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HomeMy WebLinkAbout14-5083 Supreme Coart-9fP_.enns�lvania ��;«R# 20565432 C Y Jer KMH Co I of Como Pleas CIVlI(CbVCT Sheet ForProthonotmy Ilse Onrj-: CUMBERLAND, �: C011nh: Docket Into: The information collected on this form is used solely for court administration purposes. This form does not supplement or replace the filing and service of•pleadings or other papers as required b.v law or rules of court. Commencement of Action: S a Complaint ❑ Writ of Summons ❑ Petition E Transfer from Another Jurisdiction 0Declaration of Taking C Lead Plaintiff's Name: Lead Defendant's Name: T PROGRESSIVE ADVANCED Tnx,i6n(.q C0-qfXAny RYAN SHAFFER I O Are money damages requested? ® Yes ❑ No Dollar Amount Requested: ® within arbitration limits N (check one) ❑outside arbitration limits A Is this a Class Action Suit? 13Yes 12 No Is this an MDJ Appeal? ❑ Yes 63 No Benjamin W. Lawrence, 209032 Name of Plaintiff/Appellant's Attorney: ❑ Check here if you have no attorney(are a Self-Represented [Pro Sel Litigant) Nature of the Case: Place an "X" to the left of the ONE case category that most accurately describes your PRIMARY CASE.If you are making more than one type of claim,check the one that you consider most important. TORT(do not include Mass Tort) CONTRACT(do not include Judgments) CIVIL APPEALS ❑ Intentional ❑ Buyer Protection Administrative Agencies ❑ Malicious Prosecution ❑ Debt Collection: Credit Card ❑ Board of Assessment ❑ Motor Vehicle ❑ Debt Collection: Other ❑ Board of Elections ❑ Nuisance ❑ Dept. of Transportation S ❑ Premises Liability ❑ Statutory Appeal: Other E [3 Product Liability(does not include [3 Employment Dispute Mass tort) Discrimination C ❑ Slander/Libel/Defamation ❑ Employment Dispute: Other ❑ Zoning Board 'I Other: ❑ Other: I S�hrt�0v\ O ❑ Other: N MASS TORT ❑ Asbestos B ❑ Tobacco REAL PROPERTY MISCELLANEOUS ❑ Toxic Tort-DES ❑ Ejectment ❑ Common Law/Statutory Arbitration ❑ Toxic Tort—Implant ❑ Eminent Domain/Condemnation ❑ Declaratory Judgment ❑ Toxic Waste ❑ Ground Rent ❑ Mandamus ❑ Other: ❑ Landlord/Tenant Dispute ❑ Non-Domestic Relations ❑ Mortgage Foreclosure: Residential Retraining Order ❑ Mortgage Foreclosure: Commercial ❑ Quo Waranto ❑ Partition ❑ Replevin PROFESSIONAL LIABILITY ❑ Quiet Title ❑ Other: ❑ Dental ❑ Other: ❑ Legal ❑ Medical ❑ Other Professional: Updated 1/1/2011 a �J �Q r '? d 00 4 , r IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION PROGRESSIVE ADVANCED ` 'IMurGv\U (6rApctV\y Plaintiff No: VS . COMPLAINT IN CIVIL ACTION RYAN SHAFFER Defendant FILED ON BEHALF OF Plaintiff COUNSEL OF RECORD OF THIS PARTY: Benjamin W. Lawrence, 209032 WELTMAN, WEINBERG & REIS CO. , L. P.A. 325 CHESTNUT STREET SUITE 501 PHILADELPHIA, PA 19106-2614 215-599-1500 FAX: 215-599-1505 20565432 C Y Jer KMH 'a a IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION PROGRESSIVE ADVANCED ?Y)5\J-r(UnCA CGM(SCAv')y Plaintiff VS . Civil Action No RYAN SHAFFER Defendant COMPLAINT AND NOTICE TO DEFEND You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by an attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff . You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. LAWYER REFERRAL SERVICE CUMBERLAND COUNTY BAR ASSOCIATION 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 (717) 249-3166 WELTMAN, WEINBERG & REIS CO., L.P.A. BY: Benjamin W. Lawrence, Esquire Attorney for Plaintiff(s) I.D. No. 209032 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 Phone: 215.599.1500 Fax: 215.599.1505 File#20565432 } PROGRESSIVE ADVANCED } Cumberland County INSURANCE COMPANY } Court of Common Pleas } } } V. } } RYAN SHAFER } NO. CIVIL ACTION — COMPLAINT 1. Plaintiff is a business organization licensed and authorized to conduct business in the State of Ohio with a place of business located at 5920 Landerbrook Drive, Mayfield Heights, Ohio 44124. 2. Defendant, Ryan Shaffer is an adult individual with a last know address at 403 Pitt Street, Enola, Pennsylvania 17025. 3. Progressive issued a policy of motor vehicle insurance whereby Progressive agreed to insure Plaintiff's insureds for injuries sustained in this motor vehicle accident and the Plaintiff Insureds' vehicle for damages sustained. 4. On or about September 4, 2012 Defendant was the operator of a motor vehicle which vehicle did negligently, recklessly and/or carelessly collide with Plaintiff's insured vehicle at or near the 400 block of West Dauphin Street, East Pennsboro Township, Pennsylvania. 5. The negligence and/or carelessness of the Defendant consisted of the following: a. Failing to have his motor vehicle under such control as the situation warranted; b. Operating his motor vehicle in complete disregard of the point and position of Plaintiff's vehicle; c. Failing to keep a proper lookout; d. Traveling too fast for conditions; e. Disregarding traffic control devices; f. Failing to abide by the Rules of the Road and the Motor Vehicle Code of Pennsylvania; g. Being otherwise negligent under the circumstances; and, h. Being negligent as a matter of law as may be relevant through discovery and/or at the time of trial. 6. As a result of the actions and/or omissions of Defendant, the Plaintiff's Insured was caused to sustain serious and permanent injuries in, on or about his person, all of which has caused him or will continue to cause her a great deal of pain, suffering, and inconvenience, and all of which are permanent in nature, character and duration. 7. As a further result of the actions and/or omissions of Defendant, the Plaintiff's Insured has been prevented from attending his usual and customary duties, avocations, and occupations, thereby causing him to sustain a loss of earnings and/or earning capacity, all to his great financial detriment and loss. 8. As a further result of the actions and/or omissions of Defendant, the Plaintiff's Insured has been caused to expend various sums of money for medicine and medical attention in an effort to treat and cure himself of his injuries, all to her great financial determent and loss. 9. As a direct and proximate result of Defendant's negligence, Plaintiff paid benefits to their Insured totaling $5,500.00 for the injuries sustained and $475.83 for damages to the Plaintiff Insured's vehicle, and $250.00 deductible payment by the Plaintiff's insured, less $774.81 in salvage for a total amount of $5,451.02 in damages. See attached as Exhibit "1" a copy of the damage documentation which documents Plaintiff further intends to introduce at the arbitration in this matter. 10. Pursuant to the insurance policy issued by Progressive and as a result of the aforesaid payment, Progressive became subrogated to the claim of its Insured against Defendant. WHEREFORE, Plaintiff demands Judgment against Defendant in the amount of $5,451.02 plus interest and costs. WELTMAN, WEINBERG & REIS, CO., L.P.A. Benjamin W. Lawrence, Esquire PA I.D. #209032 325 Chestnut Street Suite 501 Philadelphia, PA 19106 (215) 599-1500 WWR#20565432 EXHIBIT 1 J � Date: 9/14/2012 06:17 AM Estimate ID: 12-3141476-01 Estimate Version: 0 Committed Profile ID: CPA:All Parts BRENNER COLLISION CENTER - WEST 6271 Carlisle Pike,Mechanicsburg,PA 17050-2306 (717)697-8400 Fax: (717)697-1863 Damage Assessed By: Umlauf Jeffrey Appraised For: ALLISON GAYER (717)730-1575 Type of Loss: Property Damage Date of Loss: 9/4/2012 Deductible: 250.00 Claim Number: 12-3141476-01 Insured: MEGAN BAKER Owner: MEGAN BAKER Address: 407 WEST DAUPHIN ST,ENOLA,PA 17025 Telephone: Home Phone: (717)433-6265 Contact Phone: (717)433-6265 Mitchell Service: 910303 Description: 2008 Chevrolet Equinox LS Vehicle Production Date: 12/07 Body Style: 4D Ut Drive Train: 3AL Inj 6 Cyl AWD VIN: 2CNDL13F486075149 License: GBF-1213 PA Mileage: 42,494 OEM/ALT: A Search Code: LANCASTERI Color: MAROON Options: PASSENGER AIRBAG,DRIVER AIRBAG,POWER LOCK,POWER WINDOW,REAR WINDOW DEFOGGER MANUAL AIR CONDITION,CRUISE CONTROL,TILT STEERING COLUMN,ANTI-LOCK BRAKE SYS. TRACTION CONTROL,ALUM/ALLOY WHEELS,AUXILIARY INPUT,4WD OR AWD,FRONT AIR DAM TRIP COMPUTER,TELEMATIC SYSTEMS,VARIABLE ASSISTED STEERING,ANTI-THEFT SYSTEM AUTOMATIC HEADLIGHTS,VEHICLE THEFT TRACKING/NOTIFICATION DAYTIME RUNNING LIGHTS,AM/FM STEREO CD/MP3 PLAYER,ELECTRONIC STABILITY CONTROL FRONT BUCKET SEATS,KEYLESS ENTRY SYSTEM,POWER DISC BRAKES,REAR SPOILER REAR WINDOW WIPER Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units_ Front Door — 1 000783 BOY REPAIR L Frt Door Repair Panel Existing 2.5'# 2 TIME ADJUSTMENT INC'S JAMB 3 REF REFINISH/REPAIR L Frt Door Repair Panel C 2.5" 4 MODIFIED REFINISH WITH FULL CLEAR COAT 5 001431 BOY REMOVEANSTALL R Frt Otr Belt Moulding 0.5 # 6 001435 BOY REMOVEIINSTALL R Frt Door Rear Applique 0.2 7 001433 BOY REMOVEIINSTALL R Frt Rear View Mirror INC 8 002742 BOY REMOVE/INSTALL R Frt Door Adhesive Emblem Existing 0.2 r 9 001437 BOY REMOVE/INSTALL R Frt Door Trim Panel 0.4 10 001439 BOY REMOVEIINSTALL R Frt Otr Door Handle 0.3 ADDITIONAL COSTS&MATERIALS 11 936011 ADD'L COST APPEARANCE ALLOWANCE 50.00 12 $50 ALLOWANCE ON RT ROCKER MLDG 13 936012 ADD'L COST HAZARDOUS WASTE DISPOSAL 3.00 ADDITIONAL OPERATIONS 14 REF ADD'L OPR Clear Coat 0.8 15 900500 BOY . ADD'L LABOR OP CORROSION PROTECTION Sublet 15.00 . 02' 16 900500 BOY " ADD'L LABOR OP CAR COVER Sublet 4.00 ' 0.2' MANUAL ENTRIES 17 900500 BOY ` REMOVE/INSTALL CLEAN AND RETAPE DOOR INSIGNIA Sublet 1.00 ' 0.1` Additional Costs&Materials 18 ADD'L COST Paint/Materials 82.50 ` ESTIMATE RECALL NUMBER: 09/14/2012 06:17:08 12-3141476-01 Mitchell Data Version: OEM: JUL 12 V0906 MAPP:JUL 12_V Copyright(C)1994-2012 Mitchell International Page 1 of 4 Software Version: 7.0.443 All Rights Reserved E Date: 9114/2012 06:17 AM Estimate ID: 12-3141476-01 Estimate Version: 0 Committed Profile ID: CPA:All Parts *-Judgment Item #-Labor Note Applies C-Included in Clear Coat Calc r-CEG R&R Time Used For This Labor Operation Prior Damage: .............................I................ .......... 1. RT FENDER 2. RT REAR DOOR MLDG 3. RT REAR DOOR 4. REAR GATE 5. REAR BUMPER 6. LT REAR DOOR 7. LT REAR DOOR MLDG S. LT FRT DOOR 9. WINDOW TINT BUBBLED. 10.LT QUARTER SCUFFS 11.LT ROOF RAIL ALL MANUFACTURERS REQUIREMENTS REGARDING SEATBELT AND SUPPLEMENTAL RESTRAINT SYSTEM REPLACEMENT MUST BE ADHERED TO. IF ADDITIONAL PARTS OR OPERATIONS ARE NECESSARY TO PROPERLY ACCOMPLISH THIS, PLEASE CONTACT THE ESTIMATING CLAIMS REPRESENTATIVE. THIS IS A DAMAGE ASSESSMENT ONLY - NOT AN AUTHORIZATION TO REPAIR -BASED ON DAMAGE VISIBLE OR CERTAIN AT THE TIME IT WAS WRITTEN. IF FRAME OR UNIBODY REPAIR IS INCLUDED ON THIS ESTIMATE, THE AMOUNT SHOWN INCLUDES TIME OR ALLOWANCE FOR MEASURING BEFORE, DURING AND AFTER THOSE REPAIRS. YOU ARE UNDER NO REQUIREMENT TO USE ANY SPECIFIED REPAIR SHOP. INFORMATION REGARDING REPAIR FACILITIES WHICH WILL BE ABLE TO REPAIR THE VEHICLE FOR THE APPRAISED AMOUNT IS AVAILABLE FROM THE INSURANCE COMPANY. TO ENSURE PROPER AND PROMPT PAYMENT FOR ADDITIONAL DAMAGE DISCOVERED DURING THE COURSE OF REPAIRS, CONTACT PROGRESSIVE FOR SUPPLEMENT HANDLING PROCEDURES. Estimate Totals Add'I Labor Sublet 1. Labor Subtotals Units _Rate_ Amount Amount Totals II. Part Replacement Summary Amount Body 4.6 46.00 0.00 20.00 231.60 T Refinish 3.3 46.00 0.00 0.00 151.80 T Total Replacement Parts Amount 0.00 Taxable Labor 383.40 Labor Tax @ 6.000% 23.00 Labor Summary 7.9 406.40 ESTIMATE RECALL NUMBER: 09/14/2012 06:17:08 12-3141476-01 Mitchell Data Version: OEM: JUL 12_VO906 MAPPAUL 12_V Copyright(C)1994-2012 Mitchell International Page 2 of 4 Software Version: 7.0.443 All Rights Reserved i Date: 9/14/2012 06:17 AM Estimate ID: 12-3141476-01 Estimate Version: 0 Committed Profile ID: CPA:All Parts III. Additional Costs Amount IV. Adjustments Amount ...zso.00-. Taxable Costs 85.50 Insurance Deductible Sales Tax @ 6.000% 5.13 Appearance Allowance 50.00 Total Additional Costs 90.63 Customer Responsibility 200.00- Paint Material Method:Rates Init Rate=25.00 I. Total Labor: 406.40 It. Total Replacement Parts: 0.00 III. Total Additional Costs: 90.63 Gross Total: 497.03 IV. Total Adjustments: 200.00- Net Total: 297.03 Point(s)of Impact 9 Left Side(P) — Insurance Co: PROGRESSIVE INSURANCE Inspection Site: BRENNER COLLISION WEST(Service Center Only) Address: 6271 Carlisle Pike Mechanicsburg,PA 17011 (717)730-1410 (717)730-1410 Inspection Date: 9/132012 PROGRESSIVE HONORS THE PREVAILING LABOR MARKET RATE IN YOUR AREA FOR YOUR PROPERTY. IF YOU CHOOSE A SHOP THAT CHARGES IN EXCESS OF PREVAILING LABOR MARKET RATES OR ADDITIONAL COSTS ABOVE THE APPRAISED AMOUNT, YOU WILL BE RESPONSIBLE FOR THE DIFFERENCE. LIFETIME GUARANTEE FOR SHEET METAL AND PLASTIC BODY PARTS The replacement parts written on the estimate are intended to return your vehicle to its pre-loss condition with proper installation. After repair, if any sheet metal or plastic body part included in the estimate fails to return your vehicle to its pre-loss condition (assuming proper installation) , in terms of form, fit, finish, durability or functionality, Progressive will arrange and pay for the replacement of the part, to the extent not covered by a manufacturer's or other warranty. This service will be performed at no cost to you (including associated repair and rental car costs) . To obtain service under this Guarantee, call Progressive at 1-800-274-4641. This Guarantee applies as long as you own or lease the vehicle. This Guarantee is not transferable and terminates if you sell or otherwise transfer your vehicle. THIS GUARANTEE DOES NOT COVER NORMAL WEAR AND TEAR OR DAMAGE CAUSED BY IMPROPER MAINTENANCE, NEGLECT, ABUSE OR SUBSEQUENT ACCIDENT. THIS GUARANTEE IS LIMITED TO ARRANGING FOR THE SELECTION OF REPAIR PARTS THAT WILL RETURN YOUR VEHICLE TO ITS PRE-LOSS CONDITION. ACCORDINGLY, PROGRESSIVE WILL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL OR CONSEQUENTIAL DAMAGES THAT RESULT FROM THE INSTALLATION OR USE OF ESTIMATE RECALL NUMBER: 09/14/2012 06:17:08 12-3141476-01 Mitchell Data Version: OEM: JUL 12 V0906 MAPP:JUL 12 V Copyright(C)1994-2012 Mitchell International Page 3 of 4 Software Version: 7.0.443 All Rights Reserved Date: 9/14/2012 06:17 AM Estimate ID: 12-3141476-01 Estimate Version: 0 Committed THESE PARTS. Profile ID: CPA:All Parts Part Type Terms and Abbreviations NEW and OEM or part number displayed - These refer to a new, original equipment manufacturer part. NON-OEM and A/M and Qual REPL - These refer to an after-market part, which is a new, non-original equipment manufacturer part. USED/RECYCLED and LKQ - These refer to a used OEM part. REMANUFACTURED and RECOND. and RECORE - These refer to used/recycled OEM parts that have been refurbished. BDY=BODY, BDS=BODY STRUCTURE, REF=REFINISH, GLS=GLASS, FRM=FRAME, MCH=MECHANICAL, ADD'L COST=ADDITIONAL COST, ADD'L OPR=ADDITIONAL OPERATION, FRT=FRONT, RR=REAR, L=LEFT, R=RIGHT,UPR=UPPER,LWR=LOWER, OTR=OUTER, INR=INNER, ASSY=ASSEMBLY, SUSP=SUSPENSION, EXT=EXTENSION, BRK=BRACKET, INST=INSTRUMENT, ATG=ASSEMBLY TIME GUIDE. IF THIS APPRAISAL HAS BEEN PREPARED BASED UPON THE USE OF AFTERMARKET CRASH PARTS, AND IF THE USE OF AN AFTERMARKET CRASH PART VOIDS THE EXISTING WARRANTY ON THE PART BEING REPLACED OR ANY OTHER PART, THE AFTERMARKET CRASH PART SHALL HAVE A WARRANTY EQUAL TO OR BETTER THAN THE REMAINDER OF THE EXISTING WARRANTY. REPAIR SHOP'S AUTHORIZED REPRESENTATIVE'S SIGNATURE INDICATING AGREEMENT ON COST TO RETURN THE VEHICLE TO PRE-LOSS CONDITION INCLUDING TOW/STORAGE CHARGES: SHOP SIGNATURE: EST. COMPLETION DATE: ANY PERSON WHO KNOWINGLY AND WITH THE INTENT TO INJURE OR DEFRAUD ANY INSURER FILES AN APPLICATION OR CLAIM CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION SHALL, UPON CONVICTION, BE SUBJECT TO IMPRISONMENT FOR UP TO SEVEN YEARS AND PAYMENT OF A FINE OF UP TO $15,000. APPRAISER SIGNATURE Event Log File Created: 09/13/2012 06:14:46 PM Estimate Started: 09113(2012 06:17:32 PM Estimate Printed: 09/14/2012 06:17:25 AM Estimate Committed: 09/14/2012 06:17:08 AM Estimate Uploaded: Estimate not uploaded ESTIMATE RECALL NUMBER: 09/14/2012 06:17:08 12-3141476-01 Mitchell Data Version: OEM: JUL 12 V0906 MAPP:JUL712 V Copyright(C)1994-2012 Mitchell International Page 4 of 4 43— Software Version: 7.0.4All Rights Reserved ' Print CRS W0300025 Page 1 of 9 POLICE NWEALTH OF RASH REPOlRYIPdG FORM Pa Crash Number Case dosed Reportable Crash Pal...-..J AA-'500 i •YQs O No a Yes O No 1 W0300025 Incident Number Potice A en Patrol Zone 2012090175 21101 [2 IF Agency Name Precinct invest: ation Date(MM•OD-YYYY) East Pennsboro Township ENOLA 09 - 04 - 2012 1 �t D'rs atch Time(MR) Arrival Time(MID Investigator Badge Number 2344 2346 PTLM.DMMLLE R CRAUL 16I6 Reviewer Bade Number A roval Date (MM-DD-YYYY) •9- JCi� 6^07 lU County County Name Municipality Munlci ality Name A�s7yof Hr/eek g 21 Ci mberland 101 asI IT oro Township O Sun O Thu z Crash Date MM-DD-YYYY) Crash T(me(MID No of Units Poo le In ured Killed• *If>00 O Non O Fri 20122344 2 4 1 0 complete 0 Tue O Sat Forrss F O Wed Q Unk workzone f y CoSm�le rt 2q O Ye, -No I School Bus O Yaz - School Zone Notify PENNpOT Related Related O Yes No fiRalritenanca O Yes No a tnrseceron ml O 4 Way Intersection O "Y•intersection O a Multi•LO OfRamp O Railroad Crossin0 Midblock tg = Traffic 00 'T"intersection O e Round About O On Ramp O Crossover Q Other a g apyerla Route Number Segment(OptionaD Travel Lanes Seed omit _ 0 North House Number (tfa livable) 02 2s ,S:l O south 407 r Street NameStraot Ending O For Wdd•Mock crashes only Use 407 W.DAUPHIN ST 0 West Postai House Number and make sure O O Unknown Principal Roadway Street Name Is fled in H usln thisOption O Interstate O Tumpike 0 Turnpike O State O County Local Road C7 Private O Other/ (Not Tum ike) (East,W Sur Hi h Road or Street Road Unknown Route Number Segment( tionai) Travel lanes Speed Limit Q North ll-7i O South Street Name C Q EastStreet Ending � s = .2 U west. O O Unknown O interstate O Turnpike O Turnpike O State O County o Local Road O Private O Other/ .. (Not Turnpike) (EZN,,t) Spur Highway Road or Street Road Unknown Intersecting Rt Mum Or Mile Post Or seg ment Marker Feet II L__._.__._J•❑ �"� cc No 250 �� Or Intersecting Street Name St Endfn a O Sout 0 Enter .3N.1�ER ST E 0wast or wast informaation lor b Landmarks raks Intersecting Rt Num Or Mile Post Or Segment Marker t TdhIss rton v o O North Distance From Crash E •❑ M O South Scene to Landmark 1 Or Intersecting Street Name St Endin �O East (For Crash between ' GNLER Landmark 1 and p'v to O West Landma►k 1) Degrees Minutes Seconds Degrees Minutes Seconds r 6 latitude:� �; Longitude:— � �'�•� ' Traffic ContraLDevice Q Yield Sign Q Police Officer or Teo_ UMUb rno M Not Applicable O Traffic Signal Active RR Crossing Flagman a No Controls Q Device Functioning Emer pricy e ® Flashing Traffic O Controls g O Other Type TLD Improperly O Siiggnaall O Signal g O Stop Sign O Crossing Controls O Unknown 0 unctioning O Properlyunctioning © Unknown Lorre Uos�d(If`Not Applrrable;sk/p rest of the lane Unsure secQor� O North Q Eazt O North and South OAR O Not Applicable O Partially a Fully O Unknown I Dln'*A O South 0 West Q East and West (N.S,E,W) a i;$ • � .Tl'rl1�G . Yes O No aEsd O Unknown No <30 Min. 30.60 Min. O 1-3 111O 3.6 hrs O 6.9 his O>9 hours O Unknown i FORM rr AA•soa(svrkr) PENNDOT COPY --— http://www.dot6.state pa-us/ersapp/Printlmages/XmIFiles/20120907262012091408435543... 9/14/2012 Received Date: 10/10/2012 Print CRS W0300025 Page 2 of J 11DOLICE CISH RE t��fER9�S5�T0.V�ift�l9/!a Crash Number IP�aB�f01�S1�98�e9°E�i]R3�a F®9@&lA /A Jr(30 2 rake use oMy Pager .p Motor vehicle in =• W0300025 g Type O Transport Hit&Run Vehicle O illegally Parked O Legally Parked O Non-Motorized Commercial Vehicle to unit Q Pedestrian Q Pedestrian on Skates, Disabled From 5 in Wheelchair,etc O Previous Crash O Train O Phantom Vehicle O Yes 0 No (if'Pedestrian'or"Pedestrian on Skates in v hee/chair etc' Com late form M Section 28} (If Yes,Complete Form Q Unit No First Name Ml Date of Birth(MM DD Y, 01 RYAN Delete? Lest Name 13 1984 Q SHAFFER Tele hone Number Address/G /State 7178056948 403 PITT ST ENOLA PA zi' Driver License Number 17025 state Class 26751041 Alcohol/Druas 5usaected PA � rs O No Q Illegal Drugs Driver or Pedestrian PhvsFcal Condition O MedicationApparently NNI O Alcohol O Alcohol and Drugs 0 Unknown O Normal O U al Dru g O Fatigue Q Medication ` O Drriinkinen O Sldc Q Asleep Unknown �' Alcohor Test�/pPe 0 Test Not Given Q Breath O Other Primary Vehkle Code Vloratlon Charged? O Blood Q Urine Q Unknown if ACCIDENTS INVOLVING DEATH •Yes C7 No y Arcohol Test Results lest Given O Test Refused Q Ra ullt can Driver Presence 1=Driver Operated 3=Driver Fled Scene Test Given, O Vehicle Contaminated Results � 4-Hit and Run 2=No Driver 9=Unknwvn Owner/Driver 00-Not Applicable 02-Private Vehicle Not 04-State Police Vehicle 07-Municipal Police Veh 09--Federal Gov Veh Ol 01-Private Vehicle Owned/ Owned4-eased by Driver OS=PENNDOT Vehicle 08-Other Municipal 9gbOther Leased by Driver 03-Rented Vehicle 06=Other State Gov Veh Government Vehicle 99--Unknown Same as Owner First Name owner test Pdame or Business Name(!f Pedestrian,skip this Section) Driver Q 7ESSICA 33EATM PEREZ-RIVERA Address/City I State I Zip 55 IVEY LN HARRISBURG PA 17104 Vehicle Make *Make Code VIN Other 98 LE8PLNLC971100362 Model Year Vehicle Model (see oveday) 2007 License Plate CYCLONE W Reg.State Est.Speed Vehicle Towed 2389V Towed By PA E0 Yes •No --� Jns Insurance Company Polity Poo Q YYes es No O known A rallin tx ' Tntl It No.of '� 1`Towing Pass Veh 4=MobilelModular Home 7:Seml-Traller Ta No e Tra.of 0� CRL4 ❑2=Towing Truck S=Camper B=Other Tag Year rTa-gg St Un'tts: 3-Toying Utility Trailer 6=Full Trailer 9-Unknown Direction of D Wehide Position Ol +Movement *STee !�-� 98Special t/sage Ove Vehicle ColorTo ?Vile 05=Lar a Truck 06-Yelg 20--Unicy12=Commerclalo7=sav01=Automobile 06=SUV 08=Gol02=Motorcyde 07-Van 21=OttherApplicable Carrierger 01=Slue 09=bro03-Sus 10=SnowmobRe 22=Norse Veh 13-Taxi 02=Red04=Small Truck 11=Farm Equip 23=Horse&Rider 02=Ambulance 21=Tractor Trailer 03=Whlte 10=OraCompletefon' 12=Construction Equip 24=Train 03-Police ZZ=Twin Trailer I 1=Purn 26) 13=AN 25=T rop 08=Other Emergency 23=Tri 04=Bl X122-Othor 21,Complete 18=Other Type Spec Veh 98-1 vehicle 31-Mople dfied Iler Veh05=Black Section 27) 19=Unk.Type Spec Veh 99-Unknown 11�upil Transport 99=Unknown Initial Impact Point n =M31-L,vel Ol 0D=Non•Collision 14=UndercarrWgeO=None 2=Funct -Downhill RoadA_lhrnm�ntOi-12=Cock Points 1S-T =Bottom of Hill13=Top 99=Unkno nnh1L9 Unknoti ab =Top of F611 2=Curvedi=Unknown 9aUnknown r nn sop tsuozl PE:NNOOT COPY - http://www.dot6.state.pa.us/crsapp/Printhnages/XmIFiles/20120907262012091408435543... 9/14/2012 Received Date: 10/10/2012 page 3 of 9 print CRS W0300025 d®1�i 11i9[F�S L=Or-MUMSYLVANIA hili l�l�Illl l�l� trash Number JPaICE CRASH IRWDUM d$s FORM Page: AA 500 2 ""m u:e onv W0300025 Motor Vehtde in O Hit&Run Vehicle O Illegally Parked a Leggy Parked O Non-Motorized Commercial Vehlde TYI O Trataport Q Yes Na ro — nir Pedestrian on Skates,O Disabled From ?rain O Phantom Vehicle ;; O Pedestrian O in Wheelchair,etc Previous Crash (if ye;Complete Form 0 7 (if•Pedestrian•er"Pedestrian on Skates in Wheelchair etc• [om lete Form l M S to of Birth(MM DD YYYY—)-- �--} Unit No First Name t^1 (—'1 ' ! 02 ilJ! L—�J Tela hone NuLmber—+--, Last Name Delete/ O Z�iP Address/Ci /State State Class Driver License Number �{ � Driver or Pedestrian PhvsJcaf CondtN?nu Alcohol/Divas Suspected Medication Q spa fly O Ilseegal Drug O Fatigue Q Mediation Q No O Illegal Drugs O O Alcohol O Alcohol and Drugs O Unknown O Dardeen O Sick O Asleep O Unknown ` Alcoh �ilmary Vehicle Coda Violation Charged? ol Test Tvoe O Other 1j0 Test Not Galen O Breath O Yes O No Uma if O Blood O Urine OT esence 1=Driver Operated 3=Dtver Fled Scene Alcohol Test Results 0 Test Refused Q �t El Vehide 4=Hit and Run 10-= O Contaminated Results 2 2-No Driver 9--Unknown i OwnedprNer OD=Not Applicable 02=Private Vehicle Not 04-State Police Vehicle 07-Municipal police Veh 09=Federal Gov Veh � 01-private vehicle owned/ OwnedAeased by Diner OS=pENNDOT Vehicle 08-Other Municipal 99=unkn !Rased by Driver 03aRented Vehicle 06=Other State Gov Veh Government Vehicle 9 = nknown Owner Last Name or Business Name(ff Pedestr ian skip this Section)edtort)Same as Owner First Name Driver O It�EGAN L BAKER -.----_— vehicle Matra 'Wlatce Code Address J g y i state 17J Chevrolet 20 6601 SALEM PARK CM MD NICSBURG PA 17050 Model Year vehicle Moder (see overlay) VIN 2008 EQUINOX 2CNDL13F486075149 Eocene Plate Reg.State Est.Speed Vere Towed Towed BY GBF1213 1'A 000 CD Yes to No Insurance insurance Company Policy No $ a Yes O No O known PROGxESSIVE ADVANCED I 47667663-7 a Ta year Tag � 1 Towing Pass Veh $=C abpolModular Nome $=OtherTrailer lag N � Trarltn T B=Other tz '� Untt TleilonDa mt Q 3 Towing UtIMYT00 S64 ItTrailer 9- n Units: .. +Vehide Position Movement *See 5 al Usa e Direction of [� .r--- 12 O6 Overlay U 12=Comrnerdal vehicle Color Vehide VM 05=Large Trude 20=Unicycle,Bicycle, 00 Passenger 06-SUV Tricycle OD.Not Applicable Carder o-Yellow 01=Automobile 07=Van 21.0ttrer Pedalcyci¢ Otepre Veh 13=Yard 02 0741ver O6 02=Motorcyde 1D.Snowmobile 22=Horse&Bp9gy 02=Ambulance 21 Tractor Trailer 08=Gold 03=9us 1!farm Equip 23=Horse&Rider 03-Police 22--Twin Trailer 01=81ue 09--Brown 04=Sme11 Trude OB=Other Emergency 23 Triple Trailer 02=Aad 10=Orange Of"02" Complete Form 12=Construction Equip 24=?rain 13=ATV 25=Trolley Vehicle 31-Modified Veh 03=White 11-Purple M,Section 26) 18=Other Type Spec Veh 98=01her 11=Pupa Transport 99=Unknown tki=Glean 1z-Other (!f 20"or'21',Complete 19=Unk,Type$pec Veh 99=Unknown 05=81ack 99=Unknown Form M Section 27) Road Alianment initial Impact Parnt namaae Indicator G{adfent 3.Dottorn l 1nStraight 0-- on 2�FuncUonal 4=Bottom it 2.Curved 03 Oo=Non Colilsion 14=Undercarriage Fil1=M•uwr 3=Disabling 3 1=Level 5-To of Hill �— ^g=Unknown 01.12-Clock Points 1S.Towed Unit 9=Unknown 2=Uphill g=Unk,Wwn 13:Fop 99=Unknown PENNpf3T COPY FORM r M-600(12102) http;//www.dot6.state.pa.us/OrSapp/printlmages/XmlFiles/20120907262012091408435543... 9/14/2012 Received Date: 10/10/2012 yAt Print CRS W0300025 Page 4 of 9 COMMONWEALTH OF Poua CRASH REPORTING FO BliANlA Page Dash Number AA 500 3 vilae' Use 0* 0 W0300025 /�1=D jA Passen%oloccupant E N neyfs t AppNcable G O�No Applicable 2=Passengger 01=Driver-All Vehkles 01-Shoulder Belt Used 1-Not Ejected 7-Pedestrian 02-Front Seat Middle Position 02-Lop Bek Used 2 Total Elected 8=01her 03-Front Seat Right Side 03-tap And Shoulder Belt Used 3RPartla ly jetted 9--Unknown 04--Second Row-Left Side Or 04--Chad Safety Seat Used 9-Unknown Motorcycle Passenger 05-Motorcycle Helmet Used OS=SemncFRow-Middle Position 06411cyde Helmet Used 06-Second Row-Right Side 10=Safety Belt Used Improperly H Not Ejected Jr Not Applicable F=Female 07nThird Row Or Greater- 11-Child Safety Seat Used improperly 1-Through Side Door Opening Left Side 12=Helmet Used Improperly 2 Through Side Window U=Unknown 03-Third Row Or Greater- 90-Restraint Used,Type Unknown 3=Through Windshield rJ Middle Position 99=Unknown 4 Through Badc Door 09Third now Or Greater- 5-Through Back Door Tailgate Opening a Right Side safee 6 Through Roof Opening(Sunroof! O,No� 10=Sleeper Section of Tmckcab 00=None sed/Not Applicable Convertible Top Down1 I Wn Other Enclosed Ot=Front Air Bag Deppl!oyed(For This Seat) 7=Through Roof Opening(Convertible 1-Killed Passenger Or Cargo Area 02=Side Air Bag Deployed(For This Seat) To up) 2=Major Injury 12--in Open Area 03=tither Type Air Ba Deployed 9-Unknown is 3=Moderate (Back Of Pickup,Etc.) 04=Muhiple Air Bags Deployed Inju 13 Trailing Unit OS=.Motorcyde Eye tektlon 4=f�iinor Injury 14-tiding On Vehicle Exterior 06=BkydM Wearing VbowfteelPads ' Bdnjury,Uak 15-Bus Passenger 10--Air Bag Not Deployed,Switch On OO��likable Severity 98Other II-Air Bag Not Deployed,Switch OfI 1-Not Extdcated 9=Unknown if 99-Unknown 12=Air Bag Not Deployed, 2=Extricated By Mechanical Means Injury Unk S 13witch Se in 3-Freed By Non-Mechanical Means =Alr Bag Removed(Prior To Crash) 8--Other 19--Unknown 9 Air Bag Deployed 9-Unknown 99-Unknown 13 EMS Agency. EASTPENNSBORO EMS Medlin Favi ty HARRISBURG HOSPITAL Unit ivo Person No Date of Birth (MM-OD-YYYY) A B C D E F G H I Delete? 14 O 04 FO4 ���❑����❑❑ 01 01 13 - 1984 8 M 0 O1 OS 99 0 0 0 Name/Address/Phone EMS Transport o Same as SHAFFER,RYAN P 403 PITT ST ENOLA PA 17025 7178056948 O Yes O No Operator Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I 02 O1 0 12 21 1985 8�FF a Ol 99 99 u 0�0� Name I Address/Phone taws Transport same as B�{Lx�MEGAN L 407 W DAUPHIN ST ENOLA PA 17025 717756890 O Yes a No Operator Unit No Person No Delete? ate o Bs � 02 02 O F,2--]-F22 - 1986 2—]1M 03 00 00 0�L_I Name/Address/Phone EMS Transport Same as IBAKER,JAYSON K 407 W DAUPHIN ST ENOLA PA 17025 717756890 Yes O No Operator Unit No Person No Date of Birth MM-DD-YYYY) A B C D E F G H I 02 03 Deo ? 08 - 27 - 2010 2❑ 06 04 00 Q Q D Name I Address I Phone EMS Transport Same Operator r BAKED,LUCAS 407 W DAUPH N ST ENOLA PA 17025 OR Yes O No Unit Person No Delete? Date of Birth (MM•DD-YYYY) A B C b E F G H I 0 o-=-c�ooac�o=ooa Name/Address/Phone EMS Transport Same as O Yes O No Operator Unit No Person No Delete? Date of Birth(MM•DD-KYjjY�'Y'')�� A B C D E F G H I = = 0 - -L__— lCJ❑❑=="❑❑❑ Name/Address i Phone EMS Transport Same as 0 Yes O No Operator FORM r AA-500(12" PENNDOT COPY http://www.dot6.state.pa.us/orsapp/Printhnages/XrnIFiles/20120907262012091408435543... 9/14/2012 Received Date: 10/10/2012 Print CRS W0300025 Page 5 of 9 POLLIICE CRASH REPORTING FORMMONWEALTH OF Page 111111111111101 trash Number AA 500 4 =- I 0 W0300025 Crash D—edfifion o O-Non-CollWon 2--Head On 4-Angle 6=Sidesw1pe "- It Pedestrian 1=Rear End 8= er to Rear 6= eswl (Op Sfte D'1 eedV n) V- (�ackiirg) ame g�rection) 7=Hit Fixed Object 9=0therNnkndlvm-- Relation to Roadway D Icon Travel Lanes 3.Medlan C>=Outside Qraf/away 7-Gore(Ramp Intersection) _ 2-Shoulder 4--Roadside �In Parkin Lane 9--Unknown is Ei 1=DayFight �LOf9fits Street Dawn 8s011ter Yvmtnation 3 p � U _ S reket b°gnte 4_Dusk _ Road aynLili .� 1 pto A vores 6�0 7=Sleet&For 9-Unknown iNeatherCondttions � Co�licns Sleet{Ham 9 9 2aRaln- -- --4--snow �6=Rein&Fog 8-Other — s Road Surfare Conditions 1 O=Dry 2=OpS,a,ind,Mud,Did, 4=Stash Glee Patches 9--Other 1 aWet 3�now covered 5=1ce 7-W Covered r-Standing Harm Everitt !/R Most? fly Poie 111-umber Narmfu(Events(Harm Event) 30=Hit Fence Or Wall 9 58 Q 03n t Unit 1 31=Hit Building Unit No 02=1-it Unit 2 32-Hit Culvert 03-Hit Unit 3 33-HR Bridge Pier Or Abutment O1 2 02 ❑ Q 04=Hit unit 4 34=HParapet End 05=Hit Ural 5 35=Hh Bri a Rab 06=tan Other Trotfk Unit 35,-Mt Bou der Or Obstacle Please Pu07 Hit Deer On Roadway Events tot 3 a Q 08=Hit Other Animal 37-Hit Impact Attenuator Sequential 09=Collision With Other Non 38-Hit Fire Hydrant Order Fixed Object 39=Hit Roadway Equipment a 11=Struck By Unit 1 40--Hit Mall Box 4 O 12=Struck By Unit 2 411it Traffic Wand to 10 13=Struck By Unit 3 42-Hit Snow Bank EO Harm Event LIR Most? Utility Pole Ntrmber 14-Struck By Unit 4 43=Hit Temporary Construction ` 15=Struck By Unit 5 Barrcer 16-Struck By Other Traffic Unit 48-Hlt Other Fixed Object I O1 Q 21=HR Tree Or Shrubbery 49=11h Unknown Fixed Object Unit No 22 Hit Embankment 50=Overturn/Roll Over 23=Hk Utility Pole 51-Struck By Thrown Or Fairing 02 2 24aHit Traffic SIN Ob 25=Hk Guard Rail 5Z=fbf Holes Or Other Put 26-Hit Guard Rai!End Pavement Irregularities Please 3 � � � 274-lit Curb 53=Jacknife Events in Evenh n 2S it Concrete Or 54-Hre M Vehicle Order 4 Q Lo dudirtal Barrier 58-Other wn C llision Harmful 29=Hit Ditch 99=Unknown Harmful Event First Unit No Harm Event Most Unit No Harm Event Driver Action M). 17-Careless Or Illegal 17 armful � 7iaimfN � � 00=No CrWasuU�ng did Backing n he Wray Ol 58 vF enf-In Ol 58 01=Driver Was PaVacted 18-Drivfn On The Wrong e rash 02-Driving Using Hand Held Phone Side Of Road Do rat rrpuftushtaaa6onmm ffole"pn o3_-Drivinglsi ng Hands Free Phone 19=Makinglmproper Fnvironmental/Roadway 04=Making iQeg5l U-Turn Entrance To Hrgilway OSrlmproper/Careless Turning 2Q Making Improper ExR Potential Factors(&R) t 28 2 3 06 Turning From Wrong Lane from HI hvray 00--None 1 t.SBppa Mad Conditions ace/5rlow 07Proce rg Wio 21=Caretess Park/ngNnparkirg fist ry J CIWWR me After Stop 22=0verNnder 01=Windy Conditions 12-Su ante On Roadway 08=Running Sto Sign Compensation At Curve 02--Sudden Weather Conditions 13-Potholes 0%Running Rff light 23�peeding 03=Other Weather Cond'dions 14--Broken Or Cracked Pavement 10aFall 70 f�espond 7o za=Driving Too Fast For Conditions 04=Deer In Roadway 15-TCO Obstructed OlherTraffk Control Device 2S=Farure To Maintain Proper Speed 05=Dbstade On Roadway 16=Soh Shoulder or Shoulder Drop Off 11-Tailgal riyy26=DAvvet Fleeing Police(Pol Chase) 06=00wAnimal In Roadway 28;--Other Roadway Factor 12-Sudden SlowingStapping 27=Dtly,,Wx*lenced to 07=Glare 29-Other Environmental Factor 13=IIIegaliy Stop On Road 28=Faariwe To Use Specialized Equip eD8=Work Zone Related 99=Unknown 14-Careless Passing Or lane 9i-Affected 8y Physical Condition 0 Change 96=OtherI roper m Passible Vehicle Fa!lares M 12=Wipers 15=Passin in No Passng Zone mp°Pe Drnnng Actions OD-None 06--6 haunt 13=Drfver Seating/Control lfi=DrMr@ The Wrong Way On ggUnknown ° D1=Tires 07=Nead6ahts 14=Body,Doors,Hood,Etc 1-way street 02-Brake System D8=SigAnal hts 15■Trailer Hitch 03=SteeringSystem 094therLlghu 16aWheels knit O1 9 24 2 25 3F2-71.4= 17=Airbags 04°Susporwdut t0 fon 1g=TrailerOverbaded 05=PwverTroin itaMirrors 19=11nsecuret ifted V Npit O1 t 99 2 20=tmprt>perTrailer r�Tow ar i�nqq Ur'L 02 1 2 3 4 21�Obstnxied Wutdshieid Pedestrian Action(P) 03--Working Unft02 00 99--Unknown00=None 04.Pushing Vehicle No 1 2 01=Entering Ot Crossing At 05=ApproachIng Or leaving Vehicle SpedifW Location 06=Working On Vehicle indicated Prime Factor unit No Factor Code 02=WaWny.Running,Jogging, 07�Stanftq 00rat repeat this into=60n on Or Playing 98--other is rmrldpte utas Ol 2G 99-Unknown E/R v D P Unit No Ol unit No 02 0 Q = 0 If 1:(R is the Prime Factor Type,leave Unit No blank FORst•AA-soa n=4 PENNOOT COPY http://www.dot6.state.pa.us/crsapp/Printbuages/XmIFiles/20120907262012091408435543... 9/14/2012 Received Date: 10/10/2012 4 J Print CRS W0300025 Page 6 of 9 r , JPENNSYLVANIA POLICE CRASH REPORTING FORM lli�III�I�!l��il�ll�Page crash Number . AA 500 5 1 F6---j W0300025 0* Witness Name Address Phone 21 1 2 Narrative and additional witnesses. Accident Investigation Notification Issued?O PropertyDamage O on TUESDAY,SEPTEMBER 4,2012 AT 11:44 PM,I WAS DISPATCHED TO A HIT AND RUN AUTO ACCIDENT IN FRONT OF 407 W.DAUPHIN STREET.THE CALLER HAD ADVISED COUNTY DISPATCHERS THAT A MOTORCYCLE HAD STRUCK HIS PARKED VEHICLE AND FLED THE AREA.THE CALLER,JAYSON K.BAKER,DID PROVIDE THE DISPATCHERS WITH A PA REGISTRATION NUMBER OF 2389V FOR THE FLEEING MOTORCYCLE.I ARRIVED ON SCENE AT 11:46 PM.I LOCATED THE VICTIM VEHICLE AND SPOKE WITH HIM BRIEFLY.HE STATED THAT THE MOTORCYCLE HAD FLED,HEADING EASTBOUND ON W DAUPHIN STREET.I COULD SMELL A STRONG ODOR OF GASOLINE SO 1 DID NOT BELIEVE THE MOTORCYCLE COULD HAVE GOTTEN FAR.1 SEARCHED THE AREA FOR THE ro MOTORCYCLE UNTIL OTHER OFFICERS ARRIVED IN THE AREA.I THEN RETURNED TO THE SCENE TO SPEAK WITH THE VICTIM,JAYSON.HE EXPLAINED THAT HIS SON WAS RUNNING A HIGH FEVER SO HE AND HIS WIFE DECIDED TO TRANSPORT HIM TO THE HOSPITAL.JAYSON WAS LOADING HIS YOUNG SON INTO THE VEHICLE WHEN A MOTORCYCLE CAME AROUND THE CORNER FROM N HUMER STREET TO W DAUPHIN STREET AT A HIGH RATE OF SPEED.JAYSON YELLED AT THE OPERATOR OF THE MOTORCYCLE TO"SLOW DOWN".THE MOTORCYCLE THEN TURNED AROUND AT THE NEXT INTERSECTION,W DAUPHIN STREET AT GIVLER AVENUE AND ACCELLERATED AT A HIGH RATE OF SPEED BACK TOWARDS JAYSON.THE MOTORCYCLE THEN LOST CONTROL SLIDING ONTO IT'S SIDE.THE MOTORCYCLE WAS SLIDING RIGHT AT JAYSON AND THE VEHICLE SO JAYSON ATTEMPTED TO JUMP INSIDE.(NOTE:WHEN THE MOTORCYCLE BEGAN TO SKID,JAYSON WAS STANDING IN THE OPEN DOOR AREA OF THE FRONT PASSENGER SEAT.)JAYSON WAS UNABLE TO MAKE IT INTO THE VEHICLE BEFORE THE MOTORCYCLE STRUCK THE CAR.THE MOTORCYCLE STRUCK THE FRONT PASSENGER CAR DOOR CAUSING SCRATCHES ON THE DOOR AND PUSHED INTO JAYSON'S LEGS IN HIS KNEE AREA.JAYSON PICKED UP HIS PHONE TO CALL FOR POLICE AND THE MOTORCYCLIST BEGGED HIM NOT TO CALL.THE OPERATOR OF THE MOTORCYCLE THEN FLED THE SCENE.THE REGISTRATION ON THE MOTORCYCLE CAME BACK TO JESSICA BEATRIZ PEREZ- RIVERA ON IVEY LANE IN ff FORM I A"00(12" PENNDOT COPY http://www.dot6.state.pa.us/ersapp/PrintImages/XmIFiles/20120907262012091408435543... 9/14/2012 Received Date: 10/10/2012 } Print CRS W0300025 Page 7 of 9 OF J >POUCEC6Rffi�6@4mG 1t*i�RAt�R30A Page O New IIBII�IIIIuI�UI Crash Number AA500N Change/ W0300025 Continuation Harrative and additional evitnesses: sz HARRISBURG CITY.I REQUESTED AN OFFICER GET IN CONTACT WITH HER AND HAVE HER CALL ME.PEREZ-RIVERA DID CALL ME AND SHE ADVISED THAT SHE SOLD THE MOTORCYCLE IN SEPTEMBER OR OCTOBER OF 2011 TO A MALE FROM ENOLA.SHE STATED THAT SHE SIGNED THE TITLE AND GAVE IT TO HIM BUT NEVER HAD IT NOTORIZED.PEREZ-RIVERA DID KEEP A PHOTOCOPY OF THE PURCHASER'S DRIVERS LICENSE IN CASE ANYTHING WOULD EVER HAPPEN.SHE PROVIDED ME WITH THE PHOTOCOPY AND IT IDENTIFIED THE PURCHASER AS RYAN P.SHAFFER FROM 403 PITT STREET,ENOLA,WHICH IS VERY CLOSE TO THE CRASH SCENE.I THEN RESPONDED TO SHAFFER'S RESIDENCE AND LOCATED THE MOTORCYCLE INSIDE A DETATCHED GARAGE.SHAFFER,HOWEVER,WOULD NOT ANSWER THE DOOR.ON SATURDAY,SEPTEMBER 8,2012 1 PLACED A PHONE CALL TO SHAFFER.HE DID AGREE TO COME TO THE STATION TO SPEAK WITH ME.SHAFFER STATED THAT THE BIKE WAS NEVER RUNNING RIGHT AND THAT HE WAS WORKING ON IT AND DECIDED TO TAKE IT FOR A RIDE AROUND THE BLOCK.SHAFFER'S LICENSE IS DUI SUSPENDED.CHARGES FILED AGAINST SHAFFER. I I i i FORM 0AA-SM CMM PENNDOT COPY http://www.dot6.state.pa.us/crs app/PrintImages/MnIFiles/2012090726201209140843 5543... 9/14/2012 Received Date: 10/10/2012 i Print CRS W0300025 Page 8 of 9 r , COPARW MALYN OF �-1 i WI�$OC R Rffid FORM Page Page O New �J Crash Numbar .AA 500 M "°'t'"°° � O Change/ hane/ on W0300025 Unit No For Answers to the below(except for Engine Size and Helmet Type)use the following codes:Y a Yes N=No U=Unknown 01 Engine Size.01200 CC t?river protection 7 Helmet Tyge paElnnoer Protedion 7 Helmet 7vne 0-No Helmet 0-No Helmet Motorcvde Has?mp Driver Has? IS Eye Protection a 1=Full Helmet Eye Protection a 1=Full Helmet oN U 2=314 Style 2-3/4 Style Passenger ❑ MC Education 3=Half Helmet 3-Half Helmet 26 g Q tong Sleeves Style F] Long Sleeves Style b Saddle g Niand/ 9-Unknown 9=Unknown unk M tong Pants Helmet Stay On? tong Pants 1:1Heimet Stay On? aTrailer Helmet has Heimet has M Over Ankle Boots a DOT or Snell ❑ Over Ankle Boots DOT or Snell Designation Designation 1 Unit No Use Codes ❑ Passenger? ❑ Helmet? Unit No Use Codes ❑Passenger? ❑ Helmot7 Y=Yes Y-Yes .. N=No = N=No U=Unknown Q UUgghts7 Reflectors?ad Rear U=Unknown Head tights? 0 Rear Reflectors? Unit Pedestrian!.o®llgn � Unit No location L J 01-Marked Ciosswall 01=Miarked Crosswalks at Intersection 02-At intersection-No Crosswalks 02=At Intersection-No Crosswalks esti an signals 03 a Non-intersection Crosswalks O!desfr109 Signals 03= Non tntersection Crosswalks O Yes 04= Driveway Access O Yes 04=Dilreway Access 05- In Roadway 20O No 05=Not in Roadway ONO 06=Not In Roadway a O Not at lntersectjon 07=Median O Not at Intersection 07= Median $ 08-Wand 08- Island IL Pedestrian Vothing 09.Shoulder P fign Clothing og.Shoulder O tight to-Sidewalk O tight 10-Sidewalk 11=<10 Feet Off Road 11=<10 Feet Off Road O Dark 12->10 Feet OH Road O Dark ` 12->10 Feet Off Road O Reflective 13=Outside TrafrKway O Reflective 13-Outside Tramway 14=Shared PatFsfTrails 14-Shared Paths/Tralls O Unknownn99=Unknown O Unknown 99=Unknown W01*Zone Tvne 3111heie In Work Ione 1V&rkzQM5DQed lane Closum? O Construction O Warniist ng Zone Road posed with (long Term) tg WEJ L ❑ Detour? Cc Maintenance Q Advance Warning Area (Ifficef pfmn (Mark af/that ❑ Work on Shoulder (Short Term) O Yes apply,If not or Median? O Transition Area ,workers Present involved or Intermittent or 291 O UUTity CompanyO Activity Area O Yes O No unknow,leave ❑ Moving Work? O Unknown blank) Q Other O Termination Area O No ❑ Flagger Control? O Other O Unknown ❑ Other f fit all warning signs In Narrative Additional M-Page htfomsallon wauoawaomtpz� Pi2NNUOT COPY http://www.dot6.state.pa.us/orsapp/Printlmages/XmIFiles/20120907262012091408435543... 9/14/2012 Received Date: 10/10/2012 t` Print CRS W0300025 Page 9 of 9 Crash Number:W0300025 Incident Number:2012090176 sy 107N.Dal h St Ott, r� http://w ww.dot6.state.pa.us/ersapp/Printlmages/Xm]Files/20120907262012091408435543... 9/14/2012 Received Date: 10/10/2012 Claim Payment Detail Page 1 of 1 Claim Payment Detail { 12-3141476 ) Payment Information Disbursement Number: 766330894 Total Amount: $178.80 EFT Trace Number: Invoice Number: Paid To: ENTERPRISE RENT-A-CAR Mailing Address: ENTERPRISE RENT-A-CAR 3950 HARTZDALE DR CAMP HILL,PA 17011-7828 In Payment Of: ENTERPRISE RENT-A-CAR RENTAL INVOICE#57PRD009494 Vendor Information Name: ENTERPRISE RENT... 1099 Required: Type: GLASS SHOP Reviewed Summary Issuing Rep: A091257 Approved By: Issue Date: 09-21-12 Review Date: Last Updated Rep: A091257 Reviewed By: Bank Information Type: Loss Bank Code: CTB Stop Reason: Cleared: 09-25-12 Stop Date: Exposure Detail: RENTAL Party Name: BAKER, MEGAN L Amount Paid: $178.80 Property Description: 08 CHEVR EQUINOX Deductible Taken: $0.00 Payment Type: FINAL PAYMENT Property Damage: $0.00 Rental: $178.80 http://claimspayments/Alpha/ClaimsPaymentsWeb/default.aspx?p... 7/2/2014 Claim Payment Detail Page 1 of 1 Claim Payment Detail { 12-3141476 ) Payment Information Disbursement Number: 479452345 Total Amount: $5,500.00 EFT Trace Number: Invoice Number: Paid To: JAYSON&MEGAN BAKER, INDIVIDUALLY,&AS HUSBAND&WIFE,& THEIR ATTORNEY,ANGINO-ROVNER,ONLY************************ Mailing Address: 4503 NORTH FRONT STREET HARRISBURG,PA 17110-1799 USA In Payment Of: SETTLEMENT OF UM CLAIM ONLY Vendor Information Name: ANGINO AND ROVN... 1099 Required: Type: ATTORNEY Reviewed Summary Issuing Rep: DMS0026 Approved By: Issue Date: 09-03-13 Review Date: Last Updated Rep: DMS0026 Reviewed By: Bank Information Type: Loss Bank Code: AS2 Stop Reason: Cleared: 09-08-13 Stop Date: Exposure Detail. UM Party Name: BAKER,JAYSON K Amount Paid: $5,500.00 Payment Type: FINAL PAYMENT Deductible Taken: $0.00 Workers Comp Type: Medical: $0.00 Wage: $0.00 OEL: $5,500.00 http://claimspayments/Alpha/ClaimsPaymentsWeb/default.aspx?p... 7/2/2014 VERIFICATION I, Benjamin W. Lawrence, Esquire, attorney for the Plaintiff(s) do hereby swear and affirm that the averments in the attached Complaint are true and correct to the best of my knowledge, information and/or belief. These averments are made subject to the penalties of 18 Pa.C.S.A. §4904 relating to unsworn falsification to authorities. Benja Lawrence ol� Date �`5 Claim Payment Detail Page 1 of 1 Claim Payment Detail ( 12-3141476 ) Payment Information Disbursement Number. 766322123 Total Amount: $297.03 EFT Trace Number: 711251711 Invoice Number: 7448912 Paid To: BRENNER COLLISION CENTER WEST Mailing Address: 6271 CARLISLE PIKE MECHANICSBURG,PA 17055 USA In Payment Of: Progressive Invoice Number:7448912 Vendor Information Name: 1099 Required: No Type: Reviewed Summary Issuing Rep: SDW0004 Approved By: Issue Date: 09-18-12 Review Date: Last Updated Rep: SDW0004 Reviewed By: Bank Information Type: Loss Bank Code: CTB Stop Reason: Cleared: 09-19-12 Stop Date: Exposure Detail:COLL Party Name: BAKER,MEGAN L Amount Paid: $297.03 Property Description: 08 CHEVR EQUINOX Deductible Taken: $250.00 Payment Type: FINAL PAYMENT Property Damage: $297.03 Rental: $0.00 http://claimspayments/Alpha/ClaimsPaymentsWeb/default.aspx?p... 7/2/2014 Ronny R Anderson Sheriff Jody S Smith Chief Deputy Richard W Stewart Solicitor SHERIFF'S OFFICE OF CUMBERLAND COUNTY C u 111tec f�•r,. 7..13114 OCT -1 Ph 2. 3; CUMBERLAND PENNSY�_VAN A� OFF iM OF THF, £VSRIFF Progressive Advanced Insurance Company vs. Ryan P Shaffer Case Number 2014-5083 SHERIFF'S RETURN OF SERVICE 09/23/2014 08:53 PM - Deputy Shawn Gutshall, being duly sworn according to law, served the requested Complaint & Notice by "personally" handing a true copy to a person representing themselves to be the Defendant, to wit: Ryan P Shaffer at 403 Pitt Street, East Pennsboro, Enola, PA 17025. GUTSHALL, DEPUTY SHERIFF COST: $61.90 SO ANSWERS, September 24, 2014 (c) CountySui.e Sheriff, Teleosoft, Inc. RONIV R ANDERSON, SHERIFF