutual Fire Ins.Co. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA ORPHAN'S COURT DIVISION IN RE: SETTLEMENT OF PERSONAL INJURY CLAIM OF KYLE STIMELING A MINOR No. JOINDER IN PETITION We, Mark and Tammy Stimeling, parents and guardians of Kyle Stimeling, a minor, do hereby join in the Petition of Michael Diller, James Sadler, Catherine Sadler, Jordan Sadler, Lori Schweitzer, Alex Schweitzer and Nationwide Mutual Fire Insurance Company for Court Approval of Minor's Settlement/Compromise. J~ ~T 0 Tammy $timeling, 1 Mother of Kyle Stimeling ""- 1-6S- Date: V' #' d ?f'fi~ ~ Mark Stimeling, Father of Kyle Stimeling Ii ~ c io)~@~O!fl~m ~n MAR (J 2 2004 I ~ i ,~ By 1137AKENNEBECDRIVE .CHAMBERSBURG,PA 17201 .. :d March 1, 2004 HOLY SPIRIT HOSPITAL ATTN: MEDICAL RECORDS AND BILLING 503 N 21ST ST CAMP HILL, PA 17011-2288 MAY l. 0 2004 OUR CLAIM NUMBER: S8 37 HO 2727191231200301 DATE OF LOSS: 12-31-2003 YOUR PATIENT: Kyle Stimeling (parents-Tammy and Mark) PATIENT NUMBER: ADDRESS: 6 Red Fox Lane Mechanicsburg, PA 17055 SOCIAL SECURITY: DATES OF SERVICE: 12/31103 We enclosed our Consent Form signed by the above patient authorizing you to furnish us with the following medical records: (X ) Admission/Face Sheet of Chart (X ) Emergency Room Report (X ) History and Physical (X ) Doc:tor/Hospital Notes (X) Discharge Summary (X) All Consults Reports () Laboratory Reports () ETOH Level () Doctor's Office Visit Notes () Other (see below) () Nurse Notes/Social Service Notes () Medication Sbeets (X ) Operative Reports (X) Radiology Reports (X ) Myelogram, MRI or cr Scans (X ) Itemized Bill () Outpatient Progress Notes () Projected MMI () RTW Date () Plan of Treatment If there are any questions in regard to this request, please contact me. Thank you for your cooperation. NATIONWIDE MUTUAL FIRE INSURANCE COMPANY Annette Long Claims Department (717)263-7965 CHMTON.B OQ ~-o~ ~:est t'~ T r Aseoc = ~ 7 non pre Ie p'" 1 - JlIIl slt! C Cd! ~ """' ab.s COmp '.... Pill kal Any person who knowingly and with intent to defraud any insurance company or othet person files an application for iDsurance or stalcm<:m of claim containing any malerially fa1se infonnation or conceals for the purpose of misleoding. information eoaceroing any fact morenal !hereto commils a fraudulent iDsurance act, which is a crime and subjects such a penon to crimiuaI and civil penalties. ;J.{p~ :3 @ . I lA~ ./ PERMISSION TO OaVAIN MEDICAL INFOR~WON I AUTHORIZE any phy,iclen, T' ., hospltal,- or any other medical . --> - professional or health cared Prohvlder. _'. I "'J9. di~CrOse all information regarding me Icel ietq~ of. physical condition of. and InJurles ~ ,,~ I. s+..........\"II\~ . I i~n and after the accident dale of t\. t' .."",<>....3 \ ,20 (:).3 This informallo may be given to any Claims Personnel of: o Natfonwide Mutual Insurance Company lil' Nelionwlde Mutual Fire Insurance Company C Nationwide C3enerellnsurlll'lce Company C NationwIde Property end Casualty Insurance Company o Nationwide Indemnity Insurance Company o Colonlal Assurance I UNDERSTAND that this Information will be used to determine or to verify the extent ot my/hlslher loss. and to evaluate mylhislher claim arising out of this accldenl I AGREE that this authortzation.wlll remein valid until this claim Is concluded, unless revoked by delivery of written nollce 10 the above-named Insurance company. I UNDERSTAND that I (or my'reprelentative) am enti!(ed to reeelve 8 copy of Ihl9 authorization. CIlllmNo.: S~31 ~~1'2.. ,(C\. 1'2.31 03~\ InSured: Mi ch_...1;\ t"li\\.t!.i' A photocopy of this form may be accepted a6 the original. I (or Ihe patienl named above) have received health care for injuries caused by thr. accident from: y..\~ ~t.V'''f "tJ~ ,....-eI'\lln. ' )c; .:lV"- .'>Clj , . X-J..~i; C,...,H,.... Sl ('"...,....p j.j,11 1"7< [XIC",'. IJ~"'\I&" 1:11:. r'\\Qr.o;, A41..n=ss' U"'t10'.IJrmtl.U.I:.l( 'nu~1i ""(1'''': X.~hi S.J.tA t-bp,~f X (!"...-..,; I-!-.I{ I\II"fC": I< ,;1.. ~(, ~ l,J;ou: x ~ ~Q .ltIJ;l'l 1.1", 01 t'~j t. CfI~~~I"'C. ['Il~liI\f 1.NIN\1ft nil':; 1" NOl A RrI rASE or ClAIM rOI1 OAI'1I\GES NOTE: IF YOUR STATE HAS PRIVACY LAWS, nus FORM HAS BEEN DesIGNED TO PROTECT YOUR RlGHTS UNDER THEM. re : ::-Jt:lC to>:aL rS2 Li L : J1 [Bt>SLto2L ,L ~:~ 7S:60 ~~ L2-63~ N,"ME: AD.DRESS: BIRTHDATE: EIiPLOYER: ADDRESS: CHURCH: COMMENT: NAME: ADDRESS: NAME: ADDRESS: ADMIT DR: ATTND DR: REFER DR: ADMIT OX: COMPLAINT: STIMELING .KYLE~ Il"'ED FOX LANE 0,,/25/1991 A~C:: STUDENT NONE PER MOM I rt ( .L~N. I .LNt- Ul'\MA I lUN . I SS .: 999-02-2591 /MECHAN I""""'URG /PA/17"'" PH. : 71-r. 795-8828 12 SE>'. M MS: S RACE: 1 -.oLD: 0" 1125 OCCUPATION: UNE-STUDENT / / / PH. : AMB: SILVER SPRING AMB ASSN EMERGENCY CONTACT INFORMATION STIMELING ,TAMMY REL TO PT: M WORK PH.: 6 RED FOX LANE /MECHANICSE<URG /PA/17050 NI.: 717 - 795-8828 ST IMEL ING . MARK 6 RED FOX LANE REL TO PT: F WORK PH.: /MECHANICSBURO /PA/17050 PH.: 717 - 795-8828 231365 231365 181644 FORE ION FOREIGN CASE INFORMATION HARVEY TODD J ADM SOURCE: HARVEY TODD J HOSP SERV: FERRARO KATARZYNA K BODY LEFT EYE ICO-9 DX: BODY LEFT EYE DATE/TIME: 12/31103 16 :00 DESCRIPTION: EYE INJ NAME: ADDRESS: EMPLOYER: ADDRESS: STIMELING ,TAMMY 6 RED FOX LANE UNEMPLOYED PLAN INSURANCE CO SUElSCRIBER .1 B09 BLUE CROSS STIMELING ,MARK INSUR.ADORESS: +2 INSUR.ADDRESS: +3 ." INSUR.ADDRESS: INSUR.ADDRESS: COMMENTS: FMD: SNOKE EO I'l6 PATIENT TYPE: S FINANCIAL CLS: B ACCIDENT INFORMATION Ace IND: 0 JOB RELATED: N LOCATION: GUARANTOR INFORMATION PT REL TO GUAR: 0 /MECHANICSBURG /PA/17050 CONTACT NAME: / / I 5S +: PH .: 717 - 795-8828 F'H +: INSURANCE INFORMATION COB F'OL ICY GROUP . REL pc VFY CARD PRECERT/AUTH . PRECERT PHONE. 1 YWP20354635 000 005026580000 o Y Y Y 'v'0 f}n;\r>J '\:;'\(0 PRIVACY NOTICE 12-31-03 ERl SEN PATIENT NAME: STIMELING ,KYLE E REGISTERED BY: ADBB PT.: 22380703 MR.: 26232" ADM DATE: 01/01/0" 02:15 NURS STA: 6WST ROOM/BED: 643 01 END OF DOCUMENT 02:30 01/01/04 FROM HG47,ADADMTFl HOLY SPIRIT HOSPITAL PT t: 22381438 CAMP HILL, PENNSYLVANIA 17011 MR .: 210952 ADMISSION FORM CONFIDENTIAL: N - ...-- PATIENT INFORMATION 1\ r--. -- ADM. DATE: 12/3112003 CHIEF COMPLAINT Pellet to left trye. HISTORY OF PRESENT ILLNESS Tl1lo 13 yeor-old male p.....nte to th. Emergency Department after ~e WII. playing wtth lome friends. Apparontly. l1e _I walking up to them.nd thtry were p18ylng wlth lorne pell.t guns and lcoldenlally one pellet ricocheted off an old car Ind .ubeequentiy .truck h18 left eye. He c18lm. thlt he Immedl.tely saw black and .ome,dola and they contacted ~Io family Ind bn>ught ~Im here by Imbul.nce. T~. p.tient doe. compl.ln <If a headache 2-3110 In ..vorlty. No na...... no vomiting. H. cl.lm. h. only..... bl.ckne.. In th.left ey.. He denl.. any other Injurlel or complalnte cu.....ntly. PAST MEDICAL HISTORY Non.. ALLERGIES No known drug allerglel. SOCIAL HISTORY FAMILY HISTORY MEDlCATIONS REVIEW OF SYSTEMS He'. d....loping .pproprlltely. Unremarklble. None. Conltltutlonll: No _Ig~t 1011. _Ig~tgaln. lever, or c~lIIl. Eyes: POlltlve for the pell.t to the left .y. and poor vlllon of th. left .ye. ENT: No vl.ion Jou, earache, dlzzlne... no..bIMeta, alnus trouble. or lore throat. Cardlovl.cul.r. No che.t pain. palpitation.. Reepirotory: No coug~. Iputum production. ~..zlng, or coughIng up blood. Gaatrolnteltlnal: No nau.ea. vomiting. dlarrh.., constipation. abdomln.1 pain. Genitourinary: No blood In urine. painful urination. orfrequ.nt urln.tlon. Mueculolkelelal: No mu.cle p41ln, joint pain, erthrltle. or JoInt 1_lIlng. Skin: No ra.l1e.. lumps, dryna... Itchln..., or .orel. Neurological: No dlzzin.... blackouta..elzuro., peralyeie, numbn.... or tingling. Endocrine: No dlabetee or tlIyrold dl....... H41metologlc/Lymp~atIc: No an.mla, ea.y brul.lng. or .wol18n gland.. PHYSICAL EXAMINATION VI181 Stgn. rovlewed on nUrN'. note.. Temperatura 97.2. pul.. 84. _plralory rate 18. blood ~ure 11217'8. The patient Ie.n II.rt, pleasant, and cooperativ., 13 ye.r-old, male. He'l lying comlortably on the bed. I did Imm.dlamly alt ~Im up and _ did ImmedIately .pply an .y. I~ield. EYES: He ~sa .n obvious anterior chamber l1yphema .nd there'l obvlou. globe pan.tratlon .nd th. eya 'a .unken on the left. T~e patlen1 hee Intael ,pupillary reoponae of the right trye. There'. no .vld.nc. of .ny other faclalllymmetrlea or tnluma. NECK: Suppl.. No palpabl. adenopathy. No jugular venous dlatentlon. No tend.meq down the midline. HOLY SPIRIT HOSPITAL Camp Hili, PA 17011 EMERGeNCY ROOM REPORT Page 1 012 NAME: Stlmellng. Kyle E MR#: 262324 ROOM: ER DR.: KATARZYNA K FERRARO, MO ORIGINAl I I -. -., - RUN CATE: 01/04/04 RUN TIME: 2301 HOLV SPIRIT HOSPITAL. CAMP HILL. PA 17011 DEPARTHENTQF LABORATORY MEDICINE STEPHENSON S. P. SWN'IIDOSS M. D.. DIRECTOR *****DISCHARGE SUHHARY***** PAGE 50 PATJOO, ~CT#:~~~~223sQ7oJlO::, H/S4" ' Uf: 26:!324 ..' , "AIlEIti:' " ROOII; 412 R!li: 12/31/03 REGal: " HARVEY .TOOD J ... ,. srA ,,:OlSlN ..' "~ED; '. 02 " tJrs, 01103104 MEMATOLOOY AUTOMATED BLOOO COUNTS - _.. .' -- >BC RBC HGB HCT HeV HCH (4.5-13.0) (400.5.20) (!l.5-I5.5) (350-450) (77.0-95.0) (250-33 0) Date Time KILL M/UL GM/OL % FL UUG -- - -- - ->12/31/03 1845 17.3 H 4.44 12.9 36.3 81.8 29.0 MCHC RO~ PLTC HPV LVMPH % HONO % (31.0-37.0) 01.6-138) 040-400) (91-12.4) (40,451 (4-81 Date Time GM/OL ~ . K/UL FL > % -- '>12/31/03 1845 355 121 439 H 9.8 10.7 L 3.8 L - -- --..- GRA~ t EOSIN % BASO % LVMPH # I"ONO # GAA~41 (45-50) (1-6) (0,1.4) 11.4-4.3) (0 1,0.7) 0.6-47) Date Tlme % % % ~._--- --- -> 12131/03 1845 85.3 H 0.1 L 01 1.9 0.7 14.7 H f-_. ,., -- -,.- EOSIN # 8ASO # (0 0-05) (OO,O!) Ja:e Time . ._- ->12/31103 1845 0.0 0.0 " denotes PANIC valUe .... denoteS NEll ,""suIts Patient: STIHELIMG,KVLE E A.ge/Sex : 12/H Acct1ilOO0223807C3 Unit#262324 I'"' ,-- RUN DATE: 01/04/04 RlJ'I TIME: 230t HOLY SPIRIT HOSPITAL. CAMP HILL. PA 17011 DEPARTIIENT OF LABORATORY MEDICINE STEPHENSON S.P. SWAMIOOSS M.D.. DIRECTOR PAGE 51 -DISC~E SlH1ARY'- P~tjel)t: STlHELING.mn' , ',' ,1000022380703 (CQirt:inuedl ' " ." , , CHEMISTRY GENERAL CHEMISTRY --. RNDM GLUC. CA,H (65-140) (8.4-102) Date Tirr.e MG/DL. I-13.iDL -_._-~--- , ->12/31/03 1845 136 9.8 RENAL FUNCTI ON _._-"-_._-_.._--~-_.~-- .---- BUN CREAT. NA K CL CO2 (5-18) (06-11) 033-145) (35-5.1) (96-108) (22-30) Date Ture MG IDL I-13.iDL. otllL otllL rrM/L rrM/L ----._--- " ." ->12/31/03 1845 15 0.5 L 141 3.5 107 21 L 'denotes PANIC value - denotes HEW resul ts Patient: ST1MELING.KYLE E Age/Sex: 121M Acct1lll000223B0703 Unit#262324 ,- - RUN DATE: 01/04104 RUN TIME: 2301 HOLY SPIRIT HOSPITAL. CAlf' HILL. PA 17011 DEPARTME'IT OF I..I\BOAATORY MEDICINE STEPHENSOO S.P. SIWIIOOSS M.D.. DIRECTOR --DISCHARGE SUHMAAy..... PAGE 52 Patient: STIMEllNG.KYLE E... . .. ~0000223a07U3 '(COf1tinue<!) OJ:800JJ034R COMPo C011: 12/31/03-2140 Reed: 12/31/03-2229 CR#03054269J ED GROUP Source: VITR FLO Ordered: EYE-AER CULT. EYE-ANA CULT CaBOent: OS VITREOUS ASPIRATE > FInal 12131/03 , .. '.. bCCASIONAl HEOTROPHllS SEEN NO ORGANISMS SEE~ > Final 01/04/04 NO DRGANISMS ISDLATED Fwa) 01/04/04 NO -ANAEROB1C DRGANISMS lSOlATtO > - denotes PANIC val\l& ... denotes HEW results Patient: STIMUING.KYlE E AqefSI!X: '121M Acct1OOO022380703 Uni1#262324 . -"" II """ '. ADM. DATE: 12/31/2003 PREOPERATIVE DIAGNOSIS: Ruptured globe. Intraocular foreign body, left eye. POSTOPERATIVE DIAGNOSIS: Same OPERATION: Repair of ruptured globe. Removal of intraocular foreign body. SURGEON: TODD J. HARVEY, M.D. ASSISTANT: THOMAS R. PHEASANT, M.D. DATE: 12/31/2003 ANESTHESIA: General endotracheal anesthesia COMPLICATIONS; None SPECIMENS: Metallic intraocular.fllreign body CLINICAL NOTE: This is a 12-year,old white male who earlier today experienced a ricochet pellet gun injury with the pellet entering the left eye at approximately 4 o'clock this afternoon. He went to Holy Spirit Hospital Emergency Room and I was called to see him at 5: 15. He was examined and found to have hand motion vision in the left eye with a dense afferent pupillary defect. His right eye had 20/20 visipn. His anterior chamber was flat and globe was shrunken. There was a entry wound at the temporal position of the left eye with a scleral laceration. A hyphema was present in the anterior chamber with bare iris structures present. There was no red reflex. His right eye was otherwise unremarkable externally. A CAT scan was performed and reviewed which showed a seVElrely shrunken, deformed left globe with an intraocular foreign body, metallic in nature present in the inferior section of the globe. Intraocular structures were barely visible due to deformation. The posterior orbit, however, looked intact. This was reviewed with Dr. Thomas Pheasant, retinal specialist and it was felt that surgical repair with planning on removal of the intraocular foreign body if possible would be undertaken. A long discussion was made with the patient and his family including his mother and father regarding the poor prognosis for this eye wit/1 surgery despite best efforts. The risks of infection, risks of retinal detachment on repair are possibilities. They were in full understanding, but wished to proceed as aggressively as possible. After discussion of these risks and benefits with the patient and family, we proceeded. OPERATIVE PROCEDURE: The patient was brought to the operating room and appropriate consent was obtained. The patient was identified. He received general endotracheal anesthesia and was prepped and draped in normal sterile fashion for intraocular surgery. A lid speculum was placed. The extent of the rupture was dissected posteriorly after a temporal peritomy was performed. The rupture extended approximately 8-10 millimeters posteriorly. It Page 1 of 2 HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 NAME: Stimeling, Kyle E MR#: 262324 ROOM: RECORD OF OPERA TJON ORIGINAL - -.. - II '"' NAME: MR#: Stimeling, "yle E 262324 extended also anteriorly into the temporal cornea with a dog-ear and stellate laceration. The wound was explored and the foreign body was visible posteriorly. A rare earth magnet was utilized as well as the large electronic magnet and the fcreign body was not retrieved. A pair of Greishaber forceps was utilized. The foreign body was grasped and isolated and removed from the globe entirely. The eye was then reformed using Viscoat and the sclera was closed using interrupted 8-0 Vicryl suture. The anterior chamber was then reformed using Viscoat. The crystalline lens was not visualized at all during the surgery. All uvea was reposited into the globe and the comea was closed using internupted 10-0 nylon sutures. The laceration was very ragged but closure was accomplished without leakage. Intraocular injections of Vancomycin 1 Mg. of.1 ml. was given intravitreallyalong with Ceftazidime and Decadron. Subconjunctival injections of Vancomycin and Ceftazidime were also given. Maxitrol ointment was applied at the conclusion of the case. A retrobulbar anesthetic was given as a SO/50 mixture of 4% Lidocaine and .5% Marcaine in the inferior orbil Fox shield and patch were placed. The patient tolerated the procedure well and went to the recovery room in stable condition. 2iY~ / TODD J. HAR y, MD TH/jr DOC#:411439 D: 12/31/2003 T: 01/0612004 12:40 P 616066 cc: TODD J. HARVEY, MD THOMAS R PHEASANT, MD Page 2 of 2 HOLY SPIRIT HOSPITAL Camp Hill. PA 17011 NAME: Stimeling. Kyle E MR#: 262324 ROOM: RECORD OF OPERATION ORIGINAL ~ ~ ~" . Dailey Eye Associates John.R. Dailey, M.D. Todd J. Harvey, M.D. 1857 Center Street Camp Hill, PA 17011 Phone (717) 761-3011 Fax (717) 761-5347 March 4, 2004 MAR 1 5 2004 Nationwide Mutual Fire Insurance Company 1137A Kennebec Drive Chambersburg, PA 17201 ATTN: Annette Long Dear Ms. Long: I am writing in reference to your request for information regarding my patient, Kyle St~eling, Cla~ No. 5837H02727191231200301. Attached to this letter you will find information from my medical chart for his outpatient visits. You may want to request information from Holy Spirit Hospital which would include his inpatient chart, x-ray findings, and other pertinent information. The itemization of his charges will be included with this letter for his outpatient and surgical intervention. In reference to the probable date of reaching maximum medical improvement, that date has passed. Kyle will not obtain improved vision from his left eye. He has no light perception vision at this time, and that will not improve. The only outstanding concern in the future is whether or not he may undergo enucleation or evisceration with placement of an orbital implant and prosthesis on the left side. That date will occur most likely in the future, however, the exact timing is uncertain. Please do not hesitate to contact my office should you require any additional information beyond what we are sending. Sincerely, 2W(f+8 Todd J. Harvey, M.D. Enclosures DAILEY EYE ASSOCIATES, INC. 1857 CENTER STREET CAMP HILL, PA 17011 761-3011 I. D. # 232152651 Provo # 342118 KYLE E. STIMELING 6 RED FOX LANE Date: Account No: Phone: Insurance Balance: Patient Balance: 03/03/04 28636.0 /728-5448 0.00 710.08 MECHANICSBURG PA 17050 Fin Class: 1 Ins: Pat: Z-CBC 1-CBC Date Proc Md Description Diag INS Charges Credits Balance -------------------------------------------------------------------------------- STIMELING, KYLE E. (28636.0) 123103 99284 57 EMERGENCY DEPARTMENT 871.2 ZPAT 100.00 100.00 020204 Check Payment - CBC #100248 100.00 0.00 123103 65285 51 LACERATION, CORNEA/ S 871. 2 SPAT 1,375.00 1,375.00 020204 Check payment-- CBC #100248 436.49 938.51 500.00 DEDUCT/109.12 COINS 020204 Adjustment - CBC 329.39 609.12 123103 65265 LT REMOVE FOREIGN BODY 871.2 SPAT 1,200.00 1,809.12 020204 Check Payment - CBC #100248 403.82 1,405.30 100.96 COINS 020204 Adjustment - CBC 695.22 710.08 010504 99024 POST OP 871.2 ZPAT 0.00 710.08 010804 99024 POST OP 871.2 ZPAT 0.00 710.08 010904 99024 POST OP 871.2 ZPAT 0.00 710.08 011604 99024 POST OP 871.2 ZPAT 0.00 710.08 012704 99024 POST OP 871.2 ZPAT 0.00 710.08 021004. 99024 POST OP 871. 2 ZPAT 0.00 710.08 021104 99024 POST OP 871.2 ZPAT 0.00 710.08 TOTAL CURRENT 31-60 61-90 91-120 OVER 120 Insurance 0.00 0.00 0.00 0.00 0.00 0.00 Patient 710.08 0.00 0.00 710.08 0.00 0.00 Total 710.08 0.00 0.00 710.08 0.00 0.00 c 1137AKENNEBECDRIVE .CHAMBERSBURG,PA 17201 .. DAILEY EYE ASSOCIATES ATIN: MEDICAL RECORDS AND BILLING 1857 CENTER ST CAMPHlLL,PA 17011 March I, 2004 YOUR PATIENT: Kyle Stirneling (parents-Tammy and Mark) OUR INSURED: Michael D Diller OUR CLAIM NUMBER: 5837 HO 2727191231200301 DATE OF LOSS: 12-31-2003 We understand that you are treating Kyle Stirneling as a result of an incident which occurred on 12-31-2003 . The attached authorization allows you to provide information about your patient's injury. Please provide the following information: () Complete nurse's report (X ) Itemization of charges () Admittance summary () Discharge summary () Complete narrative of diagnosis, treatment, and prognosis (X) Complete X-ray report (X ) History and physical () Please complete the enclosed Attending Physician's Report (X ) Complete physical treatment notes () Periods of partial and total disability as a result of the accident () Anticipated tirne until return to work (X ) Probable date of reaching maximum medical improvement () Explain how relates to the accident () Emergency room notes (X ) Entire medical file () Other: Ple:lSe feel free to call. Thank you for your cooperation. NATIONWIDE MUTUAL FIRE INSURANCE COMPANY Annette Long Claims Department (717)263-7965 Any person wlm knowingly and with intent to defraud any insurance company or other pm;on files an application for insurance or statement of claim con"'m;ng any materially false information or conceals for the purpose of misleading, informatioo conceming any fact materia1 thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. \ A~ PERMISSION TO OS:IN MEDICAL INFORMATION .....-AS I AUTHORIZE any physician,. " hospItal, ~ or any other medical professional or health care provIder -~..> to disclose all . -'. ~ information regarding medical hi8t~1;Y of, physical condition of, and Injuries t~ v:.. ~ ~ <> :S~', W\.,,~ \', V\~ ' I fiP~n and after the accident date of h p r "-IMIou-3 \ ,20 c.3 This informatlo may be given to any Claims Peraonnel of: Cl Nationwide Mutual Insurance Company 'J1 NationwIde Mutual Fire Insurance Company [J Nationwide C3enerallnsurance Company o Nationwide Properly end Casualty Insurance Company o Nationwide Indemnity Insurance Company [] ColonIal Assurance I UNDERSTAND thet this Information will be used to determine or to verify the extent of my/his/her loss, and to eveluate rny/hislher claIm arising out of this accIdent. I AGREE that this authorization, will remain valid until this claim Is concluded, unless revoked by delivery of written notice to the above-named Insurance company. I UNDERSTAND that I (or my'representative) am entitled to receive a copy of this authorization. A photocopy of this form may be accepted as the original. I (or the patient named above) have received health care for injuries caused by this accident I.....IOIIIII"V.. ..J C)..J ~ \"'-..1 ~.- " Insured: M: c\t...", "l:l \'\'\\'l.\' from: 'f... 1M: ~r...VCd O('lC ,Ulll'lM . c, , X Ie 1- .:.C\I ","",11" X }UU?I~"7 C' ud....... St r m-f' 1.1. II I l.Jt\et.(lf. lJl:l\ \1 '-to I:.~i:. i"flonl: '" AlIllrcs1' I.Jl"lCl0f. lJentLtt.l:.le t'''I;In'; II> Adanri:ll: x-JJ" \~ St' ol.l~ o_rUIII: ~bpl~1 x I\II(HC:~: C r'..... .; 1+, I I x ;l-.;2" oL/ U~U: x J, ~-O :-"!;"lItU~ Of "+Icnt. q'!l't!ICTlt~I~C. I'Ilr:nr nf "'''4I'tHtUt : - . tins IS Not A RelEASE OF CLAIM FOR. DAMAGES . NOTE: !F YOUR STATE HAS PRlVACY LAWS, THlS FORM HAS BEEN DESIGNED TO PROTECT 'YOUR RIGI-ITS UNDER THEM. ,2:~c: t'rnL rn2 HI. :J.!. rn"s.:t,2L ,L ~>:~ 7~:=2 72 L2-=~ ~Page No. "\ Pat__....d Nama d'\G' J Sl-E: tC _-f J'- - <"'1___ ~ - ~~ /"-' - c::: C~~ :S?--.'~ a:> l,,- \ <l ~ <1'Q ~.'" 4~. ~. ~v 0.-1:.. h--l ~~ 0 6'-~'. ~- T_1 r- .....- I:lt Co ' - ......-'L... Ii. - ~\.o.~ A\lt ~ ,+- ~'--'> __ --,..,d ~ /..._,- _I<-, v.~. ~ (t.. .., -..J . ~ c p...., u o "'C~I ...j"""^,,,, 1-=1-1 ~.) UAI Page No. 0 111_ S 1 , L,-"\ Patj&..~~Name ~ \. '"t-~ I VVfc.r- It s +---- 1- o ~ ,*.~ G -tt.-.~... h:J v-J"':+ rl. 0 I,,~""JV"'(' ~ I-z \..11--".I~ G.. w.I-..r- -f1.-e.+ ~ ,r.'~I<..~ ......C~ C 'O~ 1"'- 0+ S.O. -'+-0-' .rn .....d c:. ~ 1'--) K..~ '^c""('" ~'^_./'SO -/...1.-- Z" "".... \,.._ h:- 1'-11..'} ~~"'<: 1'1--0+ ____+- f'I) 'f'L-.j. f-"'-'". I ___ C~\ 01 J. -I"-t- X ch-.'~ p...../ j'\-( .I'.~\oL. ..+ ry 1ziz> 11.-r.....,.-. "'"'t to \ J , 0 -' /"<0 -t- I <.,J"- ~ ....,,"'\?-~ cJ..",-c.l 0- .,..,.~ C "",'. 3, 3/0'-/ t). " .....,..tl lAH- J- n:, ..JJo)o- ,- ~ ~, (C) G .;SJ-C: .s-+-~ )(3 I--~ , \ 0>- .......... rt.1\-"""1 ~...I """-'""l: ~ 'i 1.1,'t" A 0<- C".) -ru ....c~~ '....-- ~ ....... ~.. Page No. '- &) pati.;;;'sNam.~lt E. :1;()'](' IIf\j FE (Cl~\ 0':> ...-... <!? 0-1, \--..__ -+- ro.......- PP/z.. ,'" l. S'-E' _~+ -0 cu- p. ,. 10"'" O~ """'"' l- <...,...,")(~ <:. Of' S~,-", .;11/1(04- ~c~<\...J. .\"'" d~ ~ I"... tt-..r- -(t-, ~'f' ~~, ~--. '$'" \.--ooa l :l",,< \ ,r..---~ ~H-v...-. =-'"> "'" h-.. J/- ,..,..rt- (?L(, :J' 'K'<- o.o}("' .3.... .)~....,,~ '.) L....."T:J')~ ~.,.j..,..~ <l':) ~ ><.2.. FL...... {)r ~,,\-. ,.... , '-' ,-" Page No. ~ 1/, _ Pat"- _ _.. Name , t- S+,:rne I ;'ru', -) - JAN 2 b lUU'I L 0 rlH, ,,^- j.... '1\./ S{)I'V fl If)( m,,,^^n,,, LI ,J... hJ:P-..... / /' ' JAN 2 7 2004 kI? \( \1) ri ('\ I \... \P.,.J . . ("';>.. J {}.\. I If\l' V V'- ~ A mhrV'\o .7]l\ ,.,j Vlo..... ^)rl I III /, (h,... "I ~X1Vl t1 ( \ I Yl-mnt'\\ I ,1+ m I n/ (~ . ~' ) + ,~ f1;tYJ r-c .. ~ -' ~ ~ ~Ol ""LP ,I rt"1 (JJ J.n:; -/Ir,.oJ'LIf-r+>)/J$1 --:rl1'dr<,/1-A- /Jv ~rP/l...{) 11/ ~ ~ nD,I'HW'\"/O '-.../1 I 0 - .:S t.-1= " 7' """ ~ ' c~,- .,-......,T --r~ 6~ I :... 1L- s +- '>-r . - .;). .-, frfL - 2+ RJ1<. ~<I I C:::J ~. CM- I '-.... ..;7, (?)c.-.I'~, . ~- '^ cr---a- I , (:f).r<.cJ. ~-I-I-,c. -'"0 .. ~ +v-- , .....~.\.,-<. r -, I ~A:'I .rf> J'"-.f-..r- """'I'.w-..t c-(",I,~ 0) - Oc..c...-~. ~h."'.... Sc~ '\"'-'ll\""+----' 'IV: -=[-. J., (l ~ Ic:J \". CJ A' - v-.c 1". c.t 5-< /).r- ~,..-+ p..,- .......... I ...... '"'<:.S', P"l>C-. I-k -<: '2.---L ;) V.Ii,./. ----- tl,^'""r-.,{, ( rM ""\'0<'" ()tY\" fu. 7f\.QM~ ' ,r---> . .2. (, -u-J- . JAN 3 0200~tj< ~ 8(\ nrRl\R .l\llrl.~ \..... -' 'i;: t.:r~I_{)';;2 r-n nt"'Pr 1b l rJI"h 'TL~I 'ilK I r.:H-n 7J[1I1 {fj ,i-> "An. H U I'l ' '''<7::<1<:; (j" I-- ;" A 1J. . -:JNV fi:{)'" ~ ",0 ~ 1'" I (''"'' ~ ,{.~ S<-<".~ ()r- Ol-))'/tJLI ( .,J , _I "'-" -;;: c... SA....'\. J... "'. ~ _ \f I 1..Jv, 1_4./' S- <: I'~ TcJ?-- ~ ...",.\,,~.- +-- ""......1. .......-... ....... . ., pat~Name kYLE E. 'Sr,nE.U,.::(,. Page No.. 3 ',---,' tJ ~ G- 61- r: '. . < I 0. ...,..~") ,-. o~ , > , No V' .""C--', ~ .") .. .V' 'i ltl1.t- 5:.0>=/3 0) - .:sf>> l.,)..,. , \"-t- \.:). '(( I 2.2./04 - (",II..cl o~ . -;t-. ~... .-cl. 0'--'+ -,'" 'r--J."7. ......< (? (....J)H.. Q ~ 121 C?C<' _ .rr~ ~cl c> ",l.- -.,._",/,' ::i-.,.,~ ~- ro lo..- t-YJ"I. ~ d-",..,..\,., tt,.. "7 <' I+- -<1/ IL - ~_."+- <=:> c-~-v,.-) "M"'C "",..0./'- ~~~).Iv. t.r.+- .s $-<.;),1 /"~>v..--,' rrr- '0'.," .......-.-~~ . 4-<..1' 5'-€: <......1.- "'''-''V'l>~~J .,. 1r1( - v ..,-.JC-...I- Jt~) rf' f'--y> +---< .,(,,1.<- re o.~ C)- /'0 5.~ - cJ+ d-r ""~\("_'''t' ~ f-k . ,\,.. Vbl~+- ..) ~c..--r +t..... ~o I ().) .11 .,.......-1-"'-'""1' #) FI...... ~ J oJ.-:) iJ.l~" c f;.,.t1n./\. o-7J 1/2. '7 OJ Page No, ?- Patie.,_Name lLVLE IS. sr'I1ELING- , --...L 8, ~L. ,,~ Ot.u.. . ~......e: >, .,--~ v.t)( c y. lc~ , I 5l...~ J- ;<, ~r\ - 'IV ~('~I. , ,\10'\ ~ lo- PI..... 1-"- ... c "nI .-.. '- '-' ""';', v" Daile~ E~e Associates 'Name: _Kyle.. E.St:Me\;nj Date: 1-5-0'+ Chief Complaint: re,vex-, History (location timing. onset duration. f""lUe~lity. severity. modifying factors. .associated signs/symptoms/. ~~~~~.VJL~~. ~~ ~ <lnL~TJ~ C ,QJ'Yop\~O'2>n6-,.0:- Os+id)O~ -us-t\cL. CL. pt-S~~ Q., Lk.\iCr \-~' ~ .Visuatfcuity: 20t2f) J "1 P'Yl \Uz...: .v.fo .\L\.qo \. hOV ( ~ acc >\5C aCl 201L:f ift)'( e C\ e\ ?OJ() a-~Chf\ls X 20/ - (11= Ji..{ X 20/ -()c~J tJ add J A'r-y-c) 3 ull c.~ o Ortho Age: );2... Present RX: X X add M: -P<l ~. _APD j-TA s~ I-VF o Full -EOM Mood/ Affect Appropriate - a Other ROS/MH/PFSH j-Jpdated: Dilated: a Yes Jot No ... Each element of a "bullet" listed in parentheses was examined unlesscrossed-out. A bnormalities are described. Normal Abnormal (Comment! Gonioscopy: OD OS t . Adnexae (lids, lacrimal, orbit) -ec+ O ~....,.~t vJ . G .V\-~" \-- 'Conj. (bulbar and palpebral) 'Cornea (epithelium, stroma, endothelium, tear film) . AC (depth, cells. flare) Iris l+r." ~ . Lens (clarity, AlP capsule, cortex, nucleusl Vitreous . Disc. (nfl, C:D, appearance) Macula . Retina. vessels Return Plan: Impl"1!Ssion: 1 ~ fl '""t" V' <"-C'~~ -r I.........:. (7)- 2 3 re...A..r - '6....... r' t- v- fl.zj w' '" \ . 4 - pI-. 0.-- S_~ ;.J:-.t,'t 5 - B...... ;;.. -J.., _ c(....._; _ day __ month week __ year_____ ~L. Signature _~ ~ _______ ROS/PFSH Reviewed (Pflti~.t ,u"l/tJr f..it!! (o.."seletl 'rr_nli.,Ji.,."si.. c,uuUtio". Prlll"".i.. IlI,d th~ risks (I"J &u'lits Df tUtlt"'~lf.t.' -Lr~ '"' pl-'V ~ <:: r~"JC ~'J L/UUC: Y L Y c: L>..:>.:>UL1Cl.lC.:> . John R. Dailey, M.D. Todd J. Harvey, M.D. 1857 Center Street Camp Hill, PA 17011 Phone (717) 761-3011 Fax (717) 761-5347 January 22, 2004 J. Stephen Snoke, D.O. 1800 Carlisle Road Camp Hill, PA 17011 Dear Dr, Snoke: I wanted to update you on your patient, Kyle Stimeling, whom I first met on December 31, 2003 at the Holy Spirit Emergency Room. Kyle had been the victim of a pellet gun injury to his left eye. He unfortunately had a penetrating injury with the pellet present in the posterior segment of his left eye. Kyle underwent emergent repair of his ruptured globe with removal of his intraocular foreign body at Holy Spirit that night. He was hospitalized for three day.for IV antibiotics to help reduce the risk of endophthalmitis. He has remained infection free throughout the past three week postoperative course. His vision, however, has recovered only to light perception in that eye due to severe posterior segment damage. As of his last visit with me on January 22, 2004 Kyle was beginning to show signs of involution of his globe which will probably result in a phthisical globe. His prognosis for good vision in this eye is very limited. I am going to have him see Tom Pheasant, M.D., again within the next week or two for any recommendations he may have. Tom had initially seen Kyle with me at the Emergency Room and assisted during his surgical care. I will keep you up to date as to his progress. Kyle and his parents will need significant emotional support as we go through the next several weeks with discussions and considerations of enucleation possibly. I have not touched on that subject with them specifically to date, however, I am concerned that it may go in that direction. I will continue to keep you abreast as to his progress. Please do not hesitate to contact me should you have any questions. Best regards, Todd J. Harvey, M.D. cc: Thomas R. Pheasant, M.D. ADM. DATE: 1213112003 PREOPERATIVE DIAGNOSIS: Ruptured globe. Intraocular foreign body, left eye. POSTOPERA11VE DIAGNOSIS: Same OPERATION: Repair of ruptured globe. Removal of intraocular foreign body. SURGEON: TODD J. HARVEY, M.D. ASSISTANT: THOMAS R. PHEASANT, M.D. DATE: 12/3112003 o \L \'t> ~, .-( ~ ANESTHESIA: General endotracheal anesthesia COMPLICATIONS: None SPECIMENS: Metallic intraocular foreign body CLINICAL NOTE: This is a 12-year-old white male who earlier today experienced a ricochet pellet gun injury with the pellet entering the left eye at approximately 4 o'clocK this afternoon. He went to Holy Spirit Hospital Emergency Room and I was called to see him at 5:15. He was ex-amineo' and follf1d to /'lave /'land motion vision in the left eYl' wtth a dense afferent pupillary defed:. His right eye had 20/20 'If\t.ion. H'e. anterior chamber Wa5 flat and globe WBl!. shrunken. There was a entry wound at the temporal position of the left eye with a scleral laceration. A hyp/:lema was present in the anterior c.I1ambeT with baTe iris structures present. There was no red reflex. His right eye was otherwise unremarkable externally. A CAT scan was performed and reviewed which showed a severely shrunken, deformed left globe with an intraocular foreign body, metallic in nature present in the inferior section of the globe. Intraocular structures were barely visible due to deformation. The posterior orbit, however, looked intact. This was reviewed with Dr. Thomas Pheasant, retinaf specialist and it was felt that surgicaf repair with planning on removal of the intraocular foreign body if possible would be undertaken. A long discussion was made wtth the patient and his (amily including /'lis mother and father regarding the poor pl'ogn~i1!o ior this eye with l!.urgery despite best efforts. The risks of inlecllon, ri1!oks of retinal detachment on repair are possibilities. They were in full understanding, but wished to proceed as aggressively as pos:;ibIe. Alter discussion of tnese risks and benefits with the patient and family. we proceeded. OPERATIVE PROCEDURE: The patient was brought to the operating room and appropriate consent was obtained. The patient was identified. He recei\led general endotracheal anesthesia and was prepped and draped in normal sterile fashion tor intraocular surgery. A lid speculum was placed. The extent otthe rupttm3 was dissected posteriorty after a temporal peritomy was perf<:>rrned. The: tupll.Ufe extended approximately 6--1G millimeters posteriotly. It Page 1 of2 HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 NAME: Stime'ing. Ky/9 E MR1k 262324 ROOM: . . ,'--'~~::.T::;c~-:"7! ':::;\~ ~ ;~~r:""8" ::. >'~: ',' 1 ' I : iJ \! I , RECORD OF OPERATION COpy TO: TODD J. HARVEY. MD NAME: MR#: Stimeling, Kyle E 262324 extended also anteriorly into the temporal cornea with a dog-ear and stellate laceration. The wound was explored and the foreign body was visible posteriorly. A rare earth magnet was utilized as well as the large electronic magnet and the foreign body was not retrIeved. A pair of Greishaber forceps was utilized. The foreign body was grasped and isolated and removed from the globe entirely. Tire eye was then reforrrNld using Viscoat and the sclera was closed using interrupted 8-0 Vicryt suture. The anterior chamber was then refolTl"led using Viscoat. The crystamne Jens was not y;suaJized at all during the surgery. AlJ uvea was reposjted into the globe and the cornea was closed using interrupted 10-0 nylon sutures. The laceration was very ra,gged but closure was accomplished without leakage. Intraocular injections of Vancomycin 1 Mg. of.1 ml. was given intravitreallv along with Ceftazidime and Decadron. Subconjunctival injections of Vancomycin and Ceftazidime were also giVen. Maxitrol ointment was applied at the conclusion of the case. A retrobulbar anesthetic was given as a 50/50 mixture of 4% Lidocaine and .5% Marcaine in the inferior orbit. j=ox shield and patch were placed. The patient tolerated the procedure well and went to the recovery room in stable condition. TODD J. HARVEY, MO TH/jr DOC #: 411439 0: 12/31/2003 T: 01/08/2004 12:40 P 616086 cc: TODD J. HARVEY, MO THOMAS R PHEASAN1, MD Page 2 of 2 HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 NAME: Stll'neling, Kyle E MR#; 262324 ROOM: RECORD OF OPERATION COpy TO: TODD J. HARVEY, MO April 2, 2004 Paul J. Gitnik Centre 1201 Broughton Road Pillsburgh, Pennsylvania 15236-3451 www.gitnik.com E-mail: associates@gitnik.com Telephone: (800) 680-4806 (412) 653-4806 Facsimile: (412) 655-8721 ~ <-4 tn ~;-:t~~1 APR - 6 200~ PAUL J. GITNIK & ASSOCIATES, LLC ATTORNEYS AT LAW WITH ENCLOSURES March 30, 2004 Annette Long Nationwide Insurance 1137 A Kennebec Drive Chambersburg, P A 1720 I Re: 'Capital Advantage Insurance Company HPatient: Stimeling, Kyle Contract No.: 203546350' Date oflnjury: Dec 31, 2003 Your [nsured: Mike Diller Your Claim No.: 5837H027271912310301 Dear Ms. Long: As you are aware, this law lirm and '''SaCRA TES, INC., have been retained by Capital Advantage Insurance Company., a subsidiary of Capital BlueCross (collectively "Capital"), 10 pursue Capital's contractual and equitable subrogation lien for benefits paid on the above patient's behalf under the above-referenced contract number. II '1)" " Please be advised that the verbal Capital's subrogation lien in this case is~ We have not yet received the documentation but as soon as it is received we will forward you a copy. We reserve the right to provide you with and shall expect you to request an updated Capital Record of Claim Payments prior to the final settlement and/or resolution of this subrogation case with this law firm. When appropriate, please make your check payable to SOCRATES, INC., ESCROW ACCOUNT. If you should have any questions and/or comments, please feel free to call me. Very truly yaurs. Enclosure PAUL J. GITNIK & ASSaCIA TES. LLC ~~ fi J1 (Ji [ ,,(jQo~ Maildy z~a;ms1roU Specialist '--.,. . Capital Advantage Insurance Company' s contractual subrogation lien IS separate and dIstinct from that of I\ledicare and, or an;- other Blue Cross Plan(sl H This mfonnation has been disclosed to you from records "'hose confidentialir~ may be protected by state and tederal la.... Any funher disdosure of this infllnnation "ithour the prior "rinen consent or authorization of the person to whom it pertains may be prohibited ..... SOCRATES. r:-.:c. provides outsourcing subrogation services. conJunction with Paul J. Gitnik & Associates. LLC P"<,um,,~\1 " ..'i '" 'i ;; '" ;; '" '" ~ '" '" . '" '" ~ '" m ~ - s ~ % % % % % % % III % 'i5 'i5 \l ~ ::l ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ i ~ ~ n 0 m ::l % % % ~ 'i5 ~ ~ ~ ~ % ~ ~ 0 ~ :; 0 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ i ~ 0 m - W i\\ ".. ::l '" ~ tl ;:; :g '" ""- ~ ~ ~ " ~~ ~~ ~ ]~ \ 00; ~\ \ ~ ~8 % " ~ <;!m ; 0 -~ _m _0 ~~ ~o; ~ ~ ! ~ 5 'lAc 0; ~~ ~ ~ m !!\ ~ !"" ,_E ,. ~ ~ ; % ~ _0 ~ <0 5 ! 0 " B ~~ ~'" ~8 ~ -< ~ >;C ;; " "1! ~ t " ,,~ 91\ ~ 3 "'; ~ -~ %9 ~ >; C r "- '" 0 m m 0 ~ 2 8 9 '" '" ~ i ~ " ~ ,. " ;; ,-< B ;; m ~g ~~ '" ~ ~ ~ ~ ~ ~ Ii l& ~ ~ ~~ t tl III " " b g g g g ~ '" g b g '" " g g '" " . ,. ,,>, ~i b ~ 3~ ~ " " " " " " " " " " " ... :l g g g g g g g g g g g 11 ,. m ~l ~ '" ~~ ;(l ~ " " " " " " " " " " " '" e"" ~ .~ 8 g g g g g g 8 g ~ -< '" g g '" " ! " " " " " " " " " " " " " \ 8 g g g " g g g g g 8 8 g \ '" " ~ ~ % 11 0 " " " " " " " " " " 0 0 m ~ g g " " " " " g " " 8 " g " ~ 0 % '" " ~ c " " ~ ~ ~ -< ~ " " " " " " " " " " " ii\ " 'oS 8 g " " 8 8 8 8 8 8 8 \'J m 9- ~ \ 8 \3 ~ Z: 0 c " 0 8 \j\ % .. 15 \ll '=< '* ~ ~. m ~ " " " " " " " " " " " " " (f> '2 8 8 8 8 8 8 8 8 8 8 8 8 8 ." \!l '" \3 ,. [ ;g '6 '" % -\ " ~ S -* "'0 ~ '0 c~ 0 ~ '::" (f> ~ ~~ ." " " =i " " " " " " " " " " " m f' ~ " 8 8 8 8 8 g 8 " g " " g " w ~ ~ c:>9 ,. ~~ ~c ,. ::i '" 0,,- ~ " '" " " " " " 0 0 " " " " '" " g g " " 8 " g 8 " 8 8 " C- o g gtc € 7' € € € € € € € € € '" o '" "- ~ ~~2 Mark E. Stimeling 6RedFoxLn Mechanicsburg, PA 17050-1627 Q65 Theseservices are paid at a higher level because the out of pocket (DOP) max has been reached forthe individua1. K05 The charge exceeds the contracted amount for an In Network Provider. The subscriber is not responsibleforthis amount. K07 Theallowanceforthis procedure was included in the allowance for anotherserviceontheclaim. PPOlnNetwork PPO Out Network ~ 5~C.C: lC,c,:'C.O'J ~J:>::.CC For Kyle Paid To Date Paid To Date Paid To Date Paid To Date 5:>:'. SO ::;. '.' . . "',~ ::CO. (':iJ :;::').00 . -,~'~ ~.', J. :l '"' '-, . 'v .~, ':'5(0.00 1500.00 ':500.00 1-800-962-2242 s ::< ~ % '" --I ~ 0 \ 0 .. ~ ~ m \ " .. ~ '3. .. (l' ~ tl\ ? a ~ (f> a a <,:; -0 ,,". ~ % 8 8 ~ ~ l ~ ~ ... % ~ '€ ~S ~ -A ,,,,, ~'" m 0" '3. L. a a a '" % 8 8 :I: m ~ ". ;; 0 S\ ~~ 1;; t;1 ~ ~ E~ '8 ~ ~ ". ~ 0 0 ~ ~ g 8 8 ~ 0 ~ st" ~ .~ "'02 ~ "'~ ~ ..~ ,.. N ~ '" ~ - s ~ % ~ l' ~ 11 ~ ~ '" ~ ~ ~ 0 0 % '" ~ l!, 0 9- ~ !. ~ ~ 0 '" OJ '" CO ~.. ~ N .. CO . (II? :::!I ~ ~ ."", ~~ ~*' \ ~~ Q,!\ -i\\ e~ ~~ .,,- ".- ~,. ~~ ~% ~ .,,'1\ ]'1\ 0 ~~ '" ~~ '" 'Jl <: R. It~ ;s ~ ~ " ~~ 5 ~ % 8 8 l' ~~ ~ ~ '5. ~1; ~r '" '" % 8 8 i\\ "'." ~~ ~ ~ ~~ a S '6 8 8 -< " 16 ~ " a '" ~ ~ ~ 8 8 8 ~ " ~ 9i ~ ;; Q a a In ~ 8 8 8 0 g \ !it <2 S ~ -< Q a '" jI, g 8 8 /' Mark E. Stimeling 6AedFoxLn Mechanicsburg, PA 17050-1627 Q65 This member's annual out-ot-pocket has been reached, $ocoinsurance is no longer applied, resulting in a higher fever of payment. K05 This Participating Provider has agreed notto bill youforthedifterence between the Total Charge and theAlIowable Amount. PPO In Network PPO Out Network s ~ 5DO._ _ lece,.oo :'J00.0.: For Kyle Paid To Date Paid To Date Paid To Date Paid To Date :;-1.0. '_'...' =",>~.G~ 5eo.0C! 5'::':,. :>: :5C':. ':>:: ':::00.0: 1500.00 1500.1)0 1-800-962-2242 '" 2- ~ '3 '8 Q ~ \ " '3 \ ~ l " 'J\ ~ ~ l" 0 0 --< \;\ ~ "' <>; 0 c ~ <", g 8 8 ;:. '6 ;;;' 3 % 'it ~ " ~ ~ - ~S t; ;ll ~ ~" Z ~~ Q ~ 0 0 0 '" ~ g 8 8 '" .-Q -< ~ ::I: 0 'j\ "" ,...)) ~g '::< "'% '0 ~ ~ 5 :: '!: '2 0 g 8 8 :1 C ~ ~ \\\ '" '" fj, fj, ~ '" ..'i ~ '" - "' III '" % % ~ ~ l' ~ ~ ~ ~ ~ ~ ~ -. 0 1.\ ~ % % '" 9- (\ ? ~ ~ "' tll :-. Cl) ~ ~.. Cl) o~ ::!l ':. tit " " ? ? \1. 'F, '" " '{; ~ 'Z ',,; " ,,; ." '$ " ~ ~ ~ ~ '0 '0 ~ '<\ ~ ~ '" 'J\ <. ~ Ii"' 11'" ~ ~ ~ w.,'? ;:; 8 '8 8 l' ~r g'i ,,~ 5 :: '!: "'r "' '8 8 '8 " ':. ,,'" ~~ !:. ~ ::. ~~ ~ ~ " '8 8 8 :l " 0 '0 ~ ~ " " \ 8 8 8 0 '1l \ % ;;; ill ~ " " In ~ 8 8 8 ~ " g 0 \ ~ t 'Z ~ " " " 1.\ g 8 8 Mark E. Stimeling 6RedFoxLn Mechanicsburg, PA 17050-1627 '" Q65 This member's annual out-of.pocket has been reached, so coinsurance is no longer applied, resulting in a higher level of payment. K05 This Participating Provider has agreed not to bill you forthe difference between the Total Charge and the Allowable Amount. PPO In Network PPOOut Network 5JI~.'JJ 5C<,.O: ':":)::'0. -=:0 1-::'::;. 'J:' For Kyle Paid To Date Paid To Date Paid To Date Paid To Date ::'~ J . ;J ;, 5::(.;::' SCJ. ,>) 5C'). .:.'] ':'5:)'0. C\; lSGC.J:: lSJC'. ,:':;;J 1500. C":; 1-80()"962-2242 S :n ~ \3 '8 ~ ~ '" ( \3 l'; ~ III .." ~ Q " N Z. \ ~ \ ~ (T\ ~ " " " ,. 'ell ~ 'f). '" :;; 8 8 ~ ;. ~ '-< ~ :s . Z 0 ~ 0 3 " ~o '" "'~ 0 Q ,,'" C " ~~ '0 :n " " " '" ." S 8 8 r ,. 7 "" '" ,. 0 N 0 ~~ s ~ ;:", ~ 020 ("" 't i'\ ~ ~ z. g ~ " (Jl <;: ::l (g ~ '0. @ ~ glc ",'" l/.~~ ~ ~~ ~ ..0- ? 20 0 c ~ 'i "' .20 '" ~ - s % \5 ~ "I' ~ .. ~ ~ i \\\ ~ ~ !:!. ~ 0 ::l ~ % ~ ~ 9- ~ ~ 0 '" Ol \\\ <'> ". ~ so o~ - Y,\ -. ~ ~ 'W ~ w, \ '" ?1 ?1 ~ ~ .. ~ ~ ~ \ "' 0 co ~ "1\ ~ '~ '~ "- " "' ~~ ~g e. ~ tl ~'f! " 1) \l 8 8 ,. %F ~ "'; 't 1) 'l 3r " "' <;: ~ \g ~ 11. ~~ ",'l ~ I> ~ \i!~ \l\ tI ~'" " =< 'B tl ~ -< " ~ ,. -< '" " " " '3 s 8 S g \ ~ ~ " " " "' \ g 8 8 ~ "' ~ ~ i -< " " " 0 g 8 8 '" Mark E. Stimeling 6 Red Fox Ln Mechanicsburg, PA 17050-1627 a6S This member's annual out-af-pocket has been reached, so coinsurance is no longer applied, resulting in a higher level of payment. K05 This Participating Provider has agreed not to bill you forthe difference between the Total Charge and the Allowable Amount. MSO The allowable amountforthis service has been reduced according to muJtJpJesameday surgery guidelines PPO In Network PPO Out Network '~J s:o .:: 1:::::,). C') 1(>:::,0. (': For Kyfe Paid To Date Paid To Date Paid To Date Paid To Date :::J.O':' 5ec. c: 2-5'):. ':::: :;;,',r, /,:,-; _ ~'.' v_ :5GQ.:C 1-800-962-2242 n ~ w ~ N ~ Cl "z m ~ m >< ~ ~ ~ 'tJ ~ ~ iii ~ ~ '" ~ 0 li\ :::l ~ ~ III 1> .... ~ ~ ~ m o' ~ <i ~ ~ ~ :::l l:l 0 m 0 ..... ~ III m "''' ~ ~o :::l n~ ~ m ~ c ~ ~~ ~ ..... ~ c ?~ ;:;: " ~ m " ~~ 0 VI ~ m m ~ m~ " .~ ffiQ! ~ n ~ 0 ~O '" ~ =i~ ~ ~ ~ 5 m ~ z ~ 0 m ~ ~ ~ < ~ i:i < .V> 1> m n~ ~ ~ w ~9 ~ "'> ~ ~ 8 Iil~ 8 8 ~ 8 8 > >>' ; 15~ ~ l1 5' p 8 ~~ ~ ~ OJ ~ ~~ 8 m " m ~~ ~'" ~ ~ ~~ N W ~- ~ ~ ..Iii ~ N P N W 8 ~'" ~ " ~ 8 ~ ~ 0 p ~ " 0 m 0 8 8 0 z 8 ~ 0 m '" 0 ~ c m 'I '" 0 8 m 0 0 in m 8 8 8 0 ~ '" 8 m '" m V> n ~ 0 0 z i:i N 8 ~ in ~ '" " 0 iil ~ :i m ill p z ;;; 8 n m 0 ~ 0 " ~ 0 0 m )> 8 '" Ii' ~ 8 0 '" r 0 0 ~ 8 0 '" 1Jl "" S 8 8 m "" [;l .w " ~ ~ -< DO "" fT1 0 m " ill '" m '" '" -"* ill '" < ;;S ~ '" -< ['J ~ J. '" z m . 0 8 '" ~o )> )> ~ !:1 c '" "" ~ 0 c~ U> " " g "'~ U> " ~. 0 p ~m 0 0 -D 0 0 n 8 8 0 a ,,'" ~. 8 m 0 8 ;; .- ..., " -I:.... m ." U> 0 ~ "U C f ~'" 0 ~ ~ ~o 0 8 w o~ w m m 8 ~ ~ V N ~ 8 ~ ----- " 0 ~ n'" .~ c om", ~ ~~~ c. " ~z- .. Mark E. Stimeling 6RedFoxLn Mechanicsburg, PA 17050-1627 K05 Thecharge exceeds the contracted amount for an In Network Provider. The subscriber is not responsibleforthis amount. MSO Theallowableamount forthis service has been reduced accordingto multiple same day surgery guidelines PPO In Network PPO Out Network :: .'),j . '-"~ .1.. ')'~ ,_' For Kyle Paid To Date Paid To Date Paid To Date Paid To Date 1-800-962-2242 PAUL J. GITNIK & ASSOCIATES, LLC A TTORNEYS AT LAW Paul J. Gitnik Centre 1201 Broughton Road Pittsburgh, Pennsylvania 15236-3451 www.socratesinc.com E-mail: subrogation@socratesinc.com Telephone: (800) 680-4806 (412) 653-4806 Facsimile: (412) 655-8721 NOV I 2 ?OO~ I O~ DLfD! DZ<30 November 8. 2004 Swartz & Campbell Christina Bradley. Esquire ! 631 North Front Street ?nd Floor Harrisburg, J)A 17102 Re: *Capital Advantage Insurance Company **Patient: Stimeling, Kyle Contract No.: 203546350 Date oflnjury: Dec 31, 2003 Dear Ms. Bradley: As you are aware. this law firm has been retain('d w, legal (,ill-nse! in C;)n.;ui1ction with **SOCRA TES. !NC . W prL'''f,.j(; (J!ll~ourcing subrogation services to Capital Ad"/anLage 1J1"Uf3.1Cf C:orrpanl', a subsidiary of Cap:l<:.l HhH.:(;":'s'. (L:'.llli.~ctively ''"Capital''), the AdrninistrJtivt: Services;: h"dy ( . ,t-\SC.') ccmtractor to this self-fundci w,:lf~r~ h/~Jlt>'iT !Jl:m i"'~elf-Funded Plan") with regard to the nbc\''::'"-r.:ferenc:c':, 31d:j"l),:;,~t;')n case Erl'.:lo~.2'd please find a copy of an addirinnai c1aim(s) fJa,d uy 1_>1(11nl ii.:-i the ASO contractor. fOJ the ~ljm of 5)').JO; therefore, the preliminary subrogation claim amount is: $:;,OI:20g, paid as ufNov 08, 2004 We rcserVt the right to provide )'ou with and shall expect you to request an updated Capital RrcGrd of Claim Payments prior to tile fina: settiemem and/or resolution of this subrogation case with this firm. As you are aware, the Self-Funded Plan's contractual subrogation jnterests administered by Capital Advantage Insurance Company are separate and distinct from that of Medicare andlor any other Blue Cross P\an(s). When appropriate, please ensure that the draft is made payable to SOCRATES, INC., ESCROW ACCOUNT. If yo" should have any questions regarding this matter. please feel free to call me. Very truly yours. PAUL J GITNIK & ASSOCIATES, LLC Q-iLp ~~ Paul J. Gitnik PJG/mz Enclosure cc. Kyle Stimeling >I< Thi,: information has becn disclosed to yOll from records whose confidentiality may be pwtected hy state and federal law. Any further disdosme of this information \\'ithout the prior written consent or authorization of the person to whom it pertains may be prohibited. * * SaCRA TES. INC. provides outsourcing subrogation services. .cmpbte MAR 01 2004 12:10 FR FIRE SERUICES 'D 6576974 TO 917172637834 P.04/06 ELITE II POLICY DECLARATIONS Non.Assessable Page 1 of 3 These Declarations are a part of the polley named above and Iclentffled by polley number below. They supersede any Declarations Issued earlier. Your Elite II Policy will provide the Insurance described In this polley In return for the premium and compliance w~h all applicable polley provisions. See polley for details regarding the other coverages and additIonal coverage options, Policy Numb.,.: 58 37 HO 272719 POlicyholder: (Named InlUred) MICHAEL 0 DILl.ER 887S WERTZVILLE RD ENOLA PA 17025-1035 Issued: MAR 17, 2003 Polley Period From: APR 16, 2003 to APR , 6, 2004 but only ff the reQulrad premIum for this period has been paid, and only for annual renewal J)!!rlods ff premiums are pard as requrred. Each period begins and ends at 12:01 A.M. Standard time at the Rasldence Premlsas. The Following Change(e) Have Been Made To Your Polley: The IIm~ of lIabllty for Section I Coverage A Dwelflng Is ruvlsed. Residence Preml8ea Information: 6875 WERTZVILLE AD ENOLA ST PA ZIP 170250000 PROTECT I ON CLASS 6 RATED PROTECTION CLASS 6 I NS I DE S r NGLE CLASS AREA WITHIN 1000 FT FROM HYDRANT WITHIN 5 MILES FROM FIRE DEFT FIRE DISTRICT 0001 CAMP HILL BOROUGH OF PROTECT I ON TEAR I TORY 033 ONE FAMILY FRAME C/lYELL I NG YEAR OF CONSTRUCTION 1993 SECTION I Property Coverages COVERAGe-A-DWELUNG COVERAG~THER5TRUCTURe$ COVERAGE-C-PERSONAL PROPERTY COVERAGE-O-lOSS OF USE SECTION II Liability Coversges COVERAGE-e-PERSONAL UABILlTY FOR EACH OCCURRENCE: PROPERTY DAMAGE AND BODILY INJURY COVERAGE-F-MEDICAL PAYMENTS TO OTHERS EACH PERSON Limite Of Lllblllty Deductible: $500 AlL PERILS $ $ $ $ In case of a lose under Section I, we cover only that part of each loss over the deductible Slated. 184,200 18,420 128,940 184,200 Limits Of Liability $ 300,000 S 1,000 H5300 MAR 01 2004 12:10 FR FIRE SERUICES 657 6974 TO 9,7172637834 ;0.05/06 ELITE II POLICY DECLARATIONS Page2 of3 PERSONAL PROPERTY -SPECIAL LIMITS OF LIABIUTY The special limits shown below for each category Is the total IIm~ for each loss for all property In that category. They do not Incrva.e the Coverage - C - Personal Property. IImlta of liability. see Polley for dllla.l1s regarding the Special Limb of Uabll~y. These IIm~s are Included In the basic Policy premium. Theft Losses Only CategOlY JEWELRY, WATCHES AND FURS CAMERAS GUNS TOOLS SILVI!RWARE Limits of Liability I 1,000 1,000 1,000 1,000 2,500 All Covered L.oeses category Limita 01 Liability $ 200 $ 1 , 000 $ 1.000 $ 1,000 $ 1.000 $ 3.000 $ 500 MONEY SECURITIES WATERCRAFT TRAILERS MANUSCRIPT COMPUTERS BUSINESS PROPERTY OTHER COVERAGES/OPTIONS APPLICABLE See Polley or Endorsements for datal1s regarding the Other Coverages and Options that apply to your policy. Other Coverag.. Limits of Liability INFLATION PROTECTION APPL I ES BOECKH INDEX 0549.6 ACCIDENTAL DEATH BENEFIT EACH CHILD EACH ADULT FIRE DEPARTMENT SERVICE CHARGE CREDIT CARD. FORGERY Option. Applicable OPTION.f-EXTENDED REPLACEMENT COST PERSONAL PROPERTY OPTION-J.REPLACEMENT COST GUARANTEe DWELLING OPTION-L-PROTECTIVE DEVICE CREDIT LOCAL FIRE OR SMOKE ALARM SYSTEMS $ I 500 2.000 500 1,000 APPLIES APPLIES APPLIES PREMIUM SUMMARY Premium Based On Premium Amount POUCY PREMIUM Annual Renewal Premium Annuel Renewel Premium Includ.. Diecounta For; CLAIM FREE LONG TERM HOME'CAR HOME PROTECTIVE DEVICE S $ 530.00 530.00 MAR 01 2004 12:11 FR FIRE 5ERUICE5 657 6~74 TO 917172637834 P.06/26 "D Polley Number: 58 37 HO 272719 Policyholder: (Nemed Inlured) MICHAEL DILLER Policy Period From: APR 16, 2003 TO APR 16, 2004 ELITE II POLICY DECLARATIONS Non-Assessable Page 3 of3 Issued: MAR 17. 2003 FORMS and ENDORSEMENTS MADE PART OF POLICY Fire 2502 Fire 2630-B Fire 3358-A EJIl8 II Homeowners Policy Amendatory Endorsement Amendatory Endorsement ADDITIONAL INTERESTS SECOND MORTGAGEE WACHOVIA BANK NA P8 BOX 50010 R ANOKE VA 24040-5010 Ileued By: NATIONWIDE MUTUAL FIRE INSURANCE COMPANY Count....igned At: HARRISBURG, PA Prior Declaration Issued: MAY 24. 2002 Home Office - Columbul, Ohio By: JAMES R KISER IMPORTANT PHONE NUMBERS Nationwide 24-Hour ClailM Number: 1-800-421-3535 for QUESTIONS About Your Po/icy, Cell Your NATIONWIDE AGENT: JAMES R KISER 717-781..0190 For Heerlng Impeired: TTY 1-800-822-2421 Netlonwlde RIIlIJone' Office: 7170657-8400 *~ TOTAL PAGE.06 ** JUN-29-2004 02:29 PM CINDYFERENTZ J1.JN :29 :2004 l/JSII 55 FR F I REO SSRU I CES [::J (1 ( "='~1 ;'::':lI.:Sq. 1-'.1::::1':'::: 65'1 69?4 TO 97179:21:2934 P.Iil:z.104 ELITE II POLICY DECLARATlONI -No~;......ill1i .ll;.llll , Tilt.. ~"Illon. .,. . "" fA lilt ~IoY.llIm1d AIllM 1IlCI1cl."Ultll ~y IiI\llloy ~umHr INlOW. TIley IUplIlIId. .ny Oeclll.1lO1lt ..1IICl aa~lar. your III. I ,allaY ... lM'Ilcla l~' IMU'._ d'ICI'11leCl In I~' IIClIIay III ,lIurn far Ih. ~,._ and comallanaa will.. a.leIelt.llIll1CV alO\<talonl. '..llOIkly 10, dllalll ,"""nllno Ihl olhot .._.... .ntI addlllon.'oOWNflI opllO.., ~.II", Hum.....' II 37 "'" 211122 '"ueo: WAY 19. 2aa' l'DI\oyIlaldtr; (N.lmild 1':A'ml . .a~,... '705S-40~1 'olloy'_ 'rom, J\}oI If. 2a03 la ='" '004 IIullll'lY'lhel'8llrbodDllllllurnlDrthill/M'lcldhal balnolld,lndonly Ie, .",,\IiI ro_ ~no . p.....lu""'.,. paid IIIIqUlN4..i1h IIWIolIlltll"'I .Mlnill II 12: Of A,PoI, ftlP'ldard rUM.' r"-i __ fIO. ~,.fftI:Ma. TM r~'Iow"'o ChlnO',al H... _n ,..... To Your 'DII6r- Thl II",~ 01 IlIbllly 10, loetlo/! I ClMr'lII A 0weI1", II ......". 1I......n.. ,romll.. Inl_'IGn: ~,~ Mlll!.llr. . \.IiAil"or~~ICIN '''1 "CTlON I ~r.......y e.""i" COVEIIAQ/l-.o..ClWIIU.INQ eovtAAdI!-8-0THllIlTIIUCl'UllII COvtllAGl!.c..-eMONAl. 'IIO,elm' CClYIIlAOI II l.Ott 0' Uti 8EOTION" Ualllll, Qovnt" com~M'V ~ . L ~_ti'IHU~INl" ..... FRAME: I 03 ll,"IlI 01 LId"., D"'''''''~I.: "'0 "~l 'IIl,LI . ". ,'00 , "..'0 s eo.no , 114,800 In GIN III . IGN wr>cl.. SIQlil>n I, WI _.!'IYlhll...llf11...h r_"".. I/lIG...\IC11t1l1 it.tlel. "''''". 01 ""Mlly , fGO.ooo I 1.000 -- .-.. .. ....... ...... --..... .... ............ lUN-29-2004 02:30 PM CINDYFERENTZ 717 921 2934 P.03 !UN 29 2004 09' 56 FR FIRE SERVICES 55'i' &974 TO 9?17921:0934 1'.133/04 ELITE II POLICV DICLARATION8 'Igtl III m '.lIISONAL ,,,op.nlY-SPlCIAL LIMITI 01' LlAlllUTV T"-=:1Il IImk. ._" wow for JlOft oalllll~ry 10 ~:rJ ""'. 1Q.( .~ Jog 10' III P~Oll4l"Y In \nl' III , TlIt..... neuncttUI'"" COI'WIOI- -,iItIg"", PJII,*,Y.I!~IlUf 11ll1l1llly. 0" POlICY lor Glial' regl 'rIg ''''' I_Ill mkl '" Ulbl"y. T"-I.ll'" I In '''''' lei Irtlnl _Ie I"alloyplWmlum. Tl\tll LOINI On'y CI'~Of'/ OWlit \Y"'TC:H~II"'ND pu~a .~~l..... LlmNI of Ll&bllNy I l~Ui 1 ....., JUN-29-2004 02:30 PM CINDYFERENTZ -.-........""1.. An c.wrH ~..,.. Ca'ttCltY It...m 717 921 2934 P.04 . 1I,.v. Llm"' II 1Ja1t11/l, I 1:11 to 2 o. c OTHe.. COVI!AAGI!81OPTIONll ","PLlCA.L. ... 'olloy 0' lnelll/llm'",' 10/ GIIII, II'jI'GIIlCI ",. OllIe, 00I'It1... .IICI OPlIO"lIhl' IIII'IY 10 yOur poIloy, Ofh., C'V""" LllIlU ,f LI._lflI, .".. ,ea l/j~~ r~o~ ''''R1!C'TIO~ :T~ (~t1S'IATfta\~I'IT ~ XO'IIL~ '1 "S1A~~?S',,'i'Il~CI CMAME OpllOn, "ppllOlllllt r>>ji~~".IXT~~lI~C1U.I'\.ACl!MIHT 001T 011 ~\.A8i~i;.,;. COlT QUAlWlTl!E o I ~1:'C.~a"T.~1 IT e L FIbS), U aTlMS · r. A~AOM\i = ' P"IMIUM aUMMARY '"mlum ....d On ;8Hi'J&~"llW~toN.\L ".OP&ATY AnllUI' "lftl...1 "."'luOl A/III"""_.." 'N,"'U," '......... DIHo_ '01: HICTIYI ClEVICI I eoo a,ooa loa 1. 000 s APPlIES AP'LIE, APflt..U ....0 '/'Imlum Amo.IIl t . 313.00 ".00 411.00 FRAME: .r 03 -,..---.............--.....----- JUN-29-2004 02:31 PM CINDYFEREHTZ 1u.I 2~ 2004 1il9' 57 FR F I RIO SERV ICES (1.... ':::'4::1. 4::';jI~"+ t-'.l:J;:::J 657 6974 TO 97179212934 P.l!I4/04 'olloy Humllet; " 37 .. III,n 'lIutd, \lilY II. 2003 'IlItYllO/dWl ltlallitln"IIIfMlj JAMl!I 1AllL!Il Ptlley ".1OcI from' JUN ". '00' TO JUN 'I. EL.ITE II POLICV DICLAIUTIONS Non_MtII. '101 1013 CJ 2004 FORMa Ina iHOORliMINTI MADE PART 01' POUCY '~'II Ilft'I!f:' Ollmill'l P!1~ PI,. ., ~~ 1M D,......~ '" ....11 """" 0 ",. 1114 I.".,:f. '''''~'''plrly Indo...",,'" ADDMrnONALINTlA!8TI ""'T 1II0fl.'l'Q"QII: liE, II 0 MOM! ~ O~4'~'~ ~j A'.' " 1a1U" Iy: NATIONWID! MVTUAl, '1IIlIINSUIUNCE OOMPANT C.unt....'.n... At: t1ARIUallJM. PA ""'" D....tltlcn I.."",,: IEP ". IOO~ ",,'" 0tI~ - CO'Ulnbul. O~lo Iy\ JO"'H T IAOfllU IMI'ClIITANT PHON. NUMlle". H,'Ie"wId. ,,-Me... CI.,,,,, NIIlIlWl '-loo-q"J'3' ,.. aUIUIOII, AIlcI" '-011' "one,. C.II "'_ II.&TlOHWlPE AQINT' JONN T MORITZ , 17...'..... '01' "'''''110 l/IIllllttfl 'f'N ''''111 1220141 t N.li.n...... Il,,1olNI1 0fIIC0: "''''''....00 .....--.. L.__.___~.- FRAME: K OJ - *'" TOTl't.. PRlE.04 .. .. RELEASE AND SETTLEMENT AGREEMENT This Release and Settlement Agreement ("Agreemenf') is made and entered into among Kyle E. Stimeling, a minor, by his parents and natural guardians, Mark Stimeling and Tammy Stimeling, Mark Stimeling and Tammy Stimeling, individually; Michael Diller, Lori Schweitzer, Alex Schweitzer, James R. Sadler, Catherine Sadler, Jordan Sadler; and Nationwide Mutual Fire Insurance Company ("the Parties"). The "Claimanf' shall collectively mean Kyle E. Stimeling, a minor, by his parents and natural guardians, Mark Stimeling and Tammy Stimeling and Mark Stimeling and Tammy Stimeling, individually, their respective heirs, executors, administrators, personal representatives, successors and assigns; the "Insured" shall collectively mean Michael Diller, Lori Schweitzer, Alex Schweitzer, James R. Sadler, Catherine Sadler and Jordan Sadler; and the "Insurance Company" shall mean Nationwide Mutual Fire Insurance Company. I. RECITALS A. On or about December 31,2003, at or near 6875 Wertzville Road, Enola, Cumberland County, Pennsylvania, Kyle E. Stimeling claims to have sustained physical injuries as a result of the alleged conduct of the Insured (the "Incidenf'). In connection with the Incident, the Claimant has asserted a claim against the Insured based upon tort or tort type claims. B. The Insurance Company and the Insured have entered into a liability insurance contract which provides that the Insurance Company shall defend the Insured against any claim or suit for damages arising from the Incident, has authority to settle any such claim or suit on behalf of and as agent for the Insured, and shall insure the Insured for such liability subject to the limits set forth in the contract. C. The Parties desire to enter into this Agreement to provide, among other things, for considerations in full settlement and discharge of all claims and actions of the Claimant for damages which allegedly arose out of or due to the Incident, on the terms and conditions set forth in this Agreement NOW, THEREFORE, it is agreed as follows: II. RELEASE A. Release and Dlscharae. In consideration of the cash payment(s) referred to in Paragraph iliA and the promise to make the periodic payments referred to in Paragraph III.B. ("Periodic Payments"), the Claimant hereby completely releases and forever discharges the Insured, the Insurance Company, and any and all other persons, finns, or corporations from any and all past, present, or future claims, demands, actions, damages, costs, expenses, loss of services, and causes of action of any kind or character, whether based on tort, contract, or other theory of recovery, whether known or unknown, which have arisen in the past or which may arise in the future, whether directly or indirectly, caused by, connected with or resulting from the Incident. This release and discharge shall be a fully binding and complete settlement among all Parties to this Agreement, and their heirs, assigns, and successors. The Claimant acknowledges and agrees that this release and discharge is a general release. The Claimant expressly waives and assumes the risk of any and all claims for damages and expenses which exist as of this date, but of which the Claimant does not know or suspect to exist, whether through ignorance, oversight, error, negligence, or otherwise, and which, if known, would materially affect the Claimant's decision to enter into this Agreement. The Claimant further agrees that the Claimant has accepted the considerations set forth in Paragraphs III. A. and B. as a complete compromise of matters involving disputed issues of law and fact. The Claimant assumes the risk that the facts or law may be other than the Claimant believes. It is understood and agreed to by the Parties that this settlement is a compromise of a doubtful and disputed claim, and the payments are not to be construed as an admission of liability on the part of the Insured, by whom liability is expressly denied. B. InJuries Known and Unknown. The Claimant fully understands that the Claimant may have suffered personal injuries that are unknown to the Claimant at present and that unknown complications of present known injuries may arise, develop or be discovered in the future, including, but not limited to, subsequent death or disability. The Claimant acknowledges that the consideration received under this Agreement is intended to and does release and discharge the Insured and the Insurance Company from any claims for, or consequences arising from, the injuries which allegedly arose from the Incident; and the Claimant 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 C. Parties Released. This release and discharge shall also apply to the Insured's and the Insurance Company's past, present, and Mure officers, directors, stockholders, attomeys, agents, servants, representatives, employees, subsidiaries, affiliates, reinsurers, partners, predecessors and successors in interest, heirs, executors, personal representatives, and assigns and all other persons, firms or corporations with whom any of the former have been, are now, or may hereafter be affiliated. iii. PAYMENTS TO CLAIMANT. PAYEE. AND/OR BENEFICIARY A. Payment at Settlement land Amounts Previouslv Paid}, The Insurance Company and the Insured will pay a total of Forty Thousand Dollars ($40,000) to the Claimant, of which Three Thousand Dollars ($3,000) has already been paid, receipt of which is acknowledged. These payments include, but are not limited to, all out of pocket expenses, attomey fees, all medical liens, all rights of recovery, all medical subrogation claims, all workers' compensation subrogation claims, known and unknown, and claims for general damages. In addition, it is understood by the Claimant that the remaining Thirty Seven Thousand Dollars ($37,000) paid to the Claimant is to be held in trust for and on behalf of Kyle Stimeling, and to be used solely to pay medical liens and any Mure medical expenses necessary for the treatment of the injuries sustained by Kyle Stimeling in the loss of December 31, 2003. Any balance remaining of this Thirty Seven Thousand Dollars ($37,000) must be immediately paid to Kyle Stimeling upon his eighteenth (18th) birthday. B. Periodic Payments. The Insurance Company, on behalf of the Insured, agrees to payor cause to be paid the following Periodic Payments: (1) To Kyle E. Stimeling ("Payee"), the sum of Nine Hundred Fifty Dollars ($950) to be paid on or about the twenty fifth (25th) day of each month, beginning on or about February 25, 2009, compounding at a rate of 3.00% per annum, and continuing for the life of Kyle E. Stimeling. 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 January 25,2039. The first 3.00% increase shall be effective February 25,2010, and each subsequent increase shall be effective the twenty fifth (25111) day of February each succeeding year. 3 (2) To Kyle E. Stimeling ("Payee"), the following guaranteed lump sum payments: Twenty Thousand Dollars ($20,000) on or about February 25, 2016. Sixty Five Thousand Six Hundred Six Dollars ($65,606) on or about February 25, 2026. One Hundred Thousand Dollars ($100,000) on or about February 25,2036. One Hundred Thirty Five Thousand Dollars ($135,000) on or about February 25,2046. (3) Should Kyle E. Stimeling die before February 25, 2046, then any remaining guaranteed Periodic Payments set forth in Subparagraphs III.B.(1) and (2) shall instead be paid, subject to the provisions of Subparagraph III.B.(4) below, as they become due, to the estate of Kyle E. Stimeling ("Beneficiary"), with the last guaranteed Periodic Payment to be made on or about February 25, 2046. Should Kyle E. Stimeling die after January 25, 2039, then monthly payments as set forth in Subparagraph III.B.(1) shall cease. (4) The Payee shall have the right, after reaching the age of majority, to submit a request to change the Beneficiary by filing a written request with the owner of the Annuity Contract. The change will be effective when approved by both the owner of the Annuity Contract and the Annuity Issuer. Any change in the Beneficiary shall not in any way affect or alter any of the provisions of this Agreement. IV. ASSIGNMENT AND FUNDING OF PERIODIC PAYMENT OBLIGATION A. Asslanment of Obllaatlon. The Parties understand and agree that the Insurance Company may assign its duties and obligations to make such future Periodic Payments designated in Subparagraphs III.B. (1) and (3) to Metropolitan Insurance and Annuity Company C'Assignee") pursuant to a "Qualified Assignment and Release," within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as amended, attached as Exhibit A. When the Periodic Payment obligation is assigned to Metropolitan Insurance and Annuity Company, Metropolitan Life Insurance Company has represented that it will provide a written guarantee of such obligation in the form attached as Exhibit B. Such assignment is accepted by the Claimant 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 Periodic Payments. Upon such assignment, it is understood and agreed by and between the Parties that the Assignee shall make said Periodic Payments direcUy to the respective Payee and/or Beneficiary designated in Subparagraphs III.B.(1) and (3), and that the Payee shall submit any request to change the Beneficiary directly to the Assignee. .. The Parties expressly understand and agree that, with the Insurance Company's assignment of the duties and obligations to make such Periodic Payments 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 Periodic Payments shall cease, and instead such obligation shall be binding solely upon Metropolitan Insurance and Annuity Company. The Parties further understand and agree that when the assignment is made, the Insurance Company shall be released from all obligations to make such Periodic Payments and Metropolitan Insurance and Annuity Company shall at all times be directly and solely responsible for, and shall receive credit for, the Periodic Payments, and that when the assignment is made, Metropolitan Insurance and Annuity Company assumes the duties and responsibilities of the Insurance Company with respect to such Periodic Payments. B. Annuity Fundina. The Parties understand and agree that the Assignee may fund its obligation to make the Periodic Payments by purchasing an annuity contract (the "Annuity Contract") from Metropolitan Life Insurance Company (the "Annuity Issuer"). If such Annuity Contract is purchased, the Assignee shall be the owner of the Annuity Contract and shall have and retain all rights of ownership in the Annuity Contract. C. Assianment of Obliaation. The Parties understand and agree that the Insurance Company may assign its duties and obligations to make such future Periodic Payments designated in Subparagraphs III.B. (2) and (3) to Prudential Assigned Settlement Services Corp ("Assignee") pursuant to a "Qualified Assignment and Release," within the meaning of Section 130(c) of the Intemal Revenue Code of 1986, as amended, attached as Exhibit C. When the Periodic Payment obligation is assigned to Prudential Assigned Settlement Service Corp, The Prudential Insurance Company of America has represented that it will provide a written guarantee of such obligation in the form attached as Exhibit D. Such assignment is accepted by the Claimant 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 Periodic Payments. Upon such assignment, it is understood and agreed by and between the Parties that the Assignee shall make said Periodic Payments directly to the respective Payee and/or Beneficiary designated in Subparagraphs III.B.(2) and (3), and that the Payee shall submit any request to change the Beneficiary directly to the Assignee. The Parties expressly understand and agree that, with the Insurance Company's assignment of the duties and obligations to make such Periodic Payments to Prudential Assigned Settlement 5 Services Corp pursuant to this Agreement, all of the duties and responsibilities otherwise imposed upon the Insurance Company by this Agreement with respect to such Periodic Payments shall cease, and instead such obligation shall be binding solely upon Prudential Assigned Settlement Services Corp. The Parties further understand and agree that when the assignment is made, the Insurance Company shall be released from all obligations to make such Periodic Payments and Prudential Assigned Settlement Services Corp shall at all times be directly and solely responsible for, and shall receive credit for, the Periodic Payments, and that when the assignment is made, Prudential Assigned Settlement Services Corp assumes the duties and responsibilities of the Insurance Company with respect to such Periodic Payments. D. Annuity Fundina. The Parties understand and agree that the Assignee may fund its obligation to make the Periodic Payments by purchasing an annuity contract (the "Annuity Contract") from The Prudential Insurance Company of America (the "Annuity Issuer"). If such Annuity Contract is purchased, the Assignee 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 may direct the Annuity Issuer to make all the Periodic Payments directiy to the respective Payees and/or Beneficiaries designated in Paragraph III.B. Each Payee and Beneficiary designated in Paragraph III.B. shall be responsible for maintaining hislher current mailing address with the Annuity Issuer. The obligation assumed by the Assignee to make each Periodic Payment shall be fully discharged upon the mailing of a valid check or electronic funds transfer in the amount of such payment on or before the due date to the last address on record for the Payee or Beneficiary with the Annuity Issuer. If the Payee or Beneficiary notifies the Assignee that any check or electronic funds transfer was not received, the Assignee shall direct the Annuity Issuer to initiate a stop payment action and, upon confirmation that such check was not previously negotiated or electronic funds transfer deposited, shall have the Annuity Issuer process a replacement payment. E. Status of Claimant. Payees. and Beneficiaries. The Claimant, each Payee and each Beneficiary, as applicable, shall at all times remain a general creditor of the Assignee and shall have no rights in the Annuity Contract nor in any other assets of the Assignee. The Assignee shall not be required to set aside sufficient assets or secure its obligation to the Claimant, each Payee, or each Beneficiary, in any manner whatsoever. 6 . F. Date of Birth. The Claimant warrants and represents that Kyle E. Stimeling ("Payee") was born on February 25, 1991. Notwithstanding anything to the contrary in this Agreement, if the actual date of birth is not as stated above, and if the Insurance Company or the Assignee relies or has relied on the accuracy of the above-stated date of birth in determining the amount, timing and/or duration of the Periodic Payments or the cost of providing them, the Insurance Company or the Assignee may take such actions as are necessary to reflect the correct date of birth. These actions include but are not limited to: 1) adjusting the amount, timing and/or duration of the remaining Periodic Payments so that the Insurance Company or Assignee incurs no additional cost beyond that necessary to purchase the Annuity Contract on the date of assignment to provide the Periodic Payments based on the correct date of birth or 2) recovering from the Claimant, Payee, or Beneficiary, as appropriate, any Periodic Payments already paid in excess of the Periodic Payments that could have been provided by an Annuity Contract purchased on the date of assignment based on the correct date of birth. v. NO CHANGES IN PERIODIC PAYMENTS The Claimant acknowledges and agrees that all, some, or any part of the Periodic Payments cannot be, and may otherwise be prohibited or restricted under applicable law from being accelerated, commuted, transferred, deferred, increased or decreased by the Claimant or by any Payee or Beneficiary and that the Claimant or any Payee or Beneficiary shall not have the power to sell, mortgage, encumber, or otherwise anticipate all, some, or any part of the Periodic Payments by assignment or otherwise. Any transfer of the Periodic Payments by the Claimant may subject the Claimant to serious adverse tax consequences. VI. ENTIRE AGREEMENT This Agreement contains the entire agreement between the Claimant, the Insured, and the Insurance Company with regard to the matters set forth in it. There are no other understandings or agreements, verbal or otherwise, in relation to the Agreement, between the Parties except as expressly set forth in it. This Agreement is intended to conform with the requirements of Intemal Revenue Code Sections 104(a)(2) and 130. All provisions of this Agreement should be construed in a manner so as to effectuate that intent. 7 VII. READING OF AGREEMENT In entering into this Agreement, the Claimant represents that the Claimant has completely read all of its terms and that such terms are fully understood and voluntarily accepted by the Claimant. VIII. 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. IX. DRAFTING OF DOCUMENT AND RELIANCE BY CLAIMANT This Agreement has been negotiated by the respective Parties. The Parties to this Agreement contemplate and intend that all payments set forth in Section III constitute damages received on account of personal injuries or sickness, arising from the Incident, within the meaning of Section 104(a)(2) of the Intemal Revenue Code of 1986, as amended. However, the Claimant warrants, represents, and agrees that the Claimant is not relying on the advice of the Insured, the Insurance Company, anyone associated with them, including their attomeys and the insurance broker placing the Annuity Contract, as to the legal and income tax or other consequences of any kind arising out of this Agreement. Accordingly, the Claimant hereby releases and holds harmless the Insured, the Insurance Company, and any and all counselor consultants for the Insured and the Insurance Company from any claim, cause of action, or other rights of any kind which the Claimant may assert because the legal, income tax or other consequences of this Agreement are other than those anticipated by the Claimant. The Parties signing this Agreement, and each of them, warrant and represent that no promise, inducement or agreement not expressed in this Agreement has been made to them and that this Agreement constitutes the entire agreement between the Parties and that the terms of this Agreement are contractual and not mere recitals. The Claimant represents and agrees that the Claimant has read the Agreement and fully understands it, and is aware of the propriety and legal effect of executing it, and neither the Agreement nor the compromise and settlement recited in it were induced by fraud, coercion, 8 compulsion or mistake, nor is this Agreement nor the compromise and settlement made in reliance upon any statement or representation of any of the Parties released by this Agreement, or their representatives, agents or attomeys. X. WARRANTY OF CAPACITY TO EXECUTE AGREEMENT The Claimant represents and warrants that no other person or entity has, or has had, any interest in the claims, demands, obligations, or causes of action referred to in this Agreement, and that the Claimant has the sole right and exclusive authority to execute this Agreement and receive the sums specified in it and that the Claimant has not sold, assigned, transferred, conveyed or otherwise disposed of any of the claims, demands, obligations or causes of action referred to in this Agreement. XI. COURT APPROVAL The Parties agree that the Claimant 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. 9 XII. CONTROLLING LAW This Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. Dated: Mark Stimeling, individually and as parent and natural guardian of Kyle E. Stimeling, a minor, Claimant Dated: Tammy Stimeling, individually and as parent and natural guardian of Kyle E. Stimeling, a minor, Claimant Dated: Duly Authorized Representative for Nationwide Mutual Fire Insurance Company APPLICABLE TO PENNSYLVANIA ONLY: For your protection, Pennsylvania requires the following to appear on this fonn: 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 Infonnatlon or conceals for the purpose of misleading, Infonnatlon concemlng any fact material thereto commits a fraudulent Insurance act, which Is a crime and subjects such person to criminal and clvll penalties. 10 .' Exhibit A Uniform Qualified Assignment and Release "Claimant" Kyle E. Stimeling, a minor, by his parents and natural guardians, Mark Stimeling and Tammy Stimeling "Assignor" Nationwide Mutual Fire Insurance Company Metropolitan Insurance and Annuity Company "Assignee" "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 . 2004 (the "Settlement Agreementj 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 paymentsj; 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: 1. 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 1S0(c) of the Code. S. 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 tannlnated by a court of law or In the event that Section 13O(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 respective representatives, heirs, successors and assigns of the Claimant, the Assignor and the Assignee and upon any person or entity that may assert any right hereunder or to any of the Periodic Payments. Assignor: Nationwide Mutual Fire Insurance Camoanv By: Authorized Representative Title Claimant: Mark Stlmeling, as parent and natural guardian of Kyle E. Stlmellng, a minor Claimant: Tammy Stlmellng, as parent and natural guardian of Kyle E. Stlmellng, a minor Approved as to Form and Content: By: N/A C/almant's Attorney 11. The Claimant hereby accepts Assignee's assumption of all liability for the Periodic Payments and hereby releases the Assignor from all liability for the Periodic Payments. Assignee: Metropolitan Insurance and Annultv Companv By: Authorized Representative Title ~.. Addendum No.1 Description of Periodic Payments The following Periodic Payments: (1) To Kyle E. Stimeling ("Payee"), the sum of Nine Hundred Fifty Dollars ($950) to be paid on or about the twenty fifth (25"') day of each month, beginning on or about February 25, 2009, compounding at a rate of 3.00% per annum, and continuing for the life of Kyle E. Stimeling. 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 January 25,2039. The first 3.00% inaease shall be effective February 25,2010, and each subsequent inaease shall be effective the twenty fifth (25"') day of February each succeeding year. (2) Should Kyle E. Stimeling die before January 25, 2039, then any remaining guaranteed Periodic Payments set forth in paragraph (1) shall instead be paid, subject to the proviSiOns of paragraph (3) below, as they become due, to the estate of Kyle E. Stimeling ("Beneficiary"), with the last guaranteed Periodic Payment to be made on or about January 25, 2039. Should Kyle E. Stimeling die after January 25, 2039, then monthly payments as set forth in paragraph (1) shall cease. (3) The Payee shall have the right, after reaching the age of majority, to submit a request to change the Beneficiary by filing a written request with the owner of the Annuity Contract. The change will be effective when approved by both the owner of the Annuity Contract and the Annuity Issuer. Any change in the Beneficiary shall not in any way affect or alter any of the provisions of this Agreement. Initials Claimant: Mark StImellng Claimant: Tammy Stlmellng Asslanor: NalIonwIde Asslanee: MelropoUtan SWARTZ CAMPBELL LLC By: Christina L. Bradley, Esquire I.D. No. 89107 1631 North Front Street, 2nd Floor Harrisburg, PA 17102 (717) 233-3515 Attorney for Petitioners, Michael Diller, James Sadler, Jordan Sadler and Nationwide Mutual Fire Ins.Co. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION IN RE: SETTLEMENT OF PERSONAL INJURY CLAIM OF KYLE STIMELING A MINOR No. AFFIDAVIT We, Mark and Tammy Stimeling, parents and natural guardians of Kyle Stimeling, a minor, are over twenty-one (21) years of age, and being duly sworn according to law depose and say: 1. We hereby understand and agree that the petition to leave for compromise of minor's action filed on behalf of Kyle Stimeling, is being filed with our understanding and knowledge that Andrew G. Cassidy, Esquire has been retained by the Nationwide Mutual Fire Insurance Company on behalf of Michael Diller, James Sadler, Catherine Sadler, Jordan Sadler, Lori Schweitzer, Alex Schweitzer, and Nationwide Mutual Fire Insurance Company to assist in the filing of this petition and that he does not represent either us or Kyle Stimeling in this matter. 2. That we have read all the foregoing and fully understand same and affix our signatures hereto under oath as my free, voluntary, and uncoerced act and deed. 3. We are aware that we have the right to retain legal counsel on our own behalf or on behalf of minor, Kyle Stimeling, and we have voluntarily decided to handle this matter without obtaining legal representation. 4. We approve of the proposed settlement because we believe it represents reasonable and fair compensation for the injuries sustained by Kyle Stimeling in this accident, and because we . believe, under the circumstances, the settlement is in Kyle's best interest. 5. It is further understood and agreed that once the Court has approved the settlement as outlined in this petition, and once the settlement documents are executed, no further claim for can be made against Michael Diller, James Sadler, Catherine Sadler, Jordan Sadler, Lori Schweitzer, Alex Schweitzer and Nationwide Mutual Fire Insurance Company, for any of the injuries sustained by minor, Kyle Stimeling, in the accident of December 31, 2003, whether now known or unknown, including any and all claims for past and/or future medical expenses. 6. It is understood that any portion of the settlement funds distributed to us in this matter are to be held in trust for our son Kyle Stimeling and used only to pay any medical liens and or medical expenses incurred as a result of the injuries sustained by Kyle in the accident of December 31,2003, and ifany funds paid to us in trust remain when Kyle turns 18, they must be immediately turned over to Kyle. ~4 ~-~ Mark Stimeling, parent and natural guardian of minor, Kyle Stimeling 1.