HomeMy WebLinkAbout05-01-14 c _ M
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WILLIAM D. CLEGG, Administrator of the IN THE ORPHANS' CO ' ( F o
Estate of LORI A. CLEGG CUMBERLAND COUNT-Yi2,
PENNSYLVANIA ° i` m
NO. 21-12-0440 � N
PETITION FOR APPROVAL OF SETTLEMENT
AND ALLOCATION OF PROCEEDS OF
WRONGFUL DEATH AND SURVIVAL ACTIONS
AND NOW, thiso2911 day of April, 2014, comes Petitioner, William D. Clegg,
Administrator of the Estate of Lori A. Clegg, through his attorney, Herman A. Gailey, III,
Esquire, and petitions the Court as follows:
I. Petitioner, William D. Clegg, is an adult individual residing at 345 Foxleigh
Drive, Hanover, York County, Pennsylvania 17331.
2. Letters of Administration were issued to Petitioner on April 13, 2012, by the
Register of Wills, Cumberland County, Pennsylvania, said letters being docketed to number 21-
12-0440. A copy of the Short Certificate is attached hereto as Exhibit A and made a part hereof
by reference.
3. Lori A. Clegg died on March 23, 2012.
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4. At the time of her death, Lori A. Clegg was 32 years of age, having been born on
August 15, 1979.
5. Ms. Clegg did not leave a Will.
6. On March 23, 20t2, in the early morning, Lori A. Clegg was operating her
vehicle westbound on Route 283 in Mount Joy Township, Lancaster, Pennsylvania.
7. At the above time and place, a truck and livestock trailer owned by Ronald
Ressler and being operated by Matthew Miller, was traveling eastbound on Route 283 in Mount
Joy Township, Lancaster, Pennsylvania.
8. A large wheel and tire assembly from Ressler's trailer became disengaged from
the trailer, traveled across the roadway, and entered the westbound lane of Route 283 directly
into the path of the vehicle being operated by Lori A. Clegg and a forceful collision occurred.
9. As a result of the collision, Lori A. Clegg was pronounced dead at the scene.
10. Further information regarding the facts and circumstances surrounding the motor
vehicle accident are contained in the Commonwealth of Pennsylvania Police Crash Report, a
copy of which is attached as Exhibit B and made a part hereof by reference.
11. As a result of the circumstances of the motor vehicle accident, Petitioner has
made a claim against Ronald Ressler's automobile insurance company, Progressive Insurance
Company. That policy provided $100,000 liability limits. The full limits of liability coverage
have been offered to settle that component of this claim. A copy of Progressive's tender letter is
attached as Exhibit C.
12. Progressive's tender of$100,000 to the Estate of Lori Clegg is contingent upon
signature of a release. A copy of Progressive's release in the above amount is attached as
Exhibit D.
13. Petitioner respectfully requests that this Court grant permission to resolve the
liability claim with Progressive Insurance Company.
14. Statutory wrongful death beneficiaries are as follows:
(a) William D. Clegg, father, and
(b) Sharon Clegg, mother.
15. William Clegg, Administrator of the Estate of Lori A. Clegg, is Petitioner in this
matter and believes that the above partial settlement is fair and reasonable.
16. Sharon Clegg, mother of Lori A. Clegg and wrongful death and survival
beneficiary, has executed a Joinder form evidencing her concurrence in the proposed settlement
and this Petition. The Joinder form executed by Sharon Clegg is attached hereto as Exhibit E.
17. Petitioner has entered into a contingency fee agreement with the law firm of
Martz & Gailey in this matter with respect to the settlement of this claim.
18. There are no present creditors of the Estate of Lori A. Clegg.
19. The Commonwealth of Pennsylvania, Department of Revenue, Bureau of
Individual Taxes has reviewed this matter. The Department of Revenue has no objection to the
allocation of settlement proceeds between wrongful death and survival claims with respect to the
settlement proposed for present distribution. This is evidenced by a letter from the Department
of Revenue, Trust Valuation Specialist dated March 3, 2014, attached as Exhibit F.
20. Proposed distribution of the total liability settlement is as follows:
A. Wrongful Death Action- $ 50,000 (50 %)
$ 32,018.34 William and Sharon Clegg
$ 1,315.00 Martz & Gailey (50% costs)
$ 16,666.66 Martz & Gailey (50% fee)
B. Survival Action - $ 50,000 (50%)
S 32,018.34 William Clegg, Administrator
$ 1,315.00 Martz &Gailey (50% costs)
$ 16,666.66 Martz & Gailey (50% fee)
WHEREFORE, Petitioner prays your Honorable Court to enter an Order authorizing
settlement and allocation in accordance with the terms set forth above and that leave of Court be
granted to sign a Release to resolve the liability portion of this claim.
Respectfully submitted,
Herman A. Gailey, III,
& GAILEY LLP
96 South George Street
Suite 430
York, PA 17401
(717) 852-8379
ID No.: 31097
WILLIAM D. CLEGG, Administrator of the IN THE ORPHANS' COURT OF
Estate of LORI A. CLEGG CUMBERLAND COUNTY,
PENNSYLVANIA
NO. 21-12-0440
VERIFICATION
I, William D. Clegg, do hereby verify that the facts set forth in the foregoing Petition for
Approval of Partial Settlement and Allocation of Wrongful Death and Survival Action are true to
the best of my knowledge, information and belief.
I understand that false statements made herein are made subject to the penalties of the 18
Pa. C.S.A. 4904 relating to unsworn falsification to authorities.
ILLIAM D. CL/EGG
Date: 2
WILLIAM D. CLEGG, Administrator of the IN THE ORPHANS' COURT OF
Estate of LORI A. CLEGG CUMBERLAND COUNTY,
PENNSYLVANIA
NO. 21-12-0440
CERTIFICATE OF SERVICE
I hereby certify that I have thisday of April, 2014, served a true and correct copy
of the foregoing Petition for Approval of Partial Settlement and Allocation of Proceeds of
Wrongful Death and Survival Actions on the following individuals as set forth below by first
class mail:
Joseph F. Murphy, Esquire
Foray Ullman
540 Court Street
Reading, Pennsylvania 19603
Tortfeasor Counsel
Respectfully submitted:
TL4 ' esp
Herman A. Gailey, I I, Esquire
MARTZ & GAILEY, LLP
96 South George Street, Suite 430
York, Pennsylvania 17401
(717) 852-8379
ID Number: 31097
COMMONWEALTH OF PENNSYLVANIA SHORT CERTIFICATE
COUNTY OF CUMBERLAND
I, GLENDA FARNER STRASBAUGH
Register for the Probate of wills and Granting
Letters of Administration in and for
CUMBERLAND County, do hereby certify that on
0 the 13th day of April, Two Thousand and Twelve,
Letters of ADMINISTRATION
in common form were granted by the Register of
said County, on the
estate of LORI A CLEGG late of NEW CUMBERLAND BOROUGH
lFirst,Middle.Last)
in said county, deceased, to WILLIAM D CLEGG
(First,Middle,Land
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the
seal of said office at CARLISLE, PENNSYLVANIA, this 13th day of April
Two Thousand and Twelve.
File No. 2012- 00440
PA File No. 21- 12- 0440
Date of Death 312312012
S. S. # 220-15-2132 ,
egist f Wills
U2 epufy
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
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J IOM E CH ktASlEfa�FF PENNS Crash Number
M ANIA IIIIIIIIIIIIIIIIIIIIIIIII �
Page
W0270221
Case Closed Reportable Crash =1 ]
AA'500 1 O yes w No •Yes O No
-_ ---� _ police Agency Patrol Zone
In<idcnt Number 36505 225
2012-03-219 Invesllgation vale(MM•DD•VWYI '
cAgon Name Prcalnct 03 a 23 0 2012
6 Northwest Lancaster County R o2`�'�'�'
Sedge Number
p, DlspatAs lime(mi0 Anival Tme(miD Invastigatat 13
Cg 0056 ` 0102 M[CHAEL R BRYANT
Badge Number
As) royal Date (MM-DD•V•IYY)
Ravlewar 1 05 a 29 2012
SAMUEL GATCHELL lIl _l - -}=_— .—=.— =_r=
County Counts Name Munlsl alt Municipality Name O Sun Q Thu
36 Lancaster 225 ount Joy Township O Man •Fri
Crash Time(miD N 3eo le Inlured Klleda complete Q Tue Q Sat
Cs Crash Date(MM•DD•YYYVI 1 Form F Q Wed Q Link
a 0050
's3 03 a 23
Sthoel Zan° Yes w No Naint nonce TO Yes No
DVYCS,Complete Ves No School Bus Q Yes No Relettd O maintenance
Worhzond FOrm M_Se<pon 29 O Related
Q Mulfi•teg 00
r± oct T>� Q 4 Way Inlegecuon Q 'Y-Intersection InlelsoNOn Q Off Ramp O chair d Crossing
0 Trallic Circle/ Q on Ramp O Crossover O Other .yea Discoid
a Midblock Q •T'Intersetion O Round About -
Nousa Number (if applicable)
O North
Route Number (Segment(ootionaU 'travel Lanes Spepd Limit p O south
02 65 0 East rottalMWck amts ood use
a
Street Ending c w West Donal Xmne NUmbtr and make We
Street Name 11W rdrdpal Randoms�States Mme is
a PA RT 283 WEST O unknosm rdU in a wela cis:Option
local Road Pitfall Olherl
e A Inlentate O Tompaa 0 Suf Pike NtgAwaY Q rtoadd O or Street O Road O Unknown
2gOrea Q (Not TumDike) (East/weSD
d Route:Number� _
Segment Travel lanes Speed Limit Q North
Ilrr--dll O South
Street Ending
to I Street Neme 6 Q well'
f .p d O Q Unknown .
local Road Privase Other/
c
IAQ tale Q (Easvke Q Turnpike O wa O Ra°adN Q or SVeel O Road Unknown
3 Slgnla6 Q (NOt TUlnpikt) lEasvWesU SDUr 9 Y Fears
Intersecting Re plum Or Mile Post Or Segnlem Maher C O North I==
y C�.o : O South II_�----sl
'n Si Ending� O Fast Or Miles
Or Intersecting Street Namc E O West
b Please 3 O
IEnter Information a Ion BOTN Distance From Crash
Undmarks InicrseNng Rt Num rO—r-M-il—a P-oR� Or Segment Marher O North scene So landmark 1 if Using, ^' �I I I ❑ :O Soush
$ This Option 1; —J = yl Ending (fen Crash aili I
E Or Intersecting Street Name O East landmark 1 and
E O West landmark 20
9 °
Degrecl Minutes Seconds ��s Minutes Select ��1
76 36 ; 37 000 J
to lucid: 40 11 06 000 Longhudo: — -
9o5ce Officer or Trn nay en/nn Emergency
..r 1 eld Q Yield Sign - O Flagman Device Funclionin9 preemptive
No COmrols O Imptopedf Q Signalp
a Not Applicable O Traffic Signal O Active RR Crossing Q Other Type TCD
' ep Controls Devine Not Ocslce Functioning O Unknown
e rU- Flafhing Traffic Passive RR O Q Pr _
O signal O Stop Sign Q Crossin Controls O Unknown Fu a toning opedy_
������.���r Q No nk O East O North and South O All
L",jg' ((Ff 4VUt App It blo',ski Felt of the tone Closure sectsoN Lan"Clpfud;
(O Not Applicable O Panialty •Fully Q Unknovm
SiscS ge O South
weX O fast and west
aB I
° Qalljt Yes 0 No Q ckvs lary Q<30 Mie.�O 3060 Min. Q 1.3 I,rs O 7-6 his �6�9 h6 O>9 hours O Unknown I
S2etal!/=d Unknown 0 --,
FORM raa30a(rated
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Dm Q 2G9Q�(4aVOPIVING I"CR A(dpiQ Page: IIIIIIII�IIIIIIIIIIIIIIII�I G
E ash Number
AA 5002 /o cUOO"rr W0270221 _
o - Motor eh do in O Hit&Run Vehicle O illegally Parked O tefloy Parked Oclop-Mororited Commemfar Vehfele
Transport �
Yes No
to Und Pedestrian on Skates.O previous From O Tram O Phantom Vehicle
O Pedestrian O in Wheelchair.etc previous crash (If Yes,Complete Form O
(if'Pedestdan'or'Pedestrian on Skates.in Wheelchair.etc' Com fete form M_Se[Uon.8
Unit NO First Name
MI Cate of Birth(MM-DD-YYYY)
01 MATTHEW A� 09 09 1995
lulu hone Number
oelete? East Name 3304735544
O MILLER
Z.
Address/C I state 44842
463 COUNTY ROAD 2575 LOUDONVILLE OH
State ClasO
Orivar License Number
TW704286
AIcohOUDruas SUrplcted Driver or Pedesl/Wn Ph '1121 Condition
dican O A paienlly U
H Illegal Drugs O M Uegal Drug O fatigue O Medication
a No O Nrma e '
u O Alcohol O Alcohol and Drugs O Unknown O Had Been . O Side O Asleep 0 Unknown
Drintinp
5 Alcohol Test Type Primary Vehicle Code Wells pn Cha[gtd?
M Test Not Given O!ream O Other O Yes O No
(known if
z O Blood O Urine O Vest Given
q
At hot rest ReN O Test Refused Re gpow n Ddvar yrerenro I=Veher Operated 3=Dnvel Ned ken!
O ResulU ❑ Vehicle 4cNil and Run
Test
no O Contaminaamino l
. ted Results 2=NO Omer 9=1.1nknown
Ownerlarlver 00-Not Applicable 02=Private Vehicle Not Od=Stale police Vehice 07=Municipal Police Veh 09=Federal Gov Veh
01=P(hate Vehicle Owned/ Ovmeddaased by Driver OS=PENNDOT Vehicle D8.0vaer Municipal 98=Other
02 Leased by Oriver 03=11ented Vehicle other State Gov Vch Government Vehicle g9.Unknown
Owner last Name or Business Name 01 Pedestrian,skip this Section)
Same as Owner First Namc
Driver O RONALD RPSSLER
Address I City I State I ZID vehicle Make •Mayo Cade
Chevrolet 20
15110 WOOSTERNW NORTH LAWRENCE OH 44666 (see Overlay)Madol Year Vehlcld Model
"I" SILVERADO 3soo
IGCJK39697E570602 20Ve
License Plate - Reg.Stale Est Speed Vehicle Towed TaWCd By
PGE2591 OH 999 O Yes No
Insuranco
Insurance Company - Polici No
o Yet O No O mown PROGRESSIVE 07645573.1
fmilin T I.Towing Pass.Veh d=MObue/Modular Home LSemirTraivr Tag N� Tag Year Tag St
° Un NO,of ^� 2=Towing Truck S=Camper B=Omer TP 3607 ��-11 OH
tt Trailin ❑ Unit 7 unknown Q lJ
7 Unlls:9 1 3=Towing Utility Trailer 6+full Trailer 9=
lrenion of a *Vehicle Poshion qq •Mpvement 01 'See Special usage
Overlay
rave 12ceommtr[ial
yehfrre Color Veh1Ue TVae OS=large Truck 20=Vnlcyck,a2Ycle, 0U Passenger
06=YtUOw 01=Automobile O6'=5UV T^Ncle 00•"01 ApDfCable Carder
07 06.Ycu r 04 02=Motorcycle 07=Van 21=01her Pedtcycit 01.1ire Veh 13=70x1
09-Gold 03-Bus 10=Snowmobile 22=Horse&B�gy 02,Ambvlance 21.Traclot Trailer
01=Blue 09=Brown 04=Small truck 11=Farm EOUip 23=Horse F 0.�r 03=POliC[ 22-Tv4n Traler
02=bed 10=Orange (d'02r.Complete Form 12=ConsVuction EOuip 24=Train a :cHher Emergency 23=Triplo Trailer
03=White I I=Purple M Section 26) 13=AN 25=Trolley Vehicle 31=Modified Veh
04=Gleen =01 of (11'20'or'71".Complete IBcOther pe Spcc Veh 96=01htr
05=91ack 99=Unknown Form Secilon 271
s9=Unk.Type Spec Veh 99=Unknown Il=Pupil Ttanspert 99+Unknown
[phial Impact Pnint
D mane lndlrarnr Gradient 3=Downhill Road Alinn-err
00=Non,Collidon 14-Undercauiage I=W,,O 2cPVnaianal ❑ 4=80110m of Hill ❑ Z=Cur ed
a qq a 1=Minor 3=Disabling I 1.ltvel 5=Top of Hill -1 ~-2�Cuned
Ol-12aCl0ck POIMf 15=Tov td Unit 2-Uphill 9=Unknown
13=Tap S=T 9=Unknown 9=Unknown
FORM"M-500('ada) PENNOOT COPY
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05-31-'12 08:41 FROM-Northwest Regional P 7173673382
T-711 P0004J0011 F-175
�a IoP2�7L�S A�G6 6:6s(P(fDGIdBT Sn G®026jA ?"„!A
Gash Number
Page a .
AA 500 2 ro4o o y -- C —t
L=.—! W0270221
Moto lie On
e ! LaMpOn O Hit&Run VehidB Q Illegally Patted 0 t¢galq Parked Q Non-MatariYCd Commta7at Vehittp
+a Y
Unit Pedestrian on Skates, Disabled from 0 Yes ! NO
{ Pedestrian O - Q Q Train Q Phantom Vehicle
R m Wheelchair.eit Previovs crash
Rl'P¢destrtdn'or'Pedtttrtan on Skatez to tNheekfiair,etc•,Complete Form M,Srctian 28 (fi Yet,Complete term q
Unit No First Name Ms Date of Birth(MM-00-YYyy)
02 LORi i A� 08 15 1474
Oelele? East Name _Txt h_oste.Nmher
Q CLEGG
-- '
Address t Ct t 7 State - Zt
S
3158 ROSEMONT AVE NEW CUMBERLND PA 17070
Oliver Limnso Number state Class ,
g 25DD73J8 PA � k
y5 ArrohaVDruos Sul l�erted Ddvcr or Pavlast'lan Phwkof Condition
to y: ! No Q Illegal Drugs O M¢di(airon r NX21"lly 0 Ns?'l Drug Q Fatigue 0 Medical'"
g 0 Alcohol Q Alcohol and Drugs 0 Unknown Had teen Il
y 0 Dunking O Sick Q Asleep Q Unknown
Tat Alcohol lest Type Primary Vehicle Code VldhNon
11 ! Test Not Given O Breath O Other Chalgedl '
s Q Yes ONO '
Blood 0 Urnt Q More",
y°
Alcohol TeN Results CD Test Refused Q Beiui6 n er prosence I=Dr'lor Operated 3=Driver Fled Scene y
® � O Con Given, O VtFkb 9-Unknown
and Run .
Contaminated Results 2=Nn Other 9=Vnknawn
O"200thT 00sNot Applicable O2:Pirvata Vebido Not 04=State Pokte Vehltle 07=Murubpal police Veh 09=Federal Gov Veh
Ot.PMate Vehsde Owned! Owntdrt.eaNd by Driver OS=PENNDOT Vehicle 08=0ther Municipal 98�ther
0I teased by Driver 03=11ented Wilde 06=10ther Stale Gov Veh Govtrnment Vehicle 99.Unknown
Same as Name Owner Last Name or 0.1mess Name PtP<destnon,ski this Section)
Driver Q TNN L01 I A —� CLEOG
r Address 1 City t STate 1 zip Vehicle Make make Code
315 ROSEMONT AVE B NEW CUMBERLND PA 17070 Hoa4a 37
VIN Model Year Vehicle Model (see overlay)
1HGCP26359A094245 20D9 ACCORD p
License Plate Aeg.Sure Est.Speed Vehicle yawed Towed fly
HF08639 PA 944 ! Yet O No COCICER'S TOWING
tnsurann, insurance company Poiisy NO _
!Yes O NO Q known GEiCO �� 4172.43-27.77
n
TM 11,104 T I=Touting Pass.Veh 9=MOhile(Modular Home 7=Semi-TUler Tag No Tag Year Tag St
k nU It N0.of D UV, ❑2=Towing Truck 5=Camper 8:Otfier
,a
Trailing O 3-Towing Ut6tyTrailer 6-FUR Trailer 9.Vnknokn J
Direction of Q 'Vehicle Petition D3 -movement DI 'See Special Usage
ravT eT Overlay
Vehicle toter Vehtde Tr-e 05=tafge Tnrck 20=Unicycle,t:Cycle, OO 12=Pasenger i
06.Yellow Dt 01=Womobife 06=SUV Tdcyde Passenger
03 07e$ilver OD.Not Applicable Carrier
02=Motorcycle O7=Van 21=other Pedslcyde O1.Bre Veh 13=Tali
08di01d 63=Bus II=Far Equip 22=ttone8U91 0Z.Ambuynct 2t=Tram TraBzr
01=elue 09=8fown 44=Smog Luck l l=Farm EQuip z3=Norse d eider 03=PO8ce 22=Twin Trailer
02:1ted 1040fange (if 102'.Complete Farm 12=ConsVuNon Equip 244rain 08.OtAer Emergency 23:Tripie Trailer
03-white IWu(ple r At,Section Ili} 13=ASV 25=Trolley V¢hicte 3s 160e Tra Veh
04=Graen 12=01her Rt'20-or-21",ComptoM 18=01her Type Spec vch 98=01her 4t=vepi Transport 99=Unknown
0S=81ack 99:Unknown Corm M,Section 171 19=Unk.Type Spec Veh 99=Unknown
fnhia7lmpact Polnt Damage mdfcator Grndiem 3=0ownh8l L oad Aiianmaof
13 00=NaroCOBition td=UnO'carriage O:NOne 7-Functional
4:eouom os F61f L-Araight
01.12=CIO(k Points 955 1=ed Unis t-Minor 3=0itabiing o tdeml 6_TO Os Hilt o I=Curved
r3=Top 99=Unknewn 9.Unknowo 2`Vphif g=Unkn)wn 9=Vnkncwn
•_<-
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175-31-' 1Z I68:4Z FNUCI-Nortnwest Hegional la 7I73ti73 U T-711 P0005/0011 F-175
COMMONWEALTH
ICE CRASH Ft wORY N1G FORM Page IIIIIIII°I�Illllllli III Crash Number
J POL C A
AA 500 3 roar,ureors/ W0270221
Q 1=DAYtr p LbKNotA PassenTenocCupant E OO.None"Se /Not Applicable �7 O�ol Applicable
0 1--Not Elected
2=Passenger 01=Dever a AN Ve ides Ot=Shoulder Ball Used 2dotaBqq Elected
7=Pedcstrpn 02=Front Seal Middle Position 02:lap Belt UsCd 3=Parllagy Ejected
B=Other 03-front Seat Right Side 03.Lap And Shoulder Belt Used gdlnkn9wn a
9=unknown Es"econd Row•Left Side Or 04-Child Safety Seat Used
A010,VRcr Passenger OSaflic la iel nelmet used H )
05=SeconddRow•Middle Position 11O.Say(Ie Melmel Used
SSor 074hir nd Row•Right Side I I.Chiil eat used Improperly �•hr ugh Side eNot r Applicable mink
F sfemale 07dhird Row Or Greater- 11.Chil Safety he Seat opcf ImDropeM 2=Through Side Oooz Opening
e S left Side 12-Helmet theednprpe Unknown
]=Through Side Window
o M=Male 06=Third Row Or Greater• 90=0.esbaml Used, pe Unknown 3-Though Windshield
U=Unknown Middle Position 99+Vnknown 4=1hrough Back Ooor
09=7hild Row Or Greater- 5=Through Back Door Taa ate Olerling
Right Side 6=Through goal Opening9 lSunrooll
miury rnyarlrg 10s51eeper Section of Tmckcab F 00=None std/No[Applicable Convemble Top Down)
F, 0---Not Injured S 1=1n Other Enclosed OI=Front Air Bag De�oyed(For This Seat) ?-Through Root Opening(Convertible
}=Killed Passenger Or Cargo Area 02=51de Air Bag Del oyed(For This Seal) Top Up)
2=Major Injury 12=11 0 en Area 03-0ther Type An 9a9 Deployed 9�lnknown 1
a 3=Moderate (Back Of Pickup,Etc.) 05=Mo1roplecAUEBagpro0seaoond 1I1—•
Injury 13=flailing Unit h It
4WinOr ONy 1d=Ridng On Vehicle ERterier 06=Biryditl Wearing flbawlKne9rPads
:,=Unknown Unk 15=BUS Passenger ID.AII Bag Not Deployed,Switch On I O=Not AppsSable
1 11-Air Bag Not Deployed.Switch Oil 1dJ01 faldcated
Seventy 98=00her IbAir Bag Not Deployed, 2=Eet(2ated By Mechanical Means
9=Unknown if 99=Unkncwn B, .
Unk Big Res oyed?y 8.Othd By No•MKhanical Means
Injury 13=AG Bag Removed{Prior To ed B=Other
19=Unknown It All Bag Deployed 9-Unknown
99=unknown
O EMS Agency: NORTHWEST EMS Medlwl Facility: NIA
Unit NO Person No Deieto7 Dale Of Birth (MM•DDYYYY) ooacoor�000
O1 O1 O 09 . - 09 - 1995 1 M 0 01 99 99 0 ' 0 0
w EMS Transport
Name I Address I Phone
0 same as MILLER,MATTHEW A 463 COUN'l'Y ROAD 2575 LOUDONVILLE OH 44 Q Yes eloJ
Operator
Unit NO Person No Cato of Binh (MM DO YYYY) A B C D
Delete' oaaa 03 99E 99f 0� 0❑ 0�
O1 02 O 06 13 1966
Name!Addre»I Profits EMS Transport
Same as RESSLER RONALD 3 151 10 WOOSTER NW NORTH LAWRENCE OH 4466 p Yes •No
Operator
Unit No Person No Delete' DartOY�❑ e C �0El❑oa
02 Ol O 08 15 1979 t F l Ol 03 00 0 0 8
Name I Address I Phone EMS Transport
0 same as CLEGG,LORI A 315B ROSEMDNT AVE NEW CUMBERLND PA 17070 O Yes W No
Operator _
Uri Pers� Delete} Date of 0irh IMM•DDNYYY) A tl t u F G N 1
0 0-o-�ooac�uooa❑
Same of
EMS Transport
Name/Address/Phone
Q Yes ONO
-
Operator
'
Unit Person Delete? Dale of alrth (MM•DD YYYY) A D C D E IF U n J s
Q o �ooa000aa❑
EMS Tra
Name(Address/Phone nsport
Yes ONO
0 Same as
Operator
Unit NO Pcts oatDal-¢�oS Binh lO�'m�O❑❑===❑❑❑
DelRloT
IL—�II Namc 1 Addms 1 Phone EMS Transport
Q Yes 0 N
opt as
Operator
V�--tl Sl
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05-31-'12 08:42 FROM-Northwest Regional P 7173673382 T-711 P0006/0011 F-175
PO PENNSYLVANIA Crash Number
LLKE CRASH R PORTING FORM Page I�IIIIII�I"IIII�IIIIIIII
AA 500 4 1d`t r`0 N '� W0270221
O=Nan-Collision ?^Head On 4l"Is S�Sldeswlpe &Ha Pedsslaan
Crash Description 9 1=Rear End 3- ar to Rear 5= Idwwi (Opposite OileNon)
L ___
(BaWDal (Same 6pmttlon) 7=Hil Fixed Oblen 9=9NerNnxnovm
s
Retailers to Roadway 1 1.On Travel Lanes 3=Medlan S=OulslOa Traf6away 7cOOro(Ramp Inlerseoban) —
2=900er 4=1liOa05ide B=In Palling Lana 9=11hknolm
E § -`_ 1-9ayaght 9--0 ark-street 5-, arm &Olhtr
sf M IRUminatlon 22 2=Dad(•NO LI 6=21& Ilnkqohw0
0 N SUNb hle_- 4=0usk oa wa 1x3.1'n��_ ��--
t=70(oo Pfdyerse a.Sleet(Hail S=Fog TSI94t8 Fog 9=UnWrotvn
TL VRather Conditions 5 l dlons 6=Raln 8 Fog a-Other
• � _ — -_ � 2=Aaln S=Snow..,—_,� mac•=--.z—�—_'-__ —`-_�_�
2= and,Mud.Din, av5lusn &Ice Patches 8=Olean
s aced sulPam coneD7onr In 0=0ry OR 7=W 1�9r•51sdw9
�LJJ 1=Wm 3=Snow Covered S=Ice os rule —
HarmEV¢nf /R Most? ry6eTl Number Hanel lEVentr(HUm fyen0 31-HR fence Or W911.
01=Hi1 Und 1 31=Hit Building
1 02 ❑ p 02--Hit Unit 2 )2=HA Culvert
Unit NO 03=Hit Unit 3 33=Hi1 Bride Pier Or Abutment
04-Hit Unit 4 34=Nit Parapet End
01 2 ❑ Q O5=Hi1 Unit 5 35=Hll Brdyge� Rao
06=Hit 011Mr Traffic Unit 36=Hi1 Boadery Obstacle
07-1111 Darr On Roadway
Please Put 3 O Q Q 06=Hi101her Animal 37=Hi11mPad rant for
Event,In 094011dion With Other Hon 38=Hil Hot Hydrant
Sequential Fixed Object, l9=Hil Roadway Equipment ,
Order �� 1 I=Shuck By Unit 1 d0=11i1 Mail Box
u 4 II-W ck By unit 41=Hil YraHic Island
•� — 13=5Iru(k By Unit 3 42=Hit Snow Bank
all € 14-Slmdc By Unit 4 43-Mil Temporary COnsuu0ion
o Wrm Event l/R Mort7 Utility PolB HUmhlr 1S=SUvck By Units Bander
163truck B Other Traf6t unit 48=Hi101her Fhed ObI'Ien
9 09 ❑ r 21=Hit Tree Or Shrubbery 49=Hit Unknovm fierO Objen -
`u
Unit No 22=Hit Embankment 51-5v,nurNBONOeer
23d1il UBlity Pde - SIiVU(k By Thrown Or fdliinq ,
^ 02 2 O ❑ Q 24=Hit Tralirt Sign Object
25.Hit Guard Rail 52=Pot Holes Or Other
'G 26=Hit Guard flag fed Pavement Irregularities
please Put O 27=Hit CuN
53=1a(kpfe
9 Q 54-Fire
1.01hen Vehicle
Events in 28=161 Concrete Or SE=Other Non.CalKsion
sequential Longitudinal BalkMr 99=Unknown HamUul Event
Older 4 O Q 29=Hit 0itth ----� '
17.CareleSS Or Illegal
'First
Unit Na Narm Event Moat Una No Harm Event Orver Aelan f0) Backing On
17a�mlul 00=No Cr Was is Acton
1a
F. IB=06dng On The Wrong
02 09 aoAt n 02 09 01=odrer Was ms rayed Sae of awe a
e=a-vh 02=Drhing Using NJnd Held shone 19=MPUn Improper
oo.a utp:rdau(wamsxot t,sr 03=Dynfng Using Hands Free Phone 9 Doper
04-Making Illegal U-Ture , Enlgn(e To Highway
O as.lmproDedtareless larvn9 20=Making Iniproprr Em
EhvlmnmenUl/ROadwa 1 29 2 $ 3 064oming From Wrong Lane From Hs Paray
potenflal Factors(00 07=Pmrwedmg W/O 2ldaetless PaAingNnpNUng
00-None 11=5fppery Road Conditions pce/snOW) Clearance After stop 22=peetwder
01=Wordy Cor>Qtioni IhSuhhslante On Roadway 08=Runarog$to 5i n Compensalion At Cave na
02=5udden Weather Condtians 13-POPoles 09=Running Rey LPp'io 23dpetdino 19
03-01her Weather Conditions Id=Broken 0l Cracked Pavtmenl 10=01huPf TgllicSCOnld Oedce 2S Baurc TO Malnlam
For Pmpc Speed
04-0te In Roadway IS=TCD Obsuuac-0
0S=0bilade On Roadway I6.6oft Shoulder Or Shoulder Drop OH 11=Ta2 ci 26_Diirn„e�e e^`�(Pan Chase)
06=Other Animal In P.wdway 28=Other Roadway factor n=Su den Slade (ooppppo
07=01are 29=01heo Envronmental favor i3=etegaly Slopped On Roe 28.Pailute To We Spedal'aed Equip
14=Camless Passing Or Lane 92=AHt(led ey Physical Cond4ion
10 o
09-Work Zone Related 99.Unknown Charge 98=01her Improper Dmeg Actions
m Puslhfe Vehld[Failure'(V) 12=WipP2 15=Pdifing In No Pas s'v7 Zone gg=unknown
06-FNsaust 13=Omer SeatingaConVUI r6aDridn9 The Wrmg way 0n
00=None 14=11 Doors,Hood,Etc I-Way Street
E 01=3res 07=Htadll i9 15=Ldi er i61fA 3 4�
02=Brake Srif[m 09=0 cf lights 16=Wheels a Not Ol f 27 2
m 03=Sterling_Syllem 09=0 cr Lights 17=Aikags
7 Oct=Suiptnnon 10=110rn 19=Tra2NOvedoted 3 d�
05-Power Train 11=Miuon 19=UnsecurH$hihed UDR 02 y � it
Unit Trailet lead No
�d No 1 16 2 20dmp open Taving
v p1 21=ObsW(ted Wndshield ped ttrian AnlenlP] 03-Working
Unit U2 1 00 g 99=Unknown 00=None O4+PUSMng VcMde I
No 01=Enle(in9 Or C(OSSrry At OsoApproaching Or iNVing VxhiD!
Specified tma6on 06=Working On Whklt
Unit Ho Faelor Code , 02=0r Playing gRvnning,b9g'ng. 96 Olherw9
Volndlta tcd prime favor 99=Unknown
l secs-iiz moi an Ol l6
,s P»a' Unit NO 02 O
E/R V D D Unit NO Ol O
O e Q Q if EIR Is the Prime Factor
Type,leave Una No blank
PonaS a AA•sw isvml—� PENNOOT COi°Y
http://NvLvTv.dot6.state.pa.0 s/CrsappfP ri nti mages/Xn31Fi les/20120313 342012052915 402140... 5/29/2012
05-31-'12 08:42 FROM-Northwest Regional P 7173673382
T-711 P0007/0012 F-175
COMMONWEALTH Of PENNSYLVANIA Crash Number
POLICE CRASH REPORTING FORM Page
AA 500 5 W0210221
r
..............
.... .........
—A
4—
Ik( P
Witness Name I Address
J
Narrative and additional witnesses: Actident investigation Notificatfon Issued7 0 Property Damage 0
Unit 2 was found disabled in the travel lane by a passerby.Unit 2 had suffered significant frontal impact starting
at the hood. Driver was found deceased behind the wheel with engine running,
t
A large Mee)With tire mounted on it was found behind Unit 2 and sitting up against the guard rail off the
shoulder of the roadway.Paint chips on the wheel indicate it had collided vrth Unit 2.
Wheel marks found in the grass median indicate the wheel had come from the east bound side of the roadway.
No vehicles were located disabled missing a wheel,and no marks were present on the roadway indicating that
the vehicle which lost the wheet was draging an axle.This suggests a dualwheel trailer of pick up truck,
Owner of unit 1,identified as Ronald J Ressler,came forward after being made aware of the accident by a friend
who had seen the story on the news.The owner identified the driver as Matthew Miller, 16 years of age.The
owner operates a livestock hauling business and does not have proper license and documentation for
Commerical Motor Vehicles(DOT,PUC,ICC numbers)Driver,Miller is also not properly licensed to operate
Commercial Motor Vehicles.Owner Ressler,confirmed Unit 1 was travelling on the east bound side of the
roadway at the time of the collision.
Upon speaking with Owner, Ressler and Driver, Miller we learned that the two did not notice that a wheel had
been lost on the trailer until reaching their destination,at the New Hollandsales barn In New Holland
FORM I RAIN(I=n PENNOOT COPY
http://vA,vw.dot6,state,pa.us/crsapp/Printim ages/Xm IF i les/20120313 34201205241 5 402140... 5129/2012
05-31-' 12 08:42 FROM-Northolest Regional P 7173673382 T-711 P0008/0011 F-175
J ® t� a�ff�ff pggySi�ht/ACSfA o New 11111 III 11511111II1 Crash Number
�6ICC CRA4,ff Dacpal0VizG 7024 Pa ea W0270221
raxa un Ony Ir I I Change/
AA 500 N L� r p cominuafioe .
Narcavye and additional ueimesses:
n PA Owner Ressler was not made aware of the accident until evening hours on Friday March 23rd,2012,
after he had returned home to Ohio. Our department received notification from Resslers attorney on
Monday evening March 26th,2012 of his Intention to come forward and provide required information.
May 24,2012.Upon review of this CRASH report it was determined that the notation in Block 12 of the
report as when if in fact relates
hould have been coded 1as(7)Semi-Trailer,I made the Correction this 1 as a(6)Trailer,
date.
a
F
n
ronyaaasu+vr�a '—~_ PENNOOT COPY , ...
http://www.dot6.state.pa.us/crsapp/Printlniages/Xm IF i les/20 1 203 133420 1 20529 1 5 4021 4 0... 5/29/2012
05-•31-'12 08:43 FROM-Northwest Hegional P 7173673382 T-711 P0009/0011 F-175
�S � �I IIIIII�I�IIIIIIIII�I� Coah NuSUor
J �� ��UORb Dago: O New
AA 500 C Q Conn nuatlxn W0270221
UnR NO Number o1 AN CS Carrier Phone
Ol 04 'n'N<xreaabto�b 330 ) 466 _ 2951
Cartier feamc
R&3kNTERPRISES
GVWR I
AdS r l t 1 0 W OOSTER W 034000
Overshe load
Q Yes O No
IR
slate Zip unknevm
otr OH 44666
NORTH LAWRENCE
n USOOTB ICC4 - IUCI
0
9
5 Unto BC&VT * QAVte Transport VeCIde CAndauralien O Truck Tractor(Bobtal0
O Nod APplicable O slat Bed O GarbagclRefuse O Not Applicable (D TracterlSchii•Tralleds)
faclosxd Box O Dump Passenger Car•only Record If
Van/
Q Bus O HaaMal Placard Displayed O Medlurnliteavy Ttud-cannot
8 O Cargo Tank O Concrete Miter Q OtherlUnknown U ht Truck Nan,MI61116.panel classify O Ps9kup or SUV with Plahlat plaurd) O small Bus(Seat 9.15 Poop'z,
IIaxAMaut Materhl Including oriver)
O Yes No Enter tdigit hazardous material class Single Unit Trusts R Aolis,fi Bus(Seats More Than 15
Q ❑ O ❑ Q Tiros) O People,Including Me Drivel)IC7
❑ I ❑ I ❑ I ❑ O Singla Unit Trvda(3 or ldose APlCS)
Single Unll Trudy Noumvin O pdsar
O number of Axles) Q Unknown
r TrudcRmll¢t(s)
R<fNro lndlmrdr 7.NO Releaso 2=Releau ODUrted 9=Unhnown
Unit No Number of Axles /Caller phone
O ([ede
nayM NVmarren)
er TY Por vnt
Carrier Name
GYwn
Address
Oversize Ledd
Q Yes ONO
c O Unhnown
� Stab Zip�
b
USDOTY ICC P PUC 1
G
v
T
5 Cam,00cf.j Time O Auto Transport Ve�f rte Cnnyunfin^ O Trudy Tractor(BONr)ll)
O Not Apeliubte Q flat Bea O GarbagelReiuse O Not Applicable
Pdssengat Car•Only Record if O TratloOSatnldyeilo4s)
O VanlEndosed Box O Dump O Bus O NatMat Placard Olsplayad O MediumlNzavy Moll-Cannot
O Cargo Tent, O Conn:a Mixer O OtherlUnlmOmM tight Truck(Van_phlnl•Van,Panel, classify
O pickup or SUV wrdl NatMat platatd) Small Bus(Seats<.15 DeW.C,
(yar+rtlaut Mace al O Including Ddvzr)
a Yes ONO Enter 1-digit hazardous material class Q Single Unit Truck(E Axles,6 Bus(Seats More flan 15
O ❑ Q D Sims) O Deoyle.Including GtC Odvx4
Q single Unit Truck U or Mxrx nxlc>)
Single Unit Truck(Udsnomn O (thv
O Number cf Axles) O UnhnowA
❑ I O � ❑ Q Truchrtraileds)
p 10 Z�. D
nNrase lndfrasvr d=No ReleasC Zc RCIease Oaurred 9=Un4howA
toaifa AUSmtt®1 PENNDOT COPY
http://ww W.dot6.state.pa.us/ersapp/p rind mages/Xi"IFiles/20120313342012052915402140... 5/29/2012
X06-31-' r% 0666 t•tturl-mrtnwest xeg.ional N 71'(3673382 1'-711 P0010/0011 F-175
^_j Begun�0 'd6d-o DaM Orm POMM fkOQ Q New III I II 1 IIIIIIIIII ICI Crean Numbar
Page W02770202221
AA 500 F ronw ue Dnb = O Change / on
_ � —
RoadSurhre fvna 0 Brick or Block O Din SpedalludsdIction O Military 0 Olher federal Sites
No Special O Indian Refervatfon 0 Other
U Conuete Stag.Gravel or O Other IullsdictlOD Celle eNnIM$ity Unknown
O Blacktop Scone O Unknown O National Park O Camps
please compide Unit Information for each unit involved In a PoPal crash.D0 not repeat the information In the fields above On multiple pages.
Unit NO principle Impact paint 0 0
01 O
hers-Collision 11 12 p10
010 oi0
Orfver ResWr6onr . Be client 0 Not Pennsylvania OTgp O09 010
cmm�lw— nY— O Compiled With Driver
Renri<9Ons Not Unknown 0Undercarriagt
O No Rertrictionsr O Complied With O Compliance DOB Od0
Not Applicable (ompllance •Towed Unit 07 05 OS
Q unknpvm 0 O
e Required- � NOta Pennrylvanla OUnknown O
a pricer Endoarvnwlt OComplied lMnh Driver
Compliance Required•Non 0 Unknown - Avoidance Maneuver
0 Compl•�ance Compliance No Avoidance Braking-Other O Other Avoidance
O None Required RNulred. a Manewer d Evidence Maneuver
Is y O Compliance Unknown Braking;Skid steers Evidence
s` ve• O Inconclusive
Driver Urons•_ Not Required for O Unk if COl or O Marla Evident O or Driver Stated
mrnnfianae O Vehicle Class COI Required Braki No Skid g g
No Valid ULCnSe 0 free a Pennsylvania 0 Marks Driver 0 Steedn and Braking O Unknown
for pas Driver Evidence or Stated
Staled
0 Not Licensed O Valid License for O Unknown Under Rlde Indicator
Class Undcrride,No
Other he Underrlde or 0 Compartment 0 override,Other
orug test Tt!oe 0 Blood • O r Override Intuslon
Unknown If Test
None O Urine O Given Undcrride, Undcrride, Unknown it
Comportment O Compartment Undcrride or
ONa rest Results•(Ug to Four Raultrl D a O 0 - Intrusion Unknown Override
Intrusion
O=No Test Given 5=AmDhelaminc+ Bole,Light and
I=NO Drug Reported-6=PCD ❑ ❑ Emergency We 0 Lights Flashing 0 Siren
2=MBdluana other Not In Emergency
=COCame 9=Unknown Tell Use O Siren sounding O Unknown
4v OplattS Result
Unit No Fdndolelmpart PO ln( 0
L� O Non-Collislon L-1 1 12 0
Ol 020 .
RtsuiclionS
ome anro Noit a Pen
nryvanla (a Top`aont Complied Driver
009 03 0 Driver R 'crown Not DU O Undercauiage 0t lidne
O No Rerictiond O Complied With Comp O 00 O
Net Applicable Compliance 0 Towed Unit 07 06 050
w Unknown
e Cam d•
Camp Not a penn
O sylvania DUnknown O O
Driver fndoraemenr O Complied With Driver
_amp ranee 0 Required-Non O Unknown rive fdanre Manewer
Compliance Compliance No Avoidance orating Other Other Avoidance
IM None Required Required- O Maneuver Evidence O Manewer
as O Compliance Unknown Bmkino•Skid steering•tvldente C)Inconclusive
Not Required Tor Unk if COL or O Me�k+Fvidtnt O or Driver Stated
river I/cnw D vehicle Class O COL Required
mp Once Braking-Na Skid Steering and Brakin Unknown
No Valid License 0 Not a Pennsylvania 0 Marks Driver O Evidence of Staled g O
Q for Class Driver State4
O Not licensed Valid license for 0 Unknovm
mow Under Ride lndlrator Underside.No
override,Other
Druq rest NCC 0Stood pother M NoUderdda or 0Compartment OVehidc
Unknown if lest Intrusion
a None 0 Urino O Given Underside, Underride, Unknown if
Drug rest Refults•CUD fo Four Resulbr D O ❑ O Compartment O Compartment O Uveulde or
Intrusion Intrusion Unknown Undtaie
O=No Teti Given S=Amphetamines DBOth Lights one
t e No Drug Reported 6=PCP Fmerennty Uw O Light ilazhing Oren
2=Manluana B=other ❑ ❑
3e Cocaine 9=Unknown Ttn � Not
te In Emergency C) Siren Sounding OVnknown
4 e Opiates Result
rosrJddneratrcua . PENNDOT COPY
http://www.dot6.state.pa.us/ersupp/printlmages/Xmlfi les/20120313342012052915402140... 5/29/2012
05-31-'12 08:43 FROM-Northwest Regional P 7173673382 T-711 P0011/0011 F-175
Crash Number: W0270221
Incident Number: 2012-03-219
PA RT 283 West Bound
Unit 1 PA RT 283 East Bound
http://www.dot6.st ate.pa.us/crsapp/Printlmages/Xnl IF i I es/20 1 203 133420 1 20 5291 5 402 1 40... 5/29/2012
PROGRESSIVE CLAIMS
5165 CAMPUS DR
SUITE 100
PLYMOUTH PROGREJJ/!/E'
H MEETING,PA 19462
008203
Underwritten By:
Artisan and Truckers Casualty
Company
MARK&GAI LEY Claim Number: 12-2913040
HERMAN GAILEY Loss Date: March 23, 2012
96 SOUTH GEORGE STREET
SUITE 430 Document Date: August 24,2Q12
YORK, PA 17401 Page 1 of 1
t rrt irhrllllhdulPrlrrrh ti4ulr4rinrtlrtrlrllru,lq
cla i ms.progress ive.com
Track the status and details of your claim,
e-mail your representative or report a
new claim.
Important information about your claim
Thank you for discussing LORI All CLEGG's claim on August 20,2012.
We would like to confirm our offer of$100,000.00 for settlement of LORI ANN CLEGG'S Bodily Injury claim.
As discussed I will be happy to provide you with a joint tonfeasor release.
Please extend this Offer to your client as soon as possible so we can take the next step to resolve this claim.
If you have any questions,please contact us.
)ANE KENNEDY
Claims Department
1-610-567-3656
1-800-PROGRESSIVE (1-800-776-4737)
Fax: 1-610-397-0840
jane_kennedy @progressive.com
Enclosure
Form 2463.01 xY.r0r1081-P.A
RELEASE OF ALL CLAIMS
FOR AND 1N CONSIDERATION OF the sum of One Hundred Thousand Dollars,
($100,000.00), receipt of which is hereby acknowledged, 1, William D. Clegg, as Administrator
of the Estate of Lori A. Clegg, being of lawful age, for myself, for the Estate of Lori A. Clegg,
and for my and its heirs, beneficiaries, administrators, executors, successors, and assigns
[hereinafter referred to as the Reieasor(s)], hereby remise, release and forever discharge Ronald
and Josephine Ressler, Ronald and Josephine Ressler t/d/b/a R&J Enterprises, R&J Enterprises,
R&J Enterprises, Inc., and Matthew Miller, their heirs, successors, and assigns and all other
persons, firms, corporations, and entities of whatsoever nature [hereinafter referred to as the
Releasee(s)], of and from all, and all manner of, actions and causes of action, suits, debts,
accounts, bonds, covenants, contracts, agreements, judgments, claims and demands of
whatsoever kind, in law or in equity, known or unknown, foreseen and unforeseen, which we
now have or may hereafter have, especially the liability arising out of the accident that occurred
on or about the 23`d day of March, 2012 on Route 283 West, Mt. Joy Township, Lancaster
County, Pennsylvania, which is the subject of a civil action filed in the Lancaster County Court
of Common Pleas, Pennsylvania, at docket number 12-09987.
Releasors further promise and agree to indemnify and hold harmless Releasees, from all
claims or demands of whatever kind, arising from or relating to any payment that has been, or
will be, made to, or on behalf of, the undersigned on account of the incident giving rise to the
aforementioned suit including, but not limited to, workers' compensation claims; health,
medical, or life insurance claims; underinsured motorist claims; or any other claims or demands
which have been or might be made by any persons or entities• who contend that they are
subrogated to, or have liens against, any recovery the undersigned might make as a consequence
of the above-described incident or accident.
- 1 -
It is agreed that this Release shall apply to all injuries and/or damages, including those
unknown and unanticipated, resulting from the aforementioned accident, casualty, happening or
event. I realize that I may have suffered damages or injuries I know nothing about.
It is understood and agreed that this settlement is the compromise of a disputed claim
entered into to avoid litigation and said settlement is not to be construed as an admission of
liability on the part of any party being released hereunder, any such liability being hereby
expressly denied.
This Release contains the ENTIRE AGREEMENT between the parties hereto, and the
terms of this Release are contractual and not a mere recital.
We further state that we have carefully read the foregoing Release, know and understand
the contents thereof, and we sign the same as our own free act.
IN WITNESS WHEREOF, we have set our hand and seal this day of
2414.
SIGNED IN THE PRESENCE OF: CAUTION! READ BEFORE SIGNING
(SEAL)
Witness William D. Clegg, as Administrator of the
Estate of Lori A. Clegg
Commonwealth of Pennsylvania
County of
2 _
On this day of 2014, before me personally appeared
William D. Clegg known to be the person described herein, and who executed the foregoing
instrument and who acknowledged that he voluntarily executed the same.
Notary Public
My Term Expires
- 3 -
WILLIAM D. CLEGG, Administrator of the IN THE ORPHANS' COURT OF
Estate of LORI A. CLEGG CUMBERLAND COUNTY,
PENNSYLVANIA
NO. 21-12-0440
IOINDER
This is to confirm that I have reviewed the foregoing Petition for Approval of Partial
Settlement and Allocation of Proceeds of Wrongful Death and Survival Action in the above-
stated case. This proposed settlement and distribution of funds is acceptable to me in all ways
and by signature of this Joinder, I hereby join in the Petition referenced above.
Date I SHARON CLEGG
SWORN and SUBSCRIBED to
before me this ;;,� day of
February, 2014 NOTARIAL SEAL
CYNTHIA R TAVARES
Notary Public
`- i .+•�-DFNN:T,WP.,YORK COUNTY
a� My fpiea-Sep-Y3-2lTrti"— —.
ARY P.v L C
My Commission Expire
pennsylvania
DEPARTMENT OF REVENUE
March 3, 2014
Herman A. Gailey,Esquire
Martz&Gailey
96 South George Street, Suite 430
York,PA 17401
Re: Estate of Lori Ann Clegg
File Number 2112-0440
Court of Common Pleas Cumberland County
Dear Mr. Gailey:
The Department of Revenue has received the Petition for Approval of Settlement Claim to be
filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has
been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to
settle the actions.
Pursuant to the Petition, the 32 year old decedent died as a result of a motor vehicle accident.
Decedent is survived by her parents.
Please be advised that,based upon these facts and for inheritance tax purposes only, this
Department has no objection to the proposed allocation of the net proceeds of this action, $32,125.84 to
the wrongful death claim and $32,125.84 to the survival claim. Proceeds of a survival action are an asset
included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42
Pa.C.S.A. §8302; 72 P.S. §9106, 9107. Costs and fees must be deducted in the same percentages as the
proceeds are allocated. In re Estate of Merrvman, 669 A.2d 1059 (Pa. Cmwlth. 1995).
I trust that this letter is a sufficient representation of the Department's position on this matter. As
the Department has no objections to the Petition, an attorney from the Department of Revenue will not be
attending any hearing regarding it. Please contact me if you or the Court has any questions or requires
anything additional from this Bureau.
(�Sinc rely,
i
i`,�S a on E. Baker
Trust Valuation Specialist
Inheritance Tax Division
Bureau of Individual Taxes I PO Box 280601 1 Harrisburg, PA 17128 1 717.783.5824 1 shabaker @pa.gov