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HomeMy WebLinkAbout14-2817 S_ reme Cou �> f}Pennsylvania vw ' A � :. ' Cour �df,COI11I130I1 Pleas For Prothonotary Use Only: CI�v 1 Cave Shut ��'yt Docket No: CU�hBRLN� County 'ern The information collected on this form is used solely for court administration purposes. This form does not supplement or replace the filing and service ofpleadings or other papers as required by law or rules of court. Commencement of Action: S Complaint 0 Writ of Summons Petition E 0 Transfer from Another Jurisdiction ❑� Declaration of Taking Lead Plaintiffs Name: Lead Defendant's Name: C T DONEGAL MUTUAL INSURANCE COMPANY KATHLEEN HARRISON Dollar Amount Requested: O within arbitration limits I Are money damages requested? IM Yes ❑ No (check one) ®outside arbitration limits i0 j N Is this a Class Action Suit? 0 Yes No Is this an MDJAppeal? 0 Yes 12 No A Name of Plaintiff/Appellant's Attorney: GEORGE A. MILLER, ESQ. i 0 Check here if you have no attorney(are a Self-Represented (Pro Sel Litigant) E Nature of the Case: Place an"X"to the left of the ONE case category that most accurately describes your PRIMARY CASE. If you are making more than one type of claim,check the one that you consider most important. TORT(do not include Mass Tort) CONTRACT(do l:ol include Judgments) CIVIL APPEALS 0 Intentional 0 Buyer Plaintiff Administrative Agencies �9 Malicious Prosecution 0 Debt Collections Credit Card 0 Board of Assessment x, Motor Vehicle 0 Debt Collection:Other 0 Board of Elections 0 Nuisance 0 Dept.of Transportation 0 Premises Liability 0 Statutory Appeal:Other S Product Liability(does not include il Employment Dispute: E mass tort) Slander/Libe]/Defamation Discrimination Q C 0 Other: Employment Dispute:Other 13 Zoning Board T 0 Other: I ❑� Other: O MASS TORT 0 Asbestos N 0 Tobacco 0 Toxic Tort-DES 0 Toxic Tort-Implant REAL PROPERTY MISCELLANEOUS 0 Toxic Waste 0 Ejectment 0 Common Law/Statutory Arbitration B 0 Other: © Eminent Domain/Condemnation 0 Declaratory Judgment 0 Ground Rent-; a Mandamus © Landlord/Tenant Dispute ©Non-Domestic Relations 0 Mortgage Foreclosure:Residential Restraining Order PROFESSIONAL LIABLITY 0 Mortgage Foreclosure:Commercial 0 Quo Warranto 0 Dental 0 Partition 0 Replevin 0 Legal 0 Quiet Title 0 Other: 0 Medical 0 Other: 0 Other Professional: Updated 1/1/2011 , c g l�j ii? 5�� L'►%" X11 `t IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION DONEGAL MUTUAL INSURANCE CASE NO. ' LIOI COMPANY, as subrogee for CHRISTOPHER and AMY CODE NO. HAVERSTOCK, TYPE OF PLEADING: Plaintiff, COMPLAINT IN CIVIL ACTION vs. FILED ON BEHALF OF: KATHLEEN HARRISON, DONEGAL MUTUAL INSURANCE Defendant. COMPANY, as subrogee for CHRISTOPHER and AMY HAVERSTOCK, Plaintiff COUNSEL OF RECORD FOR THIS PARTY: GEORGE A. MILLER, ESQUIRE Pa. I.D. No. 22525 BROMBERG & MILLER FIRM I.D. No. 937 1030 Fifth Avenue, Suite 102 PITTSBURGH, PA 15219 File No. 58557 (412) 232-0440 o 7Y tool it6 36,5s-cl 7 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION DONEGAL MUTUAL INSURANCE COMPANY, as subrogee for CHRISTOPHER and AMY HAVERSTOCK, No. Plaintiffs VS. KATHLEEN HARRISON, Defendant. NOTICE TO DEFEND You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served,by entering a written appearance personally or by attorney and filing in writing with the court your defense or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE.IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER,THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Lawyer Referral Service Cumberland County Bar Association 32 S. Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION DONEGAL MUTUAL INSURANCE, No. COMPANY as subrogee for CHRISTOPHER and AMY HAVERSTOCK Plaintiff, VS. KATHLEEN HARRISON, Defendant. COMPLAINT IN CIVIL ACTION AND NOW come(s) DONEGAL MUTUAL INSURANCE COMPANY, as subrogee for CHRISTOPHER and AMY HAVERSTOCK, Plaintiff, by and through their attorney,GEORGE A.MILLER,ESQ.,and BROMBERG&MILLER,Attorneys at Law,and file(s) the within COMPLAINT IN CIVIL ACTION as follows: 1. The Plaintiff is Donegal Mutual Insurance Company, part of Donegal Insurance Group, located at 1195 River Road, Marietta, PA 17547. 2. Defendant is Kathleen Harrison,an adult individual whose address is 116 C. West Vine Street, Camp Hill, PA 17011. 3. The Plaintiff was at all times pertinent hereto the insurer of Christopher and Amy Haverstock, Plaintiff's subrogor. 4. On or about October 1,2013,Defendant was operating her vehicle on Route 15 in Mechanicsburg, Cumberland County, in such a negligent manner as to strike the rear of Plaintiff's insured's vehicle, which was stopped at a traffic light. 5. Defendant's negligence is more specifically described below: a. Failure to maintain a proper lookout ahead of vehicle; b. Failure to have the vehicle under control; and C. Operating a motor vehicle without proper insurance. 6. As a direct and proximate result of the negligence of the Defendant, Plaintiff's subrogor sustained damages to its motor vehicle totaling $1,984.96 (one thousand, nine hundred eighty-four dollars and ninety-six cents). 7. A copy of the damage estimate is attached hereto and marked collectively as Exhibit "A." The said Exhibits will be offered at trial pursuant to Pa. R.C.P., Rule 1305. The repairs have been made. 8. Pursuant to a policy of insurance between Plaintiff and its subrogor,Plaintiff paid said amount, less any deductible to or on behalf of Plaintiff's subrogor, and has a legal enforceable interest in subrogation in this matter. 9. Demand has been made upon the Defendant for payment, including the subrogor's deductible, which demand has been refused. WHEREFORE, the Plaintiff, Donegal Mutual Insurance Company, demands judgment against the Defendant in the sum of$1,984.96, together with costs of suit. Respectfully submitted, BROMBERG& MILLER BY: ORGE A. MILLER, Esquire Donegal Mutual Insurance Company, as subrogee for Christopher and Amy Haverstock, Plaintiff VERIFICATION The undersigned, V\kk �A-c , does hereby verify that he/she is the 1 hg V V OJv%CX c O�:\V\A of y t SM , Plaintiff v sl ?y P-1 '�C���V W, VX Cb\A Com-. hisein,that he/she is authorized to make this verification on behalf of the Plaintiff,and that the facts contained in the foregoing COMPLAINT IN CIVIL ACTION are true and correct to the best of his/her knowledge and belief. This statement is made subject to the penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities. DONEGAL MUTUAL INSURANCE COMPANY By:� Title Gj File No. 58557 SUPPLEMENT RECONCILIATION Supplement Si Claim#: PAF-PA-01.13.0368204 Insured Policy#: PAF-3154324 File#: Claim Rep: Denise Shearer Insured: CHRISTOPHER&AMY HAVERSTICK Inspection Date/Time: 10%0912013 01:09 PM Owner Name: CHRISTOPHER&AMY HAVERSTICK Company: DONEGAL INSURANCE Vehicle: 2004 Lincoln Aviator Luxury 4 DR Wagon ................ .... ........................................................................................................................................................................................... . Deleted Lines ....... ................................................................................................... Line Guide Part Operation Price ADJ% B% Labor Rate , 1 519 Bumper Assembly,Rear LIKE KIND&OUAL.PRT $475.00 +25.00 2.0 SM .;.............................................................................................................................................................................................................................. .Added Lines ................................................................................................ . o..........o........................................: Line Guide Part Operation Price ADJ/e B,6 Labor Rate 2 519 Cover,Rear Bumper Replace OEM S1 $574.12 1.6 SM 3 559 Sensor,RR Bumper LT Replace OEM S1 $206.53 INC SM 4 559 Sensor,RR Bumper LT Refinish S1 0.1 RF 5 565 Bumper,Rear Replace OEM S-1 $215.20 2.0 SM 6 573 Brkt,Rear Bumper Mtg LT Replace OEM S1 $61.18 INC SM 7 574 Brkt,Rear Bumper Mtg RT Replace OEM S1 $61.18 INC SM 8 641 Brkt,RR Bumper Sensor LT Replace OEM S1 $48.24 INC SM 9 642 Brkt,RR Bumper Sensor RT Replace OEM S1 $49.22 INC SM 10 DIAGNOSTICS Sublet Repair S1 $94.95" SM' 11 SUBLET Repair S-1 1.0` SM` 12 CAP COVR/RR BUMPER Replace OEM S1 $60.58" SM` ......................... .................. :Changed Lines .................................................................. ............. ............................................................................................................................................ ...: Line Guide Part Operation Price ADJ°/ B'/ Labor Rate 13 517 Pad,Rear Bumper Step R&I Assembly S1 INC SM Pad,Rear Bumper Step 0.4 SM 14 557 Sensor,RR Bumper LT R&I Assembly S-1 INC SM Sensor,RR Bumper LT 0.1 SM 15 558 Sensor,RR Bumper RT R&I Assembly S1 INC SM Sensor,RR Bumper RT 0.1 SM 16 559 Sensor,RR Bumper LT R&I Assembly S1 INC SM Sensor,RR Bumper LT 0.1 SM 17 560 Sensor,RR Bumper RT R&I Assembly S1 INC SM Sensor,RR Bumper RT 0.1 SM CalculationChan..eS�.,..,...,..,,.,..,,.,..,....,,..,...,..,..,...,..,,.,,..,r.,...,......,..,..,..,..,...,..,..,..,..,..,..,,.,..,,,,,.,.,,..,,,,..,..,.,,,.,.,,..,..,..,..,..,..,.,...,.ws.,..,.,,..,..,.,,...,...... ...........................9 .....................---.---.................................................................................------............. ............................ From To Difference Gross Paris $0.00 $1,276.25 $1,276.25+ Other Parts $484.00 $9.00 $475.00- Paint Materials $26.00 $98.80 $26.00 $101.40 $2.60+ Line Item Markup $118.75 $0.00 $118.75- Tax on Parts&Material 6.000% $42.09 6.000% $83.20 $41.11+ SM-Sheet Metal $46.00 $128.80 $46.00 $211.60 $82.80+ RF-Refinish $46.00 $174.80 $46.00 $179.40 $4.60+ Tax On Labor 6.000% $18.22 6.000% $23.46 $5.24+ Sublet Repairs $0.00 $94.95 $94.95+ Tax On Sublet 6.000% $0.00 6.000% $5.70 $5.70+ Actual Supplement 1 Net Total $919.50+ ---------------------------------------------------------------------- -------------- -.-------------------------------------------------------------------------------------------------------- ......... -Summary ............. ......................................-....-................................ Net Total Date Time Appraiser Original Estimate $565.46 10;0712013 07:34 AM DONEGAL INSURANCE Supplement 1 $1,484.96 12/06/2013 11:43 AM DONEGAL INSURANCE 12,'06!201311:58 AM EXHIBIT Page 1 Di 2 � p�• dl JD a B 2004 Lincoln Aviator Luxury 4 DR Wagon Claim#: PAF-PA-DI-13-0368204 This report contains proprietary information of Audatex and may not be disclosed to any third party(other than the ate}''" insured,claimant and others on a need to know basis in order to effectuate the claims process)without Audatex's Audatex prior written consent. Af Copyright(C)2013 Audatex North America,Inc. Audatex Estimating is a trademark of Audatex North America,Inc. I i I i i j i i 12;06!2013 11:58 AM Page 2 of 2 I I 2004 Lincoln Aviator Luxury 4 OR Wagon 1 ClalmX: PAF-PA-01-13-0366204 10!09,201301:09PM 7 RI 558 Sensor,RR Bumper RT R& I Assembly S1 INC SM 8 E 559 Sensor,RR Bumper LT 4C5Z15K859AAA $206.53 S1 INC SM 9 L 559 Sensor,RR Bumper LT Refinish S1 0.1 RF 0.1 I Surface 10 RI 559 Sensor,RR Bumper LT R&I Assembly S1 INC SM 11 L 560 Sensor,RR Bumper RT Refinish 0.1 RF 0.1Surface 12 RI 560 Sensor,RR Bumper RT R&I Assembly S1 INC SM 13 E 641 Brkt,RR Bumper Sensor LT 2C5Z15A862CA $48.24 S1 INC SM 14 E 642 Brkt,RR Bumper Sensor RT 2C5Z15AB62AA $49.22 S1 INC SM 15 RI 517 Pad,Rear Bumper Step R& I Assembly S1 INC SM 16 EC Flex Additive Replace Economy $6.00' SM 17 EC Hazardous Waste Removal Replace Economy $3.00' SM 18 SB DIAGNOSTICS Sublet Repair $94.95' S1 SM" 19 1 SUBLET Repair; S1 1.0" SM' >>TAKE SUBLET 20 E CAP COVR/RR BUMPER Replace OEM $60.58' S1 SM" 20 Items I MC Message 01 CALL DEALER FOR EXACT PART#/PRICE 13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE • Estimate Total& Entries':....,.....,..,..,..,....................,................ ,.._.........,..............,.....,.....,,.,..,...,.....,..,....:...,........,:.....,..,...........,..,........:._.._.... .............................................i...............--.--.............--........----.--..........--•--.......--.--.--..........-----..........--.....................': Gross Parts $1,276.25 Other Parts $9.00 Paint Materials $101.40 Parts&Material Totalj $1,386.65 Tax on Parts&Material @ 6.000% $83.20 i Labor Rate Replace Repair Hrs Total Hrs Hrs Sheet Metal(SM) $46.00 3.6 1.0 4.6 $211.60 Mech/Elec(ME) $47.00 Frame(FR) $48.00 Refinish(RF) $46.00 3.9 3.9 $179.40 Paint Materials $26.00 Labor Total 8.5 Hours $391.00 Tax on Labor @ 6.000°a $23.46 Sublet Repairs I $94.95 Tax on Sublet CO-) 6.000°/a $5.70 Gross Total $1,984.96 Less: Deductible $500.00- Net Total I $1,484.96 Actual Supplement Total $919.50 Less:Previous Net Total $565.46- Net Supplement Total $919.50 Alternate Parts Y/00/00/00/00100 CUM 00/00/00100/00 Zip Code: 17406 york Audatex Estimating 7.0.123 S1 12/06/2013 11:58 AM REL 7.0.123 DT 11/0112013 Copyright(C)2013 Audatex North America,Inc. I PQ6%2013 11:56 AM Page 3 of 6 I I i i i DONEGAL INSURANCE GROUP 1195 RIVER ROAD P.O.SOX 302 MARIETTA,PA 17647-0302 (717)426-1931 FAX: 717 426-7023 ESTIMATE i0/0912013 0i:09 PM ..........................._.............................................................._...........................................................................................................................I.__................, Owner ................................................................................................................................ .........................I... .......................I.............. Owner: CHRISTOPHER&AMY HAVERSTICK Address: 137 MARTEL CIRCLE I Cell: (717)805-9066 City State Zip: Dillsburg,PA 17019 FAX- ............................. .................... AX:................................................................. ...I... Control Information :.................................... .............................................................................................. Claim#: PAF-PA-01-13-0368204 Insured Policy#: PAF-3154324 Loss Dateffime: 10/01/2013 08:00 AM Loss Type: Colilslon Deductible: $500.00 File#: Accounting*: 0005684 i Ins.Company: Donegal Insurance Group, Agent: Denise Shearer Address: Work/Day: (800)877-0600x7416 Email: denlseshearer@donegalgroup.00m Insured: CHRISTOPHER &AMY HAVERSTICK Address- Cell: (717)805.9066 Claim Rep: Denise Shearer Address: Work/Day: (800)877-0600x7416 Email: deniseshearer@donegaigroup.com ..............................................I......... Inspection ................_...............::.._._............._..:...:.:.......::.......__............ Inspection Date: 10/09/2013 01:09 PM Inspection Type: Field Inspection Location: mechanicsburg Contact: Address: 137 MARTEL CIRCLE Cell: (717)805-9066 City State Zip: Dillsburg,PA 17019 Primary Impact: Rear Secondary Impact: Driveable: Yes Rental Assisted: Assigned Date/Time, Received Date/Time: 10/07/2013 07:31 AM First Contact Date/Time: Appointment Date/Time: 10108/2013 08:00 AM Company: DONEGAL INSURANCE Appraiser License#: 150311 Contact: YVONNE DAVIS Work/Day: (717)413-8564 Address: 1195 RIVER RD FAX: (855}229 8005 City State Zip: Marietta, PA 17547-0302 Email: yvonnedavis@donegalgr up.00m _......,.,..........,.........._.........._............_.....................,.,,,..�,. ..............,`" ...................__._...,.. ....r.....................,.... ......... ..Repairer ,...,... ... .....:,.,..... .. . ....,........, .... .........,. K.. ' Contact: Repairer: UN K Address: UNK Work/Day: City State Zip: YORK.PA FAX: Target Complete Date/Time: Days To Repair: 2 Page 1 of 5 1 Wogf2013 01:18 PM I I 10/4912013 41:09 PM 2004 Lincoln Aviator LmWy 4 DR Wagon Claim L:PAF-PA-01-13.0368204 ........, ................:..,..........,..,.............................,._................,...,....:.,...........--...._..,.......,.........,...............,..........��..............-....................................,............. Remarks :.......,..._.,,,..._..:..._.,,......:.......................... ALL SUPPLEMENTS DAMAGE MUST BE APPROVED BY THE APPRAISER -COPY OF APPRAISAL GIVEN TO OWNER OCT 9,2013 Vehicle ..........:!............................................................................................... ...................................: 2004 Lincoln Aviator Luxury 4 DR Wagon 8cyl Gasoline 4.6 5 Speed Automatic Lie-Plate: FME789f39 Lie State: PA VIN: 5LMEUBSH64ZJ25100 Lic Expire: Prod Date: Mileage: 0 Mileage Type: Non Readable Veh lnsp#: Code: 08453A Condition: Int.Calor: Ext.Color: BLACK Int.Refinish: Ext.Refinish: Two-Stage Options Alarm System Aluminum/Alloy Wheels 4-Wheel Drive Camper/Towing Package Anti-Lock Brakes 13odyside Ciadd'+ng Compact Disc W/Tape Cruise Control Center Console Dual Power Seats Dual Air Conditioning Dual Airbags Fender Flares Fog tights Dual Zone Auto A/C d Power Mirrors Intermittent Wipers Garage Door Opener Heated Keyless Entry System Leather Seats J Parkin Assts Steer Wheel Lighted Entry System Overhead Gonsole Parking Assist System Power Brakes' Power Door Locks Power Adjustable Pedals I Privacy Glass Power Steering Power Windows Rear Window Defroster Rear Window Wiper/Washer Rear Heater Running Boards Reverse Sensing System Roof/Luggage! Strg Wheel Radio Control Tachometer Side Alrbags Tilt Steering Wheel Tinted Glass Thins Seat(trucks) Trip Computer Tire Pressure Monitor Trailer Hitch Wood Interior Trim 1 _....,...._......................................._......._............... ..,.....,...,.... :...:.........__.................,......................,..._... -.... .......... M......,.:., .,..,.........._.... E gs .:.,.......,......... Damages ,__..,. .._. . Price ADJ°k Korb Hours R Line Op Guide MC Description MFR.Part No. 12.0 SM 1 EU 519 Bumper Assembiy,Rear LIKE KIND&QUAL.PRT $475.00 +25.00 >>LKQ Penn-Mar lnc.800-334-9811 >>269 River Road >>York Haven PA 17370 >>Quote#231380341462594, Stock#$U05805-300,Charles 3.7 RF 2 L 519 13 Cover,Rear Bumper Refinish 2.6 Surface 0.6 Two-stage setup 0.5 Two-stage 0,1 SM 3 RI s57 Sensor,RR Bumper LT &I Assembly 0.1 SM 4 RI 558 Sensar,RR Bumper AT i•,i&I Assembly 0.1 SM 5 RI 559 Sensor,RR Bumper LT f4&I Assembly 0,1 RF 6 L 560 Sensor,RR Bumper AT Refinish 0.1 Surface 0.1 SM 7 RI 560 Sensor,RR Bumper AT R&I Assembly 0,4 SM 8 RI 517 Pad,Rear Bumper Step &I Assembly Page 2 of 5 10!00!2013 01:19 PM 10/09/2013 01:09 PM 2004 Lincoln Aviator Luxury 4 OR Wagon Claim a:PAF•PA•Ot•t3-0366264 9 EC Flex Additive Replace Economy $6.00' SM 10 EC Hazardous Waste Removal Replace Economy $3.00, SM 10 Items MC Message 13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE EstimateTotal&Entries.............................................................................................................................................................................................. Other Parts $484.00 .80 Paint Materials $98 $118.76 Line Item Markup $701.55 Parts&Material Total ( $42.09 Tax on Parts&Material @ 6.000`!0 Labor Rate Replace RepairlHrs Total Hrs Hrs Sheet Metal(SM) $46.00 2.8 2.8 $128.80 Meeh/Elea(ME) $47.00 Frame(FR) $48.00 Refinish(RF) $46.00 3.8 3.8 $174.80 Paint Materials $26.00 Labor Total 6.6 Hours $303.60 Tax on Labor @ 6.000% $18.22 $1,065.46 Gross Total $500.00- Less:Deductible $565.46 Net Total I Alternate Parts Y/00/00/00100100 CUM 00100/00/00100 Zip Code:17406 york i Audatex Estimating 7.0.019 ES 10/09/2013 01:19 PM REL 7.0.019 DT 09/01/2015 Copyright(C)2013 Audatex North America,Inc. 1.1 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEVS TWO-STAGE REFINISH FORMULA. I ABBREVIATION LEGEND: LKQ = LIKE KIND IN QUALITY, A/M - AFTERMARKET, RECOND = RECONDITION, O/H= OVERHAUL, REPL = REPLACE, RPR = REPAIR, REFN = REFINISH, SECT = SECTION, R & I = REMOVE AND INSTALL, ALGN ALIBLND = BLEND, ASSY=GN, SUBL = SUBLET, L = LEFT, ASSEMBLY, FRNT/FRT = FRONT, HL/H/LAMP = HEADLAMP, INR = INNER, MLD/MLDG = MOLDING, ; MTG = MOUNTING, O;TR = OUTER, PNLS = PANELS, R/RT = RIGHT, REPL = REPLACEMENT, . SUSP = SUSPENSION, W/O MLD = WHEEL OPENING MOLDING, RIC = RACKET, LIC =I LICENSE, R/F = RIGHT FRONT, R/R = RIGHT REMOTE CONTROL, BRKT = B -FT= LREAR, PNL = PANEL, FT = FRONT, PXN REAR, L/F = LEFT FRONT, RL/RAC = PARTS EXCHANGE NEW, OEM = ORIGINAL EQUIPMENT MANUFACTURER, PRT = PART, NAGS = NATIONAL ASSOCIATION OF GLASS SUPPLIER, REMAN = REMANUFACTUREDr PART = PARTIAL • Page 3 of 5 I 101092013 01:13 PM i I DONEGAL INSURANCE GROUP 1195 RIVER ROAD P.O.BOX 302 MARIETTA,PA 17547-0302 (717)426-1931 FAX: (717)426-7023 ***SUPPLEMENT 1 *** 10/09/2013 01:09 PM ................................................................................... .................... . ...... ........................................... Owner .............................................................................................................................................................................................................................i Owner: CHRISTOPHER&AMY HAVERSTICK Address: 137 MARTEL CIRCLE iCell: (717)805-9066 City State Zip: Dillsburg, PA 17019 FAX: ..........................................................................................................:................................................................................................................................. Control Information ................................................................................................................................. Claim#: PAF-PA-01-13-0368204 Insured Policy#: PAF-3154324 Loss Date/Time: 10/01/2013 08:00 AM Loss Type: Collision Deductible: $500.00 File#: Accounting#: 0005684 Ins.Company: Donegal Insurance Group Agent: Denise Shearer Address: Work/Day: (800)877-0600x7416 Email: deniseshearerQa donegalgroup.com Insured: CHRISTOPHER&AMY HAVERSTICK Address: Cell: (717)805-9066 i Claim Rep: Denise Shearer Address: Work/Day: (800)877-0600x7416 Email: deniseshearerCa donegalgroup.com :................................................................................................... a................_........... . ...................................................................................................:. .Inspection ..__ __,. _._._.__.__.__ ..._..._..,. w__r.__...._..._._._..._.._..._....._ : ..... ._.,..._._.._w_.._..__... ..a_.._. ..........,... .. ._.. _.,...__ _..._......_....r.._.._ ._. _ ._ .,_. Inspection Date: 10/09/2013 01:09 PM i Inspection Type: Field Inspection Location: mechanicsburg Contact: Address: 137 MARTEL CIRCLE Cell. (717)805-9066 City State Zip: Dillsburg, PA 17019 Primary Impact: Rear Secondary Impact: Driveable: Yes Rental Assisted: Assigned Date/Time: Received Date/Time: 10/07/2013 07:31 AM First Contact Date/Time: Appointment Date/Time: 10/08/2013 08:00 AM Company: DONEGAL INSURANCE Appraiser License#: 150311 Contact: YVONNE DAVIS Address: 1195 RIVER RD Work/Day: (717)413-8664 City State Zip: Marietta, PA 17547-0302 FAX: (855)229-8005 Email: yvonnedavis@donegalgroup.com Orig Company: DONEGAL INSURANCE Appraiser License#: 150311 Contact: YVONNE DAVIS Address: 1195 RIVER RD Work/Day: (717)413-8664 City State Zip: Marietta, PA 17547-0302 FAX: (855)229-8005 Email: yvonnedavis@donegalgroup.com s..Repairer._._ ._..:........................_..... _..._.._._:.._:...... ......__... _._...._.__.__._._.:.. .............._:._......._..... .... ..._........._....w:._.._.:......_. ...__._:..... ...._ ...................__...._.....__. .:._.._ Repairer: i Contact: I2-06%2013 11:56 AM Page 1 of 6 i 2004 Lincoln Aviator Luxury 4 DR Wagon Claim#: PAF-PA-01-13-0368204 10109i2013 01:09 PM MAJOR'S SELECT COLLISION CENT Address: 269 MULBERRY DR Work/Day: (717)766-4461 City State Zip: MECHANICSBURG, PA 17055 FAX: (717)766-4194 License#: 251871655 j Regulation ID: Target Complete Date/Time: Days To Repair: 2 •Remarks::.......,.:.:.,..................:.,.....,..,......:.,........,.........:...:.:......-:-:......:.,,......:.,.....,..::.....::............,.....::..:..:.....:.....:........:..:....::.,....:.::.,................:... ------------- -------.............................................................. .......................................... ALL SUPPLEMENTS DAMAGE MUST BE APPROVED BY THE APPRAISER -COPY OF APPRAISAL GIVEN TO OWNER OCT 9,2013 Vehicle ..........................................................................................................:,................................................................................................................................i 2004 Lincoln Aviator Luxury 4 DR Wagon 8cyl Gasoline 4.6 5 Speed Automatic Lic.Plate: FME78969 Lic State: PA Lic Expire: VIN: 5LMEU88H64ZJ25100 Prod Date: Mileage: 0 Veh Insp#: Mileage Type: Non Readable Condition: I Code: Q8453A Ext.Color: BLACK Int.Color: Ext.Refinish: Two-Stage i Int.Refinish: Options 4-Wheel Drive Alarm System Aluminum/Alloy Wheels Anti-Lock Brakes Bodyside Cladding Camper/Towing Package Center Console Compact Disc W/Tape Cruise Control Dual Air Conditioning Dual Airbags Dual Power Seats Dual Zone Auto A/C Fender Flares Fog Lights Garage Door Opener Heated Power Mirrors Intermittent Wipers Keyless Entry System Leather Seats Leather/Wood Steer Wheel Lighted Entry System Overhead Console Parking Assist System Power Adjustable Pedals Power Brakes Power Door Locks Power Steering Power Windows Privacy Glass Rear Heater Rear Window Defroster Rear Window Wiper/Washer Reverse Sensing System Roof/Luggage Rack Running Boards Side Airbags Strg Wheel Radio Control Tachometer Third Seat(trucks) Tilt Steering Wheel Tinted Glass Tire Pressure Monitor Trailer Hitch Trip Computer Wood Interior Trim i .......... ...................... ..------.------........... . .............i.................................................................................................................................. Damages .. .. ..: :...:....._....:.....,... i.. :.....,.. .:._......:.,..,....:.......:._...,....:.........._.._...,.: ...........:.......,........ . . .. .. .. .. Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R 1 E 565 Bumper,Rear 2C5Z17906AA $215.20 S1 2.0 SM 2 E 519 01 Cover,Rear Bumper 2C5Z17K835EAA $574.12 S1 1.6 SM 3 L 519 13 Cover,Rear Bumper Refinish 3.7 RF 2.6 i Surface 0.6 Two-stage setup 0.51 Two-stage 4 E 573 Brkt,Rear Bumper Mtg LT 2C5Z17D943AA $61.18 S1 INC SM 5 E 574 Brkt,Rear Bumper Mtg RT 2C5Z17D942AA $61.18 Si INC SM 6 RI 557 Sensor;RR Bumper LT R& I Assembly S1 INC SM 12,06,2013 11:58 AM Page 2 of 6 I I i 2004 Lincoln Aviator Luxury 4 OR Wagon Claim;#: PAF-PA-01-13-0368204 t0!09l201301:09PM Estimate Summary Page DONEGAL INSURANCE Gross Total Less:Deductible $1,984.96 Net Total $500.00- Actual Supplement Total $1,484.96 Less:Previous Net Total $919'50 Net Supplement Total $565.46- $919.50 Audatex Estimating 7.0.123 S1 12106/2013 11:58 AM REL 7.0.123 DT 11/01/2013 Copyright(C)2013 Audatex North America,Inc. 1210612013 11:58 AM Page 6 of 6 Ronny R Anderson Sheriff Jody S Smith Chief Deputy Richard W Stewart Solicitor SHERIFF'S OFFICE OF CUMBERLAND COUNTY tCitiuto ,fyb , THE F',. , HGNOL%, 20ili JUN —1' PM 3: i CU PND ENNSYLVANI COUNTY OFFICE OF WF $HFRIFF Donegal Mutual Insurance Company Subrogee for Christopher and Amy Have vs. Kathleen Harrison Case Number 2014-2817 SHERIFF'S RETURN OF SERVICE 05/22/2014 05:24 PM - Deputy Dawn Kell, being duly sworn according to law, served the requested Complaint & Notice by handing a true copy to a person representing themselves to be Greg Harrison, Son, who accepted as "Adult Person in Charge" for Kathleen Harrison at 116 C West Vine Street, Shiremanstown Borough, Camp Hill, PA 17011. cl-tA7n 12-e_0-0 DAWN KELL, DEPUTY SHERIFF COST: $62.39 SO ANSWERS, May 23, 2014 RONNY R ANDERSON, SHERIFF (c) CountySuite Sheriff, Teieosoft, k?c. IL HE PEWTH. Z©f Lor' JUS. j BERLAND co PENNS }'1. /,� hll wiry IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION DONEGAL MUTUAL INSURANCE COMPANY SUBROGEE FOR CASE NO. 14-2817 CIVIL CHRISTOPHER AND AMY HAVERSTOCK CODE NO. Plaintiff, TYPE OF PLEADING: vs. KATHLEEN HARRISON Defendant, File No. 58557 PRAECIPE TO ENTER DEFAULT JUDGMENT FILED ON BEHALF OF: DONEGAL MUTUAL INSURANCE COMPANY COUNSEL OF RECORD FOR THIS PARTY: GEORGE A. MILLER, ESQUIRE Pa. I.D. No. 22525 BROMBERG & MILLER FIRM I.D. No. 937 1030 Fifth Avenue, Ste 102 PITTSBURGH, PA 15219 (412) 232-0440 al4 131°. )/4rl 19di LP( Nofe I37cwlp0( IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION DONEGAL MUTUAL INSURANCE COMPANY SUBROGEE FOR CHRISTOPHER AND AMY HAVERSTOCK Plaintiff, No. 14-2817 CIVIL vs. KATHLEEN HARRISON Defendant, PRAECIPE TO ENTER DEFAULT JUDGMENT TO: PROTHONOTARY, COURT OF COMMON PLEAS OF CUMBERLAND COUNTY KINDLY ENTER DEFAULT JUDGMENT IN THE ABOVE CASE AGAINST THE DEFENDANT(S), KATHLEEN HARRISON, in the amount of ONE THOUSAND NINE HUNDRED EIGHTY FOUR DOLLARS AND NINETY SIX CENTS ($1,984.96) plus costs and interest from the date of entry, the Defendant(s) having failed to file an Answer to the Complaint. More than ten (10) days have elapsed since serving the Defendant(s) with a copy of the "IMPORTANT NOTICE," a copy of said Notice with the PROOF OF SERVICE being attached hereto as Exhibit "A. BY: Respectful) submitted, ORGE A. MILLER, Esquire ATTORNEY for DONEGAL MUTUAL INSURANCE COMPANY 14-2817 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION DONEGAL MUTUAL INSURANCE COMPANY AS SUBROGEE FOR CHRISTOPHER AND AMY HAVERSTOCK, Plaintiff, vs. KATHLEEN HARRISON Defendant. NO. 14-2817 PROOF OF SERVICE THE UNDERSIGNED, George A. Miller, Attorney for Plaintiff herein, does hereby verify that the IMPORTANT NOTICE, a copy of which is attached hereto, was mailed to the Defendant(s) herein on JUNE 23, 2014, by U.S. Mail, First Class, Postage Paid. This statement is made subject to the penalties of 18 Pa. C.S., Section 4904, relating to unsworn falsifications to authorities. George A. Miller, Esquire IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION DONEGAL MUTUAL INSURANCE COMPANY AS SUBROGEE FOR CHRISTOPHER AND AMY HAVERSTOCK, Plaintiff, vs. KATHLEEN HARRISON Defendant. TO: KATHLEEN HARRISON Date of Notice: JUNE 23, 2014 NO. 14-2817 IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IFYOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP. LAWYER REFERRAL SERVICE CUMBERLAND COUNTY BAR ASSOCIATION 32 S. BEDFORD STREET CARLISLE, PA 17013 717-249-3166, 800-990-9108 Q eorge A. Mille , Esquire 1030 Fifth Avenue, Ste 102 Pittsburgh, PA 15219 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION DONEGAL MUTUAL INSURANCE COMPANY SUBROGEE FOR CHRISTOPHER AND AMY HAVERSTOCK Plaintiff, vs. KATHLEEN HARRISON Defendant, CASE NO.: 14-2817 CIVIL NOTICE OF JUDGMENT TO: DEFENDANT (S) ABOVE NAMED: KATHLEEN HARRISON 116 C WEST VINE STREET, CAMP HILL, PA 17011 TAKE NOTICE, that on ,244 , JUDGMENT was entered against you and in favor of the Plaintiff (s) in the amount of ONE THOUSAND NINE HUNDRED EIGHTY FOUR DOLLARS AND NINETY SIX CENTS ($1,984.96) plus costs and interest from date of entry. PROTHONOTARY By: LU-OFIQ F-7i0 THONO 11111. ; 2014 P 22 C 81 3: 0,) I'VE-RC/1AD C 0 OiY P S YI.VA IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION DONEGAL MUTUAL INSURANCE CASE NO.: 14-2817 CIVIL COMPANY SUBROGEE FOR CHRISTOPHER AND AMY CODE NO. HAVERSTOCK TYPE OF PLEADING: Plaintiff, vs. KATHLEEN HARRISON AFFIDAVIT IN SUPPORT OF CERTIFICATION OF MOTOR VEHICLE JUDGMENT FILED ON BEHALF OF: Defendant. DONEGAL MUTUAL INSURANCE COMPANY COUNSEL OF RECORD FOR THIS PARTY: GEORGE A. MILLER, ESQUIRE Pa. I.D. No. 22525 BROMBERG & MILLER FIRM I.D. No. 937 1030 Fifth Avenue, Suite 102 PITTSBURGH, PA 15219 (412) 232-0440 File No. 57779 155 ,75 t* to .a01) -P--4fr?1 3 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION DONEGAL MUTUAL INSURANCE COMPANY SUBROGEE FOR CHRISTOPHER AND AMY HAVERSTOCK, Plaintiff, CASE NO. 14-2817 CIVIL vs. KATHLEEN HARRISON, Defendant ' AFFIDAVIT IN SUPPORT OF CERTIFICATION OF MOTOR VEHICLE JUDGMENT COMMONWEALTH OF PENNSYLVANIA, SS: COUNTY OF ALLEGHENY, I, GEORGE A. MILLER, ESQUIRE, being duly sworn according to law, depose and state: 1. I am an attorney in good standing, admitted to practice in the courts of this Commonwealth, and am counsel of record for the Plaintiff -judgment creditor, DONEGAL MUTUAL INSURANCE COMPANY, in the above -captioned matter. 2. I am authorized to make this Affidavit on behalf of the Plaintiff. 3. The address of the Plaintiff is 1195 River Road, Marietta, PA 17547. 4. The last -known address of the Defendant, 116 C. WEST VINE ST., CAMP HILL, PA 17011. . 5. The judgment reflected at Docket No. 2817 of 2014 of the Court of Common Pleas of Cumberland County, PA is in the amount of $1,984.96 is valid, enforceable and unsatisfied, and is the result of a motor vehicle accident upon which suspension of driver's, operating privileges is authorized. SWORN TO and subscribed before me this '7 day 21441-. -24 / of otary Public COMMON OF NNSY v Notarial Seal • Laura D. Miller, Notary Public Ross Twp., Allegheny County My Commission Expires March 28, 2016 EMBER, PENNSYLVANIA ASSOCIATION OF OT ES GEORGE A. MILLER, ESQUIRE