Loading...
HomeMy WebLinkAbout14-5687IN RE: THE MATTER OF KRISTEL LYNN : IN THE COURT OF COMMON PLEAS SMITH, As Parent and Natural Guardian of : CUMBERLAND COUNTY, PENNSYLVANIA QUENTIN ALEXANDER WINGFIELD, : Petitioner : NO. 1 Sia PETITION OF APPROVAL OF SETTLEMENT AND DISTRIBUTION OF PROCEEDS FOR MINOR TO THE HONORABLE JUDGES OF SAID COURT: > c -7- 74r: CZ" Petitioner, Kristel Lynn Smith, Parent and Natural Guardian of Quentin Alexander- • Wingfield, a Minor, through her counsel, Tucker Arensberg, P.C., petitions this Honorable Court for an Order pursuant to 20 Pa. C.S.A. §5301 and Pa.R.C.P. 2039 and respectfully represent as follows: 1. Petitioner, Kristel Lynn Smith, is an adult individual who resides at 707 Hummel Avenue, Apartment A, Lemoyne, Cumberland County, Pennsylvania 17043. Kristel Lynn Smith is the parent and natural guardian of Quentin Alexander Wingfield (hereinafter "the Minor"). Kristel Lynn Smith has primary physical and legal custody of the Minor, Quentin Alexander Wingfield. 2. The Minor's date of birth is February 26, 2005. 3. On the date of the accident, January 3, 2013, the Minor was struck by a vehicle driven by Yang Yang Pan immediately after exiting his school bus. Yang Yang Pan was uninsured at the time of the accident. The accident took place at 603 Hummel Avenue, Lemoyne, Cumberland County, Pennsylvania. At the time of the accident, Yang Yang Pan disobeyed the school bus lights and stop sign while striking the Minor in the middle of the street. a s -NI a Hi iqIU SL1 4. The West Shore School District was the owner and operator of the school bus from which the Minor had just disembarked. At the time of the accident, the West Shore School District maintained uninsured motorist coverage for their school buses pursuant to the policy with ACE/USA. The uninsured motorist policy limits for the West Shore School District bus in question was $100,000.00 on the date that the Minor was struck. (See ACE/USA Declaration page attached hereto as Exhibit 1 and incorporated herein). 5. On the date of the accident, the Minor resided with Petitioner. On the date of the accident, the Petitioner had an auto insurance policy with GEICO Insurance Company, Policy No.: 4220504783. Petition maintained $100,000.00 of uninsured motorist coverage through her GEICO Insurance Company on the date of the accident. 6. On the date of the accident, the Minor was also a resident of the household of his father, Matthew Wingfield. The Minor's father periodically had visitation with the Minor and thus the Minor was also a resident of the father's household. On the day of the accident, the father maintained auto insurance policy with Erie Insurance Company, Policy No.: 006 1310243 H. The Minor's father had $100,000.00 of uninsured motorist coverage through his policy with Erie Insurance Company on the date of the accident. 7. The Minor sustained various, serious injuries as a result of the accident in question. The Minor's most serious injury was a severe facture of his right leg. The Minor required care and treatment for the injuries sustained in the auto accident in question. The Minor had surgical repair of his fracture in his right leg at the Hershey Medical Center and received follow-up treatment through the physicians at the Hershey 2 Medical Center. The Minor has not fully recovered from the injuries sustained in the accident, although he has been released from care to return as needed. 8. ACE/USA, has accepted liability for the accident of January 3, 2013, and has offered to pay its $100,000.00 of uninsured motorist policy limits. ACE/USA is requesting the Petitioner sign a Release in exchange for payment of the $100,000.00 uninsured motorist policy limits. (See Release attached hereto as Exhibit 2 and incorporated herein). 9. The Petitioner considers the offer of the payment from ACE/USA of $100,000.00 to be a fair and reasonable under the circumstances as that is their policy limits. The Petitioner believes that it is in the best interest of the Minor to accept the $100,000.00 policy limit payment from ACE/USA at this time. The Petitioner has retained Dennis R. Sheaffer, Esquire, of the law firm of Tucker Arensberg, P.C., to represent the Minor in his claim. The Petitioner has entered into a written Fee Agreement with Tucker Arensberg, PC., for payment of Twenty -Five (25%) percent of all amounts received on behalf of the Minor. (See Attorney's Fee Agreement attached hereto as Exhibit 3 and incorporated herein). 10. The Petitioner incurred substantial medical expenses. GEICO insurance has paid its Five Thousand ($5,000.00) Dollars first party medical limits for treatment of the injuries sustained by the Minor in the auto accident. Erie Insurance also had a Five Thousand ($5,000.00) Dollar policy limit for medical benefits which it shared with GEICO. ACE/USA maintained a Ten Thousand ($10,000.00) Dollar policy limit for medical benefits under its policy with the West Shore School District. ACE/USA has paid Four Hundred Seventy -Eight ($478.00) Dollars for the Minor's medical treatment. 3 ACE/USA intends to pay the remaining Nine Thousand Five Hundred and Twenty -Two ($9,522.00) Dollars toward the Minor's medical expenses and lien. 11. Medical expenses in excess of the applicable first party medical benefits under the relevant auto insurance policies were paid by the health insurance coverage on the Minor as of date of the accident. The Minor was insured though CHIP in Pennsylvania. Aetna Insurance maintained the coverage on the Minor through CHIP. Aetna paid $30,407.11 for medical expenses related to the treatment of the Minor's injuries from the auto accident in question. (See Aetna lien statement attached hereto as Exhibit 4 and incorporated herein). Aetna is entitled to be reimbursed Thirty Thousand Four Hundred and Seven and 11/100 ($30,407.11) Dollars in medical expenses it paid. 12. The total payment amount of One Hundred Thousand and 00/100 ($100,000.00) Dollars is hereby ordered to be distributed as follows: Tucker Arensberg, P.C. (25% fees): $ 25,000.00 Reimbursement for Costs Advanced: Medical Records $ 638.71 Stumar Investigation $ 645.00 Total Costs: $ 1,283.71 Attorneys' Fees and Costs: $ 26,283.71 Aetna Insurance Lien: $ 30,407.11 Total Deduction: $ 56,690.82 Balance to Kristel Lynn Smith, as Parent and Natural Guardian of Quentin Alexander Wingfield, A Minor: $ 43,309.18 4 13. The balance of Forty-three Thousand Three Hundred Nine and 18/100 ($43,309.18) Dollars payable on behalf of the Minor shall be deposited in the name of "Quentin Alexander Wingfield, a Minor", in a bank, building and loan association, savings and loan association, or credit union, deposits and which are insured by a Federal Governmental Agency, provided that the amount deposited in any one such savings institution shall not exceed the amount which accounts are thus insured. No withdrawal shall be made from such account until the Minor obtains majority, except as authorized by a prior Order of Court. Proof of the deposit shall be promptly filed of record with the Court, pursuant to Pa.R.C.P. 2039(b)(2). 14. Counsel for the Petitioner and the Minor is continuing to proceed with claims against GEICO Insurance Company and Erie Insurance Company for additional uninsured motorist benefits pursuant to those policies. WHEREFORE, your Petitioner respectfully requests this Honorable Court to enter an Order approving the proposed settlement and distribution of funds for the payments to the Minor. The Petitioner respectfully requests the Court to approve payment of the Attorney's Fees and costs as well as the medical lien payment. The Petitioner also requests the Court authorizing the Petitioner to execute a Release as the Minor's Parent and Natural Guardian in favor of ACE/USA and further authorize the Petitioner to take any other steps necessary to complete payment of the funds by ACE/USA. 5 Dated: September 26, 2014 HBG DB:145393-1 028542-158622 Respectfully submitted, TUCKER ARENSBERG, P.C. By: Dennis R. S eaffer Attorney I.D. #39182 2 Lemoyne Drive, Suite 200 Lemoyne, PA 17043 (717) 234-4121 Attorney for Petitioner 6 VERIFICATION I, the undersigned, KRISTEL LYNN SMITH, as Parent and Natural Guardian of QUENTIN ALEXANDER WINGFIELD, hereby certify that I am the PLAINTIFF in the foregoing action, and that the statements made in the foregoing document are true and correct to the best of my knowledge, information and belief. I understand that any false statements made to this verification are subject to the penalties of 18 Pa. C.S.A. §4904, relating to unsworn falsification to authorities. DATE: Septemberaq , 2014 H B G D B :1464 32-1 028542-158622 rist l Lynn Smith, Parent and Natural Guardian of Quentin Alexander Wingfield EXHIBIT 1 DA -3K41 b 02/2003 Copyright, Insurance Services Office, Inc. 2000 6 08/13/2012 Page 1 of 54 ACE USA BUSINESS AUTO DECLARATIONS Indemnity Insurance Co of North America P.O. Box 1000 436 Walnut Street Philadelphia, PA 19106 POLICY NUMBER: CAL H08596098 New Business 3k Ys5.$i�.s`' f .NSURE; T. i .. � y � Xv � ate+ Wi;• 1 ,z `.-5-' 4�. -.F .. - --- ox ti> T r- ,..r, --,.M �:• _�--- ; -.^a.... Crl `F CAii Y� �C C 's`;'� t,# MH :e � l i^^.S�? is 3�.+�` �i %�-i tt.� - "M1" �t-it:" r� 4A..!` •-Y -"� h ..m d • k rpt 3? l^i=-' ,ms. ai' .+.._-C+, ,it, � z--• t .,.s.„. �' uyyyt`�" '< f\ b`."t''',`ji C��-i --3 1Y _ .:uy 'h `' „y �T qrN� ,, ..w_.,,� :� �} � �� w' .... l'i :acil#.,..si< ....•.._Tj+�...'tx+T ,_z-.. _..-L�_.s 7 jib-. tfi. I _.3rE f tt Y.z w. Named Insured: WEST SHORE SCHOOL DISTRICT Address: PO BOX 803 PENNSYLVANIA - THIS POLICY SCHOOL CODE 655 PROVIDES COVERAGE FOR NEW CUMBERLAND PA 17070 COLLISION DAMAGE TO RENTAL VEHICLES SUBJECT TO THE DEDUCTIBLE INDICATED IN ITEM FOUR. DC . , • �RU--fi,`x � � 4r Producer Number: PS0219 Producer Name: THE HDH GROUP INC Producer Address: US STEEL TOWER 600 GRANT ST SUITE 1100 PITTSBURGH PA 15219--280 ITEM ONE POLIC INtb.. , =IONa :' �7 1 �p 3 z � --xtr�.'-!'4af^'riG-'..P'f-.1FL .�='fie..'F.r�T�9fl i'.'T...?f•"e!F>i-..li[-.N_a. 'F� i•y4th"N{ �, +.,k>- 1?d 3.�.4'$�'{-i Y_ i Yi. �... 2+ �Y.� F.m'%-.. FYi ,-YAlaispen 1.1: ..2«'?,�#v. _^,Y�'.3i'� . - _�s._M Form of Business: Other Named Insured's Business: Policy Period: Policy covers from 07/01/2012 to 07/01/2013 12:01 am standard time at the named insured's address stated above. Audit Period: NON -AUDITABLE Estimated Total Premium: $80,425.00 Deposit/Minimum Premium (Including taxes and surcharges) In return for the payment of premium and subject to all the terms of this policy we agree with you to provide the insurance as stated in this policy. DA -3K41 b 02/2003 Copyright, Insurance Services Office, Inc. 2000 6 08/13/2012 Page 1 of 54 ACE USA Indemnity Insurance Co of North America P.O. Box 1000 436 Walnut Street Philadelphia, PA 19106 POLICY NUMBER: CAL H08596098 New Business BUSINESS AUTO DECLARATIONS FORMS AND ENDORSEMENTS ATTACHED TO POLICY AT INCEPTION SCHEDULE OF ENDORSEMENTS ALL20887 (10/06) PRODUCER COMPENSATION NOTICE ALL21101 (11/06) TRADE OR ECONOMIC SANCTIONS ENDORSEMENT ALL274760609 DISCLAIMER NOTICE COMMERCIAL LINES DEREGULATION CC1 K11 G SIGNATURE ENDORSEMENT CA00010310 BUSINESS AUTO COVERAGE FORM IL00171198 COMMON POLICY CONDITIONS ILP0010104 TREASURY DEPT. (OFAC) 100210908 NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT (BROAD FORM) CA23840106 EXCLUSION OF TERRORISM 101200511 PENNSYLVANIA CHANGES - DEFENSE COSTS CA01800997 PENNSYLVANIA CHANGES CA21920612 PENNSYLVANIA UNINSURED MOTORISTS COVERAGE - NONSTACKED CA21930612 PENNSYLVANIA UNDERINSURED MOTORISTS COVERAGE NONSTACKED CA22370306 PENNSYLVANIA BASIC FIRST PARTY BENEFIT CA22380395 PENNSYLVANIA ADDED AND COMBINATION FIRST PARTY BENEFITS ENDORSEMENT 102460907 PENNSYLVANIA CHANGES - CANCELLATION AND NONRENEWAL IL09100702 PENNSYLVANIA NOTICE CA24021293 PUBLIC TRANSPORTATION AUTOS DA26325 (01/09) RENTAL REIMBURSEMENT COVERAGE DA26326 (01/09) OPTIONAL LIMITS - LOSS OF USE EXPENSES DA372450212 SCHOOLS AND COLLEGES AUTOMOBILE SPECIAL CONDITIONS (PA) DA24541 PHYSICAL ABUSE OR SEXUAL MISCONDUCT EXCLUSION DA-3K41b 02/2003 Copyright, Insurance Services Office, Inc. 2000 58 08/13/2012 Page 53 of 54 POLICY NUMBER: CAL H08596098 COMMERCIAL. AUTO CA 21 92 06 12 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PENNSYLVANIA UNINSURED MOTORISTS COVERAGE - NONSTACKED For a covered "motor vehicle" licensed or principally garaged in, or "garage operations" conducted in, Pennsylvania, this endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: WEST SHORE SCHOOL DISTRICT Endorsement Effective Date: 07/01/2012 SCHEDULE Limit Of Insurance: $100,000 Each "Accident" Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Coverage 1. We will pay all sums the "insured" is legally entitled to recover as compensatory damages from the owner or driver of an "uninsured motor vehicle". The damages must result from "bodily injury" sustained by the "insured" caused by an "accident". The owner's or driver's liability for these damages must result from the ownership, maintenance or use of an "uninsured motor vehicle". 2. No judgment for damages arising out of a "suit" brought against the owner or operator of an "uninsured motor vehicle" is binding on us unless we: a. Received reasonable notice of the pendency of the "suit" resulting in the judgment; and b. Had a reasonable opportunity to protect our interests in the "suit". CA 21 92 06 12 82 B. Who Is An Insured If the Named Insured is designated in the Declarations as: 1. An individual, then the following are "insureds": a. The Named Insured and any "family members". b. Anyone else "occupying" a covered "motor vehicle" or a temporary substitute for a covered "motor vehicle". The covered "motor vehicle" must be out of service because of its breakdown, repair, servicing, "loss" or destruction. c. Anyone for damages he or she is entitled to recover because of "bodily injury" sustained by another "insured". © Insurance Services Office, Inc., 2011 Page 1 of 4 2. A partnership, limited liability corporation or any other form of organization, then the following are "insureds":a. Anyone "occupying" a covered "motor vehicle" or a temporary substitute for a D. covered "motor vehicle". The covered "motor vehicle" must be out of service because of its breakdnwn, repair, servicing, 'Ioss" or destruction. b. Anyone for damages he or she is entitled to recover because of "bodily injury" sustained by another "insured". C. Exclusions This insurance does not apply to any of the following: 1. Any claim settled without our consent. However, this exclusion does not apply if such settlement does not adversely affect our rights of recovery under this coverage. 2. The direct or indirect benefit of any insurer or self -insurer under any disability benefits or similar law, except workers' compensation taw. 3. Anyone using a vehicle without a reasonable beUefthatthe person is entitied to do so. 4. Punitive or exemplary damages. 5. "Bodily injury" suatainad by: a. An individual Named Insured while "occupying" when struck by any vehicle owned by that Named Insured that is not a covered "auto" for Uninsured Motorists Coverage under this Coverage Form; b. Any "family member" while "occupying" or when struck by any vehicle owned by that "family member" that is not a covered "auto" for Uninsured Motorists Coverage under this Coverage Form; or c. Any "family member" while "occupying" or when struck by any vehicle owned by the Named Insured that is insured for Uninsured Motorists Coverage on a primary basis under any other Coverage Form or policy. G. "Bodily injury" arising directly or indirectly out of: a. War, including undeclared or civil war; b. Warlike action by a military foroe, including action in hindering or defending against an actual or expected attack, by any government, sovereign or other authority using military personnel or other agents; or Page 2 of 4 83 c. |nauneciion, rebeUion, revnuUnn, usurped power, action taken by govemmental authority in hindering or defending against any of these. Limit Of Insurance 1. Regardless of the number of covered "motor vehicles", ^inounedn", premiums paid, claims made or vehicles involved in the "accident", the most we will pay for all damages resulting from any one "accident" is the Limit Of Insurance for Uninsured Motorists Coverage shown in the Schedule or Declarations. 2. Any amount payable for damages under this coverage shall be reduced by all sums paid by or for anyone who is legally responsible. This includes all sums paid for the same damages under this Coverage Form's Liability Coverage. This also includes all sums paid for an "insured's" attorney either directly or as part of the amount paid to the "insured". 3. No one will be entitled to receive duplicate payments for the same elements of "loss" under this Coverage Form and any Liability Coverage form, Medical Payments Coverage endorsement or Underinsured Motorists Coverage endorsement attached to this Coverage Part. We will not make a duplicate payment under this coverage for any element of "loss" for which payment has been made by or for anyone who is legaily responsible. We will not pay for any element of "loss" if a person is entitled to receive payment for the same element of "loss" under any disability benefits or similar |avv, except workers' compensation law. E. Changes In Coriditions The Conditions are changed for Pennsylvania Uninsured Motorists Coverage — Nonstacked as follows: 1. Duties In The Event Of Accident, Claim, Suit Or Loss is changed by adding the foliowing: a. Promptly notify the police if a hit-and-run driver is involved; and b. PrompUy send us copies of the legal papers if a ''suit" is brought. 2. Legal Action Against Us is replaced by the following: a. No one may bring a legal action against us under this Coverage Form until there has been full compliance with all the terms of this Coverage Form. 0Insurance Services Office, |no,2O11 CA 21 92 06 12 b. Any legal action ainst us under this Coverage Form must be brought within four years after the date on which the "insured" knows of the uninsured status of the owner or driver of the "uninsured motor vehicle". However, this Paragraph b. does not apply to an "insured" if, within four years after the date on which the "insured" knows of the uninsured status of the owner or driver of the "uninsured motor vehicle", we or the "insured" have made a written demand for arbitration in accordance with the provisions of this endorsement. 3. Transfer Of Rights Of Recovery Against Others To Us is changed by adding the following: If we make any payment due to an "accident" involving an "uninsured motor vehicle" and the "insured" recovers from another party in a separate claim or "suiV', the insured' shall hold the proceeds in trust for us and pay us back the amount we have paid, less reasonable attorneys' fees, costs and expenses incurredby the "insured" to the extent such payment duplicates any amount we have paid under this coverage. 4. Other Insurance in the Business Auto and Garage Coverage Forms and Other Insurance — Primary And Excess Insurance Provisions in the Truckers and Motor Carrier Coverage Forms are replaced by the foUowing: a. If there is other applicable similar insurance available under more than one Coverage Form or policy, the following priorities of recovery apply: First Second The Uninsured Motorists Coverage applicable to the vehicle the "insured" was "occupying"otUlaUDOeofUle "accident". The Coverage Form or poliaffording Uninsured Motorists Coverage to the "insured" as an individual Named Insured or t'family member". b. Where there is no applicable insurance available under the first priority, the maximum recovery under all Coverage Forms or poicies in the second priority may equal but not exceed the highest applicable limit for any one vehicle under any one Coverage Form or policy affording coverage to an individual Named Insured or "family member". CA 21 92 06 12 84 c. Where there is applicable insurance available under the first priority: (1) The Limit of Insurance applicable to the vehicle the "insured" was "occupying" under the Coverage Form or n|| in the first priority shall first be exhausted; and (2) The maximum recovery under all Coverage Forms or policies in the second priority may equal but not exceed the highest applicable limit for any one vehicle under any one Coverage Form or policy affording coverage to an individual Named Insured or 'famiiy member'. d. If two or more Coverage Forms or policies have equal priority: (1) The insurer against whom the claim is first made shall process and pay the claim as if wholly responsible for all lasurers with equal priority; (2) The insurer thereafter is entitled to pro rata contribution from any other insurer on the same level of priority for the benefits paid and the costs of processing the claim. 6. The foliowing condition is added: Arbitration a. If we and an "insured" disagree whether the "insured" is legally entitled to recover damages from the owner or driver of an "uninsured motor vehicle" or do not agree as to the amount of damages that are recoverable by that "inaured", then the matter may be arbitrated. Hovvever, disputes concerning coverage under this endorsement may not be arbitrated. Both parties must agree to arbitration. If so aQreod, each party will select an arbitrator. The two arbitrators will select a third. If they cannot agree within 30 days, either may request that selection be made by a judge of a court having jurisdiction. Each party will pay the expenses it incurs and bear the expenses of the third arbitrator equally. b. Unless both parties agree otherwise, arbitration will take place in the county in which the "insured" lives. Local rules of law toarbitration procedure and evidence as ar nm will apply. A decision agreed to by two of the arbitrators will be binding. © insurance Services Office, |nc,2011 Page 3 of 4 F. Additional Definitioris As used in this endorsernent: 1. "Family member" means a person related to an individual Named Insured by blood, marriage or adoption who is a resident of such Named Insureds housohn[d, including a ward or foster child. 2. "Occupying" means in, upon, getting in, on, out or off. 3. "Uninsured motor vehicle" means a land motor vehicle or "traHer": a. For which no liability bond or policy applies at the time oUan"accid�e�. b. For which an insuring orbonding company: (1) Denies coverage; (2) is or becomes insotvent; or (3) Is or becomes involved in insolvency proceedings. c. For which neither the driver nor owner can be identifiecj, The vehicle or "traiJer" must: (1) H| an "insured", a covered "motor vehicle" or a vehicle an "insured" is "occupying"; or Page 4 of 4 85 (2) Cause an "accident" resulting in "bodily injury"an "insurod"vv�hoUthdU '|naUmSO', a covered "motor vehicle" or a vehide an "insured is "occupying". If there is no physical contact with the hit-and-run vehicle, the facts of the "accident' must be proved. However,an "uninsured motor vehicle" does not include any vehicle: a. Owned or operated by a self -insurer under any applicable motor vehicle |aVv, except a self -insurer who is or who becomes insolvent and cannot provide the amounts required by that motor vehicle law; or b. Designed for use mainly off public roads while not on public roads. 4. "Motor vehicle" means a vehicle which is self-propelled except one which is propelled solely by human power or by electric p obtained from overhead trolleyvviree, but does not mean ovehio|e operated upon rails. © Insurance Services Office, Inc., 2011 CA 21 92 06 12 POLICY NUMBER CAL H08596098 COMMERCIAL AUTO CA 22380395 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PENNSYLVANIA ADDED AND COMBINATION FIRST PARTY BENEFITS ENDORSEMENT This endorsement modifies insurance provided under the foliowing: PENNSYLVANIA BASIC FIRST PARTY BENEFIT With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. This endorement changes the policy effective un the inception date of the policy unless another date is indicated below. Endorsement effectiv 07/01/2012 Named Insured WEST SHORE SCHOOL DISTRICT Countersigned by (Authorized Representative) BASIC FIRST FARTYBENEFIT is changed as foliows: SCHEDULE As indicated below, Added First Party Benefits or Combination FirsParty Binstead ofthe Basic First Party Benefit. The limits of liabilityshown for the benefits selected below replace the limits of iabilityshown in the Schedule for the Basic First Party Benefit. Benefits Limit of Liability (per insured) IM Added First Party Benefits Medical Expense Benefits Work Loss Benefits Funeral Expense Benefits Accidental Death Benefits Up to $10'000 Not Covered Not Covered Combination First Party Benefits Maximum Total Limit for All Benefits Subject to the foliowing individual limits: Medical Expense Benefits Work Loss Benefits Funeral Expense Benefits Accidental Death Benefits Up to No�ud dollar amount upeo o r No specific dollar amount Up to $2,500 (lfno entry appears above, information required to complete this endorsement Wilibe shown in the Declarations as applicable to this endorsement.) CA 22 3D03 95 93 Copyright, Insurance Services Office, Inc., 1994 Page 1 of 2 A. COVERAGE We will pay Added First Party Benefits or Combi- nation First -Party Benefits in accordance with the "Act" up to the limits stated in the Schedule or Declarations to or for an "insured" who sus- tains "bodily injury" caused by an "accident" and arising out of the maintenance or use of an "au - .10". We will only pay Combination First Party Benefits for expenses or loss incurred within 3 years from the date of the "accident". In addition to the Medical Expense Benefits de- scribed in the Basic First Party Benefit endorse- ment, Added First Party Benefits and Combina- tion First Party Benefits also consist of: 1. Work Loss Benefits consisting of: a. Loss of income. Up to 80% of the gross income actually lost by an "insured". b. Reasonable expenses actually incurred to reduce loss ofincome by hiring: (1) Special help, thereby enabling the "insured" to work; or (2) A substitute to perform the work a self-employed "insured" would have performed. However, Work Loss Benefits do not include: a. Loss of expected income for any period following the, death of an "insured"; or b. Expenses incurred for services performed following the death of an "insured"; or c. Any loss of income, or expenses incurred for services performed, during the first 5 working days the "insured" did not work after the "accident" because of the "bodily injury". 2. Funeral Expense Benefits. Actual expenses incurred for an "insured's" funeral or burial if "bodily injury" resulting from the "accident" causes his or her death within 24 months from the date of the "accident". 3. Accidental Death Benefits. A death benefit paid if "bodily injury" resulting from an "acci- dent" causes the death of you or any "family member" within 24 months from the date of the "accident". Page 2 of 2 94 B. EXCLUSIONS In addition to the exclusions in the Basic First Party Benefit endorsement, the following exclusion also applies. We will not pay: Accidental Death Benefits on behalf of any person who intentionally caused or attempted to cause "bodily injury" to himself, herself or any other person. C. LIMIT OF INSURANCE 1. Regardless of the number of covered "autos", premiums paid, claims made, "au- tos" involved in the "accident" or insurers providing First Party Benefits, the most we will pay to or for an "insured" as the result of any one "accident" is the limit shown in the Schedule or the Declarations. Combination First Party Benefits are subject to a maximum total single limit of liability with individual lim- its for specific benefits as shown in the Schedule or Declarations. 2. If Combination First Party Benefits are af- forded, we will make available at least the minimum limit required by the "Act" for the Basic First Party. Benefit. This provision will not change our total limit of liability. D. CHANGES IN CONDITIONS In addition to the CONDITIONS applicable to the Basic First Party Benefit endorsement, the follow- ing CONDITION also applies: PAYMENT OF ACCIDENTAL DEATH BENEFITS The Accidental Death Benefit under this policy will be paid to the executor or administrator of the deceased "insured's" estate. If there is no ex- ecutor or administrator, benefits shall be paid to: 1. The deceased "insured's" surviving spouse; or 2. If there is no surviving spouse, the deceased "insured's" surviving children; or 3. If there is no surviving spouse or surviving children, the deceased "insured's" estate. Copyright, Insurance Services Office, Inc., 1994 CA 22 38 03 95 SETTLEMENT AGREEMENT AND FULL AND FINAL MUTUAL RELEASE 1. FOR AND IN CONSIDERATION of One Hundred Thousand Do|hsrS/$100'000\ Dollars, made by and on behalf of West Shore School [])sthCt, receipt of which is hereby GCkDOVvedged, and releasing all claims and potential claims, and any claims that could have been brought, the undersigned, Quentin Wingfield, a minor, by and through his parent and natural guardian, Kristel Smith, in her own right and on behalf of her minor child, Quentin Wingfield, fully releases and discharges the West Shore School District and all other persons, oSSooiatiVns, corporations, whether or not named herein, theirheirs, exeCutors, administrators, successors, assigns, and iOsurers, their respective agents, oerVoOtS, and/or employees, from any and all causes of action, c|@irns, and demands for uninsured motorist benefits under the West Shore School District motor vehicle insurance policy with ACE/USA, Policy #CAL H08590098, on account of all known ijuheS.|osees.dam8ges.c|@ima.ondaUoth8r|o8seaoOd damages allegedly sustained by the undersigned and specifically from any claims or joinders for sole liability, cOnUibUboO, indemnity, d8|rns, counterclaims, or otherwise, as a result of, arising from, or in any way connected with an auto accident occurring on 3 January 2013. 2. It is expressly understood and agreed that this Settlement Agreement and Full and Fina/ Mutual Release is intended to cover, and does cover, not only all now known injuries, Iosses, damages, and caims which arise from, or are related to the accident of 3 January 2013, but also all claims which could have been brought in said legal action. 3. This is not a r�lease of any claim against the tortfeasor, Yang Yang Pan. This is not a release of any benefits, including underinsured motorist benefits, or other claims which Quentin Wingfield or Kristel Smith may have under any other applicable motor vehicle insurance policies >nduding, but not limited to, policies with GEICO and Erie Insurance. 1 of 3 4. This Release will be submitted to the Court with a petition for approval of the minor's settlement and must be approved by the Court before it has any effect. 5. Additionally, the persons and entities referenced in the preceding paragraphs of this Settlement Agreement and Full and Final Mutual Release agree not to disparage, or make disparaging remarks about, in written or electronic form, or any verbal or written cO0nlVnic@bon8, or by any method whatsoever, of any of the parties or entities who are mentioned in the preceding paragraphs. 6. Kristel Srnith, in their own right and on behalf of their minor child, Quentin Wingfield, further represents, agrees, and warrants that they shall make no claim, and have not made any claim, to Medicare or to the Social Security Administration for disability or other benefits as a result of any injuries and/or damages or claims set forth, bnJuQh1, or that could have been brought in the lawsuit referenced above. Medical expenses for treatment of the injuries to Quentin Wingfield were paid for by Aetna through CHIP in Pennsylvania. -[he|ienfor the Aetna payments will be satisfied from the proceeds of this settlement. 7. Nothing in this Settlement Agreement and Full and Final Mutual Release, including the payment of any sum by or on behalf of the West Shore School District, and/or any members of the School Board of Directors or of the administration of the West Shore School District, constitutes an admission by them of any legal wrongdoing in connection with any claim of the Plaintiffs. O. It is further understood and agreed that this is the complete release agreement, and that there are no written or oral understandings, or agnaerDeDto, directly or indirectly connected with this release and settlement that are not incorporated herein. 9. This agreement shall be binding upon and inure to the successors, assigns, heirs, executors, administrators, and legal representatives of the parties hereto. IN WITNESS WHEREOF, the parties hereto have set their hands and seal this day of , 2014, intending and agreeing to be legally bound hereof. WITNESS: Subscribed and sworn to before me this day of , 2014. Notary Public 3 of 3 Kristel Smith, as parent and guardian of Quentin Wingfield. EXHIBIT 3 LAW OFFICE TUCKER ARENSBERG, P.C. ATTORNEY'S AGREEMENT PERSONAL INJURY THIS AGREEMENT, entered into this 16th day of January, 2013, by and between TUCKER ARENSBERG P.C., (hereinafter "Attorney"), and rli r - J-• Inrr11t ivtcm. -b/ 4 -ND am I67a1-1-For Iter" ,era hereinafter "Client"). WITNESSETH: That Attorney, for the consideration hereinafter stipulated, has 0.elovriro undertaken and does hereby undertake and agree with Client to act as legal counsel in negotiating a /vine -fit;. settle ent, and if the same is not effected, in bringing, conducting and prosecuting an action against Aril )f4 -I)6- 1:7,4114 , to recover damages fogpersonal injuries sustained by the Client in an accident/incident which occurred on or about J 4tfroW 3 , '2-6513 . ATTORNEY FEE: In consideration for services so rendered by Attorney, it is hereby agreed by and between the parties hereto that Attorney shall be compensated as follows: (a) Twenty -Five (25%) percent of the gross recovery if the case is settled before jury selection in a jury trial case, before commencement of trial in a non -jury trial case, or before the commencement of the hearing in a matter first heard by arbitrators; or (b) Twenty -Five (25%) percent of the gross recovery if the case is settled any time after it proceeds to jury selection at trial or if a gross recovery is obtained in any other manner at or after the selection of the jury in a jury trial case, after commencement of the trial in a non -jury trial case or after the commencement of the hearing in a matter first heard by arbitrators. The Attorney's fee as set forth above covers only the Attorney's services through and including the trial of the Client's case and any post trial proceeding before the trial court. If the case is appealed to a court beyond the trial court, then the Client must enter a new agreement with the Attorney or make additional arrangements for the Attorney's fee for services for representing the Client in the appeal. "Gross recovery" shall mean the full amount of settlement proceeds or the full amount of verdict, including any pre -judgment interest, without reduction for expenses or costs advanced or incurred. Attorney shall have a lien on any sum or sums recovered, whether by settlement or judgment, for services rendered, costs advanced and expenses incurred under this Agreement. If for any reason the services of the Attorney are terminated, either by the Attorney or by the Client, Attorney shall have a right to be compensated for the reasonable value of the services provided to Client. The reasonable value of the Attorney's services shall be the greater of the amounts determined as follows: (a) by applying the hourly rates ordinarily charged by the Attorney during the time of Attorney's representation to the time expended by Attorney in this matter; or (b) Twenty -Five (25%) percent of the highest offer to settle Client's case received prior to termination. The right of Attorney to receive any such compensation will be contingent upon Client obtaining a recovery in this case by settlement, verdict or otherwise. Additionally, the Client will then also become responsible for the payments of all the expenses and costs incurred by TUCKER ARENSBERG, P.C. on the Client's case. Said expenses and costs will become immediately due and owing to TUCKER ARENSBERG, P.C.. EXPENSES OF LITIGATION: Any necessary and reasonable costs advanced by Attorney in the preparation and presentation of Client's claim, and all expenses attendant thereto, shall be the responsibility of the Client to pay upon the Client's obtaining a recovery in the case. Attorney retains the right to request that the Client advance said expenses and costs. Attorney may apply any funds held in escrow on behalf of Client to the costs and expenses of litigation. SETTLEMENT PROVISIONS: All offers to settle, adjust or compromise the above claim shall be reviewed between Client and Attorney before any such offer is either accepted or rejected. Client further agrees to consider seriously any recommendation for settlement made by Attorney and not to unreasonably withhold consent to such settlement recommendation. DISCHARGE OR WITHDRAWAL: In the event that Attorney subsequently determines that the claim or suit lacks merit, or Client unreasonably withholds consent to any bona fide settlement recommendation made by Attorney, or Client refuses or fails to cooperate with Attorney, or Client conceals or misrepresents facts regarding the above claim, or Client commits a breach of this Agreement, Attorney shall have the right to terminate his services upon giving reasonable notice to Client. - MISCELLANEOUS: Client understands, acknowledges and agrees that Attorney does not guarantee the outcome or eventual result of the above claim. IN WITNESS WHEREOF, the parties hereto, intending to be legally bound, have hereunto set their hands and seals to this Agreement, in execution thereof, the day and year first above written. WITNESSES: H BG DB:132482-1 999999-999999 TUCKER ARENSBERG, P.C. /1/(74 -/- Dennis R. Sheaffer NitOWC>th 17'211 171.? ^JD OP✓ OC:71/41LP e5 1111')72- am, (SEAL) (SEAL) ") v Lt Rawlings Co npanyLLC Subrogation Division August 15, 2014 Mr. Dennis R. Sheaffer Tucker Arensberg Attorneys 1500 One PPG Place Pittsburgh, PA 15222 Post Office Box 2000 LaGrange, Kentucky 40031-2000 One Eden Parkway LaGrange, Kentucky 40031-8100 Telephone (302) 58 7-127 9 Re: • Our Client: • Aetna Member/Patient: QUENTIN WINGFIELD/QUENTIN WINGFIELD Date of Loss: 1/3/2013 Our Reference No.: 58868206 UPDATE OF LIEN AMOUNT Dear Mr. Sheaffer: We previously placed your office on notice of our client's claim. The amount of our client's claim is now $30,407.11. As you are aware, the amount of the claim may increase if additional health benefits are paid. Therefore, please contact me prior to settlement to obtain the final amount. We are also requesting an update on this claim. Please provide the current status. You mayfaxyour response to the number listed below. Comments: Sincerely, c ke • John Poythress Recovery Analyst (502) 716-6913 FAX: (502) 753-7300 jp5@rawlingscompany.com TL.:.- t ....+...... ..f� ....... CERTIFICATE OF SERVICE AND NOW, this 26th day of September, 2014, Maria B. LaRue, Paralegal, for the firm of TUCKER ARENSBER, PC., attorneys for Petitioner, hereby certify that I have this day served the within document by depositing a copy of the same in the United States Mail, postage prepaid, at Lemoyne, Pennsylvania, addressed as follows: L. Roeg Williamson, JD, CCM Senior Casualty Analyst School Claims Service P. 0. Box 814 New Cumberland, PA 17070 Mari -B. LaRue, Paralegal HBGDB:145393-1 028542-158622 IN RE: THE MATTER OF KRISTEL LYNN : IN THE COURT OF COMMON PLEAS SMITH, As Parent and Natural Guardian of : CUMBERLAND COUNTY, PENNSYLVANIA QUENTIN ALEXANDER WINGFIELD, Petitioner : NO. j Lt_ SG SI LW I i ORDER AND NOW, this 1 Ch day of seri' , 2014, after due consideration of the foregoing Petition, IT IS HEREBY ORDERED AND DECREED that: 1. Payment of the uninsured motorist claim of Quentin Alexander Wingfield, a Minor, brought under the policy of insurance that the West Shore School District had with ACE/USA by virtue of the injuries the Minor sustained in an accident which occurred on January 3, 2013, for the sum of One Hundred Thousand ($100,000.00) Dollars, the policy limits, is hereby approved as being fair and equitable. 2. The net amount of Forty-three Thousand Three Hundred Nine and 18/100 ($43,309.18) Dollars for the Minor, Quentin Alexander Wingfield, is HEREBY ORDERED to be placed into a savings account in the name of the Minor in a bank, building and loan association, savings and loan association or credit union, deposits in which are insured by a Federal Government Agency, provided that the amount deposited in any one such savings institution shall not exceed the amount for which the account is thus insured. No withdrawal shall be made from such account until the Minor attains majority, except as authorized by a prior Order of this Court. Proof of deposit shall be promptly filed of record with this Court, pursuant to Pa.R.C.P. 2039(b)(2). 3. Upon payment of aforesaid sum in the manner above-described, Petitioner, Quentin Alexander Wingfield, a Minor and Kristel Lynn Smith, his Parent and Natural Guardian are hereby authorized to execute a Release in favor of ACE/USA for the uninsured motorist claim which the Minor had against the West Shore School District and ACE/USA by reason of the injuries which the Minor sustained in the accident which occurred on January 3, 2013. 4. Payment of attorney's fees and costs in the amount of Twenty Six Thousand Two Hundred Eighty -Three and 71/100 ($26,283.71) Dollars is hereby approved as being fair and equitable. 5. Payment of the medical lien in the amount of Thirty Six Thousand Four Hundred and Seven and 11/100 ($36,407.11) Dollars to Aetna Insurance is hereby approved as fair and equitable. To the extent that this amount is reduced or compromised, then the amount that is saved shall be added to the net amount set forth in Paragraph 3 and deposited in accordance with the requirements set forth in Paragraph 3. BY THE COURT: WiIliarnson,J )CCM enkor asuzl -I�r,atys C\ool Nai rn% 11C, `Tbennis R. Shea er J.