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HomeMy WebLinkAbout14-2979CALVIN CROFT, • Individually, on behalf of his siblings, and as Administrator of the ESTATE OF CAROLYN V. CROFT, Petitioner v. GEORGIA J. DAVIS, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, and NATIONWIDE MUTUAL INSURANCE COMPANY Respondent ORIGINAL IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW r„ /f-aQ T? r - <c'1 C`) PETITION TO APPROVE SETTLEMENT OF WRONGFUL DEATH AND SURVIVAL ACTIONS 4„- AND NOW, comes Calvin Croft, Individually, on behalf of his siblings, and as Administrator of the Estate of Carolyn V. Croft, deceased, by and through his attorney, Mooney & Associates, by Jason C. Imler, Esq., and petitions this Honorable Court, pursuant to 20 Pa.C.S. §3323, to enter an Order permitting settlement of this action and in support thereof aver as follows: 1. Petitioner, Calvin Croft, is a competent adult individual currently residing at 328 Duncan Ave., Front Royal, Virginia, 22630. 2. Decedent, Carolyn V. Croft, was born on February 17, 1937, and died on May 18, 2013, as a result of multiple blunt force trauma stemming from a motor vehicle collision. 3. Decedent, Carolyn V. Croft, is survived by her children, Calvin Croft, Cathy Durrer, Karen Byrd, Tim Croft, and Karl Croft. 4. At the time of her death, Decedent, Carolyn V. Croft, was a resident of 1 ?/62-7,r-Pci_figi Ggfe R--14- 06.06.5-- Cumberland County, Pennsylvania, and resided at 35 Thompson Creek Drive, Shippensburg, Pennsylvania, 17257. 5. Petitioner, Calvin Croft, was granted Letters of Administration of the Estate of Carolyn V. Croft on June 25, 2013. An original Short Certificate of Grant of Letters from the Register of Wills of Cumberland County is attached hereto and is made a part hereof, and marked as Exhibit "A." 6. Respondent, Georgia J. Davis, is an adult individual currently residing at 3680 Orrstown Road, Orrstown, Pennsylvania, 17244. 7. On May 18, 2013, at approximately 10:27 a.m., Decedent, Carolyn V. Croft, a pedestrian, was struck by a vehicle driven by Respondent, Georgia Davis, while Decedent was standing along the side of Route 11 (area of 6336 Molly Pitcher Highway) near the intersection of Lippizan Drive, in Greene Township, Franklin County, Pennsylvania. A copy of the Commonwealth of Pennsylvania Police Crash Report is attached hereto, made a part hereof, and marked as Exhibit "B." 8. As a result of this crash, Decedent, Carolyn V. Croft, sustained injuries which led to her death. 9. Decedent, Carolyn V. Croft, was pronounced dead at Chambersburg Hospital on May 18, 2013, at approximately 11:18 a.m. An original Certificate of Death is attached hereto, made a part hereof, and marked as Exhibit "C." 10. Respondent, State Farm Mutual Insurance Company, is an insurance company licensed to do business in the Commonwealth of Pennsylvania with offices located at PO Box 106114, Atlanta, GA 30348-6114. 2 11. At the time the incident occurred, Respondent, Georgia J. Davis, maintained automobile insurance coverage with State Farm Mutual Insurance Company (policy number 211544938). Said policy provided for a Bodily Injury Liability limit of $25,000 per person. 12. Respondent, Nationwide Mutual Insurance Company, is an insurance company licensed to do business in the Commonwealth of Pennsylvania with offices located at One Nationwide Gateway, Dept. 5867, Des Moines, IA 50391-5867. 13. At the time the incident occurred, Decedent, Carolyn V. Croft, maintained automobile insurance coverage with Nationwide Mutual Insurance Company (policy number 5837B539671). Said policy provided for an Underinsured Motorist limit of $100,000 per person. 14. Respondent, State Farm Mutual Insurance Company, has extended an offer of $25,000 representing the Bodily Injury policy limits. A copy of the August 28, 2013, offer letter is attached hereto, made a part hereof, and marked as Exhibit "D." 15. Respondent, Nationwide Mutual Insurance Company, has extended an offer of the $100,000 representing the Underinsured Motorist policy limits. A copy of the October 3, 2013, offer letter is attached hereto, made a part hereof, and marked as Exhibit "E." 16. Petitioner, Calvin Croft, would like to settle these claims for the respective policy limits and request this Court's permission to enter into the offered settlement. Petitioner's counsel, Jason C. Imler, Esq., believes that the proposed settlement offers are reasonable in light of the facts surrounding the case, the available insurance coverage to pursue, and the lack of other insurance coverage to pursue. A copy of the proposed settlement release from State Farm Mutual Insurance Company is attached hereto, made a part hereof, and marked as Exhibit "F." A copy of the proposed settlement release from Nationwide Mutual Insurance Company is 3 attached hereto, made a part hereof, and marked as Exhibit "G." 17. Respondent, State Farm Mutual Insurance Company, has supplied a Certificate of Coverage for policy number 211544938 showing that Respondent, Georgia J. Davis, was carrying a $25,000 per person bodily injury limit at the time the crash occurred. A copy of the Certificate of Coverage is attached hereto, made a part hereof, and marked as Exhibit "H." 18. Respondent, Nationwide Mutual Insurance Company, has supplied a Certified Copy of policy number 5837B539671 showing that Decedent, Carolyn V. Croft, was carrying $10,000 in medical benefits, and a $100,000 per person Underinsured Motorist limit at the time the crash occurred. A copy of the Certified Copy of the policy is attached hereto, made a part hereof, and marked as Exhibit "I." 19. The medical bills incurred by Carolyn V. Croft as a result of this incident were paid by her insurer, Nationwide Mutual Insurance Company. A copy of the Pay Log from Nationwide showing payment of $2,095.59 of the $10,000 limit is attached hereto, made a part hereof, and marked as Exhibit "J." 20. Inquiries have been made with Carolyn V. Croft's health insurers to verify that no liens exist. A copy of the May 1, 2014, letter from the Centers for Medicare & Medicaid Services indicating that Medicare has not paid any claims that appear related to this incident is attached hereto, made a part hereof, and marked as Exhibit "K". A copy of the October 4, 2013, letter from Rawlings Company, on behalf of Aetna, indicating that no medical bills have been paid in relation to this incident is attached hereto, made a part hereof, and marked as Exhibit "L". 21. Petitioner, Calvin Croft, also request this Honorable Court approve the allocation of the net proceeds of the settlement, after payment of attorney fees, expenses, and liens, as 4 follows: (a) For the Wrongful Death action, 80% of the net settlement proceeds payable in equal shares to each of Carolyn V. Croft's children; (b) For the Survival Action, 20% of the net settlement proceeds to the Estate of Carolyn V. Croft. 22. Petitioners sought approval of an allocation of the Wrongful Death and Survival Claim proceeds from the Pennsylvania Department of Revenue. The Department of Revenue approved an allocation of 80% to the Wrongful Death claim and 20% to the Survival Action claim. A copy of the October 24, 2013, letter from Shannon E. Baker at the Department of Revenue is attached hereto, made a part hereof, and marked as Exhibit "M." 23. Mooney & Associates has incurred general case expenses in the amount of $204.32 for which reimbursement is sought. A copy of the case -expenses itemization is attached hereto, made a part hereof, and marked as Exhibit "N." 24. As part of this petition, counsel requests approval of the payment of counsel fees in the amount of $41,666.66 for services rendered plus costs and expenses of $204.32 pursuant to the fee agreement signed by Petitioners for a total of $41,870.98. A copy of the Personal Injury Fee Agreement signed by Petitioner, Calvin Croft and his siblings, Karen Byrd, Cathy Durrer, and Tim Croft, is attached hereto, made a part hereof, and marked as Exhibit "0." WHEREFORE, Petitioner requests this Honorable Court to: (a) Authorize the payment of counsel fees, in the amount of $41,666.66, and costs, in the amount of $204.32, to Mooney & Associates for a total payment of $41,870.98, from the funds due; 5 Date: (b) Direct distribution of the net proceeds ($83,129.02) of the settlement as follows: I. To the Petitioner, Calvin Croft and his siblings, for the Wrongful Death action, in the amount of $66,503.22 representing 80% of the net proceeds which will be distributed equally to Calvin Croft, Cathy Durrer, Karen Byrd, Tim Croft, and Karl Croft; and II. To the Estate of Carolyn V. Croft for the Survival Action, in the amount of $16,625.80 representing 20% of the net proceeds. Respectfully submitted, 6 Jason C. Imler, Esq. I.D. #87911 Mooney & Associates 230 York Street Hanover, PA 17331 (717) 632-4656 Attorney for Petitioner EXHIBIT A 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 the 25th day of June, Two Thousand and Thirteen Letters TESTAMENTARY in common form were granted by the Register of said County, on the estate of CAROL YN VIRGINIA CROFT (First, Middle, Last) , late of SOUTHAMPTON TOWNSHIP in said county, deceased, to CALVIN CROFT (First, Middle, Last) 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 25th day of June Two Thousand and Thirteen. File No. 2013- 00709 PA File No. 21- 13- 0709 Date of Death 5/18/2013 S. S. # 204,-28-1850 it �LLLI /1 !4JkL(!SLL Register Of Wills et P41Wilk) De y NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL EXHIBIT 6 AA -500 TX Incident Number: Crash Involves: DUI J Fatality 0 Hit and Run ()Commercial Vehicle Q NIA 0 Work Zone 0 ATV }Snowmobile H03-2208079 Commonwealth of Pennsylvania Police Crash Report REPORTABLE CRASH 0 State Police Vehicle Commonwealth Vehicle PAGE 1 0 Local Police Vehicle 0 Local Gov Vehicle Police Agency Data Agency Name PA STATE POLICE - CHAMBERSBURG Case Closed NO Patrol Zone 28 Investigation Date 05/18/2013 Dispatch Time 10:27 hrs. Arrival Time 10:33 hrs. Investigator - VACCARO, ANTHONY Badge Number 11222 Approval Date 06/07/2013 Reviewer KANE, RANDY B Reviewer Badge Number 07774 Crash Data Date of Crash 05/18/2013 Time of Crash 10:27 hrs. Day of the Week SATURDAY Crash Description HIT PEDESTRIAN County FRANKLIN Municipality GREENE TWP Weather Conditions NO ADVERSE CONDITIONS Relation to Roadway ON TRAVEL LANES Illumination DAYLIGHT Road Surface Conditions DRY # of Units 003 ' '' # of People 002 • # of Injured 000 # Killed 001 EMS Agency CUMBERLAND AMBULANCE SHIPPENSBUR Medical Facility CHAMBERSBURG HOSPITAL School Bus Related NO School Zone Related NO PennDOT NO Notified Type of Intersection MIDBLOCK Special Location NOT APPLICABLE Work Zone Work Zone NO Work Zone Type Where in Work Zone Speed Limit Wo kers Present Officer Present Work Zone Characteristics Road Closed Work on Shoulder In ermittent or Flagger ❑ Lane Closu e ❑ with Detour ❑ or Median ❑ Moving:Work ❑ Control • Other Principal Road Route Signing STATE HIGHWAY Route Number 0011 Segment Number Travel Lanes 02 Speed Limit 45 MPH Orientation SOUTH House Number Street Name MOLLY PITCHER St. Ending HIGHWAY Intersecting Rd. Used in Intersection Crashes Route Signing Route Number Segment Number Travel Lanes Speed Limit Orientation Street Name St. Ending Distance From Landmark Used for Mid -Block Crashes Landmark 1 Route Number Or Mile Post Tenths Or Segment Marker Ramp Use Only Fee 00164 Street Name LIPPIZAN Street Ending DRIVE Or Miles Tenths Landmark 2 Route Number Or Mile Post Tenths Or Segment Marker Ramp Use Only The above en Ty is the distance from he Crash Scene to Landmark 1 Street Name PIN OAK Street Ending COURT y a. o Latitude: Degrees 40 Minutes 00 . ■ Seconds 20 • Decimal 006 Longitude: • Degrees 77 Minutes 35 . ■ Seconds 31 • Decimal 023 c Traffic Control Device NOT APPLICABLE Traffic Control Functioning NO CONTROLS o 0 Lane Closed FULLY Lane Closure Direction NORTH AND SOUTH Traffic Detoured YES Estimated Time Closed 3-6 HRS Event Information Environmental/ Roadway Potential Factors (E/R) Factor 1 NONE Factor 2 Factor 3 First Harmful Event in the Crash Most Harmful Event in the Crash Unit Number 001 Harmful Event HIT UNIT 2 Unit Number 001 'Harmful Event HIT UNIT 2 Indicated Prime Factor DRIVER ACTION Unit Number 001 Prime Factor Driver Action DRIVER WAS DISTRACTED Prime Factor EnviromentallRoadway Prime Factor Vehicle Failure Prime Factor Pedestrian Action Road Surface Type BLACKTOP Special Jurisdiction NO SPECIAL JURISDICTION Printed At: PA STATE POLICE - CHAMBERSBURG 6/10/2013 2:07 PM 1 Form # H03-2208079 AA -500 TX Incident Number: H03-2208079 Crash Involves: 0 DUI Q N/A 0 Fatality 0 Work Zone Commonwealth of Pennsylvania Police Crash Report 0 Hit and Run 0 ATV °Commercial Vehicle Snowmobile REPORTABLE CRASH 0 State Police Vehicle Commonwealth Vehicle PAGE 2 0 Local Police Vehicle 0 Local Gov Vehicle Driver/Pedestrian Information Unit Number 1 Type Unit Motor Vehicle in Transport Commercial Vehicle No First Name GEORGIA MI J Last Name DAVIS Suffix DOB 06/09/1949 Telephone Number (717) 446-4571 Street Address 3680 ORRSTOWN RD City ORRSTOWN State PA Zip Code 17244 Gender F License Number 15277851 License State PA Class C Expiration Date 06/10/2016 Owner/Driver PRIVATE VEHICLE OWNED/LEASED BY DRIVER Driver Presence DRIVER OPERATED VEHICLE Physical Condition APPARENTLY NORMAL Primary Vehicle Code Violation VC 3714 CARELESS DRIVING Person Charged NO Alcohol/Drugs Suspected NO Alcohol Test Type TEST NOT GIVEN Alcohol Test Results Driver Action DRIVER WAS DISTRACTED ', Pedestrian Action Pedestrian Signals Pedestrian Clothing Pedestrian Location 1st Harmful Event HIT UNIT 2 Left or Right Side Mos Harmful YES Utility Pole Number 2nd Harmful Event Left or Right Side Most Harmfut Utility Pole Number 3rd Harmful Event Left or Right Side Most Harmful Utility Pole Number 4th Harmful Event Left or Right Side Most Harmful Utility Pole Number Vehicle Information Owner First Name GEORGIA Owner MI J Owner Last Name or Business Name DAVIS Suffix Street Address 3680 ORRSTOWN ROAD City ORRSTOWN State PA Zip Code 17244 Vehicle Type AUTOMOBILE Special Usage NOT APPLICABLE Government Equipment Number Model Year 1997 Vehicle Make BUICK Vehicle Model CENTURY Vehicle Color GREEN VIN 2G4WS52M0V1413755 License Plate HGK3898 Reg. State PA Est. Speed 045 Vehicle Towed YES Towed By ROBINSONS Insurance YES Insurance Company STATE FARM Policy Number 2115449A0738 Expiration Date 07107/2013 Direction of Travel SOUTH Vehicle Position RIGHT LANE "CURB" Vehicle Movement GOING STRAIGHT Initial Impact Point 1 O'CLOCK Damage Indicator MINOR Gradient LEVEL Road Alignment STRAIGHT Possible Vehicle Failures NONE Trailing Units # of Units 0 Type Unit 1 Tag Number Tag Year Tag State Unit Make Unit Owner Type Unit 2 Tag Number Tag Year Tag State Unit Make Unit Owner Motorcycle Engine Size cc Passenger? Saddle Bag/Trunk? . Trailer? Driver Education? Driver Helmet Type Helmet Stayed On? DOT/Snell Designation? Eye Protection? Long Sleeves? Long Pants? Over Ankle Boots? Passenger Helmet Type Helmet Stayed On? DOT/Snell Designation? Eye Protection? Long Sleeves? Long Pants? Over Ankle Boots? Pedalcycle Passenger? Helmet? Head Lights? Rear Reflectors? Printed At: PA STATE POLICE - CHAMBERSBURG 6/10/2013 2:07 PM 2 Form # H03-2208079 AA -500 TX Incident Number: Crash Involves: 0 DUI 0 N/A H03-2208079 0 Fatality 0 Work Zone Commonwealth of Pennsylvania Police Crash Report 0 Hit and Run 0 ATV 0Commercial Vehicle 0Snowmobile REPORTABLE CRASH 0 State Police Vehicle 0 Commonwealth Vehicle PAGE 3 0 Local Police Vehicle Local Gov Vehicle Driver/Pedestrian Information Unit Number 2 Type Unit Pedestrian Commercial Vehicle No First Name CAROLYN MI V Last Name CROFT Suffix DOB 02/17/1937 Telephone Number Street Address 35 THOMPSON CREEK DR City SHIPPENSBURG State PA Zip Code 17257 Gender F License Number License State Class Expiration Date Owner/Driver NOT APPLICABLE Driver Presence Physical Condition UNKNOWN Primary Vehicle Code Violation VC 3544 PEDESTRIANS WALKING ALONG ON H Person Charged NO Alcohol/Drugs Suspected NO Alcohol Test Type TEST NOT GIVEN Alcohol Test Results Driver Action Pedestrian Action WALKING, RUNNING, JOGGING OR PLAYING Pedestrian Signals NOT AT INTERSECTION Pedestrian Clothing LIGHT Pedestrian Location IN ROADWAY 1st Harmful Event STRUCK BY UNIT 1 Left or Right Side Most Harmful YES Utility Pole Number 2nd Harmful Event Left or Right Side Most Harmful Utility Pole Number 3rd Harmful Event Left or Right Side Most Harmful Utility Pole Number 4th Harmful Event Left or Right Side Most Harmful Utility Pole Number Vehicle Information Owner First Name Owner MI Owner Last Name or Business Name Suffix Street Address City State Zip Code Vehicle Type Special Usage Government Equipment Number Model Year Vehicle Make Vehicle Model Vehicle Color VIN License Plate Reg. State Est. Speed Vehicle Towed Towed By Insurance Insurance Company Policy Number Expiration Date Direction of Travel Vehicle Position Vehicle Movement Initial Impact Point Damage Indicator Gradient Road Alignment Possible Vehicle Failures Trailing Units # of Units 0 Type Unit 1 Tag Number Tag Year Tag State Unit Make Unit Owner Type Unit 2 Tag Number Tag Year Tag State Unit Make Unit Owner Motorcycle Engine Size cc Passenger? Saddle Bag/Trunk? Trailer? Driver Education? Driver Helmet Type Helmet Stayed On? DOT/Snell Designation? Eye Protection? Long Sleeves? Long Pants? Over Ankle Boots? Passenger Helmet Type Helmet Stayed On? DOT/Snell Designation? Eye Protection? Long Sleeves? Long Pants? Over Ankle Boots? e u V v m a Passenger? Helmet? Head Lights? Rear Reflectors? Printed At PA STATE POLICE - CHAMBERSBURG 6/10/2013 2:07 PM 3 Form # H03-2208079 AA -500 TX Incident Number: H03-2208079 Crash Involves: 0 DUI • 0 NIA J Fatality 0 Work Zone Commonwealth of Pennsylvania Police Crash Report 0 Hit and Run 0 ATV °Commercial Vehicle Snowmobile REPORTABLE CRASH 0 State Police Vehicle Commonwealth Vehicle PAGE 4 0 Local Police Vehicle 0 Local Gov Vehicle Driver/Pedestrian Information Unit Number 3 Type Unit Legally Parked Commercial Vehicle No First Name MI Last Name Suffix DOB Telephone Number Street Address City State Zip Code Gender License Number License State Class Expiration Date Owner/Driver Driver Presence NO DRIVER Physical Condition Primary Vehicle Code Violation Person Charged Alcohol/Drugs Suspected Alcohol Test Type Alcohol Test Results Driver Action NO CONTRIBUTING ACTION Pedestrian Action Pedestrian Signals Pedestrian Clothing Pedestrian Location 1st Harmful Event STRUCK BY UNIT 1 Left or Right Side Most Harmful YES Utility Pole Number 2nd Harmful Event Left or Right Side Most Harmful Utility Pole Number 3rd Harmful Event Left or Right Side Most Harmful Utility Pole Number 4th Harmful Event Left or Right Side Most Harmful Utility Pole Number Vehicle Information Owner First Name CATHY Owner MI C Owner Last Name or Business Name DURRER Suffix Street Address 19 LENWOOD PARK City SHIPPENSBURG State PA Zip Code 17257 Vehicle Type AUTOMOBILE Special Usage NOT APPLICABLE Govemment Equipment Number Model Year 2000 Vehicle Make FORD Vehicle Model TAURUS Vehicle Color BLACK VIN 1FAFP58S9YA198761 License Plate HNB1765 Reg. State PA Est. Speed 000 Veh'cle Towed YES Towed By ROBINSONS insurance YES Insurance Company ERIE INSURANCE Policy Number Q101210812 Expiration Date 10/1212013 Direction of Travel SOUTH Vehicle Position SHOULDER RIGHT Vehicle Movement PARKED Initial Impact Point 9 O'CLOCK Damage Indicator MINOR Gradient LEVEL Road Alignment STRAIGHT Possible Vehicle Failures NONE Trailing Units # of Units 0 Type Unit 1 Tag Number Tag Year Tag State Unit Make Unit Owner Type Unit 2 Tag Number Tag Year Tag State Unit Make Unit Owner Motorcycle Engine Size cc Passenger? Saddle Bag/Trunk? Trailer? Driver Education? Driver Helmet Type Helmet Stayed On? DOT/Snell Designation? Eye Protection? Long Sleeves? Long Pants? Over Ankle Boots? Passenger Helmet Type Helmet Stayed On? DOT/Snell Designation? Eye Protection? Long Sleeves? Long Pants? Over Ankle Boots? m §1. V v m o. Passenger? Helmet? Head Lights? Rear Reflectors? Printed At: PA STATE POLICE - CHAMBERSBURG 6/10/2013 2:07 PM 4 Form # H03-2208079 . AA -500 TX Incident Number: Crash Involves: Q DUI 0 N/A H03-2208079 0 Fatality 0 Work Zone Commonwealth of Pennsylvania Police Crash Report 0 Hit and Run 0 ATV ()Commercial Vehicle 0 Snowmobile REPORTABLE CRASH Q State Police Vehicle 0 Commonwealth Vehicle PAGE 5 0 Local Police Vehicle 0 Local Gov Vehicle ' A u. Unit # 1 Driver Restrictions Compliance NO RESTRICTIONS/NOT APPLICABLE Driver Endorsement Compliance NONE REQUIRED Driver License Compliance VALID LICENSE FOR CLASS Principal Impact Point 1 O'CLOCK Avoidance Maneuver NO AVOIDANCE MANEUVER Under Ride Ind'cator NO UNDERRIDE OR OVERRIDE Emergency Use NOT IN EMERGENCY USE Drug Test Type NONE Drug Test Results NO TEST GIVEN A LL Unit # 2 Driver Restrictions Compliance NO RESTRICTIONS/NOT APPLICABLE Driver Endorsement Compliance NONE REQUIRED Driver License Compliance VALID LICENSE FOR CLASS Principal Impact Point 3 O'CLOCK Avoidance Maneuver Under Ride Indicator Emergency Use Drug Test Type NONE Drug Test Results NO TEST GIVEN ' R U. Unit # 3 Driver Restrictions Compliance NO RESTRICTIONS/NOT APPLICABLE Driver Endorsement Compliance NONE REQUIRED Driver License Compliance VALID LICENSE FOR CLASS Principal Impact Point 9 O'CLOCK Avoidance Maneuver NO AVOIDANCE MANEUVER Under Ride Ind.cator NO UNDERRIDE OR OVERRIDE Emergency Use NOT IN EMERGENCY USE Drug Test Type NONE Drug Test Results NO TEST GIVEN People Information Unit # 001 Person No. 001 First Name GEORGIA MI J Last Name DAVIS Suffix DOB 06/09/1949 Street Add ess 3680 ORRSTOWN RD City ORRSTOWN State PA Zip Code 17244 Phone Number (717) 446-4571 EMS Transport NO Person Type DRIVER Gender F Injury Severity NOT INJURED Seat Position DRIVER - ALL VEHICLES Safety Equipment 1 LAP AND SHOULDER BELT USED Safety Equipment 2 AIR BAG NOT DEPLOYED - UNK SWITCH SETTING Extrication NOT EXTRICATED Ejection NOT EJECTED Ejection Path NOT EJECTED/NOT APPLICABLE People Information Unit # 002 Person No. 002 First Name CAROLYN MI V Lest Name CROFT Suffix DOB 02/17/1937 Street Add ess 35 THOMPSON CREEK DR City SHIPPENSBURG State PA Zip Code 17257 Phone Number EMS Transport YES Person Type PEDESTRIAN Gender F Injury Severity KILLED Seat Position NOT A PASSENGER / OCCUPANT Safety Equipment 1 NONE USED / NOT APPLICABLE Safety Equipment 2 NONE USED / NOT APPLICABLE Extrication NOT APPLICABLE Ejection NOT APPLICABLE Ejection Path NOT EJECTED/NOT APPLICABLE a d First Name KELLEY MI A Last Name CRIDER Suffix Phone Number 7175324838 Street Address 1578 ROWE RD City SHIPPENSBURG State PA Zip Code 17257 a m First Name THOMAS MI Last Name MCGOWAN Suffix Phone Number 7173872041 Street Address 760 RT 75 S City EAST WATERFORD State PA Zip Code 17021 Ti c o z Person\Business Notified Phone Number Date Notified Time Notified hrs. Reason for Notification Printed At: PA STATE POLICE - CHAMBERSBURG 6/10/2013 2:07 PM 5 Form # H03-2208079 AA -500 TX Incident Number: H03-2208079 Crash Involves: 0 DUI 0 N/A Commonwealth of Pennsylvania Police Crash Report 0 Fatality 0 Hit and Run Commercial Vehicle 0 Work Zone 0 ATV °Snowmobile REPORTABLE CRASH 0 State Police Vehicle Commonwealth Vehicle PAGE 6 0 Local Police Vehicle OLocal Gov Vehicle E c Witness �i• a, �u i �i .�+ 1 - C z.I C ( h `� ii1 O N 11 45 mph N irArl:27 o .,L6 - Chamiaersburq Bora approx Similes il Witness 2 ta Unit 3 Final Rest .! «al Unit 1 Final Rest m Er 03ce' c CVij t D ' e SR NARRATIVE Crash Synopsis Prior to this crash, Unit 1 was traveling south in the southbound lane of State Route 0011. Unit 2, the pedestrian, was located in the southbound lane of travel of State Route 0011. Unit 3 was parked legally on the west berm facing south. This crash occurred when Unit 2 was struck by the front passenger side of unit 1. This impact occurred in the southbound lane of travel. Unit 2 was struck at the 3 o'clock position. Unit 1 continued several feet south before coming to a stop on the west berm. Unit 2, after initial impact, struck Unit 3 at the 9 o'clock position dislodging the driver side mirror from the vehicle. Unit 2 traveled over the hood of unit 3 and came to rest on the west berm. Unit 1 sustained minor damage to the front passenger side bumper and quarter panel. Unit 3 sustained minor damage to the drivers side of the vehicle. Unit 2 was pronounced deceased upon arrival to the hospital. Operator 1 was wearing her seat belt. Operator 2 suffered no injuries. Unit 1 and Unit 3 towed for evidentiary purposes. Crash Details ROADWAY The location of this crash is on State Route 0011, South of Lippizan Drive. State Route 0011 is a three lane, asphalt topped roadway consisting of a northbound, southbound and a center left turn lane. The roadway is marked with a solid yellow line, and a dotted yellow line, dividing the opposing lane of travel from the left turn lane. The east and west edges of the roadway are marked with a single white fog line. SYNOPSIS Printed At: PA STATE POLICE - CHAMBERSBURG 6/10/2013 2:07 PM 6 Form # H03-2208079 AA -500 TX Incident Number: H03-2208079 Commonwealth of Pennsylvania PAGE 7 Crash Involves: Police Crash Report REPORTABLE CRASH 0 DUI 0 Fatality 0 Hit and Run °Commercial Vehicle 0 State Police Vehicle 0 Local Police Vehicle QNWA 0 Work Zone 0 ATV Snowmobile 0 Commonwealth Vehicle 0 Local Gov Vehicle Crash Details Prior to this crash, Unit 1 was traveling south in the southbound lane of State Route 0011. Unit 2, the pedestrian, was located in the southbound lane of travel of State Route 0011. Unit 3 was parked legally on the west berm facing south. This crash occurred when Unit 2 was struck by the front passenger side of unit 1. This impact occurred in the southbound lane of travel. Unit 2 was struck at the 3 o'clock position. Unit 1 continued several feet south before coming to a stop on the west berm. Unit 2, after initial impact, struck Unit 3 at the 9 o'clock position dislodging the driver side mirror from the vehicle. Unit 2 traveled over the hood of unit 3 and came to rest on the west berm. Unit 1 sustained minor damage to the front passenger side bumper and quarter panel. Unit 3 sustained minor damage to the drivers side of the vehicle. Unit 2 was pronounced deceased upon arrival to the hospital. Operator 1 was wearing her seat belt. Operator 2 suffered no injuries. Unit 1 and Unit 3 towed for evidentiary purposes. PHYSICAL EVIDENCE Unit 1- Minor damage to the right front bumper, passenger side front quarter panel, and passenger side mirror. Unit2- .Severe injuries to her right hip, left hip, right elbow and head. Unit 3- Minor damage to the left side, driver side mirror was ripped off, and dents in the hood. This investigator arrived approximately 5 minutes after this crash. Upon arrival, this investigator made note of the current roadway conditions. Unit 2 and Unit 3 were at their final resting position upon my arrival. It was related to me that Unit l's final resting point was several feet south of Unit 3. It was related to me that Unit 1 backed up to get closer to the scene, which is where 1 observed Unit 1 upon my arrival. All lanes of travel were dry. Human tissue from Unit 2 was present in the southbound lane of travel. It was related to me that Unit 1's right side mirror was placed in Unit 1 by Operator 1. It was related to me that the debris was in the center of the southbound lane. INTERVIEWS On 05/18/13 at approximately 1038 hours, I interviewed Operator 1 at the scene of the crash. Operator 1 related that she was traveling southbound on State Route 0011. Operator 1 related that she did not see Unit 2 crossing the street. Operator 1 related that Unit 2 crossed directly in front of her vehicle. Operator 1 related that she tried to stop but could not and struck Unit 2. Operator 1 related that Unit 2 was hit by the right front of her car. Operator 1 related that she tried to stop but moved south several feet. Operator 1 related that she backed up to get closer to the scene. On 05/18/13 at approximately 1045 hours, Trooper James ERME interviewed Witness 2 ,Thomas MCGOWAN of 760 Route 0075 South, East Waterford, PA 17021, Phone: 717-387-2041. The interview took place at the scene of the crash. MCGOWAN related that he was at the yard sale across the street at the time of the crash. MCGOWAN related that he saw Unit 2 get out of her car and walk towards the front of her car. MCGOWAN related that he then saw Unit 1 strike Unit 2. On 05/18/13 at approximately 1150 hours, Trooper Brian HUPE interviewed Witness 1, Kelley Ann CRIDER of 1578 Rowe Road, Shippensburg PA 17257, Phone: 717-532-4838, Cellular Phone: 717-360-2791. This interview took place at the Chambersburg Hospital. CRIDER related that she was driving directly behind Unit 1 on State Route 0011. CRIDER related that she was about five car lengths behind Unit 1. CRIDER related that there were no other cars on the roadway between her unit and unit 1. CRIDER related that Unit 3 was parked on the southbound shoulder. CRIDER related that Unit 1 was driving at approximately 40-45 mph. CRIDER related that Unit 1 was not swerving in the lane. CRIDER related that Unit 1 was driving in the center of the southbound lane. CRIDER related that she all of a sudden saw what appeared to be a blue bird fly over Unit 1. CRIDER related as she passed Unit 3 she saw Unit 2 lying on the shoulder in front of Unit 3. CRIDER related that she realized the blue bird was Unit 2. CRIDER related that she got out of her car and yelled for someone to call 911. CRIDER related that she is an Emergency Room Registered Nurse and began to give aid to Unit 2. CRIDER related that another Registered Nurse that was driving by came and assisted her until EMS arrived. On 05/18/13 at approximately 1150 hours Trooper Brian HUPE interviewed Cristina B. DALIDA of 313 Edison Dr, Shippensburg, PA 17257, Phone: 717-372-1913. This interview took place at the Chambersburg Hospital. DALIDA related that she was driving south on State Route 0011 and noticed Unit 2 along the road. DALIDA related that she saw another woman assisting Unit 2 on the ground. DALIDA related that she gave assistance iat dAL F'H J IH I t F'ULIlit- l.1-1AMbtKSt3UKG G 7 -Frrilr# 11113-lrubura AA -500 TX Incident Number: H03-2208079 Commonwealth of Pennsylvania PAGE a Crash Involves: ' Police Crash Report REPORTABLE CRASH 0 DUI 0 Fatality 0 Hit and Run ()Commercial Vehicle 0 State Police Vehicle 0 Local Police Vehicle 0 N/A 0 Work Zone 0 ATV 0 Snowmobile 0 Commonwealth Vehicle 0 Local Gov Vehicle Crash Details because she was a Registered Nurse. DALIDA related that she left the scene once the paramedical technicians arrived. On 05/22/13 at approximately 1709 hours this officer interviewed Unit 2's daughter, Cathy Croft DURRER, DOB: 08/02/56, of 19 Lenwood Park, Shippensburg, PA 17257, Phone: 717-532-5365, and her two son's, Timothy Edward CROFT. DOB: 06/27/62, of 19 Lenwood Park, Shippensburg, PA 17257, Phone: 717-532-5365, and Calvin Duane CROFT, DOB: 12120166, of 328 Duncan Avenue, Front Royale, VA 22630, Phone: 703-855-6425. These interviews took place at the Pennsylvania State Police Barracks Chambersburg. DURRER related that Unit 2 had two knee replacements and a left hip replacement. DURRER related that Unit 2 was on numerous medications that she took on a daily basis. These are as follows: Zoloft, Diltiatom , Losartan Potassium, Coumadin , Glimepiride, Calicium pills, Alprazolam, Feso4, Centrum Silver, Furosemide, Lipitor, Synthoid and Vicodin. DURRER related that Unit 2 was really slow moving and took several minutes to get out of a car. DURRER related that Unit 2 recently had Lasik surgery on her eyes for glaucoma. DURRER related that Unit 2 was incapable of running or darting anywhere. DURRER related that family members had actually told Unit 2 several times to use a cane or walker. Timothy related that he had breakfast one hour before the crash with Unit 2. Timothy related that Unit 2 was happy to go yard sale shopping. Timothy related that Unit 2 had normal arthritis for a 76 YOA woman. On 05/29/13 at 0925 hours this officer re -interviewed Operator 1 at her residence. Operator 1 related that she did drop off a typed statement, (refer to property number H3 -20730B) at the Pennsylvania State Police Barracks Chambersburg. Operator 1 related that the statement was a clearer picture of what happened. Operator 1 related that she was still very nervous after the crash when she gave the first statement. Operator 1 related that she needed to write another statement now that she remembered better. Operator 1 related that she was traveling south on State Route 0011. Operator 1 related that she turned her head to look at the yard sale. Operator 1 related that she turned her head to the left prior to the intersection of Lippizan Drive and State Route 0011 to look at a yard sale. Operator 1 related that she in fact did not see Unit 2 at any point. Operator 1 related that she had her head turned for 4-5 seconds. Operator 1 related that she all of a sudden heard her car hit something. Operator 1 related that she didn't know what she hit. Operator 1 related that she looked in her rear mirror and saw the woman Tying on the street. ADDITIONAL INVESTIGATION On 05/18/13 at approximately 1050 hours, Trooper Eric CAMPBELL, Troop H, CARS Unit, arrived on scene to reconstruct this crash. Trooper Eric CAMPBELL, Collision Accident Reconstructionist is assigned this investigation. General Investigation Report to follow. On 05/18/13 at approximately 1110 hours, Franklin County Coroner, Jeff CONNER arrived on scene. For details on Coroner's examination reference Coroner's Report. This report will be placed in the crash attachment file upon receipt. Franklin County Coroner, Jeff CONNER, determined the cause of death to be blunt force trauma sustained from the crash. Notification to next of kin was made by Chief Deputy Paul T REED. This occurred on 05/18/13 at approximately 1118 hours. Notification was made to the deceased daughter, Cathy Croft DURRER. On 05/18/13 at approximately 1135 hours Trooper Deanna SELL , Troop H Forensic Service Unit arrived on scene to photograph the scene. Photographs of the crash will be kept in attachment file when received from FSU and a copy will be retained by FSU. Robinson's Auto Body towed Unit 1 and Unit 3. Written Statements were obtained by Operator 1, MCGOWAN, CRIDER, and DALIDA, refer to property record H3 -20730A. Operator 1's typed statement was placed into evidence under property record H3 -20730B. Unit 1 and Unit 3 were placed at Robinson's Auto Body in a secured location, refer to property record H3-20730. An entry into the fatal crash system was completed at 0756 hours on 05/19/13. Unit 2's Pennsylvania Driver's License was released to the Franklin County Coroners office. Unit 2 was pronounced deceased on 05/18/13 at 1118 hours at the Chambersburg Hospital by Doctor CONNOR. Assisted on scene by Trooper Eric CAMPBELL, Trooper Brian HUPE, Trooper James ERME, Trooper Jason BRINDLE, and Corporal Bradley FORD. On 05/22/13 at approximately 1555 hours Unit 1 and Unit 3 were released to their owners. This report remains open pending the Franklin County Coroners report, CARS report, the determination of Pilule At. I'Ab1AItPOLK,t-1 tlHMtftK�tSUKU 1 WILD 1 8-rurnr# t1U3-LLUt1U(`•i AA -500 TX Incident Number: H03-2208079 Crash Involves: Police Crash Report REPORTABLE CRASH 0 DUI 0 Fatality 0 Hit and Run ° Commercial Vehicle 0 State Police Vehicle (3 Local Police Vehicle 0 N/A 0 Work Zone 0 ATV Q Snowmobile (} Commonwealth Vehicle 0 Local Gov Vehicle Commonwealth of Pennsylvania PAGE 9 Crash Details prosecution from the Franklin County District Attorney's Office and disposition of all property. Printed At: PA STATE POLICE - CHAMBERSBURG 6/10/2013 2:07 PM 9 Form # H03-2208079 AA -500N TX Incident Number: H03-2208079 Commonwealth of Pennsylvania Police Crash Report Supplemental Narrative Page 1 Police Agency Data Supplementing Officer Agency PA STATE POLICE - HARRISBURG Supplementing Officer SELL, DEANNA Badge Number 08909 Investigation Date 5/18/2013 Originating Agency PA STATE POLICE - CHAMBERSBURG Originating Officer TPR ANTHONY VACCARO Reviewer KANE, RANDY B Reviewer Badge Number 07774 Approval Date 6/7/2013 Narrative On 05/18/13, at approximately 1039 hours, 1 was requested to respond to the scene of a traffic crash in which there was a fatality. The crash was located along SR 11, Molly Pitcher Highway, near the intersection of Lippizan Dr, Greene Twp, Franklin Co. The request was to photograph the scene and collect any evidence. I arrived at the scene on 05/18/2013, at approximately 1120 hours. Upon arrival I photographed the scene using a Nikon D3 12.1 mega pixel digital camera with a Nikon Nikkor 24mm-120mm lens, a Nikon Nikkor 60mm lens, and a Nikon SB -800 flash unit as needed. I did not collect any evidence from the scene. 1 departed the scene on 05/18/2013 at approximately 1315 hours. I transferred 120 images from the camera onto a DVD at PSP Gettysburg on 06/01/2013. A master copy of the DVD will be retained by the Troop H FSU. A copy of the DVD may be forwarded to the investigator upon request. The images were also uploaded to the FSU S.A.N. drive for retention. Refer to Troop H FSU #2013-0154. PA STATE POLICE - HARRISBURG 6/10/2013 2:07 PM 1 H03-2208079 AA -500N TX Incident Number: H03-2208079 Commonwealth of Pennsylvania Police Crash Report Supplemental Narrative Page 1 Police Agency Data Supplementing Officer Agency PA STATE POLICE - HARRISBURG Supplementing Officer CAMPBELL, ERIC Badge Number 08202 Investigation Date 5/18/2013 Originating Agency PA STATE POLICE - CHAMBERSBURG Originating Officer TPR ANTHONY VACCARO Reviewer KANE, RANDY B Reviewer Badge Number 07774 Approval Date 6/7/2013 Narrative Reporting officer: Trooper Eric R. Campbell Collision Analysis and Reconstruction Unit Pennsylvania State Police Troop H 3031 Old Harrisburg Rd, Gettysburg, PA 17325 Phone: (717) 334-8111 E-mail: ercampbell@pa.gov Date of report: 06/04/2013 I conducted forensic mapping at the scene of this incident. Refer to General Investigation Report H03-2208079 for details. Please note that, other than to authorized government agencies, the General Investigation Report is only available pursuant to a subpoena duces tecum issued by a Pennsylvania or Federal court, and properly served on: Commissioner Pennsylvania State Police 1800 Elmerton Avenue Harrisburg PA 17110 PA STATE POLICE - HARRISBURG 6/10/2013 2:07 PM 1 H03-2208079 EXHIBIT C H105.805 REV (9/11) LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 P 19573301 Certification Number Type/Print In Permanent Black Ink 2g 5 This is to certify that the information here given is correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing, al Registrar COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH.. VITAL RECORDS CERTIFICATE OF DEATH State File Number: Date Issued To Be Completed/Verified By: FUNERAL DIRECTOR 1. Decedent's Legal Name (First, Middle, Last, Suffi ) Carolyn Virginia CROFT 2. Sex Female 3. Social Security Number 204-28-1850 4. Date of Death 0.40/Day/Yr) (Spell Mo) May 18, 2013' 5a. Age -Last Birthday (Yrs) Sb. Under 1 Year Sc. Under 1 Day 6. Date of Birth (Mo/Day/year) (Spell Month) 7a. Birthplace (City and State or Foreign Country) Months Days Hours Minutes - - Chambersburg, PA 76 I I February 17, 1937 7b. Birthplace (County) Franklin 8a. Residence (State or Foreign Country) 8b. Residence (Street and Number - Include Apt No.) 35 Thompson Creek Dr. 8c. Did Decedent Live In a Township? @(Yes, decedent lived In Southampton twp, ad. Residence (counPA Cumberland 8e. Residence (Zip Code) 17257 ONo, decedent lived within limits of city/born. 9. Ever In US Armed Forces? 10. Mar 0 Yes ($( No 0 Unknown I 0 Divorced tal Status at Time of Death 0 Married T( Widowed 111. Surviving Spouse's Name (If wife, give name prior to first marriage) 0 Never Married 0 Unknown 12. Father's Name (First, Middle, Last, Suffix) Charles R. Luckett, Sr. 13. Mother's Name Prior to First Marriage (First, Middle, Last) Carolyn V. Hammond 14a. Informant's Name I14b. Relationship to Decedent Cathy Durrer Daughter 14c. Informant's Mailing Address (Street and Number, City, State, Zip Code) 35 Thompson Creek Drive Shippensburg PA 17257 If Death Occurred In a Hospital: CI Inpatient )g( Emergency Room/Outpatient': 0 Dead on Arrival 35a. Place of Death Check only one) If Death Occurred Somewhere Other Than a Hospital: tj Hospice Facility C Decedent's Home 0 Nursing Home/Long-Term Care Facility 0 Other (Specify) 156. Facility Name (If not Institution, give street and number) Chambersburg Hospital 1Sc. City or Town, State, and zip Code I15d. County of Death Chambersburg, PA 17201 Franklin 16a. Method of Disposition 0 Burial 1a Cremation 0 Removal from State 0 Donation - 0 other (Specify)May 16b. Date of Disposition 23, 2013 16c. Place of Disposition (Name of cemetery, crematory, or other place) Hollinger Crematory 16d. Location of Disposition (City or Town, State, and Zip) Mt. Holly Springs, PA 17065 17,.�1g)n^aature of Funeral Service Licensee or Person In Charge of Interment - -- u 176. License Number FD-014831-L 17c. Name and Complete Address of Funeral Facility Fogelsanger-Bricker Funeral Home 112 VV King St. PO Box 336, Shippensburg, PA 17257 18. Decedent's Education - Check the box that best describes the highest degree or level of school completed at the time of death. 0 8th grade or less 1X No diploma, 9th - 12th grade 0 High school graduate or GED completed O Some college credit, but no degree 0 Associate degree (e.g. AA. AS) '0 Bachelor's degree (e.g. BA, AB, BS) 0 Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) 0 Doctorate (e.g. PhD, Edo) or Professional degree 19. Decedent of Hispanic Origin - Check the box that best describes whether the decedent is Spanish/Hispanic/Latino. Check the "No" box if decedent Is not Spanish/Hispanic/Latino. M No, not Spanish/Hispanic/Latino 0 Yes, Mexican, Mexican American, Chicano 0 Yes, Puerto Rican 0 Yes, Cuban 0 Yes, other Spanish/Hispanic/Latino (Specify) 20. Decedent's Race - Check ONE OR MORE races to indicate what the decedent considered himself or herself to be. gia White 0 Korean 0 Black or African American 0 Vietnamese 0 American Indian or Alaska Native 0 Other Asian 0 Aslan Indian 0 Native Hawaiian 0 Chinese 0 Guamanian or Chamorro 0 Filipino 0 Samoan 0 Japanese 0 Other Pacific Islander 0 Other (Specify) (e.g. MO, DOS, DVM, LLB, JO) 21. Decedent's Single Race Self -Designation - Check ONLY ONE to indicate what the decedent considered himself or he self to be. M White 0 Japanese 0 Samoan 0 Black or African American 0 Korean In Other Pacific Islander 0 American Indian or Alaska Native 0 Vietnamese 0 Don't Know/Not Sure 22a. Decedent's Usual Occupation - Indicate type of work done during most of working life. DO NOT USE RETIRED. Houseparent 0 Asian Indian 0 Other Aslan 0 Refused 0 Chinese 0 Native Hawaiian 0 Other (Specify) 22b. Kind of Business/Industry 0 Filipino ' 0 Guamanian or Chamorro Education To Be Completed By: MEDICAL CERTIFIER ITEMS 23a - 2314 MUST BE COMPLETED BY PERSON WHO PRONOUNCES OR CERTIFIES DEATH - 23a. Date Pronounced Dead (Mo/Day/Yr) .. 23b, Signature of Person Pronouncing Death (Only when applicable) 23c. License Number 23d. Date Signed (Mo/Day/Yr) 24. Time of Death 11:18 AM - 25. Was Medical Examiner or Coroner Contacted? 1a Yes 0 No CAUSE OF DEATH i Approximate 26. Part 1. Enter the chain of events --di eases, injuries, or complications --that directly caused the death. DO NOT enter terminal events such as cardiac arrest. Interval: respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary I Onset to Death IMMEDIATE CAUSE -- 1 8. Multiple Blunt Force Trauma I 1 hr (Final disease or condition Due to (or as a consequence of): resulting in death) - b. Pedestrian Struck by Oncoming Vehicle Sequentially list conditions, Due to (or a consequence of): If any, leading to the cause - listed on line a. Enter the c. While Crossing Roadway - i UNDERLYING CAUSE Due to•(or as a consequence of): (disease or injury that initiated the events resulting d. , in death) LAST, Due to (or a consequence of): 26. Part II. .Enter other significant conditions contributing to death but not resulting in the underlying cause given in Part I 27., Was an perfrformed? autopsy No 28. Were autopsy findings available to complete the caulJof death? 0 Yes No 29. If Female: of pregnant within past year 0 regnant at time of death 0 Not pregnant, but pregnant within 42 days of dear- 30. Did Tobacco Use Contribute to Death? 0 Yes 0 Probably 14 No 0 Unknown 31. Manner of Dea h 0 Natural 0 Homicide M Accident 0 Pending Investigation 0 Suicide 0 Could not be determined 0 Not pregnant, but pregnant 43 days to 1 year before deet- 32. Date o Injury (Mo/Day/Yr) (Spell Month) 0 Unknown If pregnant within the past yea, May 18, 2013 33. Time of Injury Approximately 10:19 AM 34. Place of InJury (e.g. home; construction site; farm; school) Road 35. Location of InJury (Street and Number City, State, Zip Code) Area of 6336 Molly Pitcher Hwy N, Greene. PA 36. Injury at Work O Yes ISI 00 37. If Transportation InJury, Specify: 0 Driver/Operator B( Pedestrian 0 Passenger 0 Other (Specify) 38. Describe How InJury Occurred: Pedestrian Struck by Oncoming Vehicle While Crossing Roadway 39a. Certifier (Check only 0 Certifying physician 0 Pronouncing 8. Certifying ]8( Medical Examiner/Coroner Signature of certifier: one): - To the best of my knowledge, death occurred due to the cau physician - To the best of my knowledge, death occurred - On the basis of examination, and/or investigation, in /' Title e(s) and manner stated at the time, date, and place, and due to the cause(s) and manner stated my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated of certifier: Coroner License Number: . ,,,,7-,-,/-6..v., 39b. Name, Address and Zip Code of Person Completing Cause of Death (Item 26) Mr. Jeffrey R Conner 1497 Loudon Road, Chambersburg, PA 17202 39c. Date Signed (Mo/Day/Yr) May 22, 2013 40. Registrar's District Number •a/- /`� 41. Registrar's»qu a 'fir G t Istrar File Date (Mo/Day/Yr) �j, 42.� a�f �� % 43. Amendments // Disposition Permit No. 0882089 H105-143 REV 07/2011 EXHIBIT D Providing Insurance and Financial Services Home Office, Bloomington, IL Statefarmo August 28, 2013 Mooney & Associates 230 York St Ste 1 Hanover PA 17331-3272 RE: Claim Number: 38-2N72-868 Date of Incident: May 18, 2013 Our Insured: Georgia Davis Dear Attorney Imler: State Farm Claims PO Box 106114 Atlanta GA 30348-6114 This letter will confirm our agreement to settle this claim for $25,000. This amount includes any and all liens and statutory rights of recovery attached to this loss, known or unknown, on behalf of the injured party. Carefully review the enclosed Release. If you agree with all the terms and conditions of the Release, please sign and date the Release where designated. Have a witness verify your signature(s) and complete the witness portion of the Release by signing the form below your signature and printing their name and address in the space provided. Once we receive the completed Release, we will issue our payment for $25,000. Please also forward a copy of the court approval. Sincerely, Erica A Conway for John Curry Rodgers Claim Representative (888) 713-4694 Ext. 6103587643 Fax: (888) 713-4693 State Farm Fire and Casualty Company Enclosures: Release EXHIBIT E 111 Nationwide' Nationwide Insurance Allied Insurance Nationwide Agribusiness Titan Insurance On Your Sick" Victoria Insurance Jason C. Imler, Esq. C/O Mooney & Associates 230 York Street Hanover, PA 17331 Claim details Insurer: Policyholder Claimant: Claim number Loss date: Dear Mr. Imler, Nationwide Mutual Insurance Company Carolyn Croft Estate of Carolyn Croft 58 37 B 539671 05182013 01 05-18-2013 Jason C. Imler, Esq. Date prepared October 3, 2013 Claim number 58 37 B 539671 05182013 01 Questions? Contact Claims Associate Craig Robinson robinc19@nationwide.com Phone (610) 234-2790 FAX (866) 263-1507 As you know, I am handling the above -captioned Underinsured Motorist (UI) claim. This confirms Nationwide's Ul settlement offer of $100,000. In accordance with same, please find enclosed our release for our insured's (estate's) signature, witnessing and notary. Please have the release executed and returned at your first opportunity. Additionally, and as previously discussed, as this claim involves a fatality, court approval will be needed prior to Nationwide issuing its UI settlement check. It is my understanding there are no pending Pennsylvania D.P.W. or Medicare claims or liens. However, if there are, they will be addressed by the court with the settlement approval. Let me know if the estate is interesting in putting the settlement proceeds in an annuity and, if so, I will quickly obtain structured settlement quotes. If you need to speak to me further, please do not hesitate to give me a call. For more information If you have any questions or concerns, please contact me at (610) 234-2790 or robinc19@nationwide.com. Sincerely, Craig Robinson Nationwide Mutual Insurance Company NESRO Class Claims One Nationwide Gateway, Dept. 5867 DES MOINES, IA 50391-5867 Enclosure Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. EXHIBIT F Release For the Sole Consideration of 38-2N72-868 Twenty-five Thousand and 00/100 dollars the receipt and sufficiency whereof is hereby acknowledged, the undersigned hereby releases and forever discharges Georgia Davis, State Farm Insurance Companies and their heirs, executors, administrators, agents and assigns, and all other persons, firms or corporations liable or, who might be claimed to be liable, none of whom admit any liability to the undersigned but all expressly deny any liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, and particularly on account of all injuries, known and unknown, both to person and property, which have resulted or may in the future develop from an accident which occurred on or about May 18, 2013, at or near State Hwy 11 Near Lippizan Drive/Pin Oak Court, Green Twp, PA. This release expressly reserves all rights of the parties released to pursue their legal remedies, if any, against the undersigned, their heirs, executors, agents and assigns. Undersigned hereby declares that the terms of this settlement have been completely read and are fully understood and voluntarily accepted for the purpose of making a full and final compromise adjustment and settlement of any and all claims, disputed or otherwise, on account of the injuries and damages above mentioned, and for the express purpose of precluding forever any further or additional claims arising out of the aforesaid accident. Undersigned hereby accepts draft or drafts as final payment of the consideration set forth above. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. In Witness Whereof, I/We have hereunto set my/our hand(s) and seal(s) this day of , (year) In presence of: Witness Signature Witness Name (Print) Address Signed X: Name: Signed X: Name: EXHIBIT G **RELEASE** UNDERINSURED MOTORIST COVERAGE Know all men 14 LliCse prrssanls. Thal, fur Um sUIt Uunsieleraliurr u( the surra of One Hundred TIruusaned DuIlars ($100,000.00), the receipt of which from the Nationwide Mutual Insurance Company (hereinafter called "Nationwide") is hereby acknowledged, the undersigned hereby releases, discharges, and for his/her self, his/her executors, administrators, successors and assigns, does forever release and discharge Nationwide of and from all claims of whatsoever kind and nature prior to and including the date hereof growing out of the Underinsured Motorist Coverage of an Automobile Insurance Policy number 539671 issued by Nationwide to Carolyn Croft, and resulting or to result from an accident which occurred on 05-18-2013 at or near Route 11, Greene Twp., PA.. This release constitutes permission from Nationwide to the insured to settle with the Underinsured Motorist, and contains the ENTIRE AGREEMENT of the parties hereto, and the terms of this release are contractual and not merely a recital. The undersigneds are responsible for payment of any outstanding medical liens and will indemnify and hold Nationwide harmless from any such liens. I/We further state that I/we have carefully read the foregoing release and know the contents thereof, and I/we sign the same as my/our own free act. WITNESS Hand and seal this day of , 20 In the presence of: CAUTION! READ BEFORE SIGNING Witness Signature Your Signature Witness Signature Your Signature State of , County of On this day of , 20 . Before me personally appeared , to me known to be the person...described herein, and who executed the foregoing instrument and he/she acknowledged that he/she voluntarily executed the same. My term expires , 20 CLAIM NUMBER: 58 37 B 539671 05182013 01 Notary Public Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. HIBIT H Providing Insurance and Financial Services Home Office, Bloomington, IL State Farm® May 13, 2014 Mooney & Associates 230 York St Ste 1 Hanover PA 17331-3272 RE: Claim Number: 38-2N72-868 Date of Loss: May 18, 2013 Our Insured: Georgia Davis Your Client: Carolyn V Croft Dear Attorney Imler: State Farm Claims PO Box 106114 Atlanta GA 30348-6114 Enclosed is a Confirmation of Coverage for the policy that was in force on behalf of Georgia Davis. If you have any questions, please contact us. Sincerely, Conway epresentative (88: 713-4694 Ext. 6103614715 State Farm Fire and Casualty Company Enclosure(s): Confirmation of Coverage AoStateFarnr Confirmation of Coverage 38-2N72-868 Claim Number This policy is issued by: EJ State Farm Mutual Automobile Insurance Company 0 State Farm County Mutual Insurance Company of Texas Eg State Farm Fire and Casualty Company 0 State Farm Lloyds 0 State Farm Indemnity Company El State Farm Guaranty Insurance Company 0 State Farm Florida Insurance Company (Write in the name of the appropriate State Farm° affiliate) This confirms that policy number 211544938, covering a(n) 1997 Buick CENTURY, 2G4WS52MOV1413755, was issued to Georgia Davis and was in effect on the accident date of May 18, 2013. The coverages and limits of liability for this policy on that date were: Bodily Injury Liability $25,000 per person/$50,000 per loss; Property Damage Liability $25,000 per loss. This certificate of insurance neither affirmatively nor negatively amends, extends or alters the coverage afforded by the policies described here. State of ffi County of 0-etow.oe ) SS ) Subscribed and sworn to before me this ?thday of My Commission Expires: NOTARIAL SEAL SUSAN V HENDERSON Notary Public CONCORD TWP.. DELAWARE COUNTY My Commission Expires Jun 9, 2015 11/27/2013 1721 , (year) (2021/ Note Public EXHIBIT Nationwide Insurance Allied Insurance Nationwide Agribusiness Titan Insurance On Your Side Victoria Insurance Mooney & Associates Jason C. Imler 230 York Street Hanover, PA 17331 Your requested Dear Mr. Imler, documents are enclosed Mooney & Associates Jason C. Imler Page 1 of 1 Date prepared June 11, 2013 Claim number 58 37 B 539671 05182013 01 Questions? Contact Claims Associate Deanna Boone booned2@nationwide.com Phone (717)657-6747 I'm handling a Medical Benefits claim involving your client, Carolyn Croft, for an accident that occurred on 05-18-2013. Enclosed you'll find the policy documents you requested. Claim details Your client: Carolyn Croft Insurer: Nationwide Mutual Insurance Company Policyholder: Carolyn Croft Claim number: 58 37 B 539671 05182013 01 Loss date: 05-18-2013 Thank you for your cooperation If you have any questions or concerns, please contact me at (717)657-6747 or booned2@nationwide.com. Sincerely, Deanna Boone Nationwide Mutual Insurance Company PO Box 26005 Daphne, AL 36526-1126 Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. Certification I, Rhonda Mounts, as a duly authorized Nationwide Insurance associate entrusted with oversight of the system of record from which this copy was produced, based upon information and belief, certify under the penalty of perjury that this attached copy of policy #5837B539671 was made at or near the time of certification, as part of regularly conducted business activities, and is a true and accurate copy of the official record kept as part of regular business activities. Signature Rhonda Mounts Print Name Processor, Imaging Title Date: May 28, 2013 03055000912039 Prepared on February 28, 2013 Page 1 of 4 Nationwide® Your Policy Declarations On Your Side Policyholder (Named Insured): Carolyn Croft 35 Thompson Creek Dr Shippensburg, PA 17257-9452 Nationwide Auto Policy Policy Period: Mar 24, 2013 - Sep 24, 2013 Policy Number: 5837B 539671 Keep these Declarations for your records. General Policy Information Issued: February 28, 2013 These Declarations are a part of the policy named above and identified by the policy number above. They supersede any Declarations issued earlier. Your policy provides the coverages and limits shown in the schedule of coverages. They apply to each insured vehicle as indicated. Your policy complies with the motorists' financial responsibility laws of your state only for vehicles for which Property Damage and Bodily Injury Liability coverages are provided. Policy Period: March 24, 2013 -September 24, 2013 but only if the required premium for this period has been paid and only for six month renewal periods if renewal premiums have been paid as required. This policy is initially effective at (1) the time the application for insurance is completed, or (2) 12:01 a.m. on the first day of the policy period, whichever is later. Each renewal period begins and ends at 12:01 a.m. standard time at the address of the named insured stated herein. This policy expires at 12:01 a.m. at the address of the named insured stated herein. Your carrier is Nationwide Mutual Insurance Company, NAIC #23787. IMPORTANT MESSAGES: IF THIS DECLARATIONS PAGE SHOWS THAT COLLISION COVERAGE APPLIES TO YOUR AUTO, THERE IS ALSO COLLISION COVERAGE FOR DAMAGE TO A RENTED AUTO. COVERAGE IS SUBJECT TO CONDITIONS AND LIMITATIONS LISTED IN THE POLICY OR ATTACHED ENDORSEMENTS. Premium Summary and Other Charges 2008 Kia Spectra $ 887.40 Total Policy Premium $ 887.40 How You Saved on this Policy with Nationwide • Passive Restraint • Safe Driver • Anti Theft Device Thank you for being a long-term customer. • Accident Free Listed Driver(s) Name Carolyn Croft V-105 Date of Birth Marital Status 02/17/37 Widowed Continued on the next page Nationwide® On Your Side For coverage definitions and descriptions, visit Nationwide.com Prepared on February 28, 2013 Page 2 of 4 Your Policy Declarations Nationwide Auto Policy Policy Period: Mar 24, 2013 - Sep 24, 2013 Policy Number: 5837B 539671 Insured Vehicle(s) and Schedule of Coverages 2008 Kia Spectra VIN KNAFE121X85570462 Coverages Comprehensive and $ 1,500 IN Customization Including Car Key Replacement Coverage Collision and $ 1,500 IN Customization Including Pet Injury Collision Coverage Property Damage Liability Bodily Injury Liability Uninsured Motorists -Bodily Injury Underinsured Motorists -Bodily Injury Towing and Labor First Party Benefits Option 1 -Medical Benefit Option 4 -Funeral Benefit FuII Tort Vehicle Endorsements 3455A' 3475 Lienholder-Wells Fargo Dealer Limits of Liability Actual Cash Value Actual Cash Value Less $ 200 $ 100,000 Each Occurrence $ 100,000 Each Person $ 300,000 Each Occurrence (Non -Stacked) $ 100,000 Each Person $ 300,000 Each Occurrence (Non -Stacked) $ 100,000 Each Person $ 300,000 Each Occurrence $ 50 Each Disablement $ 10,000 $ 5,000 Lien Expires On Mar31, 2015 Premium $ 54.80 $ 372.70 $ 143.70 $ 206.10 $ 8.10 $ 44.40 $ 1.40 $ 54.90 $ 1.30 Total for this Vehicle $ 887.40 Policy Level Schedule of Coverages Coverages Limits of Liability Accident Forgiveness Feature - Accident Currently Forgiven Premium Incl Policy Form and Endorsements V-0378 Nationwide Auto Policy V-3329 Amendatory Endorsement V-3393 Guaranteed Automobile Insurance Coverage (Pennsylvania) V-3457 Amendatory Endorsement (Pennsylvania) V-3453 Amendatory Endorsement V-3535 Amendatory Endorsement V -3455A Car Key Replacement Coverage V-3475 Pet Injury Collision Coverage Continued on the next page 03055000912048 Prepared on February 28, 2013 Page 3 of 4 Nationwide® Your Policy Declarations On Your Side For Office Use Only: H0815655 01/17/13 $ 0.00 Issued By: Nationwide Mutual Insurance Company Countersigned At: Harrisburg, PA. By: R Sue Dangello Nalu How to Contact Us Your Nationwide Agent R. Sue Dangello 717.532.8478 Customer Service 1.877.669.6877 Internet Nationwide.com 24 -Hour Claims Reporting 1.800.421.3535 Hearing Impaired (TY) 1.800.622.2421 Nationwide Auto Policy Policy Period: Mar 24, 2013 - Sep 24, 2013 Policy Number: 5837B 539671 Table Of Contents Page INSURING AGREEMENT Di DEFINITIONS Di TERRITORY D2 COVERAGES: 1111 1111 Physical Damage P1 -P6 (damage to your auto) Comprehensive Collision Towing and Labor Auto Liability L1-L5 (for damage or injury to others caused by your auto) Property Damage and Bodily Injury First Party Benefits F1 -F5 Uninsured Motorists U1 -U4 (for bodily injury caused by uninsured motorists) Underinsured Motorists U11 -U14 (for bodily injury caused by underinsured motorists) GENERAL POLICY CONDITIONS Insured Persons' Duties After an Accident or Loss G1 How Your Policy May Be Changed G1 Optional Payment of Premium in Installments G1 G1 Cancellation During Policy Period G2 Dividends G2 If You Become Bankrupt G2 Unauthorized Use of Other Motor Vehicles G2 Fraud and Misrepresentation G3 Legal Action Limitations G3 Subrogation G3 Non -Sufficient Funds G3 Unlicensed Drivers G4 Renewal/Non-Renewal MUTUAL POLICY CONDITIONS Nationwide Mutual Insurance Company Nationwide Mutual Fire Insurance Company G4 V -037-B Nationwide Auto Policy Insuring Agreement For the policyholder's payment of premiums and fees in amounts we require and subject to all of the terms and conditions of this pdicy, we agree to provide the coverages the policyholder has selected. These selections are shown in the enclosed Declarations, which are a part of this policy contract. The selected coverages in this policy apply only to occurrences while this policy is in force. Renewal premiums for terms of six months each must be paid in advance. Definitions This policy uses certain common words for easy reading. They are defined as follows: 1. "POLICYHOLDER" means the first person named in the Declarations. The policyholder is the named Insured under this policy but does not include the policyholder's spouse. If the first named insured is an organization, that organization is the policyholder. 2. "YOU" and "YOUR" mean: a) the policyholder and spouse, if resident of the same household, when the policyholder is a person; or b) the sole proprietor or majority shareholder of an organization, or general partner of a family limited partnership, as shown In the Declarations, and spouse, if resident of the same household, when the policyholder is an organization. 3. "RELATIVE" means one who regularly lives in your household and who Is related to you by blood, marriage or adoption (including a ward or foster child). A relative may live temporarily outside your household. 4. "INSURED" means one who is described as entitled to protection under each coverage. 5. "WE," "US," "OUR," and "THE COMPANY" mean or refer to the company issuing the policy --Nationwide Mutual Insurance Company, Nationwide Mutual Fire Insurance Company, Nationwide Property and Casualty Insurance Company, Nationwide General Insurance Company, or Nationwide Insurance Company of America. 6. "YOUR AUTO" means the vehide(s) described in the Declarations. 7. "MOTOR VEHICLE" means a land motor vehicle designed primarily to be driven on public roads. This does not include vehicles operated on rails or crawler treads. Other motorized vehicles designed for use mainly off public roads shall be included within the definition of motor vehicle when used on public roads. 8. "PRIVATE PASSENGER AUTO" means a four-wheel: a) private passenger auto; b) van; or c) pickup truck having either four or six wheels. 9. "DEDUCTIBLE" means the amount of loss to be paid by the insured. We pay for covered loss above the deductible amount shown in the Declarations. 10. "OCCUPYING" means in, upon, entering, or alighting from. 11. "BODILY INJURY" means: a) physical injury; b) sickness; c) disease; or d) resultant death; of any person which results directly from a motor vehicle accident. 12. "PROPERTY DAMAGE" means: a) destruction of tangible property; 01 Nationwide Auto Policy b) damage or injury to it; and c) Toss of its use. 13. "NON -ECONOMIC LOSS" means pain and suffering and other non -monetary detriment. 14. "BIOLOGICAL DETERIORATION OR DAMAGE" meaning damage or decomposition, breakdown, and/or decay of manmade or natural material due to the presence of fungi, algae, lichens, slime, mold, bacteria, wet or dry rot and any by-products of these organisms, however produced. Fungi as used above include, but are not limited to: yeasts, mold, mildew, rust, smuts, or fleshy fungi such as mushrooms, puffballs and coral fungi. Other words are also defined. All defined words are in bold print. Territory The policy applies in Canada, the United States of America and Its territories or possessions, or between their ports. All coverages except Uninsured Motorists and Underinsured Motorists apply to occurrences in Mexico, if within 50 miles of the United States boundary. We will base the amount of any Comprehensive or Collision loss in Mexico on cost at the nearest United States point. This policy does not apply In any territory except as stated In this provision. NOTE: You will need to buy auto insurance from a Mexican insurance company --regardless of coverage provided by this policy --before driving In Mexico. Otherwise, you may be subject to jail detention, auto impoundment, and other legal complications in case of an accident. D2 Physical Damage (damage to your auto) ADDITIONAL DEFINITIONS APPLICABLE TO THESE COVERAGES For purposes of these coverages only: 1. "LOSS" means direct and accidental Toss or damage to your auto. Your auto includes its equipment. 2. "EQUIPMENT" means anything usual and incidental to the use of a motor vehicle as a motor vehicle. Any type of trailer is not equipment. Coverage Agreements COMPREHENSIVE COVERAGE 1. We will pay for Toss to your auto not caused by collision or upset. We will pay for the loss less your deductible. Coverage is Included for: a) damage from contact with: (1) animals; or (2) falling or flying objects. b) broken glass: (1) even if caused by collision or upset; and (2) if you do not have Collision coverage. If your Comprehensive and Collision coverages have different deductibles, the smaller deductible will apply to broken glass. For damage to your auto's windshield, we may offer to have It repaired in lieu of replacement. We will not apply a deductible for the repair of the windshield. However, if the repair is not satisfactory, we will replace the windshield subject to your deductible. 2. Also, if your auto has a loss under this coverage we will: a) pay for resulting damage to your clothing and luggage or that of any relative. Maximum payment is $200. We will pay for stolen clothing or luggage only if your auto Is stolen. b) repay your travel costs after your auto is stolen. Maximum payment is $15 per day --not to exceed $450 per occurrence. These costs must be incurred within a certain time. It starts 48 hours after you report the theft to us and the police. It ends when your auto is returned to you or a settlement is agreed to. c) repay you for the cost of travel from where your auto was disabled to where you were going. Maximum payment is $10. COLLISION COVERAGE 1. We will pay for loss to your auto caused by collision or upset. We will pay for the loss less your deductible. We will not subtract the deductible amount for broken glass if you have full (no deductible) Comprehensive coverage in force. 2. Also if your auto has a Toss under this coverage we will: a) pay for resulting damage to your clothing and luggage or that of any relative. Maximum payment is $200. b) repay you for the travel cost to where you were going. Maximum payment is $10. P1 Physical Damage TOWING AND LABOR COSTS COVERAGE We will pay towing and labor costs if your auto is disabled. We will pay only for labor costs at the place where your auto is disabled. Our maximum payment per disablement is shown in the Declarations. Coverage Extensions USE OF TRAILERS The insurance on your auto covers a trailer used by you or a relative. 1. The trailer must be: a) designed for use with a private passenger auto; and b) used with a vehicle that is insured under these coverages. 2. The trailer must not be: a) otherwise Insured; b) owned by you or a relative; or c) used for business purposes with a vehicle that's not a private passenger auto. 3. The maximum amount payable is $500. USE OF OTHER MOTOR VEHICLES The insurance on your auto also covers other motor vehicles as follows: 1. A motor vehicle you do not own, while it Is used in place of your auto for not more than 30 days. Your auto must be out of use because of: a) breakdown; c) servicing; or b) repair; d) Toss. 2. A four-wheel motor vehicle newly acquired by you. You must report the acquisition of the vehicle to us during the first 30 days you own the vehicle. Also, if the newly acquired vehicle does not replace your auto, all household vehicles owned by you must be insured by us or an affiliate for this extension of coverage to apply. We provide this coverage only If you do not have other collectible insurance. You must pay any added premium resulting from this coverage extension. 3. A private passenger auto owned by a non-member of your household and not covered in item 1. of this section. a) This applies only while such auto is used by you ora relative. b) We will not pay for loss: (1) that results from the operation of an auto: (a) repair shop; (c) sales agency; or (b) public garage or parking place; (d) service or maintenance facility. (2) involving a private passenger auto owned by an employer d an insured. (3) involving a private passenger auto furnished or available to you or a relative for regular use. (4) to any rented motor vehicle. 4. A rented private passenger auto, including its loss of Income. a) This applies only: (1) while such auto Is rented by you or a relative; (2) if such auto is rented from a rental company for less than 28 days; and (3) for loss of income that is: (a) verifiable by us; and P2 Physical Damage (b) owed to a rental company because: (1) the rental company had a customer willing to rent a private passenger auto; and (2) there was no other vehide available for rental in place of the damaged rented auto. b) We will not pay for Toss involving a private passenger auto rented or leased by anyone for or on behalf of the employer of an insured. Coverage Exclusions We will not pay for loss: 1. To more than one: a) recording tape; b) compact disc; or c) other recording media. 2. To a container to be used for storing or carrying: a) recording tapes; b) compact discs; or c) other recording media. 3. To any device which is a: a) tape player; b) compact disc player or recorder; c) video cassette player or recorder; d) television; e) electronic navigational system; f) citizens band radio; g) two-way mobile radio; h) telephone; or i) any other device which records, emits, amplifies, receives and/or transmits sound. However, this exclusion (3.) does not apply: a) to such a device, its antenna or its other parts or accessories if permanently installed by the original manufacturer or new car dealer as part of the purchase agreement for the vehicle; or b) up to the first $1,500 of the actual cash value of any and all such devices, antennas, or other parts and accessories that are permanently Installed but were not a part of the new car purchase agreement for the vehicle. However, payment under this subpart b) shall not exceed the actual cash value of the Insured vehicle In which the devices are Installed. Permanently installed means installed, using bolts, brackets, or welding. A device attached only by wires is not "permanently installed." No coverage will be provided for any item that Is not permanently installed. No coverage will be provided for the devices designed to detect or deter speed monitoring equipment excluded In exclusion 4. below, whether permanently installed or not. 4. To scanning monitor receivers used for radar detection, or any other device designed to detect or deter the monitoring of speed. 5. To a camper or living quarters unit which can be mounted on or attached to a vehicle. We will pay the Toss if: a) the unit is reported to us; and b) the required premium is paid; before the loss. P3 Physical Damage 6. Caused by and limited to: a) wear and tear; b) freezing; c) mechanical or electrical breakdown or failure. This exclusion (6.) does not apply to Towing and Labor coverage. 7. To any motor vehicle while used: a) to carry persons or property for a fee; or b) for retail or wholesale delivery, including but not limited to pizza, magazine, newspaper and mail delivery. This exclusion (7.) does not apply to motor vehicles used in shared -expense car pools. 8. To any motor vehicle due to an act of war, including insurrection, rebellion or revolution. 9. To any motor vehicle which occurs: a) while it is being used on a temporary or permanent basis, for the transportation of, or in exchange for, any illegal substance, or In connection with any criminal trade or transaction by: (1) you; (2) a relative; or (3) anyone else with your knowledge or permission; or b) due to confiscation of your auto by any law enforcement agency because of your auto's use in such activities. 10. Caused intentionally by or at the direction of an insured, including willful acts the result of which the insured knows or ought to know will follow from the insured's conduct. 11. To your auto while rented or leased to others. 12. To a motor vehicle, while being used in any prearranged or organized racing, speed, demolition, stunting activity, competitive event, or driver's education course conducted on a racetrack; or in practice or preparation for such event or course. 13. To your auto or any other motor vehicle due to diminution in value or depreciation. 14. Caused by or resulting from nuclear hazard, meaning any: a) nuclear reaction; b) nuclear discharge; c) radiation; or d) radioactive contamination; whether controlled or uncontrolled or however caused, or as a consequence of any of these. Loss caused by nuclear hazard is not considered Toss caused by fire, smoke or explosion. 15. Caused directly or indirectly by biological deterioration or damage. Such loss is excluded regardless of any other cause or event that contributes concurrently or In any sequence to the Toss. Limits and Conditions o f Payment ACTUAL CASH VALUE The limit of our coverage is the actual cash value of your auto or its damaged parts at the time of loss. To determine actual cash value, we will consider: 1. fair market value; 2. age; and 3. condition of the property; P4 Physical Damage at the time of Toss. In addition to our payment of the loss, necessary and reasonable towing and storage will be paid to protect the auto from further damage. Covered storage costs are not to exceed four days of storage charges Incurred prior to the date you report the loss to us. LOSS SETTLEMENT At our option, we may: 1. pay you directly for a loss; 2. pay to repair or replace your auto or its damaged parts with the parts furnished either by original equipment manufacturers or non -original equipment manufacturers; 3. return stolen property at our expense and pay for any damage. AMOUNTS PAYABLE FOR TOWING AND LABOR COSTS The limit of our coverage for a Toss is limited to the amount shown in the Declarations. Limits apply as stated in the Declarations. Insuring more than one person or vehicle under this policy does not increase our limits. OTHER INSURANCE If there is other insurance that covers any Toss, we will pay only our share of the loss. Our share is our proportion of the total insurance collectible for the Toss. For Toss to motor vehicles other than your auto, we will pay only the insured loss not covered by other insurance or self insurance. Coverage Conditions AUTO RECOVERY When an insured auto which has been stolen or abandoned is located, we have the right to take it into our care and custody. CONTROLLING STORAGE COSTS When an insured is involved in a Collision or Comprehensive loss, we have the right to move the vehicle from any impound lot, storage site, towing yard or any other facility to control storage costs, towing costs or other fees. The insured will be promptly notified whenever any such action is undertaken. Loss Payable Clause This clause applies to the Comprehensive and Collision coverages provided by this policy. It protects the lienholder named in the policy Declarations. Payment for Toss will be made according to the interest of the policyholder and lienholder. At our option, payment may be made to both Jointly, or to either separately. Either way, the company will protect the interests of both. Protection of the Ilenholder's financial interest will not be affected by any change in ownership of the vehicle insured, nor by any act or omission by any person entitled to coverage under this policy. However, protection under this clause does not apply: a) in any case of conversion, embezzlement, secretion, or willful damaging or destruction, of the vehicle committed by or at the direction of an insured. b) to the loss of any motor vehicle while it is being used on a temporary or permanent basis, for the transportation of, or in exchange for, any illegal substance, or in connection with any criminal trade or transaction. If the company cancels or refuses to renew the policy, the lienholder will receive notice at least 10 days before protection of its interest will end. The company will also notify the lienholder if coverage under the policy is excluded for any named driver. The lienholder shall notify the company upon learning of any change In ownership of the vehicle. P5 Physical Damage To the extent of payment to the lienholder, the company will be entitled to the lienholder's rights of recovery. The company will do nothing to Impair the right of the lienholder to recover the full amount of its claim. Assignability No interest In these coverages can be transferred without our written consent. However, if the policyholder dies, the coverages will stay in force for the rest of the policy period. They will apply for anyone having proper temporary custody of your auto. P6 Auto Liability Coverage Exclusions This coverage does not apply to: 1. Property damage or bodily injury caused intentionally by or at the direction of an insured, including willful acts the result of which the insured knows or ought to know will follow from the insured's conduct. 2. Use of any motor vehicle: a) to carry persons or property for a fee; or b) for retail or wholesale delivery, Including but not limited to pizza, magazine, newspaper and mail delivery. This exclusion does not apply to motor vehicles used in shared -expense car pools. 3. a) Any person for any occurrence arising out of the operation of an auto: (1) repair shop; (3) sales agency; or (2) public garage or parking place; (4) service or maintenance facility. b) However, this exclusion does not apply to: (1) you; (2) a relative; or (3) a partner, employee, or agent of you or a relative; with regard to the use of your auto. 4. Property damage caused by any insured: a) to a motor vehicle that is owned or operated by, or in the custody of, that insured; or b) to any other property that is owned by or in the custody of any insured or anyone occupying your auto. This exclusion does not apply to a: (1) rented home; or (2) rented private garage. 5. Bodily injury to any person eligible to receive any benefits required to be provided or voluntarily provided by any insured under a: a) workers' compensation; b) unemployment compensation; c) non -occupational or occupational disease; d) disability benefits; or any similar law. 6. Bodily injury to an employee of any insured while engaged in employment. However, it does cover an employee at your home who is not, or Is not required to be, covered by any workers' compensation law. 7. The United States of America or any of its agencies. It also does not apply to any employee of the United States of America or any of its agencies while such person is acting within the scope of his or her office or employment and the provisions of the Federal Tort Claims Act apply. 8. Any person protected under nuclear energy liability insurance. This exclusion applies even if that insurance has been exhausted. 9. Non -economic Toss of or for any person who has elected or has deemed to have elected "Limited Tort" in accordance with the Pennsylvania Motor Vehicle Financial Responsibility Law. 10. Bodily injury or property damage arising out of the ownership, maintenance or use of your auto while rented or leased to others by any insured. L3 Auto Liability 11. Bodily injury or property damage arising out of the ownership, maintenance or use of a motor vehicle, while being used in any prearranged or organized racing, speed, demolition, stunting activity, competitive event, or driver's education course conducted on a racetrack; or In practice or preparation for such event or course. 12. Bodily injury arising directly or indirectly from the inhalation of, ingestion of, contact with, exposure to, existence of or presence of any fungi, algae, lichens, slime, mold, bacteria, wet or dry rot and any by-products of these organisms, however produced. Fungi as used above include, but are not limited to: yeasts, mold, mildew, rust, smuts, or fleshy fungi such as mushrooms, puffballs and coral fungi. 13. Property damage caused directly or indirectly by biological deterioration or damage. Such loss is excluded regardless of any other cause or event that contributes concurrently or in any sequence to the loss. Limits and Conditions of Payment AMOUNTS PAYABLE FOR LIABILITY LOSSES Our obligation to pay Property Damage or Bodily Injury Liability losses Is limited to the amounts per person and per occurrence stated in the Declarations. The following conditions apply to these limits: 1. The limit shown: a) for Property Damage Liability Is for all property damage in one occurrence. b) for Bodily Injury Liability for any one person applies to one person's bodily injury, including death, and includes all claims resulting from or arising out of that one person's bodily injury, including death. This per person policy limit shall be enforceable regardless of the number of insureds, claims made, vehicles or premiums shown in the Declarations or policy, or vehicles involved in the accident. c) for Bodily Injury Liability for each occurrence is, subject to the per person limit described in paragraph b) above, the total limit of our liability for all legal damages when two or more persons sustain bodily injury, including death, as a result of one occurrence. TIfe per occurrence policy limit shall be enforceable regardless of the number of insureds, claims made, vehicles or premiums shown in the Declarations or policy, or vehicles involved in the accident. 2. Liability limits apply as stated in the Declarations. The insuring of more than one person or vehicle under this policy does not increase our liability limits. 3. In any loss covered under items 2. and 3. of "USE OF OTHER MOTOR VEHICLES," the highest liability limit applicable to any one vehicle on this policy will apply. 4. A motor vehicle and attached trailer are considered one vehicle for Auto Liability coverage. 5. Any payment under this coverage shall be reduced by any amount paid under the Uninsured Motorists or Underinsured Motorists coverage of this policy. OTHER INSURANCE 1. In any loss involving the use of your auto, we will be liable for only our share of the loss if there is other collectible liability insurance. Our share is our proportion of the total insurance limits for the loss. 2. For losses covered under "USE OF OTHER MOTOR VEHICLES,"our coverage is excess over any other collectible: a) insurance; b) self insurance; c) proceeds from a governmental entity; or d) sources of recovery. L4 1111 1111 Auto Liability (for damage or Injury to others caused by your auto) Coverage Agreement PROPERTY DAMAGE AND BODILY INJURY LIABILITY COVERAGE 1. We will pay for damages for which you are legally liable as a result of an accident arising out of the: a) ownership; b) maintenance or use; or c) loading or unloading; of your auto. A relative also has this protection. So does any person or organization who is liable for the use of your auto while used with your permission. 2. Damages must involve: a) property damage; or b) bodily injury. 3. We will pay such liability losses up to the limits stated in the Declarations. In addition to these limits and as to any covered damages, we will: a) defend at our expense, with attorneys of our choice, any suit against the insured. We may settle or defend any claim or suit as we think proper. b) pay: (1) all expenses incurred by us; and (2) all costs levied against the insured, including prejudgment Interest on that portion of the award which does not exceed the limits of this coverage; in any such suit. c) pay premiums: (1) of not more than $250 per insured for bail bonds required because of an accident or traffic violation. (2) for appeal bonds in defended sults and for bonds to release attached property. The amount of such bonds shall not be more than the limits of liability shown in the Declarations. Although paying such premiums, we are not required to apply for or furnish any bonds. d) pay post -Judgment Interest on all damages awarded. We will not pay interest that accrues after such time as we have: (1) paid; (2) formally offered; or (3) deposited in court; the amount for which we were liable under this policy. e) pay expenses incurred by an insured for emergency medical aid to others at the time of accident. f) pay all reasonable expenses incurred by an insured at our request, but not more than $50 per day for loss of earnings. 4. After the limits of this coverage have been paid, we will not defend any suit or pay any claim or judgment. L1 Auto Liability Coverage Extensions USE OF TRAILERS 1. This coverage applies to the use of a trailer by: a) you; b) a relative; or c) someone else with your permission. 2. The trailer must be: a) designed for use with a private passenger auto; and b) used with a vehide that is insured under this coverage. 3. The trailer must not be used for business purposes with a vehicle that's not a private passenger auto. USE OF OTHER MOTOR VEHICLES This coverage also applies to certain other motor vehicles as follows: 1. A motor vehicle you do not own, while it is used in place of your auto for not more than 30 days. Your auto must be out of use because of: a) breakdown; c) servicing; or b) repair; d) loss. 2. A four-wheel motor vehicle newly acquired by you. This coverage applies only during the first 30 days you own the vehicle unless It replaces your auto. If the newly acquired vehicle does not replace your auto, all household vehicles owned by you must be insured by us or an affiliate for this extension of coverage to apply. We provide this coverage only if you do not have other collectible insurance. You must pay any added premium resulting from this coverage extension. 3. A motor vehicle owned by a non-member of your household and not covered in item 1. of this section. a) This applies only while the vehicle Is being used by you or a relative. It protects you or the relative as the operator, and any person or organization, except as noted below in b), who does not own the vehicle but is legally responsible for its use. b) This does not apply to losses involving a motor vehicle: (1) used in the business or occupation of you or a relative except a private passenger auto used by you, your chauffeur, or your household employee; (2) owned, rented or leased by an employer of an insured; (3) rented or leased by anyone for or on behalf of an employer of an insured; or (4) furnished or available to you or a relative for regular use. Furnished for regular use does not include a motor vehicle rented from a rental company for less than 28 days. FINANCIAL RESPONSIBILITY We will adjust this policy to comply: 1. With the financial responsibility law of any state or province which requires higher liability limits than those provided by this policy. 2. With the kinds and limits of coverage required of non-residents by any compulsory motor vehicle insurance law, or similar law. However, any loss payment under thls coverage will be made only over and above any other collectible motor vehicle insurance. In no case will anyone be entitled to duplicate payments for the same loss. When we certify this policy as proof under any financial responsibility law, it will comply with the law to the extent of the coverage required by the law. L2 Auto Liability If more than one policy issued by us or a company affiliated with us applies on an excess basis to the same loss, we will pay only up to the highest limit of any one of them. Assignability No interest in this coverage can be transferred without our written consent. However, if the policyholder dies, the Liability coverage will stay in force for the rest of the policy period for: 1. Anyone having proper temporary custody of your auto until a legal representative is appointed; and 2. The appointed legal representative L5 1:. pal First Party Benefits Coverage Agreement This coverage provides First Party Benefit options in accordance with the Pennsylvania Motor Vehicle Financial Responsibility Law. The options and limits which the policyholder has selected are shown in the Declarations. We will pay First Party Benefits for the bodily injury of an insured as a result of an accident that arises out of the maintenance or use of a motor vehicle as a motor vehicle. We will pay these benefits regardless of who is at fault In the accident. ADDITIONAL DEFINITIONS APPLICABLE TO THIS COVERAGE For purposes of this coverage: 1. "RELATIVE" means the following residents of the policyholder's household: a) spouse; b) anyone related to the policyholder or spouse by blood, marriage or adoption; and c) a minor in the legal custody of the policyholder or such relative. A relative may live temporarily outside the household. 2. "MOTOR VEHICLE" means any vehicle which is self-propelled, except one which is propelled: a) solely by human power; or b) by electric power obtained from overhead trolley wires but not operated upon rails. 3. "NECESSARY MEDICAL TREATMENT AND REHABILITATIVE SERVICES" means: a) treatment; b) accommodations; and c) products or services; which are determined to be necessary by a licensed health care provider unless they shall have been found or determined to be unnecessary by a state -approved Peer Review Organization (PRO). INSUREDS The policyholder and relatives are covered while occupying or injured by any motor vehicle. Persons other than the policyholder and relatives are covered: a) while occupying your auto. b) as non -occupants of a motor vehicle if injured as a result of an accident in Pennsylvania involving your auto. Options OPTION 1 -MEDICAL BENEFIT We will pay all reasonable expenses for necessary medical treatment and rehabilitative services. We will pay such expenses up to the limit shown on the Declarations. Subject to the applicable provisions of the Motor Vehicle Responsibility Law concerning the statute of limitations, there is no time limitation for this benefit, provided that, within 18 months after the date of the accident, it is determined with reasonable medical probability that further expenses may be incurred as a result of the injury. F1 First Party Bene fits OPTION 2 -INCOME LOSS BENEFIT If this option Is selected by payment of premium, we will pay for loss of income from work the insured was unable to do because of bodily injury. We will not pay under this benefit until five working days have been lost. We will not pay for these five days of lost income. "LOSS OF INCOME" means: a) 80 percent of actual loss of gross income. Gross income is income received from work performed while normally employed in gainful activity. b) reasonable expenses actually incurred for hiring a substitute to perform self-employment services in order to reduce loss of gross income or for hiring special help which permits a person to work and reduce Toss of gross income. We will pay such benefits up to the limit shown on the Declarations. However, the total limit of this benefit is subject to the monthly maximum shown on the Declarations. Income loss benefits do not continue after a person dies. OPTION 3 -ACCIDENTAL DEATH BENEFIT If this option Is selected by payment of premium, we will pay the Accidental Death Benefit for the policyholder or a relative who suffers accidental bodily injury causing death from a covered accident. We will pay the Accidental Death Benefit limit shown in the Dedarations. Death must occur within two years of, and as a direct result of, the accident. Payment will be made to the: a) executor; or b) administrator; of the estate. In the alternative, payment will be made to the surviving spouse. OPTION 4 -FUNERAL BENEFIT if this option is selected by payment of premium, we will pay reasonable expenses directly related to the: a) funeral; b) burial; c) cremation; or d) other form of disposition of the remains of a deceased insured. These expenses must be the direct result of death from a covered accident within two years of the date of the accident. Payment will be made to any person presenting bills for qualified expenses incurred. We will pay such expenses up to the limit shown on the Declarations. OPTION 5 -COMBINED LOSS BENEFITS If this option is selected by payment of premium, we will pay the benefits described in Options 1, 2, 3, and 4 above. However, total benefits payable under this option are limited to: a) the aggregate limit shown on the Declarations for this option; or b) three years from the date of the accident; whichever occurs first. Option 5 is subject to the following conditions: a) within 18 months after the date of the accident, it must be determined with reasonable medical probability that future medical expenses will be incurred as a result of the injury. b) in no event will benefits be paid beyond three years from the date of the accident. c) there is no monthly dollar maximum for Income Loss Benefits. d) the maximum Accidental Death Benefit payable is $25,000. e) the maximum Funeral Benefit payable is $2,500. f) benefits under d) and e) are only payable if death occurs within two years of the date of the accident. F2 First Party Benefits OPTION 6 -EXCESS MEDICAL BENEFITS if this option is selected by payment of premium, we will pay the Excess Medical Benefits for an insured who suffers accidental bodily injury from a covered accident. Excess Medical Benefits are reasonable expenses for necessary medical treatment and rehabilitative services. We will pay such expenses in excess of $100,000 but not to exceed one million dollars. We will not pay Excess Medical Benefits to an insured who is not eligible for Option 1 --Medical Benefits under this policy. Our liability to one person in one accident is $50,000 per year. Subject to this limit for any one person in any one year, our aggregate limit for any one person is one million dollars for any one accident. During the first 18 months of eligibility, we shall approve payments for an insured without regard to the $50,000 per year limit. For purposes of this option, the first 18 months of eligibility begins when the insured has incurred $100,000 of eligible necessary medical treatment and rehabilitative services expenses. If the insured is covered by Option 5 --Combined Loss Benefits package (or a similar auto benefits package with another insurer), applicable Medical Benefit limits greater than $100,000 in such package shall be excess over any sums paid or payable under Excess Medical Benefits. Coverage Exclusions We will not pay First Party Benefits in certain circumstances, as follows: 1. The policyholder and relatives are not covered for bodily injury arising out of the maintenance or use of a motor vehicle that the policyholder owns that is not an insured motor vehicle. An insured motor vehicle is one on which there are First Party Benefits and to which the Auto Bodily Injury Liability coverage in this policy applies. 2. There is no coverage for bodily injury to a relative arising out of the maintenance or use of a motor vehicle owned by such relative which is not insured for First Party Benefits and Auto Bodily Injury Liability coverage under this or any other policy. 3. There is no coverage for anyone while occupying a: a) motorcycle; b) motor -driven cycle; c) motorized pedalcycle, or similar type vehicles; or d) a recreational vehicle not intended for highway use. 4. There is no coverage for anyone, other than the policyholder or a relative, who knowingly converts a motor vehicle. 5. There is no coverage for anyone injured by your auto while It Is unoccupied and parked so as not to cause unreasonable risk of injury. 6. There Is no coverage for use of any motor vehicle by an insured: a) to carry persons or property for a fee; or b) for retail or wholesale delivery, including but not limited to pizza, magazine, newspaper and mai delivery. This exclusion does not apply to motor vehicles used in the shared -expense car pools. 7. There is no coverage for anyone, other than the policyholder, who is the owner of a currently registered motor vehicle and who does not have financial responsibility. Financial responsibility means the type of financial responsibility that was self -certified to the Department of Transportation to obtain the registration. 8. We will not pay any benefits to or for anyone who injures themselves: a) or another intentionally, Including an attempt to intentionally injure themselves or another; b) while committing a felony; or c) while seeking to elude lawful apprehension or arrest by a law enforcement official. F3 First Party Benefits 9. a) There is no coverage for any person for any occurrence arising out of the operation of a motor vehicle: (1) repair shop; (2) public garage or parking place; (3) sales or leasing agency; or (4) service or maintenance facility. b) However, this exclusion does not apply to the use of your auto to: a) the policyholder; or b) a relative. 10. There is no coverage for Toss sustained by any person as a direct result of loading or unloading any motor vehicle, except while occupying the motor vehicle. 11. There is no coverage for bodily injury caused by or resulting from: a) an act of war, including insurrection, rebellion or revolution; or b) nuclear hazard meaning any: (1) nuclear reaction; (2) nuclear discharge; (3) radiation; or (4) radioactive contamination; whether controlled or uncontrolled or however caused, or as a consequence of any of these. 12. There is no coverage for bodily injury arising directly or indirectly from the inhalation of, Ingestion of, contact with, exposure to, existence of or presence of any fungi, algae, lichens, slime, mold, bacteria, wet or dry rot and any by-products of these organisms, however produced. Fungi as used above include, but are not limited to: yeasts, mold, mildew, rust, smuts, or fleshy fungi such as mushrooms, puffballs and coral fungi. 13. There is no coverage for bodily injury arising out of the ownership, maintenance or use of a.motor vehicle, while being used in any prearranged or organized racing, speed, demolition, stunting activity, competitive event, or driver's education course conducted on a racetrack; or in practice or preparation for such event or course. Limits and Conditions of Payment Limits apply as stated in the attached Declarations. However, the Insuring of more than one person or vehicle under this First Party Benefits coverage does not Increase the limit of coverage to any one person in any one accident. In no event will any insured be entitled to more than the highest limit applicable to any one motor vehicle under this or any other policy. The following conditions apply to the relationship of this coverage to other insurance or benefits that pay be available: PRIORITIES OF POLICIES We will pay First Party Benefits in accordance with the order of priorities set forth by law. We will not pay if there is other insurance at a higher level of priority, even if the limits of that insurance have been paid. The highest priority level listed below is the FIRST level which provides benefits for a named insured. The priority order is: FIRST— For a named insured on any policy, the policy on which that person is the named insured. SECOND— For a relative, the policy covering the relative as an insured. THIRD— For the occupants of an insured motor vehicle, the policy on that motor vehicle. FOURTH— For a person who is not the ocupant of a motor vehicle, the policy on any motor vehicle involved in the accident. F4 First Party Benefits NO DUPLICATION OF BENEFITS; OTHER INSURANCE In any occurrence where other similar auto insurance or self-insurance of equal priority to that provided in this coverage is available and the claim is first presented to us, we will process and pay the claim as if wholly responsible up to the limits of our policy. The total limits available from all such insurance will be considered not to exceed the highest limits available from any one source of coverage. In no instance may an insured or legal representative recover duplicate benefits from the same elements of loss under this and other similar auto insurance or self-insurance. WORKERS' COMPENSATION REDUCTION There is no coverage for bodily injury occurring during the course and scope of employment if workers' compensation benefits are payable or available for the bodily injury. Any amount payable to anyone under this coverage will only be in excess of and not in duplication of any valid and collectible workers' compensation benefit. Insured Persons' Duties The insured, or someone on the insured's behalf, will report any accident to us in writing as soon as practicable. This report will identify the injured and give reasonably obtainable information about the time, place and circumstances of the accident. As soon as practicable, the insured or someone on the insured's behalf will submit written proof of claim to us, under oath if required. This proof will include detailed information about the nature and extent of bodily injury, treatment and rehabilitation received and contemplated, and anything else that may help us determine what benefits are payable in what amounts. The injured person must grant us authorization, if we request it, to obtain copies of medical, income and income tax reports and records. Injured persons must submit to examinations by company -selected physicians as often as the company reasonably requires. The injured person must submit to examination under oath as often as reasonably requested by us. F5 Uninsured Motorists (for bodily injury caused by uninsured motorists) ADDITIONAL DEFINITION APPLICABLE TO THIS COVERAGE An "UNINSURED MOTOR VEHICLE" is: 1) one for which there Is no bodily injury liability bond or insurance at the time of the accident. 2) one for which the insuring company denies coverage or becomes insolvent. 3) an unidentified motor vehicle which causes bodily injury to an insured by physical contact with: a) such insured; or b) a vehicle the insured is occupying. The driver and the owner of the unidentified vehide must be unknown. A report must be made to the police within 24 hours and us within 30 days, or as soon as practicable. It must state that the insured has a legal action due to the accident. It must include facts to support the action. We may inspect any vehide the insured was occupying. We will not consider as an uninsured motor vehicle: 1) a motor vehicle for which there is liability insurance or self-insurance applicable at the time of the accident; 2) any vehicle in use as a residence or premises; 3) any equipment or vehicle designed for use mainly off public roads except while on public roads; 4) any motor vehicle insured under the Auto Liability coverage of this policy; nor 5) any motor vehicle furnished for the regular use of you, a resident, or a relative. Coverage Agreement YOU AND A RELATIVE We will pay compensatory damages, including derivative claims, which are due by law to you or a relative from the owner or driver of an uninsured motor vehicle because of bodily injury suffered by you or a relative. Damages must result from an accident arising out of the: 1. ownership; 2. maintenance; or 3. use; of the uninsured motor vehicle. OTHER PERSONS We will also pay compensatory damages, including derivative claims, which are due by law to other persons who suffer bodily injury while occupying: 1. Your auto. 2. A motor vehicle you do not own, while it is used as a temporary substitute for your auto. Your auto must be out of use because of: a) breakdown; b) repair; c) servicing; or d) loss. U1 Uninsured Motorists 3. A four-wheel motor vehicle newly acquired by you. This applies only during the first 30 days you own the vehicle, unless it replaces your auto. RECOVERY 1. Before recovery, we and any Injured party seeking protection under this coverage must agree on two points: a) whether there is legal right to recover damages from the owner or driver of an uninsured motor vehicle; and if so, b) the amount of such damages. 2. Any judgment against the uninsured will be binding on us only if it has our written consent. 3. The injured party shall provide notice of an uninsured motorist daim within two years after the date of the accident. If the injured party fails to provide such notice, and this failure precludes our ability to subrogate against liable parties, coverage may be denied as provided in Insured Persons' Duties No. 2 below. 4. Where multiple policies apply, payment shall be made in the following order of priority: a) a pdicy covering a motor vehicle occupied by the injured person at the time of the accident. b) a policy covering a motor vehicle not involved In the accident with respect to which the injured person is an insured. 5. Where multiple sources of equal priority apply, the insured against whom a claim is asserted first under the priorities set forth in 4. above shall process and pay the claim as if wholly responsible. We are thereafter entitled to recover contribution pro rata from the other insurer for the benefits paid and the cost of processing the claim. Coverage Exclusions This coverage does not apply to: 1. Use of any motor vehicle: a) to carry persons or property for a fee; or b) for retail or wholesale delivery, Including but not limited to pizza, mazagine, newspaper and mall delivery. This exclusion does not apply to motor vehicles used in shared -expense car pools. 2. Use of any motor vehicle by an insured without the owner's permission. 3. Punitive or exemplary damages. 4. Directly or indirectly benefit any workers' compensation or disability benefits carrier, or any person or organization qualifying as a "self -Insurer" under a workers' compensation, disability benefits, or similar law. To the extent that workers' compensation, disability or self-insured benefits under workers' compensation are paid or payable, this coverage is excess. 5. Bodily injury suffered while occupying or struck by a motor vehicle owned by you or a relative, but not insured for auto liability coverage under this or any other policy. 6. Bodily injury suffered while occupying a motor vehicle owned by you or a relative but not insured for Uninsured Motorists coverage under this policy; nor to bodily injury from being hit by any such motor vehicle. 7. Non -economic loss of any insured who has elected or has deemed to have elected "Limited Tort" in accordance with the Pennsylvania Motor Vehicle Financial Responsibility Law. 8. Bodily injury of any insured if the insured settles, without our written consent, with a liable party. 9. Bodily injury suffered while occupying a motor vehicle being used in any prearranged or organized racing, speed, demolition, stunting activity, competitive event, or driver's education course conducted on a racetrack; or in practice or preparation for such event or course. U2 Uninsured Motorists 10. Bodily injury to you or a relative using a non -owned motor vehicle that Is available for regular use by you or a relative. Insured Persons' Duties 1. The insured must: a) submit written proof of claim to us. It must be under oath, if required. It must include details of: (1) the nature and extent of injuries; (2) treatment; and (3) any other facts which could affect the amount of payment. b) provide all facts of the accident and the names of all witnesses. c) submit to oral examination under oath as often as we require with good reason. d) be examined by doctors, including doctors examining the insured for rehabilitation purposes, or vocational specialists, chosen by us as often as we require with good reason. At our request, the injured person must promptly authorize us to: (1) speak with any doctor who has treated him; (2) read all medical history and reports of the injury; (3) obtain copies of wage and medical reports and records; and (4) obtain copies of all medical bills as they are incurred. Failure to do the above precludes recovery under this coverage. 2. We require the insured to file suit against any and all liable parties to preserve and protect our subrogation rights. Failure to do so precludes recovery under this coverage. 3. The insured must obtain our written consent to: a) settle any legal action brought against any liable party; or b) release any party. Failure to do so precludes recovery under this coverage. Our Right to Recovery This applies to the extent of any payment we make under this coverage. We will have first right to any amount the insured receives from any liable party. The insured will: 1. Hold In trust for us his right to recover against any such party; and 2. Furnish us all papers in any suit the insured files. Our payment of a claim may result from the insolvency of an insurer. If so, we have the right to recover from the insurer, but not its insured. Limits and Conditions of Payment AMOUNTS PAYABLE FOR UNINSURED MOTORISTS LOSSES We agree to pay losses up to the limits stated in the policy Declarations. The following applies to these limits: 1. The Uninsured Motorists bodily injury limit shown for any one person Is for all legal damages, including all derivative daims, claimed by anyone due to bodily injury to one person as a result of one occurrence. The per -person limit is the total amount available when one person sustains bodily injury, including death, as a result of one occurrence. No separate limits are available to anyone for U3 Uninsured Motorists derivative claims, statutory claims, or any other claims made by anyone arising out of bodily injury, including death, to one person as a result of one occurrence. The total limit or our liability shown for each occurrence is the total amount available when two or more persons sustain bodily injury, including death, as a result of one occurrence. In no event shall any one person recover more than the per -person limit shown. 2. Coverage applies as stated in the Declarations. The insuring of more than one person or vehicle under this policy does not increase our Uninsured Motorists payment limits. In no event will any insured be entitled to more than the highest per -person limit applicable to any one motor vehicle under this policy or any other policy issued by us. However, if your Declarations show you have elected "Uninsured Motorists --Bodily Injury Stacked" coverage, the sum of limits for your autos apply to you or a relative as stated in the Declarations. 3. Any payment under this coverage shall be reduced by any amount paid under the Auto Liability coverage of this policy. 4. The insured may recover for bodily injury under the Auto Liability coverage or the Uninsured Motorists coverage of this policy, but not under both coverages. OTHER INSURANCE If there is other insurance: 1. For bodily injury suffered by an insured while occupying a motor vehicle you do not own, we will pay the insured loss not covered by other insurance. 2. Except as stated above, if there is other insurance similar to this coverage under any other policy, we will be liable for only our share of the loss. Our share is our proportion of the total Insurance limits for the loss. 3. If more than one policy applies, the total limits applicable will be considered not to exceed the highest limit amount of any one of them. 4. When the Declarations show you have elected "Uninsured Motorists --Bodily Injury Stacked" coverage, the total limits applicable will be considered not to exceed the highest limit amount of any one of them for an insured other than you or a relative. DUPLICATE PAYMENT We will make no duplicate payment to or for any insured for the same element of loss. Assignability No interest in this coverage can be transferred without our written consent. However, if the policyholder dies, this coverage will continue in force for the rest of the pciicy period. It will apply to the following having proper custody of your auto: 1. your relatives; 2. your heirs; 3. an appointed legal representative; or 4. anyone else using your auto with the express permission of the legal representative. U4 Underinsured Motorists (for bodily injury caused by underinsured motorists) ADDITIONAL DEFINITION APPLICABLE TO THIS COVERAGE An 'UNDERINSURED MOTOR VEHICLE" is a motor vehicle for which bodily injury liability coverage, bonds or Insurance are in effect. However, their total amount is insufficient to pay the damages an insured is entitled to recover. We will pay damages that exceed such total amount. We will not consider as an underinsured motor vehicle: 1) a motor vehicle for which there is sufficient liability insurance or self -Insurance applicable at the time of the accident to pay losses and damages; 2) any vehicle in use as a residence or premises; 3) any equipment or vehicle designed for use mainly off public roads except while on public roads; 4) any motor vehicle insured under the Auto Liability coverage of this policy, nor 5) any motor vehicle furnished for the regular use of you, a resident, or a relative. Coverage Agreement YOU AND A RELATIVE We will pay compensatory damages, including derivative claims, which are due by law to you or a relative from the owner or driver of an underinsured motor vehicle because of bodily injury suffered by you or a relative. Damages must result from an accident arising out of the: 1. ownership; 2. maintenance; or 3. use; of the underinsured motor vehicle. OTHER PERSONS We will also pay compensatory damages, including derivative claims, which are due by law to other persons who suffer bodily injury while occupying: 1. Your auto. 2 A motor vehicle you do not own, while it Is used as a temporary substitute for your auto. Your auto must be out of use because of: a) breakdown; b) repair; c) servicing; or d) loss. 3. A four-wheel motor vehicle newly acquired by you. This applies only during the first 30 days you own the vehicle, unless it replaces your auto. RECOVERY 1. Before recovery, we and any injured party seeking protection under this coverage must agree on two points: a) whether there Is legal right to recover damages from the owner or driver of an underinsured motor vehicle; and If so, U11 Underinsured Motorists b) the amount of such damages. 2. Any judgment against the underinsured will be binding on us only if it has our written consent. 3. The injured party shall provide notice of an underinsured motorist claim within two years after the date of the accident. If the injured party fails to provide such notice, and this failure precludes our ability to subrogate against liable parties, coverage may be denied as provided in Insured Persons' Duties No. 2 below. 4. Where multiple policies apply, payment shall be made in the following order of priority: a) a policy covering a motor vehicle occupied by the injured person at the time of the accident. b) a policy covering a motor vehicle not involved in the accident with respect to which the injured person is an insured. 5. Where multiple sources of equal priority apply, the insured against whom a claim is asserted first under the priorities set forth In 4. above shall process and pay the claim as if wholly responsible. We are thereafter entitled to recover contribution pro rata from the other insurer for the benefits paid and the cost of processing the claim. Coverage Exclusions This coverage does not apply to: 1. Use of any motor vehicle: a) to carry persons or property for a fee; or b) for retail or wholesale delivery, including but not limited to pizza, magazine, newspaper and mail delivery. This exclusion does not apply to motor vehicles used in shared -expense car pools. 2. Use of any motor vehicle by an insured without the owner's permission. 3. Punitive or exemplary damages. 4. Directly or indirectly benefit any workers' compensation or disability benefits carrier, or any person or organization qualifying as a "self -insurer" under a workers' compensation, disability benefits, or similar law. To the extent that workers' compensation, disability or self-insured benefits under workers' compensation are paid or payable, this coverage is excess. 5. Bodily injury suffered while occupying or struck by a motor vehicle owned by you or a relative but not insured for Auto Liability coverage under this or any other policy. 6. Bodily injury suffered while occupying a motor vehicle owned by you or a relative but not insured for Underinsured Motorists coverage under thls policy; nor to bodily injury from being hit by any such motor vehicle. 7. Non -economic Toss of any insured who has elected or has deemed to have elected "Limited Tort" in accordance with the Pennsylvania Motor Vehicle Financial Responsibility Law. 8. Bodily injury of any insured If the insured settles, without our written consent, with a liable party. 9. Bodily injury suffered while occupying a motor vehicle being used in any prearranged or organized racing, speed, demolition, stunting activity, competitive event, or driver's education course conducted on a racetrack; or in practice or preparation for such event or course. 10. Bodily injury to you or a relative using a non -owned motor vehicle that is available for regular use by you or a relative. U12 Underinsured Motorists Insured Persons' Duties 1. The insured must: a) submit written proof of claim to us. It must be under oath, if required. It must include details of: (1) the nature and extent of injuries; (2) treatment; and (3) any other facts which could affect the amount of payment. b) provide all facts of the accident and the names of all witnesses. c) submit to oral examination under oath as often as we require with good reason. d) be examined by doctors, including doctors examining the insured for rehabilitation purposes, or vocational specialists, chosen by us as often as we require with good reason. At our request, the injured person must promptly authorize us to: (1) speak with any doctor who has treated him; (2) read all medical history and reports of the injury; (3) obtain copies of wage and medical reports and records; and (4) obtain copies of all medical bills as they are Incurred. Failure to do the above precludes recovery under this coverage. 2. We require the insured to file suit against any and all liable parties to preserve and protect our subrogation rights. Failure to do so precludes recovery under this coverage. 3. The insured must obtain our written consent to: a) settle any legal action brought against any liable party; or b) release any party. Failure to do so precludes recovery under this coverage. Our Right to Recovery This applies to the extent of any payment we make under this coverage. We will have first right to any amount the insured receives from any liable party. The insured will: 1. Hold in trust for us his right to recover against any such party; and 2. Furnish us all papers in any suit the insured files. Our payment of a claim may result from the insolvency of an insurer. If so, we have the right to recover from the insurer, but not its insured. Limits and Conditions of Payment AMOUNTS PAYABLE FOR UNDERINSURED MOTORISTS LOSSES We agree to pay losses up to the limits stated In the policy Declarations. The following applies to these limits: 1. The Underinsured Motorists bodily injury limit shown for any one person is for all legal damages, including all derivative claims, claimed by anyone due to bodily injury to one person as a result of one occurrence. The per -person limit is the total amount available when one person sustains bodily injury, including death, as a result of one occurrence. No separate limits are available to anyone for derivative claims, statutory claims, or any other claims made by anyone arising out of bodily injury, including death, to one person as a result of one occurrence. U13 Underinsured Motorists The total limit of our liability shown for each occurrence is the total amount available when two or more persons sustain bodily injury, including death, as a result of one occurrence. In no event shall any one person recover more than the per -person limit shown. 2. Coverage applies as stated in the Declarations. The insuring of more than one person or vehicle under this policy does not increase our Underinsured Motorists payment limits. In no event will any insured be entitled to more than the highest per -person limit applicable to any one motor vehicle under this policy or any other policy issued by us. However, if your Declarations show you have elected 'Underinsured Motorists—Bodily Injury Stacked" coverage, the sum of limits for your autos apply to you or a relative as stated in the Declarations. 3. Any payment under this coverage shall be reduced by any amount paid under the Auto Liability coverage of this policy. 4. The insured may recover for bodily injury under the Auto Liability coverage or the Underinsured Motorists coverage of this policy, but not under both coverages. 5. No payment will be made until the limits of all other auto liability insurance and bonds that apply have been exhausted by payments. 6. An insured who recovers damages for an uninsured motorists claim cannot recover damages for an underinsured motorists claim for the same accident. OTHER INSURANCE If there Is other insurance: 1. For bodily injury suffered by an insured while occupying a motor vehicle you do not own, we will pay the insured loss not covered by other Insurance. 2. Except as stated above, if there is other Insurance similar to this coverage under any other policy, we will be liable for only our share of the loss. Our share is our proportion of the total insurance limits for the loss. 3. If more than one policy applies, the total limits applicable will be considered not to exceed the highest limit amount of any one of them. 4. When the Declarations show you have elected Underinsured Motorists --Bodily Injury Stacked" coverage, the total limits applicable will be considered not to exceed the highest limit amount of any one of them for an insured other than you or a relative. DUPLICATE PAYMENT We will make no duplicate payment to or for any insured for the same element of loss. Assignability No interest In this coverage can be transferred without our written consent. However, if the policyholder dies, this coverage will continue in force for the rest of the pdicy period. It will apply to the following having proper custody of your auto: 1. your relatives; 2. your heirs; 3. an appointed legal representative; or 4. anyone else using your auto with the express permission of the legal representative. U14 General Policy Conditions We, you, and anyone insured by this policy are bound by and must comply with all the terms, conditions and obligations of the policy. The following are policy conditions: 1. INSURED PERSONS' DUTIES AFTER AN ACCIDENT OR LOSS The insured will: a) give us or our agent prompt notice of all losses and provide written proof of claim if required. b) notify the police of all theft losses as soon as practicable. c) promptly deliver to us all papers dealing with any claims or suits. d) submit to examinations under oath as often as reasonably requested by us. e) assist us and, if applicable, the defense counsel chosen for you by us, with any claim or suit. f) if injured, submit to examinations by company -selected physicians as often as the company reasonably requires. The injured person must grant us authority, at our request, to obtain copies of all wage and medical, dental or other health care provider records. g) protect damaged property insured under this policy and make it available to us for inspection before its repair or disposal and reinspection during the repair process. h) provide ail records and documents we reasonably request and permit us to make copies. I) comply with and be bound by the terms, conditions and obligations of the policy. 2. HOW YOUR POLICY MAY BE CHANGED a) Any terms of this policy which may be in conflict with statutes of the state in which the policy is issued are hereby amended to conform. b) Any insured will automatically have the benefit of any extension or broadening of coverage in this policy, as of the effective date of the change, provided it does not require more premium. c) No other changes may be made in the terms of this policy except by endorsement or policy revision. d) The premium for each coverage is based on information in our possession. Any change or correction in this information will allow us to make an adjustment of the premium as of the date the change is effective. e) The policyholder has a duty to notify us as soon as possible of any change which may affect the premium or the risk under this policy. This includes, but is not limited to, changes in: (1) the principal garaging address of the insured vehicie(s), which must be reported to us within 30 days of the date the address change becomes effective; (2) drivers; (3) use of the insured vehicle(s); or (4) desired coverages, deductibles, or limits. 3. OPTIONAL PAYMENT OF PREMIUM IN INSTALLMENTS The policyholder may pay the premium for this policy in installments, under terms and conditions approved where required by the Insurance Department. For each separate installment payment there is an Installment service charge. Your agent can provide more information. 4. RENEWAL/NON-RENEWAL This policy Is written for a six-month policy period. We will renew it for successive policy periods, subject to the following conditions: a) Renewal will be in accordance with policy forms, rules, rates and rating plans in use by us at the time. 01 General Policy Conditions b) Prior to the expiration date of a policy term for which premium has been paid, we will mail a notice to the policyholder for the premium required to renew or maintain the policy in effect. We will mail this notice to the address last known to us. c) All premiums, premium installment payments, and fees must be paid when due, whether payable directly to us or through any premium finance plan. d) At the end of each 12 -month period after the first effective date of the policy or any coverage, we will have the right to refuse to renew any coverage or the entire policy. If we elect not to renew, we will mail notice to the policyholder 60 days in advance of the date when coverage will terminate. Such mailing to the last known address will be considered proof of notice. 5. CANCELLATION DURING POLICY PERIOD The policyholder may cancel this policy or any of its coverages by mailing notice to us of the future date of cancellation desired. Premium refund, if any due will be made as soon as practicable after the date of cancellation. We will calculate any returned premium according to the rules, rates, fees and forms in effect and on file if required, for our use in your state. If this policy or any coverage has been in effect less than 60 days, we have unlimited right of cancellation. We may cancel by mailing notice to the policyholder 15 days in advance of termination. After any coverage of this policy has been in force 60 days, our right to cancel such coverage during the policy period is limited. We may cancel during an annual policy period: a) if premiums, premium installment payments, or fees are not paid when due, whether payable directly to us or through any premium finance plan. b) if the driver's license or motor vehicle registration of any named insured has been suspended or revoked during the policy period; c) if it is determined that any insured has concealed a material fact, has made a material allegation contrary to fact, or has made a misrepresentation of a material fact and that such concealment, allegation or misrepresentation was material to the acceptance of the risk by us. We must mail notice to the policyholder: a) 15 days in advance of termination for nonpayment of premium. b) 15 days in advance of termination for loss of license or of motor vehicle registration. c) 60 days in advance of termination for concealment or misrepresentation. In any case of cancellation by us, our mailing of notice to the policyholder's last known address or delivery of it to the policyholder will constitute proof of notice. We will retain premium for days covered during the policy period. Premium refund, If any due, will be made as soon as practicable. Mailing or delivery of our check will constitute tender of refund. 6. DIVIDENDS The policyholder is entitled to any dividends which are declared by the Board of Directors and are applicable to coverages in this policy. 7. IF YOU BECOME BANKRUPT Bankruptcy or insolvency of any insured will not relieve us of any obligation under the terms of this policy. 8. UNAUTHORIZED USE OF OTHER MOTOR VEHICLES Protection in this policy does not apply to other motor vehicles which any insured: a) uses without a reasonable belief that the insured is entitled to do so. b) has stolen. c) knows to have been stolen. G2 General Policy Conditions 9. FRAUD AND MISREPRESENTATION a) THIS POLICY WAS ISSUED IN RELIANCE ON THE INFORMATION YOU PROVIDED AT THE TIME OF YOUR APPLICATION FOR INSURANCE COVERAGE. WHEN THIS POLICY HAS BEEN IN EFFECT LESS THAN 60 DAYS, WE MAY RESCIND COVERAGE UNDER THIS POLICY, DENY COVERAGE UNDER THIS POLICY, OR, AT OUR ELECTION, ASSERT ANY OTHER REMEDY AVAILABLE UNDER APPLICABLE LAW, IF YOU OR ANY INSURED PERSON SEEKING COVERAGE UNDER THIS POLICY, KNOWINGLY, OR UNKNOWINGLY CONCEALED, MISREPRESENTED OR OMITTED ANY MATERIAL FACT OR ENGAGED IN FRAUDULENT CONDUCT AT THE TIME THE APPLICATION WAS MADE OR AT ANY TIME DURING THE POLICY PERIOD. b) AFTER THIS POLICY HAS BEEN IN EFFECT 60 DAYS OR MORE, AND IF: (1) YOU OR ANY INSURED PERSON SEEKING COVERAGE UNDER THIS POLICY KNOWINGLY MISREPRESENTED OR OMITTED ANY MATERIAL FACT; AND (2) SUCH MISREPRESENTATION OR OMISSION COULD NOT HAVE REASONABLY BEEN DISCOVERED BY US IN LESS THAN 60 DAYS; AND (3) THE UNDISCLOSED INFORMATION WOULD HAVE PROMPTED US TO REFUSE ACCEPTANCE OF THE RISK; WE MAY RESCIND COVERAGE UNDER THIS POLICY AS TO COVERAGES RELATING TO THE ACTUAL PERPETRATOR OF THE FRAUD OR MISREPRESENTATION, OR, AT OUR ELECTION, ASSERT ANY OTHER REMEDY AVAILABLE UNDER APPLICABLE LAW. 10. LEGAL ACTION LIMITATIONS No legal action may be brought against the company concerning any of the coverages provided in this policy until the insured has fully complied with all terms of the policy. Under the liability coverages of this policy, no legal action may be brought against the company until judgment against the insured has been finally determined after trial. This policy does not give anyone the right to make us a party to any action to determine the liability of an insured. '11. SUBROGATION We have the right of subrogation under the: a) Physical Damage; b) Auto Liability; c) Medical Payments; d) Uninsured Motorists; and e) Underinsured Motorists; coverages in this policy and its endorsements. This means that after paying a loss to you or others under this policy, we will have the insured's right to sue for or otherwise recover such loss from anyone else who may be liable. Also, we may require reimbursement from the insured out of any settlement or Judgment that duplicates our payments. These provisions will be applied in accordance with state law. Any insured will sign such papers, and do whatever else is necessary, to transfer these rights to us, and will do nothing to prejudice them. If payment of a claim under Uninsured Motorists coverage arises out of the insolvency of an insurer, we will have right of recovery against the insurer or its receiver, but not its Insured. We are not entitled to recovery under Uninsured Motorists or Underinsured Motorists coverage until the insured has been fully compensated for damages. 12. NON -SUFFICIENT FUNDS The company reserves the right to impose a fee for any premium payment that is unable to be processed due to non -sufficient funds, or if there are non -sufficient funds In an account that is being utilized for electronic funds transfer (EFT) payments. This is under the terms and conditions approved where required by the Department of Insurance. G3 General Policy Conditions 13. UNLICENSED DRIVERS Protection under this policy does not apply to the use of any motor vehicle when operated by an individual without a current valid operator's license. MUTUAL POLICY CONDITIONS (Applicable only to policies issued by Nationwide Mutual Insurance Company --Nationwide Mutual Fire Insurance Company.) if this policy is issued by Nationwide Mutual Insurance Company or Nationwide Mutual Fire Insurance Company, the policyholder is a member of the company issuing the policy while this or any other policy issued by one of these two companies is in force. While a member, the policyholder Is entitled to one vote only --regardless of the number of policies issued to the policyholder --either In person or by proxy at meetings of members of said company. The annual meeting of members of Nationwide Mutual Insurance Company will be held at the Home Office at Columbus, Ohio, at 10 a.m. on the first Thursday of April. The annual meeting of members of Nationwide Mutual Fire Insurance Company will be held at the Home Office at Columbus, Ohio, at 9:30 a.m. on the first Thursday of April. If the Board of Directors of either of the above companies should elect to change the time or place of meeting, that company will mall notice of the change to the policyholder at the address last known to It. The company will mail this notice at least 10 days in advance of the meeting date. This policy is non -assessable, meaning that the policyholder is not subject to any assessment beyond the premiums the above companies require for each policy term. IN WITNESS WHEREOF: Nationwide Mutual insurance Company, Nationwide Mutual Fire Insurance Company, Nationwide Property and Casualty Insurance Company, Nationwide General Insurance Company, or Nationwide Insurance Company of America, whichever is the issuing company as shown In the Declarations, has caused this policy to be signed by its President and Secretary, and countersigned as may be required by a duly authorized representative of the company 6gt-w 74.17 Secretary Nationwide Mutual Insurance Company Nationwide Mutual Fire Insurance Company Nationwide General Insurance Company Nationwide Insurance Company of America -mad a Qi President Nationwide Mutual Insurance Company Nationwide Property & Casualty Insurance Company Nationwide Mutual Fire Insurance Company President Nationwide Insurance Company of America (1(4(AL14 Secretary 9� 1G/.4 LC/ Nationwide Property & Casualty Insurance Company President Nationwide General Insurance Company Nationwide Insurance Companies/Home Office: Columbus, Ohio 43215-2220 Nationwide Mutual Insurance Company • Nationwide Mutual Fire Insurance Company Nationwide Property and Casualty Insurance Company • Nationwide General Insurance Company Nationwide Insurance Company of America G4 Endorsement 3329 Amendatory Endorsement Please Attach this important addition to your auto policy. It is agreed this policy is amended as follows: PHYSICAL DAMAGE (damage to your auto) ADDITIONAL DEFINITIONS APPLICABLE TO THESE COVERAGES Item 2. Is replaced to read: 2. "EQUIPMENT" means anything usual and incidental to the use of amotor vehicle as a motor vehicle. Equipment does not include customization or any type of trailer. The following definition is added: 3. "CUSTOMIZATION" means devices, accessories, enhancements, and changes, other than those offered by the manufacturer of the motor vehicle specifically for that model, which alter the appearance, performance or function of a motor vehicle. This includes custom refinish, decals, and graphics. COVERAGE EXCLUSIONS We will not pay for Toss: To Customization, other than original equipment from the manufacturer, in or upon your motor vehicle. However, this exclusion does not apply up to the first $1,500 of Customization. LIMITS AND CONDITIONS OF PAYMENT ACTUAL CASH VALUE The following sentence is added: The limit of coverage shall not be Increased for Customization unless such Customization has been specifically declared to us and an additional charge is paid. This endorsement applies as stated in the policy Declarations. This endorsement is issued by the company shown in the Declarations as the issuing company. NATIONWIDE INSURANCE COMPANIES One Nationwide Plaza Columbus, OH 43215-2220 Hearing or Voice Impaired: 1-800-622-2421 (TTY only) nationwide.com V-3329 Endorsement 3393 Guaranteed Automobile Insurance Coverage (Pennsylvania) Please attach this important addition to your auto policy. In recognition of your loyalty to Nationwide, we are pleased to provide Guaranteed Automobile Insurance Coverage. It is agreed that the policy is amended as follows: GENERAL POLICY CONDITIONS • The following General Policy Condition Is added: GUARANTEED AUTOMOBILE INSURANCE COVERAGE a) The company guarantees to insure the policyholder for the automobile Insurance coverages and limits provided by this policy. We have the right to refuse to renew this auto policy as provided under the General Policy Conditions. If we exercise our right to nonrenew, we will offer to issue an equivalent new policy. This new policy may be issued by another company under the same ownership or management as our company. Additionally, this new policy may offer different terms and conditions as your previous policy Renewal will be In accordance with the policy forms, rules and rating plan in use by us at each six-month term. The premium for the coverage provided by this policy and attached endorsements is based on information in our possession. Any change or correction in this information will allow us to make an adjustment of the premium. Our right to cancel this coverage is limited to the applicable conditions stated in the General Policy Conditions of your policy. All other provisions of this policy apply. The endorsement is issued by the company shown in the Declarations as the issuing company. NATIONWIDE INSURANCE COMPANIES One Nationwide Plaza Columbus, OH 43215-2220 Hearing or Voice Impaired: 1-800-622-2421 (TTY only) nationwide.com V-3393 Endorsement 3453 Amendatory Endorsement Please attach this important addition to your auto policy. With this endorsement, the policy Is amended as follows: Physical Damage (damage to your auto) ADDITIONAL DEFINITIONS APPLICABLE TO THESE COVERAGES The following definition is added: "BETTERMENT" is the Increase in value of: a) a vehicle; or b) property; or c) any parts of a vehicle or property; as a result of repairing or replacing certain parts damaged in a Toss. Limits and Conditions of Payment ACTUAL CASH VALUE is replaced to read: ACTUAL CASH VALUE The limit of our coverage is the actual cash value of your auto or its damaged parts at the time of Toss. To determine actual cash value, we will consider: 1. fair market value; 2, age; 3. condition of the property; and 4. betterment; at the time of Toss. If a repair or replacement results in betterment, we will not pay for the amount of betterment. In addition to our payment of the loss, necessary and reasonable towing and storage will be paid to protect the auto from further damage. Covered storage costs are not to exceed four days of storage charges incurred prior to the date you report the loss to us. The limit of coverage shall not be increased for Customization unless such Customization has been specifically declared to us and an additional charge is paid. This endorsement applies as stated in the policy Declarations. This endorsement Is issued by the company shown in the Declarations as the issuing company. Nationwide Mutual Insurance Company and Affiliated Companies One Nationwide Plaza Columbus, OH 43215-2220 Hearing or Voice Impaired: 1-800-622-2421 (TTY only) nationwide.com Nationwide and the Nationwide framemark are federally registered service marks of Nationwide Mutual Insurance Company. © 2009 Nationwide Mutual Insurance Company, All Rights Reserved V-3453 Nationwide® Insurance Endorsement 3455A — Car key replacement coverage Please attach this important addition to your auto policy. The policy is amended to provide Car key replacement coverage. Coverage is subject to all terms and conditions of the policy, except as changed by this endorsement. Car key replacement coverage If you have Comprehensive coverage, as shown in the Declarations, we will reimburse you for reasonable expense incurred to replace the key or electronic entry device for your auto and for the services to gain entry into your auto. The most we will pay is $400 per occurrence for all expenses. Coverage is subject to the following conditions: 1. The key or electronic entry device for your auto is lost "®' or locked in your auto and you are unable to enter your auto. 2. Original copies of receipts for servicesmitefor. rsement is payable. No deducts g :��: y �s»"., _-s maa •��.is ea �`'sement. This endor The endors atx is i by= ompany shown in the Declarations as the issuing company. V -3455-A ©2009 Nationwide Mutual Insurance Company, All Rights Reserved/ Nationwide Mutual Insurance Company and Affiliated Companies/ One Nationwide Plaza Columbus, OH 43215 Nationwide, the Nationwide framemark, and Nationwide is On Your Side are service marks of Nationwide Mutual Insurance Company Endorsement 3457 Amendatory Endorsement (Pennsylvania) Please attach this important addition to your auto policy. It Is agreed this policy is amended as follows: DEFINITIONS Item 11. is replaced to read: 11. "BODILY INJURY" means accidental bodily harm to a person and that person's resulting illness, disease or death. PHYSICAL DAMAGE (damage to your auto) LOSS PAYABLE CLAUSE is replaced to read: LOSS PAYABLE CLAUSE This clause applies to the Comprehensive and Collision coverages provided by this policy. It protects the Iienholder named in the policy Declarations. Payment for Toss will be made according to the interest of the policyholder and Iienholder. At our option, payment may be made to both jointly, or to either separately. Either way, the company will protect the interests of both. Protection of the Iienholder's financial interest will not be affected by any change In ownership of the vehicle insured, nor by any act or omission by any person entitled to coverage under this policy. However, protection under this clause does not apply: 1. In any case of: a) fraud; b) misrepresentation, either In the application process, or In the presentation of a claim; c) material omission; d) conversion; e) embezzlement; f) secretion; or g) willful damaging or destruction of your auto; committed by or at the direction of you or a relative. 2. To the Toss of your auto while It is being used by you, a relative, or any person with your permission on a temporary or permanent basis, for the transportation of, or In exchange for, any illegal substance, or in connection with any criminal trade or transaction. 3. Where the loss is otherwise not covered under the terms of this policy. We will protect the Iienholder's interest for 10 days from the date we notify them that the policy has terminated, for any reason. If we pay the Iienholder for any loss or damage suffered during that 10 -day period, we have the right to recover the amount of any such payment from you. The company will not notify the Iienholder each time you renew this policy, and we may cancel this policy according to the terms. The company will also notify the Iienholder if coverage under the policy is excluded for any named driver. However, If the named excluded driver was operating the vehicle at the time of the loss, there is no coverage under the policy. The Iienholder shall notify the company upon learning of any change in ownership of the vehicle. © 2009 Nationwide Mutual Insurance Company, All Rights Reserved V-3457 Page 1 of 2 To the extent of payment to the lienholder, the company will be entitled to the Iienholder's rights of recovery. The company will do nothing to impair the right of the lienholder to recover the full amount of its claim. IF WE BECOME OBLIGATED TO REIMBURSE A LIENHOLDER UNDER THIS COVERAGE DUE TO YOUR FAILURE TO MEET THE POLICY REQUIREMENTS OR THROUGH YOUR FAILING TO MAKE YOUR PREMIUM PAYMENTS, WE HAVE THE RIGHT TO RECOVER FROM YOU ANY MONEY WE PAY. GENERAL POLICY CONDITIONS Item 9. is replaced to read: 9. FRAUD AND MISREPRESENTATION a) THIS POLICY WAS ISSUED IN RELIANCE ON THE INFORMATION YOU PROVIDED AT THE TIME OF YOUR APPLICATION FOR INSURANCE COVERAGE. WITHIN THE FIRST 60 DAYS THIS POLICY HAS BEEN IN EFFECT, WE MAY RESCIND COVERAGE UNDER THIS POLICY, DENY COVERAGE UNDER THIS POLICY, OR, AT OUR ELECTION, ASSERT ANY OTHER REMEDY AVAILABLE UNDER APPLICABLE LAW, IF YOU OR ANY INSURED PERSON SEEKING COVERAGE UNDER THIS POLICY, KNOWINGLY, OR UNKNOWINGLY CONCEALED, MISREPRESENTED OR OMITTED ANY MATERIAL FACT OR ENGAGED IN FRAUDULENT CONDUCT AT THE TIME THE APPLICATION WAS MADE OR AT ANY TIME DURING THE POLICY PERIOD. b) AFTER THE FIRST 60 DAYS THIS POLICY HAS BEEN IN EFFECT, AND IF: (1) YOU OR ANY INSURED PERSON SEEKING COVERAGE UNDER THIS POLICY KNOWINGLY MISREPRESENTED OR OMITTED ANY MATERIAL FACT; AND (2) SUCH MISREPRESENTATION OR OMISSION COULD NOT HAVE REASONABLY BEEN DISCOVERED BY US IN LESS THAN 60 DAYS; AND (3) THE UNDISCLOSED INFORMATION WOULD HAVE PROMPTED US TO REFUSE ACCEPTANCE OF THE RISK; WE MAY VOID COVERAGE UNDER THIS POLICY, DENY COVERAGE UNDER THIS POLICY, OR AT OUR ELECTION, ASSERT ANY OTHER REMEDY AVAILABLE UNDER APPLICABLE LAW. IF WE VOID COVERAGE UNDER THIS POLICY, THIS SHALL NOT AFFECT THE LIABILITY COVERAGE OF THIS POLICY. c) WE DO NOT PROVIDE COVERAGE TO ANY INSURED UNDER THIS POLICY WHEN YOU OR ANY OTHER PERSON OR ORGANIZATION SEEKING COVERAGE OR PAYMENT UNDER THE POLICY HAS CONCEALED OR MISREPRESENTED ANY MATERIAL FACT OR ENGAGED IN FRAUDULENT CONDUCT IN CONNECTION WITH THE FILING OR SETTLEMENT OF ANY CLAIM UNDER THIS POLICY. d) NO PERSON OR ORGANIZATION WHO ENGAGES IN FRAUDULENT CONDUCT IN CONNECTION WITH THE APPLICATION PROCESS, AN ACCIDENT OR FILING A CLAIM, OR ENGAGES IN ANY MATERIAL MISREPRESENTATION REGARDING THE ISSUANCE OF THIS POLICY SHALL BE ENTITLED TO RECEIVE ANY PAYMENT UNDER THIS POLICY AT ANY TIME. This endorsement applies as stated in the policy Declarations. This endorsement is issued by the company shown in the Declarations as the issuing company. Nationwide Mutual Insurance Company and Affiliated Companies One Nationwide Plaza Columbus, OH 43215-2220 Hearing or Voice Impaired: 1-800-622-2421 (TTY only) nationwide.com Nationwide and the Nationwide framemark are federally registered service marks of Nationwide Mutual Insurance Company. © 2009 Nationwide Mutual Insurance Company, All Rights Reserved Page 2 of 2 V-3457 Nalbmrlde Nationwide® Insurance Endorsement 3475 — Pet injury collision coverage Please attach this important addition to your auto policy. The policy is amended to provide Pet injury collision coverage. Coverage is subject to all terms and conditions of the policy, except as changed by this endorsement. Pet injury collision coverage If you have Collision coverage, as shown in the Declarations, we will reimburse you reasonable expenses as determined by us, up to $500 for injury to your or a relative's dog or cat. The following expenses are covered: 1. Necessary veterinary expenses, including medicines; and 2. The cost to replace your dog or cat (with similar dog o��t i� ults in death. 'tea, The most we will pay is $500 per occurrence for all exp r,.f the number of dogs and cats involved. Coverage is subject to the following d" 1. It applie 2. It applie your auto at the time of a covered Collisio 3. Our obl ry under this coverage has no effect on any other policy that yo s. No deducti pplies to any payments made under this endorsement. This endorsement applies as stated in the policy Declarations. The endorsement is issued by the company shown in the Declarations as the issuing company. V-3475 ©2009 Nationwide Mutual Insurance Company, All Rights Reserved/Nationwide Mutual Insurance Company and Affiliated Companies/ One Nationwide Plaza Columbus, OH 43275 Nationwide, the Nationwide framemark, and Nationwide is On Your Side are service marks of Nationwide Mutual Insurance Company Endorsement 3535 Amendatory Endorsement Please attach this important addition to your auto policy. With this endorsement, the policy is amended as follows: MUTUAL POLICY CONDITIONS is replaced to read: MUTUAL POLICY CONDITIONS AND PROXY (Applicable only to policies issued by Nationwide Mutual Insurance Company - Nationwide Mutual Fire Insurance Company.) If this policy is issued by Nationwide Mutual Insurance Company or Nationwide Mutual Fire Insurance Company, the policyholder is a member of the company issuing the policy while this or any other policy issued by one of these two companies is in force. While a member, the policyholder is entitled to one vote only - regardless of the number of policies issued to the policyholder - either in person or by proxy at meetings of members of said company. By accepting this policy of insurance, the member appoints the Chairman of the Board of Directors of the company, with full power of substitution, to be the member's proxy, and such Individual is authorized and empowered to vote on behalf of the member on all matters presented for vote at any membership meeting of the company. The proxy will continue in force for the full duration of this policy or any renewal thereof issued by the company to the member. This proxy may be revoked at any time by providing written notice of such revocation to: Secretary, Nationwide Mutual Insurance Company/Nationwide Mutual Fire Insurance Company, Attention: Proxy Revocation, One Nationwide Plaza, Columbus, Ohio 43215. The member may also revoke this proxy in person at any meeting of the members by so announcing in the open meeting before any vote is taken or the proxy authority is exercised. This proxy granted to the Chairman of the Board of the company will be superseded by any other valid proxy presented to the Secretary of the company in accordance with the Amended and Restated Bylaws of the company under Article 11, Section 7. The annual meeting of members of the Nationwide Mutual Insurance Company will be held at the Home Office at Columbus, Ohio, at 10 a.m. on the first Thursday of April. The annual meeting of members of the Nationwide Mutual Fire Insurance Company will be held at the Home Office at Columbus, Ohio at 9:30 a.m. on the first Thursday of April. If the Board of Directors of either of the above companies should elect to change the time or place of meeting, that company will mall notice of the change to the policyholder at the address last known to it. The company will mall this notice at least 10 days in advance of the meeting date. This policy is non -assessable, meaning that the policyholder is not subject to any assessment beyond the premiums the above companies require for each policy term. This endorsement applies as stated in the policy Declarations. This endorsement is issued by the company shown in the Declarations as the issuing company. Nationwide Mutual Insurance Company and Affiliated Companies One Nationwide Plaza Columbus, OH 43215-2220 Hearing or Voice impaired: 1-800-622-2421 (TTY only) nationwide.com Nationwide and the Nationwide framemark are federally registered service marks of Nationwide Mutual Insurance Company. m 2010 Nationwide Mutual Insurance Company, All Rights Reserved V-3535 EXHIBIT J ALETZ, -WRY :5-0 1. U T 1' N earlier Name: NatialtiAlide Clahn Number: 58378 539671051.820130 & Date a/ Leas. OS / U1/ 2013 Patient Nome: CROFT, CAROLYN Page 1 of PIP Leg FilootAIOther Totik Total Charges S 5102.34 5102,34 Tail Paler ': . 2065 49;•;.'•" ' 205'59'1 Applied te Deductible $ 0.00 $ 0.00 ,..Ded111............• ...:',AgrienseType-c.','.9.eivicerevider/PaSee-..r7',',..-:*:*.'.' rst DOS:,..:7:,--:tast.1305.f,;-1;::::EtilledAteciunt'::1;:-:::Riateti:RelitteliedLictible'').-2..:Cripay:::`:Defel7atilid:::,..,...,OtediNtreber,.. ,,Arliz.iirrt Pard N40158596 S.ledial • CHAMBERSBURG HOSPITAL 2013-05-18 2013-05-18 2635.38 594.41 0.00 0.00 2al.a-os-ze sg4Ai. ...... .................. ..... ..... ..„ . ... ... ..............,.,....,.........„......... .. ,. .. . .. . . . .. .._. r. NN0158597: -. :Medicl ; - : : • -.;, :.cONNOit,..i:MICHA ;: ' ;•;:' ': , ' : *;201305:18;,.' '2013 65'18 • ...:.: '• ;:;: .: 587.10. : ':‘: :..-. -265.0i -. ---- • ... • -.- • 0,00: - :- .006.'2013:0745a . • ..• .. -- -..•-•-• •...-.... .... -..... .... 265,01 . .... .. . . .. . „ . ... . . .. . . . . „ , . . . . . . , .. . .. .. . . ..... .. . . .. . . . . . N\N0885331 Medical WSEMS-CHAMBERS BURG ALS 7013-05-18 2013-0S-18 98126 785.49 000 0.00 2013-07-09 78549 Nbit0925025' .' :Medical -.• ••••-•-•-'-.-51-UPPENS8URG AREAR4S-'.---."-'.-.'. 2013-0548.y. 2013-05-18 .".'-'.'-' -' 898.00••••••-• <'.• -.454,68 .:...:.: . : .. :: . 0.00 000 ..013 07,.. ... :: -.; .....::.. :.:.:....f.:.-.• ..:.:-....-.:;. 456.65: • hftps://ad.alsreview.com/Concentrawebflow/(S(huz55j45vm2hy145sg4ydw55))/PrintGrid.aspx?APP=CFV_PIPRESULT&CLAI... 7/25/2013 EXHIBIT K •LJ�GUUUVU�4L V LUG (E-1/11S NTERS FOR MEDICARE & MEDICAID SERVICES cog&R Coordination of Benefits and Recovery May 1, 2014 1420 1 MB 0.435 ***AUTO**MIXED AADC 720 R:1420 T:13 P:16 PC:3 F:380701 MOONEY & ASSOCIATES 230 YORK ST STE 1 HANOVER, PA 17331-3272 111111111111111111111-11111-111 111111"11IIIIIIIIITIEIE111EEIJIIEI1 Beneficiary Name: Medicare Number: Case Identification Number: Insurer Policy Number: Date of Incident: CROFT, CAROLYN V 204281850A 20133 09090 00659 382N72868 May 18, 2013 Dear MOONEY & ASSOCIATES: This letter follows a previous letter notifying you of Medicare' s priority right to recovery as defined under the Medicare Secondary Payer provision. To date, Medicare has not paid any claims that currently appear related to the beneficiary' s pending settlement, judgment, or award for the above referenced incident. It is possible that Medicare may have paid claims related to the date of incident but may not have been retrieved and/or included for the following reasons: the nature of the injury or illness has not been provided or is incomplete, or all claims have not been submitted by the providers. However, Medicare may pay related claims in the future. Therefore, when the case does settle, please complete the attached, "Final Settlement Detail Document" and return it to us. Upon receipt of the completed documents, we will perform a final search of Medicare claims history and notify you if a refund is due Medicare. Please note: If the underlying claim involves ingestion, exposure, implantation, or other non -trauma based injury, Medicare may have excluded the paid claims related to your case. Please contact the Benefits Coordination & Recovery Center (BCRC) immediately with a description of the injury so that we may associate the appropriate claims with the case. NGHP • PO BOX 138832 • OKLAHOMA CITY, OK 73113 SGLAO8NGHP Page 1 of 4 CMS ce TF15 FOR MEDICARE & MEniC&D SERVIcES &QB&R' Coordination of Benefits and Recovery Should conditional payment information become available, it will be posted under the "MyMSP" tab of the www.mymedicare.gov website. The information at www.mymedicare.gov will be updated weekly with any changes or newly processed claims. If you wish, you may track the medical expenses that were paid by Medicare, and if you have an attorney or other representative, provide him/her with this information. This may help you/ your attorney with . finalizing your settlement. If you have any questions concerning this matter, please contact the Benefits Coordination & Recovery Center (BCRC) by phone at 1-855-798-2627 (TTY/TDD: 1-855-797-2627 for the hearing and speech impaired), in writing at the address below, or by fax to 405-869-3309. When sending correspondence, please include the Beneficiary Name along with the Medicare and Case Identification Numbers (shown above). Sincerely, BCRC Enclosure: Final Settlement Detail Document Payment Summary Form CC: Estate of CAROLYN V CROFT NGHP • PO BOX 138832 • OKLAHOMA CITY, OK 73113 SGLAO8NGHP Page 2 of 4 Attorney Case Information �GI%I Medicare Sec 'Wary Payer Recovery Porta OM46I01 WOK. a $umums'nan Home About This Site CMS Links How To... Reference Materials Page 1 of 1 Skip Navigation Contact Us Logoff Case Information Case ID: 20133 09090 00659 Case Type: Liability Case Status: Open What is this? Beneficiary Medicare Number: *****1850A Beneficiary DOB: 02/17/1937 Beneficiary Last Name: Croft , Print This page Rights and Responsibilities Letter Mail Date: 11/12/2013 Conditional Payment Letter Mail Date: Current Conditional Payment Amount: $0.00 Conditional Payment Amount was updated on: 04/25/2014 Authorization Level: Proof of Representation Demand Letter Mail Date: Authorization Status: Verified Demand Amount: Please select an action from the following list, if the option is disabled it may not be available for the case at this time: a View/Request Authorizations (Proof of Representation or Consent to Release) liw Request an update to the conditional payment amount What is this? 0 Request a mailed copy of the conditional payment letter What is this? 0 View/Dispute Claims Listing What is this? 0 Provide the Notice of Settlement Information Submit Query Submit Query Privacy Policy 1 User Agreement Quick Help Help About This Page https://www.cob.cros.hhs.gov/MSPRP/msprpCase! displayCaseFromList?listKey=2tngZFZ... 5/19/2014 EXHIBIT L riuril. Cirr raxIwaKei V. JaSVfI L. irriier tsq. rage. 11:z uate. 1U/4/Z01=3 1 Z. 1 &.41 t-Wi Rahe wlings Company LLC Subrogation Division Post Office Box 2000 LaGrange, Kentucky 40031-2000 One Eden Parkway LaGrange, Kentucky 40031-8100 Telephone (502) 587-1279 To: Our File No: Fax Number: From: Phone: Fax: Email Subject: Pages: TELECOPY Jason C. Imler Esq. 59424866 (717)632-3612 Denise Harris 818-908-3760 x233 502-753-6875 drnh(arawlingscompany.com Carolyn Croft 2 Message: Please see attached. Confidential Healthcare Information Enclosed Healthcare information is personal and sensitive information, and you, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Disclosure of this information without additional patient consent or as permitted by law is prohibited. Unauthorized disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state law. IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this information is STRICTLY PROHIBITED. If you have received this message in error, please notify us immediately and destroy the related message. Under Hawaii law, The Rawlings Company is a registered collection agency that is attempting to collect a claim. Any information obtained will be used for that purpose. This fax was sent with GFI FaxMaker fax server. For more information, visit: http://www.gfi.com Frorn. '3U9 raxMaKer To. Jason G. Irnier Esq. Rahe wlings Company LLC Subrogation Division Mr. Jason C. Imler, Esquire MOOONEY & ASSOCIA TES 230 York Street Hanover, PA 17331 Page. 212 Date. 10/4/2013 12.19.41 PM October 04, 2013 Re: Our Client: Aetna Member/Patient: CAROLYN CROFT/CAROLYN CROFT Date of Loss: 5/18/2013 Our Reference No.: 59424866 Your Clicnt: Carolyn Virginia Croft (doocaScd) Your Number: n/a Dear Mr. Lnler, Esquire: Post Office Box 2000 LaGrange, Kentucky 40031-2000 One Eden Parkway LaGrange, Kentucky 40031-8100 (818) 908-3760 We represent Aetna. Our client has not paid any medical bills to date in relation to the accident referenced above. Our file is now closed. Sincerely, Denise M. Harris Senior Recovery Analyst 818-212-2214 FAX: (502) 753-6875 dmh@rawlingscompany.com This fax was sent with GFI FaxMaker fax server. For more information, visit: http://www.gfi.com EXHIBIT M pennsylvania DEPARTMENT OF REVENUE October 24, 2013 Jason Imler, Esquire Mooney & Associates 230 York Street Hanover, PA 17331 Re: Estate of Carolyn Croft File Number 2113-0709 Court of Common Pleas Cumberland County Dear Mr. Imler: The Department of Revenue has received your correspondence. Attached was the petition to approve a compromise settlement to be filed on behalf of the above -referenced estate in regard to a wrongful death and survival action. It was sent to this office for the Commonwealth's approval of the allocation to the proceeds paid to settle the actions. According to the Petition, the 76 year old decedent died as a result of being struck by a motor vehicle. Decedent is survived by her five adult children. Pursuant to the Supreme Court of Pennsylvania, before there can be any recovery in damages by one in family relation for negligent death of another in the same relation, there must be a pecuniary loss. Manning v. Capelli, 411 A.2d 252, 270 Pa.Super. 207, Super.1979. Family relation required to maintain action under Wrongful Death Act is defined to require showing of pecuniary loss by relatives seeking damages as result of wrongful death of decedent; there must be pecuniary loss by one in family relation before there is any recovery in damages. Hodge v. Loveland, 690 A.2d 243, 456 Pa.Super. 188, Super.1997, reargument denied, appeal denied 723 A.2d 672, 555 Pa. 701. Occasional gifts and services are not sufficient on which to ground a pecuniary loss. Gaydos, Supra, 301 PA at 530, 152 A. and 552. However as the proceeds in this matter are a minimal gross of $125,000.00, this Office has no objection to the allocation that you have requested. Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $100,000.00 to the wrongful death claim and $25,000.00 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 Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has any questions or requires anything ad itional from this Bureau. Sinc y, annon E. Baker Trust Valuation Specialist Inheritance Tax Division Bureau of Individual Taxes 1 PO Box 280601 1 Harrisburg, PA 17128 1 717.783.5824 1 shabaker@pa.gov MOONEY ASS4GIATES ATTORNEYS AT LAW www;rnooney4 aw;corn. Telephone: 717-632-4656 Carolyn Croft May 12, 2014 Regarding: Personal Injury Acct. No.: 8773-14 Additional Charges : Amount 7/22/2013 Payment to EMS 29.18 Payment to Healthport 63.39 4/9/2014 Payment to Prothonotary of Cumberland County 103.75 5/23/2014 Payment to PA State Police - Accident Report 8.00 Total additional charges $204.32 Balance due $204.32 PAYMENT IN FULL IS DUE BY THE 24TH OF EACH MONTH. UNPAID BALANCES AFTER THE 24TH WILL BE CHARGED 24% INTEREST. WE ACCEPT CREDIT CARD PAYMENTS AT OUR WEBSITE: WWW.MOONEYANDASSOCIATES.COM OR VIA TELEPHONE AT (717) 632-4656 PAYMENTS SUBMITTED VIA REGULAR MAIL MUST BE SENT TO: MOONEY Si ASSOCIATES 230 YORK STREET, HANOVER, PA 17331 EXHIBIT O ectiky C itoA croiev. 4r Es-feek or CcoreireLe vot ore MOONEY & ASSOCIAES, LLC PERSONAL INJURY FEE AGREEMENT , do hereby retain Mooney & Associates, as my attorneys in this matter to represent me and to process, negotiate, arbitrate a settlement or to institute in my name, any legal proceedings or actions that, in their judgment are necessary ains anyone who is or may be liable as a result of injuries and damages I sustained in an incident that occurred on 5 18 13 I agree not to settle, negotiate or adjust the above claim or any proceedings based thereon without the written consent of my said attorneys. In consideration of the services to be rendered by Mooney & Associates, I hereby covenant, promise and agree to pay them for their professional services rendered, ONE-THIRD (1/3) of whatever sum is recovered as a result of settlement prior to filing suit; or FORTY PERCENT (40%) of whatever sum is recovered if suit is filed or in the event of arbitration or mediation. I will reimburse Mooney & Associates for any necessary expenses advanced on my behalf in pursuing my claim. Examples of typical expenses include Court filing fees, investigation, auto mileage, photocopies, court reporters, medical records, expert witness fees, etc. Ifno money is obtained, client will not owe a legal fee or expenses. In the event that an appeal of my case is necessary, either because I decide to appeal or because the other party appeals, I agree to pay any additional costs incurred. I agree to pay an additional fee to be mutually agreed upon at the time of appeal based upon the usual fees reasonable for such appeal. I agree that Mooney & Associates may associate additional lawyers to assist with this case and I agree to the sharing of fees between lawyers. I understand the terms herein apply to other lawyers associated on this case. I understand that the association of other lawyers does not increase the amount of the attorney fees at the conclusion of the case. I understand that Counsel reserves the right to withdraw their representation if they desire to do so, for any reason(s) they deem proper within the rules of professional responsibility. I understand and agree that if counsel terminates the attorney/client relationship, I may obtain the contents of my file upon payment to Mooney & Associates for costs incurred up to the date of termination. I understand that if I terminate the attorney/client relationship, I will be responsible to Mooney & Associates for costs incurred up to the date of termination, notwithstanding language in the agreement to the contrary and regardless of whether I desire the contents of my file. I agree to keep my attorneys advised of my whereabouts at all times and to cooperate in the preparation and pursuit of my case, to appear on reasonable notice for depositions and court appearances, and to comply with all reasonable requests made of me in connection with the preparation of my case. If a recovery is made on my behalf, it is my understanding that I will be given the option of taking possession of my medical records at the time of settlement. If I elect not to take my medical records with me at the time of settlement, I agree to the destruction of my medical records at that time. I understand that the remainder of my file will be retained by Mooney & Associates for a period of seven (7) years from the date of settlement, at which time it will be destroyed in a manner which preserves confidentiality and with no further notice to me and I consent to same. I agree to receive correspondence from Mooney & Associates via password protected email. (Initial) I agree that a lawsuit by its nature is unpredictable and that my attorneys have made no guarantee regarding the successful termination of my claim. I acknowledge that I have read and understand this Agreement and have received a copy of same. The terms set forth herein are accepted and approved. Attorney Sign re Date < �r4,,eu e-/- @ /- c © ").1 '-Email Address 5 CALVIN CROFT, .• Individually, on behalf of his siblings, IN THE COURT OF COMMON PLEAS and as Administrator of the CUMBERLAND COUNTY, ESTATE OF CAROLYN V. CROFT, PENNSYLVANIA Petitioner v. •CIVIL ACTION - LAW /9— z9/ 9 2;C7 -)— GEORGIA J. DAVIS, STATE FARM . MUTUAL AUTOMOBILE .• INSURANCE COMPANY, and .• NATIONWIDE MUTUAL .• INSURANCE COMPANY .• Respondent . ORDER OF COURT AND NOW, this a3 ay of Mid- , 2014, upon consideration of the foregoing Petition, IT IS HEREBY ORDERED that: 1. The above Petitioners may compromise the wrongful death and survival action claims set forth in the within Petition to Approve Settlement of Wrongful Death and Survival Actions, for the principal total sum of $125,000.00. 2. The payment of counsel fees is approved, in the amount of $41,666.66, and costs, in the amount of $204.32, to Mooney & Associates, from the funds due for a total of $$41,870.98. 3. Direct distribution of the net proceeds ($83,129.02) of the settlement as follows: I. To the Petitioner, Calvin Croft and his siblings, for the Wrongful Death action, in the amount of $66,503.22 representing 80% of the net proceeds which will be distributed equally to Calvin Croft, II. Cathy Durrer, Karen Byrd, Tim Croft, and Karl Croft; and To the Estate of Carolyn V. Croft for the Survival Action, in the amount of $16,625.80 representing 20% of the net proceeds. BY THE COURT: J.