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HomeMy WebLinkAbout14-4400THE PROTHDN• ,T`.ARY Z0 E 4 JUL 2$. Mill '40-. CUMBERLANO COUNTY PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA In re: David Cassel as Executor and Lisa Sanna, as Executrix of the Estate of Arlene M. Cassel, and of the Estate of Willard F. Cassel, Jr., NO. - 400 aiVi Fri PETITION FOR COURT APPROVAL OF SETTLEMENT AND DISTRIBUTION OF PROCEEDS OF WRONGFUL DEATH AND SURVIVAL ACTION COMES NOW, the Petitioners, David Cassel as Executor and Lisa Sanna, as Executrix of the Estate of Arlene M. Cassel, deceased, and of the Estate of Willard F. Cassel, Jr„ deceased, by and through Griffith, Strickler, Lerman, Solymos & Calkins, and Michael B. Scheib, Esquire, and respectfully requests permission to enter into the below described settlement, and in support thereof avers: A. ARLENE M. CASSEL 1. Arlene M. Cassel, deceased, died on May 10, 2011, as a result of injuries she sustain in a motor vehicle accident which occurred on May 9, 2011 in Cumberland County, Pennsylvania. A copy of the Local Registrar's Certification of Death for Arlene M. Cassel, is attached hereto as Exhibit "A". 45 113 .r75 Qp AYE dell $8fo51 3O b'75 2. David Cassel, son and Executor of the Estate of Arlene M. Cassel and of the Estate of Willard F. Cassel, Jr., is an adult individual residing at 3514 Margo Road, Camp Hill, Pennsylvania 17011. 3. Lisa Sanna, daughter and Executrix of the Estate of Arlene M. Cassel and of the Estate of Willard F. Cassel, Jr, is an adult individual residing at 4 Crooked Drive, Enola, Pennsylvania 17025. 4. This motor vehicle accident occurred on May 9, 2011 on Carlisle Pike, Hampden Township, Cumberland County, Pennsylvania. Carlisle Pike is a four lane road with two lanes running eastbound. At the time of the accident, Willard F. Cassel, Jr. was operating a motor vehicle in the left hand lane travelling eastbound on Carlisle Pike. At the time of the accident, Arlene M. Cassel, was a passenger in the motor vehicle accident being operated by Willard F. Cassel, Jr. At the time of the accident, a vehicle owned and operated by James Hunt was exiting from a parking lot located at 6320 Carlisle Pike intending to turn left onto Carlisle Pike. Mr. Hunt pulled from between vehicles that were stopped in the right hand lane, eastbound, on Carlisle Pike, and struck the Cassel vehicle on the passenger's side door. A copy of the police accident report is attached hereto as Exhibit "B". 5. As a result of the aforesaid motor vehicle accident, Arlene M. Cassel, sustained injuries resulting in her death. 6. At the time of the accident, James Hunt was insured, by Allstate Insurance Company with bodily injury limits in the amount of $300,000 per person and $300,000 per each occurrence. See Policy Details attached hereto as Exhibit "C." 7. Allstate Insurance Company extended an offer of $150,000 to the Estate of Arlene M. Cassel for wrongful death and survival. See copy of email correspondence from Allstate dated January 16, 2012 attached as Exhibit "D." 8. Arlene M. Cassel, at the time of her death, had a Will. A copy of her Will is attached as Exhibit "E". 9. Arlene M. Cassel, at the time of her death, is survived by her husband, Willard F. Cassel, Jr.. 10. Willard M. Cassel, Jr., died on July 14, 2011, as a result of acute congestive heart failure and not as a result of the aforementioned motor vehicle accident. A copy of the Local Registrar's Certification of Death for Willard F. Cassel, Jr., is attached hereto as Exhibit "F". 11. .Arlene M. Cassel, deceased, and Willard M. Cassel, Jr., deceased, are survived by their four children, Timothy Cassel, David Cassel, Lisa Sanna and Matthew Cassel. 12. David Cassel and Lisa Sanna were appointed Executor and Executrix of the Estate of Arlene M. Cassel and of the Estate of Willard F. Cassel, Jr., on August 4, 2011, by the Register for the Probate of Wills of Cumberland County. A copy of the Short Certificates are attached as Exhibit "G". 13. An outstanding debt due Medicare in the amount of $47,069.89 associated with the claim of Arlene M. Cassel, deceased was satisfied from the Estate of Arlene M. Cassel. See letter of CMS dated August 14, 2013 attached as Exhibit "H". 14. No complaint was filed against the Defendant. 15. It is proposed that 50% of the settlement proceeds go to the wrongful death action and 50% of the settlement proceeds go to the survival action. 16. The proposed distribution of the settlement is as follows: a. $51,465.06 for the wrongful death action to David Cassel, as Executor and Lisa Sanna as Executrix of the Estate of Arlene M. Cassel; and a., b. $51,465.05 for survival action to David Cassel, as Executor and Lisa Sanna as Executrix of the Estate of Arlene M. Cassel. 17. Petitioners, David Cassel as Executor and Lisa Sanna as Executrix of the Estate of Arlene M. Cassel understand that Michael B. Scheib, Esquire was retained by Allstate Insurance Company to obtain Court approval of the Petition for Court Approval for Settlement of Wrongful Death and Survival Action. Attorney Scheib was not involved in the decision to settle this claim. AttorneyScheib will not be paid from the settlement funds. 18. A Release of All Claims was executed by David Cassel as Executor and Lisa Sanna as Executrix of the Estate of Arlene M. Cassel and of the Estate of Willard F. Cassel, Jr., discharging Allstate Insurance Company and their insured, James Hunt to settle the Wrongful Death and Survival Action. A copy of the Release of All Claims is attached hereto as Exhibit "I". 19. The Commonwealth of Pennsylvania, Department of Revenue, Office of Chief Counsel was served with a copy of this Petition and has no objection to the proposed allocation as evidenced in the letter from the Department of Revenue attached hereto as Exhibit "J". WHEREFORE, Petitioners, David Cassel as Executor and Lisa Sanna as Executrix of the Estate of Arlene M. Cassel, and of the Estate of Willard F. Cassel, Jr., respectfully requests this Honorable Court approve the settlement in the Wrongful . Death and Survival Action in this matter. B. WILLARD F. CASSEL, JR. 20. Willard F. Cassel, Jr., deceased, as aforesaid, died on July 14, 2011, as a result of acute congestive heart failure and not as a result of the aforementioned motor vehicle accident. 21. As a result of the aforesaid motor vehicle accident, Willard F. Cassel, Jr., sustained personal injuries, including pain and suffering and loss of consortium. 22. Allstate Insurance Company extended an offer of $150,000 for survival action to David Cassel as Executor and Lisa Sanna as Executrix of the Estate of Willard F. Cassel, Jr., for the benefit of Willard J. Cassel, Jr. WHEREFORE, Petitioners, David Cassel as Executor and Lisa Sanna as Executrix of the Estate of Arlene M. Cassel, and of the Estate of Willard F. Cassel, Jr., respectfully requests this Honorable Court enter an Order authorizing settlement in accordance with the terms as set forth above. Dated: 2� , 2014 By: GRIFFITH, STRICKLER, LERMAN, SOLYMOS & CALKINS B. 1'JEIB, E Attorney I.D. No. 63868 110 South Northern Way York, Pennsylvania 17402 Telephone (717) 757-7602 Fax (717) 757-3783 mscheib@gslsc.com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA David Cassel as Executor and Lisa Sanna, as Executrix of the Estate of Arlene M. Cassel, and of the Estate of Willard F. Cassel, Jr., Plaintiffs vs. James Hunt, Defendant VERIFICATION CIVIL ACTION - LAW No. We, David Cassel as Executor and Lisa Sanna as Executrix of the Estate of Arlene M. Cassel and of the Estate of Willard F. Cassel, Jr., are the Petitioners in this action and hereby verify that the statements made in the foregoing Petition are true and correct to the best of our knowledge, information and belief. We understand that the statement in said Petition are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities. Dated: Dated: 7-1 g D ' • t ass1, As Executor of the Estate of Arlene M. Cassel and as Executrix of the Estate of Willard F. Cassel, Jr. Lisa Sanna, As Executrix of the Estate of Arlene M. Cassel and of the Estate of Willard F. Cassel, Jr. 01105 sob ItEV (Ot•97) v "DP c% V(N' LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It Is Illegal to duplicate this copy by photostat or photograph. Fre for lists certificate. WOO •'his is to certify that the Wormvim bore given is • c erectly copied from an orngmal C'G%e of Death duly filed vat me as. Local Registrar Mc omgv 0•1 certificate vvili he forwarded to the State V>ita1 Records Office for permanent filing, .00 wit Ter *am rypf /MORN RECEIVE AUG 15141 aADELPe.AwEsTmoo COMMONWEALTH OF PtNNSYLYANIA ■ DEPARTMENT OF HUM • VITA RECORDS CORONERS CERT1PSCATE Of DEATH (Set inslvcROM .xd.Yamptes On r.wiw run F E •••aaer • 1 •••••••••••••••••- Ader>e Wier Cassel 0••r 11••• bows Mb•DOW ORM Oro. rr•1•••1 ><erai+a 172 .• 24 — 91e9 it May M2011 { t4p$ rM iiwI 41M•111.•yM(� — 1. .•'Here• •- Ja)lr.. de..* 80 .••iiil NMI" II -/19 Q} MAL Pa aMIOr/•00044sI� QOr++tw.r Oprar Ma 4:4•••••••• Is C•••••1,401•••• 31 a•.aaya.•p..•r•.•ti • Q.ra.r S',•°Y rotor ••■w+•a wo quire •••***0•001' 11) Vs [)** •••••••••••••••••••••••••11 Cilw.• rs.•a•:'•wrl•a4■af Oa1QM1lm .....r.. 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Crash 0 Yes 0 No 0 Yes Q No• 'AA •500 1 Page 1 Page 1 of 8 IIIIJIII 1111 II1 IIIJIIII Crash Number .—"1 W0214632 a 0 a Incident Number • - • HAM20110500338 Agency -Name Hampden Township Dispatch Time (mil) Arrival Time (mil) 1040 Reviewer 1040 Precinct Ponce Agency 21103 Investit rtor OFFICER MARY H01`1'ENSTEIN Patrol Zone 100 Invests ation Date (MM DD-YYYY, 09 JEFFREY A SNYDER Coun County Name Cumberland Crash Date (MM-DD-YYYY) 09 05 2011 Badge Number 19-11 Plunicipai' . Municipality Name Hampden Township Ceras It Time (mil) 103:+ 2011 Badge Number 19-20 Approval Date (MM-DD-YYYY) 05 No of Units People Injured 2 3 gilled* 1 2011 °If> 00 complete Form F Day of Week 0 Sun Q'Thu 0 Mon 0 Fri Q Tue 0 Sat O Wed 0 Unk Workzone (f Yes Complete Yes 0 No Form M. Section 29) S:hool Bus O yes 0 No R slated School Zone 0 Yes 0 No Related • Notify PENN00T0 Yes 0 No Maintenance Intersection Type 04 Way Intersection 0 'Y' 1 itersection Q Multi-Leq 0 O(( Ram Intersection p 0 Railroad Crossing 0 Midblock 0 'T' Intersection 0 RTraFSii Ciirrcl •0 On Ramp Q Crossovers 0 Other 01511 0 0 ra A °Spedal Locarlon 00 * See Overlap Route Number 0011 Street Name Segment (Optional) Travel I.anes Speed Limit 04 40 CARLISLE Route 0 Interstate . O Turnpike rt Turnpike Q State Signing (Not Turnpike) (East/west) Spur Highway c 0 Street Ending c PK O North 0 south O East O West 0 Unknown House Number (if applicable) 6320 For Mid -block crashes only. Use postal House Number and make sure Prindpal Roadway Street Name is filled in if using this option County O Local Road O Private - O Other/ Road or Street Road Unknown 0 5 0 ® Traffic Detoured Unknown 0 • Route Number tS s Street Name Se ment (Optional) Travel Lanes Speed Limit e 0 4.6 Street Ending • ry O North Q South O East 0 West O Unknown signing Interstate Tumpike Turnpike Signrn¢ O (Not Turnpike) 0 (East/West) �� Spur 0 State Coun Highway Road 0 Local Road 0 Private 0 Other/ or Street Road Unknown In Use For Mk/ • Block Ga Please Enter Information for BOTH Landmarks if Using This Option 0 Intersecting Rt Num Or Mile Post_ Or Intersecting Street Name Or Segment Marker Z O St Ending 0 North 0 South 0 East 0 West Feet Or Miles N Or Intersecting Street Name Intersecting Rt Num Or Mile Pott: Or Segment Marker o` St Ending a O North 0 South 0 East O West Distance From Crash Scene to Landmark 1 (For Crash between Landmark 1 and Landmark 2) Latitude: Degrees Minutes Seconds 40 14 46 000 , Longitude: — Traffic Control Device Q Yield Sign 0 Not Applicable J Traffic Signal 0 Active RR Ctssing Flashing Traffic Controls O Signal O Stop Sign O Passive RR Crossing Confols Degrees Minutes Seconds 77 00 05 000 O Police Officer or Flagman 0 Other Type TCD 0 Unknown • 7332. EcoOforrino Device Functioning Emeency 0 No Controls r"-% Improperly Preemrgptive Signal Device Not Device Functioning O functioning Properly J Unknown Lane closed Of 'Not Applicable; skip rest of the Lane 1; fa acre section) 0 Not Applicable 0 Partially 0 Fully I;_) Unknown Lane [lneum 0 North ' 0 East 0 North and South 0 All t 0 South 0 West O East and West (N,S,E,W) Yes 0 No O Esti Time gicrad 0 < 31) Min. O 30-60 Min. 0 1-3 hrs Q 3-6 hrs O 6-9 hrs 0 > 9 hours 0 Unknown FORS"( 5 AA -500 (12/02) PENNDOT COPY http://www. dot6. state.pa.us/crsapp/Prinl Li xiages/Xm1Files/20110482762011051611081181... 5/16/2011 Print CRS W0214632 coasifoompana CiAA POUCE Cr 111EPOVOME4ORIN M 500 2 P9612 u5e C• wit , .4 ID Unit Pager Page 2 of 8 11111:111 10. —..,-....•:Xrah:Nontber • . • ..- .• • • ' . . . . . . . . 0 !rvit391. Vghide in 0 -Hit a Run VeIri ID flleg4Parked Q LeaIly Pa1ced 0 Nbn-..Ntotorieed o Pedestrian 0Fedell*.6041t*a t)146d 624;6 Wheelchnir. Freinpittt*: . . . 1.• • • . Of •Pedestrian or''..fi.dettrieti on ikatiti.i wheetchiketc.';.Dae of Brth4M-DD-YYYy)06: •4. •COminOclal. • !Ok.10... :(;)• . • Unit No 01 Delete? 0 First Nathe JAMES ••• -fteleChicte Nucitie... • 40:4585511 • •••• MlftsslaW/Stato 12 SOUTH ROAD MECHANICSOUR fa, PA 17050 ., 1 Vehicle Color 0Yellow 05 07=Siver 014lue . 09* --Brown 02=Red •10=Orange• 03. --White 11=Purple 04 --Green 05=Black 99Unitri0Viel FORIA8h40.00tIMM http://www.dot6state.te.usieisOWNIAWikti/Xnane 20i1 Print CRS W0214632 .._1 FUME CRASAVOUNG.0011410 M 500 2 Poke Use Only '. M pde in 0 Hit.&Run -Matilde0. Iliegalty'Pthed : g.:leya➢y:Pa Unft Pedestrian CD .•: thairr. n on Pre r s crosfi «f 'PedesUian''orPedest ian_oh Skates.: in`VI/heel ha r, etc . Complete`Forin 10 1t Page- 3. of 8 Pa Delete? p CASSEL;JR . ' Address 1 City / State 328 S WASHINGTON $T MECHANIC:'.SEUKGPA Alcohol Test Results..Test.Refutid ua O (=y� Test'Given,' i �+ I• anta ririated Resulii• i . ;. Owner/Driver.. 0C=wot-Appl cable ...:. _02=Privaltr, I itle Np• : 01=Pnvate Vehide Owned/ tlwrs!a9lL `:by. 01 Ceased by Driver tl3=Ren@: i1• (elude;, Same as OWner First Name..: . . driver, Q WILLARD 2 8i ARL : Address 1. city / State / 328 S WASHINGTON ST MEGHANI4 JM3LW28G7Y0118081. • 1=Towing :Pass `•, i e/Modular Home 75etti%Trsarler' �r --t{ 2=Towing-True • "- I' 13=Tawing Utifty taiilu-'uI1Traiiei:.; L Vehicle Color • P6. -Yellow . 04 07=Silver 0ti=Gotd Ot�lue 09=Brown 02=Red 10=0rarige 03=Wtyte 1 i?urple 04 -=Green 12=0ttier . D5=8tack 99 --Unknown Initial impact Pbint.' 02 o0 don -Coniston .1.4 1ndercainege 01-12=Clodt Points . • irowed Unit:. 13 Toll' " 994Jnkno01 FOAM i AA300 pal http://www.dot6.state.pa.wicrsapp/Prig; were Print CRS W0214632 13 COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM AA 500 3 Police Use Only Page Page 4 of 8 11111111111111 a......1 W0214632 FORM M AA -500 (12/02) PENNDOT COPY http://www.dot6.state.pa.us/crsapp/Prinli Images/XmlFiles/201104827620.11051611081181... 5/16/2011 Person Type. Seat Position' Sett( Equipment One: Election: A 1=Driver D 00=Not A Passenger/Occupant E OO=None Used / Not ApptKable G O=Not Applicable 2=Passenger 01=Driver - All Vehicles 01=Shoulder Belt Used 1=Not Ejected 7=Pedestnan 02=Front Seat Middle Position 02=Lap Belt Used 2=Totally Ejected -fond 6 ey e6=Through & a o g. 8 Other 03 -Front -Seat -Right -Side 0343p Shoulder Belt -Used J=Paifiahy Ejected - 9=Unknown 04=Second Row - Left Side Cr 04 --Child Safety Seat Used 9=Unknown Motorgcle Passenger 05=Motorcyde Helmet .Used 05=Seco Row - Middle Position 06=Bicyde Helmet Used H F1ec*n Path' 06=Second Row SPA' - Right Side 10=Safety Belt Used Improperly • O=Not Ejected / Not Applicable F =Female 07=Third Row Or Greater - 11=Child Safety Seat Used Improperly B M=Male Left Side 12=Helmet Used Improperly 1=Through Side Door Opening 3=Through U =Unknown 08=Third Row Or Greater - 90=Restraint Used, Type Unknown =Through Side Window Position 99=Unknown =Through Windshield 09=Third Row Or Greater - 4=Through Back Door • • Right Side &Aty Eauioment Two: S=Through Back Door Tailgate Opening Injury Severity: 10=Sleeper Section of Trucl: b F 00=None Used /Not Applicable Roof Opening (Sunroof/ O=Not Injured 11=1n Other Enclosed 01=Front Air Bag Deployed (For This Seat) Convertible Top Down) 1=Killed Passenger Or Cargo Area . 02=Side Air Bag, Deployed (For This Seat) 7=Top Ups Roof Opening (Convertible 2=Major Injury 12=ln Open Area 03=Other Type Air Bag Deployed 9lnknown 3=Moderate (Bade Of Pickup, Etc) 04=Multiple Air Bags Deployed Injury 13=Trailing Unit 05=Motorcycle Eye Protection 4=Minor Injury 14=Riding On Vehide Exter or 06=Bicyclist Wearing Elbow/Knee/PadsPeron. • 8=Injury, Unk 15=Bus Passenger 10=Air Bag Not Deployed, Switch On i p=lot Applicable Seventy 98=Other 11=Air Bag Not Deployed, Switch Off 1dklot Extricated 9=Unknown if 99=Unknown 12=Air Bag Not Deployed, 2=xtricated By Mechanical Means Injury Unk Switch Setting • 3=Freed By Non - Mechanical Means 13=Air Bag Removed (Prior To Crash) 8=Omer 19=Unknown If Air Bag Deployed 9=Unknown 99 --Unknown • EMS Agency: HAMPDEN EMS Medical Facility: HERSHEY MEDICAL CENTER Unit No Person No Date of Birth (MA-DD-YYYY) A 8" C D E F ' G H I Delete? 01 01 0 06 -111 ] - 1947 n n n 01 03 " 10 71[(7,1 n 1 0 No Name / Address / Phone Transport • SamEMS e as Operator HUNT, JAMES E 12 SOUTH :ROAD MECHANICSBURG PA 17050 71745 0 Yes Unit No Person No Date of Birth (MM -D )-YYYY) A B C ' D E F G H I Delete? � 02 01 0 03 - 17 . j - 1930 1 M I" 101 00 10: 1 o , 1 0 No . Name / Address / Phone EMS Transport Same as • Operator CASSEL;JR, WILLARD F 32.E S WASHINGTON ST MECHANICSBURG P 0 Yes Unit No Person No Delete? Date of Birth (MM .131)-YYYY) A B C D E F -� G H I 0 No 02 02 o 03 - 15 `- 1931 pi F f 1 103 . 00 10 1 0 121 Name / Address / Phone EMS Transport • operator ARLENE CASSEL 328 S. WASHINGTON ST. MECHANICSBURG PA 170 0 Yes Unit No Person No rtYB C Date of Birth (MM-DD-YYY) A D E F G H I p 0 No I Delete? o _ _ , Fir] flu Name / Address / Phone •EMS Transport • Same as Operator 0 Yes Unit No Person No Date of Birth (MM- )C-YYYY) A B C •D • E F GH Delete? r - ]- n n 0 No Name / Address / Phone EMS Transport • Same as . Operator O Yes Unit No Person No Date of Birth (MM -135 A B CD E F G- H I 0 No ` Delete? - I 'j - fl f 111-1 11 Name / Address / Phone EMS Transport • Same as Operator 0 Yes FORM M AA -500 (12/02) PENNDOT COPY http://www.dot6.state.pa.us/crsapp/Prinli Images/XmlFiles/201104827620.11051611081181... 5/16/2011 Print CRS W0214632 1 , COMMONWEALTH OFPENNSVIVANIA POLIC.E CRASH REPORTING rm AA 500 4 Poke Use** . Page 5 •of.11. • htstniitier V0214612, . • . Relation to Roadway 15 16 17 is Weather Conditions • ..Environmental Rbachvail fOtential Factors 0CNone 01=WindyCondidons.. °Midden Weather Cianations 0.3,20ther Weather tOnditions °Weer In Roadway. • • Clibstade OnRoadway 06.0ther Animal In Roadway 07.=Glare • 08=Work Zone Related Possible Vehicle Fai1w PO • . 130=None OlAres Ca. -Brake System 03=SteerngSystem 044u Orr -Power Tram Unit No. Unit No 01 02 ••••., " , • • 064)chaust 074Iead OSL-tgiti 10=HOm 1141irrort • • ' • 1 1-9. 0 *: . 00 19 • R/R61 • A.6400 • ..s " • • Unit lea •:fottOrte.d.ir 10t., . _ . . . .1f etis the:PrinieWitic • . TYPe; P1)101° .•. , . . . :14 ••• • . • • ?:-:;!' http://www.dot6.stae.pa.10/ets40-kin 0,4*** Print CRS W0214632 2 COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM AA 500 5 Poke Use Only "Page 6 Page 6 of 8 111 11111 111 I 1111 Crash Number W0214632 FORM rt AA -500 (1Z ) PENNDOT COPY http://www.dot6.state.pa.us/crsapp/Prir: tlznages/XmlFiles/20110482762011051611081181... 5/16/2011 [ 1 i .—.i—_x__.._!.....!.__ _•_ __._ ..._. _._ .._.moi,...._ _ — I i : ._._t I i : i i . F t i i ! ' d: _.......!_..."' ,_...__ .._..._i__.......L_...__ s .....«.._t.««.__ __._............_ «...._-1...«_.__._..._..L___.L.._...6.__._a....._._ s• ........._ _................ _._.>•«..._...s..«_....a...__.K-..._ _. _ ...,...._.«._.. �... . A: 1 i !^ [ • i ! i i t F i I , ..._... i _..._a.. —.._..L__.w..__o--._.�.—_.,..t.._.__ i j t 3 i_....._—.......5___.._{._....._n.._.._.a___....r....__.i...._._f_..._..L_....«.L _.— t _.._ _ _..—i......._t.....__.. i ! _....._i•^'___ ..._._.! • t ! t IWitness and Narrative 1 Witness Name Address Phone 2 Narrative and additional witnesses: Accident Investigation Notifit:ation Issued? 0 Property Damage 0 Unit 1 was exiting the parking lot of Mc(;afferty Ford, 6320 Carlisle Pike, turning left onto westbound Carlisle , Pike. Unit 2 was eastbound in the left lane of the Carlisle Pike. Oper Unit 1 stated that the right lane of eastbound traffic was stopped. There was a space in traffic for Unit 1 to pass through. Oper Unit 1 stated that an unknown person waived him out onto the Carlisle Pike. As Unit 1 entered the Carlisle Pike, it struck Unit :! that was eastbound in the left lane. Unit 1 stopped after the collision, 1 blocking the left eastbound lane. Oper Unit 2 stated that he was eastbound in the left lane of the Carlisle Pike when he saw Unit 1 entering his lane. Oper Unit 2 attempted to swerve left to avoid Unit 1 but was unsuccessful. Oper Unit 2 was able to stop his vehicle in the center tum lane after tile collision. Both units were towed by/to Roadside Auto Rescue. Pass Unit 2 later died from injuries sustained from the collision. f FORM rt AA -500 (1Z ) PENNDOT COPY http://www.dot6.state.pa.us/crsapp/Prir: tlznages/XmlFiles/20110482762011051611081181... 5/16/2011 ?not CRS W0214632 25 • COMPOlattY.AM 01P,OkStiViiiggit MEM GAM MIEVIDIEVEM AA 500 F Police Use Of* . Page.7 of 8' •..CciffitritmdoP' • ", • . ' • •• • Road Sulfite b 0 Concrete 0 Bladctop 0 Bridc or Block O fag,. Gravel. or coo 0 iwlsdkbon b Indian ties.ervel00" • • Nationeriaii. . Please complete Unit Information for ear:flu/zit involvedi; Oratatirailt. Do nate tbe inferinalien'in the jieMs.• _above. Mi"ntnitiP.le Unit No 01 Driver. Restrictions ' :14100:Inswith• ComPilaisce Resbictiont Not NotestricNonst C).CompNed With Not Applicable ,......tompgance . •14 UnknOwra. Myr Enclorseniestt Compliance -'•:" • 12 - Not a PennSylvartia' ot • •••• "-: Drive .P1OMPIA-92cJ- tinknOuin ce ,Qe•' CornPlian F-#1.Tia CO.b . " :5. Conipftegured-With Required - Non 0 None Required :CjimPrian, 0 Not Licensed cl a ennsylpanin Dr.)* • ifrilutcniny D'Apliance 0 coolant*Delzr.nr.ant : • . . , . r—v Nat Riaiiired fat (41JnkfCD1.or • .. Vehide cosi 11-g$14fred_, —Nbf Valid ikense • • • IhtaTenrnykania ValidIke-Me for b O titAiiiidinceManeuver • • • — • Braking - Skid .• •'";• • • • MOO'Evident No Skid DiNerc.." Dmq Test Results- RIP to Freq. ' * • 0 NO Test Given • 5.= AnclithetlinInes • I = No Drug Reported. $.= PCP • . 2 = itilarquana 8 = Other. 3 = Cocaine , 9 =-Unlmovin.Test 4=OpMes AekWu• • ' • tlialininen ' . • . • • :.". Braking - Other Other Avoidance . • Driver license Compliance EvidenceorStated Myer lkense Compliance 0 Not licensed Drug Test Type 0 None . • • . . ORA Duro Test Resisfts - (Up t� Four Resottst . . 0 = No Test Diven . 5= Atnnhetanines . 1 = No Drug Reported • B = PCP . :. •-• 2 =Marijuana 8= Other . - • 3 = Combie 9 =1-inknoivii Teit 4 .-. Opiates RicevIts . • • . IFOREI AA401111:51119 PENNDOTGOPY Print CRS W0214632 Crash Number VV0214632 Incident Number HAM20110500338 Page 8 of 8 http://www.dot6.state.pa.us/crsapp/Prin 1:11mages/XmlFile's/201104827620.11051611081181... 5/16/2011 . crash Reporting System Synopsis Pagelof2 .Quality:Assurance Crash Synopsis created 05/1612011 for Crash 111urnlierih102l4:1g /ebGrou Police Agency Data: The crash report was: recorded by police agency.r 11D3 -Hampden Towns( ip patrol:tone.- IQU; under,ncldei t n4rtibet;HAM 0:11050b338: The dispatch date was 0510912011, the dispatch tiro was; t040 hours; the rnvesiigatron'date Was 05/09/2011 the arrival time was 4044 :.. hours. The investigator was OFFICER MARY liOTTL.NSTEIN; badge number -'(9-20 The repoitwas apprpved on 05/tt11011:... .._: •.. Crash Data: This is an angle crash occurred in Cumberland inure ofdiaimipdenTownship..0n 11A0nday. 0510.g/2D11 at:1035 fiours� The. illumination at the time of the crash was daylight 7'rie 2 -uni crash involved 3 people w ttl t rhlury ,there was 1 fataliitjr a g result of this.. crash. This is a reportable crash. The crash dict not o;cur rn a workzone The Blacktop roadway surface Was dry. Weather conditions . included No adverse conditions. A notification of ar•,secident investigation was;issued fine indicateed prime:factorforthis trash was a driveet action (making an improper entrance to the highway) :for.unit0l The first harmful event:for this crash.was that• unit:l• Hitunit 02 and tfie most • harmful event for this crash was that unit 2 was stn ad, by.:unit 1.:•:.::: ' :. Type Location: This was a mid -block (non intersection) crash, whici.• learired:at`no aped Principal Roadway: Cumberland County, route 0011, the orientation ofthe roadWaywas No • state highway route signing. GPS: faners) t}ie:speed>.l it was40;Mph;.witha The police -entered Latitude. was 4014:46.000'.and ti.+a, ppfiCe=entered:tongiiude'was' TCD: Traffic Control Device: no traffic control device, No Work zone: Type of Work Zone: not a Work zone. Lane Closure: Fuliyclosed. Lane Bosun: direction East and West.:T?:? UNIT INFORMATION: 1 • .MES E.Addreess °12 SO `,:.RO:.: _NECK ",'S „aIAM IJTH AD„ . ANICSBURG . • PA 17050. This2002 Ford identified by VJAt FIJIZU�� I 1UD40055 W registered lri PA w�h L1i ease MJi' 88 Travel speed Unknown ALLSTATE. The Unitwas towed y+aROADSIDAUT E O? ESCUE Thls1was not a.: Usage. Not appticabfe " The rnitial i npact point w s at1 •o cloc•k Damage Indicator: Functional (mod may betlndriveakF);jr Vehicle role art unit 02 iettide pos ion iii theteft lane Duron. of travel West, Movement; Turning lest, Gradient.on a lever.rani!tvny,:Abignrnent .5fra'iijht:' ` ::: • • Unit Number 1 was a motor vehicle in. transport The tri;it was owned by HIl ' e n as Unit insured: vehicle has insurance; Insrirance Comparr . i commercial vehicle. This Link. Was an SUV, Vehicle eol�t 13iadk, Special Driver Information: The driver of this unit was JAMES E HUNT Address:;,(:.': iO • fi AD:.NI EH (iN1 BURG PA470511761 hone:717-458=5511..... License#: 26232228, State: PA. DOB: 06/111194:7. Age € . Seic; Male<': eat.position: riveirs seat Prima►3r felt'; uip'ment iap.atc shoulder belt were used. Secondary safety equipment: lir :bag not deployed, switch on hr,Uty severity: Not )njured. ilk Not ejs Alcohol/Drugs Suspected: none suspected Alcohol Teel ,Type: Test,rrot given, Alcohol TestResults Result= 0.00 Drives aotron(s) 9.: making an improper entrance to the. highway, The indiwtIcti 's`condition was apparently rltitPrial. Vehicle co ,,400CLE ENTERING R httP://www.dot6.state.pa.-osiersap genet sis is=etitee ts: ss' :;; 51:5. 0:11 Crash Reporting System Page 2 of.2 CROSSING ROADWAY was violated: Citation was written. UNIT INFORMATION; 2 Unit Number 2 was a motor vehicle in transport. The unit was owned by CASSEL; WILLARD F & ARLENE M. Address: 328 S WASHINGTON ST MECHANICSBURG PA 17055. This 2000 Mazda identified by VIN: JM3LW28G7Y0118087 was registered in. PA with License DCD5493. Travel speed: Unknown. Unit in5ured: vehicle has insurance, Insurance Company: NATIONWIDE. The Unit was towed by ROADSIDE AUTO RESCUE. This was not a commercial vehicle.,This Unit was a van, Vehicle color: Green, Special Usage: Not applicable. The initial impact point was at 2 o'clock, Damage Indicator. Disabling (severe - not driveable), Vehicle role: was struck by unit 1. Vehicle position. in the left-lareTDire-ction-of travel:-NorthTMoveirent:-Going-straight, Gradient-on-a-level-ro-adway;-Alignment'Streight. Driver Information: The driver of this unit was WILLARD F CASSEL;JR Address: 328 S WASHINGTON ST MECHANICSBURG PA 17055. Telephone: 717- 766-6835, Drivers License #: 07300950, State: PA. DOB: 03/17/1930. Age: 81. Sex: Male. Seat position: driver's seat Primary safety equipment: None used / Not applicable. Secondary safety equipment: Air bag not deployed, switch on. Injury severity: Injury, Unk Severity, Ejection: Not ejected. Alcohol/Drugs Suspected: none suspected, Alcohol Test Type: Test not given, Alcohol Test Results: Result = 0.00. The individual's condition was apparently normal. Vehicl a code N/A was violated. Passenger Information: a passenger 02: ARLENE CASSEL, Address: 328 S. WASHINGTON ST. MECHANICSBURG PA 17055. Telephone: 717-766-6835. DOB: 03/15/1931. Age: 80. Sex: Female. Seat position: Front seat right side. Primary safety equipment: None used / Not applicable. Secondary safety equipment: Air bag not deployed, switch on. I ijury severity: IGIled. Ejection: Not ejected. http://www.dot6.state.pa.us/crsapp/gen :11ateSyno psis.do?method—executeGenerate Synopsis 5/16/2011 Exhibit C Allstate Fire and Casualty insurance Company Policy Number 9 18 949666 02/07 Your Agent C Jeffrey Conant (717) 258 4554 Policy Effective nate Feb 7, 2011 COVERAGE FOR VEHICLE 0 2 2002 Ford Truck Explorer COVERAGE LIMITS DEDUCTIBLE PREMIUM_ Automobile Liability Insurance — Full Tort • Bodily Injury $300,000 $300 000 $100 000 • Property Damage Medical Expenses Accidental Death Uninsured Motonsts Insurance Full Tort / Stacked Limits each person Not Applicable each occurrence each occurrence Not Applicable $5,000 each person Not Applicable 4111111, $25,000 each person Not Applicable dillir $15,000 each person Not Applicable AMP $30,000 each accident Undennsured Motonsts Insurance $15,000 each person Full Tort / Stacked Limits $30,000 each accident Not Applicable AIM Auto Collision Insurance Actual Cash Value $500 (Safe Dnving Deductible Reward - deductible reduction amount available is $0 ) Auto Comprehensive Insurance Actual Cash Value $0 Towing and Labor Costs Coverage $50 each disablement Not Applicable. Rental Reimbursement Coverage up to $30 per day for Not Applicable a maximum of 30 days Total Premium for 02 Ford Truck Explorer DISCOUNTS Your premium for this vehicle reflects the following discounts Anti -theft Passive Restraint 55 and Retired Multiple Policy Antilock Brakes Utility Car Premier Plus Allstate Easy Pay Plan RATING INFOR JAPE 3 0 7012 1111i1111of I GNI t'HII JU Sci.t'riin vvmbT MCO 'damnation not Page 6 Knotty 11 Wil PA0I0M113 ALL -STATE. LEGAL 800-222-0510 ED11 RECYCLED Exhibit D. ' • ; Gardner, Charles From: Sent: To: Subject: Attachments: Gardner, Charles Monday, January 16, 2012 1:56 PM 'aceman007@comcast.net' 0202093688 Estate of Willard and Arlene Cassel.pdf; Gardner, Charles.vcf Ni Lisa, Per our conversation, we are offering our policy limit of $300,000 ($150,000 for each claim). Attached are the structured settlement proposals. These are examples, if you are interested, please let me know and I can have Mr. Michael Mullen of Ringler Associates contact you with more information and other possible ways to structure your settlement. You can always choose not to structure. Estate of Willard and Arlene C... Charles Gardner, SCLA Senior Claims Service. Adjuster Email Charles.Gardner@Allstate.com Direct Phone 610-251-3247 Toll Free 888-233-2675 ext. 2513247 Fax 866-233-2675, claim number required Mailing PO Box 660636, Dallas, Tx 75266 Gardner, Charles.vcf (4 KB) ALLSTATE LEGAL SUPPLY GO. Exhibit E ED 1 LAST WILL Ai TESTA; MT ARL4 7;•i• OASSL j. ROBERT STAUFFER. ATIDIINEY AT LAW MARKET SQUARE BUILDING MECHANICSBURG, PA. 17055 11111, f.tAMMOIORN CO., WILLIAMS/Oft, PA• ARLENE M. CASSEL ARLENE M. CASSEL, of the Borough of Mechanicsburg, County of Cumberland and State of Pennsylvania, , being of sound and disposing end, ,memory d understanding, do make; publish and declare this my Last Will and Testament, hereby revoking and making void any: and all former Wills by meat any time heretofore made. 1. .I direct the payment of all my just debts and funera3 expenses asc onaftermy decease as the same can be conveniently done. 1 give, devise i and bequeath all the rest, residue and remainder of 0y estate, personal and mixed, whatsoever and wheresoever the same maybe situate, to my husband, WILLARD F. CASSEL;41., absolutely and: unconditionally. 3. In the event that my husband, WILLARD F. CASSEL, JR., should predecease me, or should he die within thirty (30) days from the date of my death, then in either such event, 1 direct the settlement and distribution of my estate to be made in the following manner, to wit: (a) 1 give and bequeath the sum of One Thousand ($1,000.00) Dollars to my -1- ve and bequeath the sum of One Thousand ($1,000.00) Dollars to my granddaughter, KRISTEN M. CASSEL. (c) I give and bequeath the sum of One 'Thousand ($1,000.00) Dollars apiece, to each of my following named granddaughters, to wit, MARISSA J. SANNA, NICOLE E. SANNA, KATELYN M. CASSEL and COURTNEY E. CASSEL, and in the event that any or all of the above named granddaughters have not attained the age of eighteen (18) years at the time of my death, then in such event, I direct that their bequest and share in my estate be placed in an interest bearing account at a local banking institution, until such time as they attain the age of eighteen (18) years, at which time the same shall be paid over to them, free of any further restrictions (d) I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal and mixed, whatsoever and wheresoever the same may be situate, to my four (4), children to wit, TIMOTHY S. CASSEL, DAVID M. CASSEL, LISA A. SANNA and MATTHEW A. CASSEL, share and share alike per stirpes. LASTLY, I nominate, constitute and appoint my husband, WILLARD F. CASSEL, JR, Executor of this my Last Will and Testament and in the event that my said husband should predecease me, or should he be unable or unwilling to serve in such capacity for any reason, then in such event, I nominate, constitute and appoint my daughter, LISA A. _2 SANNA and my son, DAVID M. CASSEL,. Co -Executors of this my Last Will and Testament in his place and stead and in all instances, I direct that my personal representative be excused from posting bond or other security for the faithful performance of their duties, on. SS OF, I have hereunto set my hand and seal this Ra- day of A. D. 2005. akhAte__ ea,42121, (SEAL) Arlene M. Cassel 3 PL D OMM E DRIVE A D. NEW JERSEY 02°16 (2) 0''�'� Exhibit F Ca© LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING It Is illegal to duphcate this copy by photostat or photograph. Nei IWO MO MYJ0 MUNRO r is to certify that the information ,here given t: correctly coped from an anginal Certificate of Dead duly Med with me as Local teVstrat Tfio origins certificate vidl be forwarded to the State vita Records Office for permanent Mag. C OmMQe1WEALTh OF PENNSYLVANIA • DE►AATMeNf of NEALfl4 • VrTM RECD cERTInCATE Of Mani Se. Ii i.c4on..no.xsmples co ewe*.) hy7/ / ja Date Issued RECEIVED An 152011 PidADaPHIA W $1 MCO {UTERI 1.505E0 ' 1. 1 A 10. is I P A' 6, - En imiwnemlifiaii iii ' L4' rL..a...:,aa, i -am . .:3vs�Z .-4 ] Z-. .Yt'�'.u.>•Ii. r • MUmatialMw m�hMi CON ur.IRawl \. MI .4 * ` M� ,w.rlllinaf d � * a . _ _d11,,6.0# ' t - + ►Lbs + or � t Tal j1 ���111���� .1 i : Y • ,o. .. iMEM. ... ... •• a.. Dram .f.a6. 09....►11tt.tw0/.laJagt001g". 1...4 1a.r..d.4:to.d.w•01' ( 5 Mtiwf !� 11�1r11Visa wre. ...v++.IJ va Mose sear. 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ExPibit G Fax Server OHLEW 3/7/2013 12:19:35 PM PAGE 2/009 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND estate of ARLENL M CASSEL `4.A SHORT CERTIFICA' 14.) 1, GLENDA FARNER STRASBAUGH Register for the Probate of Wills and Granti.r Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 4th day of August, Two Thousand and Eleven, LetterD TESTAMENTARY in common form were granted by the Register of said County, on the , late of AAECHAN/CSBLJRG EOROUGH rt 31 Madre Lasa in said county deceased, to LISA A SANNA DAVIDMCASSEL IF p Mddt Lauf (Frsr Mrddle Lasa and that same has not since been revoked ar]d IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 7th day of November Two Thousand and Twelve File No PA Fz Z e No Date of Death il 3 2011 00849 21 17 0849 5/10/2011 17: 2- 9189 De.uty NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL PAGE 2/9 ` RCVD AT 317/2013 1 19 24 PM !Eastern Standard Timel ` SVR A0185-XFX0009S!11 ` DNIS 63279* CSID Fax Server OHLEW ` DURATION (mm -ss) 02-53 Fax Server OHLEW 3/7/2013 12:19:35 PM PAGE 3/009 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND h �rh SHORT CERTIFICATI Ik1 <p I~h T, GLENDA FW NER STRASBAUGH Fn Register for the Probate of Wills and Grantiz Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 4th day or August_ Two Thousand and Eleven Letters TESTAMENTARY in common form were granted by the Register of said County, on the estate of W/LLARD F CASSEL JR , late of MECHANICSBURG BOROUGH !First M dIe Lam in said county, deceased, to LISA A SANNA and LFnoa Matite Lost) DA V/D M CASSEL rf Sf M ddlt L yL 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, P1 WNSYLVANIA, this 7th day of Nov-ember-- Two ovemberTwo Thousand and Twelve File No 2011 00850 PA File No 21 11 0850 Date of Death 7/14/2011 S S # 161 24 6656 NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL PAGE 3/9 * RCVD AT 317/2013 1 19 24 PM [Eastern Standard Time) * SVR A0185-XFX00094111 * DNIS 63279* CSID Fax Server OHLEW * DURATION (mm -ss) 02-53 Exhibit H Learn about your letter at www. mSprc. in f o CMS/CEVIERSIgrAIEDIONEAMMIC4IDARY7CES Sincerely, MSPRC Case Analyst JAX Medicare Secondary Payer Recovery Contractor MLOOINGHP MSPRC No Fault/Liability Page 2 of 2 P.O. Box 138832 Oklahoma City, OK 73113 MSPRC Learn about your letter at www.rnsprcinfo CMS aav�a .. 5xraosarKs August 14, 2013 280 1 MB 0.405 ***AUTO**MIXED AADC 720 R:280 T:6 P:6 PC:1 F:303101 LISA SANNA 4 CROOKED DR ENOLA, PA 17025-1526 'IIIsiIIII'll'lllliIlll,lh'11llllllliilyllhllulitlhl,IllfhIi Beneficiary Name: Medicare Number: Entitlement Date: Date of Incident: Case Identification Number: DCN: Dear Lisa Sanna: Arlene Cassel 172249189A March 01, 1996 May 09, 2011 201234509000414 10072513-0002934 We have received check number 0137 in the amount of $47,069.89. This amount has been applied to the outstanding debt due Medicare. The principal amount of the debt and interest (if applicable) has been reduced to zero and our file is being closed. If a refund is due it will be processed and forwarded to the appropriate party under separate cover. If the original check submitted to Medicare had multiple payees it will be the attorney and/or beneficiary's responsibility to disburse the funds to all other payees. If you have any questions concerning this matter, please call the Medicare Secondary Payer Recovery Contractor (MSPRC) at 1-866-677-7220 (TTY/TDD: 1-866-677-7294 for the hearing and speech impaired) of you may contact us in writing at the address below. When sending any correspondence please provide the Beneficiary Name, Medicare Health Insurance Claim Number (the number on the Medicare card), and Case IdentifcationNumber (if known). This will allow us to associate the correspondence to the appropriate records. Medicare Secondary Payer Recovery Contractor MSPRC No Fauli/Liability P.O. Box 138832 Oklahoma City, OK 73113 ML001NGHP Exhibit 1 APR 3 0 litRELEASE OF ALL CLAIMS PNAADQPtAWEST MCO CLAIM No ; 0202093688 This Indenture Witnesseth that, in consideration of the sum of three hundred thousand and 00/100 Dollars (S300,000), for myself and for my heirs, personal representatives and assigns,1 do hereby release and forever discharge lames and Linda Runt. Allstate, its affiliates and its subsidiaries and any other person, firm or corporation charged or chargeable_with responsibility or liability, their hers, representatives and assigns, from any and all claims, demands, damages, costs, expenses, loss of services, actions, and causes of action whatsoever and any claims for pre• and post judgment interest and any claims for attorney fees, arising from any act or occurrence up to the present time and particularly on account of all personal injury, disability, property damages, loss or damages of any kind already sustained or that 1 may hereafter sustain in consequence of or ansing out of an accident that occurred on or about this the 9th day of May, 2011 at or neat Carlilse Pike/Silvex Spring Rd, Mechanicsburg, PA. To procure payment of the said sum, 1 hereby declare; that tam more than 18 years of age, that no representation about the nature and extent of said injuries, disabilities or damages made by a physician, attorney or agent of any party hereby released, nor any representation regarding the nature and extent of legal liability or fmancial responsibility ofany of the parties hereby released, hive inducer! me to make this settlement, that in determining said sum there has been taken #nto consideration not only the ascertained injuries, disabilities and damages, but also the possibility that the injuries sustained ixuy be permanent and progressive and recovery therefrom uncertain and indefinite, so that consequences not now anticipated may result from the said accident The undersigned further covenant to indemnify and hold harmless the said party or parties from and against all claims and demands Whatsoever on account of or in any way arising out of the said occurrence or its results both to person and property. This provision applies, but is not limited to, subrogation claims by any other party. 1 hereby agree that, as a further consideration and inducement for this compromise settlement, this settlement shall apply to all unknown and unanticipated injuries and damages resulting or arising from said accident, casualty or event, as well as to those now disclosed. 1 understand that the parties hereby released admit no liability of any sort by reason of said accident and that said payment and settlement in compromise is made to terminate further controversy respecting all claims for damages that 1 have heretofore asserted or that 1 or any personal representative might hereafter assert because of the said accident. 1 further understand that such liability as I may or shall have incurred, directly or indirectly, in connection with or for d.an ges arising out of the accident to each person or organization released and discharged of liability hereixi and to any other person or organization, is expressly reserved to each of them, such liability not being waived, agreed upon, discharged not settled by this release. The undersigned expressly covenants and warrants that all Medicare, Medicaid, hospital, medical provider, health care provider, medical supplier and other medical liens, subrogation rights, rights of payment, rights of reimbursement and claims of any nature whatsoever, arising now or in the future, as a result of health care services provided to the undersigned have been or will be satisfied, settled, compromised ox paid by express agreement with Medicare, Medicaid, each insurance carrier and each hospital, health care provider, medical provider or medical supplier by the undersigned prior to final disbursement of the settlement proceeds: The undersigned covenants and warrants that all such claims, hens%payment obligations and assignments have been disci -in- rung -to -he s-reieaserf prion to-settlenaent; ` be riders`i ed agrees to xn�c emxziiMe Me -1W -W hold harmless the parties released for any and all losses, claims, demands or causes of action, and any damages, judgments, fees, expenses, costs (including interest) of any nature whatsoever paid and incurred as a result of any breach of these warranties and covenants. The undersigned understands and agrees that the parties released have relied on these material representations as part of the consideration and inducement for this settlement. The undersigned understands and agrees that such liability as he/she may or shall have incurred, arising now or in the future, as a result of health care services provided to the undersigned, including any health care lien, statutory or otherwise, is expressly reserved to each and every health care provider or payor based on such services, such liability not being in any way waived, agreed upon, discharged, released or settled or impacted in anyway, by this release. Ibis specifically includes, but is not limited to, any liability the undersigned may have to any hospital, health care provider, medical provider. medical supplier, Medicare or Medical& If any subrogation; claims, liens or rights to payment of any land against these settlement proceeds do in fact exist, the undersigned shall distribute -these funds in accord with such claims, liens or nghts to payment (or shall direct bis/het attorney to do so) The undersigned agrees to indemnify, defend and bold harmless the parties released for any and all losses, claims, denxinds or causes of action, and any damages, judgments, fees, expenses, costs (=chiding interest) of any nature . whatsoever paid and_inClgred as * result of any breach of these agreements and covenants.. The undersigned_ ....... understands and agrees that the parties released have relied on these material representations as part of the consideration and inducement for this settlement. 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 person to crinunal and civvill per shies. Signed and sealed this :.....'....... day of STATE OF SS COUNTY OF � .... On this�2 � day ofugAt (S (SEAL) r J - v� '/J before me personally Appeared g-4 �2� �e actcnowted ed that/0- S executed the My commission expires sem/, to me lrno to be the person who executed the foregoing instrument, and Same as V, 4�7ee act . • • :: , ' / . Art .7 "iJ// ��' "TARY P L T 'C ,..SO pHwEA R t MNSYI MIA Notarial seat Adam eraaey smth, Motor/Public FatMew rw .,YakCounty , . My COMMISOCA &pies 311y 3, 2016 14emact, P6w•S►1YAWUASSWA'ROriO6tO ARiLt cP3F019 0202093688 M.52 ALL-STRTE. LEGAL 800-222-0510 EDI T RECYCLED Exhibit J NMI pennsytvania DEPARTMENT OF REVENUE May 23, 2014 Michael B. Scheib, Esquire Griffith Strickler, Lerman Solymos & Calkins 110 South Northern Way York, PA 17402 Re: Estate of Willard F. Cassel, Jr. File Number 2111-0850 Court of Common Pleas Cumberland County Dear Mr. Scheib: This correspondence is in response to a letter received concerning an action which was raised during the deceased lifetime and was not related to the death if the decedent. The Pennsylvania Department of Revenue, Inheritance Tax Division takes the position on this issue that the decedent would have, if still alive, received this settlement for his own use, and therefore is not a Wrongful Death settlement and would be an asset of the decedent and is fully taxable in his estate. I hope that this has answered your question. If you have any other questions or concerns, please call me at 717-783-5824. Shannon E. Baker Trust Valuation Specialist Inheritance Tax Division Bureau of Individual Taxes Bureau of Individual Taxes 1 PO Box 280601 1 Harrisburg, PA 17128 1 717.783.5824 1 shabaker@state.pa.us ennsylvania DEPARTMENT OF REVENUE May 23, 2014 Michael B. Scheib, Esquire Griffith Strickler, Lerman Solymos & Calkins 110 South Northern Way York, PA 17402 Re: Estate of Arlene M. Cassel File Number 2111-0849 Court of Common Pleas Cumberland County Dear Mr. Scheib: The Department of Revenue has received the Petition for Approval of Settlement Claim to be filed on behalf of the above -referenced Estate in regard to a wrongful death and survival action. It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. According to the Petition, the 80 -year -old -decedent died as a result of a motor vehicle accident. Decedent is survived by her two adult children. Her husband, William Cassel deceased prior to the completion of this cause of action, is not an eligible wrongful death beneficiary. Hodge v. Loveland, 690 A.2d 243 (Pa.Super. 1997). The petition also indicates that all of the beneficiaries are adults, were not dependent on the decedent, and have suffered limited pecuniary (financial) loss. 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. Please be advised that based upon these facts and case law, the Department disagrees to the proposed allocation of a 80/20 split between wrongful death and survival action. However, for inheritance tax purpose only, this Department would not object totheallocation of the net proceeds of this action, $51,465.06 to the wrongful death claim, and $51,465.05 to the survival claim. This is equal to a 50/50 split. 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. I trust that this letter is a sufficient representation of the Department's position on this matter. Please contact me if you or the Court has any questions or requires anything additional from this Division. Trust Valuation Specialist Bureau of Individual Taxes 1 PO Box 280601 1 Harrisburg, PA 17128 1 717.783.5824 1 shabaker@pa.gov IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA In re: David Cassel as Executor and Lisa Sanna, as Executrix of the Estate of Arlene M. Cassel, and of the Estate of Willard F. Cassel, Jr., AND NOW, this day of : NO. 2014 — 4400 CIVIL TERM : CIVIL ACTION - LAW ORDER , 2014, upon consideration of the Petition for Court Approval for Settlement of Wrongful Death and Survival Action, it is hereby ordered and decreed that the settlement in the amount of $300,000 payable as follows: a. b. c. $98,534.95 for the wrongful death action payable to the Estate of Arlene M. Cassel, which is based on $51,465.06 for the wrongful death recovery and $47,069.89 for the Medicare lien. $51,465.05 for survival action payable to the Estate of Arlene M. Cassel. $150,000 for survival action to David Cassel as Executor and Lisa Sanna as Executrix of the Estate of Willard F. Cassel, Jr. pistribution: /Michael B. Scheib, Esquire Griffith, Strickler, Lerman, Solymos & Calkins 110 S. Northern Way York, PA 17402 vrSavid Cassel 3514 Margo Road Camp Hill, PA 17011 Edward E. Guido, Judge Lisa Sanna 4 Crooked Drive Enola, PA 17025 Zrn r—� xcp cp -4 zrz